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Tierney AP, Milnes S, Phillips A, Simpson N, Bailey M, Corke C, Orford NR. Effect of a person-centred goals-of-care form and clinical communication training on shared decision-making and outcomes in an acute hospital: a prospective longitudinal interventional study. Intern Med J 2024; 54:1197-1204. [PMID: 38520171 DOI: 10.1111/imj.16381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/09/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Patients with a life-limiting illness (LLI) requiring hospitalisation have a high likelihood of deterioration and 12-month mortality. To avoid non-aligned care, we need to understand our patients' goals and values. AIM To describe the association between the implementation of a shared decision-making (SDM) programme and documentation of goals of care (GoC) for hospitalised patients with LLI. METHODS A prospective longitudinal interventional study of patients admitted to acute general medicine wards in an Australian tertiary hospital over 5 years was conducted. A SDM programme with a new GoC form, communication training and clinical support was implemented. The primary outcome was the proportion of patients with a documented person-centred GoC discussion (PCD). Clinical outcomes included hospital utilisation and 90-day mortality. RESULTS 1343 patients were included. The proportion of patients with PCDs increased from 0% to 35.4% (adjusted odds ratio (aOR), 2.38; 95% confidence interval (CI), 2.01-2.82; P < 0.001). During this time, median hospital length of stay decreased from 8 days (interquartile range (IQR), 4-14) to 6 days (IQR, 3-11) (adjusted estimate effect, -0.38; 95% CI, -0.64 to -0.11; P = 0.005) and rapid response team activation from 28% to 13% (aOR, 0.87; 95% CI, 0.78-0.97; P value = 0.01). Documented treatment preference of high-dependency unit care decreased from 39.7% to 24.4% (aOR, 0.81; 95% CI, 0.73-0.89; P value < 0.001), and ward-based care increased from 31.9% to 55.1% (aOR, 1.24; 95% CI, 1.14-1.36; P value < 0.001). CONCLUSION The implementation of a SDM programme was associated with increased documentation of person-centred GoC, changed patient treatment preference to lower intensity care and reduced hospital utilisation.
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Affiliation(s)
- Andrew P Tierney
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Sharyn Milnes
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Anita Phillips
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Nicholas Simpson
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine (SPHPM), Monash University, Melbourne, Victoria, Australia
| | - Charlie Corke
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Neil R Orford
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine (SPHPM), Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
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White NM, Barnett AG, Lee XJ, Farrington A, Carter H, McPhail SM, Cardona M, Hillman K, Callaway L, Willmott L, White BP, Harvey G, Graves N, Brown C. Impact of a prospective feedback loop aimed at reducing non-beneficial treatments in older people admitted to hospital and potentially nearing the end of life. A cluster stepped-wedge randomised controlled trial. Age Ageing 2024; 53:afae115. [PMID: 38851216 PMCID: PMC11162291 DOI: 10.1093/ageing/afae115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Indexed: 06/10/2024] Open
Abstract
OBJECTIVES To investigate if a prospective feedback loop that flags older patients at risk of death can reduce non-beneficial treatment at end of life. DESIGN Prospective stepped-wedge cluster randomised trial with usual care and intervention phases. SETTING Three large tertiary public hospitals in south-east Queensland, Australia. PARTICIPANTS 14 clinical teams were recruited across the three hospitals. Teams were recruited based on a consistent history of admitting patients aged 75+ years, and needed a nominated lead specialist consultant. Under the care of these teams, there were 4,268 patients (median age 84 years) who were potentially near the end of life and flagged at risk of non-beneficial treatment. INTERVENTION The intervention notified clinicians of patients under their care determined as at-risk of non-beneficial treatment. There were two notification flags: a real-time notification and an email sent to clinicians about the at-risk patients at the end of each screening day. The nudge intervention ran for 16-35 weeks across the three hospitals. MAIN OUTCOME MEASURES The primary outcome was the proportion of patients with one or more intensive care unit (ICU) admissions. The secondary outcomes examined times from patients being flagged at-risk. RESULTS There was no improvement in the primary outcome of reduced ICU admissions (mean probability difference [intervention minus usual care] = -0.01, 95% confidence interval -0.08 to 0.01). There were no differences for the times to death, discharge, or medical emergency call. There was a reduction in the probability of re-admission to hospital during the intervention phase (mean probability difference -0.08, 95% confidence interval -0.13 to -0.03). CONCLUSIONS This nudge intervention was not sufficient to reduce the trial's non-beneficial treatment outcomes in older hospital patients. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019).
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Affiliation(s)
- Nicole M White
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Adrian G Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Xing J Lee
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Alison Farrington
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Hannah Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Digital Health and Informatics Directorate, Metro South Health, Woolloongabba, Brisbane, Australia
| | - Magnolia Cardona
- Bond University Evidence Based Practice Professorial Unit, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Population Health, The University of New South Wales, Kensington, New South Wales, Australia
| | - Kenneth Hillman
- Simpson Centre for Health Services Research, South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
- School of Clinical Medicine, University of New South Wales, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medial Research, Liverpool, New South Wales, Australia
| | - Leonie Callaway
- Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, School of Law, Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben P White
- Australian Centre for Health Law Research, School of Law, Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Gillian Harvey
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Duke-NUS Postgraduate Medical School, National University of Singapore, Singapore
| | - Christine Brown
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
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Paulik O, Whitaker R, Mesuria M, Wong D, Swanson K, Green H, Sikhosana N, Fernandez R. Implementation and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT™) in acute care. Australas J Ageing 2024. [PMID: 38558296 DOI: 10.1111/ajag.13308] [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: 12/04/2023] [Revised: 02/18/2024] [Accepted: 03/03/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES The Supportive and Palliative Care Indicators Tool (SPICT™) has been used to identify patients at risk of deteriorating and dying within 1 year. Early identification and integration of advance care planning (ACP) provides the opportunity for a better quality of life for patients. The aims of this study were to identify the number of patients who were SPICT™ positive; their mortality rates at 6 and 12 months of the SPICT™ assessment; and level of adherence to ACP documentation. METHODS A retrospective audit of the Supportive and Palliative Care database was conducted at an acute aged care precinct in a major metropolitan tertiary referral hospital in New South Wales, Australia. Data comprising demographics, clinical conditions, SPICT™ positivity and compliance with ACP documentation were collected. SPICT™-positive patients and mortality were tracked at 6 and 12 months, respectively. RESULTS Data from 153 patients were collected. The mean age of the patients was 84.1 (±7.8) years, and the length of hospital stay was 10 (±24.7) (range 1-269) days. Approximately 37% were from residential care, and 80% had family deciding on their care. About 15% died during hospitalisation, and 48% were discharged to a care facility. The ACP documentation showed various levels of completion. Mortality rates at 6 and 12 months were 36% and 39%, respectively. Most patients (99%) were SPICT™-positive, with indicators correlating with higher mortality rates at both follow-ups. CONCLUSIONS The study emphasises the critical need for addressing ACP and palliative care among older patients with life-limiting conditions. It underscores the importance of timely discussions, documentation, and cessation of futile interventions.
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Affiliation(s)
- Olivia Paulik
- St George Hospital, Sydney, New South Wales, Australia
| | | | | | - Debbie Wong
- St George Hospital, Sydney, New South Wales, Australia
| | - Katie Swanson
- St George Hospital, Sydney, New South Wales, Australia
| | - Heidi Green
- Australian Centre for Health Engagement, Evidence and Values (ACHEEV), School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Nqobile Sikhosana
- School of Nursing and Midwifery, University of Newcastle, Newcastle, New South Wales, Australia
| | - Ritin Fernandez
- School of Health Sciences, University of Newcastle, Newcastle, New South Wales, Australia
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Bracci EL, Barnett AG, Brown C, Callaway L, Cardona M, Carter HE, Graves N, Hillman K, Lee XJ, McPhail SM, White BP, Willmott L, Harvey G. Process evaluation of a tailored nudge intervention to promote appropriate care and treatment of older patients at the end-of-life. BMC Geriatr 2024; 24:202. [PMID: 38413877 PMCID: PMC10900675 DOI: 10.1186/s12877-024-04818-4] [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: 08/16/2023] [Accepted: 02/16/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention. METHODS Qualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the intervention at a site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed. RESULTS Overall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level. CONCLUSIONS An intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 06/05/2019).
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Affiliation(s)
- Ella L Bracci
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.
| | - Adrian G Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Christine Brown
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Leonie Callaway
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Magnolia Cardona
- Institute for Evidence-Based Health Care, Bond University, Robina, Queensland, Australia
- School of Psychology, University of Queensland, Herston, Queensland, Australia
| | - Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Duke-NUS Postgraduate Medical School, National University of Singapore, Singapore, Singapore
| | - Kenneth Hillman
- School of Clinical Medicine, UNSW Medicine & Health, Southwest Sydney Clinical Campuses, Discipline of Critical Care, Sydney, NSW, Australia
| | - Xing J Lee
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Ben P White
- Australia Centre for Heath Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australia Centre for Heath Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Gillian Harvey
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
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Choi HR, Ho MH, Lin CC. Futile life-sustaining treatment in the intensive care unit - nurse and physician experiences: meta-synthesis. BMJ Support Palliat Care 2024; 14:36-46. [PMID: 38050047 DOI: 10.1136/spcare-2023-004640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/19/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Continuing futile life-sustaining treatment prolongs patients' suffering and family members' and medical staff's psychological distress. Additionally, continuing futile treatment is inefficient in healthcare resource distribution. Although the withdrawal of futile life-sustaining treatment is ideal, the prevalence is variable. OBJECTIVE To synthesise nurses' and physicians' experiences with continuing futile life-sustaining treatment in the intensive care unit. DESIGN This meta-synthesis was conducted following the thematic synthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses and Enhancing transparency in reporting the synthesis of qualitative research statement were used in reporting the synthesis of qualitative research statements. METHODS AND DATA SOURCES A systematic search was conducted following the inclusion and exclusion criteria in APA PsycINFO, CINAHL Plus, EMBASE, MEDLINE, PubMed and Web of Science in May 2023. Two reviewers independently screened and extracted the data. The extracted data were analysed using thematic analysis of qualitative research. FINDINGS A total of 16 studies were finally included, and 141 quotes were extracted and analysed. The main findings were categorised into four themes: (1) contextual and cultural diversity, (2) perceptions of futile treatment, (3) professional roles and responsibilities, and (4) emotional distress. CONCLUSION The study highlights the influence of culture, religion and family members, as well as perceptions of futile treatment among clinicians, on continuing futile life-sustaining treatment. Also, nurses' awareness of their roles and responsibilities in ensuring patients' comfort at end of life was revealed. This study informs future research to explore the experiences of futile life-sustaining treatment across various contexts.
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Affiliation(s)
- Hye Ri Choi
- School of Nursing, University of Hong Kong, Hong Kong, Hong Kong
| | - Mu-Hsing Ho
- School of Nursing, University of Hong Kong, Hong Kong, Hong Kong
| | - Chia-Chin Lin
- School of Nursing, University of Hong Kong, Hong Kong, Hong Kong
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Beran RG, Devereux JA. Futile treatment - when is enough, enough? AUST HEALTH REV 2024; 48:103-107. [PMID: 38300254 DOI: 10.1071/ah22277] [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: 11/09/2023] [Accepted: 01/19/2024] [Indexed: 02/02/2024]
Abstract
Objective This paper examines two aspects of treatment decision making: withdrawal of treatment decisions made by a patient; and decisions to not proceed with treatment by a health professional. The paper aims to provide an overview of the law relating to the provision of treatment, then highlight the uncertainty as to the meaning of and costs associated with futile treatment. Methods The paper reviews the current legal and medical literature on futile treatment. Results Continuing treatment which is futile is not in the patient's best interests. Futility may be understood in both quantitative and qualitative terms. Recent legal cases have expanded the definition of futility to focus not on the nature of the treatment itself, but also on the health of the patient to whom treatment is provided. Conclusions As Australia's population ages, there is likely to be an increased focus on the allocation of scarce health resources. This will, inevitably, place constraints on the number and variety of treatments offered to patients. The level of constraint will be felt acutely where a proposed treatment offers little clinical efficacy. It is time to try to understand and agree on a workable definition of futility.
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Affiliation(s)
- Roy G Beran
- Department of Neurology, Liverpool Hospital, PO Box 598, Northbridge, Sydney, NSW 1560, Australia; and Ingham Institute of Applied Science, South Western Sydney Health District, Liverpool, NSW, Australia; and South Western Clinical School, University of New South Wales, Sydney, NSW, Australia; and School of Medicine, Griffith University, Southport, Qld, Australia; and School of Medicine, Blacktown Hospital, Western Sydney University, Sydney, NSW, Australia
| | - J A Devereux
- Law School, University of Queensland, Brisbane, Qld, Australia
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Xia Q, Kularatna M, Virdun C, Button E, Close E, Carter HE. Preferences for Palliative and End-of-Life Care: A Systematic Review of Discrete Choice Experiments. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1795-1809. [PMID: 37543206 DOI: 10.1016/j.jval.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/20/2023] [Accepted: 07/22/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVES Understanding what matters most to patients and their caregivers is fundamental to delivering high-quality care. This systematic review aimed to characterize and appraise the evidence from discrete choice experiments eliciting preferences for palliative care. METHODS A systematic literature search was undertaken for publications up until August 2022. Data were synthesized narratively. Thematic analysis was applied to categorize attributes into groups. Attribute development, frequency, and relative importance were analyzed. Subgroup analyses were conducted to compare outcomes between patient and proxy respondents. RESULTS Seventeen studies spanning 11 countries were included; 59% of studies solely considered preferences for patients with cancer. A range of respondent groups were represented including patients (76%) and proxies (caregivers [35%], health providers [12%], and the public [18%]). A total of 117 individual attributes were extracted and thematically grouped into 8 broad categories and 21 subcategories. Clinical outcomes including quality of life, length of life, and pain control were the most frequently reported attributes, whereas attributes relating to psychosocial components were largely absent. Both patients and proxy respondents prioritized pain control over additional survival time. Nevertheless, there were differences between respondent cohorts in the emphasis on other attributes such as access to care, timely information, and low risk of adverse effects (prioritized by patients), as opposed to cost, quality, and delivery of care (prioritized by proxies). CONCLUSIONS Our review underscores the vital role of pain control in palliative care; in addition, it shed light on the complexity and relative strength of preferences for various aspects of care from multiple perspectives, which is useful in developing personalized, patient-centered models of care for individuals nearing the end of life.
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Affiliation(s)
- Qing Xia
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Mineth Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Claudia Virdun
- Cancer and Palliative Care Outcomes Centre, Centre for Healthcare Transformation, School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Elise Button
- Cancer and Palliative Care Outcomes Centre, Centre for Healthcare Transformation, School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Eliana Close
- Australian Centre for Health Law Research, School of Law, Faculty of Business and Law (Close), Queensland University of Technology, Brisbane, QLD, Australia
| | - Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
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Ul Hassan SS, Ali W, Khan H, Raja AR, Hassan M, Haque G, Ayub F, Waqar MA, Latif A. Confronted With Death: Factors Affecting End of Life Decisions in the Intensive Care Unit. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231198360. [PMID: 37632273 DOI: 10.1177/00302228231198360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
To determine how often care is limited at the end of life and the factors that are associated with this decision, we reviewed the medical records of all patients that passed away in the intensive care units (ICU) of Aga Khan University. We found that a majority of patients had Do-Not-Resuscitate orders in place at the time of death. Our analysis yielded 6 variables that were associated with the decision to limit care. These are patient age, sex, duration of mechanical ventilation, Glasgow Coma Scale (GCS) ≤8 at any point during ICU stay, GCS ≤8 in the first 24 hours following ICU admission, and mean arterial pressure <65 mm of Hg while on vasopressors in the first 24 hours following ICU admission. These variables require further study and should be carefully considered during end of life discussions to allow for optimal management at the end of life.
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Affiliation(s)
| | - Wajid Ali
- Dean's Clinical Research Fellow, Aga Khan University, Karachi, Pakistan
| | - Hamza Khan
- Dean's Clinical Research Fellow, Aga Khan University, Karachi, Pakistan
| | | | | | - Ghazal Haque
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
| | - Farwa Ayub
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
| | | | - Asad Latif
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
- Department of Anesthesiology, Aga Khan University Hospital, Karachi, Pakistan
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, USA
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Baek AR, Hong SB, Bae S, Park HK, Kim C, Lee HK, Cho WH, Kim JH, Chang Y, Lee HB, Gil HI, Shin B, Yoo KH, Moon JY, Oh JY, Min KH, Jeon K, Baek MS. Comparison of the end-of-life decisions of patients with hospital-acquired pneumonia after the enforcement of the life-sustaining treatment decision act in Korea. BMC Med Ethics 2023; 24:52. [PMID: 37461075 PMCID: PMC10353089 DOI: 10.1186/s12910-023-00931-y] [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: 12/23/2022] [Accepted: 07/12/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Although the Life-Sustaining Treatment (LST) Decision Act was enforced in 2018 in Korea, data on whether it is well established in actual clinical settings are limited. Hospital-acquired pneumonia (HAP) is a common nosocomial infection with high mortality. However, there are limited data on the end-of-life (EOL) decision of patients with HAP. Therefore, we aimed to examine clinical characteristics and outcomes according to the EOL decision for patients with HAP. METHODS This multicenter study enrolled patients with HAP at 16 referral hospitals retrospectively from January to December 2019. EOL decisions included do-not-resuscitate (DNR), withholding of LST, and withdrawal of LST. Descriptive and Kaplan-Meier curve analyses for survival were performed. RESULTS Of 1,131 patients with HAP, 283 deceased patients with EOL decisions (105 cases of DNR, 108 cases of withholding of LST, and 70 cases of withdrawal of LST) were analyzed. The median age was 74 (IQR 63-81) years. The prevalence of solid malignant tumors was high (32.4% vs. 46.3% vs. 54.3%, P = 0.011), and the ICU admission rate was lower (42.9% vs. 35.2% vs. 24.3%, P = 0.042) in the withdrawal group. The prevalence of multidrug-resistant pathogens, impaired consciousness, and cough was significantly lower in the withdrawal group. Kaplan-Meier curve analysis revealed that 30-day and 60-day survival rates were higher in the withdrawal group than in the DNR and withholding groups (log-rank P = 0.021 and 0.018). The survival of the withdrawal group was markedly decreased after 40 days; thus, the withdrawal decision was made around this time. Among patients aged below 80 years, the rates of EOL decisions were not different (P = 0.430); however, mong patients aged over 80 years, the rate of withdrawal was significantly lower than that of DNR and withholding (P = 0.001). CONCLUSIONS After the LST Decision Act was enforced in Korea, a DNR order was still common in EOL decisions. Baseline characteristics and outcomes were similar between the DNR and withholding groups; however, differences were observed in the withdrawal group. Withdrawal decisions seemed to be made at the late stage of dying. Therefore, advance care planning for patients with HAP is needed.
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Affiliation(s)
- Ae-Rin Baek
- Division of Allergy and Pulmonary Medicine, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soohyun Bae
- Department of Integrated Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Hye Kyeong Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Ilsan, Korea
| | - Changhwan Kim
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Hyun-Kyung Lee
- Department of Internal Medicine, Division of Pulmonology, Allergy and Critical Care Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Woo Hyun Cho
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jin Hyoung Kim
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Heung Bum Lee
- Department of Internal Medicine, Research Center for Pulmonary Disorders, Jeonbuk National University Medical School, Jeonju, Korea
| | - Hyun-Il Gil
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Beomsu Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kwang Ha Yoo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jae Young Moon
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University College of Medicine, Sejong Hospital, Sejong, Korea
| | - Jee Youn Oh
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Kyung Hoon Min
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Seong Baek
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Republic of Korea.
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10
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Subbe C, Hughes DA, Lewis S, Holmes EA, Kalkman C, So R, Tranka S, Welch J. Value of improving patient safety: health economic considerations for rapid response systems-a rapid review of the literature and expert round table. BMJ Open 2023; 13:e065819. [PMID: 37068893 PMCID: PMC10111929 DOI: 10.1136/bmjopen-2022-065819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
OBJECTIVES Failure to rescue deteriorating patients in hospital is a well-researched topic. We aimed to explore the impact of safer care on health economic considerations for clinicians, providers and policymakers. DESIGN We undertook a rapid review of the available literature and convened a round table of international specialists in the field including experts on health economics and value-based healthcare to better understand health economics of clinical deterioration and impact of systems to reduce failure to rescue. RESULTS Only a limited number of publications have examined the health economic impact of failure to rescue. Literature examining this topic lacked detail and we identified no publications on long-term cost outside the hospital following a deterioration event. The recent pandemic has added limited literature on prevention of deterioration in the patients' home.Cost-effectiveness and cost-efficiency are dependent on broader system effects of adverse events. We suggest including the care needs beyond the hospital and loss of income of patients and/or their informal carers as well as sickness of healthcare staff exposed to serious adverse events in the analysis of adverse events. They are likely to have a larger health economic impact than the direct attributable cost of the hospital admission of the patient suffering the adverse event. Premorbid status of a patient is a major confounder for health economic considerations. CONCLUSION In order to optimise health at the population level, we must limit long-term effects of adverse events through improvement of our ability to rapidly recognise and respond to acute illness and worsening chronic illness both in the home and the hospital.
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Affiliation(s)
- Christian Subbe
- Bangor University, School of Medical Sciences, Bangor, UK
- Department of Medicine, Ysbyty Gwynedd, Bangor, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Sally Lewis
- National Clinical Director for Value-Based Healthcare & Honorary Professor Swansea University Medical School, Swansea University, Swansea, UK
- National Clinical Director for Value-Based Healthcare, Wales, UK
| | - Emily A Holmes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Cor Kalkman
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ralph So
- Intensive Care and Medical Manager Department Quality, Safety and Innovation, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - John Welch
- Intensive Care, University College London Hospitals NHS Foundation Trust, London, UK
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11
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White BP, Willmott L, Close E. Better Regulation of End-Of-Life Care: A Call For A Holistic Approach. JOURNAL OF BIOETHICAL INQUIRY 2022; 19:683-693. [PMID: 36251135 PMCID: PMC9908626 DOI: 10.1007/s11673-022-10213-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/10/2022] [Indexed: 06/16/2023]
Abstract
Existing regulation of end-of-life care is flawed. Problems include poorly-designed laws, policies, ethical codes, training, and funding programs, which often are neither effective nor helpful in guiding decision-making. This leads to adverse outcomes for patients, families, health professionals, and the health system as a whole. A key factor contributing to the harms of current regulation is a siloed approach to regulating end-of-life care. Existing approaches to regulation, and research into how that regulation could be improved, have tended to focus on a single regulatory instrument (e.g., just law or just ethical codes). As a result, there has been a failure to capture holistically the various forces that guide end-of-life care. This article proposes a response to address this, identifying "regulatory space" theory as a candidate to provide the much-needed holistic insight into improving regulation of end-of-life care. The article concludes with practical implications of this approach for regulators and researchers.
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Affiliation(s)
- Ben P. White
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, Queensland 4001 Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, Queensland 4001 Australia
| | - Eliana Close
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, Queensland 4001 Australia
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12
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Brown C, Lee XJ, Farrington A, Shield C, Carter HE, McPhail SM, Cardona M, Hillman K, Callaway L, Willmott L, White BP, Harvey G, Graves N, Barnett AG. Impact of a prospective feedback loop on care review activities in older patients at the end of life. A stepped-wedge randomised trial. BMC Geriatr 2022; 22:860. [PMID: 36380290 PMCID: PMC9666964 DOI: 10.1186/s12877-022-03554-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background Hospitalisation rates for older people are increasing, with end-of-life care becoming a more medicalised experience. Innovative approaches are warranted to support early identification of the end-of-life phase, communicate prognosis, provide care consistent with people’s preferences, and improve the use of healthcare resources. The Intervention for Appropriate Care and Treatment (InterACT) trial aimed to increase appropriate care and treatment decisions for older people at the end of life, through implementation of a prospective feedback loop. This paper reports on the care review outcomes. Methods A stepped-wedge randomised controlled trial was conducted in three large acute hospitals in Queensland, Australia between May 2020 and June 2021. The trial identified older people nearing the end of life using two validated tools for detecting deterioration and short-term death. Admitting clinical teams were provided with details of patients identified as at-risk with the goal of increasing awareness that end of life was approaching to facilitate appropriate patient centred care and avoid non-beneficial treatment. We examined the time between when the patient was identified as ‘at-risk’ and three outcomes: clinician-led care review discussions, review of care directive measures and palliative care referrals. These were considered useful indicators of appropriate care at the end of life. Results In two hospitals there was a reduction in the review of care directive measures during the intervention compared with usual care at 21 days (reduced probability of − 0.08; 95% CI: − 0.12 to − 0.04 and − 0.14; 95% CI: − 0.21 to − 0.06). In one hospital there was a large reduction in clinician-led care review discussions at 21 days during the intervention (reduced probability of − 0.20; 95% CI: − 0.28 to − 0.13). There was little change in palliative care referrals in any hospital, with average probability differences at 21 days of − 0.01, 0.02 and 0.04. Discussion The results are disappointing as an intervention designed to improve care of hospitalised older people appeared to have the opposite effect on care review outcomes. The reasons for this may be a combination of the intervention design and health system challenges due to the pandemic that highlight the complexity of providing more appropriate care at the end of life. Trial registration Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03554-x.
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13
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Sepulveda JMG, Baid D, Johnson FR, Finkelstein EA. What is a Good Death? A Choice Experiment on Care Indicators for Patients at End of Life. J Pain Symptom Manage 2022; 63:457-467. [PMID: 34793947 PMCID: PMC9341237 DOI: 10.1016/j.jpainsymman.2021.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/06/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022]
Abstract
CONTEXT Health systems should aim to deliver on what matters most to patients. With respect to end of life (EOL) care, knowledge on patient preferences for care is currently lacking. OBJECTIVES To quantify preference weights for key EOL care indicators. METHODS We developed a discrete choice experiment survey with 13 key indicators related to patients' experience in the last six weeks of life. We fielded the survey to a web-panel of caregiver proxies for recently deceased care recipients. We obtained 250 responses in each of five countries: India, Singapore, Kenya, the UK and the US. Latent-class analysis was used to evaluate preference weights for each indicator within and across countries. RESULTS A 2-class latent-class model was the best fit. Class 1 (average class probability = 64.7%) preference weights were logically ordered and highly significant, while Class 2 estimates were generally disordered, suggesting poor data quality. Class 1 results indicated health care providers' ability to control patients' pain to desired levels was most important (11.5%, 95% CI: 10.3%-12.6%), followed by clean, safe, and comfortable facilities (10.0%, 95% CI: 9.0%-11.0%); and kind and sympathetic health care providers (9.8%, 95% CI: 8.8%-10.9%). Providers' support for nonmedical concerns had the lowest preference weight (4.4%, 95% CI: 3.6%-5.3%). Differences in preference weights across countries were not statistically significant. CONCLUSION Results reveal that not all aspects of EOL care are equally valued. Not accounting for these differences would lead to inappropriate conclusions on how best to improve EOL care.
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Affiliation(s)
- Juan Marcos Gonzalez Sepulveda
- Department of Population Health Sciences (J.M.G.S., F.R.J.), Duke University School of Medicine, Durham, North Carolina, USA; Program in Health Services and Systems Research (D.B., E.A.F.), Duke-NUS Medical School, Singapore; Program in Health Services and Systems Research (E.A.F.), Duke University Global Health Institute, Durham, North Carolina, USA..
| | - Drishti Baid
- Department of Population Health Sciences (J.M.G.S., F.R.J.), Duke University School of Medicine, Durham, North Carolina, USA; Program in Health Services and Systems Research (D.B., E.A.F.), Duke-NUS Medical School, Singapore; Program in Health Services and Systems Research (E.A.F.), Duke University Global Health Institute, Durham, North Carolina, USA
| | - F Reed Johnson
- Department of Population Health Sciences (J.M.G.S., F.R.J.), Duke University School of Medicine, Durham, North Carolina, USA; Program in Health Services and Systems Research (D.B., E.A.F.), Duke-NUS Medical School, Singapore; Program in Health Services and Systems Research (E.A.F.), Duke University Global Health Institute, Durham, North Carolina, USA
| | - Eric A Finkelstein
- Department of Population Health Sciences (J.M.G.S., F.R.J.), Duke University School of Medicine, Durham, North Carolina, USA; Program in Health Services and Systems Research (D.B., E.A.F.), Duke-NUS Medical School, Singapore; Program in Health Services and Systems Research (E.A.F.), Duke University Global Health Institute, Durham, North Carolina, USA
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14
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Goals of Care Conversations in Long-Term Care during the First Wave of the COVID-19 Pandemic. J Clin Med 2022; 11:jcm11061710. [PMID: 35330035 PMCID: PMC8950529 DOI: 10.3390/jcm11061710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/11/2022] [Accepted: 03/16/2022] [Indexed: 02/05/2023] Open
Abstract
Goals of care discussions typically focus on decision maker preference and underemphasize prognosis and outcomes related to frailty, resulting in poorly informed decisions. Our objective was to determine whether navigated care planning with nursing home residents or their decision makers changed care plans during the first wave of the COVID-19 pandemic. The MED-LTC virtual consultation service, led by internal medicine specialists, conducted care planning conversations that balanced information-giving/physician guidance with resident autonomy. Consultation included (1) the assessment of co-morbidities, frailty, health trajectory, and capacity; (2) in-depth discussion with decision makers about health status and expected outcomes; and (3) co-development of a care plan. Non-parametric tests and logistic regression determined the significance and factors associated with a change in care plan. Sixty-three residents received virtual consultations to review care goals. Consultation resulted in less aggressive care decisions for 52 residents (83%), while 10 (16%) remained the same. One resident escalated their care plan after a mistaken diagnosis of dementia was corrected. Pre-consultation, 50 residents would have accepted intubation compared to 9 post-consultation. The de-escalation of care plans was associated with dementia, COVID-19 positive status, and advanced frailty. We conclude that during the COVID-19 pandemic, a specialist-led consultation service for frail nursing home residents significantly influenced decisions towards less aggressive care.
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15
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Hewitt J. End-of-life decisions, nurses, and the law. Aust Crit Care 2022; 35:1-2. [DOI: 10.1016/j.aucc.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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16
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van der Padt-Pruijsten A, Leys MBL, Hoop EOD, van der Heide A, van der Rijt CCD. The effect of a palliative care pathway on medical interventions at the end of life: a pre-post-implementation study. Support Care Cancer 2022; 30:9299-9306. [PMID: 36071303 PMCID: PMC9633459 DOI: 10.1007/s00520-022-07352-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/25/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Adequate integration of palliative care in oncological care can improve the quality of life in patients with advanced cancer. Whether such integration affects the use of diagnostic procedures and medical interventions has not been studied extensively. We investigated the effect of the implementation of a standardized palliative care pathway in a hospital on the use of diagnostic procedures, anticancer treatment, and other medical interventions in patients with incurable cancer at the end of their life. METHODS In a pre- and post-intervention study, data were collected concerning adult patients with cancer who died between February 2014 and February 2015 (pre-PCP period) or between November 2015 and November 2016 (post-PCP period). We collected information on diagnostic procedures, anticancer treatments, and other medical interventions during the last 3 months of life. RESULTS We included 424 patients in the pre-PCP period and 426 in the post-PCP period. No differences in percentage of laboratory tests (85% vs 85%, p = 0.795) and radiological procedures (85% vs 82%, p = 0.246) were found between both groups. The percentage of patients who received anticancer treatment or other medical interventions was lower in the post-PCP period (40% vs 22%, p < 0.001; and 42% vs 29%, p < 0.001, respectively). CONCLUSIONS Implementation of a PCP resulted in fewer medical interventions, including anticancer treatments, in the last 3 months of life. Implementation of the PCP may have created awareness among physicians of patients' impending death, thereby supporting caregivers and patients to make appropriate decisions about medical treatment at the end of life. TRIAL REGISTRATION NUMBER Netherlands Trial Register; clinical trial number: NL 4400 (NTR4597); date registrated: 2014-04-27.
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Affiliation(s)
- Annemieke van der Padt-Pruijsten
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, the Netherlands ,Department Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Maria B. L. Leys
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, the Netherlands
| | - Esther Oomen-de Hoop
- Department Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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17
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The Attitude of Iranian Critical Care Nurses Toward Euthanasia: A Multicenter Cross-sectional Study. Crit Care Nurs Q 2021; 45:62-73. [PMID: 34818299 DOI: 10.1097/cnq.0000000000000389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Today, one of the major ethical challenges facing the world's health care system, and in particular nurses in the intensive care unit, is euthanasia or death out of pity. The aim of this study was to investigate the attitude of Iranian nurses in the intensive care unit toward euthanasia. This was an analytical cross-sectional study using census sampling. The data collection tool was the Euthanasia Attitude Scale. A total of 206 nurses working in the intensive care unit in 4 hospitals in the Mazandaran province of Iran were included in this study. The mean of total Euthanasia Attitude Scale score in intensive care unit nurses was 2.96. The mean euthanasia dimensions were ethical consideration, practical considerations, treasuring life, and naturalistic beliefs, 3.03, 2.92, 2.98, and 2.99, respectively. There was significant but low negative correlation between age and total Euthanasia Attitude Scale score, ethical considerations, and practical considerations. Male nurses exhibited significantly higher Euthanasia Attitude Scale scores, specifically in regard to ethical and practical considerations compared with female nurses. The most Iranian nurses in the intensive care unit had a negative attitude toward euthanasia for patients in the later stages of the disease. However, this opposition was less than similar studies in Iran in the past.
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18
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Chang Y, Kim KR, Huh JW, Hong SB, Koh Y, Lim CM. Outcomes of critically ill patients according to the perception of intensivists on the appropriateness of intensive care unit admission. Acute Crit Care 2021; 36:351-360. [PMID: 34634843 PMCID: PMC8907467 DOI: 10.4266/acc.2021.00283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/29/2021] [Indexed: 11/30/2022] Open
Abstract
Background It is important for intensivists to determine which patient may benefit from intensive care unit (ICU) admission. We aimed to assess the outcomes of patients perceived as non-beneficially or beneficially admitted to the ICU and evaluate whether their prognosis was consistent with the intensivists’ perception. Methods A prospective observational study was conducted on patients admitted to the medical ICU of a tertiary referral center between February and April 2014. The perceptions of four intensivists at admission (day 1) and on day 3 were investigated as non-beneficial admission, beneficial admission, or indeterminate state. Results A total of 210 patients were enrolled. On days 1 and 3, 22 (10%) and 23 (11%) patients were judged as having non-beneficial admission; 166 (79%) and 159 (79%), beneficial admission; and 22 (10%) and 21 (10%), indeterminate state, respectively. The ICU mortality rates of each group on day 1 were 59%, 23%, and 59%, respectively; their 6-month mortality rates were 100%, 48%, and 82%, respectively. The perceptions of non-beneficial admission or indeterminate state were the significant predictors of ICU mortality (day 3; odds ratio [OR], 4.049; 95% confidence interval [CI], 1.892–8.664; P<0.001) and 6-month mortality (day 1: OR, 4.983; 95% CI, 1.260–19.703; P=0.022; day 3: OR, 4.459; 95% CI, 1.162–17.121; P=0.029). Conclusions The outcomes of patients perceived as having non-beneficial admission were extremely poor. The intensivists’ perception was important in predicting patients’ outcomes and was more consistent with long-term prognosis than with immediate outcomes. The intensivists’ role can be reflected in limited ICU resource utilization.
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Affiliation(s)
- Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University College of Medicine, Sanggye Paik Hospital, Seoul, Korea
| | - Kyoung Ran Kim
- Medical Intensive Care Unit, Asan Medical Center, Seoul, Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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19
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Considering Futility of Care Decisions in Neurosurgical Practice. World Neurosurg 2021; 156:120-124. [PMID: 34563717 DOI: 10.1016/j.wneu.2021.09.078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/25/2022]
Abstract
Neurosurgeons commonly encounter futility of care decisions in their practice. Are these decisions being made with adequate consideration? What is the preparation of neurosurgical trainees for making these decisions? The advent of the COVID-19 pandemic with its extreme pressure on resources and, in particular, intensive care unit beds, has prompted many health care providers including neurosurgeons to consider more fully the potentially futile nature of some treatments and how we might better manage limited resources for the future. We review the concept of futility in neurosurgery and suggest potential solutions to the multiple challenges that arise.
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20
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Schouela N, Kyeremanteng K, Thompson LH, Neilipovitz D, Shamy M, D'Egidio G. Cost of Futile ICU Care in One Ontario Hospital. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2021; 58:469580211028577. [PMID: 34218711 PMCID: PMC8261843 DOI: 10.1177/00469580211028577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Critical care is a costly and finite resource that provides the ability to manage
patients with life-threatening illnesses in the most advanced forms available.
However, not every condition benefits from critical care. There are
unrecoverable health states in which it should not be used to perpetuate. Such
situations are considered futile. The determination of medical futility remains
controversial. In this study we describe the length of stay (LOS), cost, and
long-term outcomes of 12 cases considered futile and that have been or were
considered for adjudication by Ontario’s Consent and Capacity Board (CBB). A
chart review was undertaken to identify patients admitted to the Intensive Care
Unit (ICU), whose care was deemed futile and cases were considered for, or
brought before the CCB. Costs for each of these admissions were determined using
the case-costing system of The Ottawa Hospital Data Warehouse. All 12 patients
identified had a LOS of greater than 4 months (range: 122-704 days) and a median
age 83.5 years. Seven patients died in hospital, while 5 were transferred to
long term or acute care facilities. All patients ultimately died without
returning to independent living situations. The total cost of care for these 12
patients was $7 897 557.85 (mean: $658 129.82). There is a significant economic
cost of providing resource-intensive critical care to patients in which these
treatments are considered futile. Clinicians should carefully consider the
allocation of finite critical care resources in order to utilize them in a way
that most benefits patients.
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Affiliation(s)
| | | | | | | | - Michel Shamy
- University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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21
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Carter HE, Lee XJ, Farrington A, Shield C, Graves N, Cyarto EV, Parkinson L, Oprescu FI, Meyer C, Rowland J, Dwyer T, Harvey G. A stepped-wedge randomised controlled trial assessing the implementation, effectiveness and cost-consequences of the EDDIE+ hospital avoidance program in 12 residential aged care homes: study protocol. BMC Geriatr 2021; 21:347. [PMID: 34090368 PMCID: PMC8179705 DOI: 10.1186/s12877-021-02294-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/20/2021] [Indexed: 12/05/2022] Open
Abstract
Background Older people living in residential aged care homes experience frequent emergency transfers to hospital. These events are associated with risks of hospital acquired complications and invasive treatments or interventions. Evidence suggests that some hospital transfers may be unnecessary or avoidable. The Early Detection of Deterioration in Elderly residents (EDDIE) program is a multi-component intervention aimed at reducing unnecessary hospital admissions from residential aged care homes by empowering nursing and care staff to detect and manage early signs of resident deterioration. This study aims to implement and evaluate the program in a multi-site randomised study in Queensland, Australia. Methods A stepped-wedge randomised controlled trial will be conducted at 12 residential aged care homes over 58 weeks. The program has four components: education and training, decision support tools, diagnostic equipment, and implementation facilitation with clinical systems support. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to guide the program implementation and process evaluation. The primary outcome measure will be the number of hospital bed days used by residents, with secondary outcomes assessing emergency department transfer rates, admission rates, length of stay, family awareness and experience, staff self-efficacy and costs of both implementation and health service use. A process evaluation will assess the extent and fidelity of program implementation, mechanisms of impact and the contextual barriers and enablers. Discussion The intervention is expected to improve outcomes by reducing unnecessary hospital transfers. Fewer hospital transfers and admissions will release resources for other patients with potentially greater needs. Residential aged care home staff might benefit from feelings of empowerment in their ability to proactively manage early signs of resident deterioration. The process evaluation will be useful for supporting wider implementation of this intervention and other similar initiatives. Trial registration The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02294-8.
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Affiliation(s)
- Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia.
| | - Xing J Lee
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia
| | - Alison Farrington
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia
| | - Carla Shield
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia.,Duke-NUS Postgraduate Medical School, National University of Singapore, 8 College Rd, Singapore, 169857, Singapore
| | - Elizabeth V Cyarto
- Bolton Clarke Research Institute, 347 Burwood Hwy, Forest Hill, Victoria, 3131, Australia.,Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, 4072, Australia.,Department of Psychiatry, University of Melbourne, Parkville, VIC, 3010, Australia
| | - Lynne Parkinson
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW, 2308, Australia
| | - Florin I Oprescu
- School of Health and Behavioural Sciences, University of the Sunshine Coast, Sippy Downs, QLD, 4556, Australia
| | - Claudia Meyer
- Bolton Clarke Research Institute, 347 Burwood Hwy, Forest Hill, Victoria, 3131, Australia.,Rehabilitation, Ageing and Independent Living Research Centre, Monash University, Frankston, Victoria, 3199, Australia.,Centre for Health Communication and Participation, La Trobe University, Bundoora, Victoria, 3083, Australia
| | - Jeffrey Rowland
- Faculty of Medicine, University of Queensland, 20 Weightman St, Herston, QLD, 4006, Australia.,Faculty of Health, School of Nursing, Kelvin Grove Campus, Queensland University of Technology, Brisbane, Australia.,Metro North Health, Royal Brisbane and Women's Hospital, 7 Butterfield St, Herston, QLD, 4029, Australia
| | - Trudy Dwyer
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Rockhampton, QLD, 4702, Australia
| | - Gillian Harvey
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia.,College of Nursing and Health Sciences, Flinders University, Bedford Park, Australia, 5042
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Alazmani-Noodeh F, Abdi K, Ranjbar H. The moderating effect of spiritual beliefs on job dissatisfaction related to the futile care. BMC Nurs 2021; 20:64. [PMID: 33882900 PMCID: PMC8058750 DOI: 10.1186/s12912-021-00582-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/12/2021] [Indexed: 02/03/2023] Open
Abstract
Introduction This study aimed to assess the experience of providing futile care among intensive care unit nurses and to examine the moderating effect of spiritual beliefs on job dissatisfaction related to the sense of futile care among nurses in Intensive Care Units. Materials and methods The study had two phases. The first phase was a qualitative study. Twenty-two semi-structured interviews were conducted. In the second phase, we employed a cross-sectional design. The data from 236 nurses were collected using nurses’ perceptions of futile care questionnaire, Minnesota Satisfaction Questionnaire, and Spirituality and Spiritual Care Rating Scale. Results The main theme of the qualitative phase was a feeling of self as a useful tool in God’s hand. Sub-themes were providing care while knowing it is futile, not knowing the patient destiny, having hope for care to be fruitful, experiences patient recovery, acting to be a part of God’s plan. Futile care and job experience were two predictors of low job satisfaction. Spiritual well-being had a moderating effect and increased job satisfaction. Conclusions Futile care can decrease job satisfaction, while spiritual well-being can reduce its negative effect. Supporting spiritual aspects of nursing care can decrease turn-over intention among nurses.
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Affiliation(s)
| | - Kamel Abdi
- Nursing Department, Faculty of Medicine, Komar University of Science and Technology, Sulaymaniyah, Kurdistan Region, Iraq
| | - Hadi Ranjbar
- Institute for Futures Studies In Health, Kerman University of Medical Sciences, Kerman, Iran.
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23
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Affiliation(s)
- David L S Ryon
- Department of Medicine, Deaconess Health System, Evansville, IN
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24
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Caparica R, Amorim L, Amaral P, Uratani L, Muniz D, Hendlisz A, de Azambuja E, Glasberg J, Takahashi TK, Filho EA, Canellas R, Saragiotto D, Sabbaga J, Mak M. Malignant bowel obstruction: effectiveness and safety of systemic chemotherapy. BMJ Support Palliat Care 2020:bmjspcare-2020-002656. [PMID: 33334819 DOI: 10.1136/bmjspcare-2020-002656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/24/2020] [Accepted: 11/26/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Although systemic chemotherapy is often administered to patients with malignant bowel obstruction (MBO), its benefit remains unknown. This study assessed the outcomes of patients who received systemic chemotherapy as part of MBO treatment. METHODS For this retrospective cohort study, data were extracted from records of patients hospitalised due to MBO in a tertiary cancer centre from 2008 to 2020. Eligible patients were not candidates for surgery and received systemic chemotherapy targeting the underlying malignancy causing MBO. Primary objective was to assess patient outcomes after chemotherapy; secondary objectives were rates of intestinal function recovery, hospital discharge and grade ≥3 toxicities. The primary endpoint was overall survival (OS). RESULTS A total of 167 patients were included: median age was 55 (18-81) years, 91% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2, 75.5% had gastrointestinal tumours and 70% were treatment-naive. The median OS after chemotherapy was 4.4 weeks (95% CI 3.4 to 5.5) in the overall population. No OS difference was observed according to treatment line (p=0.24) or primary tumour (p=0.13). Intestinal function recovery occurred in 87 patients (52%), out of whom 21 (24.1%) had a reobstruction. Hospital discharge was possible in 74 patients (44.3%). Grade≥3 adverse events occurred in 26.9% of the patients, and a total of 12 deaths (7%) attributed to toxicities were observed after chemotherapy. CONCLUSIONS MBO was associated with a dismal prognosis in this mostly treatment-naive population. The administration of chemotherapy yielded a significant risk of toxicities, whereas it did not appear to provide any relevant survival benefit in this scenario.
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Affiliation(s)
- Rafael Caparica
- Department of Medical Oncology, Institut Jules Bordet, Brussels, Belgium
| | - Larissa Amorim
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Paulo Amaral
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Lucas Uratani
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - David Muniz
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alain Hendlisz
- Department of Medical Oncology, Institut Jules Bordet, Brussels, Belgium
| | | | - João Glasberg
- Department of Medical Oncology, Hospital Sao Luiz Anália Franco, Oncologia D'or, Sao Paulo, Brazil
| | | | - Elias Abdo Filho
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Canellas
- Department of Radiology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Daniel Saragiotto
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Jorge Sabbaga
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Milena Mak
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
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25
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Bouttell J, Gonzalez N, Geue C, Lightbody CJ, Taylor DR. Cost impact of introducing a treatment escalation/limitation plan during patients' last hospital admission before death. Int J Qual Health Care 2020; 32:694-700. [PMID: 33210722 DOI: 10.1093/intqhc/mzaa132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/31/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE A recent study found that the use of a treatment escalation/limitation plan (TELP) was associated with a significant reduction in non-beneficial interventions (NBIs) and harms in patients admitted acutely who subsequently died. We quantify the economic benefit of the use of a TELP. DESIGN NBIs were micro-costed. Mean costs for patients with a TELP were compared to patients without a TELP using generalized linear model regression, and results were extrapolated to the Scottish population. SETTING Medical, surgical and intensive care units of district general hospital in Scotland, UK. PARTICIPANTS Two hundred and eighty-seven consecutive patients who died over 3 months in 2017. Of these, death was 'expected' in 245 (85.4%) using Gold Standards Framework criteria. INTERVENTION Treatment escalation/limitation plan. MAIN OUTCOME MEASURE Between-group difference in estimated mean cost of NBIs. RESULTS The group with a TELP (n = 152) had a mean reduction in hospital costs due to NBIs of GB £220.29 (US $;281.97) compared to those without a TELP (n = 132) (95% confidence intervals GB £323.31 (US $413.84) to GB £117.27 (US $150.11), P = <0.001). Assuming that a TELP could be put in place for all expected deaths in Scottish hospitals, the potential annual saving would be GB £2.4 million (US $3.1 million) from having a TELP in place for all 'expected' deaths in hospital. CONCLUSIONS The use of a TELP in an acute hospital setting may result in a reduction in costs attributable to NBIs.
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Affiliation(s)
- Janet Bouttell
- University of Glasgow, Institute of Health and Wellbeing, Health Economics and Health Technology Assessment, Glasgow, Scotland, UK
| | - Nelson Gonzalez
- Western University Canada and London Health Sciences Center London, Ontario, Canada UK
| | - Claudia Geue
- University of Glasgow, Institute of Health and Wellbeing, Health Economics and Health Technology Assessment, Glasgow, Scotland, UK
| | - Calvin J Lightbody
- University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, Scotland, UK
| | - Douglas Robin Taylor
- University Hospital Wishaw, NHS Lanarkshire, Wishaw, Scotland, UK.,Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, UK
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26
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Hensher M, Canny B, Zimitat C, Campbell J, Palmer A. Health care, overconsumption and uneconomic growth: A conceptual framework. Soc Sci Med 2020; 266:113420. [PMID: 33068872 DOI: 10.1016/j.socscimed.2020.113420] [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] [Revised: 09/28/2020] [Accepted: 10/02/2020] [Indexed: 12/13/2022]
Abstract
Concerns have grown in recent decades that economic growth in many rich countries may, in fact, be uneconomic. Uneconomic growth occurs when expansion in economic activity causes environmental and social costs that are greater than the benefits of that additional activity. Health care has enjoyed a close historical relationship with economic growth, with health care spending consistently growing faster than GDP over the long term. This paper explores the possible relationship between health care and uneconomic growth. It summarises the rapidly growing evidence on the harms caused by poor quality health care and by the overuse of health care, and on the environmental harms caused by health care systems. Further, it develops a conceptual framework for considering the overconsumption of health care and the joint harms to human health and the natural environment that ensue. This framework illustrates how health-damaging overconsumption in the wider economy combines with unnecessary or low-quality health care to create a cycle of "failure demand" and defensive expenditure on health care services. Health care therefore provides important sectoral insights on the phenomenon of uneconomic growth. There are rich opportunities for interdisciplinary research to quantify the joint harms of overconsumption in health and health care, and to estimate the optimal scale of the health sector from novel perspectives that prioritise human and planetary health and well-being over GDP and profit.
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Affiliation(s)
- Martin Hensher
- Deakin Health Economics, Deakin University, BC3, 221 Burwood Highway, Burwood, VIC, 3125, Australia; Menzies Institute for Medical Research, University of Tasmania, Medical Science 1, 17 Liverpool Street, Hobart, TAS, 7000, Australia.
| | - Ben Canny
- School of Medicine, University of Tasmania, Medical Science 1, 17 Liverpool Street, Hobart, TAS, 7000, Australia.
| | - Craig Zimitat
- Curtin Learning and Teaching, Curtin University, T.L. Robertson Library, GPO Box U1987, Perth, WA, 6845, Australia.
| | - Julie Campbell
- Menzies Institute for Medical Research, University of Tasmania, Medical Science 1, 17 Liverpool Street, Hobart, TAS, 7000, Australia.
| | - Andrew Palmer
- Menzies Institute for Medical Research, University of Tasmania, Medical Science 1, 17 Liverpool Street, Hobart, TAS, 7000, Australia.
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27
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Abstract
INTRODUCTION Studies have suggested 5-20% of paediatric ICU patients may receive care felt to be futile. No data exists on the prevalence and impact of futile care in the Paediatric Cardiac ICU. The aim is to determine the prevalence and economic impact of futile care. MATERIALS AND METHOD Retrospective cohort of patients with congenital cardiac disease 0-21 years old, with length of stay >30 days and died (2015-2018). Documentation of futility by the medical team was retrospectively and independently reviewed. RESULTS Of the 127 deaths during the study period, 51 (40%) had hospitalisation >30 days, 13 (25%) had received futile care and 26 (51%) withdrew life-sustaining treatment. Futile care comprised 0.69% of total patient days with no difference in charges from patients not receiving futile care. There was no difference in insurance, single motherhood, education, income, poverty, or unemployment in families continuing futile care or electing withdrawal of life-sustaining treatment. Black families were less likely than White families to elect for withdrawal (p = 0.01), and Hispanic families were more likely to continue futile care than non-Hispanics (p = 0.044). CONCLUSIONS This is the first study to examine the impact of futile care and characteristics in the paediatric cardiac ICU. Black families were less likely to elect for withdrawal, while Hispanic families more likely to continue futile care. Futile care comprised 0.69% of bed days and little burden on resources. Cultural factors should be investigated to better support families through end-of-life decisions.
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Close E, White BP, Willmott L. Balancing Patient and Societal Interests in Decisions About Potentially Life-Sustaining Treatment : An Australian Policy Analysis. JOURNAL OF BIOETHICAL INQUIRY 2020; 17:407-421. [PMID: 32964352 DOI: 10.1007/s11673-020-09994-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 07/15/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND This paper investigates the content of Australian policies that address withholding or withdrawing life-sustaining treatment to analyse the guidance they provide to doctors about the allocation of resources. METHODS All publicly available non-institutional policies on withholding and withdrawing life-sustaining treatment were identified, including codes of conduct and government and professional organization guidelines. The policies that referred to resource allocation were isolated and analysed using qualitative thematic analysis. Eight Australian policies addressed both withholding and withdrawing life-sustaining treatment and resource allocation. RESULTS Four resource-related themes were identified: (1) doctors' ethical duties to consider resource allocation; (2) balancing ethical obligations to patient and society; (3) fair process and transparent resource allocation; and (4) legal guidance on distributive justice as a rationale to limit life-sustaining treatment. CONCLUSION Of the policies that addressed resource allocation, this review found broad agreement about the existence of doctors' duties to consider the stewardship of scarce resources in decision-making. However, there was disparity in the guidance about how to reconcile competing duties to patient and society. There is a need to better address the difficult and confronting issue of the role of scarce resources in decisions about life-sustaining treatment.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia.
| | - Ben P White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia
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29
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Lee XJ, Farrington A, Carter H, Shield C, Graves N, McPhail SM, Harvey G, White BP, Willmott L, Cardona M, Hillman K, Callaway L, Barnett AG. A stepped-wedge randomised-controlled trial assessing the implementation, impact and costs of a prospective feedback loop to promote appropriate care and treatment for older patients in acute hospitals at the end of life: study protocol. BMC Geriatr 2020; 20:262. [PMID: 32727393 PMCID: PMC7392836 DOI: 10.1186/s12877-020-01660-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hospitalisation rates for the older population have been increasing with end-of-life care becoming a more medicalised and costly experience. There is evidence that some of these patients received non-beneficial treatment during their final hospitalisation with a third of the non-beneficial treatment duration spent in intensive care units. This study aims to increase appropriate care and treatment decisions and pathways for older patients at the end of life in Australia. This study will implement and evaluate a prospective feedback loop and tailored clinical response intervention at three hospitals in Queensland, Australia. METHODS A stepped-wedge cluster randomised trial will be conducted with up to 21 clinical teams in three acute hospitals over 70 weeks. The study involves clinical teams providing care to patients aged 75 years or older, who are prospectively identified to be at risk of non-beneficial treatment using two validated tools for detecting death and deterioration risks. The intervention's feedback loop will provide the teams with a summary of these patients' risk profiles as a stimulus for a tailored clinical response in the intervention phase. The Consolidated Framework for Implementation Research will be used to inform the intervention's implementation and process evaluation. The study will determine the impact of the intervention on patient outcomes related to appropriate care and treatment at the end of life in hospitals, as well as the associated healthcare resource use and costs. The primary outcome is the proportion of patients who are admitted to intensive care units. A process evaluation will be carried out to assess the implementation, mechanisms of impact, and contextual barriers and enablers of the intervention. DISCUSSION This intervention is expected to have a positive impact on the care of older patients near the end of life, specifically to improve clinical decision-making about treatment pathways and what constitutes appropriate care for these patients. These will reduce the incidence of non-beneficial treatment, and improve the efficiency of hospital resources and quality of care. The process evaluation results will be useful to inform subsequent intervention implementation at other hospitals. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 6 May 2019).
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Affiliation(s)
- Xing J Lee
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia. .,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.
| | - Alison Farrington
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Hannah Carter
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Carla Shield
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Nicholas Graves
- Duke-NUS Postgraduate Medical School, National University of Singapore, Singapore, Singapore
| | - Steven M McPhail
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Gillian Harvey
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Adelaide Nursing School, University of Adelaide, Adelaide, South Australia, Australia
| | - Ben P White
- Australia Centre for Heath Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australia Centre for Heath Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Magnolia Cardona
- Gold Coast University Hospital, Southport, Queensland, Australia.,Institute for Evidence-Based Health Care, Bond University, Robina, Queensland, Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| | - Leonie Callaway
- Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Faculty of Medicine, University of Queensland, Herston, Queensland, Australia.,Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Adrian G Barnett
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
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30
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Damluji AA, Forman DE, van Diepen S, Alexander KP, Page RL, Hummel SL, Menon V, Katz JN, Albert NM, Afilalo J, Cohen MG. Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e6-e32. [DOI: 10.1161/cir.0000000000000741] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.
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31
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Jones RP. A pragmatic method to compare hospital bed provision between countries and regions: Beds in the States of Australia. Int J Health Plann Manage 2019; 35:746-759. [PMID: 31803962 DOI: 10.1002/hpm.2950] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/18/2019] [Indexed: 11/07/2022] Open
Abstract
A simple method is presented to evaluate bed numbers between countries using a logarithmic relationship between beds per 1000 deaths and deaths per 1000 population, both of which are readily available. The method relies on the importance of the nearness to death effect. This method was tested using data from Australian States. Beds per 1000 deaths varied considerably between States. This variation reduced after adjusting for the ratio of deaths per 1000 population which is a measure of population age structure. After this adjustment, most Australian States roughly approximate to the international average for developed countries while Tasmania was shown to have a chronic bed shortage, as has been recognized for many years. The Northern Territory and the Australian Capital Territory, both of which have the youngest populations, have more beds relative to the other States. The nearness to death effect must be incorporated into capacity planning models in order to give robust estimates of future bed demand and to evaluate differences between countries and health care systems.
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Affiliation(s)
- Rodney P Jones
- Population Health Analytics Department, Healthcare Analysis & Forecasting, Leominster, UK
- Health and Life Sciences, Coventry University, Coventry, UK
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32
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Carter HE, Lee XJ, Gallois C, Winch S, Callaway L, Willmott L, White B, Parker M, Close E, Graves N. Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia. BMJ Open 2019; 9:e030955. [PMID: 31690607 PMCID: PMC6858125 DOI: 10.1136/bmjopen-2019-030955] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 10/02/2019] [Accepted: 10/04/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To quantitatively assess the factors associated with non-beneficial treatments (NBTs) in hospital admissions at the end of life. DESIGN Retrospective multicentre cohort study. SETTING Three large, metropolitan tertiary hospitals in Australia. PARTICIPANTS 831 adult patients who died as inpatients following admission to the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES Odds ratios (ORs) of NBT derived from logistic regression models. RESULTS Overall, 103 (12.4%) admissions involved NBTs. Admissions that involved conflict within a patient's family (OR 8.9, 95% CI 4.1 to 18.9) or conflict within the medical team (OR 6.5, 95% CI 2.4 to 17.8) had the strongest associations with NBTs in the all subsets regression model. A positive association was observed in older patients, with each 10-year increment in age increasing the likelihood of NBT by approximately 50% (OR 1.5, 95% CI 1.2 to 1.9). There was also a statistically significant hospital effect. CONCLUSIONS This paper presents the first statistical modelling results to assess the factors associated with NBT in hospital, beyond an intensive care setting. Our findings highlight potential areas for intervention to reduce the likelihood of NBTs.
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Affiliation(s)
- Hannah Elizabeth Carter
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Xing Ju Lee
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cindy Gallois
- School of Psychology, Faculty of Health and Behavioural Sciences, The University of Queensland, St Lucia, Queensland, Australia
| | - Sarah Winch
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Leonie Callaway
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane and Womens Hospital, Herston, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Malcolm Parker
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Eliana Close
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Duke-NUS Medical School, Singapore, Singapore
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33
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Gruneir A, Fung K, Fischer HD, Bronskill SE, Panjwani D, Bell CM, Dhalla I, Rochon PA, Anderson G. Care setting and 30-day hospital readmissions among older adults: a population-based cohort study. CMAJ 2019; 190:E1124-E1133. [PMID: 30249758 DOI: 10.1503/cmaj.180290] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite the fact that many older adults receive home or long-term care services, the effect of these care settings on hospital readmission is often overlooked. Efforts to reduce hospital readmissions, including capacity planning and targeting of interventions, require clear data on the frequency of and risk factors for readmission among different populations of older adults. METHODS We identified all adults older than 65 years discharged from an unplanned medical hospital stay in Ontario between April 2008 and December 2015. We defined 2 preadmission care settings (community, long-term care) and 3 discharge care settings (community, home care, long-term care) and used multinomial regression to estimate associations with 30-day readmission (and death as a competing risk). RESULTS We identified 701 527 individuals (mean age 78.4 yr), of whom 414 302 (59.1%) started in and returned to the community. Overall, 88 305 in dividuals (12.6%) were re admitted within 30 days, but this proportion varied by care setting combination. Relative to individuals returning to the community, those discharged to the community with home care (adjusted odds ratio [OR] 1.43, 95% confidence interval [CI] 1.39-1.46) and those returning to long-term care (adjusted OR 1.35, 95% CI 1.27-1.43) had a greater risk of readmission, whereas those newly admitted to long-term care had a lower risk of readmission (adjusted OR 0.68, 95% CI 0.63-0.72). INTERPRETATION In Ontario, about 40% of older people were discharged from hospital to either home care or long-term care. These discharge settings, as well as whether an individual was admitted to hospital from long-term care, have important implications for understanding 30-day readmission rates. System planning and efforts to reduce readmission among older adults should take into account care settings at both admission and discharge.
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Affiliation(s)
- Andrea Gruneir
- Department of Family Medicine (Gruneir), University of Alberta, Edmonton, Alta.; ICES (Gruneir, Fung, Fischer, Bronskill, Bell, Rochon, Anderson); Women's College Research Institute (Gruneir, Bronskill, Panjwani, Rochon), Women's College Hospital; Institute of Health Policy, Management and Evaluation (Bronskill, Bell, Dhalla, Rochon, Anderson) and Department of Medicine (Dhalla), University of Toronto; Department of Medicine (Bell, Dhalla), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Health Quality Ontario (Dhalla), Toronto, Ont.
| | - Kinwah Fung
- Department of Family Medicine (Gruneir), University of Alberta, Edmonton, Alta.; ICES (Gruneir, Fung, Fischer, Bronskill, Bell, Rochon, Anderson); Women's College Research Institute (Gruneir, Bronskill, Panjwani, Rochon), Women's College Hospital; Institute of Health Policy, Management and Evaluation (Bronskill, Bell, Dhalla, Rochon, Anderson) and Department of Medicine (Dhalla), University of Toronto; Department of Medicine (Bell, Dhalla), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Health Quality Ontario (Dhalla), Toronto, Ont
| | - Hadas D Fischer
- Department of Family Medicine (Gruneir), University of Alberta, Edmonton, Alta.; ICES (Gruneir, Fung, Fischer, Bronskill, Bell, Rochon, Anderson); Women's College Research Institute (Gruneir, Bronskill, Panjwani, Rochon), Women's College Hospital; Institute of Health Policy, Management and Evaluation (Bronskill, Bell, Dhalla, Rochon, Anderson) and Department of Medicine (Dhalla), University of Toronto; Department of Medicine (Bell, Dhalla), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Health Quality Ontario (Dhalla), Toronto, Ont
| | - Susan E Bronskill
- Department of Family Medicine (Gruneir), University of Alberta, Edmonton, Alta.; ICES (Gruneir, Fung, Fischer, Bronskill, Bell, Rochon, Anderson); Women's College Research Institute (Gruneir, Bronskill, Panjwani, Rochon), Women's College Hospital; Institute of Health Policy, Management and Evaluation (Bronskill, Bell, Dhalla, Rochon, Anderson) and Department of Medicine (Dhalla), University of Toronto; Department of Medicine (Bell, Dhalla), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Health Quality Ontario (Dhalla), Toronto, Ont
| | - Dilzayn Panjwani
- Department of Family Medicine (Gruneir), University of Alberta, Edmonton, Alta.; ICES (Gruneir, Fung, Fischer, Bronskill, Bell, Rochon, Anderson); Women's College Research Institute (Gruneir, Bronskill, Panjwani, Rochon), Women's College Hospital; Institute of Health Policy, Management and Evaluation (Bronskill, Bell, Dhalla, Rochon, Anderson) and Department of Medicine (Dhalla), University of Toronto; Department of Medicine (Bell, Dhalla), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Health Quality Ontario (Dhalla), Toronto, Ont
| | - Chaim M Bell
- Department of Family Medicine (Gruneir), University of Alberta, Edmonton, Alta.; ICES (Gruneir, Fung, Fischer, Bronskill, Bell, Rochon, Anderson); Women's College Research Institute (Gruneir, Bronskill, Panjwani, Rochon), Women's College Hospital; Institute of Health Policy, Management and Evaluation (Bronskill, Bell, Dhalla, Rochon, Anderson) and Department of Medicine (Dhalla), University of Toronto; Department of Medicine (Bell, Dhalla), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Health Quality Ontario (Dhalla), Toronto, Ont
| | - Irfan Dhalla
- Department of Family Medicine (Gruneir), University of Alberta, Edmonton, Alta.; ICES (Gruneir, Fung, Fischer, Bronskill, Bell, Rochon, Anderson); Women's College Research Institute (Gruneir, Bronskill, Panjwani, Rochon), Women's College Hospital; Institute of Health Policy, Management and Evaluation (Bronskill, Bell, Dhalla, Rochon, Anderson) and Department of Medicine (Dhalla), University of Toronto; Department of Medicine (Bell, Dhalla), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Health Quality Ontario (Dhalla), Toronto, Ont
| | - Paula A Rochon
- Department of Family Medicine (Gruneir), University of Alberta, Edmonton, Alta.; ICES (Gruneir, Fung, Fischer, Bronskill, Bell, Rochon, Anderson); Women's College Research Institute (Gruneir, Bronskill, Panjwani, Rochon), Women's College Hospital; Institute of Health Policy, Management and Evaluation (Bronskill, Bell, Dhalla, Rochon, Anderson) and Department of Medicine (Dhalla), University of Toronto; Department of Medicine (Bell, Dhalla), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Health Quality Ontario (Dhalla), Toronto, Ont
| | - Geoff Anderson
- Department of Family Medicine (Gruneir), University of Alberta, Edmonton, Alta.; ICES (Gruneir, Fung, Fischer, Bronskill, Bell, Rochon, Anderson); Women's College Research Institute (Gruneir, Bronskill, Panjwani, Rochon), Women's College Hospital; Institute of Health Policy, Management and Evaluation (Bronskill, Bell, Dhalla, Rochon, Anderson) and Department of Medicine (Dhalla), University of Toronto; Department of Medicine (Bell, Dhalla), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Health Quality Ontario (Dhalla), Toronto, Ont
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McCaughey EJ, Jonkman AH, Boswell-Ruys CL, McBain RA, Bye EA, Hudson AL, Collins DW, Heunks LMA, McLachlan AJ, Gandevia SC, Butler JE. Abdominal functional electrical stimulation to assist ventilator weaning in critical illness: a double-blinded, randomised, sham-controlled pilot study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:261. [PMID: 31340846 PMCID: PMC6657036 DOI: 10.1186/s13054-019-2544-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 07/16/2019] [Indexed: 01/15/2023]
Abstract
Background For every day a person is dependent on mechanical ventilation, respiratory and cardiac complications increase, quality of life decreases and costs increase by > $USD 1500. Interventions that improve respiratory muscle function during mechanical ventilation can reduce ventilation duration. The aim of this pilot study was to assess the feasibility of employing an abdominal functional electrical stimulation (abdominal FES) training program with critically ill mechanically ventilated patients. We also investigated the effect of abdominal FES on respiratory muscle atrophy, mechanical ventilation duration and intensive care unit (ICU) length of stay. Methods Twenty critically ill mechanically ventilated participants were recruited over a 6-month period from one metropolitan teaching hospital. They were randomly assigned to receive active or sham (control) abdominal FES for 30 min, twice per day, 5 days per week, until ICU discharge. Feasibility was assessed through participant compliance to stimulation sessions. Abdominal and diaphragm muscle thickness were measured using ultrasound 3 times in the first week, and weekly thereafter by a blinded assessor. Respiratory function was recorded when the participant could first breathe independently and at ICU discharge, with ventilation duration and ICU length of stay also recorded at ICU discharge by a blinded assessor. Results Fourteen of 20 participants survived to ICU discharge (8, intervention; 6, control). One control was transferred before extubation, while one withdrew consent and one was withdrawn for staff safety after extubation. Median compliance to stimulation sessions was 92.1% (IQR 5.77%) in the intervention group, and 97.2% (IQR 7.40%) in the control group (p = 0.384). While this pilot study is not adequately powered to make an accurate statistical conclusion, there appeared to be no between-group thickness changes of the rectus abdominis (p = 0.099 at day 3), diaphragm (p = 0.652 at day 3) or combined lateral abdominal muscles (p = 0.074 at day 3). However, ICU length of stay (p = 0.011) and ventilation duration (p = 0.039) appeared to be shorter in the intervention compared to the control group. Conclusions Our compliance rates demonstrate the feasibility of using abdominal FES with critically ill mechanically ventilated patients. While abdominal FES did not lead to differences in abdominal muscle or diaphragm thickness, it may be an effective method to reduce ventilation duration and ICU length of stay in this patient group. A fully powered study into this effect is warranted. Trial registration The Australian New Zealand Clinical Trials Registry, ACTRN12617001180303. Registered 9 August 2017.
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Affiliation(s)
- Euan J McCaughey
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia. .,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia.
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands
| | - Claire L Boswell-Ruys
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia.,Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Rachel A McBain
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia.,Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Elizabeth A Bye
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia.,Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Anna L Hudson
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia
| | | | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands
| | - Angus J McLachlan
- Liberate Medical LLC, 6400 Westwind Way, Suite A, Crestwood, KY, 40014, USA
| | - Simon C Gandevia
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia.,Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Jane E Butler
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia
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35
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Scott IA. Audit‐based measures of overuse of medical care in Australian hospital practice. Intern Med J 2019; 49:893-904. [DOI: 10.1111/imj.14346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/07/2018] [Accepted: 12/07/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Ian A. Scott
- Department of Internal Medicine and Clinical EpidemiologyPrincess Alexandra Hospital Brisbane Queensland Australia
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Close E, White BP, Willmott L, Gallois C, Parker M, Graves N, Winch S. Doctors' perceptions of how resource limitations relate to futility in end-of-life decision making: a qualitative analysis. JOURNAL OF MEDICAL ETHICS 2019; 45:373-379. [PMID: 31092631 DOI: 10.1136/medethics-2018-105199] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/07/2019] [Accepted: 03/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility. SETTING Three tertiary hospitals in metropolitan Brisbane, Australia. DESIGN Qualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic analysis. RESULTS Doctors' perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing. CONCLUSIONS Doctors' ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors' role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cindy Gallois
- Faculty of Social and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Malcolm Parker
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sarah Winch
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Hickman S, Gangemi A. Going beyond "bad news": A surgical case report and systematic review of the literature surrounding futile care. Int J Surg Case Rep 2019; 59:35-40. [PMID: 31102838 PMCID: PMC6525284 DOI: 10.1016/j.ijscr.2019.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 11/06/2022] Open
Abstract
There is a paucity of literature surrounding futile care. There is no consensus definition of “futile care”. A conversation is needed to discuss training of surgeons to manage cases of futile care.
Introduction Surgeons frequently deliver “bad news” to patients, but do they know how to address situations where further surgery is considered futile? Is there a clear definition of futile care in the literature? This paper explores these questions and seeks to start a conversation about how we can train future surgeons to deliver news of futile care. Presentation of case This paper describes how one surgical team handled a difficult case of futile care and provides an interview from the perspective of a surgical resident. Discussion The case report gives one example of how the news of futile care was delivered and how appropriate steps were taken to provide continued management of the patient and support to the family. A systematic review of the literature surrounding futile care reveals no consensus on how to define futile care within the medical community. Conclusion There is a paucity of information surrounding how surgeons should manage cases of futile care. The literature focuses on the physician-patient relationship and includes methods for delivering bad news, yet it fails to identify a consensus definition of futile care and does not provide guidelines that future surgeons can follow when they encounter these cases. With this paper we seek to open a discussion about how to define futile care and how to teach future surgeons best practices when managing these cases.
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Affiliation(s)
- Scott Hickman
- University of Illinois College of Medicine, United States
| | - Antonio Gangemi
- University of Illinois Hospital and Health Sciences System, United States.
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Lightbody CJ, Campbell JN, Herbison GP, Osborne HK, Radley A, Taylor DR. Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method. BMJ Open 2018; 8:e024264. [PMID: 30385448 PMCID: PMC6252685 DOI: 10.1136/bmjopen-2018-024264] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/25/2018] [Accepted: 09/13/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital. DESIGN A retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as 'expected' or 'unexpected' using the Gold Standard Framework Prognostic Indicator Guidance. SETTING Medical, surgical and intensive care units of a district general hospital. OUTCOMES The primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical 'problems' identified using the Structured Judgement Review Method. RESULTS 289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were 'expected'. Among patients with 'expected' deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for 'problems', 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and 'problems' were significantly lower in the group with a TELP/DNACPR compared with 'DNACPR only' and 'neither': harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and 'problems': 42.3, 146.2 (p<0.01) and 333.3 (p<0.001). CONCLUSIONS The use of a TELP was associated with a significant reduction in harms, NBIs and 'problems' in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.
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Affiliation(s)
- Calvin J Lightbody
- Department of Emergency Medicine, University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, UK
| | - Jonathan N Campbell
- Department of Medicine,, University Hospital Wishaw, NHS Lanarkshire, Wishaw, UK
| | - G Peter Herbison
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Heather K Osborne
- Department of Emergency Medicine, University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, UK
| | - Alice Radley
- Department of Emergency Medicine, University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, UK
| | - D Robin Taylor
- Department of Medicine,, University Hospital Wishaw, NHS Lanarkshire, Wishaw, UK
- Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, UK
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39
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Scott IA. How much end-of-life care is of low value. Intern Med J 2018; 48:1173-1174. [DOI: 10.1111/imj.14054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 07/18/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Ian A. Scott
- Department of Internal Medicine and Clinical Epidemiology; Princess Alexandra Hospital; Brisbane Queensland Australia
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40
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Taylor DR, Lightbody CJ. Futility and appropriateness: challenging words, important concepts. Postgrad Med J 2018; 94:238-243. [PMID: 29477988 DOI: 10.1136/postgradmedj-2018-135581] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 01/27/2018] [Indexed: 11/04/2022]
Abstract
The provision of healthcare is being challenged by a 'perfect storm' of forces including an increasing population with multiple comorbidities, high expectations and resource limitations, and in the background, the pre-eminence of the 'curative medical model'. Non-beneficial (futile) treatments are wasteful and costly. They have a negative impact on quality of life especially in the last year of life. Among professionals, frequent encounters with futility cause moral distress and demoralisation. The factors that drive non-beneficial treatments include personal biases, patient-related pressures and institutional imperatives. Breaking loose from the perceived necessity to deliver non-beneficial treatment is a major challenge. Curative intent should give way to appropriateness such that curative and palliative interventions are valued equally. Goals of treatment should be shaped by illness trajectory, the risk of harms as well as potential benefits and patient preferences. This strategy should be reflected in professional training and the design of acute services.
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Affiliation(s)
- D Robin Taylor
- Department of Respiratory Medicine, University Hospital Wishaw, Wishaw, UK.,Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Calvin J Lightbody
- Emergency Medicine Department, University Hospital Hairmyres, East Kilbride, UK
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