The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study

Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review

BACKGROUND

Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them.

AIM

The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies.

DESIGN

Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies.

METHODS

Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions.

RESULTS

Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity.

CONCLUSION

Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.

Prevalence of medication errors and its related factors in Iranian nurses: an updated systematic review and meta-analysis

BACKGROUND

Nurses may make medication errors during the implementation of therapeutic interventions, which initially threaten the patient's health and safety and prolong their hospital stay. These errors have always been a challenge for healthcare systems. Given that factors such as the timing, type, and causes of medication errors can serve as suitable predictors for their occurrence, we have decided to conduct a review study aiming to investigate the prevalence of medication errors and the associated factors among Iranian nurses.

METHODS

In this systematic review and meta-analysis, studies were searched on PubMed, Web of Science, Scopus, Google Scholar, IranMedex, Magiran, and SID databases using a combination of keywords and Boolean functions. The study that reported the prevalence of medication errors among nurses in Iran without time limitation up to May 2023 was included in this study.

RESULTS

A total of 36 studies were included in the analysis. The analysis indicates that 54% (95% CI: 43, 65; I2 = 99.3%) of Iranian nurses experienced medication errors. The most common types of medication errors by nurses were wrong timing 27.3% (95% CI: 19, 36; I2 = 95.8%), and wrong dosage 26.4% (95% CI: 20, 33; I2 = 91%). Additionally, the main causes of medication errors among nurses were workload 43%, fatigue 42.7%, and nursing shortage 38.8%. In this study, just 39% (95% CI: 27, 50; I2 = 97.1%) of nurses with medication errors did report their errors. Moreover, the prevalence of medication errors was more in the night shift at 41.1%. The results of the meta-regression showed that publication year and the female-to-male ratio are good predictors of medical errors, but they are not statistically significant(p > 0.05).

CONCLUSIONS

To reduce medication errors, nurses need to work in a calm environment that allows for proper nursing interventions and prevents overcrowding in departments. Additionally, considering the low reporting of medication errors to managers, support should be provided to nurses who report medication errors, in order to promote a culture of reporting these errors among Iranian nurses and ensure patient safety is not compromised.

End-of-Life Care Preferences of Patients with Advanced Urological Malignancies: An Explorative Survey Study at a Tertiary Referral Center

Background: Many people want to die at home, but it is often not possible because they do not share their wishes with family members. This study was conducted to find out the extent to which patients with advanced urological malignancies had wishes regarding their final stage of life, made arrangements accordingly, and communicated their wishes to relatives and health care professionals. Methods: We conducted a survey among advanced urological tumor patients during their clinic visit at a German university hospital using a 31-item questionnaire. Inclusion criteria were metastatic or irresectable prostate cancer, urothelial carcinoma, or renal cell carcinoma. Results: In total, 88 patients (76 male, 12 female) completed the questionnaire, and 62 of those respondents (70%) had received their tumor diagnosis within the past 5 years. Symptoms were reported by 80%, and 18% described five or more symptoms. The majority (88%) stated that they had thought about their preferred place of death but 58% had not informed anyone about it. The preference for a hospice as the place of death correlated statistically significantly with the absence of a domestic partnership (p = 0.001) or marriage (p < 0.001) and with a high number of symptoms (≥5; p = 0.009). However, 73% had not talked with their urological oncologist about care options in case their health deteriorated though 36% of those were interested in having a conversation about it. Conclusions: Our results showed that 9 out of 10 patients reflected on their preferred place of death but only a few discussed it with anyone. Based on this finding, physicians and healthcare staff should initiate discussions about early care planning so that patients in incurable situations can express their wishes regarding their preferred place of death.

Evaluation of a French adaptation of a community-based advance serious illness planning decision aid

Objective

The Plan Well Guide™ (PWG) is a decision aid that empowers lay persons to better understand different types of care and prepares them, and their substitute decision-makers, to express both their authentic values and informed treatment preferences in anticipation of serious illness. We aimed to determine the acceptability of the newly translated French PWG and to evaluate decisional readiness and decisional conflict following its use by lay people.

Methods

This is an acceptability and exploratory outcomes evaluation.Participants were requested to read and complete the French PWG and to engage in an online interview. We used the Acceptability Scale to determine the acceptability and the Preparation for Decision-making Scale and decisional conflict Scale to evaluate decisional readiness.

Results

Forty-two (42) people participated. The average score on the Acceptability Scale was 18.1 (scale range: 4-20 [high-better]) and 26.6 on the Preparation for Decision-Making Scale (scale range: 6-30 [high-better]). A significant number of respondents reported needing more support to help them make better decisions.

Conclusion

The French PWG has been deemed acceptable and relevant for lay people not currently facing clinical decisions.

Innovation

The Plan Well Guide is innovative as it is the first decision aid empowering lay people for advance serious illness planning.

End-of-life wishes and care planning for patients with advanced skin cancer

BACKGROUND

Patients with advanced or metastatic skin cancer have a limited life expectancy and the majority die as a result of the tumor despite modern treatment options. The preferences of these patients concerning care during their last phase of life are currently unknown.

PATIENTS AND METHODS

150 patients with advanced skin cancer (AJCC/UICC stage III or IV) were interviewed using a structured questionnaire.

RESULTS

75% of the respondents wished to die in their domestic environment, although a more advanced tumor stage and increased reflection upon end-of-life care lead away from this wish. However, only 42% reported having communicated this wish to someone else. 55% of the respondents had completed advance directives, while younger patients did this significantly less often (95% CI: 0.11-0.56; p  =  0.001). The majority of patients (62%) would like to have discussions about possibilities for end-of-life care with the attending dermato-oncologist.

CONCLUSIONS

Although the moment of death is unpredictable, early initiation of end-of-life advance care planning appears prudent. The attending dermato-oncologists should take the initiative to raise the subject with their patients during routine control visits. In this context, it may be useful to present available care options to patients and relatives and to design strategies for the event of deteriorating health.

Wünsche und Vorsorgeplanung für das Lebensende von Patienten mit fortgeschrittenem Hautkrebs: End of life wishes and care planning for patients with advanced skin cancer

Hintergrund

Patienten mit fortgeschrittenem oder metastasiertem Hautkrebs haben eine eingeschränkte Lebenserwartung und versterben zum größten Teil, trotz moderner Behandlungsmöglichkeiten, an dem Tumorleiden. Bislang ist unbekannt, welche Präferenzen für die Versorgung in der letzten Lebensphase bei diesen Patienten bestehen.

Patienten und Methodik

150 Patienten mit fortgeschrittenem Hautkrebs (AJCC/UICC Stadium III oder IV) wurden mit Hilfe eines strukturierten Fragebogens interviewt.

Ergebnisse

75% der Befragten wünschen sich im häuslichen Umfeld zu versterben, wobei ein höheres Tumorstadium und ein vermehrtes Nachdenken über die Versorgung am Lebensende davon wegführen. Nur 42% haben diesen Wunsch jedoch jemandem mitgeteilt. Vorsorgedokumente haben 55% der Teilnehmer ausgefüllt, während jüngere Patienten dies signifikant seltener tun (95%‐KI: 0,11–0,56; p = 0,001). Die Mehrzahl der Patienten (62%) wünscht sich Gespräche mit dem behandelnden Dermatoonkologen über Versorgungsmöglichkeiten am Lebensende.

Schlussfolgerungen

Auch wenn der Zeitpunkt des Todes nicht absehbar ist, so erscheint eine frühzeitig in die Wege geleitete vorausschauende Versorgungsplanung für das Lebensende sinnvoll. Die behandelnden Dermatoonkologen sollten hierbei die Initiative ergreifen und Patienten bei routinemäßigen Kontrollen auf dieses Thema ansprechen. Hier könnte es von Nutzen sein, den Patienten und Angehörigen die Versorgungsmöglichkeiten vorzustellen und Strategien für den Fall einer gesundheitlichen Verschlechterung zu erstellen.

Change in Code Status Orders of Hospitalized Adults With COVID-19 Throughout the Pandemic: A Retrospective Cohort Study

Aim: Our aim was to examine how code status orders for patients hospitalized with COVID-19 changed over time as the pandemic progressed and outcomes improved. Methods: This retrospective cohort study was performed at a single academic center in the United States. Adults admitted between March 1, 2020, and December 31, 2021, who tested positive for COVID-19, were included. The study period included four institutional hospitalization surges. Demographic and outcome data were collected and code status orders during admission were trended. Data were analyzed with multivariable analysis to identify predictors of code status. Results: A total of 3615 patients were included with full code (62.7%) being the most common final code status order followed by do-not-attempt-resuscitation (DNAR) (18.1%). Time of admission (per every six months) was an independent predictor of final full compared to DNAR/partial code status (p = 0.04). Limited resuscitation preference (DNAR or partial) decreased from over 20% in the first two surges to 10.8% and 15.6% of patients in the last two surges. Other independent predictors of final code status included body mass index (p < 0.05), Black versus White race (0.64, p = 0.01), time spent in the intensive care unit (4.28, p = <0.001), age (2.11, p = <0.001), and Charlson comorbidity index (1.05, p = <0.001). Conclusions: Over time, adults admitted to the hospital with COVID-19 were less likely to have a DNAR or partial code status order with persistent decrease occurring after March 2021. A trend toward decreased code status documentation as the pandemic progressed was observed.

Does Hospitalist Care Enhance Palliative Care and Reduce Aggressive Treatments for Terminally Ill Patients? A Propensity Score-Matched Study

BACKGROUND

Information on the use of palliative care and aggressive treatments for terminally ill patients who receive care from hospitalists is limited.

METHODS

This three-year, retrospective, case-control study was conducted at an academic medical center in Taiwan. Among 7037 patients who died in the hospital, 41.7% had a primary diagnosis of cancer. A total of 815 deceased patients who received hospitalist care before death were compared with 3260 patients who received non-hospitalist care after matching for age, gender, catastrophic illness, and Charlson comorbidity score. Regression models with generalized estimating equations were performed.

RESULTS

Patients who received hospitalist care before death, compared to those who did not, had a higher probability of palliative care consultation (odds ratio (OR) = 3.41, 95% confidence interval (CI): 2.63-4.41), and a lower probability to undergo invasive mechanical ventilation (OR = 0.13, 95% CI: 0.10-0.17), tracheostomy (OR = 0.14, 95% CI: 0.06-0.31), hemodialysis (OR = 0.70, 95% CI: 0.55-0.89), surgery (OR = 0.25, 95% CI: 0.19-0.31), and intensive care unit admission (OR = 0.11, 95% CI: 0.08-0.14). Hospitalist care was associated with reductions in length of stay (coefficient (B) = -0.54, 95% CI: -0.62--0.46) and daily medical costs.

CONCLUSIONS

Hospitalist care is associated with an improved palliative consultation rate and reduced life-sustaining treatments before death.

Advance care planning for frail elderly: are we missing a golden opportunity? A mixed-method systematic review and meta-analysis

OBJECTIVE

The aim is to integrate quantitative and qualitative evidence to understand the effectiveness and experience of advance care planning (ACP) for frail elderly.

DESIGN

A mixed-methods systematic review and meta-analysis was conducted. Quality evaluation was conducted using critical appraisal tools from the Joanna Briggs Institute. Data were synthesised and pooled for meta-analysis or meta-aggregation as needed.

DATA SOURCES

An electronic search of MEDLINE, CINAHL, Embase, PubMed, PsycINFO, and Cochrane Library databases from January 2003 to April 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included experimental and mixed-methods studies. The quantitative component attempts to incorporate a broader study design. The qualitative component aids in comprehending the participant's experience with ACP and its efficacy.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers undertook screening, data extraction and quality assessment. The quantitative and qualitative data were synthesised and integrated using a convergent segregated approach.

RESULTS

There were 12 158 articles found, and 17 matched the inclusion criteria. The quality of the quantitative component of most included studies (6/10) was rated as low, and the qualitative component of half included studies (4/8) was rated as moderate. The meta-analysis showed that the intervention of ACP for frail elderly effectively increases readiness, knowledge and process of ACP behaviours. The meta-aggregation showed that the participants hold a positive attitude towards ACP and think it facilitates expressing their preferences for the medical decision.

CONCLUSION

ACP is an effective and feasible strategy to facilitate frail elderly to express their healthcare wishes timely and improve their outcomes. This study could provide proof for a better understanding of the subject and help direct future clinical practice. More well-designed randomised controlled trials evaluating the most effective ACP interventions and tools are needed for the frail elderly population.

PROSPERO REGISTRATION NUMBER

CRD42022329615.

A Quality Assessment of Goals of Care Forms in a Sample of Older Patients in Various Care Settings in Quebec, Canada

OBJECTIVE

 The objective of this study is to assess the completion and content of the Goals of Care (GOC) forms in three care settings in the province of Quebec, Canada.

METHODS

This is a retrospective, cross-sectional, mixed methods analysis of data extracted from the charts and GOC forms of patients aged over 65 who received services during the year 2018 in one of the three following care settings: (i) long-term care facility, (ii) acute care hospital, and (iii) home support services of a regional healthcare and social services center. The completion of the GOC form includes six essential sections. If one or more of the sections were not fulfilled, we considered the form incomplete. We used descriptive analysis to look at the information in the six sections and a thematic analysis to assess the information in an open-ended section.

RESULTS

We audited 589 charts, of which 67% contained a GOC form and only 96 (16%) a completed one. The most popular goal of care was ensuring comfort as a priority over prolonging life, selected on 40% of the forms. The majority of the included patients (89%) did not want cardiopulmonary resuscitation (CPR) to be attempted in the case of cardiac arrest. There was no indication of the use of advance medical directives, and scarce indication of the use of former GOC forms (18%) and living wills (2%) in completing the forms. Comments were included in 65% of the open-ended sections. The most frequent themes related to the use or non-use of interventions and to potential transfers to the hospital or to an intensive care unit. We found that the open-ended section was used on 24 forms to specify a different goal of care applicable in the event of further health deterioration.

DISCUSSION AND CONCLUSIONS

A significant proportion of charts (84%) did not contain a completed GOC form; key aspects of advance care planning were rarely considered in establishing the patient's goal of care, and the form itself lacked utility given the frequency and nature of qualitative comments. As a final product of serious illness communication and decision-making, our findings suggest that there are significant quality issues, that patients are at risk of intensification of care at the end of life, and that more needs to be done to improve serious illness decision-making and documentation.

Communication with patients with limited prognosis-an integrative mixed-methods evaluation study

PURPOSE

Oncological societies advocate the continuity of care, specialized communication, and early integration of palliative care. To comply with these recommendations, an interprofessional, longitudinally-structured communication concept, the Milestone Communication Approach (MCA), was previously developed, implemented, and evaluated. Our research question is: what are possible explanations from the patient perspective for prognosis and advance care planning being rarely a topic and for finding no differences between MCA and control groups concerning distress, quality of life, and mood?

METHODS

A pragmatic epistemological stance guided the study. A mixed-methods design was chosen including a pragmatic randomized trial (n = 171), qualitative interviews with patients (n = 13) and caregivers (n = 12), and a content analysis (133 milestone conversations, 54 follow-up calls). Data analysis involved the pillar integration process.

RESULTS

Two pillar themes emerged: 1 "approaching prognosis and advance care planning"; 2 "living with a life-threatening illness". Information on prognosis seemed to be offered, but patients' reactions were diverse. Some patients have to deal with having advanced lung cancer while nonetheless feeling healthy and seem not to be ready for prognostic information. All patients seemed to struggle to preserve their quality of life and keep distress under control.

CONCLUSION

Attending to patients' questions, worries and needs early in a disease trajectory seems key to helping patients adjust to living with lung cancer. If necessary clinicians should name their predicament: having to inform about prognosis versus respecting the patients wish to avoid it. Research should support better understanding of patients not wishing for prognostic information to successfully improve communication strategies.

TRIAL REGISTRATION

Registration: German Clinical Trial Register No. DRKS00013649, registration date 12/22/2017, ( https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013649 ) and No. DRKS00013469, registration date 12/22/2017, ( https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013469 ).

"To Be or Not to Be"-Cardiopulmonary Resuscitation for Hospitalized People Who Have a Low Probability of Benefit: Qualitative Analysis of Semi-structured Interviews

Purpose

Our aim was to understand the decision making of patients in hospital who wanted cardiopulmonary resuscitation despite low probability of benefit.

Methods

We included patients admitted to general medical wards who had a low chance of surviving in-hospital cardiopulmonary resuscitation (CPR) and had an order in the chart to administer CPR. We developed an interview guide to explore participants' decision-making process, sources of information, and emotions associated with this decision.

Results

We developed 3 themes from the data. 1) "Life is worth living . . . for now": Participants describe their enjoyment of life and desire to carry on in their current state. 2) "Making sense of CPR outcomes": Participants saw CPR outcomes as binary, either they live, or they die; deciding not to receive CPR means choosing death. Participants were optimistic they would survive CPR and cited personal experience and TV as information sources. 3) "Decision process": Participants did not engage in shared decision making. Instead, they were asked a binary yes/no question with no reflection on their values or discussion about harms or benefits.

Limitations

The probability of successful CPR in our sample is unknown. Findings may be different in a population who is imminently dying but still requesting CPR.

Conclusions

Participants chose CPR because they perceived life as worth living and CPR as a chance worth taking. Participants did not want to be left in a severely debilitated state but did not have accurate information about this risk.

Implications

Decision making about CPR in-hospital can be improved if it is grounded in accurate risk understanding and the patient's values and wishes.

Prevalence and associated factors of self-reported medical errors and adverse events among operating room nurses in China

Background

In recent decades, the prominence of medical errors (MEs) and adverse events (AEs) is fueled by several studies performed across the world. Correspondingly, a high prevalence of medical errors and adverse events have been reported. Operating room nurses (ORNs) were indispensable members of the operating process, and any kind of MEs or AEs from ORNs may cause serious results and even death to the patients. However, to the best of our knowledge, the prevalence and associated factors of MEs and AEs were never reported among ORNs in China, which is the largest country in population and health services quantity in the world.

Methods

This is a cross-sectional study, which was conducted among ORNs in China, and 787 valid questionnaires were analyzed in this study. MEs, AEs, gender, age, married status, religious belief, academic degree, manager or not, working years, working hours/week, physical disease, and mental health were evaluated in this study. MEs were evaluated by eight questions about the occurrence of eight kinds of MEs for the ORNs. For ORNs with MEs, further questions about clinical harm to the patients were interviewed, which analyzed AEs. Kessler 10 was used to evaluate the ORNs' mental health. Logistic regression was conducted to examine the factors associated with MEs and AEs.

Results

The prevalence of MEs and AEs was 27.7 and 13.9% among ORNs, respectively. The most frequent MEs that occurred among ORNs were from surgical instruments (9.1%), disinfection (9.0%), equipment and consumables (8.9%), and specimen management (7.8%). MEs were positively associated with lower working years, poor mental health, and physical disease. The physical disease was positively associated with AEs.

Conclusion

The prevalence of perceived MEs and AEs was at a higher level than other kinds of nurses. Fresh ORNs with physical and mental health problems were the risk population for MEs, and ORNs with physical disease were at a higher risk for AEs. All the findings implied that MEs and AEs were an important issue for ORNs, and ORNs with physical and mental health problems should be paid attention to control MEs and AEs.

Differing Conceptualizations of the Goals of Care Discussion: A Critical Discourse Analysis

CONTEXT

The goals of care discussion (GOCD) has been positioned as an improvement strategy to address discordance between care decisions made by seriously ill patients and care received. Interventions aimed at improving GOCDs however have had limited success. This may in part be due to the considerable variation in views on the essential components and expected outcomes of a GOCD. This variability, and consequently clinical approaches to GOCDs, may reflect fundamental differences in how the GOCD is conceptualized.

OBJECTIVE

To identify and characterize differing conceptualizations of the GOCD.

METHODS

Critical discourse analysis was used to qualitatively examine GOCDs documented for inpatients of 35 Canadian palliative medicine (PM), critical care medicine (CCM) and general internal medicine (GIM) physicians. Patterns in the ways the GOCD had been constructed were characterized by identifying different aspects of the approaches used by clinicians.

RESULTS

GOCD notes varied in the predominant style and tone (from narrative to biomedical), predominant information source (patient/family to physician), and contribution of the patient's perspective. Notably binary differences were also found in the locus of goals and located either with the patient or with the broad concept of treatments. Although not exclusively, locus of goals tended to be with the patient among PM physicians and with treatments among CCM and GIM physicians.

CONCLUSION

These findings offer clinical evidence for differing conceptualizations of the GOCD and orientations to goals as either person-centered or treatment-centered. This phenomenon may be in part discipline-based and has important implications for both clinical practice and training experiences.

Shame and Secrecy of Do Not Resuscitate Orders: An Historical Review and Suggestions for the Future

This paper clarifies some of the longstanding difficulties in negotiating Do Not Resuscitate Orders by reframing the source of the dilemmas as not residing with either the patient or the physician but with their relationship. The recommendations are low cost and low-tech ways of making major improvements to the care and quality of life of the most ill patients in hospital. With impending physician-assisted death legislation there is an urgency to find more efficient and beneficial ways for clinicians and patients to address resuscitation issues at the bedside. Paradigmatic shifts in the nature of the patient-physician relationship will need to be encouraged by the larger community. These encouraged shifts address the concepts of passive/inferior patient – active/superior physician, patient ownership of and access to all their health care information, and treating the patient as a major participant in the delivery of health care. These recommended changes will not in themselves make any patient, physician or other healthcare provider more humane and open in the patient’s final days. The goal, instead, is to have changes to the context of the discussion provide an encouraging environment for more open communication and a balanced relationship among participants with the patient being the most important.

Randomized Controlled Trial of a Decision Support Intervention About Cardiopulmonary Resuscitation for Hospitalized Patients Who Have a High Risk of Death

BACKGROUND

Many seriously ill hospitalized patients have cardiopulmonary resuscitation (CPR) as part of their care plan, but CPR is unlikely to achieve the goals of many seriously ill hospitalized patients.

OBJECTIVE

To determine if a multicomponent decision support intervention changes documented orders for CPR in the medical record, compared to usual care.

DESIGN

Open-label randomized controlled trial.

PATIENTS

Patients on internal medicine and neurology wards at two tertiary care teaching hospitals who had a 1-year mortality greater than 10% as predicted with a validated model and whose care plan included CPR, if needed.

INTERVENTION

Both the control and intervention groups received usual communication about CPR at the discretion of their care team. The intervention group participated in a values clarification exercise and watched a CPR video decision aid.

MAIN MEASURE

The primary outcome was the proportion of patients who had a no-CPR order at 14 days after enrollment.

KEY RESULTS

We recruited 200 patients between October 2017 and October 2018. Mean age was 77 years. There was no difference between the groups in no-CPR orders 14 days after enrollment (17/100 (17%) intervention vs 17/99 (17%) control, risk difference, - 0.2%) (95% confidence interval - 11 to 10%; p = 0.98). In addition, there were no differences between groups in decisional conflict summary score or satisfaction with decision-making. Patients in the intervention group had less conflict about understanding treatment options (decisional conflict knowledge subscale score mean (SD), 17.5 (26.5) intervention arm vs 40.4 (38.1) control; scale range 0-100 with lower scores reflecting less conflict).

CONCLUSIONS

Among seriously ill hospitalized patients who had CPR as part of their care plan, this decision support intervention did not increase the likelihood of no-CPR orders compared to usual care.

PRIMARY FUNDING SOURCE

Canadian Frailty Network, The Ottawa Hospital Academic Medical Organization.

The Difficulties in End-of-Life Discussions - Family Inventory (DEOLD-FI): Development and Initial Validation of a Self-Report Questionnaire in a Sample of Terminal Cancer Patients

CONTEXT

Open end-of-life communication is especially important within the patient-family unit of care and can positively affect their medical, psychological, and relational outcomes. Nevertheless, end-of-life discussions are often perceived as difficult and avoided.

OBJECTIVES

To develop and validate the Difficulties in End-of-Life Discussions - Family Inventory (DEOLD-FI) to allow a systematic assessment of reasons why people shy away from end-of-life discussions.

METHODS

Patients with advanced cancer were recruited and completed the DEOLD-FI and measures of avoidance of cancer communication, quality of life and distress, and the experienced difficulty as well as the occurrence of end-of-life discussions. Standard item analyses and an exploratory factor analysis were conducted. Construct validity was analysed through associations between the DEOLD-FI and the aforementioned measures.

RESULTS

Questionnaires were obtained from 112 participants (53% response rate; male 54%, mean age 64.9 years [range 33-94]). In the final 23-item version two factors were extracted: 'emotional burden due to end-of-life discussions' (α = 0.90) and "negative attitudes towards end-of-life discussions" (α = 0.91) explaining 69% of the variance (total scale α = 0.93). Construct validity was supported by its significant correlations with the reported difficulty in end-of-life discussions (r = 0.42) and avoidance of cancer communication (r = 0.40 to r = 0.46) and insignificant correlations with quality of life (r = -0.11), distress (r = 0.16), and physical well-being (r = 0.02). Those who had already engaged in end-of-life discussions showed significantly fewer communication barriers.

CONCLUSION

Results provide evidence that the DEOLD-FI is a valid and reliable instrument for the assessment of difficulties in end-of-life discussions. Benefits for clinical practice and research are discussed.

Clinicians' Perspectives After Implementation of the Serious Illness Care Program: A Qualitative Study

IMPORTANCE

Discussions about goals of care with patients who are seriously ill typically occur infrequently and late in the illness trajectory, are of low quality, and focus narrowly on the patient's resuscitation preferences (ie, code status), risking provision of care that is inconsistent with patients' values. The Serious Illness Care Program (SICP) is a multifaceted communication intervention that builds capacity for clinicians to have earlier, more frequent, and more person-centered conversations.

OBJECTIVE

To explore clinicians' experiences with the SICP 1 year after implementation.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was conducted at 2 tertiary care hospitals in Canada. The SICP was implemented at Hamilton General Hospital (Hamilton, Ontario) from March 1, 2017, to January 19, 2018, and at Foothills Medical Centre (Calgary, Alberta) from March 1, 2018, to December 31, 2020. A total of 45 clinicians were invited to participate in the study, and 23 clinicians (51.1%) were enrolled and interviewed. Semistructured interviews of clinicians were conducted between August 2018 and May 2019. Content analysis was used to evaluate information obtained from these interviews between May 2019 and May 2020.

EXPOSURES

The SICP includes clinician training, communication tools, and processes for system change.

MAIN OUTCOMES AND MEASURES

Clinicians' experiences with and perceptions of the SICP.

RESULTS

Among 23 clinicians interviewed, 15 (65.2%) were women. The mean (SD) number of years in practice was 14.6 (9.1) at the Hamilton site and 12.0 (6.9) at the Calgary site. Participants included 19 general internists, 3 nurse practitioners, and 1 social worker. The 3 main themes were the ways in which the SICP (1) supported changes in clinician behavior, (2) shifted the focus of goals-of-care conversations beyond discussion of code status, and (3) influenced clinicians personally and professionally. Changes in clinician behavior were supported by having a unit champion, interprofessional engagement, access to copies of the Serious Illness Conversation Guide, and documentation in the electronic medical record. Elements of the program, especially the Serious Illness Conversation Guide, shifted the focus of goals-of-care conversations beyond discussion of code status and influenced clinicians on personal and professional levels. Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity.

CONCLUSIONS AND RELEVANCE

In this qualitative study, hospital clinicians described components of the SICP as supporting changes in their behavior and facilitating meaningful patient interactions that shifted the focus of goals-of-care conversations beyond discussion of code status. The perceived benefits of SICP implementation stimulated uptake within the medical units. These findings suggest that the SICP may prompt hospital culture changes in goals-of-care dialogue with patients and the care of hospitalized patients with serious illness.

Training Residents in Advance Care Planning: A Task-Based Needs Assessment Using the 4-Component Instructional Design

BACKGROUND

Residents may learn how to perform advance care planning (ACP) through informal curriculum. Task-based instructional designs and recent international consensus statements for ACP provide opportunities to explicitly train residents, but residents' needs are poorly understood.

OBJECTIVE

We assessed residents' training needs in ACP at the Geneva University Hospitals in Geneva, Switzerland.

METHODS

Qualitative data were collected and analyzed iteratively between December 2017 and September 2019. Transcripts were coded using both a deductive content analysis based on the 4-Component Instructional Design (4C/ID) model and an inductive thematic analysis.

RESULTS

Out of 55 individuals contacted by email, 49 (89%) participated in 7 focus groups and 10 individual interviews, including 19 residents, 18 fellows and attending physicians, 4 nurses, 1 psychologist, 1 medical ethics consultant, 3 researchers, and 3 patients. Participants identified 3 tasks expected of residents (preparing, discussing, and documenting ACP) and discussed why training residents in ACP is complex. Participants described knowledge (eg, prognosis), skills (eg, clinical and ethical reasoning), and attitudes (eg, reflexivity) that residents need to become competent in ACP and identified needs for future training. In terms of the 4C/ID, these needs revolved around: (1) learning tasks (eg, workplace practice, simulated scenarios); (2) supportive information (eg, videotaped worked examples, cognitive feedback); (3) procedural information (eg, ACP pocket-sized information sheet, corrective feedback); and (4) part-task practice (eg, rehearsal of communication skills, simulation).

CONCLUSIONS

This study provides a comprehensive description of tasks and competencies to train residents in ACP.

Randomised trial of a serious illness decision aid (Plan Well Guide) for patients and their substitute decision-makers to improve engagement in advance care planning

OBJECTIVE

To evaluate the feasibility and efficacy of a serious illness decision aid (Plan Well Guide) in increasing the engagement of substitute decision-makers (SDM) in advance care planning (ACP).

METHODS

This trial was conducted (2017-2019) in outpatient settings in Ontario, Canada, aiming to recruit 90 dyads of patients aged 65 years and older at high risk of needing future medical decisions and their SDM. Participants were randomised to receive the intervention immediately or to a 3-month wait period. The Plan Well Guide was administered to the patient and SDM by a facilitator. Outcomes were change on the validated 17-item SDM ACP Engagement Survey (primary) and 15-item patient ACP Engagement Survey (secondary).

RESULTS

Of 136 dyads approached, 58 consented and were randomised and 45 completed the study (28 immediate intervention, 17 delayed intervention). The trial was stopped early because of difficulties with enrolling and following up participants. The mean changes on the SDM ACP Engagement Survey and the patient ACP Engagement Survey favoured the first group but were not statistically significant (mean difference (MD)=+0.2 (95% CI: -0.3 to 0.6) and MD=+0.4 (95% CI: -0.1 to 0.8), respectively). In a post-hoc subgroup analysis, significant treatment effects were seen in SDMs with a lower-than-median baseline score compared with those at or above the median.

CONCLUSIONS

In this statistically underpowered randomised trial, differences in SDM ACP engagement between groups were small. Further information is needed to overcome recruitment challenges and to identify people most likely to benefit from the Plan Well Guide.Trial registration number NCT03239639.

Discordant Cardiopulmonary Resuscitation and Code Status at Death

CONTEXT

One fundamental way to honor patient autonomy is to establish and enact their wishes for end-of-life care. Limited research exists regarding adherence with code status.

OBJECTIVES

This study aimed to characterize cardiopulmonary resuscitation (CPR) attempts discordant with documented code status at the time of death in the U.S. and to elucidate potential contributing factors.

METHODS

The Cerner Acute Physiology and Chronic Health Evaluation (APACHE) outcomes database, which includes 237 U.S. hospitals that collect manually abstracted data from all critical care patients, was queried for adults admitted to intensive care units with a documented code status at the time of death from January 2008 to December 2016. The primary outcome was discordant CPR at death. Multivariable logistic regression models were used to identify patient-level and hospital-level associated factors after adjustment for age, hospital, and illness severity (APACHE III score).

RESULTS

A total of 21,537 patients from 56 hospitals were included. Of patients with a do-not-resuscitate code status, 149 (0.8%) received CPR at death, and associated factors included black race, higher APACHE III score, or treatment in small or nonteaching hospitals. Of patients with a full code status, 203 (9.0%) did not receive CPR at death, and associated factors included higher APACHE III score, primary neurologic or trauma diagnosis, or admission in a more recent year.

CONCLUSION

At the time of death, 1.6% of patients received or did not undergo CPR in a manner discordant with their documented code statuses. Race and institutional factors were associated with discordant resuscitation, and addressing these disparities may promote concordant end-of-life care in all patients.

Exploring and reconciling discordance between documented and preferred resuscitation preferences for hospitalized patients: a quality improvement study

PURPOSE

A discordance, predominantly towards overtreatment, exists between patients' expressed preferences for life-sustaining interventions and those documented at hospital admission. This quality improvement study sought to assess this discordance at our institution. Secondary objectives were to explore if internal medicine (IM) teams could identify patients who might benefit from further conversations and if the discordance can be reconciled in real-time.

METHODS

Two registered nurses were incorporated into IM teams at a tertiary hospital to conduct resuscitation preference conversations with inpatients either specifically referred to them (group I, n = 165) or randomly selected (group II, n = 164) from 1 August 2016 to 31 August 2018. Resuscitation preferences were documented and communicated to teams prompting revised resuscitation orders where appropriate. Multivariable logistic regression was used to determine potential risk factors for discordance.

RESULTS

Three hundred and twenty-nine patients were evaluated with a mean (standard deviation) age of 80 (12) and Charlson Comorbidity Index Score of 6.8 (2.6). Discordance was identified in 63/165 (38%) and 27/164 (16%) patients in groups I and II respectively. 42/194 patients (21%) did not want cardiopulmonary resuscitation (CPR) and 15/36 (41%) did not prefer intensive care unit (ICU) admission, despite these having been indicated in their initial preferences. 93% (84/90) of patients with discordance preferred de-escalation of care. Discordance was reconciled in 77% (69/90) of patients.

CONCLUSION

Hospitalized patients may have preferences documented for CPR and ICU interventions contrary to their preferences. Trained nurses can identify inpatients who would benefit from further in-depth resuscitation preference conversations. Once identified, discordance can be reconciled during the index admission.

Effect of "Speak Up" educational tools to engage patients in advance care planning in outpatient healthcare settings: A prospective before-after study

BACKGROUND

Tools for advance care planning (ACP) are advocated to help ensure patient values guide healthcare decisions. Evaluation of the effect of tools introduced to patients in clinical settings is needed.

OBJECTIVE

To evaluate the effect of the Canadian Speak Up Campaign tools on engagement in advance care planning (ACP), with patients attending outpatient clinics. Patient involvement: Patients were not involved in the problem definition or solution selection in this study but members of the public were involved in development of tools. The measurement of impacts involved patients.

METHODS

This was a prospective pre-post study in 15 primary care and two outpatient cancer clinics. The outcome was scores on an Advance Care Planning Engagement Survey measuring Behavior Change Process on 5-point scales and Actions (0-21-point scale) administered before and six weeks after using a tool, with reminders at two or four weeks.

RESULTS

177 of 220 patients (81%) completed the study (mean 68 years of age, 16% had cancer). Mean Behavior Change Process scores were 2.9 at baseline and 3.5 at follow-up (mean change 0.6, 95% confidence interval 0.5 to 0.7; large effect size of 0.8). Mean Action Measure score was 3.7 at baseline and 4.8 at follow-up (mean change 1.1, 95% confidence interval 0.6-1.5; small effect size of 0.2).

PRACTICAL VALUE

Publicly available ACP tools may have utility in clinical settings to initiate ACP among patients. More time and motivation may be required to stimulate changes in patient behaviors related to ACP.

Moving from "Do Not Resuscitate" Orders to Standardized Resuscitation Plans and Shared-Decision Making in Hospital Inpatients

Not for Cardiopulmonary Resuscitation (No-CPR) orders, or the local equivalent, help prevent futile or unwanted cardiopulmonary resuscitation. The importance of unambiguous and readily available documentation at the time of arrest seems self-evident, as does the need to establish a patient’s treatment preferences prior to any clinical deterioration. Despite this, the frequency and quality of No-CPR orders remains highly variable, while discussions with the patient about their treatment preferences are undervalued, occur late in the disease process, or are overlooked entirely.

This review explores the evolution of hospital patient No-CPR/Do Not Resuscitate decisions over the past 60 years. A process based on standardized resuscitation plans has been shown to increase the frequency and clarity of documentation, reduce stigma attached to the documentation of a No-CPR order, and support the delivery of medically appropriate and desired care for the hospital patient.

Does the public feel prepared to be substitute decision-makers? Gaps in preparedness and support for a high school curriculum: a national survey

BACKGROUND

Substitute decision-makers (SDMs) make decisions on behalf of patients who do not have capacity, in line with previously expressed wishes, values and beliefs. However, miscommunications and poor awareness of previous wishes often lead to inappropriate care. Increasing public preparedness to communicate on behalf of loved ones may improve care in patients requiring an SDM.

METHODS

We conducted an online survey in January 2019 with a representative sample of the Canadian population. The primary outcome was self-reported preparedness to be an SDM. The secondary outcome was support for a high school curriculum on the role of SDMs. The effect of socio-demographics, known enablers and barriers to acting as an SDM, and attitudes towards a high school curriculum were assessed using multivariate analysis.

RESULTS

Of 1,000 participants, 53.1% felt prepared to be an SDM, and 75.4% stated they understood their loved one's values. However, only 55.6% reported having had a meaningful conversation with their loved one about values and wishes, and only 61.7% reported understanding the SDM role. Engagement in advance care planning for oneself was low (23.1%). Age, experience, training and comfort with communication were associated with preparedness in our multivariate analysis. A high school curriculum was supported by 61.1% of respondents, with 28.3% neutral and 10.6% against it.

INTERPRETATION

There is a gap between perceived and actual preparedness to be an SDM. Many report understanding their loved one's values yet have not asked them about wishes in illness or end of life. The majority of respondents support high school education to improve preparedness.

Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions

Introduction

Inter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Goals of care (GoC) discussions prior to transfer are necessary in patients at high risk for decline to ensure that the intended outcome of transfer is goal concordant. However, the frequency of these discussions is not well understood. This study was intended to assess the prevalence of GoC discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality.

Methods

This was a retrospective study of IHT patients aged 18 and older who died within 72 hours of transfer to Wake Forest Baptist Medical Center between October 1, 2016-October 2018. Documentation of GoC discussions within the electronic health record (EHR) prior to transfer was the primary outcome. We also assessed charts for primary diagnosis associated with in-hospital mortality, code status changes prior to death, in-hospital healthcare interventions, and frequency of palliative care consults.

Results

We included in this study a total of 298 patients, of whom only 10.1% had documented GoC discussion prior to transfer. Sepsis (29.9%), respiratory failure (28.2%), and cardiac arrest (27.5%) were the top three diagnoses associated with in-hospital mortality, and 73.2% of the patients transitioned to comfort measures prior to death. After transfer, 18.1% of patients had invasive procedures performed with 9.7% undergoing major surgery. Palliative care consultation occurred in only 4.4%.

Conclusion

The majority (89.9%) of IHT patients with early mortality did not have GoC discussion documented within EHR prior to transfer, although most transitioned to comfort measures prior to their deaths, highlighting that additional work is needed in this area.

Exploring patient-reported barriers to advance care planning in family practice

BACKGROUND

Although patient-centred care has become increasingly important across all medical specialties, when it comes to end of life care, research has shown that treatments ordered are not often concordant with people's expressed preferences. Patient and family engagement in Advance Care Planning (ACP) in the primary care setting could improve the concordance between patients' wishes and the healthcare received when patients cannot speak for themselves. The aim of this study was to better understand the barriers faced by older patients regarding talking to their family members and family physicians about ACP.

METHODS

In this multi-site cross-sectional study, three free text questions regarding reasons patients found it difficult to discuss ACP with their families or their family physicians were part of a self-administered questionnaire about patients' knowledge of and engagement in ACP. The questionnaire, which included closed ended questions followed by three probing open ended questions, was distributed in 20 family practices across 3 provinces in Canada. The free text responses were analyzed using thematic analysis and form the basis of this paper.

RESULTS

One hundred two participants provided an analyzable response to the survey when asked why they haven't talked to someone about ACP. Two hundred fifty-four answered the question about talking to their physician and 340 answered the question about talking to family members. Eight distinct themes emerged from the free text response analysis: 1. They were too young for ACP; 2. The topic is too emotional; 3. The Medical Doctor (MD) should be responsible for bringing up ACP 4. A fear of negatively impacting the patient-physician relationship; 5. Not enough time in appointments; 6. Concern about family dynamics; 7. It's not a priority; and 8. A lack of knowledge about ACP.

CONCLUSIONS

Patients in our sample described many barriers to ACP discussions, including concerns about the effect these discussions may have on relationships with both family members and family physicians, and issues relating to patients' knowledge and interpretation of the importance, responsibility for, or relevance of ACP itself. Family physicians may be uniquely placed to leverage the longitudinal, person- centred relationship they have with patients to mitigate some of these barriers.

Quality of clinicians' conversations with patients and families before and after implementation of the Serious Illness Care Program in a hospital setting: a retrospective chart review study

BACKGROUND

Seriously ill patients in hospital have indicated that better communication with practitioners is vital for improving care. The aim of this study was to assess whether the quality of conversations about serious illness improved after implementation of the Serious Illness Care Program (SICP).

METHODS

In this retrospective chart review study, we evaluated patients who were admitted to a medical ward at Hamilton General Hospital, had a stay of at least 48 hours, and were at risk for a lengthy stay or increased need for community-based services (inter-RAI Emergency Department Screener score of 5 or 6). The SICP study period was from Mar. 1, 2017, to Jan. 19, 2018. We used a validated codebook to assess the quality of documented conversations regarding serious illness for eligible patients before (usual care [control group]) and after SICP implementation (intervention group), specifically examining the following domains: patients' values and goals, understanding of prognosis and illness, end-of-life care planning, and code status or desire for other life-sustaining treatments.

RESULTS

The study sample included 56 patients in the control group and 56 patients in the intervention group. The overall quality of documented conversations about serious illness was significantly higher in the intervention group than in the control group (p < 0.001) and was significantly higher in the subdomains of values and goals (p < 0.001), understanding of prognosis and illness (p < 0.001) and life-sustaining treatments (p = 0.03) but not end-of-life care planning (p = 0.48).

INTERPRETATION

Implementation of the SICP in a hospital setting was associated with higher quality of documented conversations regarding serious illness with patients at high risk for clinical or functional deterioration. The SICP is transferable and adaptable to a hospital setting, and was associated with an increase in adherence to best practices compared to usual care.

Painting a Rational Picture During Highly Emotional End-of-Life Discussions: a Qualitative Study of Internal Medicine Trainees and Faculty

BACKGROUND

High-quality communication about end-of-life care results in greater patient and family satisfaction. End-of-life discussions should occur early during the patient's disease trajectory and yet is often addressed only when patients become severely ill. As a result, end-of-life discussions are commonly initiated during unplanned hospital admissions, which create additional challenges for physicians, patients, and families.

OBJECTIVE

To better understand how internal medicine attending physicians and trainees experience end-of-life discussions with patients and families during acute hospitalizations.

DESIGN

We conducted an interview-based qualitative study using an interpretivist approach. We selected participants based on purposeful maximal variation and theoretical sampling strategies. We conducted an individual, in-depth, semi-structured interview with each participant.

PARTICIPANTS

We recruited 15 internal medicine physicians with variable levels of clinical training and experience who worked in one of five university-affiliated academic hospitals.

APPROACH

Interview transcripts were analyzed inductively and reflectively. Data were grouped by themes and categories. Data collection and analysis occurred concurrently, led to iterative adjustments of the interview guide, and continued until theoretical sufficiency was reached.

KEY RESULTS

Physicians depicted end-of-life discussions as a process directed at painting a realistic picture of a clinical situation. By focusing their efforts on reaching a shared understanding of a clinical situation with patients/families, physicians self-delineated the boundaries of their professional responsibilities regarding end-of-life care (i.e., help with understanding, not with accepting or making the "right" decisions). Information sharing took precedence over emotional support in most physicians' accounts of end-of-life discussions. However, the emotional impact of end-of-life discussions on families and physicians was readily recognized by participants.

CONCLUSION

End-of-life discussions are complex, dynamic social interactions that involve multiple, complementary competencies. Focusing mostly on sharing clinical information during end-of-life discussions may distract physicians from providing emotional support to families and prevent improvements of end-of-life care delivered in acute care settings.

Advance Directives and Code Status Information Exchange: A Consensus Proposal for a Minimum Set of Attributes

Documentation of code status and advance directives for end-of-life (EOL) care improves care and quality of life, decreases cost of care, and increases the likelihood of an experience desired by the patient and his/her family. However, the use of advance directives and code status remains low and only a few organizations maintain code status in electronic form. Members of the American Medical Informatics Association's Ethics Committee identified a need for a patient's EOL care wishes to be documented correctly and communicated easily through the electronic health record (EHR) using a minimum data set for the storage and exchange of code status information. After conducting an environmental scan that produced multiple resources, Ethics Committee members used multiple conference calls and a shared document to arrive at consensus on the proposed minimum data set. Ethics Committee members developed a minimum required data set with links to the HL7 C_CDA Advance Directives Module. Data categories include information on the organization obtaining the code status information, the patient, any supporting documentation, and finally the desired code status information including mandatory, optional, and conditional elements. The "minimum set of attributes" to exchange advance directive / code status data described in this manuscript enables communication of patient wishes across multiple providers and health care settings. The data elements described serve as a starting point for a dialog among informatics professionals, physicians experienced in EOL care, and EHR vendors, with the goal of developing standards for incorporating this functionality into the EHR systems.

Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings

PURPOSE

Online programs may help to engage patients in advance care planning in outpatient settings. We sought to implement an online advance care planning program, PREPARE (Prepare for Your Care; http://www.prepareforyourcare.org), at home and evaluate the changes in advance care planning engagement among patients attending outpatient clinics.

METHODS

We undertook a prospective before-and-after study in 15 primary care clinics and 2 outpatient cancer centers in Canada. Patients were aged 50 years or older (primary care) or 18 years or older (cancer care) and free of cognitive impairment. They used the PREPARE website over 6 weeks, with reminders sent at 2 or 4 weeks. We used the 55-item Advance Care Planning Engagement Survey, which measures behavior change processes (knowledge, contemplation, self-efficacy, readiness) on 5-point scales and actions relating to substitute decision makers, quality of life, flexibility for the decision maker, and asking doctors questions on an overall scale from 0 to 21; higher scores indicate greater engagement.

RESULTS

In total, 315 patients were screened and 172 enrolled, of whom 75% completed the study (mean age = 65.6 years, 51% female, 35% had cancer). The mean behavior change process score was 2.9 (SD 0.8) at baseline and 3.5 (SD 0.8) at follow-up (mean change = 0.6; 95% CI, 0.49-0.73); the mean action measure score was 4.0 (SD 4.9) at baseline and 5.2 (SD 5.4) at follow-up (mean change = 1.2; 95% CI, 0.54-1.77). The effect size was moderate (0.75) for the former and small (0.23) for the latter. Findings were similar in both primary care and cancer care populations.

CONCLUSIONS

Implementation of the online PREPARE program in primary care and cancer care clinics increased advance care planning engagement among patients.

Patient safety in marginalised groups: a narrative scoping review

Background

Marginalised groups (‘populations outside of mainstream society’) experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising.

Methods

Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day.

Results

The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors.

Conclusions

This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks.

Trial registration

Not applicable for a scoping review.

Reducing Discrepancy Between Code Status Orders and Physician Orders for Life-Sustaining Therapies: Results of a Quality Improvement Initiative

BACKGROUND

Advanced care planning through Physician Order For Life-Sustaining Therapies (POLST) has been encouraged by professional societies. But these documents may be overlooked or ignored during hospitalization and "full-code" orders written as a default, putting patients at risk for unwanted resuscitation. After 2 instances of unwanted resuscitation in which limited support POLSTs were ignored, a series of improvements were implemented. This study measured the effectiveness of those steps in reducing POLST code status discrepancy.

METHODS

Pre-post implementation chart review of randomly chosen medical admissions to determine the rate of discordance between POLST orders (when present) and admission code status orders. Physician Order For Life-Sustaining Therapies were classified as either "full" or "limited" based on orders for life-sustaining therapies on the form. Chi-square tests or Fisher exact tests were performed on binary data to identify statistically significant differences at the 95% confidence level between pre- and postimplementation admissions.

RESULTS

In all, 444 preimplementation and 448 postimplementation admissions were evaluated. Discrepant code status orders for those with limited POLST fell from 10 (22.7%) of 44 preimplementation to 3 (4.6%) of 65 after implementation, P = .006. The number of documented code status discussions in admission notes increased from 19.6% to 63.6% (P < .001). The median age of all POLST in the chart was 1.2 years.

CONCLUSIONS

Among those patients with limited POLST orders, discrepant full-code orders increase the potential for unwanted resuscitation. Multistep improvements including documentation templates improved the process of verifying end-of-life wishes and increased meaningful code status discussions. The rate of discrepant orders fell in response to process improvements.

Discrepant Advanced Directives and Code Status Orders: A Preventable Medical Error

The United States health system has been criticized for its overuse of aggressive and medically ineffective life-sustaining therapies (LST).1 Some professional societies have elevated dialog about end-of-life (EOL) care to a quality measure,2 expecting that more open discussion will achieve more “goal-concordant care”3 and appropriate use of LST. However, even when Advanced Directives (AD) or Physician Orders for Life-Sustaining Therapy (POLST) have been created, their directions are not always followed in the hospital. This perspective discusses how preventable errors allow for use of LST even when patients designated it as unwanted. Two cases, chosen from several similar ones, are highlighted, demonstrating both human and system errors.

The Extended Postoperative Care-Score (EXPO-Score)-An Objective Tool for Early Identification of Indication for Extended Postoperative Care

Extended postoperative care and intensive care unit capacity is limited and efficient patient allocation is mandatory. This study aims to develop an effective yet simple score to predict indication for extended postoperative care, as there is a lack of objective criteria for early prediction of admission to extended care in surgical patients. This prospective observational study was divided into two periods (Period 1: Extended Postoperative Care-Score (EXPO)-Score generation; Period 2: EXPO-Score validation) and it was performed at a tertiary university center in Germany. A total of 4042 (Period 1) and 2198 (Period 2) adult patients ≥ 18 years old receiving elective or emergency surgery were included in this study. After identifying patient- and surgery-related risk factors by an expert panel, the EXPO-Score was developed through logistic regression from data of Period 1 and validated in Period 2. Three risk factors are sufficient for generating a reliable predictive EXPO-Score: (1) the American Society of Anesthesiologists’ (ASA) physical status, (2) cardiopulmonary physical exercise status expressed in metabolic equivalents (MET), and (3) the type of surgery. The score threshold (0.23) has a sensitivity of 0.87, a specificity of 0.91, and an accuracy of 0.90 for predicting indication for extended postoperative care. The EXPO-Score provides a validated, early collectable, and easy-to-use tool for predicting indication of extended postoperative care in adult surgical patients.

Accurate prognostic awareness and preference states influence the concordance between terminally ill cancer patients' states of preferred and received life-sustaining treatments in the last 6 months of life

BACKGROUND

Factors facilitating/hindering concordance between preferred and received life-sustaining treatments may be distorted if preferences and predictors are measured long before death.

AIM

To examine factors facilitating/hindering concordance between cancer patients' preferred and received life-sustaining-treatment states in their last 6 months.

DESIGN

Longitudinal, observational design.

SETTING/PARTICIPANTS

States of preferred and received life-sustaining treatments (cardio-pulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, and nasogastric tube feeding) were examined in 218 Taiwanese cancer patients by a latent transition model with hidden Markov modeling. Multivariate logistic regression modeling was used to examine factors facilitating/hindering concordance between preferred and received life-sustaining-treatment states.

RESULTS

Concordance between preferred and received life-sustaining-treatment states was poor (40.8%, kappa value (95% confidence interval): 0.05 [-0.03, 0.14]). Patients who accurately understood their prognosis and preferred comfort care were significantly more likely to receive preferred life-sustaining treatments before death than those who did not know their prognosis but wanted to know, those who were uniformly uncertain about what life-sustaining treatments they preferred to receive, and those who preferred nutritional support but declined other life-sustaining treatments. Patient age, physician-patient end-of-life-care discussions, symptom distress, and functional dependence were not associated with concordance between preferred and received life-sustaining-treatment states.

CONCLUSION

Prognostic awareness and preferred states of life-sustaining treatments were significantly associated with concordance between preferred and received life-sustaining-treatment states. Personalized interventions should be developed to cultivate terminally ill cancer patients' accurate prognostic awareness, allowing them to formulate realistic life-sustaining-treatment preferences and facilitating their receiving value-concordant end-of-life care.

Extent and Determinants of Terminally Ill Cancer Patients' Concordance Between Preferred and Received Life-Sustaining Treatment States: An Advance Care Planning Randomized Trial in Taiwan

CONTEXT

Promoting patient value-concordant end-of-life care is a priority in health care systems but has rarely been examined in randomized clinical trials.

OBJECTIVES

To examine the effectiveness of an advance care planning intervention in facilitating concordance between cancer patients' preferred and received life-sustaining treatment (LST) states and to explore modifiable factors facilitating or impeding such concordance.

METHODS

Terminal cancer patients (N = 460) were randomly assigned 1:1 to the experimental and control arms of a randomized clinical trial, with 430 deceased participants comprising the final sample. States of preferred LSTs (cardiopulmonary resuscitation, intensive care unit care, chest compression, intubation with mechanical ventilation, intravenous nutrition, and nasogastric tube feeding) and LSTs received in the last month were examined by hidden Markov modeling. Concordance and its modifiable predictors were evaluated by kappa and multivariate logistic regression, respectively.

RESULTS

We identified three LST-preference states (uniformly preferring LSTs, rejecting LSTs except intravenous nutrition support, and mixed LST preferences) and three received LST states (uniformly receiving LSTs, received intravenous nutrition only, and selectively receiving LSTs). Concordance was not significantly higher in the experimental than the control arm (kappa [95% CI]: 0.126 [0.032, 0.221] vs. 0.050 [-0.028, 0.128]; arm difference: odds ratio [95% CI]: 1.008 [0.675, 1.5001]). Preferred-received LST-state concordance was facilitated by accurate prognostic awareness, better quality of life, and more depressive symptoms, whereas concordance was impeded by more anxiety symptoms.

CONCLUSIONS

Our advance care planning intervention did not facilitate concordance between terminally ill cancer patients' preferred and received LST states, but patient value-concordant end-of-life care may be facilitated by interventions to cultivate accurate prognostic awareness, improve quality of life, support depressive patients, and clarify anxious patients' overexpectations of LST efficacy.

Gaps in public preparedness to be a substitute decision-maker and the acceptability of high school education on resuscitation and end-of-life care: a mixed-methods study

BACKGROUND

When a patient is incapable of making medical decisions for him- or herself, a substitute decision-maker makes choices according to the patient's previously expressed wishes, values and beliefs; however, little is known about public readiness to act as a substitute decision-maker in Canada. Our primary objective was to measure public self-reported preparedness to act as a substitute decision-maker, and explore the attitudes, barriers and enablers associated with preparedness.

METHODS

From November 2017 to June 2018, we conducted a mixed-methods street intercept survey at 12 pedestrian areas in Ottawa, Ontario. We used descriptive statistics and logistic regression analysis to assess predictors of perceived preparedness to be a substitute decision-maker and determine support for high school education. We analyzed qualitative interview questions using inductive thematic analysis.

RESULTS

Of the 626 eligible respondents, 196 refused to participate, leaving 430 participants (response rate 68.7%). A total of 404 surveys (94.0%) were fully complete with no missing data. The respondents were mostly female (243 [56.5%]) and residents of Ontario (364 [84.6%]). The average age was 33.9 years. Although 314 respondents (73.0%) felt prepared to be a substitute decision-maker, 194 (45.1%) reported never having had meaningful conversations with loved ones to understand their wishes in the event of critical illness. A total of 293 participants (68.1%) identified important barriers to feeling prepared. Most respondents (309 [71.9%]) agreed that high school students should learn about being a substitute decision-maker, citing age appropriateness, potential societal benefit and improved decision-making, while cautioning the need to respect different maturity levels, cultures and experiences.

INTERPRETATION

he lack of conversation between loved ones reveals a gap between perceived and actual preparedness to be a substitute decision-maker for a loved one with a critical illness. The overall acceptability of high school education warrants further exploration.

Demonstrating the impact of POLST forms on hospital care requires information not contained in state registries

Background

Physician Orders for Life-Sustaining Treatment (POLST) programs have expanded rapidly, but evaluating their impact on hospital care is challenging.

Objectives

To demonstrate how careful study design can reveal POLST’s impact at hospital admission and why analyses of state registry data are unlikely to capture POLST’s effects.

Design

Prospective cohort study.

Setting and participants

Adult in-patients with Do Not Intubate and/or Do Not Resuscitate (DNR/I) orders in the electronic medical record at the time of discharge from Johns Hopkins Hospital over 18 months. For patients with unplanned readmissions within 30 days, records were reviewed to determine if a Maryland Medical Order for Life-Sustaining Treatment (MOLST) form was presented and for the time from readmission to a DNR/I order in the EMR. Analyses were stratified by whether patients could communicate or were accompanied by a proxy at readmission.

Results

Among 1,507 patients with DNR/I orders at discharge, 124 (8%) had unplanned readmissions, 112 (90%) could communicate or were accompanied by a proxy at readmission, and 12 (10%) could not communicate and were unaccompanied. For patients who were unaccompanied and could not communicate, MOLST significantly decreased the median time from readmission to DNR/I order (1.2 vs 27.1 hours, P = .001), but this association was greatly attenuated among patients who could communicate or were accompanied by a proxy (16.4 vs 25.4 hours P = .10).

Conclusion

Among patients who wanted to avoid intubation and/or CPR, MOLST forms were protective when the patient was unaccompanied by a healthcare proxy at admission and could not communicate. Fewer than 10% of patients met these criteria during unplanned readmissions, and state registry data does not allow this sub-population to be identified.

Improving hospital-based communication and decision-making about scope of treatment using a standard documentation tool

Background

The Vancouver Island Health Authority (VIHA) implemented a standard advance care planning (ACP) document called the medical order for scope of treatment (MOST) in February 2016 to improve end of life communication and documentation. This study aims to see if the MOST implementation improves inpatient ACP documentation when compared with the ‘do not resuscitate’ (DNR) order. Improvement is measured by: (1) proportion of inpatients with documented orders for life-sustaining treatment, (2) discordance between patient’s expressed wishes and chart documentation, (3) patient satisfaction and (4) days admitted to an acute care hospital within 90 days of study inclusion.

Methods

We performed a single-centre quality improvement study tracking the effects of MOST implementation. 329 consecutive patients were enrolled at a 215-bed community hospital located in Comox, British Columbia, Canada.

Results

The MOST integrated well into the process of care, significantly improving ACP documentation from 33% preimplementation to 100% over 8 months of implementation. MOST completion was associated with a significant decrease in discordance between patients’ wishes and documented goals of care. Patients with a MOST were significantly older and had a higher charlson comorbidity score than those without a MOST. Despite this, there was no difference in the number of days study patients were admitted to hospital within 90 days of study inclusion.

Conclusions

MOST implementation improves the frequency and quality of inpatient ACP documentation with no effect on acute care utilisation.

Can a patient-directed video improve inpatient advance care planning? A prospective pre-post cohort study

BACKGROUND

Patients and their families often have an inadequate understanding of the risks and benefits of their advance care planning (ACP) options. Improving patients' knowledge of therapeutic interventions allows them to better select treatments they believe are most appropriate for their condition.

OBJECTIVES

To determine if a video aimed at educating and engaging hospitalised patients on a standardised ACP order set can improve (1) inpatient understanding of key ACP concepts, (2) ACP documentation within 48 hours of hospital admission, (3) concordance between a patient's expressed and chart-documented care preferences, (4) patient satisfaction with decision-making, and (5) patient's decisional confidence.

METHODS

A prospective, non-randomised, pre-post intervention study of 252 inpatients in a 215-bed community-based hospital in Comox, British Columbia, Canada.

RESULTS

Our video decision support tool was associated with significant improvements in (1) patient understanding of key ACP concepts (70%-100%; p<0.0001), (2) ACP documentation within 48 hours of hospital admission (81%-92%; p=0.01), (3) concordance between patients' expressed wishes and chart documentation (69%-89%; p<0.0001), (4) patient satisfaction with decision-making (Canadian Health Care Evaluation Project Lite score: 4.3-4.5, p=0.001), and (5) patient's decisional confidence (patients with no decisional conflict, increased from 72% to 93%; p<0.0001).

CONCLUSION

A 13 min video aimed at educating and engaging inpatients on ACP concepts improved patient understanding of key ACP concepts, rates of ACP documentation and patient satisfaction with decision-making.

Advance care planning documentation strategies; goals-of-care as an alternative to not-for-resuscitation in medical and oncology patients. A pre-post controlled study on quantifiable outcomes

BACKGROUND

Health services in Tasmania, Victoria and now Western Australia are changing to goals-of-care (GOC) advance care planning (ACP) documentation strategies.

AIM

To compare the clinical impact of two different health department-sanctioned ACP documentation strategies.

METHODS

A non-blinded, pre-post, controlled study over two corresponding 6-month periods in 2016 and 2017 comparing the current discretional not-for-resuscitation (NFR) with a new, inclusive GOC strategy in two medical/oncology wards at a large private hospital. Main outcomes were the uptake of ACP forms per hospitalisation and the timing between hospital admission, ACP form completion and in-patient death. Secondary outcomes included utilisation of the rapid response team (RRT), palliative and critical care services.

RESULTS

In total, 650 NFR and 653 GOC patients underwent 1885 admissions (mean Charlson Comorbidity Index = 3.7). GOC patients had a higher uptake of ACP documentation (346 vs 150 ACP forms per 1000 admissions, P < 0.0001) and a higher proportion of ACP forms completed within the first 48 h of admission (58 vs 39%, P = 0.0002) but a higher incidence of altering the initial ACP level of care (P = 0.003). All other measures, including ACP documentation within 48 h of death (P = 0.50), activation of RRT (P = 0.73) and admission to critical (P = 0.62) or palliative (P = 0.81) care services, remained similar. GOC documentation was often incomplete, with most sub-sections left blank between 74 and 87% of occasions.

CONCLUSION

Despite an increased uptake of the GOC form, overall use remained low, written completion was poor, and most quantitative outcomes remained statistically unchanged. Further research is required before a wider GOC implementation can be supported in Australia's healthcare systems.

What is the evidence that people with frailty have needs for palliative care at the end of life? A systematic review and narrative synthesis

BACKGROUND

The number of older people living and dying with frailty is rising, but our understanding of their end-of-life care needs is limited.

AIM

To synthesise evidence on the end-of-life care needs of people with frailty.

DESIGN

Systematic review of literature and narrative synthesis. Protocol registered prospectively with PROSPERO (CRD42016049506).

DATA SOURCES

Fourteen electronic databases (CINAHL, Cochrane, Embase, EThOS, Google, Medline, NDLTD, NHS Evidence, NICE, Open grey, Psychinfo, SCIE, SCOPUS and Web of Science) searched from inception to October 2017 and supplemented with bibliographic screening and reference chaining. Studies were included if they used an explicit definition or measure of frailty. Quality was assessed using the National Institute for Health tool for observational studies.

RESULTS

A total of 4,998 articles were retrieved. Twenty met the inclusion criteria, providing evidence from 92,448 individuals (18,698 with frailty) across seven countries. Thirteen different measures or definitions of frailty were used. People with frailty experience pain and emotional distress at levels similar to people with cancer and also report a range of physical and psychosocial needs, including weakness and anxiety. Functional support needs were high and were highest where people with frailty were cognitively impaired. Individuals with frailty often expressed a preference for reduced intervention, but these preferences were not always observed at critical phases of care.

CONCLUSION

People with frailty have varied physical and psychosocial needs at the end of life that may benefit from palliative care. Frailty services should be tailored to patient and family needs and preferences at the end of life.

Impact of patient-centred and family-centred care meetings on intensive care and resource utilisation in patients with terminal illness: a single-centre retrospective observational study in Taiwan

OBJECTIVE

Shared decision making is essential for patients and their families when facing serious and life-threatening diseases. This study aimed to evaluate the impact of patient-centred and family-centred care meetings (PFCCM) on intensive measures and resource utilisation during end-of-life (EOL) hospitalisation among terminally ill patients.

DESIGN AND SETTING

A retrospective cross-sectional study using electronic medical records was conducted in a tertiary referral medical centre in Taiwan.

PARTICIPANTS

We identified 6843 deceased patients with terminal illness who either received or did not receive PFCCM during EOL hospitalisation between January 2013 and December 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients who were transferred to the intensive care unit (ICU). Those who underwent invasive or non-invasive mechanical ventilation, tracheostomy, haemodialysis and surgical intervention during the final hospitalisation were determined by the use of intensive care measures; secondary measures were individual total and daily medical expenditures. A generalised estimating equation (GEE) model was used to compare the differences between the two groups. OR and beta coefficients (β) with 95% CI were estimated.

RESULTS

This study identified 459 patients (6.7%) who received PFCCM during EOL hospitalisation. Multivariate analyses showed that patients who received PFCCM were less likely to have ICU admissions (OR 0.44, 95% CI 0.34 to 0.57), undergo surgical interventions (OR 0.74, 95% CI 0.58 to 0.95) and invasive mechanical ventilation (OR 0.50, 95% CI 0.38 to 0.66) during the final hospitalisation, after adjusting for patient demographics, clinical conditions and year of admission. Additionally, a significant decrease in daily medical expenditures was observed in PFCCM patients (β -0.18, 95% CI -0.25 to -0.12) than in non-PFCCM patients.

CONCLUSIONS

Patient-physician discussion through PFCCM is associated with less intensive care utilisation and daily medical expenditure during EOL hospitalisation in terminally ill patients.

Advance care planning after hospital discharge: qualitative analysis of facilitators and barriers from patient interviews

Background

Patients who engage in Advance Care Planning (ACP) are more likely to get care consistent with their values. We sought to determine the barriers and facilitators to ACP engagement after discharge from hospital.

Methods

Prior to discharge from hospital eligible patients received a standardized conversation about prognosis and ACP. Each patient was given an ACP workbook and asked to complete it over the following four weeks. We included frail elderly patients with a high risk of death admitted to general internal medicine wards at a tertiary care academic teaching hospital. Four weeks after discharge we conducted semi-structured interviews with patients. Interviews were transcribed, coded and analysed with thematic analysis. Themes were categorized according to the theoretical domains framework.

Results

We performed 17 interviews. All Theoretical Domain Framework components except for Social/Professional Identity and Behavioral Regulation were identified in our data. Poor knowledge about ACP and physician communication skills were barriers partially addressed by our intervention. Some patients found it difficult to discuss ACP during an acute illness. For others acute illness made ACP discussions more relevant. Uncertainty about future health motivated some participants to engage in ACP while others found that ACP discussions prevented them from living in the moment and stripped them of hope that better days were ahead.

Conclusions

For some patients acute illness resulting in admission to hospital can be an opportunity to engage in ACP conversations but for others ACP discussions are antithetical to the goals of hospital care.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0379-0) contains supplementary material, which is available to authorized users.

The Feasibility of Automating Assessment of Concordance Between Advance Care Preferences and Care Received Near the End of Life

BACKGROUND

End-of-life care is patient centered when it is concordant with patient preferences. Concordance has been frequently assessed by interview, chart review, or both. These time-consuming methods can constrain sample sizes, precluding population-level quality assessment. Concordance between preferences and care as measured by automated methods is described.

METHODS

Automated processes extracted and analyzed electronic health record (EHR) data to assess concordance between 15 advance care planning preference domains and 232 related end-of-life care events for 388 patients aged 65 years or older with an inpatient encounter at Kaiser Permanente Southern California who died during or after the encounter. Patient preferences were recorded in advance directives or physician orders or reflected in hospital code status. Concordance, assessed in relation to the most recent documents, orders, or code status, occurred when patients received care they preferred or did not receive nonpreferred care. Discordance occurred when patients received care they did not prefer or did not receive care they preferred.

RESULTS

Overall concordance for 12,592 observed end-of-life care events was 97.7%. A total of 55 of 4,154 (1.3%) received care events were nonpreferred, according to patient preferences in the EHR. Automated methods could not distinguish between medically nonbeneficial treatments, those that were not medically indicated, and potential undertreatment.

CONCLUSION

Automating assessment of concordance between care near the end of life and preferences is feasible but requires model refinement and discrete care preference data. Automated methods may be most valuable as a screening tool to identify potential overtreatment and undertreatment, with chart review to verify discordance.

What happens at the end of life? Using linked administrative health data to understand healthcare usage in the last year of life in New Zealand

The end of life is often associated with increased use of healthcare services. This increased use can include over-medicalisation, or over-treatment with interventions designed to cure that are likely futile in people who are dying. This is an issue with medical, ethical, and financial dimensions, and has implications for health policy, funding and the structure of care delivery. We measured the annual use of nine pre-defined public healthcare services between 1 January 2008 and 31 December 2012 by elderly New Zealanders (65-99 years old) in their last year of life and compared it with that of the cohort of elderly New Zealanders who used healthcare in the period but did not die. We used linked, encrypted unique patient identifiers to reorganise and filter records in routinely collected national healthcare utilisation and mortality administrative datasets. We found that, in New Zealand, people do seem to use more of most health services in their last year of life than those of the same age who are not in their last year of life. However, as they advance in age, particularly after the age of 90, this difference diminishes for most measures, although it is still substantial for days spent in hospital as an inpatient, and for pharmaceutical dispensings.