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Hundt B, Stevens S. Palliative Care of Stroke Patients. AACN Adv Crit Care 2024; 35:125-133. [PMID: 38848563 DOI: 10.4037/aacnacc2024489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Critical care clinicians frequently care for patients with acute brain injury, such as stroke. Regardless of the severity of the neurologic insult, these patients have life-altering deficits that threaten their personal identity and quality of life. The sudden nature of the injury often means that there has been little discussion between patients and their families about life-sustaining treatments, and most patients are unable to speak for themselves because of impaired cognition and communication. Thus, individuals experiencing stroke and their families present clinicians with unique and complex care needs in the acute care setting. Key professional organizations have endorsed the early integration of palliative care into the treatment of patients with stroke and devastating neurologic injury. Implementing interdisciplinary primary or specialty palliative care helps clinicians adopt a patient-centered approach to care and aids in decision-making.
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Affiliation(s)
- Beth Hundt
- Beth Hundt is Stroke Program Supervisor, Centra Health, 3276 Hardware River Rd, Charlottesville, VA 22903
| | - Stacie Stevens
- Stacie Stevens is Stroke Program Manager, VCU Health, Richmond, Virginia
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Muehlschlegel S. Prognostication in Neurocritical Care. Continuum (Minneap Minn) 2024; 30:878-903. [PMID: 38830074 DOI: 10.1212/con.0000000000001433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article synthesizes the current literature on prognostication in neurocritical care, identifies existing challenges, and proposes future research directions to reduce variability and enhance scientific and patient-centered approaches to neuroprognostication. LATEST DEVELOPMENTS Patients with severe acute brain injury often lack the capacity to make their own medical decisions, leaving surrogate decision makers responsible for life-or-death choices. These decisions heavily rely on clinicians' prognostication, which is still considered an art because of the previous lack of specific guidelines. Consequently, there is significant variability in neuroprognostication practices. This article examines various aspects of neuroprognostication. It explores the cognitive approach to prognostication, highlights the use of statistical modeling such as Bayesian models and machine learning, emphasizes the importance of clinician-family communication during prognostic disclosures, and proposes shared decision making for more patient-centered care. ESSENTIAL POINTS This article identifies ongoing challenges in the field and emphasizes the need for future research to ameliorate variability in neuroprognostication. By focusing on scientific methodologies and patient-centered approaches, this research aims to provide guidance and tools that may enhance neuroprognostication in neurocritical care.
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Harrison DJ, Wu E, Singh R, Ghaith S, Suarez-Meade P, Brown NJ, Sherman WJ, Robinson MT, Lin MP, Lawton MT, Quinones-Hinojosa A. Primary and Specialist Palliative Care in Neurosurgery: A Narrative Review and Bibliometric Analysis of Glioblastoma and Stroke. World Neurosurg 2023; 180:e250-e257. [PMID: 37739173 DOI: 10.1016/j.wneu.2023.09.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/10/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVE Due to the increased demand for palliative care (PC) in recent years, a model has been proposed to divide PC into primary PC and specialist PC. This article aimed to delineate the indications for primary and specialist PC within 2 common neurosurgical conditions-glioblastoma (GBM) and stroke. METHODS A systematic review and bibliometric analysis was conducted to better appreciate the practice trends in PC utilization for GBM and stroke patients using several databases. RESULTS There were 70 studies on PC for GBM, the majority of which related to patient preference (22 [31%]). During 1999-2022, there was significant growth in publications per year on this topic at a rate of approximately 0.3 publications per year (P < 0.01). There were 44 studies on PC for stroke, the majority of which related to communication strategies (14 [32%]). During 1999-2022, there was no significant growth in stroke publications per year (P = 0.22). CONCLUSIONS Due to the progressively disabling neurological course of GBM, we suggest that a specialty PC team be used in conjunction with the neurosurgical team early in the disease trajectory while patients are still able to communicate their preferences, goals, and values. In contrast, short-term and long-term stages of management of stroke have differing implications for PC needs, with the short-term stage necessitating adept, time-sensitive communication between the patient, family, and care teams. Thus, we propose that primary PC should be included as a core competency in neurosurgery training, among other stroke specialists.
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Affiliation(s)
| | - Emily Wu
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Rohin Singh
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Summer Ghaith
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Nolan J Brown
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Wendy J Sherman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - Maisha T Robinson
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA; Division of Palliative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michelle P Lin
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Goss A, Ge C, Crawford S, Goostrey K, Buddadhumaruk P, Hough CL, Lo B, Carson S, Steingrub J, White DB, Muehlschlegel S. Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study. Neurology 2023; 101:e558-e569. [PMID: 37290972 PMCID: PMC10401677 DOI: 10.1212/wnl.0000000000207462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/13/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There are no evidence-based guidelines for discussing prognosis in critical neurologic illness, but in general, experts recommend that clinicians communicate prognosis using estimates, such as numerical or qualitative expressions of risk. Little is known about how real-world clinicians communicate prognosis in critical neurologic illness. Our primary objective was to characterize prognostic language clinicians used in critical neurologic illness. We additionally explored whether prognostic language differed between prognostic domains (e.g., survival, cognition). METHODS We conducted a multicenter cross-sectional mixed-methods study analyzing deidentified transcripts of audio-recorded clinician-family meetings for patients with neurologic illness requiring intensive care (e.g., intracerebral hemorrhage, traumatic brain injury, severe stroke) from 7 US centers. Two coders assigned codes for prognostic language type and domain of prognosis to each clinician prognostic statement. Prognostic language was coded as probabilistic (estimating the likelihood of an outcome occurring, e.g., "80% survival"; "She'll probably survive") or nonprobabilistic (characterizing outcomes without offering likelihood; e.g., "She may not survive"). We applied univariate and multivariate binomial logistic regression to examine independent associations between prognostic language and domain of prognosis. RESULTS We analyzed 43 clinician-family meetings for 39 patients with 78 surrogates and 27 clinicians. Clinicians made 512 statements about survival (median 0/meeting [interquartile range (IQR) 0-2]), physical function (median 2 [IQR 0-7]), cognition (median 2 [IQR 0-6]), and overall recovery (median 2 [IQR 1-4]). Most statements were nonprobabilistic (316/512 [62%]); 10 of 512 prognostic statements (2%) offered numeric estimates; and 21% (9/43) of family meetings only contained nonprobabilistic language. Compared with statements about cognition, statements about survival (odds ratio [OR] 2.50, 95% CI 1.01-6.18, p = 0.048) and physical function (OR 3.22, 95% 1.77-5.86, p < 0.001) were more frequently probabilistic. Statements about physical function were less likely to be uncertainty-based than statements about cognition (OR 0.34, 95% CI 0.17-0.66, p = 0.002). DISCUSSION Clinicians preferred not to use estimates (either numeric or qualitative) when discussing critical neurologic illness prognosis, especially when they discussed cognitive outcomes. These findings may inform interventions to improve prognostic communication in critical neurologic illness.
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Affiliation(s)
- Adeline Goss
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Connie Ge
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
| | - Sybil Crawford
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Kelsey Goostrey
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Praewpannanrai Buddadhumaruk
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Catherine L Hough
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Bernard Lo
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Shannon Carson
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Jay Steingrub
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Douglas B White
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Susanne Muehlschlegel
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
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Alhalabi MN, Khalaf IA, Zeilani RS, Bawadi HA, Musa AS, Nashwan AJ. Palliative care needs of Jordanian women's experience of living with stroke: a descriptive phenomenological study. BMC Palliat Care 2023; 22:106. [PMID: 37507696 PMCID: PMC10375733 DOI: 10.1186/s12904-023-01216-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Stroke is a prevalent neurological disease that can have a profound impact on women's physical, psychosocial, and spiritual well-being. In many cases, women living with stroke may have marginalized palliative care needs that are often not adequately addressed by healthcare providers. Unfortunately, the experience of women with stroke and their specific palliative care needs have been largely overlooked in research conducted in Jordan. AIM The purpose of this study is to examine the specific palliative care needs of women who have experienced a stroke and are currently living in Jordan. By conducting this research, we aim to identify the various physical, emotional, social, and spiritual needs of women with stroke and gain a better understanding of how these needs can be addressed through palliative care interventions. METHODS This research utilized a phenomenological descriptive study approach to explore the experiences of twelve women recruited from the outpatient clinic of rehabilitation centers. The data was collected through semi-structured interviews. The analysis was conducted using the method of Colaizzi (1978), which involves identifying significant statements, extracting meanings, and formulating an exhaustive description of the phenomenon under study. RESULTS The study findings uncovered three primary themes that reflect the palliative care needs of women who are currently living with stroke in Jordan, including (1) Spiritual practices, beliefs, and needs; (2) Coping with distressing symptoms; and (3) Managing the delivery of unfavorable news. DISCUSSION This study provides valuable insights into the experiences of Jordanian women living with stroke, highlighting the far-reaching consequences of this condition on various aspects of their lives. The findings reveal that stroke has a significant impact on women's physical, emotional, social, and spiritual well-being, with many facing unmet palliative care needs. By illuminating these challenges, our study underscores the importance of taking a holistic approach to stroke care that addresses the multifaceted needs of women living with stroke. Healthcare providers must consider these findings and integrate palliative care interventions into treatment plans to improve the quality of life of women living with stroke in Jordan. CONCLUSION This study provides valuable insights into the palliative care needs of women who have experienced a stroke. Our findings highlight the importance of addressing women's physical, psychosocial, and spiritual needs as part of a comprehensive approach to stroke care. We recommend integrating palliative care interventions into rehabilitation programs to improve the quality of life of women living with stroke in Jordan. By doing so, we can address the pain and complications that can arise from stroke, while also providing holistic support to address the emotional and spiritual impact of the illness. This approach has the potential to improve outcomes for women living with stroke and enhance their overall well-being.
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Affiliation(s)
- Marwa Nayef Alhalabi
- Department of Adult Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
| | - Inaam Abdulla Khalaf
- Department of Maternal and Child Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
| | - Ruqayya Sayed Zeilani
- Department of Adult Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
| | - Hala Ahmad Bawadi
- Department of Maternal and Child Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
| | - Ahmad S Musa
- Department of Adult Health Nursing, Faculty of Nursing, Al Al-Bayt University, Mafraq, Jordan
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Govind N, Ferguson C, Phillips JL, Hickman L. Palliative care interventions and end-of-life care as reported by patients' post-stroke and their families: a systematic review. Eur J Cardiovasc Nurs 2023; 22:445-453. [PMID: 36443841 DOI: 10.1093/eurjcn/zvac112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 07/20/2023]
Abstract
AIMS Internationally, there is an urgent need to implement guidelines supporting integration of palliative care into stroke clinical practice. Despite considerable advances in acute stroke management, ∼20% of all acute stroke patients die within the first 30 days. Palliative care is well established in diseases such as cancer or advanced heart failure, but evidence-based interventions of high quality are limited in stroke populations. This systematic review aims to identify and evaluate quantitative studies that describe palliative care interventions and end-of-life care as reported by patient's post-stroke and their families. METHODS AND RESULTS A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted in Cumulative Index to Nursing and Allied Health Literature, PubMed, Cochrane, Embase, Ovid, Proquest, and Scopus from 1990 to April 2021. The National Heart, Lung and Blood Institute standardized quality rating tools for quality assessment were used. Seven studies were identified, and all used descriptive quantitative designs. There were no interventional studies. The results were synthesized narratively according to the elements of palliative care interventions and end-of-life care: symptom burden and satisfaction, loss of autonomy at the end of life, and acknowledging uncertainty. CONCLUSION This review highlights the limited empirical evidence that describes palliative care interventions and end-of-life care as reported by patient's post-stroke and their families. Most of the current evidence focuses on the provision of care during the final days and hours of life, or end-of-life care, with little evidence to guide the integration of palliative care into post-stroke clinical care, especially for patients with an uncertain prognosis. Acute stroke is sudden, unexpected, and life-changing, and patients and families would benefit from well-designed targeted interventions to determine strategies that address the diverse palliative needs of this patient population. REGISTRATION PROSPERO CRD42021254536.
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Affiliation(s)
- Natalie Govind
- IMPACCT, Faculty of Health, University of Technology, PO Box 123, Broadway, Sydney, NSW 2007, Australia
| | - Caleb Ferguson
- IMPACCT, Faculty of Health, University of Technology, PO Box 123, Broadway, Sydney, NSW 2007, Australia
- School of Science, Medicine and Health, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology, PO Box 123, Broadway, Sydney, NSW 2007, Australia
- School of Nursing, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059, Australia
| | - Louise Hickman
- IMPACCT, Faculty of Health, University of Technology, PO Box 123, Broadway, Sydney, NSW 2007, Australia
- School of Science, Medicine and Health, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia
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Goss AL, Voumard RR, Engelberg RA, Curtis JR, Creutzfeldt CJ. Do They Have a Choice? Surrogate Decision-Making After Severe Acute Brain Injury. Crit Care Med 2023; 51:924-935. [PMID: 36975213 PMCID: PMC10271970 DOI: 10.1097/ccm.0000000000005850] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES In the early phase of severe acute brain injury (SABI), surrogate decision-makers must make treatment decisions in the face of prognostic uncertainty. Evidence-based strategies to communicate uncertainty and support decision-making are lacking. Our objective was to better understand surrogate experiences and needs during the period of active decision-making in SABI, to inform interventions to support SABI patients and families and improve clinician-surrogate communication. DESIGN We interviewed surrogate decision-makers during patients' acute hospitalization for SABI, as part of a larger ( n = 222) prospective longitudinal cohort study of patients with SABI and their family members. Constructivist grounded theory informed data collection and analysis. SETTING One U.S. academic medical center. PATIENTS We iteratively collected and analyzed semistructured interviews with 22 surrogates for 19 patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Through several rounds of coding, interview notes, reflexive memos, and group discussion, we developed a thematic model describing the relationship between surrogate perspectives on decision-making and surrogate experiences of prognostic uncertainty. Patients ranged from 20 to 79 years of age (mean = 55 years) and had primary diagnoses of stroke ( n = 13; 68%), traumatic brain injury ( n = 5; 26%), and anoxic brain injury after cardiac arrest ( n = 1; 5%). Patients were predominantly male ( n = 12; 63%), whereas surrogates were predominantly female ( n = 13; 68%). Two distinct perspectives on decision-making emerged: one group of surrogates felt a clear sense of agency around decision-making, whereas the other group reported a more passive role in decision-making, such that they did not even perceive there being a decision to make. Surrogates in both groups identified prognostic uncertainty as the central challenge in SABI, but they managed it differently. Only surrogates who felt they were actively deciding described time-limited trials as helpful. CONCLUSIONS In this qualitative study, not all surrogate "decision-makers" viewed themselves as making decisions. Nearly all struggled with prognostic uncertainty. Our findings underline the need for longitudinal prognostic communication strategies in SABI targeted at surrogates' current perspectives on decision-making.
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Affiliation(s)
- Adeline L Goss
- Division of Neurology, Department of Internal Medicine, Highland Hospital, Oakland, CA
| | - Rachel Rutz Voumard
- Department of Medicine, Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Clinical Ethics Unit, Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA
- Cambia Palliative Care Center of Excellence at University of Washington, Harborview Medical Center, Seattle, WA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA
- Cambia Palliative Care Center of Excellence at University of Washington, Harborview Medical Center, Seattle, WA
| | - Claire J Creutzfeldt
- Cambia Palliative Care Center of Excellence at University of Washington, Harborview Medical Center, Seattle, WA
- Department of Neurology, University of Washington, Harborview Medical Center, Seattle, WA
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Nagpal V, Osgood ML, Reidy J, Healy R, Silver B. Improving Access to Specialist Palliative Care for Patients With Catastrophic Strokes Using Best Practice Advisory- a Feasibility Study. Neurohospitalist 2023; 13:250-255. [PMID: 37441200 PMCID: PMC10334048 DOI: 10.1177/19418744231166265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
Background and Purpose The American Heart Association and American Stroke Association (AHA/ASA) strongly recommend specialty palliative care (PC) for all patients hospitalized with life-threatening or life-altering strokes to provide expert symptom management, improve communication, promote shared decision-making and relieve suffering. We piloted an intervention to remind physicians about high PC needs of their patients admitted with catastrophic stroke. Methods We worked with colleagues from medical informatics to create a "Best Practice Advisory" (BPA) to recommend a goals-of-care conversation and PC consultation for patients with a National Institutes of Health Stroke Scale (NIHSS) score of 20 or more in our electronic medical record (Epic). We evaluated the impact of this BPA, after implementation, on the number and timing of PC consults and reviewed barriers to this system change. Results The BPA was operational in Jan 2019. Data analysis showed that it fired for all patients with an entered NIHSS score of ≥20. Though a large portion of the BPAs (more than 90%) were acknowledged without documented reason (after selecting "do not order"), PC consultations per 100 patients with triggered BPA increased from the first year of implementation (11.7 in 2019) to the next 2 years (20.7 in 2020, 15.6 in 2021). Also, the providers learned to manage BPA alerts better resulting in more than 30% reduction in the number of BPA alerts fired for each patient encounter in 2020-2021 compared to 2019.
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Affiliation(s)
- Vandana Nagpal
- UMass Memorial Health, Worcester, MA, USA
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Marcey L. Osgood
- UMass Memorial Health, Worcester, MA, USA
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Jennifer Reidy
- UMass Memorial Health, Worcester, MA, USA
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Rose Healy
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Brian Silver
- UMass Memorial Health, Worcester, MA, USA
- University of Massachusetts Chan Medical School, Worcester, MA, USA
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9
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Hoda W, Bharati SJ. Palliative care in neurology patients. Int Anesthesiol Clin 2023; 61:73-79. [PMID: 37249177 DOI: 10.1097/aia.0000000000000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Wasimul Hoda
- Department of Superspeciality Anaesthesia, Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India
| | - Sachidanand J Bharati
- Department of Onco-Anaesthesia & Palliative Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, India
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10
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Khosravani H, Mahendiran M, Gardner S, Zimmermann C, Perri GA. Attitudes of Canadian stroke physicians regarding palliative care for patients with acute severe stroke: A national survey. J Stroke Cerebrovasc Dis 2023; 32:106997. [PMID: 36696725 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/05/2022] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Palliative care (PC) aims to enhance the quality of life for patients and their families when confronted with serious illness. As stroke continues to inflict high morbidity and mortality, the integration of palliative care within acute stroke care remains an important aspect of quality inpatient care. AIM This study aims to investigate the experiences and perceived barriers of PC integration for patients with acute severe stroke in Canadian stroke physicians. METHODS We conducted an anonymous, descriptive, cross-sectional web-based self-administered survey of stroke physicians in Canada who engage in acute severe stroke care. The questionnaire contained three sections related to stroke physician characteristics, practice attributes, and opinions about palliative care. Descriptive statistics, univariate, and regression analysis were performed to ascertain relations between collected variables. RESULTS Of the 132 physician associate members, 120 were surveyed with a response rate of 69 (58%). Stroke physicians reported that PC services were consulted "sometimes" and that PC services were consulted rarely for prognostication and more often for end-of-life care which they agreed was better delivered off the stroke unit. Several barriers for early integration of palliative care services were identified including uncertainty in prognosis. Stroke physicians endorsed education of both families and physicians would be beneficial. CONCLUSIONS There remain perceived barriers for integration of palliative care within the acute stroke population. Challenges include consultation of PC services, uncertainty around patient prognosis, engagement, and educational barriers. There are opportunities for further integration and collaboration between palliative care physicians and stroke physicians.
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Affiliation(s)
- Houman Khosravani
- Hurvitz Brain Sciences Program, Neurology Quality and Innovation Lab, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada; Division of Palliative Medicine, Department of Medicine, University of Toronto, Canada.
| | - Meera Mahendiran
- Department of Family and Community Medicine, University of Toronto, Canada
| | - Sandra Gardner
- Dalla Lana School of Public Health, Kunin-Lunenfeld Centre for Applied Research and Evaluation (KL-CARE), Toronto, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Division of Palliative Medicine, Department of Medicine, University of Toronto, Canada; Division of Medical Oncology, Department of Medicine, University of Toronto, Canada
| | - Giulia-Anna Perri
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Canada; Baycrest Health Sciences, University of Toronto, Canada
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11
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Brizzi K. Outpatient neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:29-48. [PMID: 36599513 DOI: 10.1016/b978-0-12-824535-4.00002-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Palliative care is an approach to patient care that focuses on enhancing quality of life through relief of physical, emotional, and spiritual sources of distress and patient-tailored discussions about goals of care. The palliative care approach can be delivered by any provider, and can occur alongside disease-modifying therapies. For patients with a serious neurologic illness or a neurodegenerative disease, neuropalliative care is a growing field focused on providing high-quality palliative care to neurology patients. There are three models of neuropalliative care delivery in the outpatient setting: a consultative model with a palliative care specialist, an integrated model with an embedded palliative care provider, and a primary palliative care model with the patient's neurology provider. The main components of an outpatient palliative care visit include symptom assessment and treatment, communication about serious illness, advance care planning, and assessment of caregiver needs. For patients with advanced illness, palliative care can help facilitate timely referral to hospice. Through a palliative care approach, outpatient care for patients with serious neurologic disease or neurodegenerative disease can focus on the issues most important to the patient, promote improved illness understanding and planning, and can improve the overall quality of care.
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Affiliation(s)
- Kate Brizzi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Medicine, Massachusetts General Hospital, Boston, MA, United States.
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12
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Neuroprognostication. Crit Care Clin 2023; 39:139-152. [DOI: 10.1016/j.ccc.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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13
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Care partner support. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:203-219. [PMID: 36599509 DOI: 10.1016/b978-0-12-824535-4.00014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Palliative care focuses on improving the quality of life of people living with serious illness and their family carers. However despite policy, clinical, and research evidence underpinning the importance of a family approach to care, as well as justification for early palliative care integration, systemic inadequacies have impeded the quality of family support. This chapter provides an overview of common concepts in caregiving, a framework through which carer well-being can be understood, and an overview of disease specific considerations for care partners. There are several main needs that are relevant to care partners across disease settings include (1) information and guidance to prepare them for the role; (2) how to alleviate discomfort for the person with illness; (3) enhancing skills for the physical tasks of the role; (4) strategies for managing the psychological, and financial implications of the care partner role; and (5) assistance in advance care planning and on preparing for the care recipient's death. Care partner coping is a result of complex interactions between stressors and mediators as they navigate chronic illness, but palliative providers with an understanding of these factors are well-positioned to address carer risk factors and provide appropriate support.
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14
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Schutz REC, Creutzfeldt CJ. Palliative care after stroke survival. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:3-11. [PMID: 36599514 DOI: 10.1016/b978-0-12-824535-4.00003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Stroke is a leading cause of both death and disability worldwide. While most research has focused on the first hours to days after acute stroke, much less is known about the experience of patients and their families living after a stroke. Stroke survivors have a high burden of physical and psychological symptoms such as pain, fatigue, and depression that are often not addressed in the postacute setting. Similarly, goals-of-care conversations that may have started during the acute hospitalization are often not followed up later. This chapter outlines the prevalence and management of common poststroke symptoms, approaches to postacute goals-of-care conversations, family needs after stroke, and provides an overview of stroke-specific hospice and end-of-life care aspects. We emphasize the need for research in each of these areas.
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Affiliation(s)
- Rachael E C Schutz
- Department of Neurology, University of Washington, Seattle, WA, United States
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15
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Greenway MRF, Robinson MT. Palliative care approaches to acute stroke in the hospital setting. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:13-27. [PMID: 36599505 DOI: 10.1016/b978-0-12-824535-4.00010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stroke is a prevalent neurologic condition that portends a high risk of morbidity and mortality such that patients impacted by stroke and their caregivers can benefit from palliative care at the time of diagnosis and throughout the disease trajectory. Clinicians who care for stroke patients should be adept at establishing rapport with patients and caregivers, delivering serious news, responding to emotions, discussing prognosis, and establishing goals of care efficiently in an acute stroke setting. Aggressive stroke care can be integrated with a palliative approach to care that involves aligning the available treatment options with a patient's values and goals of care. Reassessing the goals throughout the hospitalization provides an opportunity for continued shared decision-making about the intensity of poststroke interventions. The palliative needs for stroke patients may increase over time depending on the severity of disease, poststroke complications, stroke-related symptoms, and treatment intensity preferences. If the decision is made to transition the focus of care to comfort, the support of an interdisciplinary palliative care or hospice team can be beneficial to the patient, family members, and surrogate decision makers.
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Affiliation(s)
| | - Maisha T Robinson
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States; Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, United States.
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16
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Creutzfeldt CJ, Levitt MR, Leslie-Mazwi TM. Is Endovascular Thrombectomy for the Very Elderly? Stroke 2022; 53:2227-2229. [PMID: 35703096 DOI: 10.1161/strokeaha.122.039340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Claire J Creutzfeldt
- Department of Neurology (C.J.C., T.M.L.-M.), University of Washington, Seattle.,Cambia Palliative Care Center of Excellence (C.J.C.), University of Washington, Seattle.,Harborview Medical Center, Seattle, WA (C.J.C., M.R.L., T.M.L.-M.)
| | - Michael R Levitt
- Department of Neurological Surgery (M.R.L.), University of Washington, Seattle.,Harborview Medical Center, Seattle, WA (C.J.C., M.R.L., T.M.L.-M.)
| | - Thabele M Leslie-Mazwi
- Department of Neurology (C.J.C., T.M.L.-M.), University of Washington, Seattle.,Harborview Medical Center, Seattle, WA (C.J.C., M.R.L., T.M.L.-M.)
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17
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Comer AR, Williams LS, Bartlett S, D'Cruz L, Endris K, Marchand M, Zepeda I, Toor S, Waite C, Jawed A, Holloway R, Creutzfeldt CJ, Slaven JE, Torke AM. Palliative and End-of-Life Care After Severe Stroke. J Pain Symptom Manage 2022; 63:721-728. [PMID: 34995684 PMCID: PMC9018507 DOI: 10.1016/j.jpainsymman.2021.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The distinct illness trajectory after acute ischemic stroke demands a better understanding of the utilization of palliative care consultations (PCC) for this patient cohort. This study sought to determine the prevalence, predictors, and outcomes associated with PCC for patients hospitalized with severe ischemic stroke. METHODS This multicenter cohort study was conducted at four hospitals (2 comprehensive and 2 primary stroke centers) between January, 2016 and December, 2019. We included all patients with a discharge diagnosis of ischemic stroke and an initial National Institutes of Health Stroke Scale (NIHSS) of 10 or greater. We compared patient sociodemographic, clinical and care characteristics as well as hospital outcomes between patients who did and did not receive PCC. RESULTS The study included 1297 patients hospitalized with severe ischemic stroke. PCC occurred for 20% of all patients and this proportion varied across institutions from 11.9% to 43%. Less than half (43%) of patients who died in the hospital. In multivaraible analysis, PCC was less likely in female patients (OR .76, 95% CI .59, .99, P=0.04) but more likely in patients with higher NIHSS (OR1.95, 95% CI 1,13, 3.37, P=0.02). Patients with PCC had higher rates of moving to a plan focused on comfort measures (CMO) (P<0.01) and removal of artificial nutrition as part of a move to CMO (P<0.01). In a sub analysis of patients who died in the hospital and received PCC, patients who died on or before hospital day 3 were less likely to receive PCC than patients who died on or after hospital day 4 (24% v. 51%) (P=<0.01). CONCLUSIONS Most patients with severe stroke do not receive PCC, even among those who experience in-hospital death. The results of this study indicate there are missed opportunities for PCC to help reduce suffering after severe stroke.
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Affiliation(s)
- Amber R Comer
- Indiana University School of Health and Human Sciences (A.R.C), Indianapolis, Indiana.
| | - Linda S Williams
- Richard L. Roudebush Veterans Affairs Medical Hospital (L.S.W), Indiana University School of Medicine, Regenstrief Institute, Inc, Indianapolis, Indiana, USA
| | - Stephanie Bartlett
- Indiana University School of Health and Human Sciences (S.B., L.D., K.E., M.M., I.Z., C.W.), Indianapolis, Indiana, USA
| | - Lynn D'Cruz
- Indiana University School of Health and Human Sciences (S.B., L.D., K.E., M.M., I.Z., C.W.), Indianapolis, Indiana, USA
| | - Katlyn Endris
- Indiana University School of Health and Human Sciences (S.B., L.D., K.E., M.M., I.Z., C.W.), Indianapolis, Indiana, USA
| | - McKenzie Marchand
- Indiana University School of Health and Human Sciences (S.B., L.D., K.E., M.M., I.Z., C.W.), Indianapolis, Indiana, USA
| | - Isabel Zepeda
- Indiana University School of Health and Human Sciences (S.B., L.D., K.E., M.M., I.Z., C.W.), Indianapolis, Indiana, USA
| | - Sumeet Toor
- Indiana University School of Medicine (S.T., J.E.S.), Indianapolis, Indiana, USA
| | - Carly Waite
- Indiana University School of Health and Human Sciences (S.B., L.D., K.E., M.M., I.Z., C.W.), Indianapolis, Indiana, USA
| | - Areeba Jawed
- University Of Michigan (A.J.), Ann Arbor, Michigan, USA
| | | | | | - James E Slaven
- Indiana University School of Medicine (S.T., J.E.S.), Indianapolis, Indiana, USA
| | - Alexia M Torke
- Indiana University School of Medicine, Indiana University Center for Aging Research, Regenstrief Institute (A.M.T.), Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, Indianapolis, Indiana, USA
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18
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Reinink H, Geurts M, Melis-Riemens C, Hollander A, Kappelle J, van der Worp B. Quality of dying after acute stroke. Eur Stroke J 2021; 6:268-275. [PMID: 34746423 PMCID: PMC8564161 DOI: 10.1177/23969873211041843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/06/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction There is a lack of evidence concerning the palliative needs of patients with
acute stroke during end-of-life care. We interviewed relatives of patients
who deceased in our stroke unit about the quality of dying and compared
their experiences with those of nurses. Patients and Methods Relatives of 59 patients were interviewed approximately 6 weeks after the
patient had died. The primary outcome was a score assessing the overall
quality of dying on a scale ranging from 0 to 10, with 0 representing the
worst quality and 10 the best quality. We investigated the frequency and
appreciation of specific aspects of the dying phase with an adapted version
of the Quality of Death and Dying Questionnaire. The nurse who was most
frequently involved in the end-of-life care of the patient completed a
similar questionnaire. Results Family members were generally satisfied with the quality of dying (median
overall score 8; interquartile range, 6–9) as well as with the care provided
by nurses (9; 8–10) and doctors (8; 7–9). Breathing difficulties were
frequently reported (by 46% of the relatives), but pain was not.
Unsatisfactory experiences were related to feeding (69% unsatisfactory),
inability to say goodbye to loved ones (51%), appearing not to have control
(47%), and not retaining a sense of dignity (41%). Two-thirds of the
relatives reported that palliative medication adequately resolved
discomfort. There was a good correlation between the experiences of
relatives and nurses. Discussion and Conclusion Most relatives were satisfied with the overall quality of dying. Negative
experiences concerned feeding problems, not being able to say goodbye to
loved ones, sense of self control and dignity, and breathing difficulties.
Experiences of nurses may be a reasonable and practical option when
evaluating the quality of dying in acute stroke patients.
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Affiliation(s)
- Hendrik Reinink
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marjolein Geurts
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Neurology Erasmus Medical Center, Rotterdam, The Netherlands
| | - Constance Melis-Riemens
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annemarie Hollander
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap Kappelle
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
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19
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Riesinger R, Altmann K, Lorenzl S. Involvement of Specialist Palliative Care in a Stroke Unit in Austria-Challenges for Families and Stroke Teams. Front Neurol 2021; 12:683624. [PMID: 34630274 PMCID: PMC8492896 DOI: 10.3389/fneur.2021.683624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: Severe stroke poses vast challenges. Appropriate goals of care according to individual preferences and values have to be developed under time restrictions—often impeded by limited ability to communicate and the need for decisions by surrogates. The aim of our study was to explore the decision-making process and the involvement of specialist palliative care in the acute phase of severe stroke. Methods: Twenty patients suffering from severe ischemic stroke treated in an Austrian acute inpatient stroke unit were included in a prospective study. Their families were interviewed with a questionnaire (FS-ICU 24), which covered satisfaction with care and decision-making. With a second questionnaire, decision-making processes within the stroke team were investigated. Results: A palliative approach and early integration of specialist palliative care in severe ischemic stroke results in individualized therapeutic goals, including withholding therapeutic or life-sustaining measures, especially in patients with pre-existing illness. Conclusions: Family members benefit from understandable and consistent information, emotional support, and a professional team identifying their needs. Stroke unit professionals need skills as well as knowledge and strategies in order to make decisions and provide treatment at the end-of-life, when there may be ethical or legal issues. Close cooperation with specialist palliative care services supports both treatment teams and families with communication and decision-making for patients with severe ischemic stroke.
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Affiliation(s)
- Renate Riesinger
- Department of Palliative Care, Hospital Barmherzige Schwestern, Ried im Innkreis, Austria
| | - Klaus Altmann
- Department of Neurology, Hospital Barmherzige Schwestern, Ried im Innkreis, Austria
| | - Stefan Lorenzl
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria.,Ludwig-Maximilians-University, Munich, Germany.,Department of Neurology, Klinikum Agatharied, Hausham, Germany
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20
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Abstract
The palliative care needs of inpatients with neurologic illness are varied, depending on diagnosis, acuity of illness, available treatment options, prognosis, and goals of care. Inpatient neurologists ought to be proficient at providing primary palliative care and effective at determining when palliative care consultants are needed. In the acute setting, palliative care should be integrated with lifesaving treatments using a framework of determining goals of care, thoughtfully prognosticating, and engaging in shared decision-making. This framework remains important when aggressive treatments are not desired or not available, or when patients are admitted to the hospital for conditions related to advanced stages of chronic neurologic disease. Because prognostic uncertainty characterizes much of neurology, inpatient neurologists must develop communication strategies that account for uncertainty while supporting shared decision-making and allowing patients and families to preserve hope. In this article, we illustrate the approach to palliative care in inpatient neurology.
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Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, San Francisco, California
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21
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Young MJ, Regenhardt RW, Sokol LL, Leslie-Mazwi TM. When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative? AMA J Ethics 2021; 23:E783-793. [PMID: 34859772 PMCID: PMC8684539 DOI: 10.1001/amajethics.2021.783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Noncurative surgeries intended to relieve suffering during serious illness or near end of life have been analyzed across palliative settings. Yet sparse guidance is available to inform clinical management decisions about whether, when, and which interventions should be offered when ischemic stroke and other neurological complications occur in patients whose survival is extended by other novel disease-modifying interventions. This case commentary examines key ethical and clinical considerations in palliative neuroendovascular care of patients with acute stroke.
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Affiliation(s)
- Michael J Young
- Fellow in neurology at Massachusetts General Hospital and Brigham and Women's Hospital in Boston
| | - Robert W Regenhardt
- Neuroendovascular fellow and stroke scientist at Massachusetts General Hospital in Boston
| | - Leonard L Sokol
- Neurology resident physician at Northwestern University in Evanston, Illinois
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22
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Gao L, Zhao CW, Hwang DY. End-of-Life Care Decision-Making in Stroke. Front Neurol 2021; 12:702833. [PMID: 34650502 PMCID: PMC8505717 DOI: 10.3389/fneur.2021.702833] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/31/2021] [Indexed: 12/21/2022] Open
Abstract
Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.
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Affiliation(s)
- Lucy Gao
- Yale School of Medicine, New Haven, CT, United States
| | | | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, United States
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23
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Cowey E, Schichtel M, Cheyne JD, Tweedie L, Lehman R, Melifonwu R, Mead GE. Palliative care after stroke: A review. Int J Stroke 2021; 16:632-639. [PMID: 33949268 PMCID: PMC8366189 DOI: 10.1177/17474930211016603] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care is an integral aspect of stroke unit care. In 2016, the American Stroke Association published a policy statement on palliative care and stroke. Since then there has been an expansion in the literature on palliative care and stroke. AIM Our aim was to narratively review research on palliative care and stroke, published since 2015. RESULTS The literature fell into three broad categories: (a) scope and scale of palliative care needs, (b) organization of palliative care for stroke, and (c) shared decision making. Most literature was observational. There was a lack of evidence about interventions that address specific palliative symptoms or improve shared decision making. Racial disparities exist in access to palliative care after stroke. There was a dearth of literature from low- and middle-income countries. CONCLUSION We recommend further research, especially in low- and middle-income countries, including research to explore why racial disparities in access to palliative care exist. Randomized trials are needed to address specific palliative care needs after stroke and to understand how best to facilitate shared decision making.
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Affiliation(s)
- Eileen Cowey
- Nursing & Health Care School, University of Glasgow, Glasgow, UK
| | - Markus Schichtel
- Institute of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Joshua D Cheyne
- Cochrane Stroke Group, Centre for Clinical Brain Sciences (CCBS), University of Edinburgh, Edinburgh, UK
| | | | - Richard Lehman
- Institute of Applied Health Research, Murray Learning Centre, University of Birmingham, Birmingham, UK
| | - Rita Melifonwu
- Life After Stroke Centre, Stroke Action Nigeria, Onitsha, Nigeria
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24
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Levy SA, Pedowitz E, Stein LK, Dhamoon MS. Healthcare Utilization for Stroke Patients at the End of Life: Nationally Representative Data. J Stroke Cerebrovasc Dis 2021; 30:106008. [PMID: 34330019 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/20/2021] [Accepted: 07/10/2021] [Indexed: 10/20/2022] Open
Abstract
Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.
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Affiliation(s)
- Sarah A Levy
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
| | - Elizabeth Pedowitz
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, United States.
| | - Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
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Adapting to a New Normal After Severe Acute Brain Injury: An Observational Cohort Using a Sequential Explanatory Design. Crit Care Med 2021; 49:1322-1332. [PMID: 33730742 PMCID: PMC8282680 DOI: 10.1097/ccm.0000000000004947] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Treatment decisions following severe acute brain injury need to consider patients' goals-of-care and long-term outcomes. Using family members as respondents, we aimed to assess patients' goals-of-care in the ICU and explore the impact of adaptation on survivors who did not reach the level of recovery initially considered acceptable. DESIGN Prospective, observational, mixed-methods cohort study. SETTING Comprehensive stroke and level 1 trauma center in Pacific Northwest United States. PARTICIPANTS Family members of patients with severe acute brain injury in an ICU for greater than 2 days and Glasgow Coma Scale score less than 12. MEASUREMENTS AND MAIN RESULTS At enrollment, we asked what level of physical and cognitive recovery the patient would find acceptable. At 6 months, we assessed level of recovery through family surveys and chart review. Families of patients whose outcome was below that considered acceptable were invited for semistructured interviews, examined with content analysis. RESULTS For 184 patients, most family members set patients' minimally acceptable cognitive recovery at "able to think and communicate" or better (82%) and physical recovery at independence or better (66%). Among 170 patients with known 6-month outcome, 40% had died in hospital. Of 102 survivors, 33% were able to think and communicate, 13% were independent, and 10% died after discharge. Among survivors whose family member had set minimally acceptable cognitive function at "able to think and communicate," 64% survived below that level; for those with minimally acceptable physical function at independence, 80% survived below that. Qualitative analysis revealed two key themes: families struggled to adapt to a new, yet uncertain, normal and asked for support and guidance with ongoing treatment decisions. CONCLUSIONS AND RELEVANCE Six months after severe acute brain injury, most patients survived to a state their families initially thought would not be acceptable. Survivors and their families need more support and guidance as they adapt to a new normal and struggle with persistent uncertainty.
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Connolly T, Coats H, DeSanto K, Jones J. The experience of uncertainty for patients, families and healthcare providers in post-stroke palliative and end-of-life care: a qualitative meta-synthesis. Age Ageing 2021; 50:534-545. [PMID: 33206952 DOI: 10.1093/ageing/afaa229] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Indexed: 01/14/2023] Open
Abstract
PURPOSE recent data show that there is limited evidence and guidance regarding the best practices for the integration of palliative care (PC) and end-of-life (EOL) post-stroke. The purpose of this meta-synthesis is to understand the PC/EOL experiences after a stroke. METHODS a meta-synthesis was conducted to answer the following research question-What are post-stroke PC/EOL experiences from the perspectives of patients, families and healthcare professionals (HCPs)? This approach was completed through two main phases-a systematic search and appraisal of the literature and reciprocal translation with interpretive triangulation of the extracted data. Databases searched were MEDLINE, EMBASE, PsycINFO, Joanna Briggs Institute and CINAHL databases (from their inception to April 2020). After data were extracted, a qualitative exploratory design was used to evaluate the PC/EOL in post-stroke experiences. RESULTS the search identified 696 studies. A total of 14 studies were included in this meta-synthesis as they satisfied our eligibility criteria. Uncertainty post-stroke was the overarching main theme that emerged across post-stroke PC/EOL experiences. Within this theme of uncertainty, opportunities to decrease uncertainty emerged from two interdependent themes-presence of cohesive communication and shared dynamic decision process for both families and HCPs. CONCLUSIONS to mitigate the degree of uncertainty post-stroke, HCPs should be present, provide clear direct communication and incorporate the value-based goals of care within their medical treatment plan. These findings suggest that future research is needed to focus on how PC approaches can be integrated into stroke care programmes.
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Affiliation(s)
- Teresa Connolly
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Heather Coats
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristen DeSanto
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jacqueline Jones
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Nair KPS, Chandler B, Lee M, Oliver D, Sansam K, King L, Paisley S, Sutton A, Cantrell A. Rehabilitation medicine in palliative care of chronic neurological conditions. BMJ Support Palliat Care 2020; 13:154-160. [DOI: 10.1136/bmjspcare-2020-002415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 11/03/2022]
Abstract
BackgroundPeople living with long-term neurological conditions (LTNC) often require palliative care. Rehabilitation medicine specialists often coordinate the long-term care of these patients.ObjectiveThe aim of the present review was to undertake systematic literature searches to identify the evidence on palliative care for people with LTNC to guide rehabilitation medicine specialists caring for these patients in the UK.MethodsWe searched for evidence for (1) discussion of end of life, (2) planning for end-of-life care, (3) brief specialist palliative care interventions, (4) support for family and carers, (5) training of rehabilitation medicine specialists in palliative care, and (6) commissioning of services. The databases searched were MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database and Health Technology Assessment Database. Evidence was assimilated using a simplified version of the Grading of Recommendations Assessment, Development and Evaluation method.ResultsWe identified 2961 records through database searching for neurological conditions and 1261 additional records through database searches for specific symptoms. We removed duplicate records and conference presentations. We screened 3234 titles and identified 330 potentially relevant abstracts. After reading the abstracts we selected 34 studies for inclusion in the evidence synthesis.ConclusionsFrom the evidence reviewed we would like to recommend that we move forward by establishing a closer working relationship with specialists in palliative care and rehabilitation medicine and explore the implications for cross-specialty training.
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Lillemoe K, Lord A, Torres J, Ishida K, Czeisler B, Lewis A. Factors Associated With DNR Status After Nontraumatic Intracranial Hemorrhage. Neurohospitalist 2020; 10:168-175. [PMID: 32549939 DOI: 10.1177/1941874419873812] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage. Methods We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status. Results Of 88 patients who met inclusion criteria, 6 (7%) were do not resuscitate (DNR) on admission (aDNR). Do not resuscitate on admission patients were significantly older than those who were full code on admission (P = 0.04). There was no significant difference between admission code status and sex, marital status, active cancer, premorbid mRS, admission Glasgow Coma scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, or bleed severity. At discharge, 66 (75%) patients were full code (dFULL), 11 (13%) were DNR (dDNR), and 11 (13%) were comfort care. African American and Hispanic patients were significantly more likely to be dFULL than Asian or white patients (P = .01) and less likely to be seen by palliative care (P = .004). Patients with less aggressive code status had higher median APACHE II scores (P = .008) and were more likely to have active cancer (P = .06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity. Conclusions Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.
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Affiliation(s)
- Kaitlyn Lillemoe
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Aaron Lord
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Jose Torres
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Koto Ishida
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Barry Czeisler
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
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Mendlik MT, McFarlin J, Kluger BM, Vaughan CL, Phillips JN, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Neurologic Illnesses. J Palliat Med 2020; 22:193-198. [PMID: 30707071 DOI: 10.1089/jpm.2018.0617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with neurologic illnesses are commonly encountered by palliative care (PC) clinicians though many clinicians feel uncomfortable caring for these patients. Understanding how to diagnose, treat, communicate with, and prognosticate for neurology patients will improve the confidence and competence of PC providers in the neurology setting. This article offers PC providers 10 useful tips that neurologists with PC training think all PC providers should know to improve care for patients with neurologic illness.
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Affiliation(s)
- Matthew T Mendlik
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica McFarlin
- 2 Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Benzi M Kluger
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Christina L Vaughan
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joel N Phillips
- 4 Mercy Health Hauenstein Neurosciences, Grand Rapids, Michigan
| | - Christopher A Jones
- 5 Perelman School of Medicine and Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
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Visvanathan A, Mead GE, Dennis M, Whiteley WN, Doubal FN, Lawton J. The considerations, experiences and support needs of family members making treatment decisions for patients admitted with major stroke: a qualitative study. BMC Med Inform Decis Mak 2020; 20:98. [PMID: 32487145 PMCID: PMC7268726 DOI: 10.1186/s12911-020-01137-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2020] [Indexed: 12/01/2022] Open
Abstract
Background Treatment decision-making by family members on behalf of patients with major stroke can be challenging because of the shock of the diagnosis and lack of knowledge of the patient’s treatment preferences. We aimed to understand how, and why, family members made certain treatment decisions, and explored their information and support needs. Method Semi-structured interviews with family members (n = 24) of patients with major stroke, within 2 weeks of hospital admission. Data were analysed thematically. Results Families’ approach to treatment decision-making lay on a spectrum according to the patient’s state of health pre-stroke (i.e. patient’s prior experience of illness and functional status) and any views expressed about treatment preferences in the event of life-threatening illness. Support and information needs varied according to where they were on this spectrum. At one extreme, family members described deciding not to initiate life-extending treatments from the outset because of the patients’ deteriorating health and preferences expressed pre-stroke. Information from doctors about poor prognosis was merely used to confirm this decision. In the middle of the spectrum were family members of patients who had been moderately independent pre-stroke. They described the initial shock of the diagnosis and how they had initially wanted all treatments to continue. However, once they overcame their shock, and had gathered relevant information, including information about poor prognosis from doctors, they decided that life-extending treatments were no longer appropriate. Many reported this process to be upsetting and expressed a need for psychological support. At the other end of the spectrum were family members of previously independent patients whose preferences pre-stroke had not been known. Family members described feeling extremely distressed at such an unexpected situation and wanting all treatments to continue. They described needing psychological support and hope that the patient would survive. Conclusion The knowledge that family members’ treatment decision-making approaches lay on a spectrum depending on the patient’s state of health and stated preferences pre-stroke may allow doctors to better prepare for discussions regarding the patient’s prognosis. This may enable doctors to provide information and support that is tailored towards family members’ needs.
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Affiliation(s)
- A Visvanathan
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK.
| | - G E Mead
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - M Dennis
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - W N Whiteley
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - F N Doubal
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - J Lawton
- Usher Institute, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
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Rezaei F, Reamazannezhad N, Douki MF, Shayadeh FS, Nejati E, Ahmadian Z. Nursing care (palliative medicine) in patients with neuropsychiatric disorders. J Family Med Prim Care 2020; 9:25-30. [PMID: 32110560 PMCID: PMC7014906 DOI: 10.4103/jfmpc.jfmpc_701_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/27/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Palliative medicine is a special status focusing on the quality of life of patients suffering from special or advanced diseases. Palliative medicine can be helpful at any stage of the disease, including the diagnosis. Thus, the present study aims at reviewing the application of palliative care in mental disorders. METHOD In the present study, as many as 1,149 studies were found in the period of 1985 to 2018 by searching on different websites including Medline, Embase, ProQuest, Global Health, GoogleScholar, and Scopus. As many as 53 studies having to do with mental disorders were found, and more specifically, as many as 36 articles related to palliative medicine were applied. FINDINGS Reviewing the related literature indicates that the care needs of mental disorders patients are quite complicated. The findings indicated that predicting the complications of the disease, as well as advanced planning in terms of caring for these patients, are of significant importance. The findings indicated that over the last decade two palliative care models have been developed: integrative and consultative. CONCLUSION With the growth development of palliative care in developed countries, the knowledge of palliative care can be shared with the nurses and practitioners of neurological diseases, and this knowledge can be applied to palliate and reduce the pains and sufferings of the patients and their families.
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Affiliation(s)
- Fatemeh Rezaei
- Department of Nursing and Midwifery, Golestan University of Medical Sciences, Golestan, Babol, Iran.,Department of Nursing, Islamic Azad University, Babol Branch, Babol, Iran
| | | | | | | | - Elahe Nejati
- Department of Nursing, Yahyanejad Hospital, Babol, Iran
| | - Zaynab Ahmadian
- Department of Nursing, Nursing and Midwifery School, Islamic Azad University, Babol Branch, Babol, Iran
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Steigleder T, Kollmar R, Ostgathe C. Palliative Care for Stroke Patients and Their Families: Barriers for Implementation. Front Neurol 2019; 10:164. [PMID: 30894836 PMCID: PMC6414790 DOI: 10.3389/fneur.2019.00164] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/07/2019] [Indexed: 11/17/2022] Open
Abstract
Stroke is a leading cause of death, disability and is a symptom burden worldwide. It impacts patients and their families in various ways, including physical, emotional, social, and spiritual aspects. As stroke is potentially lethal and causes severe symptom burden, a palliative care (PC) approach is indicated in accordance with the definition of PC published by the WHO in 2002. Stroke patients can benefit from a structured approach to palliative care needs (PCN) and the amelioration of symptom burden. Stroke outcome is uncertain and outlook may change rapidly. Regarding these challenges, core competencies of PC include the critical appraisal of various treatment options, and openly and respectfully discussing therapeutic goals with patients, families, and caregivers. Nevertheless, PC in stroke has to date mainly been restricted to short care periods for dying patients after life-limiting complications. There is currently no integrated concept for PC in stroke care addressing the appropriate moment to initiate PC for stroke patients, and the question of how to screen for symptoms remains unanswered. Therefore, PC for stroke patients is often perceived as a stopgap in cases of unfavorable prognosis and very short survival times. In contrast, PC can provide much more for stroke patients and support a holistic approach, improve quality of life and ensure treatment according to the patient's wishes and values. In this short review we identify key aspects of PC in stroke care and current barriers to implementation. Additionally, we provide insights into our approach to PC in stroke care.
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Affiliation(s)
- Tobias Steigleder
- Department of Palliative Care, University Hospital Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Rainer Kollmar
- Department of Neurology and Neurointensive Care, Darmstadt Academic Hospital, Darmstadt, Germany
| | - Christoph Ostgathe
- Department of Palliative Care, University Hospital Erlangen-Nuremberg, Erlangen, Germany
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Mehta AK, Najjar S, May N, Shah B, Blackhall L. A Needs Assessment of Palliative Care Education among the United States Adult Neurology Residency Programs. J Palliat Med 2018; 21:1448-1457. [DOI: 10.1089/jpm.2018.0191] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Ambereen K. Mehta
- Division of General Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Salim Najjar
- School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Natalie May
- Department of Biomedical Sciences Graduate Program, University of Virginia Health System, Charlottesville, Virginia
| | - Binit Shah
- Depatment of Neurology, University of Virginia Health System, Charlottesville, Virginia
| | - Leslie Blackhall
- Division of General Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, University of Virginia, Charlottesville, Virginia
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35
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Palliative care education in U.S. adult neuro-oncology fellowship programs. J Neurooncol 2018; 140:377-383. [DOI: 10.1007/s11060-018-2963-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/30/2018] [Indexed: 10/28/2022]
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37
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Williams MT, Zimmerman E, Barry M, Trantum L, Dietrich MS, Doersam JK, Karlekar M. A Retrospective Review of Patients With Acute Stroke With and Without Palliative Care Consultations. Am J Hosp Palliat Care 2018; 36:60-64. [PMID: 29991277 DOI: 10.1177/1049909118787136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Despite advances in stroke care, patients continue to incur significant disability, are at risk for future events, and are inconsistently comanaged with palliative care (PC) specialty teams. The purpose of this study was to review patients with stroke admitted to our institution, comparing patients with and without PC consultation. We retrospectively reviewed medical record data of all patients with stroke admitted to our neurosciences ICU (NICU) in July 2014 to June 2015 with and without PC consultation. Review focused on stroke type, patient demographics, median days to discharge and death, and posthospitalization discharge. Of 463 patients admitted to the NICU with a stroke diagnosis, 27% (125/463) had (PC) consultation. A higher percentage of the patients with PC consult presented with hemorrhagic stroke than those without PC consult (38% vs 21%, P < .001). Patients with PC consult had longer median days to discharge and death ( P < .001) and a higher percentage of mortality (32% vs 11%). Of the 301 patients without PC consult who discharged (89.1%), 36.5% discharged to inpatient rehab while 10% discharged to a skilled nursing facility. In comparison, of the patients with PC consultation who discharged alive (41.1%), 15.7% discharged to inpatient rehab whereas 39% discharged to skilled nursing ( P < .001). The uncertainty of which patients with stroke benefit most from specialty PC is highlighted in that although sicker patients are referred to PC, a substantial portion (41%) of these patients discharge alive, of which 39.2% discharged to skilled nursing. Future research should focus on which patients with stroke would benefit from specialty PC.
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Affiliation(s)
- Molly T Williams
- 1 Division of Internal Medicine, Palliative Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eli Zimmerman
- 2 Division of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Megan Barry
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lindsay Trantum
- 4 Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mary S Dietrich
- 5 Vanderbilt University School of Nursing, Nashville, TN, USA
| | | | - Mohana Karlekar
- 1 Division of Internal Medicine, Palliative Care, Vanderbilt University Medical Center, Nashville, TN, USA
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Creutzfeldt CJ, Kluger B, Kelly AG, Lemmon M, Hwang DY, Galifianakis NB, Carver A, Katz M, Curtis JR, Holloway RG. Neuropalliative care: Priorities to move the field forward. Neurology 2018; 91:217-226. [PMID: 29950434 DOI: 10.1212/wnl.0000000000005916] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/06/2018] [Indexed: 11/15/2022] Open
Abstract
Neuropalliative care is an emerging subspecialty in neurology and palliative care. On April 26, 2017, we convened a Neuropalliative Care Summit with national and international experts in the field to develop a clinical, educational, and research agenda to move the field forward. Clinical priorities included the need to develop and implement effective models to integrate palliative care into neurology and to develop and implement informative quality measures to evaluate and compare palliative approaches. Educational priorities included the need to improve the messaging of palliative care and to create standards for palliative care education for neurologists and neurology education for palliative specialists. Research priorities included the need to improve the evidence base across the entire research spectrum from early-stage interventional research to implementation science. Highest priority areas include focusing on outcomes important to patients and families, developing serious conversation triggers, and developing novel approaches to patient and family engagement, including improvements to decision quality. As we continue to make remarkable advances in the prevention, diagnosis, and treatment of neurologic illness, neurologists will face an increasing need to guide and support patients and families through complex choices involving immense uncertainty and intensely important outcomes of mind and body. This article outlines opportunities to improve the quality of care for all patients with neurologic illness and their families through a broad range of clinical, educational, and investigative efforts that include complex symptom management, communication skills, and models of care.
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Affiliation(s)
- Claire J Creutzfeldt
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle.
| | - Benzi Kluger
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Adam G Kelly
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Monica Lemmon
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - David Y Hwang
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Nicholas B Galifianakis
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Alan Carver
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Maya Katz
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - J Randall Curtis
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Robert G Holloway
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
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Quadri SZ, Huynh T, Cappelen-Smith C, Wijesuriya N, Mamun A, Beran RG, McDougall AJ, Cordato D. Reflection on stroke deaths and end-of-life stroke care. Intern Med J 2018; 48:330-334. [PMID: 28892278 DOI: 10.1111/imj.13619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 09/03/2017] [Accepted: 09/05/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The benefit of palliative care referral for severe stroke patients on end-of-life care pathway (EOLCP) is increasingly recognised. Palliative care provides assistance with symptom management and transition to end-of-life care. Advance care planning (ACP) may help accommodate patient/family expectations and guide management. METHODS This is a retrospective study of all stroke deaths (2014-2015) at Liverpool Hospital, Sydney, Australia. Data examined included age, comorbidities, living arrangements, pre-existing ACP, palliative care referral rates and 'survival time'. RESULTS In total, 123 patient (mean age ± SD = 76 ± 13 years) deaths were identified from 1067 stroke admissions (11.5% mortality); 64 (52%) patients had ischaemic stroke and 59 (48%) intracerebral haemorrhage (ICH), and 40% suffered a prior stroke, and 43% required a carer at home or were in an aged care facility. Survival time from admission was significantly longer in patients with ischaemic stroke compared to intracerebral haemorrhage (median, interquartile range [IQR]: 9.5 [18] vs 2 [4] days, P < 0.001). Only two patients had pre-existing ACP; 44% of patients were referred to palliative care and 41% were commenced on dedicated EOLCP. Palliative care referral was less likely in patients who died under neurosurgery. EOLCP were significantly less likely to be commenced in patients who underwent acute intervention or were not referred to palliative care. CONCLUSION In this cohort, palliative care referral and EOLCP were commenced in less than 50% of patients, highlighting significant variations in clinical care. These data support the need to promote awareness of ACP, particularly in patients with prior stroke or significant comorbidities. This may help reduce potentially futile invasive investigations and treatment.
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Affiliation(s)
- Syed Z Quadri
- Department of Palliative Medicine, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Thang Huynh
- Department of Palliative Medicine, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
| | - Nirupama Wijesuriya
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
| | - Abul Mamun
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
| | - Roy G Beran
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
- School of Medicine, Griffith University, Queensland, Australia
| | - Alan J McDougall
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
| | - Dennis Cordato
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
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Robinson MT, Holloway RG. Palliative Care in Neurology. Mayo Clin Proc 2017; 92:1592-1601. [PMID: 28982489 DOI: 10.1016/j.mayocp.2017.08.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 07/25/2017] [Accepted: 08/07/2017] [Indexed: 12/12/2022]
Abstract
Palliative medicine is a specialty that focuses on improving the quality of life for patients with serious or advanced medical conditions, and it is appropriate at any stage of disease, including at the time of diagnosis. Neurologic conditions tend to have high symptom burdens, variable disease courses, and poor prognoses that affect not only patients but also their families and caregivers. Patients with a variety of neurologic conditions such as Parkinson disease, dementia, amyotrophic lateral sclerosis, brain tumors, stroke, and acute neurologic illnesses have substantial unmet needs that can be addressed through a combination of primary and specialty palliative care. The complex needs of these patients are ideally managed with a comprehensive approach to care that addresses the physical, psychological, social, and spiritual aspects of care in an effort to reduce suffering. Early discussions about prognosis, goals of care, and advance care planning are critical as they can provide guidance for treatment decisions and allow patients to retain a sense of autonomy despite progressive cognitive or functional decline. With the rapid growth in palliative care across the United States, there are opportunities to improve the palliative care knowledge of neurology trainees, the delivery of palliative care to patients with neurologic disease by both neurologists and nonneurologists, and the research agenda for neuropalliative care.
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Affiliation(s)
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
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Singh T, Peters SR, Tirschwell DL, Creutzfeldt CJ. Palliative Care for Hospitalized Patients With Stroke: Results From the 2010 to 2012 National Inpatient Sample. Stroke 2017; 48:2534-2540. [PMID: 28818864 PMCID: PMC5571885 DOI: 10.1161/strokeaha.117.016893] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Substantial variability exists in the use of life-prolonging treatments for patients with stroke, especially near the end of life. This study explores patterns of palliative care utilization and death in hospitalized patients with stroke across the United States. METHODS Using the 2010 to 2012 nationwide inpatient sample databases, we included all patients discharged with stroke identified by International Classification of Diseases-Ninth Revision codes. Strokes were subclassified as ischemic, intracerebral, and subarachnoid hemorrhage. We compared demographics, comorbidities, procedures, and outcomes between patients with and without a palliative care encounter (PCE) as defined by the International Classification of Diseases-Ninth Revision code V66.7. Pearson χ2 test was used for categorical variables. Multivariate logistic regression was used to account for hospital, regional, payer, and medical severity factors to predict PCE use and death. RESULTS Among 395 411 patients with stroke, PCE was used in 6.2% with an increasing trend over time (P<0.05). We found a wide range in PCE use with higher rates in patients with older age, hemorrhagic stroke types, women, and white race (all P<0.001). Smaller and for-profit hospitals saw lower rates. Overall, 9.2% of hospitalized patients with stroke died, and PCE was significantly associated with death. Length of stay in decedents was shorter for patients who received PCE. CONCLUSIONS Palliative care use is increasing nationally for patients with stroke, especially in larger hospitals. Persistent disparities in PCE use and mortality exist in regards to age, sex, race, region, and hospital characteristics. Given the variations in PCE use, especially at the end of life, the use of mortality rates as a hospital quality measure is questioned.
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Affiliation(s)
- Tarvinder Singh
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle.
| | - Steven R Peters
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| | - David L Tirschwell
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| | - Claire J Creutzfeldt
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
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Abstract
The Neuro-ICU is a multidisciplinary location that presents peculiar challenges and opportunities for patients with life-threatening neurological disease. Communication skills are essential in supporting caregivers and other embedded providers (e.g., neurosurgeons, advanced practice providers, nurses, pharmacists), through leadership. Limitations to prognostication complicate how decisions are made on behalf of non-communicative patients. Cognitive dysfunction and durable reductions in health-related quality of life are difficult to predict, and the diagnosis of brain death may be challenging and confounded by medications and comorbidities. The Neuro-ICU team, as well as utilization of additional consultants, can be structured to optimize care. Future research should explore how to further improve the composition, communication and interactions of the Neuro-ICU team to maximize outcomes, minimize caregiver burden, and promote collegiality.
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George BP, Kelly AG, Albert GP, Hwang DY, Holloway RG. Timing of Percutaneous Endoscopic Gastrostomy for Acute Ischemic Stroke. Stroke 2017; 48:420-427. [DOI: 10.1161/strokeaha.116.015119] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/07/2016] [Accepted: 11/18/2016] [Indexed: 12/22/2022]
Abstract
Background and Purpose—
Stroke guidelines recommend time-limited trials of nasogastric feeding prior to percutaneous endoscopic gastrostomy (PEG) tube placement. We sought to describe timing of PEG placement and identify factors associated with early PEG for acute ischemic stroke.
Methods—
We designed a retrospective observational study to examine time to PEG for ischemic stroke admissions in the Nationwide Inpatient Sample, 2001 to 2011. We defined early PEG placement as 1 to 7 days from admission. Using multivariable regression analysis, we identified the effects of patient and hospital characteristics on PEG timing.
Results—
We identified 34 623 admissions receiving a PEG from 2001 to 2011, 53% of which received the PEG 1 to 7 days from admission. Among hospitals placing ≥10 PEG tubes, median time to PEG for individual hospitals ranged from 3 days to over 3 weeks (interquartile range 6–8.5 days). Older adult age groups were associated with early PEG (≥85 years versus 18–54 years: adjusted odds ratio 1.68, 95% confidence interval 1.50–1.87). Those receiving a PEG and tracheostomy were more likely to receive the PEG beyond 7 days, and these patients were more often younger compared with PEG only recipients. Those admitted to high-volume hospitals were more likely to receive their PEG early (≥350 versus <150 hospitalizations; adjusted odds ratio 1.26, 95% confidence interval 1.17–1.35).
Conclusions—
More than half of the PEG recipients received their surgical feeding tube within 7 days of admission. The oldest old, who may benefit most from time-limited trials of nasogastric feeding for ≥2 to 3 weeks, were most likely to receive a PEG within 7 days.
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Affiliation(s)
- Benjamin P. George
- From the Department of Neurology, University of Rochester Medical Center, NY (B.P.G., A.G.K., R.G.H.); College of Arts and Science, University of Rochester, NY (G.P.A.); and Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT (D.Y.H.)
| | - Adam G. Kelly
- From the Department of Neurology, University of Rochester Medical Center, NY (B.P.G., A.G.K., R.G.H.); College of Arts and Science, University of Rochester, NY (G.P.A.); and Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT (D.Y.H.)
| | - George P. Albert
- From the Department of Neurology, University of Rochester Medical Center, NY (B.P.G., A.G.K., R.G.H.); College of Arts and Science, University of Rochester, NY (G.P.A.); and Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT (D.Y.H.)
| | - David Y. Hwang
- From the Department of Neurology, University of Rochester Medical Center, NY (B.P.G., A.G.K., R.G.H.); College of Arts and Science, University of Rochester, NY (G.P.A.); and Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT (D.Y.H.)
| | - Robert G. Holloway
- From the Department of Neurology, University of Rochester Medical Center, NY (B.P.G., A.G.K., R.G.H.); College of Arts and Science, University of Rochester, NY (G.P.A.); and Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT (D.Y.H.)
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Schutz REC, Coats HL, Engelberg RA, Curtis JR, Creutzfeldt CJ. Is There Hope? Is She There? How Families and Clinicians Experience Severe Acute Brain Injury. J Palliat Med 2016; 20:170-176. [PMID: 27763820 DOI: 10.1089/jpm.2016.0286] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with severe acute brain injury (SABI) raise important palliative care considerations associated with sudden devastating injury and uncertain prognosis. OBJECTIVE The goal of this study was to explore how family members, nurses, and physicians experience the palliative and supportive care needs of patients with SABI receiving care in the neuroscience intensive care unit (neuro-ICU). DESIGN Semistructured interviews were audiotaped, transcribed, and analyzed using thematic analysis. SETTING/SUBJECTS Thirty-bed neuro-ICU in a regional comprehensive stroke and level-one trauma center in the United States. We completed 47 interviews regarding 15 patients with family members (n = 16), nurses (n = 15), and physicians (n = 16). RESULTS Two themes were identified: (1) hope and (2) personhood. (1) Families linked prognostic uncertainty to a need for hope and expressed a desire for physicians to acknowledge this relationship. The language of hope varied depending on the participant: clinicians used hope as an object that can be given or taken away, generally in the process of conveying prognosis, while families expressed hope as an action that supported coping with their loved one's acute illness and its prognostic uncertainty. (2) Participants described the loss of personhood through brain injury, the need to recognize and treat the brain-injured patient as a person, and the importance of relatedness and connection, including personal support of families by clinicians. CONCLUSIONS Support for hope and preservation of personhood challenge care in the neuro-ICU as identified by families and clinicians of patients with SABI. Specific practical approaches can address these challenges and improve the palliative care provided to patients and families in the neuro-ICU.
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Affiliation(s)
| | - Heather L Coats
- 2 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - Ruth A Engelberg
- 2 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - J Randall Curtis
- 2 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
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Eriksson H, Milberg A, Hjelm K, Friedrichsen M. End of Life Care for Patients Dying of Stroke: A Comparative Registry Study of Stroke and Cancer. PLoS One 2016; 11:e0147694. [PMID: 26845149 PMCID: PMC4742254 DOI: 10.1371/journal.pone.0147694] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 01/07/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Although stroke is a significant public health challenge and the need for palliative care has been emphasized for these patients, there is limited data on end-of-life care for patients dying from stroke. OBJECTIVE To study the end-of-life care during the last week of life for patients who had died of stroke in terms of registered symptom, symptom management, and communication, in comparison with patients who had died of cancer. DESIGN This study is a retrospective, comparative registry study. METHODS A retrospective comparative registry study was performed using data from a Swedish national quality register for end-of-life care based on WHO`s definition of Palliative care. Data from 1626 patients who had died of stroke were compared with data from 1626 patients who had died of cancer. Binary logistic analyses were used to calculate odds ratios, with 95% CI. RESULTS Compared to patients who was dying of cancer, the patients who was dying of stroke had a significantly higher prevalence of having death rattles registered, but a significantly lower prevalence of, nausea, confusion, dyspnea, anxiety, and pain. In addition, the stroke group had significantly lower odds ratios for health care staff not to know whether all these six symptoms were present or not. Patients who was dying of stroke had significantly lower odds ratio of having informative communication from a physician about the transition to end-of-life care and of their family members being offered bereavement follow-up. CONCLUSIONS The results indicate on differences in end-of-life care between patients dying of stroke and those dying from cancer. To improve the end-of-life care in clinical practice and ensure it has consistent quality, irrespective of diagnosis, education and implementation of palliative care principles are necessary.
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Affiliation(s)
- Heléne Eriksson
- Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
| | - Anna Milberg
- Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
- Palliative Education & Research Centre, Vrinnevi Hospital, Norrköping, Sweden
- Department of Advanced Home Care, Vrinnevi Hospital, Norrköping, Sweden
| | - Katarina Hjelm
- Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
| | - Maria Friedrichsen
- Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
- Palliative Education & Research Centre, Vrinnevi Hospital, Norrköping, Sweden
- Department of Advanced Home Care, Vrinnevi Hospital, Norrköping, Sweden
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