The acceptability of an information leaflet explaining cardiopulmonary resuscitation policy in the hospice setting: a qualitative study exploring patients' views

Educação em saúde e final de vida no hospital

Objetivo: identificar ações de educação em saúde direcionadas às pessoas em final da vida e seus cuidadores, informais e formais, no hospital, além de avaliar o nível de evidência de tais ações. Síntese do conteúdo: o estudo foi realizado entre dezembro de 2019 e janeiro de 2020, nas bases de dados Web of Science, Scopus e MEDLINE. Identificaram-se 6.762 artigos, dos quais 42 integram a análise por serem artigos originais ou de revisão escritos em português, espanhol, inglês ou francês; a amostra dos estudos foi composta por pacientes maiores de 19 anos, com doença avançada e/ou em final de vida ou cuidadores ou profissionais de saúde. Os dados foram agrupados por similaridade do tema das ações, conforme Polit e Beck, e o nível de evidência avaliado segundo Melnyk e Fineout-Overholt. O vídeo foi a ação com maior força de recomendação, seguida por cartilhas. As unidades temáticas foram “Ações para o controle da dor”, “Narrativas sobre o final da vida”, “Planejamento de cuidados”, “Dialogando sobre os cuidados paliativos” e “Comunicação e final de vida”. Conclusões: ações de educação em saúde no final da vida devem considerar as tecnologias da informação e da comunicação, além das condições socioculturais, clínicas e cognitivas dessa etapa do adoecimento.

Physician's Communication in Code Status Discussions for Terminally Ill Cancer Patients in Inpatient Hospice/Palliative Care Units in Japan: A Nationwide Post-Bereavement Survey

CONTEXT

Cardiopulmonary resuscitation is one of the most important end-of-life care decisions. However, the experience of bereaved families during code status discussions is not well documented.

OBJECTIVE

The aims of this study were to describe the degree of emotional distress of bereaved families when discussing code status, identify their perceived areas for improvement and determine associated factors.

METHODS

This study is part of a nationwide post-bereavement survey, the Japan Hospice and Palliative care Evaluation 3 (J-HOPE3) study. Questionnaires were sent to the relatives of cancer patients who had died in palliative care units in Japan in 2014.

RESULTS

From an analysis of 338 questionnaires, 37% of families reported high emotional distress during code status discussions and 32% reported a need for improvement. Multiple logistic regression analyses revealed the following were associated with high-level distress: the family had hoped for the miraculous and spontaneous recovery of the patient (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.31-4.43, P = 0.0049), the family felt they could not voice their opinion about Cardiopulmonary resuscitation (OR 2.07, CI 1.12-3.81, P = 0.02), or the physician failed to adapt the explanation to the family's preparation level (OR 0.36, CI 0.18-0.68, P = 0.0015). Factors identified for improvement were: holding discussions in a relaxing atmosphere conducive to questioning (OR 0.36, CI 0.16-0.80, P = 0.012), and ensuring the physician adapted the explanation to the family's preparation level (OR 0.47, CI 0.23-0.96, P = 0.037).

CONCLUSION

We recommend the development of educational programs for code status discussions to improve the experience of bereaved family members.

CPR decision-making conversations in the UK: an integrative review

OBJECTIVES

Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) discussions with patients and their caregivers have been subjected to intense ethical and legal debate in recent years. Legal cases and national guidelines have tried to clarify the best approach to DNACPR discussions; however, there is little evidence of how best to approach them from the patient, family or caregiver perspective. This paper describes published accounts of patient, family and caregiver experiences of discussions about advance cardiopulmonary resuscitation (CPR) decision making.

METHODS

An integrative review of the UK literature between 2000 and 2016 including qualitative and quantitative studies was conducted. Worldwide, 773 abstracts were identified, and 20 papers from the UK were included in the final analysis.

RESULTS

Patient, family and caregivers prefer discussions to be initiated by someone trusted, and wishes for family involvement vary depending on the context. Timing of discussions should be individualised, though discussions earlier in the illness are often preferable. Discussions held in the acute setting are suboptimal. CPR decisions should be part of a wider discussion about future care and adequate communication skills training is important.

CONCLUSIONS

The findings of this review are at odds with the current statutory framework and potentially challenging for medical professionals who are working in a stretched health service, with pressure to discuss DNACPR decisions at the earliest opportunity. With increasing focus on person-centred care and realistic medicine, patient narratives must be considered by doctors and policy makers alike, to minimise harm.

A video to improve patient and surrogate understanding of cardiopulmonary resuscitation choices in the ICU: a randomized controlled trial

OBJECTIVE

To determine if a video depicting cardiopulmonary resuscitation and resuscitation preference options would improve knowledge and decision making among patients and surrogates in the ICU.

DESIGN

Randomized, unblinded trial.

SETTING

Single medical ICU.

PATIENTS

Patients and surrogate decision makers in the ICU.

INTERVENTIONS

The usual care group received a standard pamphlet about cardiopulmonary resuscitation and cardiopulmonary resuscitation preference options plus routine code status discussions with clinicians. The video group received usual care plus an 8-minute video that depicted cardiopulmonary resuscitation, showed a simulated hospital code, and explained resuscitation preference options.

MEASUREMENTS AND MAIN RESULTS

One hundred three patients and surrogates were randomized to usual care. One hundred five patients and surrogates were randomized to video plus usual care. Median total knowledge scores (0-15 points possible for correct answers) in the video group were 13 compared with 10 in the usual care group, p value of less than 0.0001. Video group participants had higher rates of understanding the purpose of cardiopulmonary resuscitation and resuscitation options and terminology and could correctly name components of cardiopulmonary resuscitation. No statistically significant differences in documented resuscitation preferences following the interventions were found between the two groups, although the trial was underpowered to detect such differences. A majority of participants felt that the video was helpful in cardiopulmonary resuscitation decision making (98%) and would recommend the video to others (99%).

CONCLUSIONS

A video depicting cardiopulmonary resuscitation and explaining resuscitation preference options was associated with improved knowledge of in-hospital cardiopulmonary resuscitation options and cardiopulmonary resuscitation terminology among patients and surrogate decision makers in the ICU, compared with receiving a pamphlet on cardiopulmonary resuscitation. Patients and surrogates found the video helpful in decision making and would recommend the video to others.

Why don't they accept non-invasive ventilation?: insight into the interpersonal perspectives of patients with motor neurone disease

OBJECTIVES

Although non-invasive ventilation (NIV) can benefit survival and quality of life, it is rejected by a substantial proportion of people with motor neurone disease (MND). The aim of this study was to understand why some MND patients decline or withdraw from NIV.

METHOD

Nine patients with MND (male = 7, mean age = 67 years) participated in this study. These patients, from a cohort of 35 patients who were offered NIV treatment to support respiratory muscle weakness, did not participate in NIV treatment when it was clinically appropriate. Semi-structured interviews and interpretative phenomenological analysis (IPA) were employed to explore these patient's experience of MND and their thoughts and understanding of NIV treatment.

RESULTS

Using IPA, four themes were identified: preservation of the self, negative perceptions of NIV, negative experience with health care services, and not needing NIV. Further analysis identified the fundamental issue to be the maintenance of perceived self, which was interpreted to consist of the sense of autonomy, dignity, and quality of life.

CONCLUSIONS

The findings indicate psychological reasons for disengagement with NIV. The threat to the self, the sense of loss of control, and negative views of NIV resulting from anxiety were more important to these patients than prolonging life in its current form. These findings suggest the importance of understanding the psychological dimension involved in decision-making regarding uptake of NIV and a need for sensitive holistic evaluation if NIV is declined. Statement of contribution What is already known on this subject? Non-invasive ventilation is widely used as an effective symptomatic therapy in MND, yet about a third of patients decline the treatment. Psychological disturbance generated by NIV use leads to negative experiences of the treatment. Decision-making about treatment potentials is complex and unique to each individual affected by perceived impact of disease. What does this study add? A decision concerning NIV uptake was influenced by perceived impact on individuals' sense of self. Sense of self was influenced by the maintenance of autonomy, dignity, and quality of life. Individuals' sense of self was identified to have been challenged by the disease, NIV, and their experience of health care service.

Barriers to involving older people in their resuscitation decisions: the primary-secondary care mismatch highlights the potential role of general practitioners

BACKGROUND

'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) orders are made frequently for older people in hospital. Sensitive anticipatory discussion is encouraged where possible, but usually this does not happen, despite the evidence suggesting that many older patients would like to be involved in such decisions.

METHODS

Current clinical practice in both primary care and secondary care and perceived barriers to patient involvement in resuscitation decisions was assessed using a questionnaire in Medicine for the Elderly physicians in two hospitals, and General Practitioners of teaching practices in Norfolk.

RESULTS

Response rate was 51% (n = 24/47). Hospital-based clinicians made DNACPR decisions more frequently, but discussed decisions with patients in less than 25% of cases. By contrast, GPs thought that patient involvement was more important and felt that they had a better understanding of the patient's wishes due to the long-term relationship they shared. Mental capacity was seen as the biggest barrier to patient involvement by both groups. Other barriers included lack of understanding, communication difficulties and practical concerns.

CONCLUSION

Further support and training could help clinicians improve their resuscitation decision-making practice. Advanced discussion in Primary Care with older people before they lose capacity may have a role in increasing their involvement in resuscitation decision making.

Patient-perceived usefulness and practical obstacles of patient-held records for cancer patients in Japan: OPTIM study

BACKGROUND

Although the use of a patient-held record (PHR) for cancer patients has been introduced in many settings, little is known about the role of the PHR in palliative care settings and use in Asian cultures.

AIM

This study investigated the patient-perceived usefulness and practical obstacles of using the PHR specifically designed for palliative care patients.

DESIGN

This study adopted a qualitative design based on semi-structured interviews and content analysis.

SETTING/PARTICIPANTS

Fifty cancer patients were recruited from two regions in Japan. They used the PHR for more than three months, and then were asked to participate in a face-to-face interview.

RESULTS

The content analysis revealed the following patient-perceived usefulness of the PHR: (1) increase in patient-staff communication; (2) increase in patient-family communication; (3) increase in patient-patient communication; (4) increase in understanding of medical conditions and treatments; and (5) facilitating end-of-life care discussion. The practical obstacles to using the PHR were also indicated: (1) the lack of adequate instruction about the role of the PHR; (2) undervaluing the role of the PHR and sharing information by medical professionals; (3) patients' unwillingness to participate in decision making; (4) concerns about privacy; (5) burdensome nature of self-reporting; and (6) patients' preference for their own ways of recording.

CONCLUSIONS

The PHR can be helpful in facilitating communication, understanding medical conditions and treatments, and facilitating end-of-life care discussion; however, for wide-spread implementation, resolving the obstacles related to both patients and health-care professionals is required.

Enhancing patient-professional communication about end-of-life issues in life-limiting conditions: a critical review of the literature

CONTEXT

The End of Life Care Strategy for England highlights effective communication between patients and professionals as key to facilitating patient involvement in advance care planning. The strategy emphasizes that, currently, communication in patients with noncancer life-limiting conditions is likely to be inadequate, and research has identified that patients with chronic obstructive pulmonary disease and heart failure have a poor understanding of their condition.

OBJECTIVES

To identify existing interventions of patient-professional communication developed for life-limiting conditions and explore the applicability of interventions developed within a cancer framework to other diagnostic groups.

METHODS

A comprehensive literature review of studies describing communication interventions for patients receiving end-of-life care was undertaken. Ten electronic databases were searched. Inclusion criteria were all English language studies relating to patient-professional communication interventions for patients with life-limiting conditions receiving end-of-life care.

RESULTS

Of the 755 articles initially identified, 16 met the inclusion criteria. Three core themes emerged from the synthesis of the literature: using education to enhance professional communication skills, using communication to improve patient understanding, and using communication skills to facilitate advance care planning.

CONCLUSION

Although limited, evidence relating to the development and evaluation of communication interventions for patients with life-limiting illnesses would suggest that a successful intervention should include combined components of training, patient discussion, and education. In a context of limited resources and an increasing number of patients living and dying with chronic life-limiting conditions, the need for appropriate and effective communication strategies should be seen as a priority for both research and policy.

End-of-life issues in acute stroke care: a qualitative study of the experiences and preferences of patients and families

The aims of this qualitative study were to identify patients' and family members' experiences of acute stroke and their preferences for end-of-life care. Twenty-eight purposely sampled patients with an acute stroke who had high (n = 13) and low (n = 15) disability were selected from 191 sequential cases admitted to two general hospitals in north-east England. In addition, 25 family members of other stroke patients were recruited. Views about current stroke services and preferences for end-of-life care were elicited in semi-structured interviews. Communication between patients and family members and healthcare professionals was consistently highlighted as central to a positive experience of stroke care. Honesty and clarity of information was required, even where prognoses were bleak or uncertain. Patients and family members appeared to attach as much importance to the style of communication as to the substance of the transfer of information. Where decisions had been made to shift the focus of care from active to more passive support, families, and where possible patients, still wished to be included in ongoing dialogue with professionals. Where patients were thought to be dying, family members were keen to ensure that the death was peaceful and dignified. Families reported few opportunities for engagement in any form of choice over place or style of end-of-life care. No family member reported being offered the possibility of the patient dying at home. Uncertainty about prognosis is inevitable in clinical practice, and this can be difficult for patients and families. Our findings demonstrate the importance of improving communication between patient, family and health professionals for seriously ill patients with stroke in UK hospitals.

Resuscitation on television: realistic or ridiculous? A quantitative observational analysis of the portrayal of cardiopulmonary resuscitation in television medical drama

INTRODUCTION

Patients' preferences for cardiopulmonary resuscitation (CPR) relate to their perception about the likelihood of success of the procedure. There is evidence that the lay public largely base their perceptions about CPR on their experience of the portrayal of CPR in the media. The medical profession has generally been critical of the portrayal of CPR on medical drama programmes although there is no recent evidence to support such views.

OBJECTIVE

To compare the patient characteristics, cause and success rates of cardiopulmonary resuscitation (CPR) on medical television drama with published resuscitation statistics.

DESIGN

Observational study.

METHOD

88 episodes of television medical drama were reviewed (26 episodes of Casualty, Casualty, 25 episodes of Holby City, 23 episodes of Grey's Anatomy and 14 episodes of ER) screened between July 2008 and April 2009. The patient's age and sex, medical history, presumed cause of arrest, use of CPR and immediate and long term survival rate were recorded.

MAIN OUTCOME MEASURES

Immediate survival and survival to discharge following CPR.

RESULTS

There were a total of 76 cardio-respiratory arrests and 70 resuscitation attempts in the episodes reviewed. The immediate success rate (46%) did not differ significantly from published real life figures (p=0.48). The resuscitation process appeared to follow current guidelines. Survival (or not) to discharge was rarely shown. The average age of patients was 36 years and contrary to reality there was not an age related difference in likely success of CPR in patients less than 65 compared with those 65 and over (p=0.72). The most common cause of cardiac arrest was trauma with only a minor proportion of arrests due to cardio-respiratory causes such as myocardial infarction.

CONCLUSIONS

Whilst the immediate success rate of CPR in medical television drama does not significantly differ from reality the lack of depiction of poorer medium to long term outcomes may give a falsely high expectation to the lay public. Equally the lay public may perceive that the incidence and likely success of CPR is equal across all age groups.