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Lewis ET, Harrison R, Nicholson M, Hillman K, Trankle S, Rangel S, Stokes C, Cardona M. Clinicians' and public acceptability of universal risk-of-death screening for older people in routine clinical practice in Australia: cross-sectional surveys. Aging Clin Exp Res 2021; 33:1063-1070. [PMID: 32458357 DOI: 10.1007/s40520-020-01598-w] [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: 01/29/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Clinicians' delays to identify risk of death and communicate it to patients nearing the end of life contribute to health-related harm in health services worldwide. This study sought to ascertain doctors, nurses and senior members of the public's perceptions of the routine use of a screening tool to predict risk of death for older people. METHODS Cross-sectional online, face-to-face and postal survey of 360 clinicians and 497 members of the public. RESULTS Most (65.9%) of the members of the public welcomed (and 12.3% were indifferent to) the use of a screening tool as a decision guide to minimise overtreatment and errors from clinician assumptions. Supporters of the use of a prognostic tool were likely to be males with high social capital, chronically ill and who did not have an advance health directive. The majority of clinicians (75.6%) reported they were likely or very likely to use the tool, or might consider using it if convinced of its accuracy. A minority (13.3%) stated they preferred to rely on their clinical judgement and would be unlikely to use it. Differentials in support for tools by seniority were observed, with more support expressed by nurses, interns and registrars than medical specialists (χ2 = 12.95, p = 0.044) and by younger (< 40 years) clinicians (81.2% vs. 71.2%, p = 0.0058). DISCUSSION The concept of integrating prognostication of death in routine practice was not resisted by either target group. CONCLUSION Findings indicate that screening for risk of death is seen as potentially useful and suggests the readiness for a culture change. Future research on implementation strategies could be a step in the right direction.
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Anderson RJ, Stone PC, Low JTS, Bloch S. Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study. Palliat Med 2020; 34:896-905. [PMID: 32233831 PMCID: PMC7336362 DOI: 10.1177/0269216320910934] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND When patients are likely to die in the coming hours or days, families often want prognostic information. Prognostic uncertainty and a lack of end-of-life communication training make these conversations challenging. AIM The objective of this study is to understand how clinicians and the relatives/friends of patients at the very end of life manage uncertainty and reference time in prognostic conversations. DESIGN Conversation analysis of audio-recorded conversations between clinicians and the relatives/friends of hospice inpatients. SETTING/PARTICIPANTS Experienced palliative care clinicians and relatives/friends of imminently dying hospice inpatients. Twenty-three recorded conversations involved prognostic talk and were included in the analysis. RESULTS Requests for prognostic information were initiated by families in the majority of conversations. Clinicians responded using categorical time references such as 'days', allowing the provision of prognostic estimates without giving a precise time. Explicit terms such as 'dying' were rare during prognostic discussions. Instead, references to time were understood as relating to prognosis. Relatives displayed their awareness of prognostic uncertainty when requesting prognostic information, providing clinicians with 'permission' to be uncertain. In response, clinicians often stated their uncertainty explicitly, but presented evidence for their prognostic estimates, based on changes to the patient's function previously discussed with the family. CONCLUSION Prognostic uncertainty was managed collaboratively by clinicians and families. Clinicians were able to provide prognostic estimates while being honest about the related uncertainty, in part because relatives displayed their awareness of uncertainty within their requests. The conversation analytic method identified contributions of both clinicians and families, and identified strategies based on real interactions, which could inform communication training.
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Affiliation(s)
- Rebecca J Anderson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Patrick C Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Joseph T S Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Steven Bloch
- Department of Language and Cognition, Division of Psychology and Language Sciences, University College London, London, UK
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Gramling R, Stanek S, Han PK, Duberstein P, Quill TE, Temel JS, Alexander SC, Anderson WG, Ladwig S, Norton SA. Distress Due to Prognostic Uncertainty in Palliative Care: Frequency, Distribution, and Outcomes among Hospitalized Patients with Advanced Cancer. J Palliat Med 2018; 21:315-321. [DOI: 10.1089/jpm.2017.0285] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Robert Gramling
- Division of Palliative Medicine, Department of Family Medicine, University of Vermont Medical Center, Burlington, Vermont
| | - Susan Stanek
- School of Nursing, University of Rochester, Rochester, New York
| | - Paul K.J. Han
- Maine Medical Center Research Institute, Scarborough, Maine
| | - Paul Duberstein
- Department of Psychiatry, University of Rochester, Rochester, New York
| | - Tim E. Quill
- School of Nursing, University of Rochester, Rochester, New York
| | - Jennifer S. Temel
- Department of Medicine, Harvard University, Cambridge, Massachusetts
| | - Stewart C. Alexander
- Department of Consumer Science, Department of Medicine, Purdue University, West Lafayette, Indiana
| | | | - Susan Ladwig
- Division of Palliative Care, University of Rochester, Rochester, New York
| | - Sally A. Norton
- School of Nursing, University of Rochester, Rochester, New York
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Rice J, Hunter L, Hsu AT, Donskov M, Luciani T, Toal-Sullivan D, Welch V, Tanuseputro P. Using the “Surprise Question” in Nursing Homes. J Palliat Care 2017; 33:9-18. [DOI: 10.1177/0825859717745728] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The “Surprise Question” (SQ) is often used to identify patients who may benefit from a palliative care approach. The time frame of the typical question (a 12-month prognosis) may be unsuitable for identifying residents in nursing homes since it may not be able to differentiate between those who have a more imminent risk of death within a cohort of patients with high care needs. Objective: To examine the accuracy and acceptability of 3 versions of the SQ with shortened prognostication time frames (3 months, 6 months, and “the next season”) in the nursing home setting. Design: A prospective mixed-methods study. Setting/Participants: Forty-seven health-care professionals completed the SQ for 313 residents from a nursing home in Ontario, Canada. A chart audit was performed to evaluate the accuracy of their responses. Focus groups and interviews were conducted to examine the participants’ perspectives on the utility of the SQ. Results: Of the 301 residents who were included in the analysis, 74 (24.6%) deaths were observed during our follow-up period. The probability of making an accurate prediction was highest when the seasonal SQ was used (66.7%), followed by the 6-month (58.9%) and 3-month (57.1%) versions. Despite its high accuracy, qualitative results suggest the staff felt the seasonal SQ was ambiguous and expressed discomfort with its use. Conclusion: The SQ with shortened prognostication periods may be useful in nursing homes and provides a mechanism to facilitate discussions on palliative care. However, a better understanding of palliative care and increasing staff’s comfort with prognostication is essential to a palliative care approach.
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Affiliation(s)
- Jill Rice
- Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Linda Hunter
- Perley and Rideau Veterans’ Health Centre, Ottawa, Ontario, Canada
| | - Amy T. Hsu
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- University of Ottawa, School of Epidemiology and Public Health, Ottawa, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), ICES uOttawa, Ottawa, Ontario, Canada
| | | | | | | | - Vivian Welch
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- University of Ottawa, School of Epidemiology and Public Health, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Sundararajan K, Flabouris A, Thompson C, Seppelt I. Elderly patients are at high risk of night-time admission to the intensive care unit following a rapid response team call. Intern Med J 2017; 46:1440-1442. [PMID: 27981774 DOI: 10.1111/imj.13281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/26/2016] [Accepted: 05/30/2016] [Indexed: 11/26/2022]
Abstract
Previous studies have shown that elderly patients (age ≥65 years) are less likely to be admitted to the intensive care unit following a rapid response team call and have high hospital mortality rates. This study has shown that elderly patients have a significantly higher probability of being admitted to an intensive care unit following a rapid response team call at night than during the day. However, at no time are they at greater risk than younger patients of incomplete vital sign recording, a failure to escalate care for acute deterioration or mortality.
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Affiliation(s)
- K Sundararajan
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - A Flabouris
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - C Thompson
- School of Medicine, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - I Seppelt
- Nepean Hospital and Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Liu OY, Malmstrom T, Burhanna P, Rodin MB. The Evolution of an Inpatient Palliative Care Consultation Service in an Urban Teaching Hospital. Am J Hosp Palliat Care 2016; 34:47-52. [DOI: 10.1177/1049909115610077] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Research on inpatient palliative medicine reports quality-of-life outcomes and selected “hard” outcomes including pain scores, survival, and readmissions. Objective: This case study reports the evolution of an inpatient palliative consultation (IPC) team to show how IPC induces culture change in a hospital that previously had no palliative care. Design: Retrospective chart review. Setting: A Catholic university-affiliated, inner-city hospital. Population: A total of 1700 consecutive adult inpatients from May 2009 to October 2013. Measures: Consultation records enumerated demographics, code status, powers of attorney, referring physician, reason for consultation, and discharge destination. Deidentified data were uploaded to a spreadsheet. Simple descriptive statistics were calculated. Results: Requests originated from internal medicine (24%), geriatrics (21%), neurology (including stroke and neurosurgery, 14.3%), medical intensive care unit (MICU, 12.2%), and hematology–oncology (10.3%). The MICU consults increased 17.6% over time. The numbers of consults nearly doubled after trainees began rounding with the service. Hospice discharges increased by 9.2%. Palliative management of in-hospital expirations increased 2- to 3-fold. The most common consultation requests were for pain and nonpain symptoms, establishing goals of care for patients experiencing clinical decline and convening family meetings in cases of divided judgment. Conclusion: We describe the evolution of palliative care in a safety-net hospital. Medicine services which are largely resident run adopted early. Specialty services that are attending driven adopted later. We believe house staff and nurses were the initial change agents. The number of consultations increased when house staff and students began rotating on the service suggesting unmet demand due to the limited supply of providers.
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Affiliation(s)
- On Ying Liu
- St Louis University Medical School, St Louis, MO, USA
| | - Theodore Malmstrom
- Department of Neurology and Psychiatry, St Louis University Medical School, St Louis, MO, USA
- Division of Geriatrics, Department of Internal Medicine, St Louis University Medical School, St Louis, MO, USA
| | - Patricia Burhanna
- Palliative nurse practitioner, St. Louis University Hospital, St Louis, MO, USA
| | - Miriam B. Rodin
- Division of Geriatrics, Department of Internal Medicine, St Louis University Medical School, St Louis, MO, USA
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Sundararajan K, Flabouris A, Thompson C. Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article. J Intensive Care 2016; 4:15. [PMID: 26913199 PMCID: PMC4765019 DOI: 10.1186/s40560-016-0136-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 02/03/2016] [Indexed: 11/17/2022] Open
Abstract
The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system’s afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT. There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor. The term “circadian variation/rhythm” applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states. For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.
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Affiliation(s)
- Krishnaswamy Sundararajan
- Intensive Care Unit, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Level 4, ICU, Robert Gerard Wing, Adelaide, 5000 South Australia Australia
| | - Arthas Flabouris
- Intensive Care Unit, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Level 4, ICU, Robert Gerard Wing, Adelaide, 5000 South Australia Australia
| | - Campbell Thompson
- Department of Medicine, University of Adelaide and the Royal Adelaide Hospital, Adelaide, 5000 South Australia Australia
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