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Haverfield MC, Ma J, Walling A, Bekelman DB, Brown-Johnson C, Lo N, Lorenz KA, Giannitrapani KF. Communication processes in an advance care planning initiative: A socio-ecological perspective for service evaluation. Palliat Med 2024:2692163241277394. [PMID: 39254148 DOI: 10.1177/02692163241277394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND Advance care planning initiatives are becoming more widespread, increasing expectations for providers to engage in goals of care conversations. However, less is known about how providers communicate advance care planning within and throughout a health care system. AIM To explore perspectives of communication processes in the rollout of an advance care planning initiative. DESIGN Theoretically informed secondary analysis of 31 semi-structured interviews. SETTING/PARTICIPANTS Key partners in a Veterans Health Administration goals of care initiative. RESULTS Using the constant comparative approach followed by qualitative mapping of themes to the layers of the Socio-Ecological Model, four themes and corresponding Socio-Ecological layers were identified: Goals of Care Communication Training (Policy, Community, and Institutional) requires more resources across sites and better messaging to reduce provider misconceptions and promote an institutional culture invested in advance care planning; Interprofessional Communication (Interpersonal) suggests care team coordination is needed to facilitate continuity in goals of care messaging; Communication in Documentation (Institutional, Interpersonal, and Intrapersonal) highlights the need for capturing the context for goals of care preferences; and Patient/Family Communication (Interpersonal and Intrapersonal) encourages offering materials and informational resources early to facilitate rapport building and readiness to determine goals of care. CONCLUSIONS Findings support the need for initiatives to incorporate an evaluation of how goals of care are discussed beyond the interpersonal exchange between patient and provider and signal opportunities for applying the Socio-Ecological Model to better understand goals of care communication processes, including opportunities to improve initiation and documentation of goals of care.
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Affiliation(s)
- Marie C Haverfield
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
- Department of Communication Studies, San José State University, San Jose, CA, USA
| | - Jessica Ma
- Geriatrics Research, Education, and Clinical Center, Durham VA Health System, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Anne Walling
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
- VA Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
| | - David B Bekelman
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Cati Brown-Johnson
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
- School of Medicine, Stanford University, Stanford, CA, USA
| | - Natalie Lo
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Karl A Lorenz
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
- School of Medicine, Stanford University, Stanford, CA, USA
| | - Karleen F Giannitrapani
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
- School of Medicine, Stanford University, Stanford, CA, USA
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Oyekan AA, Lee JY, Hodges JC, Chen SR, Wilson AE, Fourman MS, Clayton EO, Njoku-Austin C, Crasto JA, Wisniewski MK, Bilderback A, Gunn SR, Levin WI, Arnold RM, Hinrichsen KL, Mensah C, Hogan MV, Hall DE. Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates: One-Year Results of the Surgical Pause Program. JB JS Open Access 2023; 8:JBJSOA-D-22-00107. [PMID: 37101601 PMCID: PMC10125643 DOI: 10.2106/jbjs.oa.22.00107] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a "surgical pause" (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Anthony A. Oyekan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Email for corresponding author:
| | - Joon Y. Lee
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob C. Hodges
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen R. Chen
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan E. Wilson
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mitchell S. Fourman
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Elizabeth O. Clayton
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Jared A. Crasto
- Department of Orthopaedic Surgery, The Spine Institute of Arizona, Scottsdale, Arizona
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Bilderback
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Scott R. Gunn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William I. Levin
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie L. Hinrichsen
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Mensah
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - MaCalus V. Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Garcia R, Brown-Johnson C, Teuteberg W, Seevaratnam B, Giannitrapani K. The Team-Based Serious Illness Care Program, A Qualitative Evaluation of Implementation and Teaming. J Pain Symptom Manage 2023; 65:521-531. [PMID: 36764413 DOI: 10.1016/j.jpainsymman.2023.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 02/11/2023]
Abstract
CONTEXT Earlier and more frequent serious illness conversations with patients allow clinical teams to better align care with patients' goals and values. Nonphysician clinicians often have unique perspectives and understanding of patients' wishes and are thus well-positioned to support conversations with seriously ill patients. The Team-based Serious Illness Care Program (SICP) at Stanford aimed to involve all care team members to support and conduct serious illness conversations with patients and their caregivers and families. OBJECTIVES We conducted interviews with clinicians to understand how care teams implement team-based approaches to conduct serious illness conversations and navigate resulting team complexity. METHODS We used a rapid qualitative approach to analyze semistructured interviews of clinicians and administrative stakeholders in two team-based SICP implementation groups (i.e., inpatient oncology and hospital medicine) (n = 25). Analysis was informed by frameworks/theory: cross-disciplinary role agreement, team formation and functioning, and organizational theory. RESULTS Implementing team-based SICP was feasible. Theme 1 centered on how teams formed and managed to come to an agreement: teams with rapidly changing staffing/responsibilities prioritized communication, whereas teams with consistent staffing/responsibilities primarily relied on protocols. Theme 2 demonstrated that leaders and managers at multiple levels could support implementation. Theme 3 explored strengths and opportunities. Positively, team-based SICP distributed work burden, timed conversations in alignment with patient needs, and added unique value from nonphysician team members. Role ambiguity and conflict were attributed to miscommunication and ethical conflicts. CONCLUSION Team-based serious illness communication is viable and valuable, with a range of successful workflow and leadership approaches.
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Affiliation(s)
- Raquel Garcia
- Duke School of Medicine, Durham (R.G., K.G.), North Carolina, USA
| | - Cati Brown-Johnson
- Stanford University School of Medicine (C.B-J., W.T., B.S., K.G.), Stanford, California, USA
| | - Winifred Teuteberg
- Stanford University School of Medicine (C.B-J., W.T., B.S., K.G.), Stanford, California, USA
| | - Briththa Seevaratnam
- Stanford University School of Medicine (C.B-J., W.T., B.S., K.G.), Stanford, California, USA.
| | - Karleen Giannitrapani
- Stanford University School of Medicine (C.B-J., W.T., B.S., K.G.), Stanford, California, USA.
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Villarosa AR, Maneze D, Salamonson Y, Ramjan LM, George A. Development and psychometric testing of the intention to engage in children's healthy weight (iCHeW) guideline scale for dental staff. Obes Res Clin Pract 2022; 16:337-342. [PMID: 35842353 DOI: 10.1016/j.orcp.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 06/09/2022] [Accepted: 06/30/2022] [Indexed: 10/17/2022]
Abstract
STATEMENT OF PROBLEM In the evaluation of interdisciplinary interventions for childhood overweight and obesity, behavioural determinants can provide valuable insight into the reasons behind lack of adherence, or ineffectiveness of the intervention. Therefore, it is vital to assess the behavioural determinants of staff when evaluating the implementation of such interdisciplinary interventions. This study aimed to develop and psychometrically evaluate the intention to engage in Children's Healthy Weight guideline (iCHeW) scale, which assesses the behavioural determinants influencing dental staff's intention to conduct children's growth assessments. METHODS Initial items were generated based on review of the literature and the dimensions of the integrative model of behavioural prediction (IM). To test this scale, a cross-sectional survey design was undertaken consisting of three phases: (i) face validity; (ii) content validity; and (iii) psychometric evaluation of the iCHeW scale with a national sample of 125 dental staff. RESULTS The 35 items generated for the iCHeW scale were revised following feedback from a reference group. These 35 items were then appraised by an expert panel, yielding 27 items for psychometric testing. Using exploratory factor analysis, a five-factor solution was extracted, which corresponded to the IM domains, with the deletion of two items. Overall, Cronbach's alpha of the iCHeW scale was 0.95, with the following values for each subscale: (i) attitudes, 0.93; (ii) behavioural constraints, 0.83; (iii) perceived norms, 0.93; (iv) self-efficacy, 0.94; and (v) behavioural intention, 0.95. CONCLUSIONS The iCHeW scale is valid and reliable for assessing dental staff's intention to provide routine growth assessments to children and demonstrates potential for use with non-dental staff.
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Affiliation(s)
- Amy R Villarosa
- Australian Centre for Integration of Oral Health (ACIOH), Liverpool 1871, Australia; Western Sydney University, Penrith 2751, Australia; South Western Sydney Local Health District, Liverpool 1871, Australia; Ingham Institute for Applied Medical Research, Liverpool 1871, Australia.
| | - Della Maneze
- Australian Centre for Integration of Oral Health (ACIOH), Liverpool 1871, Australia; Western Sydney University, Penrith 2751, Australia; South Western Sydney Local Health District, Liverpool 1871, Australia; Ingham Institute for Applied Medical Research, Liverpool 1871, Australia
| | - Yenna Salamonson
- Australian Centre for Integration of Oral Health (ACIOH), Liverpool 1871, Australia; Ingham Institute for Applied Medical Research, Liverpool 1871, Australia; University of Wollongong, Wollongong 2522, Australia; Translational Health Research Institute, Western Sydney University, Penrith 2751, Australia
| | - Lucie M Ramjan
- Australian Centre for Integration of Oral Health (ACIOH), Liverpool 1871, Australia; Western Sydney University, Penrith 2751, Australia; Ingham Institute for Applied Medical Research, Liverpool 1871, Australia; Translational Health Research Institute, Western Sydney University, Penrith 2751, Australia
| | - Ajesh George
- Australian Centre for Integration of Oral Health (ACIOH), Liverpool 1871, Australia; Western Sydney University, Penrith 2751, Australia; South Western Sydney Local Health District, Liverpool 1871, Australia; Ingham Institute for Applied Medical Research, Liverpool 1871, Australia; Translational Health Research Institute, Western Sydney University, Penrith 2751, Australia; University of Sydney, Camperdown, NSW 2006, Australia
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Russell J, Quaack KR, Nunez J. Chaplain reported plans for end-of-life care conversations: Role clarity for the spiritual care specialists. J Health Care Chaplain 2022; 29:337-352. [PMID: 35757912 DOI: 10.1080/08854726.2022.2087965] [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: 10/17/2022]
Abstract
The present study examined chaplain reported plans for patient conversations regarding end-of-life (EOL) care through the lens of multiple goals. Chaplains (n = 69) were asked to curate a plan for engaging with a patient about EOL treatment options, including how they would engage in the conversation and what they would plan to discuss. Findings indicated that plans primarily consisted of relational and identity goals, with a majority navigating multiple goal orientations. Content overwhelmingly involved developing rapport with patients, eliciting patient preferences for care, and serving as a patient liaison. The current study addresses the paucity of research around the role a chaplain plays on the interdisciplinary team and their respective approach to EOL conversations. Examination of curated plans affords insight to what content is prioritized and which conversational goals are present. Integration of multiple goals offers preliminary evidence for conversational quality. Awareness of goal approach and content prioritized affords clarity on how chaplains can be called upon to support members of the interdisciplinary care team.
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Affiliation(s)
- Jessica Russell
- Department of Communication Studies, California State University, Long Beach, CA, USA
| | - Karly R Quaack
- Department of Communication, University of Texas, Austin, TX, USA
| | - Jade Nunez
- Department of Communication Studies, California State University, Long Beach, CA, USA
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Shlobin NA, Clark JR, Campbell JM, Bernstein M, Jahromi BS, Potts MB. Ethical Considerations in Surgical Decompression for Stroke. Stroke 2022; 53:2673-2682. [PMID: 35703095 DOI: 10.1161/strokeaha.121.038493] [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: 11/16/2022]
Abstract
Stroke is a major cause of morbidity and mortality. Neurosurgical decompression is often considered for the treatment of malignant infarcts and intraparenchymal hemorrhages, but this treatment can be frought with ethical dilemmas. In this article, the authors outline the primary principles of bioethics and their application to stroke care, provide an overview of key ethical issues and special situations in the neurosurgical management of stroke, and highlight methods to improve ethical decision-making for patients with stroke. Understanding these ethical principles is essential for stroke care teams to deliver appropriate, timely, and ethical care to patients with stroke.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.)
| | - Jeffrey R Clark
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.)
| | | | - Mark Bernstein
- Division of Neurosurgery, Department of Surgery, University of Toronto, University Health Network, Ontario, Canada (M.B.)
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.).,Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.).,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.)
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.).,Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.).,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.)
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