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Lee SC, Shih CY, Chen ST, Lee CY, Li SR, Tang CC, Tsai JS, Cheng SY, Huang HL. Factors Contributing to Non-Concordance Between End-of-Life Care and Advance Care Planning. J Pain Symptom Manage 2024; 67:544-553. [PMID: 38479538 DOI: 10.1016/j.jpainsymman.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/24/2024] [Accepted: 03/04/2024] [Indexed: 04/05/2024]
Abstract
CONTEXT Despite making do-not-resuscitate or comfort care decisions during advance care planning, terminally ill patients sometimes receive life-sustaining treatments as they approach end of life. OBJECTIVES To examine factors contributing to nonconcordance between end-of-life care and advance care planning. METHODS In this longitudinal retrospective cohort study, terminally ill patients with a life expectancy shorter than six months, who had previously expressed a preference for do-not-resuscitate or comfort care, were followed up after palliative shared care intervention. An instrument with eight items contributing to non-concordant care, developed through literature review and experts' consensus, was employed. An expert panel reviewed electronic medical records to determine factors associated with non-concordant care for each patient. Statistical analysis, including descriptive statistics and the chi-square test, examines demographic characteristics, and associations. RESULTS Among the enrolled 7871 patients, 97 (1.2%) received non-concordant care. The most prevalent factor was "families being too distressed about the patient's deteriorating condition and therefore being unable to let go" (84.5%) followed by "limited understanding of medical interventions among patients and surrogates" (38.1%), and "lack of patient participation in the decision-making process" (25.8%). CONCLUSIONS This study reveals that factors related to relational autonomy, emotional support, and health literacy may contribute to non-concordance between advance care planning and end-of-life care. In the future, developing an advance care planning model emphasizes respecting relational autonomy, providing emotional support, and enhancing health literacy could help patients receiving a goal concordant and holistic end-of-life care.
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Affiliation(s)
- Shih-Chieh Lee
- Department of Family Medicine (S.-C.L.), Fu Jen Catholic University Hospital, No. 69, Guizi Road, Taishan District, New Taipei City, Taiwan
| | - Chih-Yuan Shih
- Department of Family Medicine, College of Medicine and Hospital (C.-Y.S., J.-S.T.,S.-Y.C.,H.-L.H.), National Taiwan University, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Shan-Ting Chen
- Department of Nursing (S.-T.C.,C.-Y.L.,S.-R.L.,C.-C.T.), National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Ching-Yi Lee
- Department of Nursing (S.-T.C.,C.-Y.L.,S.-R.L.,C.-C.T.), National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Shin-Rung Li
- Department of Nursing (S.-T.C.,C.-Y.L.,S.-R.L.,C.-C.T.), National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Chia-Chun Tang
- Department of Nursing (S.-T.C.,C.-Y.L.,S.-R.L.,C.-C.T.), National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan; School of Nursing, College of Medicine (C.-C.T.), National Taiwan University, No. 1, Sec. 4, Roosevelt Rd., Taipei, Taiwan
| | - Jaw-Shiun Tsai
- Department of Family Medicine, College of Medicine and Hospital (C.-Y.S., J.-S.T.,S.-Y.C.,H.-L.H.), National Taiwan University, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital (C.-Y.S., J.-S.T.,S.-Y.C.,H.-L.H.), National Taiwan University, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Hsien-Liang Huang
- Department of Family Medicine, College of Medicine and Hospital (C.-Y.S., J.-S.T.,S.-Y.C.,H.-L.H.), National Taiwan University, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan.
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2
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Kim MS, Cha H, You SH, Kim S. Thirty-day mortality after palliative radiotherapy in advanced cancer patients: Optimizing end-of-life care in Asia. J Med Imaging Radiat Oncol 2024; 68:307-315. [PMID: 38450953 DOI: 10.1111/1754-9485.13635] [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: 06/28/2023] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Evidence-based guidelines recommend hypofractionated palliative radiotherapy (PRT); nonetheless, many patients receive prolonged course of PRT. To identify patients with limited benefits from PRT in end-of-life care, we evaluated the pattern of PRT at an Asian institution and factors associated with 30-day mortality after PRT (30dM). METHODS We retrospectively reviewed 228 patients who died after PRT in Yonsei Wonju Severance Christian hospital between October 2014 and March 2022. The associations between clinical factors and survival were assessed using the Cox proportional hazards method. Survival was analysed using the existing models to evaluate their performance in our cohort. RESULTS The median PRT duration was 13 (IQR, 7-15) days. Only 11.4% of the patients were treated with hypofractionated radiotherapy. One-third of the patients (32.9%) could not complete PRT and 39 (17.1%) died during PRT. The 30dM was 31.6%. The median time from PRT to death was 17 (IQR, 11-23) days for the patients who died within 30 days. The number of involved organs (≤2 vs. >2; P < 0.001), albumin level (<3.3 vs. ≥3.3; P = 0.016), admission during PRT (P < 0.001), admission 3 months before PRT (P = 0.036) and ICU care during PRT (P < 0.001) were prognostic factors. A comparison of survival based on the existing models yielded unsatisfactory results in our cohort. CONCLUSION Almost one-third of the patients received PRT in the last 30 days of life. The use of hypofractionation for PRT was low in this Asian population. Further research is necessary to develop a predictive model of early mortality, allowing tailored end-of-life care for Asian patients.
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Affiliation(s)
- Mi Sun Kim
- Department of Radiation Oncology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Hyejung Cha
- Department of Radiation Oncology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Sei Hwan You
- Department of Radiation Oncology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Sunghyun Kim
- Department of Radiation Oncology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
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3
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Koutsouki S, Kosmidis D, Nagy EO, Tsaroucha A, Anastasopoulos G, Pnevmatikos I, Papaioannou V. Limitation of Non-Beneficial Interventions and their Impact on the Intensive Care Unit Costs. J Crit Care Med (Targu Mures) 2023; 9:230-238. [PMID: 37969880 PMCID: PMC10644299 DOI: 10.2478/jccm-2023-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/30/2023] [Indexed: 11/17/2023] Open
Abstract
Introduction Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients' clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence. Aim of the study To explore decisions to limit non-beneficial life support interventions, their correlation with patients' clinical data, and their effect on the cost of care in the ICU. Material and Methods We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019-2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (NBIs), and economic data. Comparisons were made between patients with and without limitation decisions. Results NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p<0,001), greater disease severity score (APACHE IV, 71 vs. 50; p<0,001), longer length of stay (7d vs. 4.5d; p<0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p<0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p<0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p<0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p<0.001). Conclusions Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.
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Affiliation(s)
| | - Dimitrios Kosmidis
- Nursing Department, International Hellenic University, Didymoteicho, Greece
| | | | - Alexandra Tsaroucha
- Postgraduate program on Bioethics, Laboratory of Bioethics, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
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4
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Brown C, Lee XJ, Farrington A, Shield C, Carter HE, McPhail SM, Cardona M, Hillman K, Callaway L, Willmott L, White BP, Harvey G, Graves N, Barnett AG. Impact of a prospective feedback loop on care review activities in older patients at the end of life. A stepped-wedge randomised trial. BMC Geriatr 2022; 22:860. [PMID: 36380290 PMCID: PMC9666964 DOI: 10.1186/s12877-022-03554-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background Hospitalisation rates for older people are increasing, with end-of-life care becoming a more medicalised experience. Innovative approaches are warranted to support early identification of the end-of-life phase, communicate prognosis, provide care consistent with people’s preferences, and improve the use of healthcare resources. The Intervention for Appropriate Care and Treatment (InterACT) trial aimed to increase appropriate care and treatment decisions for older people at the end of life, through implementation of a prospective feedback loop. This paper reports on the care review outcomes. Methods A stepped-wedge randomised controlled trial was conducted in three large acute hospitals in Queensland, Australia between May 2020 and June 2021. The trial identified older people nearing the end of life using two validated tools for detecting deterioration and short-term death. Admitting clinical teams were provided with details of patients identified as at-risk with the goal of increasing awareness that end of life was approaching to facilitate appropriate patient centred care and avoid non-beneficial treatment. We examined the time between when the patient was identified as ‘at-risk’ and three outcomes: clinician-led care review discussions, review of care directive measures and palliative care referrals. These were considered useful indicators of appropriate care at the end of life. Results In two hospitals there was a reduction in the review of care directive measures during the intervention compared with usual care at 21 days (reduced probability of − 0.08; 95% CI: − 0.12 to − 0.04 and − 0.14; 95% CI: − 0.21 to − 0.06). In one hospital there was a large reduction in clinician-led care review discussions at 21 days during the intervention (reduced probability of − 0.20; 95% CI: − 0.28 to − 0.13). There was little change in palliative care referrals in any hospital, with average probability differences at 21 days of − 0.01, 0.02 and 0.04. Discussion The results are disappointing as an intervention designed to improve care of hospitalised older people appeared to have the opposite effect on care review outcomes. The reasons for this may be a combination of the intervention design and health system challenges due to the pandemic that highlight the complexity of providing more appropriate care at the end of life. Trial registration Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03554-x.
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Sallnow L, Smith R, Ahmedzai SH, Bhadelia A, Chamberlain C, Cong Y, Doble B, Dullie L, Durie R, Finkelstein EA, Guglani S, Hodson M, Husebø BS, Kellehear A, Kitzinger C, Knaul FM, Murray SA, Neuberger J, O'Mahony S, Rajagopal MR, Russell S, Sase E, Sleeman KE, Solomon S, Taylor R, Tutu van Furth M, Wyatt K. Report of the Lancet Commission on the Value of Death: bringing death back into life. Lancet 2022; 399:837-884. [PMID: 35114146 PMCID: PMC8803389 DOI: 10.1016/s0140-6736(21)02314-x] [Citation(s) in RCA: 198] [Impact Index Per Article: 99.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | - Afsan Bhadelia
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Yali Cong
- Peking University Health Science Center, Beijing, China
| | | | | | | | | | | | | | | | | | | | | | | | - Julia Neuberger
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Sarah Russell
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eriko Sase
- Georgetown University, Washington, DC, USA
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6
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Pramono A, Widyastuti Y, Soenarto Y, Rochmawati E, Sudadi. Predictive Factors for Cardiopulmonary Resuscitation Failure. Indian J Palliat Care 2021; 27:426-430. [PMID: 34898936 PMCID: PMC8655672 DOI: 10.25259/ijpc_447_20] [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: 07/09/2021] [Accepted: 09/04/2021] [Indexed: 11/04/2022] Open
Abstract
Objectives Patients with chronic diseases are often admitted to the hospital through the emergency room of the hospital because of complaints of dyspnoea, urinary retention, decreased consciousness and cardiac arrest requiring resuscitation. The purpose of this study is to find predictive factors for failure of cardiopulmonary resuscitation (CPR) in patients of chronic diseases. Materials and Methods This cross-sectional study took medical records of patients who were carried out from primary healthcare center in Yogyakarta from 2017 to 2019. Bivariate statistical analysis used Fisher's exact test to determine the relative risk; if P < 0.25, then multivariate analysis with logistic regression continued with the backward method to obtain the odds ratio (OR). Results The results indicate that cardiac arrest patients with sepsis are most likely to fail at CPR, whereas male patients are 9.1 times (OR 9.1); patients with acidosis, 8.1 times (OR 8.1); and patients with asystole heart rhythm, 7.8 times (OR 7.8, P < 0.05). We can conclude that male patients with sepsis, acidosis or asystole heart rhythm will almost certainly fail to receive resuscitation. Conclusion Sepsis or septic shock, the male gender, acidosis, and asystole rhythm can be determinants of mortality in patients with chronic diseases who undergo CPR. It is necessary for one to test the application of the checklist or data from other hospitals and score the predictive factors to make the determination of the success of CPR easier.
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Affiliation(s)
- Ardi Pramono
- Department of Anesthesiology, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia
| | - Yunita Widyastuti
- Department of Anesthesiology and Intensive Therapy, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Yati Soenarto
- Department of Pediatrics, Dr Sardjito Hospital Center For Bioethics And Medical Humanities, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Erna Rochmawati
- Department of Palliative Care and Nursing Education, School of Nursing, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia
| | - Sudadi
- Department of Anesthesiology and Intensive Therapy, Universitas Gadjah Mada, Yogyakarta, Indonesia
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7
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Testa RS, Praça APA, Nassar Junior AP, Santana PV, Okamoto VN, Costa RT, Caruso P. Mortality and Life-Sustaining Therapy Decisions in Patients With Cancer and Acute Respiratory Failure Due to COVID-19 or Other Causes: An Observational Study. Front Med (Lausanne) 2021; 8:620818. [PMID: 34012970 PMCID: PMC8126609 DOI: 10.3389/fmed.2021.620818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
It is unknown if patients with cancer and acute respiratory failure due to COVID-19 have different clinical or cancer-related characteristics, decisions to forgo life-sustaining therapies (LST), and mortality compared to patients with cancer and acute respiratory failure due to other causes. In a cohort study, we tested the hypothesis that COVID-19 was associated with increased in-hospital mortality and decreased decisions to forgo LST in patients with cancer and acute respiratory failure. We employed two multivariate logistic regression models. Propensity score matching was employed as sensitivity analysis. We compared 382 patients without COVID-19 with 65 with COVID-19. Patients with COVID-19 had better performance status, less metastatic tumors, and progressive cancer. In-hospital mortality of patients with COVID-19 was lower compared with patients without COVID-19 (46.2 vs. 74.6%; p < 0.01). However, the cause of acute respiratory failure (COVID-19 or other causes) was not associated with increased in-hospital mortality [adjusted odds ratio (OR) 1.27 (0.55–2.93; 95% confidence interval, CI)] in the adjusted model. The percentage of patients with a decision to forgo LST was lower in patients with COVID-19 (15.4 vs. 36.1%; p = 0.01). However, COVID-19 was not associated with decisions to forgo LST [adjusted OR 1.21 (0.44–3.28; 95% CI)] in the adjusted model. The sensitivity analysis confirmed the primary analysis. In conclusion, COVID-19 was not associated with increased in-hospital mortality or decreased decisions to forgo LST in patients with cancer and acute respiratory failure. These patients had better performance status, less progressive cancer, less metastatic tumors, and less organ dysfunctions upon intensive care unit (ICU) admission than patients with acute respiratory failure due to other causes.
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Affiliation(s)
- Renato Scarsi Testa
- Intensive Care Unit, Antonio Cândido (AC) Camargo Cancer Center, São Paulo, Brazil
| | | | | | | | | | - Ramon Teixeira Costa
- Intensive Care Unit, Antonio Cândido (AC) Camargo Cancer Center, São Paulo, Brazil
| | - Pedro Caruso
- Intensive Care Unit, Antonio Cândido (AC) Camargo Cancer Center, São Paulo, Brazil.,Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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8
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Lee XJ, Farrington A, Carter H, Shield C, Graves N, McPhail SM, Harvey G, White BP, Willmott L, Cardona M, Hillman K, Callaway L, Barnett AG. A stepped-wedge randomised-controlled trial assessing the implementation, impact and costs of a prospective feedback loop to promote appropriate care and treatment for older patients in acute hospitals at the end of life: study protocol. BMC Geriatr 2020; 20:262. [PMID: 32727393 PMCID: PMC7392836 DOI: 10.1186/s12877-020-01660-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hospitalisation rates for the older population have been increasing with end-of-life care becoming a more medicalised and costly experience. There is evidence that some of these patients received non-beneficial treatment during their final hospitalisation with a third of the non-beneficial treatment duration spent in intensive care units. This study aims to increase appropriate care and treatment decisions and pathways for older patients at the end of life in Australia. This study will implement and evaluate a prospective feedback loop and tailored clinical response intervention at three hospitals in Queensland, Australia. METHODS A stepped-wedge cluster randomised trial will be conducted with up to 21 clinical teams in three acute hospitals over 70 weeks. The study involves clinical teams providing care to patients aged 75 years or older, who are prospectively identified to be at risk of non-beneficial treatment using two validated tools for detecting death and deterioration risks. The intervention's feedback loop will provide the teams with a summary of these patients' risk profiles as a stimulus for a tailored clinical response in the intervention phase. The Consolidated Framework for Implementation Research will be used to inform the intervention's implementation and process evaluation. The study will determine the impact of the intervention on patient outcomes related to appropriate care and treatment at the end of life in hospitals, as well as the associated healthcare resource use and costs. The primary outcome is the proportion of patients who are admitted to intensive care units. A process evaluation will be carried out to assess the implementation, mechanisms of impact, and contextual barriers and enablers of the intervention. DISCUSSION This intervention is expected to have a positive impact on the care of older patients near the end of life, specifically to improve clinical decision-making about treatment pathways and what constitutes appropriate care for these patients. These will reduce the incidence of non-beneficial treatment, and improve the efficiency of hospital resources and quality of care. The process evaluation results will be useful to inform subsequent intervention implementation at other hospitals. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 6 May 2019).
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Affiliation(s)
- Xing J Lee
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia. .,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.
| | - Alison Farrington
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Hannah Carter
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Carla Shield
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Nicholas Graves
- Duke-NUS Postgraduate Medical School, National University of Singapore, Singapore, Singapore
| | - Steven M McPhail
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Gillian Harvey
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Adelaide Nursing School, University of Adelaide, Adelaide, South Australia, Australia
| | - Ben P White
- Australia Centre for Heath Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australia Centre for Heath Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Magnolia Cardona
- Gold Coast University Hospital, Southport, Queensland, Australia.,Institute for Evidence-Based Health Care, Bond University, Robina, Queensland, Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| | - Leonie Callaway
- Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Faculty of Medicine, University of Queensland, Herston, Queensland, Australia.,Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Adrian G Barnett
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
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9
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Duberstein PR, Chen M, Hoerger M, Epstein RM, Perry LM, Yilmaz S, Saeed F, Mohile SG, Norton SA. Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review. J Pain Symptom Manage 2020; 59:894-915.e14. [PMID: 31639495 PMCID: PMC8928482 DOI: 10.1016/j.jpainsymman.2019.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care. OBJECTIVE The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice. METHODS We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored. RESULTS We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs. CONCLUSION Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care.
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Affiliation(s)
- Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers University School of Public Health, Piscataway, New Jersey, USA.
| | - Michael Chen
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Michael Hoerger
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA; Tulane Cancer Center, Tulane University, New Orleans, Louisiana, USA
| | - Ronald M Epstein
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Laura M Perry
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Sule Yilmaz
- Margaret Warner School of Human Development, Rochester, New York, USA
| | - Fahad Saeed
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sally A Norton
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; School of Nursing, University of Rochester, Rochester, New York, USA
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10
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Carter HE, Lee XJ, Gallois C, Winch S, Callaway L, Willmott L, White B, Parker M, Close E, Graves N. Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia. BMJ Open 2019; 9:e030955. [PMID: 31690607 PMCID: PMC6858125 DOI: 10.1136/bmjopen-2019-030955] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 10/02/2019] [Accepted: 10/04/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To quantitatively assess the factors associated with non-beneficial treatments (NBTs) in hospital admissions at the end of life. DESIGN Retrospective multicentre cohort study. SETTING Three large, metropolitan tertiary hospitals in Australia. PARTICIPANTS 831 adult patients who died as inpatients following admission to the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES Odds ratios (ORs) of NBT derived from logistic regression models. RESULTS Overall, 103 (12.4%) admissions involved NBTs. Admissions that involved conflict within a patient's family (OR 8.9, 95% CI 4.1 to 18.9) or conflict within the medical team (OR 6.5, 95% CI 2.4 to 17.8) had the strongest associations with NBTs in the all subsets regression model. A positive association was observed in older patients, with each 10-year increment in age increasing the likelihood of NBT by approximately 50% (OR 1.5, 95% CI 1.2 to 1.9). There was also a statistically significant hospital effect. CONCLUSIONS This paper presents the first statistical modelling results to assess the factors associated with NBT in hospital, beyond an intensive care setting. Our findings highlight potential areas for intervention to reduce the likelihood of NBTs.
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Affiliation(s)
- Hannah Elizabeth Carter
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Xing Ju Lee
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cindy Gallois
- School of Psychology, Faculty of Health and Behavioural Sciences, The University of Queensland, St Lucia, Queensland, Australia
| | - Sarah Winch
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Leonie Callaway
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane and Womens Hospital, Herston, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Malcolm Parker
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Eliana Close
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Duke-NUS Medical School, Singapore, Singapore
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11
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Alyami HM, Chan RJ, New K. End-of-life care preferences for people with advanced cancer and their families in intensive care units: a systematic review. Support Care Cancer 2019; 27:3233-3244. [PMID: 31102056 DOI: 10.1007/s00520-019-04844-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Advanced cancer patients' end-of-life care preferences in oncology units, medical-surgical units, nursing homes and palliative care services have been established. However, less is known about end-of-life care preferences of patients with advanced cancer in intensive care units and their families. AIM To explore end-of-life care preferences of patients with advanced cancer and their families in intensive care units and if these align with essential elements for end-of-life care. DESIGN Electronic databases were searched up to February 2018. Reference lists of retrieved articles were screened for potential studies. RESULTS A total of 112 full text articles were retrieved. Of these, 12 articles reporting outcomes from 10 studies were eligible for inclusion. The majority were retrospective chart reviews (n = 7) and conducted in developed countries (n = 9). Care preferences change over time with deteriorating physical condition. Ongoing patient-centred communication and shared decision-making are critical as is teamwork and involvement of a palliative care team. Marital status, gender and ethnicity appear to influence care preferences. Of those studies examining patient preferences and/or the receiving of their preferences, these could be aligned with approximately half of the Australian essential elements for end-of-life care. CONCLUSIONS Providing end-of-life care for patients with advanced cancer in intensive care units is challenging. No studies have investigated prospectively the end-of-life care preferences of patients and their families in this acute setting. Further research is required to determine the elements of care preferences for patients with advanced cancer and their families in intensive care units in developing countries.
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Affiliation(s)
- Hanan M Alyami
- School of Nursing, Midwifery and Social Work, Chamberlain Building St. Lucia Campus, University of Queensland, Brisbane, QLD, 4072, Australia.
- College of Nursing, Princess Nourah bint Abdulrahman University, PO Box 84428, Riyadh, Saudi Arabia.
| | - Raymond Javan Chan
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, 4059, Australia
- Division of Cancer Services, Princess Alexandra Hospital, Woolloongabba, QLD, 4102, Australia
| | - Karen New
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, QLD, 4072, Australia
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12
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Who Benefits from Aggressive Rapid Response System Treatments Near the End of Life? A Retrospective Cohort Study. Jt Comm J Qual Patient Saf 2018; 44:505-513. [PMID: 30166034 DOI: 10.1016/j.jcjq.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/02/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many patients near the end of life are subject to rapid response system (RRS) calls. A study was conducted in a large Sydney teaching hospital to identify a cutoff point that defines nonbeneficial treatment for older hospital patients receiving an RRS call, describe interventions administered, and measure the cost of hospitalization. METHODS This was a retrospective cohort of 733 adult inpatients with data for the period three months before and after their last placed RRS call. Subgroup analysis of patients aged ≥ 80 years was conducted. Log-rank, chi-square, and t-tests were used to compare survival, and logistic regression was used to examine predictors of death. RESULTS Overall, 65 (8.9%) patients had a preexisting not-for-resuscitation (NFR) or not-for-RRS order; none of those patients survived to three months. By contrast, patients without an NFR or not-for-RRS order had three-month survival probability of 71% (log-rank χ2 145.63; p < 0.001). Compared with survivors, RRS recipients who died were more likely to be older, to be admitted to a medical ward, and to have a larger mean number of admissions before the RRS. The average cost of hospitalization for the very old transferred to the ICU was higher than for those not requiring treatment in the ICU (US$33,990 vs. US$14,774; p = 0.045). CONCLUSION Identifiable risk factors clearly associated with poor clinical outcomes and death can be used as a guide to administer less aggressive treatments, including reconsideration of ICU transfers, adherence to NFR orders, and transition to end-of-life management instead of calls to the RRS team.
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13
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Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. Lancet 2017; 390:156-168. [PMID: 28077234 PMCID: PMC5708862 DOI: 10.1016/s0140-6736(16)32585-5] [Citation(s) in RCA: 535] [Impact Index Per Article: 76.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Affiliation(s)
- Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
| | - Kalipso Chalkidou
- Institute for Global Health Innovation, Imperial College, London, UK
| | - Jenny Doust
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul Glasziou
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Iona Heath
- Royal College of General Practitioners, London, UK
| | | | | | - Divya Srivastava
- LSE Health, London School of Economics and Political Science, London, UK
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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14
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Mazutti SRG, Nascimento ADF, Fumis RRL. Limitation to Advanced Life Support in patients admitted to intensive care unit with integrated palliative care. Rev Bras Ter Intensiva 2016; 28:294-300. [PMID: 27626949 PMCID: PMC5051188 DOI: 10.5935/0103-507x.20160042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/05/2016] [Indexed: 01/16/2023] Open
Abstract
Objective To estimate the incidence of limitations to Advanced Life Support in
critically ill patients admitted to an intensive care unit with integrated
palliative care. Methods This retrospective cohort study included patients in the palliative care
program of the intensive care unit of Hospital Paulistano
over 18 years of age from May 1, 2011, to January 31, 2014. The limitations
to Advanced Life Support that were analyzed included do-not-resuscitate
orders, mechanical ventilation, dialysis and vasoactive drugs. Central
tendency measures were calculated for quantitative variables. The
chi-squared test was used to compare the characteristics of patients with or
without limits to Advanced Life Support, and the Wilcoxon test was used to
compare length of stay after Advanced Life Support. Confidence intervals
reflecting p ≤ 0.05 were considered for statistical significance. Results A total of 3,487 patients were admitted to the intensive care unit, of whom
342 were included in the palliative care program. It was observed that after
entering the palliative care program, it took a median of 2 (1 - 4) days for
death to occur in the intensive care unit and 4 (2 - 11) days for hospital
death to occur. Many of the limitations to Advanced Life Support (42.7%)
took place on the first day of hospitalization. Cardiopulmonary
resuscitation (96.8%) and ventilatory support (73.6%) were the most adopted
limitations. Conclusion The contribution of palliative care integrated into the intensive care unit
was important for the practice of orthothanasia, i.e., the non-extension of
the life of a critically ill patient by artificial means.
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15
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Willmott L, White B, Gallois C, Parker M, Graves N, Winch S, Callaway LK, Shepherd N, Close E. Reasons doctors provide futile treatment at the end of life: a qualitative study. JOURNAL OF MEDICAL ETHICS 2016; 42:496-503. [PMID: 27188227 DOI: 10.1136/medethics-2016-103370] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/24/2016] [Indexed: 05/09/2023]
Abstract
OBJECTIVE Futile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patient's life. DESIGN Semistructured in-depth interviews. SETTING Three large tertiary public hospitals in Brisbane, Australia. PARTICIPANTS 96 doctors from emergency, intensive care, palliative care, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine and medical administration departments. Participants were recruited using purposive maximum variation sampling. RESULTS Doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation towards curative treatment, discomfort or inexperience with death and dying, concerns about legal risk and poor communication skills. Second, the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty and lack of information about patient wishes. Third, there were hospital factors including a high degree of specialisation, the availability of routine tests and interventions, and organisational barriers to diverting a patient from a curative to a palliative pathway. Doctors nominated family or patient request and doctors being locked into a curative role as the main reasons for futile care. CONCLUSIONS Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level.
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Affiliation(s)
- Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Benjamin White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cindy Gallois
- Faculty of Social and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Malcolm Parker
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sarah Winch
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Leonie Kaye Callaway
- Department of Internal Medicine, The Royal Brisbane and Womens Hospital, Herston, Queensland, Australia
| | - Nicole Shepherd
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Eliana Close
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
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16
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Bluhm M, Connell CM, Janz N, Bickel K, DeVries R, Silveira M. Oncologists’ End of Life Treatment Decisions. J Appl Gerontol 2016. [DOI: 10.1177/0733464815595510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Optimal treatment decisions for older end-stage cancer patients are complicated, and are influenced by oncologists’ attitudes and beliefs about older patients. Nevertheless, few studies have explored oncologists’ perspectives on how patient age affects their treatment decisions. Methods: In-depth interviews were conducted with 17 oncologists to examine factors that influence their chemotherapy decisions for adults with incurable cancer near death. Transcripts of recorded interviews were coded and content analyzed. Results: Oncologists identified patient age as a key factor in their chemotherapy decisions. They believed older adults were less likely to want or tolerate treatment, and felt highly motivated to treat younger patients. Discussion: Qualitative analysis of in-depth interviews resulted in a nuanced understanding of how patient age influences oncologists’ chemotherapy decisions. Such understanding may inform practice efforts aimed at enhancing cancer care at the end of life for older patients.
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Affiliation(s)
| | | | | | - Kathleen Bickel
- Veterans Affairs White River Junction Medical Center, Geisel School of Medicine at Dartmouth, USA
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17
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Cardona-Morrell M, Kim J, Turner RM, Anstey M, Mitchell IA, Hillman K. Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. Int J Qual Health Care 2016; 28:456-69. [PMID: 27353273 DOI: 10.1093/intqhc/mzw060] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2016] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care. DATA SOURCES English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015). STUDY SELECTION All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL). DATA EXTRACTION A 13-item quality score estimated independently by two authors. RESULTS OF DATA SYNTHESIS Evidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%); and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%). CONCLUSION This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.
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Affiliation(s)
- M Cardona-Morrell
- The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, PO Box 6087 UNSW, Sydney NSW 1466, Australia
| | - Jch Kim
- School of Medicine, Ground floor, 30, Western Sydney University, Narellan Road & Gilchrist Drive, Campbelltown NSW 2560, Australia
| | - R M Turner
- School of Public Health and Community Medicine, Level 2, Samuels Building, Samuels Ave, The University of New South Wales, Kensington NSW 2033, Australia
| | - M Anstey
- Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Perth WA 6009, Australia
| | - I A Mitchell
- Intensive Care Unit, Building 12, Level 3, Canberra Hospital, Yamba Drive, Garran, Canberra, ACT 2605, Australia
| | - K Hillman
- The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, PO Box 6087 UNSW, Sydney NSW 1466, Australia Intensive Care Unit, Level 2, Liverpool Hospital, Elizabeth St & Goulburn St, Liverpool NSW 2170, Australia
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18
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Xia R, Wang D. Intensive care unit prognostic factors in critically ill patients with advanced solid tumors: a 3-year retrospective study. BMC Cancer 2016; 16:188. [PMID: 26946297 PMCID: PMC4779224 DOI: 10.1186/s12885-016-2242-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 03/01/2016] [Indexed: 12/15/2022] Open
Abstract
Background The objective of this study was to identify risk factors predicting prognosis of critically ill medical patients with advanced solid tumors in the intensive care unit (ICU). Methods We retrospectively analyzed all ICU unplanned medical admissions to the ICU of patients with advanced solid cancer in Tianjin Medical University Cancer Institute and Hospital between October 1, 2012 and March 1, 2015. Approval was obtained from the Ethical Commission of Tianjin Medical University Cancer Institute and Hospital to review and publish information from patients’ records. Results One hundred and forty-one patients with full code status met the criteria for inclusion from among 813 ICU admissions. ICU mortality was 14.9 % and in-hospital mortality was 29.8 %. The major reasons for unplanned ICU admission were respiratory failure (38.3 %) and severe sepsis or septic shock (27.7 %). The ICU mortality in patients who required vasopressors, mechanical ventilation or renal replacement therapy for >24 h was 25, 25.9 and 40 %, respectively. The mean overall survival was 28.6 months. After adjusting for hypertension, type of solid cancer, intervention time, need for mechanical ventilation and Acute Physiology and Chronic Health Evaluation II score, only Sepsis-related Organ Failure Assessment (SOFA) score on day 7 of ICU treatment remained a significant predictor of ICU mortality (adjusted odds ratio 1.612, 95 % confidence interval 1.137–2.285, P = 0.007). Conclusions We suggest broadening the criteria for ICU admission. The patients should be allowed an ICU trial consisting of unlimited ICU support, including invasive hemodynamic monitoring, mechanical ventilation and renal replacement therapy. An interdisciplinary meeting, including an ethics consultation, should be held to make end-of-life decisions if the SOFA score on day 7 shows clinical deterioration with no available therapeutic options.
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Affiliation(s)
- Rui Xia
- Key Laboratory of Cancer Prevention and Therapy, Intensive Care Unit, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Huanhu West Road, Ti-Yuan-Bei, Hexi District, Tianjin, 300060, China.
| | - Donghao Wang
- Key Laboratory of Cancer Prevention and Therapy, Intensive Care Unit, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Huanhu West Road, Ti-Yuan-Bei, Hexi District, Tianjin, 300060, China
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19
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Infomarkers for transition to goals consistent with palliative care in dying patients. Palliat Support Care 2015; 13:1427-34. [PMID: 25711431 DOI: 10.1017/s1478951515000103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Electronic health records (EHRs) may contain infomarkers that identify patients near the end of life for whom it would be appropriate to shift care goals to palliative care. Discovery and use of such infomarkers could be used to conduct effectiveness research that ultimately could help to reduce the monumental cost of caring for the dying. The aim of our study was to identify changes in the plans of care that represent infomarkers, which signal a transition of care goals from nonpalliative care ones to those consistent with palliative care. METHOD Using an existing electronic health record database generated during a two-year longitudinal study of nine diverse medical-surgical units from four Midwest hospitals and a known group approach, we evaluated patient care episodes for 901 patients who died (mean age = 74.5 ± 14.6 years). We used ANOVA and Tukey's post-hoc tests to compare patient groups. RESULTS We identified 11 diagnoses, including Death Anxiety and Anticipatory Grieving, whose addition to the care plan, some of which also occurred with removal of nonpalliative care diagnoses, represent infomarkers of transition to palliative care goals. There were four categories of patients, those who had: no infomarkers on plans (n = 507), infomarkers added on the admission plan (n = 194), infomarkers added on a post-admission plan (minor transitions, n = 109), and infomarkers added and nonpalliative care diagnoses removed on a post-admission plan (major transition, n = 91). Age, length of stay, and pain outcomes differed significantly for these four categories of patients. SIGNIFICANCE OF RESULTS EHRs contain pertinent infomarkers that if confirmed in future studies could be used for timely referral to palliative care for improved focus on comfort outcomes and to identify palliative care subjects from data repositories in order to conduct big-data research, comparative effectiveness studies, and health-services research.
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