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Nalda CM, McSherry ML, Schmidt CM, Neumann ML, Boss RD, Weaver MS. Video tools in pediatric goals of care communication: A systematic review. PEC INNOVATION 2022; 1:100029. [PMID: 37213739 PMCID: PMC10194233 DOI: 10.1016/j.pecinn.2022.100029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 03/13/2022] [Accepted: 03/17/2022] [Indexed: 05/23/2023]
Abstract
•Goals of Care resources are primarily in written format and for adult patients.•Video tools can support families of pediatric patients facing prognostic uncertainty.•Videos represent an effective but underutilized Goals of Care communication tool.
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Affiliation(s)
- Caitlin M. Nalda
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, MD, USA
- Corresponding author at: 200 N Wolfe Street, Room 2019, Baltimore, MD 21287, USA.
| | - Megan L. McSherry
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Cynthia M. Schmidt
- Leon S. McGoogan Health Sciences Library, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marie L. Neumann
- Division of Transplant Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Communication Studies, University of Nebraska- Lincoln, Lincoln, NE, USA
| | - Renee D. Boss
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neonatal - Perinatal Medicine, Berman Institute of Bioethics, Baltimore, MD, USA
| | - Meaghann S. Weaver
- National Center for Ethics in Health Care, Washington, DC, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, Nebraska, USA
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Harris E, Eng D, Ang Q, Clarke E, Sinha A. Goals of care discussions in acute hospital admissions - Qualitative description of perspectives from patients, family and their doctors. PATIENT EDUCATION AND COUNSELING 2021; 104:2877-2887. [PMID: 34598803 DOI: 10.1016/j.pec.2021.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/03/2021] [Accepted: 09/06/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Goals of care discussions guide care for hospital inpatients at risk of deterioration. We aimed to explore patient and family experience of goals of care during the first 72 h of admission along with their doctor's perspective. METHODS A qualitative descriptive study. Patients, family and doctors who participated in a goals of care discussion during an acute hospital admission at an Australian tertiary teaching hospital were interviewed in 2019. RESULTS Many participants found goals of care discussions appropriate and reported understanding. However, communication was commonly procedure-focused, with questioning about preferences for cardiopulmonary resuscitation and intubation. Some considered the discussion as inapplicable to their state of health, and occasionally surprising. Participants commonly related goals of care with death, and without context, this led to fear of abandonment. Previous experience with end of life care influenced decision-making. Preference for family presence was clear. CONCLUSIONS This study identifies deficiencies in goals of care communication in the acute hospital setting. Discussions are life-saving-procedure focused, leading to poor understanding and potentially distress, and jeopardising patient-centred care. PRACTICE IMPLICATIONS Assessment of patient values and clear communication on the aims of goals of care discussions is essential to optimise patient and institutional outcomes. Clinicians should consider environment and invite family participation.
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Affiliation(s)
| | - Derek Eng
- Royal Perth Hospital, Perth, Australia; School of Medicine, Division of Internal Medicine, University of Western Australia, Crawley, Australia; St John of God Subiaco Hospital, Subiaco, Australia; School of Medicine, University of Notre Dame, Fremantle, Australia.
| | - QiKai Ang
- Royal Perth Hospital, Perth, Australia.
| | | | - Atul Sinha
- Royal Perth Hospital, Perth, Australia; School of Medicine, Division of Internal Medicine, University of Western Australia, Crawley, Australia; Fiona Stanley Hospital, Murdoch, Australia.
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Swenson A, Hyde R. Understanding patients' end-of-life goals of care in the emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12388. [PMID: 33718923 PMCID: PMC7925851 DOI: 10.1002/emp2.12388] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/27/2020] [Accepted: 01/26/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Emergency departments (ED) are frequently the entryway to the health system for older, more ill patients. Because decisions made in the ED often influence escalation of care both in the ED and after admission, it is important for emergency physicians to understand their patients' goals of care. STUDY OBJECTIVES To determine how well emergency physicians understand their patients' goals of care. METHODS This was a prospective survey study of a convenience sample of ED patients 65 years and older presenting between February 18 and March 1, 2019 to an academic center with 77,000 annual visits. If a patient did not have decision-making capacity, a surrogate decision-maker was interviewed when possible. Two sets of surveys were designed, one for patients and one for physicians. The patient survey included questions regarding their goals of care and end-of-life care preferences. The physician survey asked physicians to select which goals of care were important to their patients and to identify which was the most important. Patient-physician agreement on patients' most important goal of care was analyzed with Cohen's kappa. RESULTS A total of 111 patient participants were invited to complete the survey, of whom 80 (72%) agreed to participate. The patients consisted of 43 women and 37 men with an age range from 65 to 98 years. Additionally, 16 attending and 14 resident physicians participated in the study for a total of 49 attending responses and 41 resident responses. A total of 88% of patients believed it was either very important or important to discuss goals of care with their physicians. Both patients and physicians most frequently chose "Improve or maintain function, quality of life, or independence" as the most important goal; however, there was wide variation in patient responses. Patients and attending physicians selected the same most important goal of care in 20% of cases (kappa 0.03) and patients and resident physicians selected the same goal in 27% of cases (kappa 0.11). CONCLUSIONS We found poor agreement between patients and physicians in the ED regarding patients' most important goal of care. Additionally, we found that most patients visiting the ED believe it is important to discuss goals of care with their physicians. Future work may focus on interventions to facilitate goals of care discussions in the ED.
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Affiliation(s)
- Aunika Swenson
- Department of Emergency MedicineStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Robert Hyde
- Department of Emergency MedicineMayo Clinic Alix School of MedicineRochesterMinnesotaUSA
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Caring for Pregnant Patients With CKD---An Ethical Discussion of 5 Cases. Kidney Int Rep 2021; 6:1273-1279. [PMID: 34013105 PMCID: PMC8116767 DOI: 10.1016/j.ekir.2021.02.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/22/2021] [Accepted: 02/08/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction Pregnancy planning in patients with chronic kidney disease can result in ethical conflicts due to the potential for adverse outcomes. Traditionally, many nephrologists have advised their patients to avoid pregnancy altogether; however, this approach is paternalistic and not patient-centered. An ethical framework could guide joint decision-making between physicians and their patients, but this does not currently exist. Methods We performed a literature search to identify the ethical considerations associated with this patient population. We searched for articles published between 1975 and 2019 using the terms “ethics” and “high risk pregnancy,” along with 29 chronic disease-specific MeSH terms. Subsequently, we performed a critical evaluation using established ethical theories and adapted anonymized clinical cases from the Pregnancy in Kidney Disease Clinic (PreKid Clinic) at our institution to guide the discussion. Results We identified 968 articles and excluded 947 based on their title or abstract. Twelve full-text articles were included, representing discussions, case reports, and literature reviews on the ethics of pregnancy in 8 chronic diseases. The extracted data were applied to 5 clinical cases to guide the discussion. Conclusions This clinical review focuses on 3 main ethical themes: duty to patient, duty to the fetus, and duty to society, to help physicians explore common scenarios that may arise when counseling patients around pregnancy. Primarily, physicians have a duty to facilitate autonomous decision-making and informed consent. Secondarily, they have a duty to protect the fetus and use resources judiciously as long as it does not impact the care of their patients.
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Secunda K, Wirpsa MJ, Neely KJ, Szmuilowicz E, Wood GJ, Panozzo E, McGrath J, Levenson A, Peterson J, Gordon EJ, Kruser JM. Use and Meaning of "Goals of Care" in the Healthcare Literature: a Systematic Review and Qualitative Discourse Analysis. J Gen Intern Med 2020; 35:1559-1566. [PMID: 31637653 PMCID: PMC7210326 DOI: 10.1007/s11606-019-05446-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The specific phrase "goals of care" (GOC) is pervasive in the discourse about serious illness care. Yet, the meaning of this phrase is ambiguous. We sought to characterize the use and meaning of the phrase GOC within the healthcare literature to improve communication among patients, families, clinicians, and researchers. METHODS A systematic review of the English language healthcare literature indexed in MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus was performed in October of 2018. We searched for all publications with the exact phrase "goals of care" within the title or abstract; no limitations on publication date or format were applied; conference abstracts were excluded. We used qualitative, discourse analysis to identify key themes and generate an operational definition and conceptual model of GOC. RESULTS A total of 214 texts were included in the final analysis. Use of GOC increased over time with 87% of included texts published in the last decade (2009-2018). An operational definition emerged from consensus within the published literature: the overarching aims of medical care for a patient that are informed by patients' underlying values and priorities, established within the existing clinical context, and used to guide decisions about the use of or limitation(s) on specific medical interventions. Application of the GOC concept was described as important to the care of patients with serious illness, in order to (1) promote patient autonomy and patient-centered care, (2) avoid unwanted care and identify valued care, and (3) provide psychological and emotional support for patients and their families. DISCUSSION The use of the phrase "goals of care" within the healthcare literature is increasingly common. We identified a consensus, operational definition that can facilitate communication about serious illness among patients, families, and clinicians and provide a framework for researchers developing interventions to improve goal-concordant care.
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Affiliation(s)
- Katharine Secunda
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | - Kathy J Neely
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Eytan Szmuilowicz
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Gordon J Wood
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | - Joan McGrath
- Northwestern Memorial Hospital, Chicago, IL, USA
| | - Anne Levenson
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Jonna Peterson
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Galter Health Sciences Library and Learning Center, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Elisa J Gordon
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Surgery, Division of Transplantation, Northwestern University Feinberg School of Medicine, Chicago, USA.,Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, USA.,Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Jacqueline M Kruser
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA. .,Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, USA. .,Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, USA.
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Verberne WR, Das-Gupta Z, Allegretti AS, Bart HAJ, van Biesen W, García-García G, Gibbons E, Parra E, Hemmelder MH, Jager KJ, Ketteler M, Roberts C, Al Rohani M, Salt MJ, Stopper A, Terkivatan T, Tuttle KR, Yang CW, Wheeler DC, Bos WJW. Development of an International Standard Set of Value-Based Outcome Measures for Patients With Chronic Kidney Disease: A Report of the International Consortium for Health Outcomes Measurement (ICHOM) CKD Working Group. Am J Kidney Dis 2018; 73:372-384. [PMID: 30579710 DOI: 10.1053/j.ajkd.2018.10.007] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/14/2018] [Indexed: 12/14/2022]
Abstract
Value-based health care is increasingly promoted as a strategy for improving care quality by benchmarking outcomes that matter to patients relative to the cost of obtaining those outcomes. To support the shift toward value-based health care in chronic kidney disease (CKD), the International Consortium for Health Outcomes Measurement (ICHOM) assembled an international working group of health professionals and patient representatives to develop a standardized minimum set of patient-centered outcomes targeted for clinical use. The considered outcomes and patient-reported outcome measures were generated from systematic literature reviews. Feedback was sought from patients and health professionals. Patients with very high-risk CKD (stages G3a/A3 and G3b/A2-G5, including dialysis, kidney transplantation, and conservative care) were selected as the target population. Using an online modified Delphi process, outcomes important to all patients were selected, such as survival and hospitalization, and to treatment-specific subgroups, such as vascular access survival and kidney allograft survival. Patient-reported outcome measures were included to capture domains of health-related quality of life, which were rated as the most important outcomes by patients. Demographic and clinical variables were identified to be used as case-mix adjusters. Use of these consensus recommendations could enable institutions to monitor, compare, and improve the quality of their CKD care.
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Affiliation(s)
| | - Zofia Das-Gupta
- International Consortium for Health Outcomes Measurement, London, United Kingdom
| | | | - Hans A J Bart
- patient representative, Dutch Kidney Patients Association (NVN), Bussum, the Netherlands
| | - Wim van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Guillermo García-García
- University of Guadalajara Health Sciences Center, Hospital Civil de Guadalajara "Fray Antonio Alcalde," Guadalajara, Jalisco, Mexico
| | - Elizabeth Gibbons
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (EG)
| | - Eduardo Parra
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Marc H Hemmelder
- Dutch Renal Registry (Renine), Nefrovisie, Utrecht; Medical Center Leeuwarden, Leeuwarden
| | - Kitty J Jager
- ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Markus Ketteler
- Klinikum Coburg, Coburg, Germany; University of Split School of Medicine, Split, Croatia
| | - Charlotte Roberts
- International Consortium for Health Outcomes Measurement, London, United Kingdom
| | | | - Matthew J Salt
- International Consortium for Health Outcomes Measurement, London, United Kingdom
| | - Andrea Stopper
- European Renal Care Providers Association, Brussels, Belgium
| | | | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care Kidney Research Institute, Nephrology Division and Institute for Translational Health Sciences, University of Washington, Spokane, WA
| | - Chih-Wei Yang
- Chang Gung Memorial Hospital, Linkou; Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - David C Wheeler
- Centre for Nephrology, University College London, London, United Kingdom
| | - Willem Jan W Bos
- St Antonius Hospital, Nieuwegein; Leiden University Medical Center, Leiden, the Netherlands
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Myers J. Measuring quality of end-of-life communication and decision-making: Do we have this right? CMAJ 2017; 189:E978-E979. [PMID: 28760833 DOI: 10.1503/cmaj.170280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jeff Myers
- Department of Family and Community Medicine, Division of Palliative Care, Sunnybrook Health Sciences Centre, Toronto, Ont.
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