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Arends SAM, Thodé M, Pasman HRW, Francke AL, Jongerden IP. How physicians see nurses' role in decision-making about life-prolonging treatments in patients with a short life expectancy: An interview study. PATIENT EDUCATION AND COUNSELING 2023; 114:107863. [PMID: 37356117 DOI: 10.1016/j.pec.2023.107863] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Exploring physicians' views on hospital nurses' role in decision-making about potentially life-prolonging treatments in patients with a short life expectancy. METHODS A qualitative study using semi-structured interviews with hospital physicians. Data were collected from May to September 2019 and analyzed following principles of thematic analysis. RESULTS Fifteen physicians working in different hospitals and specialisms participated. Physicians stated that they are responsible for the final decision about potentially life-prolonging treatments. They considered nurses' role in decision-making to be complementary to the roles of both patients and the physicians themselves, especially when there are doubts or complex situations. Physicians varied in how important they found nurses' involvement in the decision-making process: some physicians saw the involvement of nurses as "situation-dependent", while others viewed nurses' involvement as standard practice. Furthermore, physicians mentioned practical obstacles to involving nurses, like the limited time available to both nurses and physicians themselves. CONCLUSION Physicians recognize a complementary role for nurses in decision-making about potentially life-prolonging treatment, especially in cases with doubts or complex situations. PRACTICE IMPLICATIONS Physicians and nurses should engage with each other to make nurses' involvement less situation-dependent. This inter-professional collaboration regarding decision-making about life-prolonging treatments should be stimulated, supported and maintained.
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Affiliation(s)
- Susanne A M Arends
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Amsterdam, the Netherlands.
| | - Maureen Thodé
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Section General Internal Medicine, Department of Internal Medicine, Amsterdam, the Netherlands
| | - H Roeline W Pasman
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Amsterdam, the Netherlands
| | - Anneke L Francke
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Amsterdam, the Netherlands; Netherlands Institute for Health Services Research - Nivel, Utrecht, the Netherlands
| | - Irene P Jongerden
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Amsterdam, the Netherlands
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Gautier WC, Abaye M, Dev S, Seaman JB, Butler RA, Norman MK, Arnold RM, Witteman HO, Cook TE, Mohan D, White DB. An Online Training Program to Improve Clinicians' Skills in Communicating About Serious Illness. Am J Crit Care 2022; 31:189-201. [PMID: 35466353 DOI: 10.4037/ajcc2022105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Large-scale efforts to train clinicians in serious-illness communication skills are needed, but 2 important gaps in knowledge remain. (1) No proven training method exists that can be readily scaled to train thousands of clinicians. (2) Though the value of interprofessional collaboration to support incapacitated patients' surrogates is increasingly recognized, few interventions for training intensive care unit (ICU) nurses in important communication skills can be leveraged to provide interprofessional family support. OBJECTIVE To develop and test a web/videoconference-based platform to train nurses to communicate about serious illness. METHODS A user-centered process was used to develop the intervention, including (1) iteratively engaging a stakeholder panel, (2) developing prototype and beta versions of the platform, and (3) 3 rounds of user testing with 13 ICU nurses. Participants' ratings of usability, acceptability, and perceived effectiveness were assessed quantitatively and qualitatively. RESULTS Stakeholders stressed that the intervention should leverage interactive learning and a streamlined digital interface. A training platform was developed consisting of 6 interactive online training lessons and 3 group-based video-conference practice sessions. Participants rated the program as usable (mean summary score 84 [96th percentile]), acceptable (mean, 4.5/5; SD, 0.7), and effective (mean, 4.8/5; SD, 0.6). Ten of 13 nurses would recommend the intervention over 2-day in-person training. CONCLUSIONS Nurses testing this web-based training program judged it usable, acceptable, and effective. These data support proceeding with an appropriately powered efficacy trial.
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Affiliation(s)
- William C. Gautier
- William C. Gautier is a medical student, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Menna Abaye
- Menna Abaye is a research project manager, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Shelly Dev
- Shelly Dev is an assistant professor, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Jennifer B. Seaman
- Jennifer B. Seaman is an assistant professor, School of Nursing, Department of Acute and Tertiary Care, University of Pittsburgh, Pennsylvania
| | - Rachel A. Butler
- Rachel A. Butler is a research program manager, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Marie K. Norman
- Marie K. Norman is an associate professor, School of Medicine, General Internal Medicine, Medicine and Clinical and Translational Science, Innovation Design for Education and Assessment (IDEA) Lab, University of Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Robert M. Arnold is a professor, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, and University of Pittsburgh Medical Center Palliative and Supportive Institute, Pennsylvania
| | - Holly O. Witteman
- Holly O. Witteman is a professor, Department of Family and Emergency Medicine & Office of Education and Professional Development, Faculty of Medicine, Laval University, Québec, Canada
| | - Tara E. Cook
- Tara E. Cook was an assistant professor, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pennsylvania
| | - Deepika Mohan
- Deepika Mohan is an associate professor, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Douglas B. White
- Douglas B. White is a professor, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
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A Pilot Randomized Trial of an Interactive Web-based Tool to Support Surrogate Decision Makers in the Intensive Care Unit. Ann Am Thorac Soc 2021; 18:1191-1201. [PMID: 33326348 DOI: 10.1513/annalsats.202006-585oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Breakdowns in clinician-family communication in intensive care units (ICUs) are common, yet there are no easily scaled interventions to prevent this problem.Objectives: To assess the feasibility, usability, acceptability, and perceived effectiveness of a communication intervention that pairs proactive family meetings with an interactive, web-based tool to help surrogates prepare for clinician-family meetings.Methods: We conducted a two-arm, single-blind, patient-level randomized trial comparing the Family Support Tool with enhanced usual care in two ICUs in a tertiary-care hospital. Eligible participants included surrogates of incapacitated patients judged by their physicians to have ≥40% risk of death or severe long-term functional impairment. The intervention group received unlimited tool access, with prompts to complete specific content upon enrollment and before two scheduled family meetings. Before family meetings, research staff shared with clinicians a one-page summary of surrogates' main questions, prognostic expectations, beliefs about the patient's values, and attitudes about goals of care. The comparator group received usual care enhanced with scheduled family meetings. Feasibility outcomes included the proportion of participants who accessed the tool before the first family meeting, mean number of logins, and average tool engagement time. We assessed tool usability with the System Usability Scale, assessed tool acceptability and perceived effectiveness with internally developed questionnaires, and assessed quality of communication and shared decision-making using the Quality of Communication questionnaire.Results: Of 182 screened patients, 77 were eligible. We enrolled 52 (67.5%) patients and their primary surrogate. Ninety-six percent of intervention surrogates (24/25) accessed the tool before the first family meeting (mean engagement time, 62 min ± 27.7) and logged in 4.2 times (±2.1) on average throughout the hospitalization. Surrogates reported that the tool was highly usable (mean, 82.4/100), acceptable (mean, 4.5/5 ± 0.9), and effective (mean, 4.4/5 ± 0.2). Compared with the control group, surrogates who used the tool reported higher overall quality of communication (mean, 8.9/10 ± 1.6 vs. 8.0/10 ± 2.4) and higher quality in shared decision-making (mean, 8.7/10 ± 1.5 vs. 8.0/10 ± 2.4), but the difference did not reach statistical significance.Conclusions: It is feasible to deploy an interactive web-based tool to support communication and shared decision-making for surrogates in ICUs. Surrogates and clinicians rated the tool as highly usable, acceptable, and effective.
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Anantapong K, Davies N, Chan J, McInnerney D, Sampson EL. Mapping and understanding the decision-making process for providing nutrition and hydration to people living with dementia: a systematic review. BMC Geriatr 2020; 20:520. [PMID: 33267831 PMCID: PMC7709405 DOI: 10.1186/s12877-020-01931-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/25/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND This systematic review aimed to explore the process of decision-making for nutrition and hydration for people living with dementia from the perspectives and experiences of all involved. METHODS We searched CINAHL, the Cochrane Library, EMBASE, MEDLINE and PsycINFO databases. Search terms were related to dementia, decision-making, nutrition and hydration. Qualitative, quantitative and case studies that focused on decision-making about nutrition and hydration for people living with dementia were included. The CASP and Murad tools were used to appraise the quality of included studies. Data extraction was guided by the Interprofessional Shared Decision Making (IP-SDM) model. We conducted a narrative synthesis using thematic analysis. PROSPERO registration number CRD42019131497. RESULTS Forty-five studies were included (20 qualitative, 15 quantitative and 10 case studies), comprising data from 17 countries and 6020 patients, family caregivers and practitioners. The studies covered a range of decisions from managing oral feeding to the use of tube feeding. We found that decisions about nutrition and hydration for people living with dementia were generally too complex to be mapped onto the precise linear steps of the existing decision-making model. Decision-making processes around feeding for people living with dementia were largely influenced by medical evidence, personal values, cultures and organizational routine. Although the process involved multiple people, family caregivers and non-physician practitioners were often excluded in making a final decision. Upon disagreement, nutrition interventions were sometimes delivered with conflicting feelings concealed by family caregivers or practitioners. Most conflicts and negative feelings were resolved by good relationship, honest communication, multidisciplinary team meetings and renegotiation. CONCLUSIONS The decision-making process regarding nutrition and hydration for people living with dementia does not follow a linear process. It needs an informed, value-sensitive, and collaborative process. However, it often characterized by unclear procedures and with a lack of support. Decisional support is needed and should be approached in a shared and stepwise manner.
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Affiliation(s)
- Kanthee Anantapong
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.
- Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand.
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Justin Chan
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Daisy McInnerney
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, Sterling Way, London, UK
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Herrera KM, Milone G, Davis JA, Persad MD, Dinglas C, Heiselman C, Buckley A, Garretto D, Pastore LM. Psychological measures of patient's decision-making for prenatal genetic testing. J Matern Fetal Neonatal Med 2020; 35:4130-4136. [PMID: 33207999 DOI: 10.1080/14767058.2020.1847074] [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: 10/23/2022]
Abstract
OBJECTIVE To use a questionnaire to determine the levels of maternal decision-related distress, clarity of the pros and cons, and certainty when considering prenatal genetic diagnostic testing; and to assess the relationship between these constructs and patient characteristics. METHOD Cross-sectional study. Voluntary, anonymous questionnaires distributed 2017-2019 to women referred for invasive prenatal genetic testing. Excluded: English or Spanish illiterate. Maternal characteristics were collected. Questions evaluated distress, decisional certainty, and decisional clarity on a 5-point Likert scale (range: 0 = low/uncertain/unclear to 4 = high/certain/clear). Analysis: non-parametric Kruskal-Wallis, correlation statistics, and ANOVA. RESULTS Forty-four female patients completed it. Most were married, white, Catholic, and multiparous. 58% had already made a testing decision. Patients expressed low distress levels (mean 1.18 ± 0.80) and expressed high decisional certainty (mean 3.28 ± 0.76) and clarity (mean 3.30 ± 0.99). Decisional certainty and clarity were positively correlated (r = 0.47, p < .01), whereas distress was negatively correlated with decisional certainty (r = -0.8136, p < .0005) and decisional clarity (r = -0.49, p = .007). No significant differences by religion or parity. Greater distress (p < .05) and less decisional clarity (p = .07) occurred between those still debating testing vs those who had decided. CONCLUSIONS Higher maternal distress scores were associated with lower decisional certainty and decisional clarity in women considering prenatal genetic testing.
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Affiliation(s)
- Kimberly M Herrera
- Department of Obstetrics, Gynecology and Reproductive Medicine, Renaissance School of Medicine Stony Brook University, Stony Brook, NY, USA
| | - Gina Milone
- Department of Obstetrics, Gynecology and Reproductive Medicine, Renaissance School of Medicine Stony Brook University, Stony Brook, NY, USA
| | - Jay A Davis
- Department of Obstetrics, Gynecology and Reproductive Medicine, Renaissance School of Medicine Stony Brook University, Stony Brook, NY, USA
| | - Malini D Persad
- Department of Obstetrics, Gynecology and Reproductive Medicine, Renaissance School of Medicine Stony Brook University, Stony Brook, NY, USA
| | - Cheryl Dinglas
- Department of Obstetrics, Gynecology and Reproductive Medicine, Renaissance School of Medicine Stony Brook University, Stony Brook, NY, USA
| | - Cassandra Heiselman
- Department of Obstetrics, Gynecology and Reproductive Medicine, Renaissance School of Medicine Stony Brook University, Stony Brook, NY, USA
| | - Ayisha Buckley
- Department of Obstetrics, Gynecology and Reproductive Medicine, Renaissance School of Medicine Stony Brook University, Stony Brook, NY, USA
| | - Diana Garretto
- Department of Obstetrics, Gynecology and Reproductive Medicine, Renaissance School of Medicine Stony Brook University, Stony Brook, NY, USA
| | - Lisa M Pastore
- Department of Obstetrics, Gynecology and Reproductive Medicine, Renaissance School of Medicine Stony Brook University, Stony Brook, NY, USA
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A Randomized Comparative Trial to Evaluate a PICU Navigator-Based Parent Support Intervention. Pediatr Crit Care Med 2020; 21:e617-e627. [PMID: 32639470 DOI: 10.1097/pcc.0000000000002378] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Communication breakdowns in PICUs contribute to inadequate parent support and poor post-PICU parent outcomes. No interventions supporting communication have demonstrated improvements in parental satisfaction or psychologic morbidity. We compared parent-reported outcomes from parents receiving a navigator-based parent support intervention (PICU Supports) with those from parents receiving an informational brochure. DESIGN Patient-level, randomized trial. SETTING Two university-based, tertiary-care children's hospital PICUs. PARTICIPANTS Parents of patients requiring more than 24 hours in the PICU. INTERVENTIONS PICU Supports included adding a trained navigator to the patient's healthcare team. Trained navigators met with parents and team members to assess and address communication, decision-making, emotional, informational, and discharge or end-of-life care needs; offered weekly family meetings; and did a post-PICU discharge parent check-in. The comparator arm received an informational brochure providing information about PICU procedures, terms, and healthcare providers. MEASUREMENTS AND MAIN RESULTS The primary outcome was percentage of "excellent" responses to the Pediatric Family Satisfaction in the ICU 24 decision-making domain obtained 3-5 weeks following PICU discharge. Secondary outcomes included parental psychologic and physical morbidity and perceptions of team communication. We enrolled 382 families: 190 received PICU Supports, and 192 received the brochure. Fifty-seven percent (216/382) completed the 3-5 weeks post-PICU discharge survey. The mean percentage of excellent responses to the Pediatric Family Satisfaction in the ICU 24 decision-making items was 60.4% for PICU Supports versus 56.1% for the brochure (estimate, 3.57; SE, 4.53; 95% CI, -5.77 to 12.90; p = 0.44). Differences in secondary outcomes were not statistically significant. Most parents (91.1%; 113/124) described PICU Supports as "extremely" or "somewhat" helpful. CONCLUSIONS Parents who received PICU Supports rated the intervention positively. Differences in decision-making satisfaction scores between those receiving PICU Supports and a brochure were not statistically significant. Interventions like PICU Supports should be evaluated in larger studies employing enhanced recruitment and retention of subjects.
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Wu F, Zhuang Y, Chen X, Wen H, Tao W, Lao Y, Zhou H. Decision-making among the substitute decision makers in intensive care units: An investigation of decision control preferences and decisional conflicts. J Adv Nurs 2020; 76:2323-2335. [PMID: 32538477 DOI: 10.1111/jan.14451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 04/10/2020] [Accepted: 05/22/2020] [Indexed: 01/22/2023]
Abstract
AIMS To explore decision control preferences and decisional conflicts and to analyse their association among the surrogate decision makers in the intensive care unit. DESIGN The study carried out a cross-sectional survey among the surrogates. METHODS The participants were 115 surrogate decision makers of critical patients, from August to September 2019. A Chi-squared test and logistic regression were used to assess decision control preferences and decisional conflicts, and Spearman's rank correlation coefficient was employed to examine their association. RESULTS Of the 115 surrogate decision makers, 51.3% preferred a collaborative role, and 63.48% were somewhat unsure about making decisions. Logistic regression analysis identified decision control preferences was associated with surrogates' age, education level, and personality traits, while decisional conflicts was associated with surrogates' age, education level, character, medical expense burden, and Acute Physiology and Chronic Health Evaluation-II score. Cohen's kappa statistics showed a bad concordance of decision-making expectations and actuality, with kappa values of 0.158 (p < .05). Wherein surrogates who experienced discordance between their preferred and actual roles, have relatively higher decisional conflicts. CONCLUSION This study identified individual differences of surrogate decision makers in decision control preferences and decisional conflicts. These results imply that incorporation of the individual decision preferences and communication styles into care plans is an important first step to develop high quality decision support. IMPACT This research is a contribution to the limited study on decision control preferences and decisional conflicts among surrogate decision makers of critically ill patients. Moreover based on the investigation of understanding the status and related factors of decision preferences and decisional conflicts set the stage for developing effective decision support interventions.
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Affiliation(s)
- Feixia Wu
- School of Nursing, Huzhou University, Huzhou, China
| | - Yiyu Zhuang
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiangping Chen
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huan Wen
- School of Nursing, Huzhou University, Huzhou, China
| | - Wenwen Tao
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuewen Lao
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongchang Zhou
- School of Medicine and Nursing Sciences, Huzhou University, Huzhou Central Hospital, Huzhou, China
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Michelson KN, Charleston E, Aniciete DY, Sorce LR, Fragen P, Persell SD, Ciolino JD, Clayman ML, Rychlik K, Jones VA, Spadino P, Malakooti M, Brown M, White D. Navigator-Based Intervention to Support Communication in the Pediatric Intensive Care Unit: A Pilot Study. Am J Crit Care 2020; 29:271-282. [PMID: 32607571 DOI: 10.4037/ajcc2020478] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Communication in the pediatric intensive care unit (PICU) between families and the health care team affects the family experience, caregiver psychological morbidity, and patient outcomes. OBJECTIVE To test the feasibility of studying and implementing a PICU communication intervention called PICU Supports, and to assess families' and health care teams' perceptions of the intervention. METHODS This study involved patients requiring more than 24 hours of PICU care. An interventionist trained in PICU-focused health care navigation, a "navigator," met with parents and the health care team to discuss communication, decision-making, emotional, informational, and discharge or end-of-life care needs; offered weekly family meetings; and checked in with parents after PICU discharge. The feasibility of implementing the intervention was assessed by tracking navigator activities. Health care team and family perceptions were assessed using surveys, interviews, and focus groups. RESULTS Of 53 families approached about the study, 35 (66%) agreed to participate. The navigator met with parents on 71% and the health care team on 85% of possible weekdays, and completed 86% of the postdischarge check-ins. Family meetings were offered to 95% of eligible patients. The intervention was rated as helpful by 97% of parents, and comments during interviews were positive. CONCLUSIONS The PICU Supports intervention is feasible to implement and study and is viewed favorably by parents.
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Affiliation(s)
- Kelly N. Michelson
- About the Authors: Kelly N. Michelson is an attending physician, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, and a professor, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Elizabeth Charleston
- Elizabeth Charleston is lead clinical research coordinator, Danica Y. Aniciete is a clinical research coordinator/navigator, Virginia A. Jones is a clinical research associate, and Pamela Spadino is a parent of a medically complex child, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Danica Y. Aniciete
- Elizabeth Charleston is lead clinical research coordinator, Danica Y. Aniciete is a clinical research coordinator/navigator, Virginia A. Jones is a clinical research associate, and Pamela Spadino is a parent of a medically complex child, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Lauren R. Sorce
- Lauren R. Sorce is the Founders Board nurse scientist, Department of Nursing, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Feinberg School of Medicine, Northwestern University
| | | | - Stephen D. Persell
- Stephen D. Persell is an associate professor, Division of General Internal Medicine and Geriatrics, Department of Medicine, Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University
| | - Jody D. Ciolino
- Jody D. Ciolino is an associate professor, Division of Biostatistics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University
| | - Marla L. Clayman
- Marla L. Clayman is an adjunct faculty member at Northwestern University
| | - Karen Rychlik
- Karen Rychlik is a statistician, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, and an instructor, Feinberg School of Medicine, Northwestern University
| | - Virginia A. Jones
- Elizabeth Charleston is lead clinical research coordinator, Danica Y. Aniciete is a clinical research coordinator/navigator, Virginia A. Jones is a clinical research associate, and Pamela Spadino is a parent of a medically complex child, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Pamela Spadino
- Elizabeth Charleston is lead clinical research coordinator, Danica Y. Aniciete is a clinical research coordinator/navigator, Virginia A. Jones is a clinical research associate, and Pamela Spadino is a parent of a medically complex child, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Marcelo Malakooti
- Marcelo Malakooti is an atending physician and medical director, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, and an assistant professor, Department of Pediatrics, Feinberg School of Medicine, Northwestern University
| | - Melanie Brown
- Melanie Brown is an associate professor of pediatric critical care medicine, Department of Pediatrics, University of Chicago Medicine Comer Children’s Hospital, Chicago, Illinois
| | - Douglas White
- Douglas White is director, Program in Ethics and Decision Making in Critical Illness, and vice chair, professor, and Endowed Chair for Ethics, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Pastore LM, Rubin LR, SantaBarbara JN, Stelling J, Lobel M. Initial psychometric analysis of novel instruments to assess decisional distress and decisional uncertainty in women who have considered using preimplantation genetic testing. Prenat Diagn 2020; 40:1220-1227. [PMID: 32367519 PMCID: PMC10041134 DOI: 10.1002/pd.5730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/05/2020] [Accepted: 04/28/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To analyze psychometric properties of two novel instruments assessing decisional distress and uncertainty experienced by individuals considering preimplantation genetic testing (PGT). METHODS The new PGT Decisional Distress instrument (22 items) assesses negative/positive emotions. The new PGT Decisional Uncertainty instrument assesses Clarity about test benefits/disadvantages (5 items) and Certainty of having adequate information/support to make a good decision (7 items). Scales ranged from 0 to 4. Psychometrics (central tendencies, internal consistency reliability, and discriminant validity) were evaluated. Stratified analysis by decision stage was conducted. All participants had considered or used PGT in the previous 6 months. RESULTS N = 106 females (mean age 36.5 ± 4.8 years; 16% non-Caucasian; 9% Hispanic) across 16 US states completed an online anonymous questionnaire. On average, respondents reported minimal distress (mean 0.96), high clarity (mean 3.26), and high certainty (mean 3.06), particularly those who had already decided compared to undecided women (P ≤ .02). Instruments had excellent internal consistency (Cronbach's α's 0.92-0.94) and displayed sufficient inter-individual variability (SD's 0.75-0.89). Correlations confirmed expected patterns of association between instruments (P's < .01), indicating discriminant validity. CONCLUSION We document initial reliability and validity of new instruments to measure emotional distress and uncertainty in female patients who have recently considered PGT for single-gene or chromosomal disorders.
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Affiliation(s)
- Lisa M. Pastore
- Department of Obstetrics/Gynecology and Reproductive Medicine Stony Brook Medicine Stony Brook New York USA
| | - Lisa R. Rubin
- Department of Psychology The New School for Social Research New York New York USA
| | | | - James Stelling
- Department of Obstetrics/Gynecology and Reproductive Medicine Stony Brook Medicine Stony Brook New York USA
| | - Marci Lobel
- Department of Psychology Stony Brook University Stony Brook New York USA
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Lincoln T, Shields AM, Buddadhumaruk P, Chang CCH, Pike F, Chen H, Brown E, Kozar V, Pidro C, Kahn JM, Darby JM, Martin S, Angus DC, Arnold RM, White DB. Protocol for a randomised trial of an interprofessional team-delivered intervention to support surrogate decision-makers in ICUs. BMJ Open 2020; 10:e033521. [PMID: 32229520 PMCID: PMC7170558 DOI: 10.1136/bmjopen-2019-033521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Although shortcomings in clinician-family communication and decision making for incapacitated, critically ill patients are common, there are few rigorously tested interventions to improve outcomes. In this manuscript, we present our methodology for the Pairing Re-engineered Intensive Care Unit Teams with Nurse-Driven Emotional support and Relationship Building (PARTNER 2) trial, and discuss design challenges and their resolution. METHODS AND ANALYSIS This is a pragmatic, stepped-wedge, cluster randomised controlled trial comparing the PARTNER 2 intervention to usual care among 690 incapacitated, critically ill patients and their surrogates in five ICUs in Pennsylvania. Eligible subjects will include critically ill patients at high risk of death and/or severe long-term functional impairment, their main surrogate decision-maker and their clinicians. The PARTNER intervention is delivered by the interprofessional ICU team and overseen by 4-6 nurses from each ICU. It involves: (1) advanced communication skills training for nurses to deliver support to surrogates throughout the ICU stay; (2) deploying a structured family support pathway; (3) enacting strategies to foster collaboration between ICU and palliative care services and (4) providing intensive implementation support to each ICU to incorporate the family support pathway into clinicians' workflow. The primary outcome is surrogates' ratings of the quality of communication during the ICU stay as assessed by telephone at 6-month follow-up. Prespecified secondary outcomes include surrogates' scores on the Hospital Anxiety and Depression Scale, the Impact of Event Scale, the modified Patient Perception of Patient Centredness scale, the Decision Regret Scale, nurses' scores on the Maslach Burnout Inventory, and length of stay during and costs of the index hospitalisation.We also discuss key methodological challenges, including determining the optimal level of randomisation, using existing staff to deploy the intervention and maximising long-term follow-up of participants. ETHICS AND DISSEMINATION We obtained ethics approval through the University of Pittsburgh, Human Research Protection Office. The findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02445937.
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Affiliation(s)
- Taylor Lincoln
- Department of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anne-Marie Shields
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Praewpannarai Buddadhumaruk
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chung-Chou H Chang
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Francis Pike
- Department of Neuroscience, Ely Lilly and Company, Indianapolis, Indiana, USA
| | - Hsiangyu Chen
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elke Brown
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Veronica Kozar
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Caroline Pidro
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeremy M Kahn
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joseph M Darby
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- ICU Service Center, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Susan Martin
- Donald Wolff Center for Quality Improvement and Innovation, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Derek C Angus
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- ICU Service Center, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Department of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Palliative Support Institute, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Douglas B White
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- ICU Service Center, UPMC Health System, Pittsburgh, Pennsylvania, USA
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Development and acceptability of a shared decision-making tool for commercial peanut allergy therapies. Ann Allergy Asthma Immunol 2020; 125:90-96. [PMID: 32057932 DOI: 10.1016/j.anai.2020.01.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/27/2020] [Accepted: 01/30/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Shared decision making (SDM) is the process through which patients and their medical provider mutually explore therapy goals, risk/benefit, and treatment options regarding medical care. Decision aids are tools that aid in the process of values clarification and help assess decisional needs and potential decisional conflicts. OBJECTIVE To develop and assess acceptability of a decision aid for commercial peanut allergy therapies. METHODS The creation of this decision aid occurred in 3 stages, including a qualitative study to assess decisional needs, development of a draft decision aid through multiple iterations in accordance with international guidelines and decision aid experts, and assessment of decisional acceptability, decisional conflict, and decisional self-efficacy related to using the decision aid. RESULTS The decision aid went through 9 iterations, resulting in a 4-page aid with 7 parts, explaining the therapies, key risks and benefits of therapy choices, relative importance of key attributes of the therapies, and a self-check assessment regarding informational adequacy and how to take the next steps. A total of 24 subjects assessed the decision aid, noting it had good acceptability, high decisional self-efficacy (mean score 91.9/100), and low decisional conflict (mean score 20.2/100). Respondents rated the information content as adequate and sufficient and the information regarding the therapy choices as fair and balanced without a clear bias or presenting a "best choice." CONCLUSION We have developed this decision aid as a tool to help caregivers navigate the complexity of decision making for peanut allergy treatment options. The decision aid was noted to have good acceptability, with scores reflective of the instrument enhancing decisional self-efficacy and reducing decisional conflict.
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Suen AO, Butler RA, Arnold R, Myers B, Witteman HO, Cox CE, Argenas A, Buddadhumaruk P, Bursic A, Ernecoff NC, Shields AM, Tran DK, White DB. Developing the family support tool: An interactive, web-based tool to help families navigate the complexities of surrogate decision making in ICUs. J Crit Care 2019; 56:132-139. [PMID: 31896447 DOI: 10.1016/j.jcrc.2019.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/24/2019] [Accepted: 12/05/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Although family members of incapacitated, critically ill patients often struggle in the role of surrogate decision maker, there are no low-cost, easily-scaled interventions to address this problem. AIM OF THE STUDY To develop and pilot-test the Family Support Tool, an interactive, web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs. MATERIAL AND METHODS We used a mixed methods, user-centered process to create the Family Support Tool, including: 1) creation of a preliminary design by an expert panel; 2) engagement of a key stakeholder panel to iteratively refine the preliminary design; 3) user testing of a low-fidelity prototype of the tool by 6 former ICU surrogates; 4) creation of a web-based prototype; and 5) user testing of the web-based prototype with 14 surrogates and ICU physicians, including semi-structured interviews and quantitative measurement of usability, acceptability, and perceived effectiveness. RESULTS The initial design contained a collection of videos and exercises designed to help individuals understand the surrogate's role and think through the patient's values and preferences. Based on family stakeholders' feedback about the emotional overwhelm they experience early in an ICU stay, we redesigned the tool to be viewed in sections, with the first section focused on decreasing surrogates' emotional distress, and later sections focused on helping surrogates prepare for family meetings. Surrogates actively making decisions in the ICU judged the final tool to be highly usable (mean summary score 83.5, correlating to 95th percentile when normalized to devices of its type), acceptable (mean 4.2 +/- 0.5 out of 5), and effective (mean 4.3 +/- 0.6 out of 5). All surrogates reported the tool helped them consider goals of care and all indicated they would recommend the tool to a friend. CONCLUSIONS We successfully developed a web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs that has high potential for scalability. Surrogates judged the tool to be usable, acceptable, and effective. These data support proceeding to test the tool in a pilot randomized clinical trial.
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Affiliation(s)
- Angela O Suen
- University of Pittsburgh, School of Medicine, Department of Medicine, Division of General Internal Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, United States of America
| | - Rachel A Butler
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Robert Arnold
- University of Pittsburgh, School of Medicine, Department of Medicine, Division of General Internal Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, United States of America; University of Pittsburgh Medical Center Palliative and Supportive Institute, Iroquois Building, Suite 308, 3600 Forbes Avenue at Meyran Avenue, Pittsburgh, PA 15213, United States of America
| | - Brad Myers
- Carnegie Mellon University, School of Computer Science, Human Computer Interaction Institute, 5000 Forbes Avenue, Pittsburgh, PA 15213, United States of America
| | - Holly O Witteman
- Université Laval, Department of Family & Emergency Medicine, Bureau 4617, Pavillon Ferdinand-Vandry, 1050 Avenue de la Médecine, Quebec, QC G1V 0A6, Canada
| | - Christopher E Cox
- Duke University, School of Medicine, Department of Medicine, Division of Pulmonary & Critical Care Medicine, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Amanda Argenas
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Praewpannanrai Buddadhumaruk
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Alexandra Bursic
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Natalie C Ernecoff
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Anne-Marie Shields
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Dang K Tran
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Douglas B White
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America.
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Abstract
OBJECTIVES We aimed to critically evaluate decision aids developed for practitioners and caregivers when providing care for someone with dementia or for use by people with dementia themselves. Decision aids may be videos, booklets, or web-based tools that explicitly state the decision, provide information about the decision, and summarize options along with associated benefits and harms. This helps guide the decision maker through clarifying the values they place on the benefits or harms of the options. DESIGN We conducted a systematic review of peer-reviewed literature in electronic databases (CINAHL, The Cochrane Library, EMBASE, MEDLINE, and PsychINFO) in March 2018. Reference lists were searched for relevant papers and citations tracked. Data were synthesized with meta-analysis and narrative synthesis. Papers were included if they met the following criteria: 1) the focus of the paper was on the evaluation of a decision aid; 2) the decision aid was used in dementia care; and 3) the decision aid was aimed at professionals, people with dementia, or caregivers. RESULTS We identified 3618 studies, and 10 studies were included, covering three topics across six decision aids: 1) support with eating/feeding options, 2) place of care, and 3) goals of care. The mode of delivery and format of the decision aids varied and included paper-based, video-based, and audio-based decision aids. The decision aids were shown to be effective, increasing knowledge and the quality of communication. The meta-analysis demonstrated that decisions are effective in reducing decisional conflict among caregivers (standardized mean difference = -0.50, 95% confidence interval [ - 0.97, - 0.02]). CONCLUSION Decision aids offer a promising approach for providing support for decision-making in dementia care. People are often faced with more than one decision, and decisions are often interrelated. The decision aids identified in this review focus on single topics. There is a need for decision aids that cover multiple topics in one aid to reflect this complexity and better support caregivers.
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Abstract
The aim of this study was to illuminate the way of being a family when one family member is in the midst of living and dying. A family systems frame and a life world perspective were used in interviews with five families. A qualitative analysis inspired by Giorgi revealed dialectic and dynamic processes in constant motion within and between the continua being in affinity-being in loneliness, being in power-being in helplessness, and being in continuity-being in disruption. When families were moving in the direction of being in affinity, power, and continuity, these seemed to be prerequisites for enduring their challenged life situation and for giving them a kind of repose. When the movements were in the opposite direction, existential and emotional suffering were manifested as individual embodied experiences such as depression and anxiety.
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Seaman JB, Arnold RM, Buddadhumaruk P, Shields AM, Gustafson RM, Felman K, Newdick W, SanPedro R, Mackenzie S, Morse JQ, Chang CCH, Happ MB, Song MK, Kahn JM, Reynolds CF, Angus DC, Landefeld S, White DB. Protocol and Fidelity Monitoring Plan for Four Supports. A Multicenter Trial of an Intervention to Support Surrogate Decision Makers in Intensive Care Units. Ann Am Thorac Soc 2018; 15:1083-1091. [PMID: 30088971 PMCID: PMC6322040 DOI: 10.1513/annalsats.201803-157sd] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Individuals acting as surrogate decision makers for critically ill patients frequently struggle in this role and experience high levels of long-term psychological distress. Prior interventions designed to improve the sharing of information by the clinical team with surrogate decision makers have demonstrated little effect on surrogates' outcomes or clinical decisions. In this report, we describe the study protocol and corresponding intervention fidelity monitoring plan for a multicenter randomized clinical trial testing the impact of a multifaceted surrogate support intervention (Four Supports) on surrogates' psychological distress, the quality of decisions about goals of care, and healthcare use. We will randomize the surrogates of 300 incapacitated critically ill patients at high risk of death and/or severe long-term functional impairment to receive the Four Supports intervention or an education control. The Four Supports intervention adds to the intensive care unit (ICU) team a trained interventionist (family support specialist) who delivers four types of protocolized support-emotional support; communication support; decisional support; and, if indicated, anticipatory grief support-to surrogates through daily interactions during the ICU stay. The primary outcome is surrogates' symptoms of anxiety and depression at 6-month follow-up, measured with the Hospital Anxiety and Depression Scale. Prespecified secondary outcome measures are the Patient Perception of Patient Centeredness Scale (modified for use with surrogates) and Impact of Event Scale scores at 3- and 6-month follow-up, respectively, together with ICU and hospital lengths of stay and total hospital cost among decedents. The fidelity monitoring plan entails establishing and measuring adherence to the intervention using multiple measurement methods, including daily checklists and coding of audiorecorded encounters. This approach to intervention fidelity may benefit others designing and testing behavioral interventions in the ICU setting. Clinical trial registered with www.clinicaltrials.gov (NCT01982877).
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Affiliation(s)
| | - Robert M. Arnold
- Department of General Internal Medicine, Section of Palliative Care and Medical Ethics, School of Medicine
- UPMC Palliative and Supportive Institute, Pittsburgh, Pennsylvania
| | | | | | | | - Kristyn Felman
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
| | - Wendy Newdick
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
| | - Rachel SanPedro
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
| | | | - Jennifer Q. Morse
- School of the Health Sciences, Chatham University, Pittsburgh, Pennsylvania
| | - Chung-Chou H. Chang
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
- Department of General Internal Medicine and
| | | | - Mi-Kyung Song
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia and
| | - Jeremy M. Kahn
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
| | - Charles F. Reynolds
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
| | - Seth Landefeld
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Douglas B. White
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
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Evaluation of decision support tools for patients with advanced cancer: A systematic review of literature. Palliat Support Care 2018; 17:356-364. [DOI: 10.1017/s1478951518000512] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveMedical decisions in the context of advanced cancer are more based on patient values and preferences than during the early stages of the disease. The implementation of shared decision-making is particularly important with an oncology palliative care population. However, few decision support tools focus on this population. This literature review aims to identify decision support tools related to palliative care for an oncological population and to assess their quality using International Patient Decision Aids Standards criteria.MethodThe tools were identified through PsycINFO, EMBASE, MEDLINE, and CINAHL databases; the inventory of tools to assist the decisions of the Ottawa Hospital Research Institute; and through the register of Cochrane trials. They were then evaluated using the third version of the International Patient Decision Aids Standards instrument.ResultSixteen tools were identified, which targeted five types of cancer and addressed a particular decision or the use of chemotherapy in addition to palliative care. The quality of the reviewed tools varies.Significance of resultsClinicians can use four decision support tools related to palliative care with an oncology population that meet a certain quality standard. Further studies are needed to develop new decision support tools targeting more types of cancer and decisions.
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Ejem D, Dionne-Odom JN, Turkman Y, Knight SJ, Willis D, Kaufman PA, Bakitas M. Incongruence between women's survey- and interview-determined decision control preferences: A mixed methods study of decision-making in metastatic breast cancer. Psychooncology 2018; 27:1950-1957. [DOI: 10.1002/pon.4747] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/28/2018] [Accepted: 04/17/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Deborah Ejem
- School of Nursing; University of Alabama at Birmingham; Birmingham AL USA
| | | | - Yasemin Turkman
- School of Nursing; University of Alabama at Birmingham; Birmingham AL USA
| | - Sara J. Knight
- Department of Preventive Medicine; University of Alabama at Birmingham; Birmingham AL USA
| | - Dan Willis
- School of Nursing; University of Wisconsin-Madison; Madison WI USA
| | - Peter A. Kaufman
- Section of Hematology Oncology; Dartmouth-Hitchcock Medical Center; Lebanon NH USA
| | - Marie Bakitas
- School of Nursing; University of Alabama at Birmingham; Birmingham AL USA
- Department of Medicine; Division of Geriatrics, Gerontology, and Palliative Medicine; Birmingham AL USA
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Fairlie DE. Specific Words and Experience Matter to Surrogates When Making End of Life Decisions. HEALTH COMMUNICATION 2018; 33:537-543. [PMID: 28278611 DOI: 10.1080/10410236.2017.1283560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This grant funded preliminary study investigated the relationship between end-of-life terminologies and decisional conflict in surrogate decision makers using a convenience sample of 234 adults aged 50 and older. Participants were randomized into two groups; each received a survey packet that varied only in the use of the words "Do Not Resuscitate (DNR)" and "Allow Natural Death (AND)." The Decisional Conflict Scale (DCS) was administered and demographic data were collected. No difference was found in the total DCS scores based on the AND and DNR versions. However, AND respondents perceived their decision as a good decision and were eight times more likely to sign the document than DNR participants. Experienced decision-makers evolved as a discrete group. They had lower mean total DCS scores and lower mean subscores, indicating that prior experience is an important aspect of end-of-life decision-making. Experienced AND participants were more likely to perceive their decision as good and were more likely to be sure of their decision, indicating that they respond more favorably to the words Allow Natural Death. Respondents to the DNR version were likely to not sign or postpone signing. Those who frequently attended religious services were twice as likely as those who rarely attend religious services of implementing their decision; whether the decision is to sign or not to sign the AND or DNR. Finally, participants were more likely to withdraw from the study when the term DNR was used. Recommendations for future research are presented.
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Affiliation(s)
- Dawn E Fairlie
- a School of Health Sciences, Department of Nursing , College of Staten Island, City University of New York
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Abstract
Determining effective decision support strategies that enhance quality of end-of-life decision making in the intensive care unit is a research priority. This systematic review identified interventional studies describing the effectiveness of decision support interventions administered to critically ill patients or their surrogate decision makers. We conducted a systematic literature search using PubMed, CINAHL, and Cochrane. Our search returned 121 articles, 22 of which met the inclusion criteria. The search generated studies with significant heterogeneity in the types of interventions evaluated and varied patient and surrogate decision-maker outcomes, which limited the comparability of the studies. Few studies demonstrated significant improvements in the primary outcomes. In conclusion, there is limited evidence on the effectiveness of end-of-life decision support for critically ill patients and their surrogate decision makers. Additional research is needed to develop and evaluate innovative decision support interventions for end-of-life decision making in the intensive care unit.
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Mahat-Shamir M, Possick C. The experience of women carriers of BRCA mutations following risk-reducing surgery: A cultural perspective. Health Care Women Int 2016; 38:344-360. [PMID: 27926354 DOI: 10.1080/07399332.2016.1267182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In this qualitative study, we examine the experience of 13 Jewish Israeli women carriers of BRCA mutations following risk-reducing surgery. Thematic analysis of in-depth, semi-structured interview texts yielded three themes: (a) dialectic of vulnerability and control, (b) presentation of self as a "normal" woman, and (c) genetic chain of negative life events and guilt. Aspects of Israeli culture impacting participants' experiences are: personal and collective responsibility, the shift toward consumerism, and pro-natal ideology. The findings may be useful for health practitioners working with other nationalities with similar cultural characteristics and to prompt practitioners to explore their own and their patients' perceptions regarding women's risk-reducing surgery and genetic illnesses.
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Affiliation(s)
| | - Chaya Possick
- a School of Social Work, Ariel University , Ariel , Israel
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21
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Ernecoff NC, Witteman HO, Chon K, Chen YI, Buddadhumaruk P, Chiarchiaro J, Shotsberger KJ, Shields AM, Myers BA, Hough CL, Carson SS, Lo B, Matthay MA, Anderson WG, Peterson MW, Steingrub JS, Arnold RM, White DB. Key stakeholders' perceptions of the acceptability and usefulness of a tablet-based tool to improve communication and shared decision making in ICUs. J Crit Care 2016; 33:19-25. [PMID: 27037049 DOI: 10.1016/j.jcrc.2016.01.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 01/10/2016] [Accepted: 01/10/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Although barriers to shared decision making in intensive care units are well documented, there are currently no easily scaled interventions to overcome these problems. We sought to assess stakeholders' perceptions of the acceptability, usefulness, and design suggestions for a tablet-based tool to support communication and shared decision making in ICUs. METHODS We conducted in-depth semi-structured interviews with 58 key stakeholders (30 surrogates and 28 ICU care providers). Interviews explored stakeholders' perceptions about the acceptability of a tablet-based tool to support communication and shared decision making, including the usefulness of modules focused on orienting families to the ICU, educating them about the surrogate's role, completing a question prompt list, eliciting patient values, educating about treatment options, eliciting perceptions about prognosis, and providing psychosocial support resources. The interviewer also elicited stakeholders' design suggestions for such a tool. We used constant comparative methods to identify key themes that arose during the interviews. RESULTS Overall, 95% (55/58) of participants perceived the proposed tool to be acceptable, with 98% (57/58) of interviewees finding six or more of the seven content domains acceptable. Stakeholders identified several potential benefits of the tool including that it would help families prepare for the surrogate role and for family meetings as well as give surrogates time and a framework to think about the patient's values and treatment options. Key design suggestions included: conceptualize the tool as a supplement to rather than a substitute for surrogate-clinician communication; make the tool flexible with respect to how, where, and when surrogates can access the tool; incorporate interactive exercises; use video and narration to minimize the cognitive load of the intervention; and build an extremely simple user interface to maximize usefulness for individuals with low computer literacy. CONCLUSION There is broad support among stakeholders for the use of a tablet-based tool to improve communication and shared decision making in ICUs. Eliciting the perspectives of key stakeholders early in the design process yielded important insights to create a tool tailored to the needs of surrogates and care providers in ICUs.
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Affiliation(s)
- Natalie C Ernecoff
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Holly O Witteman
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada; Office of Education and Continuing Professional Development, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; Research Centre of the CHU de Québec, Quebec City, Quebec, Canada
| | - Kristen Chon
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yanquan Iris Chen
- Human-Computer Interaction Institute, Carnegie Mellon University, Pittsburgh, PA
| | - Praewpannarai Buddadhumaruk
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jared Chiarchiaro
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Anne-Marie Shields
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Brad A Myers
- Human-Computer Interaction Institute, Carnegie Mellon University, Pittsburgh, PA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care, Harborview Medical Center, University of Washington, Seattle, WA
| | - Shannon S Carson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Wendy G Anderson
- Department of Medicine and Division of Hosiptal Medicine and Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Michael W Peterson
- Department of Medicine, University of California San Francisco Fresno Medical Education Program, Fresno, CA
| | - Jay S Steingrub
- Division of Pulmonary and Critical Care Medicine, Baystate Medical Center, Springfield, Massachusetts and Tufts University School of Medicine, Boston, MA
| | - Robert M Arnold
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Douglas B White
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Chiarchiaro J, Ernecoff NC, Buddadhumaruk P, Rak KJ, Arnold RM, White DB. Key stakeholders' perspectives on a Web-based advance care planning tool for advanced lung disease. J Crit Care 2015; 30:1418.e7-1418.e12. [PMID: 26404957 DOI: 10.1016/j.jcrc.2015.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/10/2015] [Accepted: 09/01/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE There is a paucity of scalable advance care planning strategies that achieve the diverse goals of patients, families, and clinicians. We convened key stakeholders to gain their perspectives on developing a Web-based advance care planning tool for lung disease. MATERIALS AND METHODS We conducted semistructured interviews with 50 stakeholders: 21 patients with lung disease, 18 surrogates, and 11 clinicians. Interviews explored stakeholders' desired content and design features of a Web-based advance care planning tool. Participants also rated the tool's acceptability and potential usefulness. We analyzed the interviews with modified grounded theory and validated themes through member checking. RESULTS Stakeholders highly rated the acceptability (median, 5; interquartile range, 5-5) and potential usefulness (median, 5; interquartile range, 4-5) of a Web-based tool. Interviewees offered several suggestions: (1) use videos of medical scenarios and patient narratives rather than text, (2) include interactive content, and (3) allow the user control over how much they complete in 1 sitting. Participants identified challenges and potential solutions, such as how to manage the emotional difficulty of thinking about death and accommodate low computer literacy users. CONCLUSIONS There is strong stakeholder support for the development of a Web-based advance care planning tool for lung disease.
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Affiliation(s)
- Jared Chiarchiaro
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh PA; Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA.
| | - Natalie C Ernecoff
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA
| | - Praewpannarai Buddadhumaruk
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA
| | - Kimberly J Rak
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh PA
| | - Douglas B White
- Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh PA; Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA; Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Kwak J, De Larwelle JA, Valuch KO, Kesler T. Role of Advance Care Planning in Proxy Decision Making Among Individuals With Dementia and Their Family Caregivers. Res Gerontol Nurs 2015; 9:72-80. [PMID: 26020579 DOI: 10.3928/19404921-20150522-06] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 04/24/2015] [Indexed: 11/20/2022]
Abstract
Health care proxies make important end-of-life decisions for individuals with dementia. A cross-sectional survey was conducted to examine the role of advance care planning in proxy decision making for 141 individuals with cognitive impairment, Alzheimer's disease, or other types of dementia. Proxies who did not know the preferences of individuals with dementia for life support treatments reported greater understanding of their values. Proxies of individuals with dementia who did not want life support treatments anticipated receiving less support and were more uncertain in decision making. The greater knowledge proxies had about dementia trajectory, family support, and trust of physicians, the more informed, clearer, and less uncertain they were in decision making. In addition to advance care planning, multiple factors influence proxy decision making, which should be considered in developing interventions and future research to support informed decision making for individuals with dementia and their families.
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Jull J, Giles A, Boyer Y, Stacey D. Cultural adaptation of a shared decision making tool with Aboriginal women: a qualitative study. BMC Med Inform Decis Mak 2015; 15:1. [PMID: 25889846 PMCID: PMC4320550 DOI: 10.1186/s12911-015-0129-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 01/06/2015] [Indexed: 12/03/2022] Open
Abstract
Background Shared decision making (SDM) may narrow health equity gaps experienced by Aboriginal women. SDM tools such as patient decision aids can facilitate SDM between the client and health care providers; SDM tools for use in Western health care settings have not yet been developed for and with Aboriginal populations. This study describes the adaptation and usability testing of a SDM tool, the Ottawa Personal Decision Guide (OPDG), to support decision making by Aboriginal women. Methods An interpretive descriptive qualitative study was structured by the Ottawa Decision Support Framework and used a postcolonial theoretical lens. An advisory group was established with representation from the Aboriginal community and used a mutually agreed-upon ethical framework. Eligible participants were Aboriginal women at Minwaashin Lodge. First, the OPDG was discussed in focus groups using a semi-structured interview guide. Then, individual usability interviews were conducted using a semi-structured interview guide with decision coaching. Iterative adaptations to the OPDG were made during focus groups and usability interviews until saturation was reached. Transcripts were coded using thematic analysis and themes confirmed in collaboration with an advisory group. Results Aboriginal women 20 to 60 years of age and self-identifying as First Nations, Métis, or Inuit participated in two focus groups (n = 13) or usability interviews (n = 6). Seven themes were developed that either reflected or affirmed OPDG adaptions: 1) “This paper makes it hard for me to show that I am capable of making decisions”; 2) “I am responsible for my decisions”; 3) “My past and current experiences affect the way I make decisions”; 4) “People need to talk with people”; 5) “I need to fully participate in making my decisions”; 6) “I need to explore my decision in a meaningful way”; 7) “I need respect for my traditional learning and communication style”. Conclusions Adaptations resulted in a culturally adapted version of the OPDG that better met the needs of Aboriginal women participants and was more accessible with respect to health literacy assumptions. Decision coaching was identified as required to enhance engagement in the decision making process and using the adapted OPDG as a talking guide.
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Affiliation(s)
- Janet Jull
- Bruyère Research Institute & University of Ottawa, 85 Primrose Avenue, Room 312, University of Ottawa, Ontario, K1R 7G5, Canada.
| | - Audrey Giles
- Faculty of Health Sciences, School of Human Kinetics, University of Ottawa, 334 Monpetit, Ottawa, Ontario, K1N 6 N5, Canada
| | | | - Yvonne Boyer
- , Box 181, Merrickville, Ontario, K0G 1 N0, Canada
| | - Dawn Stacey
- Faculty of Health Sciences, School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8 M5, Canada
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Mitchell TM, Beal C. Shared Decision Making for Routine Infant Circumcision: A Pilot Study. J Perinat Educ 2015; 24:188-200. [PMID: 26834440 PMCID: PMC4720865 DOI: 10.1891/1058-1243.24.3.188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
It is important that expectant parents receive accurate information about the benefits and risks of circumcision as well as the benefits and risks of having an intact foreskin when making a decision about routine infant circumcision (RIC). A pilot study was conducted using the shared decision making (SDM) conceptual model to guide expectant parents through a 3-phase decision-making program about RIC as part of their childbirth education class. The participants showed a high level of preparedness following each of the 3 phases. Preparedness score were highest for those who decided to keep their expected sons' penises natural. This SDM program was an effective way of guiding expectant parents through the decision-making process for RIC.
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Pyl N, Menard P. Evaluation of nurses' perceptions on providing patient decision support with cardiopulmonary resuscitation. ISRN NURSING 2012; 2012:591541. [PMID: 23304547 PMCID: PMC3529485 DOI: 10.5402/2012/591541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 10/05/2012] [Indexed: 11/23/2022]
Abstract
The decision whether to receive cardiopulmonary resuscitation (CPR) is a decision in which the personal values of the patient must be considered along with information about the risks and benefits of the treatment. A decision aid can be used to provide patient decision support to a patient who is seriously ill and needs to consider CPR options. The goal of this project was to identify the barriers and facilitators to using a CPR decision aid, through evaluating nursing perceptions on providing patient decision support. Using a needs assessment, it was determined that implementing a patient decision aid for CPR status in the Acute Monitor Area (AMA) of The Ottawa Hospital would be an excellent quality improvement project. The nurses who chose to participate were given an education session regarding patient decision support. Questionnaires were distributed to evaluate their views of patient decision support and decision aids before and after the education session and implementation of the CPR decision aid. Questionnaire results did not indicate a significant change between before or after education session and decision aid implementation. Qualitative reports did indicate that nurses generally have positive attitudes toward patient decision support and decision aids. The nurses identified specific barriers and facilitators in their commentaries. This clinically relevant data supports the idea that patient decision support should be integrated into daily nursing practice.
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Affiliation(s)
- Nicole Pyl
- The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6
| | - Prudy Menard
- The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6
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Kryworuchko J, Hill E, Murray MA, Stacey D, Fergusson DA. Interventions for Shared Decision-Making About Life Support in the Intensive Care Unit: A Systematic Review. Worldviews Evid Based Nurs 2012; 10:3-16. [DOI: 10.1111/j.1741-6787.2012.00247.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2011] [Indexed: 12/12/2022]
Affiliation(s)
- Jennifer Kryworuchko
- Assistant Professor, College of Nursing; University of Saskatchewan; Saskatoon; SK; Canada
| | - Elina Hill
- Student, Department of English; University of Victoria; Victoria; BC; Canada
| | - Mary Ann Murray
- School of Nursing, Faculty of Health Sciences; University of Ottawa; Ottawa; ON; Canada
| | - Dawn Stacey
- Associate Professor, School of Nursing, Faculty of Health Sciences; University of Ottawa; Associate Scientist and Director Patient Decision Aids Research Group Ottawa Hospital Research Institute; Nursing Best Practice Research Unit; Ottawa; ON; Canada
| | - Dean A. Fergusson
- Senior Scientist and Associate Director, Clinical Epidemiology Program, Ottawa Health Research Institute; Director, OHRI Methods Centre; Director, University of Ottawa Centre for Transfusion Research; Assistant Professor, Departments of Medicine, Surgery, & of Epidemiology and Community Medicine; University of Ottawa; Ottawa; ON; Canada
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Meisner RC, Khin EK, Dorfman J, Norris L. A 60-Year-Old Male with Hairy-Cell Leukemia and Existential Distress. Psychiatr Ann 2012. [DOI: 10.3928/00485713-20120323-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Khatri PJ, O'Connor AM, Dervin GF. Decision support needs of patients choosing between unicompartmental and total knee arthroplasty for advanced medial compartment osteoarthritis of the knee. J Arthroplasty 2011; 26:1343-9. [PMID: 21397451 DOI: 10.1016/j.arth.2010.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 12/17/2010] [Indexed: 02/01/2023] Open
Abstract
Patients with isolated medial knee osteoarthritis are often candidates for both unicompartmental knee arthroplasty and total knee arthroplasty and must choose between these 2 options. We interviewed 20 such patients to describe their decision support needs and 14 knee arthroplasty surgeons to describe their requirements in supporting patients' decision making. Patients and surgeons both desired active patient participation in the decision. Of 14 surgeons, 13 identified a knowledgeable patient as the most important factor in facilitating decision making, but many worried about confusing patients from information overload. Patients, on the other hand, demonstrated poor knowledge of the advantages and disadvantages of each surgical option, and 17 of 20 desired supplemental educational resources. Thus, most patients choosing between unicompartmental knee arthroplasty and total knee arthroplasty would appreciate and benefit from a decision support intervention.
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Affiliation(s)
- Prateek J Khatri
- Department of Orthopaedic Surgery, Ottawa Hospital, Ottawa, Ontario, Canada
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Bakitas M, Kryworuchko J, Matlock DD, Volandes AE. Palliative medicine and decision science: the critical need for a shared agenda to foster informed patient choice in serious illness. J Palliat Med 2011; 14:1109-16. [PMID: 21895453 PMCID: PMC3236099 DOI: 10.1089/jpm.2011.0032] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2011] [Indexed: 12/25/2022] Open
Abstract
Assisting patients and their families in complex decision making is a foundational skill in palliative care; however, palliative care clinicians and scientists have just begun to establish an evidence base for best practice in assisting patients and families in complex decision making. Decision scientists aim to understand and clarify the concepts and techniques of shared decision making (SDM), decision support, and informed patient choice in order to ensure that patient and family perspectives shape their health care experience. Patients with serious illness and their families are faced with myriad complex decisions over the course of illness and as death approaches. If patients lose capacity, then surrogate decision makers are cast into the decision-making role. The fields of palliative care and decision science have grown in parallel. There is much to be gained in advancing the practices of complex decision making in serious illness through increased collaboration. The purpose of this article is to use a case study to highlight the broad range of difficult decisions, issues, and opportunities imposed by a life-limiting illness in order to illustrate how collaboration and a joint research agenda between palliative care and decision science researchers, theorists, and clinicians might guide best practices for patients and their families.
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Affiliation(s)
- Marie Bakitas
- Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, Lebanon, New Hampshire 03756, USA.
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31
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Candy B, Jones L, Drake R, Leurent B, King M. Interventions for supporting informal caregivers of patients in the terminal phase of a disease. Cochrane Database Syst Rev 2011:CD007617. [PMID: 21678368 DOI: 10.1002/14651858.cd007617.pub2] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients in the terminal phase of a disease may have complex needs. It is often family and friends who play a central role in providing support, despite health professional input and regardless of whether the patient is at home or elsewhere. Such informal caring may involve considerable physical, psychological, and economic stresses. A range of supportive programmes for caregivers is being developed including psychological support and practical assistance. OBJECTIVES To assess the effects of supportive interventions that aim to improve the psychological and physical health of informal caregivers of patients in the terminal phase of their illness. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2 2010); MEDLINE (1950 to May 2010); EMBASE (1980 to May 2010); PsycINFO (1872 to May 2010); CINAHL (1937 to May 2010); National Health Service Research Register (2000 to November 2008) and Dissertation Abstracts (1716 to May 2010). We searched the reference lists of relevant studies; contacted experts; and handsearched journals. SELECTION CRITERIA Randomised controlled trials (RCTs) of interventions to support adults who were caring for a friend or relative with a disease in the terminal phase. Interventions could include practical and emotional support and/or the facilitation of coping skills. Interventions could support caregivers indirectly via patient care. DATA COLLECTION AND ANALYSIS Two authors independently screened citations against the selection criteria. Data were extracted by one author and checked by another. This included extraction of any adverse effects. Risk of bias assessment was undertaken by two authors. We contacted trial authors to obtain missing information. Trial data were combined, where appropriate, on the review's primary outcomes. MAIN RESULTS We included eleven RCTs involving 1836 caregiver participants. Nine interventions were delivered directly to the caregiver. Seven of these provided support in the caring role, another involved a family life review, and one grief therapy. None provided practical support. The other two interventions aimed to support caregivers indirectly via patient care. Overall the risk of bias is unclear, as all trials under-reported methods.There is low quality evidence that interventions directly supporting the caregiver significantly reduce psychological distress in the short term (8 trials: standardised mean difference (SMD) -0.15; 95% confidence interval (CI) -0.28 to -0.02). There is also low quality evidence that these interventions in the short term may marginally improve coping skills and quality of life, but neither results were statistically significant (7 trials: SMD -0.05; 95% CI -0.24 to 0.14; 6 trials: SMD 0.08; 95% CI -0.11 to 0.26, respectively). One study assessed physical outcomes, specifically sleep improvement, and found no difference (median effect 0.00). No study measured health service use or adverse outcomes. In one study, however, a subgroup of intervention participants had higher levels of family conflict.Evidence was less clear on the indirect interventions. While both trials in this category found that supporting the patient may reduce psychological distress, none of the four assessments were statistically significant. There were no evaluations of coping with the caring role, quality of life, service use or adverse outcomes. In one trial there was no difference between trial arms in the proportion of caregivers reporting good physical health. AUTHORS' CONCLUSIONS There is evidence that supportive interventions may help reduce caregivers' psychological distress. These findings suggest that practitioners should enquire about the concerns of caregivers and should consider that they may benefit from additional support. There is, however, a need for further research to explore the benefits identified, and to assess the interventions' effects on physical health, and potential harms. Trials need to report their methods fully.
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Affiliation(s)
- Bridget Candy
- Marie Curie Palliative Care Research Unit, Department of Mental Health Sciences, Royal Free & University College Medical School, Hampstead Campus, Rowland Hill Street, London, UK, NW3 2PF
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Babcock CW, Robinson LE. A novel approach to hospital palliative care: an expanded role for counselors. J Palliat Med 2011; 14:491-500. [PMID: 21410337 DOI: 10.1089/jpm.2010.0432] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A large tertiary hospital in central Georgia has found a novel approach to hospital palliative care. APPROACH It is unique in that the approach has a strong counseling base in providing the palliative service, rather than major reliance on advance practice nurses or palliative physicians. The Medical Center of Central Georgia employs master's prepared counselors who spend the hours needed to assist families in making difficult end-of-life decisions. MODEL Using a family systems therapy approach, these counselors have developed the Transitions and Palliative Care Therapy Model, which has proved to be a successful means of providing the services. The model includes the "7 Core Components of Communication and Decision Making," which gives the counselors actual interventions to use in working through these complex cases. OUTCOMES The growth of the program over 7 years is staggering with the outcomes far exceeding even the predicted volume from the Center to Advance Palliative Care. CONCLUSIONS The model has the counselor at the heart of the team, keeping the communication open and flowing. The Transitions and Palliative Care Therapy Model has become an accepted standard of practice at Medical Center of Central Georgia and continues to be a successful means of managing the most complex cases in the hospital.
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Affiliation(s)
- Carol W Babcock
- Center for Palliative Care/Transitions, Medical Center of Central Georgia, Macon, Georgia 31201, USA
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Smith TJ, Dow LA, Virago EA, Khatcheressian J, Matsuyama R, Lyckholm LJ. A pilot trial of decision aids to give truthful prognostic and treatment information to chemotherapy patients with advanced cancer. THE JOURNAL OF SUPPORTIVE ONCOLOGY 2011; 9:79-86. [PMID: 21542415 PMCID: PMC3589716 DOI: 10.1016/j.suponc.2010.12.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Most cancer patients do not have an explicit discussion about prognosis and treatment despite documented adverse outcomes. Few decision aids have been developed to assist the difficult discussions of palliative management. We developed decision aids for people with advanced in curable breast, colorectal, lung, and hormone-refractory prostate cancers facing first-, second-, third-, and fourth-line chemotherapy. We recruited patients from our urban oncology clinic after gaining the permission of their treating oncologist. We measured knowledge of curability and treatment benefit before and after the intervention. Twenty-six of 27 (96%) patients completed the aids, with ameanage of 63, 56% female, 56% married, 56% African American, and 67% with a high school education or more. Most patients (14/27, 52%) thought a person with their advanced cancer could be cured, which was reduced (to 8/26, 31%, P = 0.15) after the decision aid. Nearly all overestimated the effect of palliative chemotherapy. No distress was noted, and hope did not change. The majority (20/27, 74%) found the information helpful to them, and almost all (25/27, 93%) wanted to share the information with their family and physicians. It is possible to give incurable patients their prognosis, treatment options, and options for improving end-of-life care without causing distress or lack of hope. Almost all find the information helpful and want to share it with doctors and family. Research is needed to test the findings in a larger sample and measure the outcomes of truthful information on quality of life, quality of care, and costs.
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Affiliation(s)
- Thomas J Smith
- Massey Cancer Center of Virginia Commonwealth University, School of Education, VCU School of Medicine, Department of Social and Behavioral Health, and the Virginia Cancer Institute, Richmond, Virginia 23298-0230, USA.
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Metcalfe A, Pumphrey R, Clifford C. Hospice nurses and genetics: implications for end-of-life care. J Clin Nurs 2010; 19:192-207. [PMID: 20500257 DOI: 10.1111/j.1365-2702.2009.02935.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM The overall aim of this study is to determine hospice nurses' perception of the importance of genetics to hospice care provision and their personal level of confidence in carrying out genetics-related activities within an end-of-life care context. BACKGROUND Hospices nurses regularly care for patients and their families affected by inherited genetic conditions (e.g. some cancers). Therefore, nurses need knowledge and awareness of the implications of genetic conditions and confidence in their abilities to provide appropriate care and support for patients and families. DESIGN Survey. METHOD Questionnaires were sent to a stratified sample of hospice nurses (n = 1149) in England and Wales. Using Likert scales, nurses were asked to rate the importance of and their confidence in undertaking a range of scenario-based activities that accompany caring for a patient and family affected by a genetic condition in the hospice setting. Open questions invited comments on their experiences of nursing patient/family in similar situations. Follow-up telephone interviews were carried out with hospice nurse educators to explore emerging issues. RESULTS Response rate was 29% (n = 328). Hospice nurses felt that all aspects of genetics-related care were 'very important' to hospice care, but lacked confidence in their ability to carry out the activities. Many respondents had not considered the relevance of genetics to hospice-care prior to completing the questionnaire but now considered it essential to end-of-life care even if they were not confident to provide it. CONCLUSION Hospice nurses' need genetics education focusing on the psychosocial implications of caring for patients and families affected by genetic conditions to enable them to provide the complex care and support in face of the difficult issues that arise in practice. RELEVANCE TO CLINICAL PRACTICE This study highlights the genetics education needs of hospice nurses in providing end-of life care for patients and their families affected by inherited genetic conditions.
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Affiliation(s)
- Alison Metcalfe
- School of Health & Population Sciences, University of Birmingham, Edgbaston, Birmingham, UK.
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Allen JD, Mohllajee AP, Shelton RC, Drake BF, Mars DR. A computer-tailored intervention to promote informed decision making for prostate cancer screening among African American men. Am J Mens Health 2009; 3:340-51. [PMID: 19477736 PMCID: PMC2856320 DOI: 10.1177/1557988308325460] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
African American men experience a disproportionate burden of prostate cancer (CaP) morbidity and mortality. National screening guidelines advise men to make individualized screening decisions through a process termed informed decision making (IDM). In this pilot study, a computer-tailored decision-aid designed to promote IDM was evaluated using a pre-/posttest design. African American men aged 40 years and older were recruited from a variety of community settings (n = 108). At pretest, 43% of men reported having made a screening decision; at posttest 47% reported this to be the case (p = .39). Significant improvements were observed between pre- and posttest on scores of knowledge, decision self-efficacy, and decisional conflict. Men were also more likely to want an active role in decision making after using the tool. These results suggest that use of a computer-tailored decision aid is a promising strategy to promote IDM for CaP screening among African American men.
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Affiliation(s)
- Jennifer D Allen
- Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, MA 02115, USA.
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Rich SE, Williams CS, Zimmerman S. Concordance of family and staff member reports about end of life in assisted living and nursing homes. THE GERONTOLOGIST 2009; 50:112-20. [PMID: 19549716 DOI: 10.1093/geront/gnp089] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To identify differences in perspectives that may complicate the process of joint decision making at the end of life, this study determined the agreement of family and staff perspectives about end-of-life experiences in nursing homes and residential care/assisted living communities and whether family and staff roles, involvement in care, and interaction are associated with such agreement. DESIGN AND METHODS This cross-sectional study examined agreement in 336 family-staff pairs of postdeath telephone interviews conducted as part of the Collaborative Studies of Long-Term Care. Eligible deaths occurred in or within 3 days of leaving one of a stratified random sample of 113 long-term care facilities in four states and after the resident had lived in the facility (3)15 days of the last month of life. McNemar p values and kappas were determined for each concordance variable, and mixed logistic models were run. RESULTS Chance-adjusted family-staff agreement was poor for expectation of death within weeks (66.9% agreement, kappa = .33), course of illness (62.9%, 0.18), symptom burden (59.6%, 0.18), and familiarity with resident's physician (59.2%, 0.05). Staff were more likely than family to expect death (70.2% vs 51.5%, p < .001) and less likely to report low symptom burden (39.6% vs 46.6%, p = .07). Staff involvement in care related to concordance and perspectives of adult children were more similar to those of staff than were other types of family members. IMPLICATIONS Family and staff perspectives about end-of-life experiences may differ substantially; efforts can be made to improve family-staff communication and interaction for joint decision making.
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Affiliation(s)
- Shayna E Rich
- Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, 660 West Redwood Street, Suite 200, Baltimore, MD 21201, USA.
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Metcalfe A, Pumphrey R, Clifford C. Children affected by genetic conditions in end-of-life care. Part 2: findings and discussion. Int J Palliat Nurs 2009; 15:22-8. [DOI: 10.12968/ijpn.2009.15.1.37949] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Alison Metcalfe
- School of Health and Population Sciences, University of Birmingham, England
| | - Rachel Pumphrey
- School of Health and Population Sciences, University of Birmingham, England
| | - Collette Clifford
- School of Health and Population Sciences, University of Birmingham, England
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Preferences of older and younger adults with serious mental illness for involvement in decision-making in medical and psychiatric settings. Am J Geriatr Psychiatry 2008; 16:826-33. [PMID: 18827229 DOI: 10.1097/jgp.0b013e318181f992] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES There is a growing call for greater consumer participation in health care encounters. Prior research suggests that older age is associated with a greater preference for a more passive role in clinical decision-making, yet little is known about preferences for persons with mental illness. This pilot study compared preferences for involvement in decision-making between older and younger adults with serious mental illness. DESIGN Cross-sectional observational survey. PARTICIPANTS The authors surveyed 33 older adults (>or=50 years) and 32 younger adults (<50 years) with serious mental illness from two mental health center clinics and one residential facility for their preferences on decision-making with their psychiatrists and primary care providers. MEASUREMENTS Measures included the Control Preferences Scale, the Autonomy Preference Index, and the Decision Self-Efficacy Scale. RESULTS Contrary to our primary hypothesis, older adults reported a stronger desire for involvement in decision-making compared with younger adults. However, both age groups were similar in their desire for information to aid in decision-making. The majority in both age groups also preferred a collaborative role with a psychiatrist for medication decisions, an autonomous role for decisions related to psychosocial interventions, and a passive role with their primary care provider. Older and younger adults expressed similar decision self-efficacy. CONCLUSION Our study suggests that older persons with serious mental illness have a stronger desire for involvement in decision-making than younger consumers. Additionally, role preference for involvement in decision-making varies across different clinical decisions and for psychopharmacological versus psychosocial interventions.
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Adriaansen M, Van Achterberg T, Borm G. The Usefulness of the Staff–Patient Interaction Response Scale for Palliative Care Nursing for Measuring the Empathetic Capacity of Nursing Students. J Prof Nurs 2008; 24:315-23. [DOI: 10.1016/j.profnurs.2007.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Indexed: 12/30/2022]
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Mitra D, Jacobsen MJ, O'Connor A, Pottie K, Tugwell P. Assessment of the decision support needs of women from HIV endemic countries regarding voluntary HIV testing in Canada. PATIENT EDUCATION AND COUNSELING 2006; 63:292-300. [PMID: 16876376 DOI: 10.1016/j.pec.2006.04.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2006] [Revised: 04/20/2006] [Accepted: 04/20/2006] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To describe the decision support needs of immigrant and refugee women from HIV endemic countries regarding decision-making about voluntary counseling and testing for HIV (VCT) in Canada; and the needs of practitioners who support these women in making this decision, in a culturally appropriate manner. METHODS Adapted, semi-structured questionnaires, based on the Ottawa Decision Support Framework (ODSF), were used to interview practitioners and patients. Practitioners from diverse backgrounds were purposefully selected from centers providing VCT in Ottawa. Adult, English-speaking immigrant and refugee women from HIV endemic countries were recruited from a clinic specializing in immigrant health services. Responses were tabulated using descriptive statistics, and emerging themes coded to identify unique factors affecting decision-making. RESULTS Analysis revealed differences between practitioner and patient perceptions of the decision-making needs of women from HIV endemic countries regarding VCT. Practitioners identified women's lack of knowledge about HIV transmission and prevention as a primary need, while patients identified inadequate awareness of HIV screening and treatment services, and their benefits and harms. Patients also perceived that women would not be aware of the various VCT options, while few practitioners highlighted this concern. Both groups held similar viewpoints about counseling strategies that could improve decision-making. CONCLUSION Women were unaware of the options available to them for VCT. Both practitioners and patients highlighted the issue of stigma and negative outcomes associated with testing that created barriers or contributed to delays in women receiving testing. Women preferred anonymous testing, and recommended that information and decision support regarding HIV testing be provided via non-targeted strategies, and integrated within general health services or public education. PRACTICE IMPLICATIONS Decision support in the context of VCT can improve decision quality, empowering patients to make informed decisions based on personal values. Study findings can inform the development of clinical guidelines for the routine offering of VCT.
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Affiliation(s)
- Debjani Mitra
- Department of Epidemiology, University of Ottawa, Roger Guindon, 451 Smyth Road, Ottawa, ON, Canada.
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Matsuyama R, Reddy S, Smith TJ. Why Do Patients Choose Chemotherapy Near the End of Life? A Review of the Perspective of Those Facing Death From Cancer. J Clin Oncol 2006; 24:3490-6. [PMID: 16849766 DOI: 10.1200/jco.2005.03.6236] [Citation(s) in RCA: 286] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The number of patients receiving chemotherapy near the end of life is increasing, as are concerns about goals of treatment, toxicity, and costs. We sought to determine the available sources of knowledge, the choices, and concerns of actual patients, and how patients balanced competing issues. Methods We used a literature search from 1980 to present. Results Available patient sources provide little information about prognosis, choices, alternatives, consequences, or how to choose. Many patients would choose chemotherapy for a small benefit in health outcomes, and for a smaller benefit than perceived by their health care providers for their own treatment. Adverse effects are less a concern for patients than for their well health care providers. There are no decision aids to assist patients with metastatic disease in making their choices, such as there are for adjuvant breast therapy. Conclusion The perspective of the patient is different from that of a well person. Patients are willing to undergo treatments that have small benefits with major toxicity. Receiving realistic information about the different options of care and the likelihood of successful treatment or adverse effects is difficult. These factors may explain some of the increased use of chemotherapy near the end of life. Decision aids and honest, unbiased sources to inform patients of their prognosis, choices, consequences, typical outcomes, and ways to make decisions are needed. More prospective information about how patients make their choices, and what they would consider a good choice, would assist informed decision making.
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Affiliation(s)
- Robin Matsuyama
- Massey Cancer Center of Virginia Commonwealth University, Richmond, VA 23298-0230, USA
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