Advance Directives, Hospitalization, and Survival Among Advanced Cancer Patients with Delirium Presenting to the Emergency Department: A Prospective Study

Predictive value of the Naples prognostic score on postoperative delirium in the elderly with gastrointestinal tumors: a retrospective cohort study

BACKGROUND

Postoperative delirium (POD) is a common complication among elderly patients after surgery. The Naples Prognostic Score (NPS), a novel prognostic marker based on immune-inflammatory and nutritional status, was widely used in the assessment of the prognosis of surgical patients. However, no study has evaluated the relationship between NPS and POD. The aim of this article was to investigate the association between NPS and POD and test the predictive efficacy of preoperative NPS for POD in elderly patients with gastrointestinal tumors.

MATERIALS AND METHODS

In the present study, we retrospectively collected perioperative data of 176 patients (≥ 60 years) who underwent elective gastrointestinal tumor surgery from June 2022 to September 2023. POD was defined according to the chart-based method and the NPS was calculated for each patient. We compared all the demographics and laboratory data between POD and non-POD groups. Univariate and multivariate logistic regression analysis was used to explore risk factors of POD. Moreover, the accuracy of NPS in predicting POD was further assessed by utilizing receiver operating characteristic (ROC) curves.

RESULTS

20 had POD (11.4%) in a total of 176 patients, with a median age of 71 (65-76). The outcomes by univariate analysis pointed out that age, ASA status ≥ 3, creatinine, white blood cell count, fasting blood glucose (FBG), and NPS were associated with the risk of POD. Multivariate logistic regression analysis further showed that age, ASA grade ≥ 3, FBG and NPS were independent risk factors of POD. Additionally, the ROC curves revealed that NPS allowed better prognostic capacity for POD than other variables with the largest area under the curve (AUC) of 0.798, sensitivity of 0.800 and specificity of 0.667, respectively.

CONCLUSION

Age, ASA grade ≥ 3, and FBG were independent risk factors for POD in the elderly underwent gastrointestinal tumor surgery. Notably, the preoperative NPS was a more effective tool in predicting the incidence of POD, but prospective trials were still needed to further validate our conclusion.

TRIAL REGISTRATION

The registration information for the experiment was shown below. (date: 3rd January 2024; number: ChiCTR2400079459).

Factors associated with attitudes toward advance directives in nurses and comparisons of the levels between emergency nurses and palliative care nurses

AIM

Little is known about attitudes toward advance directives and factors associated with them among emergency and palliative care nurses who often or daily face end-of-life circumstances. Thus, we aimed to compare the levels of attitudes toward advance directives, communication skills, knowledge about end-of-life care (knowledge), and awareness of the concept of a good death (good death awareness) between emergency and palliative care nurses, and to examine factors associated with attitudes toward advance directives in the total sample.

METHODS

In this cross-sectional, correlational study, data were collected from 153 nurses (59 emergency and 94 palliative care nurses) at three tertiary hospitals using online or offline surveys and were analyzed using t-tests and multiple linear regression analysis.

RESULTS

The levels of attitudes, communication skills, knowledge, and good death awareness were moderate in both groups. Attitudes in emergency compared to palliative care nurses were less positive (46.78 vs. 48.38; p = .044), and knowledge was significantly lower (13.64 vs. 15.00; p = .004). Communication skills and good death awareness between the two groups were similar. In the total sample, emergency practice (B = -1.59, p = .024), and lower levels of good death awareness (B = 0.30, p < .001), communication skills (B = 0.18, p = .001), and education (B = -2.84, p = .015) were associated with less positive attitudes (F = 9.52, p < .001; R²  = 0.35).

CONCLUSIONS

The findings demonstrate the need for improvements in attitudes, knowledge, communication skills, and good death awareness in both groups, especially emergency nurses. Two modifiable targets of interventions to improve nurses' attitudes were also noted.

Perception, knowledge and attitudes on advance medical directives among hospital staff: Using mixed methodology

BACKGROUND

It is necessary to examine the level of perception, knowledge and attitudes of the medical staff for advance medical directives, which are practical alternatives to good practice for end-of-life care in the actual medical field.

PURPOSE

This study was conducted to determine the degree of perception, knowledge and attitude of cancer hospital medical staff about advance medical directives, and to confirm the relationship between them. It also explored their experiences with advance medical directives.

METHODS

This study used a convergent design to collect quantitative and qualitative data separately in the mixed methodology. This design adheres to the STROBE guidelines. Participants were a total of 140 subjects (70 doctors and 70 nurses) with more than 3 years and considered to have sufficient experience related to the study purpose. Focus group participants were a total 19 persons (9 doctors and 10 nurses).

RESULTS

Mean score for perception was 35.40, which indicates lower perception when compared to the median value (37.50 points). Perception of advance medical directives had significant, positive relations with attitude of advance medical directives (p = .032). The perception on attitude of advance medical directives factor was significantly influencing (p = .021). As a result of the analysis based on qualitative research questions, six subjects and 11 categories were created by deriving meaningful sentences from the statements.

CONCLUSION

This study suggests that the perception of medical professionals about advance medical directives has a positive correlation with attitudes, as well as a causal relationship.

RELEVANCE TO CLINICAL PRACTICE

Based on the finding from this study, concrete strategies and interventions to improve the perception of advance medical directives among cancer hospital medical staff are needed.

Oncologic emergency in patients with skeletal metastasis of unknown primary

Aim

Patients with skeletal metastasis from prediagnosed primary malignancy sometimes have concurrent oncologic emergency (OE) during the first visit. This study aims to investigate the types of OEs and treatment outcome in such patients.

Methods

We have experienced 359 patients with skeletal metastasis from unknown primary malignancy. Among them, 130 patients required immediate admission for OE treatment (OE group), 229 patients had no OE and did not required immediate admission (non‐OE group).

Results

The recognized types of OE were spinal cord compression in 60 patients, cancer pain in 30, hypercalcemia in 19, delirium in 16, deep vein thrombosis in 13, acute renal failure in 6, respiratory failure in 3, gastrointestinal hemorrhage in 3, and disseminated intravascular coagulation in 1. The overall 5‐year survival rates were 28% and 37% in the OE and non‐OE groups, respectively (P < 0.001). The multivariate analysis revealed that delirium (hazard ratio 4.2; 95% confidence interval, 1.6–12.5; P < 0.005) and respiratory failure (hazard ratio 22.6; 95% confidence interval, 4.5–92.8; P < 0.001) were significant prognostic factors in patients with OEs, whereas other OEs did not confer a significant risk for patient outcomes.

Conclusion

In this study, OE was observed in as many as 36% of patients with skeletal metastasis from unknown primary malignancy. Delirium and respiratory failure were only two significant prognostic risk factors, which suggest that many of the OEs in untreated advanced cancer patients have probable chance to resolve. Early detection followed by appropriate treatment of such OEs is recommended.

Influence of advance directives on reducing aggressive measures during end-of-life cancer care: A systematic review

CONTEXT

Although the literature recognizes the participation of patients in medical decisions as an important indicator of quality, there is a lack of consensus regarding the influence of advance directives (ADs) on reducing aggressive measures during end-of-life care involving cancer patients.

OBJECTIVE

A systematic review was conducted to analyze the influence of ADs on reducing aggressive end-of-life care measures for cancer patients.

METHOD

We searched the Medline, Embase, Web of Science, and Lilacs databases for studies published until March 2018 using the following keywords, without language restrictions: "advance directives," "living wills," "terminal care," "palliative care," "hospice care," and "neoplasms." Article quality was assessed using study quality assessment tools from the Department of Health and Human Services (NHLBI).

RESULTS

A total of 1,489 studies were identified; 7 met the inclusion criteria. The studies were recently published (after 2014, 71.4%). Patients with ADs were more likely to die at the site of choice (n = 3) and received less chemotherapy in the last 30 days (n = 1). ADs had no impact on intensive care unit admission (n = 1) or hospitalization (n = 1). One study found an association between ADs and referral to palliative care, but other did not find the same result.

SIGNIFICANCE OF RESULTS

Of the seven articles found, four demonstrated effects of ADs on the reduction in aggressive measures at the end of life of cancer patients. Heterogeneity regarding study design and results and poor methodological quality are challenges when drawing conclusions.

Treatment Limitation Decisions in Critically Ill Patients With a Malignancy on the Intensive Care Unit

Background:

Treatment limitation decisions (TLDs) on the ICU can be challenging, especially in patients with a malignancy. Up-to-date literature regarding TLDs in critically ill patients with a malignancy admitted to the ICU is scarce. The aim was to compare the incidence of written TLDs between patients with an active malignancy, patients with a malignancy in their medical history (complete remission, CR) and patients without a malignancy admitted unplanned to the ICU.

Methods:

We conducted a retrospective cohort study in a large university hospital in the Netherlands. We identified all unplanned admissions to the ICU in 2017 and categorized the patients in 3 groups: patients with an active malignancy (study population), with CR and without a malignancy. A TLD was defined as a written instruction not to perform life-saving treatments, such as CPR in case of cardiac arrest. A multivariate binary logistic regression analysis was used to identify whether having a malignancy was associated with TLDs.

Results:

Of the 1046 unplanned admissions, 125 patients (12%) had an active malignancy and 76 (7.3%) patients had CR. The incidence of written TLDs in these subgroups were 37 (29.6%) and 20 (26.3%). Age (OR 1.03; 95% CI 1.01 -1.04), SOFA score at ICU admission (OR 1.11; 95% CI 1.05 -1.18) and having an active malignancy (OR 1.75; 95% CI 1.04-2.96) compared to no malignancy were independently associated with written TLDs. SOFA scores on the day of the TLD were not significantly different in patients with and without a malignancy.

Conclusions:

This study shows that the presence of an underlying malignancy is independently associated with written TLDs during ICU stay. Patients with CR were not at risk of more written TLDs. Whether this higher incidence of TLDs in patients with a malignancy is justified, is at least questionable and should be evaluated in future research.

Advance directives in the emergency department

Advance directives are documents to convey patients' preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient-centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.

Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments

IMPORTANCE

Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management.

OBJECTIVE

To provide a benchmark description of patients who present to the ED with active cancer.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018.

MAIN OUTCOMES AND MEASURES

The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified.

RESULTS

Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics.

CONCLUSIONS AND RELEVANCE

This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.

Patient Perspectives on Advance Care Planning via a Patient Portal

BACKGROUND

Patient portals can offer patients an opportunity to engage in the advance care planning (ACP) process outside of clinical visits.

OBJECTIVE

To describe patient perspectives on use of patient portal-based ACP tools.

DESIGN

Interviews with patients who used portal-based ACP tools. The tools included an electronic Medical Durable Power of Attorney (MDPOA) form to designate a medical decision maker, a patient-centered educational web page, online messaging, and patient access to completed advance directives stored in the electronic health record (EHR).

SETTING

Regional health-care system with a common EHR.

MEASUREMENTS

Semistructured interviews with purposefully sampled patients who used the ACP tools. Questions explored motivations for using the tools and perceptions about how the tools fit into ACP. Analysis followed a grounded hermeneutic editing approach.

RESULTS

From 46 patients (mean age: 49, 63% female), 4 key themes emerged: (1) individualized explorations of the ACP tools, (2) personal initiation and engagement with ACP tools through the portal, (3) value of connecting ACP portal tools to clinical care, and (4) practicality of the ACP tools. Patients described benefits of communicating with health-care team members who referred them to online ACP tools, as well as having the electronic MDPOA form connected to clinical care.

CONCLUSIONS

Patients considered the portal-based ACP tools to be practical and feasible to use within the scope of their own ACP experiences. Further study is needed to understand whether portal-based ACP tools increase the quality and quantity of ACP conversations and documentation that is available to inform medical decision-making.