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Song J, Topaz M, Landau AY, Klitzman RL, Shang J, Stone PW, McDonald MV, Cohen B. Natural Language Processing to Identify Home Health Care Patients at Risk for Becoming Incapacitated With No Evident Advance Directives or Surrogates. J Am Med Dir Assoc 2024; 25:105019. [PMID: 38754475 DOI: 10.1016/j.jamda.2024.105019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES Home health care patients who are at risk for becoming Incapacitated with No Evident Advance Directives or Surrogates (INEADS) may benefit from timely intervention to assist them with advance care planning. This study aimed to develop natural language processing algorithms for identifying home care patients who do not have advance directives, family members, or close social contacts who can serve as surrogate decision-makers in the event that they lose decisional capacity. DESIGN Cross-sectional study of electronic health records. SETTING AND PARTICIPANTS Patients receiving post-acute care discharge services from a large home health agency in New York City in 2019 (n = 45,390 enrollment episodes). METHODS We developed a natural language processing algorithm for identifying information documented in free-text clinical notes (n = 1,429,030 notes) related to 4 categories: evidence of close relationships, evidence of advance directives, evidence suggesting lack of close relationships, and evidence suggesting lack of advance directives. We validated the algorithm against Gold Standard clinician review for 50 patients (n = 314 notes) to calculate precision, recall, and F-score. RESULTS Algorithm performance for identifying text related to the 4 categories was excellent (average F-score = 0.91), with the best results for "evidence of close relationships" (F-score = 0.99) and the worst results for "evidence of advance directives" (F-score = 0.86). The algorithm identified 22% of all clinical notes (313,290 of 1,429,030) as having text related to 1 or more categories. More than 98% of enrollment episodes (48,164 of 49,141) included at least 1 clinical note containing text related to 1 or more categories. CONCLUSIONS AND IMPLICATIONS This study establishes the feasibility of creating an automated screening algorithm to aid home health care agencies with identifying patients at risk of becoming INEADS. This screening algorithm can be applied as part of a multipronged approach to facilitate clinician support for advance care planning with patients at risk of becoming INEADS.
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Affiliation(s)
- Jiyoun Song
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Maxim Topaz
- Columbia University School of Nursing, New York, NY, USA; Data Science Institute, Columbia University, New York, NY, USA; Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | - Aviv Y Landau
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert L Klitzman
- Columbia University College of Physicians and Surgeons, New York, NY, USA; Columbia University Joseph Mailman School of Public Health, New York, NY, USA
| | - Jingjing Shang
- Columbia University School of Nursing, New York, NY, USA
| | | | | | - Bevin Cohen
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Center for Nursing Research and Innovation, Mount Sinai Health System, New York, NY, USA.
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2
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Archer AD, Hahamyan HA, White-Archer ML, Mannino EA, Roche KF, Burns JB. Application of the Geriatric Trauma Outcome Score in a Rural Setting. Am Surg 2024; 90:1860-1865. [PMID: 38516793 DOI: 10.1177/00031348241241624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
OBJECTIVE To retrospectively apply the Geriatric Trauma Outcome (GTO) score to the patient population of a rural South Central Appalachian level 1 trauma center and identify the potential utility of the GTO score in guiding goals of care discussions. METHODS Trauma registry data was extracted for 5,627 patients aged 65+ from 2017 to 2021. GTO score was calculated for each patient. Descriptive statistics were calculated for age, Injury Severity Score (ISS), GTO score, receipt of red blood cells, discharge status, and code status. A simple logistic regression model was used to determine the relationship between GTO score and discharge status. The probability of mortality was then calculated using GTO score, and the distribution of code status among patients with ≤50, 51-75%, and >75% probability of mortality was examined. RESULTS For every 10-point increase in GTO score, odds of mortality increased by 79% (OR = 1.79; P < .001). Patients had an estimated 50% probability of mortality with a GTO score of 156, 75% with 174, and 99% with a score of 234, respectively. Seventeen patients had a GTO score associated with >75% probability of mortality. Of those 17 patients, four retained a full code status. CONCLUSIONS Our analysis demonstrates that the GTO score is a validated measure in a rural setting and can be an easily calculated metric to help determine a geriatric patient's probability of mortality following a trauma. The results of our study also found that GTO score can be used to inform goals of care discussions with patients.
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Affiliation(s)
- Allen D Archer
- Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Henrik A Hahamyan
- Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Melissa L White-Archer
- Department of Biostatistics and Epidemiology, East Tennessee State University, Johnson City, TN, USA
| | - Elizabeth A Mannino
- Department of Surgery, East Tennessee State University, Johnson City, TN, USA
| | - Keelin F Roche
- Department of Surgery, East Tennessee State University, Johnson City, TN, USA
| | - J Bracken Burns
- Department of Surgery, East Tennessee State University, Johnson City, TN, USA
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3
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Young Y, Perre T, Shayya A, Barnes V, O'Grady T. Unveiling the Influencers: An Exploration of Factors Determining Advance Directive Completion Among Community-Dwelling Adults. Am J Hosp Palliat Care 2024; 41:762-770. [PMID: 37937749 DOI: 10.1177/10499091231213636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
INTRODUCTION Advance directives (AdvDirs) align end-of-life care with personal values, averting unnecessary treatments. This study explores factors influencing AdvDir completion. METHODS We conducted a cross-sectional study with community-dwelling adults (n = 166) age range 18-93, using a survey to gather sociodemographics, beliefs, and AdvDir experiences. Multivariate logistic regression quantifies associations between selected covariates and AdvDir completion. RESULTS We found that 36% of respondents had completed AdvDirs. The majority were comfortable discussing death (77%) and end-of-life care (84%) and recognized the importance of AdvDirs (79%). Age, education level, self-perceived health status, exposure to end-of-life planning, and the preference to limit treatment in potential future Alzheimer's scenarios significantly influenced AdvDir completion. CONCLUSION In conclusion, the study highlights: (1) The need for age-specific, personalized AdvDir education initiatives, and (2) The necessity of intensified AdvDir awareness efforts, particularly for individuals favoring unlimited treatment in Alzheimer's or dementia scenarios.
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Affiliation(s)
- Yuchi Young
- Department of Health Policy, Management, & Behavior, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
| | - Taylor Perre
- Home Care Association of New York State (HCA), Albany, NY, USA
| | - Ashley Shayya
- Department of Health Policy, Management, & Behavior, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
| | - Virgile Barnes
- Department of Health Policy, Management, & Behavior, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
| | - Thomas O'Grady
- Department of Epidemiology and Biostatistics, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
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4
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Vincent JL. Ethical issues surrounding appropriate care for older persons in the Intensive Care Unit. Panminerva Med 2024; 66:146-154. [PMID: 38536008 DOI: 10.23736/s0031-0808.24.05089-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Increasing numbers of older patients are being admitted to the Intensive Care Unit (ICU) as the world's population ages. The biological process of ageing, senescence, results in altered ability to maintain normal homeostasis and organ function, including of the cardiovascular, immune, and neuromuscular systems. This contributes towards increased frailty in older patients, associated with functional limitations and increased vulnerability. Although widely defined using chronological age, the concept of "old age" is thus multifactorial, including biological, but also psychological and sociocultural aspects, which should all be taken into account when considering what is appropriate in terms of ICU admission and management. As for all patients, but perhaps particularly in this subgroup, decisions regarding ICU admission and treatment and the withdrawing and withholding of life support must be individualized.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium -
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5
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Clarfield AM, Dwolatzky T. Age and Ageing During the COVID-19 Pandemic; Challenges to Public Health and to the Health of the Public. Front Public Health 2021; 9:655831. [PMID: 34778158 PMCID: PMC8578819 DOI: 10.3389/fpubh.2021.655831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 09/24/2021] [Indexed: 11/13/2022] Open
Abstract
The distribution of the SARS-CoV-2 virus has reached pandemic proportions. While COVID-19 can affect anyone, it is particularly hazardous for those with "co-morbidities." Older age is an especially strong and independent risk factor for hospital and ICU admission, mechanical ventilation and death. Health systems must protect persons at any age while paying particular attention to those with risk factors. However, essential freedoms must be respected and social/psychological needs met for those shielded. The example of the older population in Israel may provide interesting public health lessons. Relatively speaking, Israel is a demographically young country, with only 11.5% of its population 65 years and older as compared with the OECD average of >17%. As well, a lower proportion of older persons is in long-term institutions in Israel than in most other OECD countries. The initiation of a national program to protect older residents of nursing homes and more latterly, a successful vaccine program has resulted in relatively low rates of serious COVID-19 related disease and mortality in Israel. However, the global situation remains unstable and the older population remains at risk. The rollout of efficacious vaccines is in progress but it will probably take years to cover the world's population, especially those living in low- and middle-income countries. Every effort must be made not to leave these poorer countries behind. Marrying the principles of public health (care of the population) with those of geriatric medicine (care of the older individual) offers the best way forward.
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Affiliation(s)
- A Mark Clarfield
- Ben-Gurion University of the Negev, Beersheba, Israel.,Department of Geriatrics, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Tzvi Dwolatzky
- Rambam Health Care Campus, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute Technology, Haifa, Israel
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6
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Patel R, Torke A, Nation B, Cottingham A, Hur J, Gruber R, Sinha S. Crucial Conversations for High-Risk Populations before Surgery: Advance Care Planning in a Preoperative Setting. Palliat Med Rep 2021; 2:260-264. [PMID: 34927151 PMCID: PMC8675221 DOI: 10.1089/pmr.2021.0015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 01/18/2023] Open
Abstract
Background: High-risk patients undergoing elective surgery are at risk for perioperative complications, including readmissions and death. Advance care planning (ACP) may allow for preparation for such events. Objectives: (1) To assess the completion rate of advance directives (ADs) and their association with one year readmissions and mortality (2) to examine clinical events for decedents. Design: This is an observational cohort study conducted through chart review. Setting/Subjects: Subjects were 400 patients undergoing preoperative evaluation for elective surgery at two hospitals in the United States. Measurements: The prevalence of ADs at the time of surgery and at one year, readmissions, and mortality at one year were determined. Results: Three-hundred ninety patients were included. In total, 102 (26.4%) patients were readmitted, yet did not complete an AD. Seventeen (4.4%) patients filed an AD during follow-up. Nineteen patients died and mortality rate was 4.9%. There was a significant association between completing an AD before death. Of the decedents, seven (37%) underwent resuscitation, but only four had ADs. Conclusions: Many high-risk surgical patients would benefit from ADs before clinical decline. Preoperative clinics present a missed opportunity to ensure ACP occurs before complications arise.
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Affiliation(s)
- Roma Patel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alexia Torke
- IU Health Physicians, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Division of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, Indiana, USA
- Fairbanks Center for Medical Ethics, IU Health, Indianapolis, Indiana, USA
- Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, Indiana, USA
| | - Barb Nation
- Indiana University School of Medicine, Indianapolis, Indiana, USA
- IU Health Physicians, Indianapolis, Indiana, USA
| | - Ann Cottingham
- Indiana University School of Medicine, Indianapolis, Indiana, USA
- Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, Indiana, USA
- Advanced Scholars Program for Internists in Research and Education (ASPIRE) Indiana University (IU) School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jennifer Hur
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel Gruber
- Advanced Scholars Program for Internists in Research and Education (ASPIRE) Indiana University (IU) School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Shilpee Sinha
- Indiana University School of Medicine, Indianapolis, Indiana, USA
- IU Health Physicians, Indianapolis, Indiana, USA
- Advanced Scholars Program for Internists in Research and Education (ASPIRE) Indiana University (IU) School of Medicine, Indianapolis, Indiana, USA
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7
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Vranas KC, Plinke W, Bourne D, Kansagara D, Lee RY, Kross EK, Slatore CG, Sullivan DR. The influence of POLST on treatment intensity at the end of life: A systematic review. J Am Geriatr Soc 2021; 69:3661-3674. [PMID: 34549418 DOI: 10.1111/jgs.17447] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. METHODS We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life). RESULTS Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes. CONCLUSION We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.
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Affiliation(s)
- Kelly C Vranas
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Wesley Plinke
- Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Donald Bourne
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Devan Kansagara
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Christopher G Slatore
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Donald R Sullivan
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
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8
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Ermers DJM, van Beuningen-van Wijk MPH, Rit EP, Stalpers-Konijnenburg SC, Taekema DG, Bosch FH, Engels Y, van Mierlo PJWB. Life-sustaining treatment preferences in older patients when referred to the emergency department for acute geriatric assessment: a descriptive study in a Dutch hospital. BMC Geriatr 2021; 21:58. [PMID: 33446116 PMCID: PMC7807792 DOI: 10.1186/s12877-020-02002-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/29/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In many cases, life-sustaining treatment preferences are not timely discussed with older patients. Advance care planning (ACP) offers medical professionals an opportunity to discuss patients' preferences. We assessed how often these preferences were known when older patients were referred to the emergency department (ED) for an acute geriatric assessment. METHODS We conducted a descriptive study on patients referred to the ED for an acute geriatric assessment in a Dutch hospital. Patients were referred by general practitioners (GPs), or in the case of nursing home residents, by elderly care physicians. The referring physician was asked if preferences regarding life-sustaining treatments were known. The primary outcome was the number of patients for whom preferences were known. Secondary outcomes included which preferences, and which variables predict known preferences. RESULTS Between 2015 and 2017, 348 patients were included in our study. At least one preference regarding life-sustaining treatments was known at referral in 45.4% (158/348) cases. In these cases, cardiopulmonary resuscitation (CPR) policy was always included. Preferences regarding invasive ventilation policy and ICU admission were known in 17% (59/348) and 10.3% (36/348) of the cases respectively. Known preferences were more frequent in cases referred by the elderly care physician than the GP (P < 0.001). CONCLUSIONS In less than half the patients, at least one preference regarding life-sustaining treatments was known at the time of referral to the ED for an acute geriatric assessment; in most cases it concerned CPR policy. We recommend optimizing ACP conversations in a non-acute setting to provide more appropriate, desired, and personalized care to older patients referred to the ED.
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Affiliation(s)
- Daisy J M Ermers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, PO Box 9101, Nijmegen, HB, 6500, The Netherlands.
| | | | - Evi Peters Rit
- Department of Geriatrics, Meander medical center, Amersfoort, The Netherlands
| | | | - Diana G Taekema
- Department of Geriatrics, Rijnstate, Arnhem, The Netherlands
| | - Frank H Bosch
- Department of Intensive Care Medicine, Rijnstate, Arnhem, The Netherlands.,Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, PO Box 9101, Nijmegen, HB, 6500, The Netherlands
| | - Patricia J W B van Mierlo
- Department of Geriatrics, Rijnstate, Arnhem, The Netherlands.,Center of Supportive and Palliative Care, Rijnstate, Arnhem, The Netherlands
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9
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Abstract
This integrative review presents the most recent and relevant critical care nursing research publications in the United States. A comprehensive search identified publications on the topics of delirium; early mobility; communication; palliative care; tele-intensive care unit; care bundle implementation; and prevention, detection, and early management of infection. The evidence is summarized for each of these topics, as well as other research, with suggestions and guidance for end users.
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Affiliation(s)
- Sheila A Alexander
- Acute and Tertiary Care, School of Nursing, Critical Care Medicine, School of Medicine, University of Pittsburgh, 336 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, USA.
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10
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Rodi H, Detering K, Sellars M, Macleod A, Todd J, Fullerton S, Waller A, Nolte L. Exploring advance care planning awareness, experiences, and preferences of people with cancer and support people: an Australian online cross-sectional study. Support Care Cancer 2020; 29:3677-3688. [DOI: 10.1007/s00520-020-05878-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/05/2020] [Indexed: 01/05/2023]
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11
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Gupta A, Bahl B, Rabadi S, Mebane A, Levey R, Vasudevan V. Value of Advance Care Directives for Patients With Serious Illness in the Era of COVID Pandemic: A Review of Challenges and Solutions. Am J Hosp Palliat Care 2020; 38:191-198. [PMID: 33021094 DOI: 10.1177/1049909120963698] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Advance care directives (ACDs) are instructions regarding what types of medical treatments a patient desires and/or who they would like to designate as a healthcare surrogate to make important healthcare decisions when the patient is mentally incapacitated. At end-of-life, when faced with poor prognosis for a meaningful health-related quality of life, most patients indicate their preference to abstain from aggressive, life-sustaining treatments. Patients whose wishes are left unsaid often receive burdensome life sustain therapy by default, prolonging patient suffering. The CoVID pandemic has strained our healthcare resources and raised the need for prioritization of life-sustaining therapy. This highlights the urgency of ACDs more than ever. Despite ACDs' potential to provide patients with care that aligns with their values and preferences and reduce resource competition, there has been relatively little conversation regarding the overlap of ACDs and CoVID-19. There is low uptake among patients, lack of training for healthcare professionals, and inequitable adoption in vulnerable populations. However, solutions are forthcoming and may include electronic medical record completion, patient outreach efforts, healthcare worker programs to increase awareness of at-risk minority patients, and restructuring of incentives and reimbursement policies. This review carefully describes the above challenges and unique opportunities to address them in the CoVID-19 era. If solutions are leveraged appropriately, ACDs have the potential to address the described challenges and ethically resolve resource conflicts during the current crisis and beyond.
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Affiliation(s)
- Amol Gupta
- 24508The Brooklyn Hospital Center, NY, USA
| | | | - Saher Rabadi
- 12340University of Texas Health Sciences Center, Houston, TX, USA
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12
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Phua CS, Ng A, Brooks C, Harrington Z, Vedam H, Huynh T, Seccombe D, Aouad P, Cordato D. Prevalence and factors associated with advanced care directives in a motor neuron disease multidisciplinary clinic in Australia. Postgrad Med J 2020; 97:566-570. [PMID: 32788311 DOI: 10.1136/postgradmedj-2020-138184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/30/2020] [Accepted: 07/04/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Motor neuron disease (MND) is a neurodegenerative disorder leading to functional decline and death. Multidisciplinary MND clinics provide an integrated approach to management and facilitate discussion on advanced care directives (ACDs). The study objectives are to analyse (1) the prevalence of ACD in our MND clinic, (2) the relationship between ACD and patient demographics and (3) the relationship between ACD decision-making and variables such as NIV, PEG, hospital admissions and location of death. METHODS Using clinic records, all patients who attended the MND clinic in Liverpool Hospital between November 2014 and November 2019 were analysed. Data include MND subtypes, symptom onset to time of diagnosis, time of diagnosis to death, location and reason of death. ACD prevalence, non-invasive ventilation (NIV) and percutaneous endoscopic gastrostomy (PEG) requirements were analysed. RESULTS There were 78 patients; M:F=1:1. 44 (56%) patients were limb onset, 28 (36%) bulbar onset, 4 primary lateral sclerosis and 2 flail limb syndrome presentations. 27% patients completed ACDs, while 32% patients declined ACDs. Patients born in Australia or in a majority English-speaking country were more likely to complete ACDs compared to those born in a non-English-speaking country. There was no significant correlation between ACD completion and age, gender, MND subtype, symptom duration, NIV, PEG feeding, location of death. CONCLUSION One-quarter of patients completed ACDs. ACDs did not correlate with patient age, gender, MND subtype and symptom duration or decision-making regarding NIV, PEG feeding or location of death. Further studies are needed to address factors influencing patients' decisions regarding ACDs.
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Affiliation(s)
- Chun Seng Phua
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, Australia .,School of Medicine, University of New South Wales, Sydney, Australia
| | - Aloysius Ng
- Department of Intensive Care, Lismore Base Hospital, Lismore, Australia
| | - Christopher Brooks
- School of Medicine, University of New South Wales, Sydney, Australia.,Department of Neurosurgery, Liverpool Hospital, Liverpool, Australia
| | - Zinta Harrington
- School of Medicine, University of New South Wales, Sydney, Australia.,Department of Respiratory and Sleep Medicine, Liverpool Hospital, Liverpool, Australia
| | - Hima Vedam
- School of Medicine, University of New South Wales, Sydney, Australia.,Department of Respiratory and Sleep Medicine, Liverpool Hospital, Liverpool, Australia
| | - Thang Huynh
- School of Medicine, University of New South Wales, Sydney, Australia.,Department of Palliative Care, Liverpool Hospital, Liverpool, Australia
| | - Desi Seccombe
- School of Medicine, University of New South Wales, Sydney, Australia.,Department of Palliative Care, Liverpool Hospital, Liverpool, Australia
| | - Patrick Aouad
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, Australia.,School of Medicine, University of New South Wales, Sydney, Australia
| | - Dennis Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, Australia.,School of Medicine, University of New South Wales, Sydney, Australia
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13
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Baker EF, Marco CA. Advance directives in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:270-275. [PMID: 33000042 PMCID: PMC7493570 DOI: 10.1002/emp2.12021] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/23/2019] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Eileen F. Baker
- University of Toledo College of Medicine and Life SciencesToledoOhio
- Riverwood Emergency Services, Inc.PerrysburgOhio
| | - Catherine A. Marco
- Department of Emergency MedicineWright State University Boonshoft School of MedicineDaytonOhio
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14
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Detering KM, Buck K, Ruseckaite R, Kelly H, Sellars M, Sinclair C, Clayton JM, Nolte L. Prevalence and correlates of advance care directives among older Australians accessing health and residential aged care services: multicentre audit study. BMJ Open 2019; 9:e025255. [PMID: 30647047 PMCID: PMC6340468 DOI: 10.1136/bmjopen-2018-025255] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES It is important that the outcomes of advance care planning (ACP) conversations are documented and available at the point of care. Advance care directives (ACDs) are a subset of ACP documentation and refer to structured documents that are completed and signed by competent adults. Other ACP documentation includes informal documentation by the person or on behalf of the person by someone else (eg, clinician, family). The primary objectives were to describe the prevalence and correlates of ACDs among Australians aged 65 and over accessing health and residential aged care services. The secondary aim was to describe the prevalence of other ACP documentation. DESIGN AND SETTING A prospective multicentre health record audit in general practices (n=13), hospitals (n=12) and residential aged care facilities (RACFs; n=26). PARTICIPANTS 503 people attending general practice, 574 people admitted to hospitals and 1208 people in RACFs. PRIMARY AND SECONDARY OUTCOME MEASURES Prevalence of one or more ACDs; prevalence of other ACP documentation. RESULTS 29.8% of people had at least one ACD on file. The majority were non-statutory documents (20.9%). ACD prevalence was significantly higher in RACFs (47.7%) than hospitals (15.7%) and general practices (3.2%) (p<0.001), and varied across jurisdictions. Multivariate logistic regression showed that the odds of having an ACD were positively associated with greater functional impairment and being in an RACF or hospital compared with general practice. 21.6% of people had other ACP documentation. CONCLUSIONS In this study, 30% of people had ACDs accessible and a further 20% had other ACP documentation, suggesting that approximately half of participants had some form of ACP. Correlates of ACD completion were greater impairment and being in an RACF or hospital. Greater efforts to promote and standardise ACDs across jurisdictions may help to assist older people to navigate and complete ACDs and to receive care consistent with their preferences. TRIAL REGISTRATION NUMBER ACTRN12617000743369.
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Affiliation(s)
- Karen M Detering
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Kimberly Buck
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Rasa Ruseckaite
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Helana Kelly
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Marcus Sellars
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Craig Sinclair
- Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia
| | - Josephine M Clayton
- Centre for Learning and Research in Palliative Care, Hammond Care, Greenwich Hospital and Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
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15
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Ecarnot F, Quenot JP, Besch G, Piton G. Ethical challenges involved in obtaining consent for research from patients hospitalized in the intensive care unit. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S41. [PMID: 29302597 DOI: 10.21037/atm.2017.04.42] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Clinical research remains a vital contributor to medical knowledge, and is an established and integral part of the practice of medicine worldwide. Respect for patient autonomy and ethical principles dictate that informed consent must be obtained from subjects before they can be enrolled into clinical research, yet these conditions may be difficult to apply in real practice in the intensive care unit (ICU). A number of factors serve to complexify the consent process in critically ill patients, notably decisional incapacity of the patient due to illness or sedation. Obtaining consent for research from a designated proxy or family member, commonly termed a "surrogate decision maker" (SDM) may be difficult, since SDMs dealing with the emotional, psychological and logistic impact of a sudden hospitalisation of their loved-one are not always receptive to the idea of research or emotionally equipped to reflect rationally on the opportunities being proposed to them. In addition, time constraints and workload pressures on the attending physician may render consent opportunities unfeasible, and the resulting loss of eligible patients could represent a bias in clinical trials, or limit the generalizability of their results. Alternative procedures such as deferred or waived consent have been used in the past and may be suitable alternatives in certain conditions, provided appropriate approval from institutional review boards (IRBs) can be obtained, in accordance with existing legislation. Some of the main questions inherent to the conduct of clinical research in critically ill patients are discussed in this review.
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Affiliation(s)
- Fiona Ecarnot
- Department of Cardiology, University Hospital, Besancon, France.,EA3920, University of Burgundy Franche-Comté, Besancon, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, 14 rue Paul Gaffarel, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.,INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Guillaume Besch
- EA3920, University of Burgundy Franche-Comté, Besancon, France.,Department of Anesthesiology and Surgical Intensive Care Unit, University Hospital, Besancon, France
| | - Gaël Piton
- EA3920, University of Burgundy Franche-Comté, Besancon, France.,Department of Critical Care, University Hospital, Besancon, France
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16
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Marco CA, Mozeleski E, Mann D, Holbrook MB, Serpico MR, Holyoke A, Ginting K, Ahmed A. Advance directives in emergency medicine: Patient perspectives and application to clinical scenarios. Am J Emerg Med 2017; 36:516-518. [PMID: 28784259 DOI: 10.1016/j.ajem.2017.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 07/30/2017] [Accepted: 08/01/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, United States.
| | - Eric Mozeleski
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, United States
| | - Dennis Mann
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, United States
| | - Michael B Holbrook
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
| | - Mark R Serpico
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
| | - Alban Holyoke
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
| | - Karolin Ginting
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
| | - Ahnas Ahmed
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
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