Family Carers' Experiences of Goals of Care Conversations in Acute Hospital Settings

End-of-life Goals of Care (GoC) discussions aim to support care that is consistent with patients' preferences and values. This study uses an exploratory qualitative design drawing upon a social constructivist epistemology to examine family carers' perspectives on GoC within acute Australian hospital settings. Twenty-five family carers of aging inpatients were recruited from six Australian hospitals to participate in recorded, semi-structured interviews. Data were transcribed and analyzed using reflexive thematic analysis. Three main themes were developed. Theme 1 explored carers' experiences of GoC discussions-identifying varying levels of preparedness and carers' hopes for open, two-way discussions initiated by empathic Health Care Professionals (HCPs). Theme 2 examined carers' unmet needs for time, space, consistency, and support to make careful decisions. Theme 3 identified carers advocating for patients' needs when they could not do it themselves. Preparing carers and normalizing GoC discussions relating to end-of-life care maximizes benefits for patients, carers, and HCPs involved.

A Qualitative Exploration of Seriously Ill Patients' Experiences of Goals of Care Discussions in Australian Hospital Settings

BACKGROUND

Goals of care (GOC) is a communication and decision-making process that occurs between a clinician and a patient (or surrogate decision-maker) during an episode of care to facilitate a plan of care that is consistent with the patient's preferences and values. Little is known about patients' experiences of these discussions.

OBJECTIVE

This study explored patients' perspectives of the GOC discussion in the hospital setting.

DESIGN

An explorative qualitative design was used within a social constructionist framework.

PARTICIPANTS

Adult patients were recruited from six Australian hospitals across two states. Eligible patients had had a GOC discussion and they were identified by the senior nurse or their doctor for informed consent and interview.

APPROACH

Semi-structured individual or dyadic interviews (with the carer/family member present) were conducted at the bedside or at the patient's home (for recently discharged patients). Interviews were audio-recorded and transcribed verbatim. Data were analysed for themes.

KEY RESULTS

Thirty-eight patient interviews were completed. The key themes identified were (1) values and expectations, and (2) communication (sub-themes: (i) facilitators of the conversation, (ii) barriers to the conversation, and (iii) influence of the environment). Most patients viewed the conversation as necessary and valued having their preferences heard. Effective communication strategies and a safe, private setting were facilitators of the GOC discussion. Deficits in any of these key elements functioned as a barrier to the process.

CONCLUSIONS

Effective communication, and patients' values and expectations set the stage for goals of care discussions; however, the environment plays a significant role. Communication skills training and education designed to equip clinicians to negotiate GOC interactions effectively are essential. These interventions must also be accompanied by systemic changes including building a culture supportive of GOC, clear policies and guidelines, and champions who facilitate uptake of GOC discussions.

Effectiveness of a patient blood management data system in monitoring blood use in Western Australia

The aim of this paper is to describe a linked patient blood management (PBM) data system and to demonstrate its usefulness by presenting the blood usage data obtained. Our existing datasets already collected much of the required information in relation to PBM. However, these datasets were not linked. A patient identifier was used to link the Patient Administration System with the Laboratory Information System. Data linkage was achieved by linking the Laboratory Information System with the Patient Administration System records where blood transfusion or laboratory result date/time fell between admission and discharge date/time. The two datasets were then consolidated into the PBM data system. Blood usage data obtained from the system showed that between August 2008 and July 2009 there were 59,627 patient completed separations in the pilot hospital. Of the total transfused units, 62% were red blood cells (RBC), followed by fresh frozen plasma (22%), cryoprecipitate (9%) and platelets (8%). Around 50% of RBC transfusions were administered to patients >70 years of age. General medicine represented 21% of RBC usage, followed by haematology (19%), orthopaedics (17%) and general surgery (16%). Patients with 100 g/l pre-transfusion haemoglobin received 9% of RBC transfusions and patients with 71-100 g/l pre-transfusion haemoglobin received 73% of RBC transfusions. The post-transfusion haemoglobin in RBC transfusions exceeded 100 g/l in 33% of patients. Databases were successfully linked to produce a powerful tool to monitor blood utilisation and transfusion practices within a pilot PBM program. This will facilitate effective targeting of PBM strategies and ongoing monitoring of their impact.

A comparison of eosinopenia and C-reactive protein as a marker of bloodstream infections in critically ill patients: a case control study

Diagnosis of bloodstream infections in critically ill patients is difficult. This case control study involved a total of 22 patients with confirmed bloodstream infections and 44 concurrent controls from an intensive care unit in Western Australia. We aimed to assess whether eosinopenia and C-reactive protein are useful markers of bloodstream infections in critically ill patients. The patients with bloodstream infections had a more severe disease and a longer length of intensive care unit (10.7 vs 4.0 days, P = 0.001) and hospital stay (40.9 vs 17.9 days, P = 0.015) than the controls. Univariate analyses showed that C-reactive protein (area under the receiver operating characteristic curve 0.847, 95% confidence interval (CI) 0.721 to 0.973), eosinophil counts (area under the receiver operating characteristic curve 0.849, 95% CI 0.738 to 0.961) and fibrinogen concentrations (area under the receiver operating characteristic curve 0.730, 95% CI 0.578 to 0.882) were significant markers of bloodstream infections. C-reactive protein concentration was, however the only significant predictor in the multivariate analysis (odds ratio 1.21 per 10 mg/l increment, 95% CI 1.01 to 1.39, P = 0.007). C-reactive protein concentration appears to be a better marker of bloodstream infections than eosinopenia in critically ill patients. A large prospective cohort study is needed to assess whether eosinopenia is useful in addition to C-reactive protein concentrations as a marker of bloodstream infections.

C-reactive protein concentration as a predictor of intensive care unit readmission: a nested case-control study

PURPOSE

The purpose of this study is to assess the ability of potential clinical predictors and inflammatory markers to predict intensive care unit (ICU) readmission during the same hospitalization.

MATERIALS AND METHODS

A nested case-control study utilized prospectively collected de-identified data of a 22-bed multidisciplinary ICU in a university hospital.

RESULTS

There were 1,405 consecutive ICU admissions in 2004, and of these, 18 were regarded as ICU readmissions (1.3%). The destination and timing of ICU discharge, the Sequential Organ Failure Assessment scores, white cell counts, and fibrinogen concentrations at discharge were not associated with ICU readmission. C-reactive protein (CRP) concentration within 24 hours before ICU discharge was associated with ICU readmission (mean CRP concentrations of cases vs controls, 177.8 vs 56.5 mg/L, respectively; P < .0001). The results remained unchanged after adjustment with the propensity scores. The area under the receiver operating characteristic curve for the CRP concentrations to predict ICU readmission was 0.884 (95% confidence interval, 0.765-0.999; P < .0001). Patients readmitted to the ICU had a higher predicted mortality in their second ICU admission (34.9% vs 26.1%; P < .01) and a longer total hospital stay (33.3 vs 20.3 days; P < .003) than patients without ICU readmission.

CONCLUSIONS

A high CRP concentration within 24 hours before ICU discharge is associated with a higher risk of readmission to the ICU.

Elimination kinetics of sevoflurane and halothane from blood, brain, and adipose tissue in the rat

Using the rat as an animal model, the elimination kinetics of sevoflurane and halothane from brain, blood, and adipose tissue were compared. Elimination of sevoflurane and halothane from blood and brain was biexponential. The rapid, alpha-elimination rates of sevoflurane from blood and brain were faster than the corresponding rates for halothane. However, the slower beta-elimination rates from brain and blood, as well as the elimination rates from adipose tissue, were similar for both volatile anesthetics. Thus, the potential for residual postoperative impairment from subanesthetic tissue concentrations of halothane and sevoflurane may be similar even though sevoflurane is initially eliminated more rapidly from blood and brain.

Diarrhoea during enteral feeding in the critically ill: a comparison of feeds with and without fibre

This randomised double-blind study examined the frequency of diarrhoea in intensive care unit patients given a fibre-containing feed, Enrich, and a fibre-free feed, Ensure. A daily 'diarrhoea score' was calculated from the frequency, volume and consistency of the stools. A score greater than 12 indicated diarrhoea, and greater than 50 severe diarrhoea. Ninety one patients met the criteria for participation: Enrich 45, Ensure 46. The groups were similar in age, sex ratio, feed volume, antibiotic usage, upper gastro-intestinal bleeding prophylaxis and plasma albumin concentrations. Diarrhoea occurred in 16 patients given Enrich and 13 given Ensure, severe diarrhoea affecting 5 and 9 respectively (NS). Forty seven of 343 (14%) Enrich feeding days and 51 of 342 (15%) Ensure feeding days were complicated by diarrhoea--severe diarrhoea: 8 and 12 feeding days (NS). We conclude soy polysaccharide (21 g/L) did not reduce diarrhoea in intensive care unit patients given enteral feeds.