1
|
Meehan CP, White E, CVitan A, Jiang L, Wu WC, Wice M, Stafford J, Rudolph JL. Factors Associated With Early Palliative Care Among Patients With Heart Failure. J Palliat Med 2024. [PMID: 38608234 DOI: 10.1089/jpm.2023.0539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
Background: Heart failure (HF) is a progressive, life-limiting illness for which palliative care (PC) is considered standard of care. Among patients that do receive PC, consultation tends to occur late in the illness course. Objective: Our primary aim was to examine patient factors associated with receiving PC in HF. Secondarily, we sought to determine factors associated with early PC encounters. Design: This was a retrospective cohort study of U.S. Veterans with prior hospitalization who died between January 1, 2011 and December 31, 2020. Setting/Subjects: Subjects were Veterans with HF who died with a prior admission to a Veterans Affairs hospital in the United States. Measurements: We calculated the time from PC encounter to death. We characterized HF patients who died without PC, with late PC (≤90 days before death), and with early PC (>90 days before death). Results: We identified 232,079 Veterans with a mean age of (76.5 ± 10.7) years. Within the cohort, 56.5% (n = 131,122) of Veterans died with no PC, 22.5% (n = 52,114) had PC <90 days before death, and 21.0% (n = 48,843) had PC >90 days before death. Veterans who died without PC tended to be younger with fewer comorbidities. Conclusions: While more than 20% of HF patients in our cohort had PC well in advance of death, more than half died without PC. PC involvement seemed to be driven by comorbidities rather than HF. Effective collaboration with Cardiology is needed to identify patients who would benefit from earlier PC involvement.
Collapse
Affiliation(s)
- Caroline P Meehan
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Emily White
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Alexander CVitan
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Lan Jiang
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Wen-Chih Wu
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mitchell Wice
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Geriatrics and Extended Care, Providence VA Healthcare System, Providence, Rhode Island, USA
| | - Jensy Stafford
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
2
|
Tierney AP, Milnes S, Phillips A, Simpson N, Bailey M, Corke C, Orford NR. Effect of a person-centred goals-of-care form and clinical communication training on shared decision-making and outcomes in an acute hospital: a prospective longitudinal interventional study. Intern Med J 2024. [PMID: 38520171 DOI: 10.1111/imj.16381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/09/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Patients with a life-limiting illness (LLI) requiring hospitalisation have a high likelihood of deterioration and 12-month mortality. To avoid non-aligned care, we need to understand our patients' goals and values. AIM To describe the association between the implementation of a shared decision-making (SDM) programme and documentation of goals of care (GoC) for hospitalised patients with LLI. METHODS A prospective longitudinal interventional study of patients admitted to acute general medicine wards in an Australian tertiary hospital over 5 years was conducted. A SDM programme with a new GoC form, communication training and clinical support was implemented. The primary outcome was the proportion of patients with a documented person-centred GoC discussion (PCD). Clinical outcomes included hospital utilisation and 90-day mortality. RESULTS 1343 patients were included. The proportion of patients with PCDs increased from 0% to 35.4% (adjusted odds ratio (aOR), 2.38; 95% confidence interval (CI), 2.01-2.82; P < 0.001). During this time, median hospital length of stay decreased from 8 days (interquartile range (IQR), 4-14) to 6 days (IQR, 3-11) (adjusted estimate effect, -0.38; 95% CI, -0.64 to -0.11; P = 0.005) and rapid response team activation from 28% to 13% (aOR, 0.87; 95% CI, 0.78-0.97; P value = 0.01). Documented treatment preference of high-dependency unit care decreased from 39.7% to 24.4% (aOR, 0.81; 95% CI, 0.73-0.89; P value < 0.001), and ward-based care increased from 31.9% to 55.1% (aOR, 1.24; 95% CI, 1.14-1.36; P value < 0.001). CONCLUSION The implementation of a SDM programme was associated with increased documentation of person-centred GoC, changed patient treatment preference to lower intensity care and reduced hospital utilisation.
Collapse
Affiliation(s)
- Andrew P Tierney
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Sharyn Milnes
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Anita Phillips
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Nicholas Simpson
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine (SPHPM), Monash University, Melbourne, Victoria, Australia
| | - Charlie Corke
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Neil R Orford
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine (SPHPM), Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Saito T, Konta T, Kudo S, Ueno Y. Factors associated with community residents' preference for living at home at the end of life: The Yamagata Cohort Survey. Glob Health Med 2024; 6:70-76. [PMID: 38450115 PMCID: PMC10912798 DOI: 10.35772/ghm.2023.01072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/30/2023] [Accepted: 10/26/2023] [Indexed: 03/08/2024]
Abstract
Japan's rapidly aging and high-mortality society necessitates a wider awareness and implementation of advance care planning. This Yamagata Cohort study investigated local residents' preferences for where they would like to spend their final days, and the underlying factors associated with those preferences with a self-administered questionnaire survey of local residents aged 40 years and over . Logistic regression analyses were used to assess those factors and, specifically, the choice of "Home" as the preferred place for end-of-life residence. Among the 10,119 responders, 61% chose their home as the most desirable place to spend their final days. The multiple logistic regression analysis showed that the independent factors associated with the choice of "Home" were: male, older age, not living with someone who needs care, not discussing the end of life, currently happy, struggling to live on current income, not feeling anxious or depressed, and current place of residence the same as their grandparents' birthplace. This suggested that reducing the burden of home care and addressing frequent emotional issues such as happiness and anxiety could increase the number of people choosing "Home". Open-ended comments indicated the importance of getting information and options, and discussing the choice of place for terminal care in light of individual backgrounds including having reservations about family. Support and systems are needed to understand what community residents consider important when deciding where to spend their final days, and to bridge the gap between their desired location and their actual end of life.
Collapse
Affiliation(s)
- Tomoko Saito
- Department of Nursing, Yamagata University School of Medicine Hospital, Yamagata, Japan
| | - Tsuneo Konta
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Sachiko Kudo
- Department of Nursing, Yamagata University School of Medicine Hospital, Yamagata, Japan
| | - Yoshiyuki Ueno
- Department of Gastroenterology, Yamagata University School of Medicine, Yamagata, Japan
| |
Collapse
|
4
|
Tantardini C, Pelizzari C. [ Advanced Care Planning (ACP) and Hemodialysis: a Pilot Project for the Application of Italian Law 219/2017 in Dialysis Units]. G Ital Nefrol 2024; 41:2024-vol1. [PMID: 38426684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
The law 219/2017 is the first Italian law about advanced care planning (ACP). ACP is an important part of the therapeutic relationship between patients and doctors: thanks to ACP patients can think and discuss about end of life decisions, considering clinical aspects, but also psychological, cultural, social and ethical issues. Patients prepare themselves in advance because of the possibility of future cognitive impairment, can identify a surrogate decision maker and make end-life decisions according to their goals and values. End-stage kidney disease (ESRD) is often characterized by important symptoms, psychological suffering and social disadvantage, and patients affected by ESRD often have slow physical and cognitive decline. Despite this, access to palliative care is reduced for these patients as compared to patients affected by other end-stage organ failures. This is the reason why we want to explore the possibility of applying APC to ESRD patients. This pilot study, regarding three patients from the Dialysis Unit of ASST Crema in Italy, has been conducted to verify the applicability of the law 219/2017 in Dialysis Units. It shows that we have to deeply investigate this issue from both sanitary workers' and patients' and families' points of view. We need more studies with a larger number of patients and a longer period of follow-up, but we also need to teach sanitary workers how to approach APC and to teach people what APC is and why it's so important for everyone.
Collapse
|
5
|
Choi S, Ko H. Factors affecting advance directives completion among older adults in Korea. Front Public Health 2024; 12:1329916. [PMID: 38371241 PMCID: PMC10869548 DOI: 10.3389/fpubh.2024.1329916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/15/2024] [Indexed: 02/20/2024] Open
Abstract
Objective Advance directives (ADs) provide an opportunity for patients to enhance the quality of their end-of-life care and prepare for a dignified death by deciding treatment plans. The purpose of this study was to explore the multiple factors that influence the advance directives completion among older adults in South Korea. Methods This was a secondary analysis of a cross-sectional study of 9,920 older adults. The differences in ADs based on subjects' sociodemographic characteristics, health-related characteristics, and attitude toward death were tested using the chi-squared and t-test. A multinomial logistic regression model was used to identify the influencing factor of ADs. Results The number of chronic diseases, number of prescribed medications, depression, insomnia, suicide intention, and hearing, vision, or chewing discomfort were higher in the ADs group compared to the non-ADs group. The influencing factors of the signing of ADs included men sex, higher education level, exercise, death preparation education, lower awareness of dying-well, and experience of fracture. Conclusion Information dissemination regarding ADs should be promoted and relevant authorities should consider multiple options to improve the physical and psychological health of older adults, as well as their attitude toward death to increase the ADs completion rate.
Collapse
Affiliation(s)
| | - Hana Ko
- College of Nursing, Gachon University, Yeonsu-gu, Incheon, Republic of Korea
| |
Collapse
|
6
|
Kadden D, Weber M, Herbst L, Weber DE. The Impact of Words: Multisource Feedback Provides Students With a Deeper Understanding and Reflection on Goals of Care Discussions. Am J Hosp Palliat Care 2024; 41:173-178. [PMID: 37248859 DOI: 10.1177/10499091231175907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Background: Physician communication during goals of care (GOC) discussions impact experiences for patients and families at end-of-life (EOL). Simulation allows training in a safe environment where feedback from simulated patients (SP), clinicians, and self-reflection can be incorporated. Objectives: To determine if multisource feedback from SP scenarios enriches feedback provided to trainees. Design: Fourth-medical students participated in two SP GOC discussions during an advanced care planning (ACP) curriculum. Students received feedback from SPs and faculty and completed a video review with self-reflection. Setting and Subjects: Forty-seven fourth-year medical students at the University of Cincinnati College of Medicine participated in the curriculum from 2019-2021. Measurements: An inductive thematic analysis of the narrative data was performed examining all sources of feedback from the SP sessions. Results: Six themes emerged from the feedback: the warning shot: words to say and why it helps; acknowledging emotion: verbal vs non-verbal responses; organization: necessity of a clear path; body language: adding to and distracting from the conversation; terminology to avoid: what jargon encompasses and how it impacts patients; and silence: perceived importance by everyone. SP feedback focused on the personal emotional impact of a student's word choice and body language. Faculty feedback focused on specific learning points through examples from the conversation and expanded to hypothetical scenarios. Student self-reflection after video review allowed students to see challenges that they did not notice while immersed in the encounter. Conclusion: Multisource feedback from simulated GOC discussions provides unique insights for students to guide their development in leading difficult conversations.
Collapse
Affiliation(s)
- Daniel Kadden
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Madeline Weber
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lori Herbst
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Department of Family and Community Medicine, Division of Palliative Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Danielle E Weber
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| |
Collapse
|
7
|
Caplan H, Santos J, Bershad M, Spritzer K, Liantonio J. Assessment of Feelings Towards Advanced Care Planning in the Latino Community. Am J Hosp Palliat Care 2024; 41:187-192. [PMID: 37159467 DOI: 10.1177/10499091231173413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Previous studies have noted that participation in advanced care planning (ACP) and end-of-life (EOL) discussions remain low among Latino communities. Various studies have found that interventions within Latino communities can positively improve engagement in ACP, however, minimal research exists regarding patient satisfaction of ACP discussions with healthcare providers outside of preorganized educational interventions. Our study aims to understand how conversations about ACP are perceived by Latino patients in a primary care setting. METHODS Subjects were identified from the institution's family medicine clinic from October 2021 to October 2022. Participants were those over the age of 50 who identified as Latino and were available at the clinic on the day of survey administration. An 8-question, 5-point, Likert scale survey assessed perceptions about ACP planning and gauged satisfaction of conversations with health care providers. The survey concluded with a multiple-choice question inquiring about individuals whom patients have spoken to regarding ACP/EOL wishes. Survey data was gathered through Qualtrics. RESULTS Of the 33 patients, the majority have at least somewhat thought about their EOL wishes (avg = 3.48/5). Most usually felt they were given enough time with their doctor (avg = 4.12/5) and comfortable speaking about ACP and EOL decisions (avg = 4.55/5). Generally, participants felt somewhat happy with how their doctor has spoken about ACP/EOL care (avg = 3.24/5). However, patients only felt a little to somewhat satisfied with the explanation of ACP/EOL from providers (avg = 2.82/5) and a little to somewhat confident in having the proper forms in place (avg = 2.76/5). Religious officials were a little to somewhat important to these conversations (avg = 2.55/5). Overall, patients have discussed ACP more frequently with family members and friends than health care providers, lawyers, or religious leaders. CONCLUSIONS The initial data demonstrates that many Latino patients are engaging in ACP conversations, both with healthcare providers and loved ones. Patients largely feel comfortable discussing EOL wishes with their doctor suggesting a trustful relationship. However, patients are only somewhat happy with these ACP conversations. Our study highlights a need for enhanced ACP education to improve satisfaction and confidence in formal documentation. Physicians should continue to engage and individualize ACP discussions to increase EOL preparedness among Latino patients.
Collapse
|
8
|
Hughes I, Lavery J. Contemporary challenges for SCPDNs in the provision of end-of-life care. Br J Community Nurs 2024; 29:26-31. [PMID: 38147447 DOI: 10.12968/bjcn.2024.29.1.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
The advancement in the knowledge and skills required by the Specialist Community Practitioner District Nurse (SCPDN) is integral in supporting end-of-life care. An integrated and multi-disciplinary team approach is pivotal for high quality patient care delivery, which involves individuals and their significant others in decision-making at a sensitive time. Advanced care planning and the use of therapeutic communication by the SCPDN can help to support autonomy in individuals during uncertain times, enabling them to express their end-of-life wishes. The SCPDN, guided by the evidence base, must provide holistic care and manage palliation while ensuring the patient is at the centre of all decisions.
Collapse
Affiliation(s)
- Irene Hughes
- Lecturer, Nursing and Advanced Practice, Liverpool John Moores University
| | - Joanna Lavery
- Senior Lecturer, Nursing and Advanced Practice, Liverpool John Moores University
| |
Collapse
|
9
|
Sekimoto A, Miyake H, Nagai H, Yoshioka Y, Yuasa N. Predictors of 1-year mortality after gastrectomy for gastric cancer. World J Surg 2024; 48:138-150. [PMID: 38686784 DOI: 10.1002/wjs.12005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/15/2023] [Indexed: 05/02/2024]
Abstract
PURPOSE One-year mortality is important for referrals to specialist palliative care or advance care planning (ACP). This helps optimize comfort for those who cannot be cured or have a lower life expectancy. Few studies have investigated the risk factors for 1-year mortality after gastrectomy for gastric cancer (GC). METHODS A total of 1415 patients with gastric cancer (stages I-IV) who underwent gastrectomy between 2005 and 2020 were included. The patients were randomly assigned to the investigation group (n = 850) and validation group (n = 565) in a 3:2 ratio. In the investigation group, significant independent prognostic factors for predicting 1-year survival were identified. A scoring system for predicting 1-year mortality was developed which was validated in the validation group. RESULTS Multivariate analysis revealed that the following seven variables were significant independent factors for 1-year survival: age ≧78, preoperative comorbidity, total gastrectomy, postoperative complication (Clavien-Dindo classification CD ≧ 3a), stage III and IV, and R2 resection. While developing a 1-year mortality score (OMS), an age ≧78 was scored 2, preoperative comorbidity, total gastrectomy, and postoperative complication (CD ≧ 3a) were scored 1, and stage III, IV, and R2-resection were scored 2, 3, and 3, respectively. OMS 3 had a sensitivity of 91% and a specificity of 66% for predicting death within 1 year. In the validation group, OMS 5 had a sensitivity of 55% and a specificity of 93% for predicting death within 1 year. CONCLUSIONS OMS may provide important information and help surgeons select the timing of ACP in patients with GC.
Collapse
Affiliation(s)
- Akihiro Sekimoto
- Department of Gastrointestinal Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nakamura-ku, Nagoya, Japan
| | - Hideo Miyake
- Department of Gastrointestinal Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nakamura-ku, Nagoya, Japan
| | - Hidemasa Nagai
- Department of Gastrointestinal Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nakamura-ku, Nagoya, Japan
| | - Yuichiro Yoshioka
- Department of Gastrointestinal Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nakamura-ku, Nagoya, Japan
| | - Norihiro Yuasa
- Department of Gastrointestinal Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nakamura-ku, Nagoya, Japan
| |
Collapse
|
10
|
Wice M, Rudolph JL, Jiang L, Edmonson HM, Page JS, Wu WC, Defillo-Draiby J. Trends in Palliative Care Utilization in Deceased Veterans With Heart Failure. Palliat Med Rep 2023; 4:344-349. [PMID: 38155911 PMCID: PMC10754341 DOI: 10.1089/pmr.2023.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/30/2023] Open
Abstract
Background Specialist-level palliative care in the final days does not allow time to alleviate symptoms and suffering. This analysis examined the change in the time from initial specialty-level palliative care to death among Veterans with heart failure. Methods This retrospective cohort study examined Veterans with a diagnosis of heart failure (HF) who died between 2011 and 2021. We examined the decedents from each year as a separate cohort. The primary outcome was time from specialty-level palliative care (SPC) encounter to death in the year death occurred. Results Of the cohort (n = 232,079), 56.5% did not receive SPC. Specialist-level palliative care >90 days before death more than doubled from 10.1% (2011) to 26.2% (2021), and Specialist-level palliative care in the last day of life was cut from 2.5% to 0.9%. Conclusion For Veterans with HF, specialist-level palliative care moved earlier in the disease course and has a substantial growth opportunity.
Collapse
Affiliation(s)
- Mitchell Wice
- Center of Innovation in Long Term Services and Support, Providence VA Healthcare System, Providence, Rhode Island, USA
- Geriatrics and Extended Care, Providence VA Healthcare System, Providence, Rhode Island, USA
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - James L. Rudolph
- Center of Innovation in Long Term Services and Support, Providence VA Healthcare System, Providence, Rhode Island, USA
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Center for Gerontology and Health Services Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Lan Jiang
- Center of Innovation in Long Term Services and Support, Providence VA Healthcare System, Providence, Rhode Island, USA
| | - Hal M. Edmonson
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - John S. Page
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Wen Chih Wu
- Center of Innovation in Long Term Services and Support, Providence VA Healthcare System, Providence, Rhode Island, USA
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Julio Defillo-Draiby
- Center of Innovation in Long Term Services and Support, Providence VA Healthcare System, Providence, Rhode Island, USA
- Geriatrics and Extended Care, Providence VA Healthcare System, Providence, Rhode Island, USA
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
11
|
Kwon JE, Kim YH. Changes in the End-of-Life Process in Patients with Life-Limiting Diseases through the Intervention of the Pediatric Palliative Care Team. J Clin Med 2023; 12:6588. [PMID: 37892726 PMCID: PMC10607513 DOI: 10.3390/jcm12206588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Kyungpook National University Children's Hospital initiated pediatric palliative care (PPC) services in January 2019, focusing on children and adolescents with life-limiting conditions (LLC). A study examined changes in the end-of-life processes in patients with LLC before and after a PPC intervention. This study included 48 deceased patients under 18 years at the hospital, divided into two groups: January 2015 to December 2016 without PPC (25 patients, Period 1) and January 2019 to April 2022 with PPC (23 patients, Period 2). Analysis of medical records revealed the following: no age/sex differences; more active advanced care planning in Period 2 (15/23 vs. 7/25, p = 0.01); discussing withholding/withdrawing treatment increased in Period 2 (91.3% vs. 64.0%, p = 0.025); intubation and CPR were less frequent in Period 2 (intubation 2/23 vs. 19/25, p = 0.000; CPR 3/23 vs. 11/25, p = 0.018); Period 1 had more deaths in the ICU (18/25 vs. 10/23, p = 0.045); and 3 patients in Period 2 chose home deaths. A survey in Period 2 revealed high satisfaction with emotional support (91.7%), practical assistance (91.6%), and symptom management (83.3%). PPC facilitated discussions on advanced care planning and treatment choices, ensuring peaceful and prepared farewells for children with LLC and their families.
Collapse
Affiliation(s)
| | - Yeo Hyang Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Pediatric Palliative Care Center, Kyungpook National University Children’s Hospital, Daegu 41404, Republic of Korea;
| |
Collapse
|
12
|
Molitch-Hou E, Zhang H, Gala P, Tate A. Impact of the COVID-19 Public Health Crisis and a Structured COVID Unit on Physician Behaviors in Code Status Ordering. Am J Hosp Palliat Care 2023:10499091231204943. [PMID: 37786255 PMCID: PMC10985045 DOI: 10.1177/10499091231204943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Purpose: Code status orders are standard practice impacting end-of-life care for individuals. This study reviews the impact of a COVID unit on physician behaviors towards goal-concordant end-of-life care at an urban academic tertiary-care hospital. Methods: We conducted a retrospective cohort study of code status ordering on adult inpatients comparing the pre-pandemic period to patients who tested positive, negative and were not tested during the pandemic from January 1, 2019, to December 31, 2020. Results: We analyzed 59,471 unique patient encounters (n = 35,317 pre-pandemic and n = 24,154 during). 1,631 cases of COVID-19 were seen. The rate of code status orders among all inpatients increased from 22% pre-pandemic to 29% during the pandemic (P < .001). Code status orders increased for both patients who were COVID-negative (32% P < .001) and COVID-positive (65% P < .001). Being in a cohorted COVID unit increased code status ordering by an odds of 4.79 (P < .001). Compared to the pre-pandemic cohort, the COVID-positive cohort is less female (50% to 56% P < .001), more Black (66% to 61% P < .001), more Hispanic (6.5% to 5%) and less white (26% to 30% P < .001). Compared to Black patients, white patients had lower odds (.86) of code status ordering (P < .001). Other race/ethnicity categories were not significant. Conclusions: Code status ordering remains low. Compared to pre-pandemic rates, the frequency of orders placed significantly increased for all patients during the pandemic. The largest increase occurred in patients with COVID-19. This increase likely occurred due to protocols in the COVID unit and disease uncertainty.
Collapse
Affiliation(s)
- Ethan Molitch-Hou
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| | - Hui Zhang
- Center for Health and The Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Pooja Gala
- NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Alexandra Tate
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| |
Collapse
|
13
|
Jacobson E, Troost JP, Epler K, Lenhan B, Rodgers L, O'Callaghan T, Painter N, Barrett J. Change in Code Status Orders of Hospitalized Adults With COVID-19 Throughout the Pandemic: A Retrospective Cohort Study. J Palliat Med 2023; 26:1188-1197. [PMID: 37022771 PMCID: PMC10623069 DOI: 10.1089/jpm.2022.0578] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 04/07/2023] Open
Abstract
Aim: Our aim was to examine how code status orders for patients hospitalized with COVID-19 changed over time as the pandemic progressed and outcomes improved. Methods: This retrospective cohort study was performed at a single academic center in the United States. Adults admitted between March 1, 2020, and December 31, 2021, who tested positive for COVID-19, were included. The study period included four institutional hospitalization surges. Demographic and outcome data were collected and code status orders during admission were trended. Data were analyzed with multivariable analysis to identify predictors of code status. Results: A total of 3615 patients were included with full code (62.7%) being the most common final code status order followed by do-not-attempt-resuscitation (DNAR) (18.1%). Time of admission (per every six months) was an independent predictor of final full compared to DNAR/partial code status (p = 0.04). Limited resuscitation preference (DNAR or partial) decreased from over 20% in the first two surges to 10.8% and 15.6% of patients in the last two surges. Other independent predictors of final code status included body mass index (p < 0.05), Black versus White race (0.64, p = 0.01), time spent in the intensive care unit (4.28, p = <0.001), age (2.11, p = <0.001), and Charlson comorbidity index (1.05, p = <0.001). Conclusions: Over time, adults admitted to the hospital with COVID-19 were less likely to have a DNAR or partial code status order with persistent decrease occurring after March 2021. A trend toward decreased code status documentation as the pandemic progressed was observed.
Collapse
Affiliation(s)
- Emily Jacobson
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan P. Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Katharine Epler
- Department of Internal Medicine, University of California San Diego, San Diego, California, USA
| | - Blair Lenhan
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Lily Rodgers
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Thomas O'Callaghan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Natalia Painter
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie Barrett
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
14
|
Pelz S, Rho E, Wolfensberger F, Blum D. [Symptom Control in Nephrological Palliative Care]. Praxis (Bern 1994) 2023; 112:516-523. [PMID: 37855651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Nephrology may have quite a lot in common with with palliative care. Examples of this are the conservative therapy of a terminal chronic kidney disease or dialysis termination. Nevertheless, palliative co-care of patients with chronic kidney disease still happens rather rarely. On the one hand, this might be due to lacking experience regarding the benefits and opportunities of incorporating palliative care in nephrology care, on the other hand, palliative care is often misunderstood as pure "end-of-life" care. By highlighting the whole spectrum of palliative care, we aim to promote these two disciplines in order to integrate palliative care services into the nephrological treatment concept at an early stage.
Collapse
Affiliation(s)
- Stefan Pelz
- Kompetenzzentrum Palliative Care, Klinik für Radio-Onkologie, Universitätsspital Zürich
| | - Elena Rho
- Klinik für Nephrologie, Universitätsspital Zürich
| | - Fanny Wolfensberger
- Kompetenzzentrum Palliative Care, Klinik für Radio-Onkologie, Universitätsspital Zürich
| | - David Blum
- Kompetenzzentrum Palliative Care, Klinik für Radio-Onkologie, Universitätsspital Zürich
| |
Collapse
|
15
|
Tung HJ, Yeh MC. Use of Advance Directives in US Veterans and Non-Veterans: Findings from the Decedents of the Health and Retirement Study 1992-2014. Healthcare (Basel) 2023; 11:1824. [PMID: 37444658 DOI: 10.3390/healthcare11131824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Evidence shows that older patients with advance directives such as a living will, or durable power of attorney for healthcare, are more likely to receive care consistent with their preferences at the end of life. Less is known about the use of advance directives between veteran and non-veteran older Americans. Using data from the decedents of a longitudinal survey, we explore whether there is a difference in having an established advance directive between the veteran and non-veteran decedents. Data were taken from the Harmonized End of Life data sets, a linked collection of variables derived from the Health and Retirement Study (HRS) Exit Interview. Only male decedents were included in the current analysis (N = 4828). The dependent variable, having an established advance directive, was measured by asking the proxy, "whether the deceased respondent ever provided written instructions about the treatment or care he/she wanted to receive during the final days of his/her life" and "whether the deceased respondent had a Durable Power of Attorney for healthcare?" A "yes" to either of the two items was counted as having an advance directive. The independent variable, veteran status, was determined by asking participants, "Have you ever served in the active military of the United States?" at their first HRS core interview. Logistic regression was used to predict the likelihood of having an established advance directive. While there was no difference in having an advance directive between male veteran and non-veteran decedents during the earlier follow-up period (from 1992 to 2003), male veterans who died during the second half of the study period (from 2004 to 2014) were more likely to have an established advance directive than their non-veteran counterparts (OR = 1.24, p < 0.05). Other factors positively associated with having an established advance directive include dying at older ages, higher educational attainment, needing assistance in activities of daily living and being bedridden three months before death, while Black decedents and those who were married were less likely to have an advance directive in place. Our findings suggest male veterans were more likely to have an established advance directive, an indicator for better end-of-life care, than their non-veteran counterparts. This observed difference coincides with a time when the Veterans Health Administration (VHA) increased its investment in end-of-life care. More studies are needed to confirm if this higher utilization of advance directives and care planning among veterans can be attributed to the improved access and quality of end-of-life care in the VHA system.
Collapse
Affiliation(s)
- Ho-Jui Tung
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, P.O. Box 8015, Statesboro, GA 30460-8015, USA
| | - Ming-Chin Yeh
- Nutrition Program, Hunter College, City University of New York, New York, NY 10065, USA
| |
Collapse
|
16
|
Henderson KK, Oliver JP, Hemming P. Patient Religiosity and Desire for Chaplain Services in an Outpatient Primary Care Clinic. J Pastoral Care Counsel 2023; 77:81-91. [PMID: 36660791 DOI: 10.1177/15423050221147901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Outpatient chaplaincy is a new specialty in healthcare, with a relative paucity of research studies exploring the need for spiritual care interventions in ambulatory settings. Over the past 3 years, our interdisciplinary team at the Duke Outpatient Clinic has piloted the extension of professional spiritual care into this hospital-based resident teaching clinic offering primary care to underserved populations in Durham, NC. In this article, we report the results of a series of surveys that we conducted at the clinic to assess patients' perceptions of chaplain services, understanding of Chaplains' roles, and desire for chaplain services in specific hypothetical scenarios. As part of this survey, we also asked patients about their personal levels of extrinsic and intrinsic religiosity using the well-validated Duke University Religion Index. Our results indicate which chaplain interventions are most desired among this patient population in relation to patients' self-reported religiosity. We hypothesized that only our more religious patients would strongly desire chaplain support for the majority of scenarios presented. We were surprised to find that a majority of our patients-regardless of their own level of religiosity-express desire for support from an outpatient healthcare chaplain when they need a listening ear, are grieving a loss, or are seeking prayer.
Collapse
Affiliation(s)
- Katherine K Henderson
- Department of Chaplain Services and Education, Duke University Hospital, Durham, NC, USA
| | - John P Oliver
- Department of Chaplain Services and Education, Duke University Hospital, Durham, NC, USA
| | - Patrick Hemming
- Duke Outpatient Clinic, Division of General Internal Medicine, Duke University, Durham, NC, USA
| |
Collapse
|
17
|
Abstract
Evidence supports that older adults with cognitive impairment can reliably communicate their values and choices, even as cognition may decline. Shared decision-making, including the patient, family members, and healthcare providers, is critical to patient-centered care. The aim of this scoping review was to synthesize what is known about shared decision-making in persons living with dementia. A scoping review was completed in PubMed, CINAHL, and Web of Science. Keywords included content areas of dementia and shared decision-making. Inclusion criteria were as follows: description of shared or cooperative decision making, cognitively impaired patient population, adult patient, and original research. Review articles were excluded, as well as those for which the formal healthcare provider was the only team member involved in the decision-making (e.g., physician), and/or the patient sample was not cognitively impaired. Systematically extracted data were organized in a table, compared, and synthesized. The search yielded 263 non-duplicate articles that were screened by title and abstract. Ninety-three articles remained, and the full text was reviewed; 32 articles were eligible for this review. Studies were from across Europe (n = 23), North America (n = 7), and Australia (n = 2). The majority of the articles used a qualitative study design, and 10 used a quantitative study design. Categories of similar shared decision-making topics emerged, including health promotion, end-of-life, advanced care planning, and housing decisions. The majority of articles focused on shared decision-making regarding health promotion for the patient (n = 16). Findings illustrate that shared decision-making requires deliberate effort and is preferred among family members, healthcare providers, and patients with dementia. Future research should include more robust efficacy testing of decision-making tools, incorporation of evidence-based shared decisionmaking approaches based on cognitive status/diagnosis, and consideration of geographical/cultural differences in healthcare delivery systems.
Collapse
Affiliation(s)
| | | | - Dan Wilson
- Health Sciences Library, 2358University of Virginia, USA
| | - Laura Jepson
- School of Nursing, 2358University of Virginia, USA
| | - Soojung Ahn
- School of Nursing, Vanderbilt University, USA
| | | |
Collapse
|
18
|
Lezard R, Latham H. Advance planning for co-caring couples. Br J Community Nurs 2023; 28:198-206. [PMID: 36989202 DOI: 10.12968/bjcn.2023.28.4.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
This article explores joint advance planning for co-caring couples in the community, a group growing in number and need. A health crisis for one, exposes the vulnerability of the other. Lack of planning for this eventuality leaves health and social care struggling to provide an adequate safety net in a short timeframe. This inability to adequately support, can lead to harm to the couple. The authors conducted a formal reflective investigation to discover themes that impacted on their ability to meet the needs of such a couple in their care. The themes were: the need for advanced care planning in co-caring situations; capacity assessed through different lenses; using safeguarding systems appropriately to support questions of capacity; challenges when care is not accepted; and compassion fatigue. These themes were then used to develop an action plan to improve ways of working to reduce risk in these situations.
Collapse
Affiliation(s)
- Ruth Lezard
- Advanced Clinical Practitioners for Long-Term Conditions, Sirona Care and Health, Bristol, UK
| | | |
Collapse
|
19
|
Haines KL, Nguyen BP, Antonescu I, Freeman J, Cox C, Krishnamoorthy V, Kawano B, Agarwal S. Insurance Status and Ethnicity Impact Health Disparities in Rates of Advance Directives in Trauma. Am Surg 2023; 89:88-97. [PMID: 33877932 DOI: 10.1177/00031348211011115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Advanced directives (ADs) provide a framework from which families may understand patient's wishes. However, end-of-life planning may not be prioritized by everyone. This analysis aimed to determine what populations have ADs and how they affected trauma outcomes. METHODS Adult trauma patients recorded in the American College of Surgeons Trauma Quality Improvement Program (TQIP) from 2013-2015 were included. The primary outcome was presence of an AD. Secondary outcomes included mortality, length of stay (LOS), mechanical ventilation, ICU admission/LOS, withdrawal of life-sustaining measures, and discharge disposition. Multivariable logistic regression models were developed for outcomes. RESULTS 44 705 patients were included in the analyses. Advanced directives were present in 1.79% of patients. The average age for patients with ADs was 77.8 ± 10.7. African American (odds ratio (OR) .53, confidence intervals [CI] .36-.79) and Asian (OR .22, CI .05-.91) patients were less likely to have ADs. Conversely, Medicaid (OR 1.70, CI 1.06-2.73) and Medicare (OR 1.65, CI 1.25-2.17) patients were more likely to have ADs as compared to those with private insurance. The presence of ADs was associated with increased hospital mortality (OR 2.84, CI 2.19-3.70), increased transition to comfort measures (OR 2.87, CI 2.08-3.95), and shorter LOS (CO -.74, CI -1.26-.22). Patients with ADs had an increased odds of hospice care (OR 4.24, CI 3.18-5.64). CONCLUSION Advanced directives at admission are uncommon, particularly among African Americans and Asians. The presence of ADs was associated with increased mortality, use of mechanical ventilation, admission to the ICU, withdrawal of life-sustaining measures, and hospice. Future research should target expansion of ADs among minority populations to alleviate disparities in end-of-life treatment.
Collapse
Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Benjamin P Nguyen
- Department of Surgery, 20868Kaweah Delta Health Care District, Medical Center, Visalia, CA, USA
| | - Ioana Antonescu
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Jennifer Freeman
- Department of Surgery, 3402TCU and UNTHSC School of Medicine, Fort Worth, TX, USA
| | - Christopher Cox
- Division of Pulmonary Critical Care, Department of Medicine, 22957Duke University Medical Center, Durham, NC, USA
| | - Vijay Krishnamoorthy
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Brad Kawano
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
20
|
Muacevic A, Adler JR, Sano C, Ohta R. Deciding a Treatment Plan for an Older Patient With Severe Idiopathic Pulmonary Fibrosis: A Case Report. Cureus 2023; 15:e34154. [PMID: 36843784 PMCID: PMC9949734 DOI: 10.7759/cureus.34154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 01/25/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a group of diseases in which the main loci of lesions, mainly inflammatory and fibrotic, are within the interstitium of the alveolar and bronchiolar regions. Steroid therapy is the standard treatment for acute exacerbation of IPF, whereas antifibrotic agents are the standard treatment for chronic IPF. However, the vulnerability of older patients indicates that these treatments may be discontinued. Here, we report the case of an 86-year-old woman who had a dry cough for over a year and was subsequently diagnosed with IPF based on imaging studies. After using steroid pulses to treat acute exacerbations, the patient was transitioned to the chronic management phase, and time was allowed to plan the patient's advanced care with her family. The use of high-dose steroids in older patients with frailty is contraindicated. This case emphasizes the importance of considering initial intensive treatment for IPF in older patients for better palliative care.
Collapse
|
21
|
King O, Collman E, Evans A, Richards J, Hughes E, Acquah L, Parsons H, Morrison J. Improving the visibility and communication of treatment escalation plans in Somerset NHS foundation trust. Int J Risk Saf Med 2022; 33:S69-S72. [PMID: 35871371 PMCID: PMC9844060 DOI: 10.3233/jrs-227027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Advance care treatment escalation plans (TEPs) are often lost between healthcare settings, leading to duplication of work and loss of patient autonomy. OBJECTIVE This quality improvement project reviewed the usage of TEP forms and aimed to improve completeness of documentation and visibility between admissions. METHODS Over four months we monitored TEP form documentation using a standardised data extraction form. This examined section completion, seniority of documenting clinician and transfer of forms to our hospital electronic patient record (EPRO). We added reminders to computer monitors on wards to improve EPRO upload. RESULTS Initial data demonstrated that 95% of patients (n = 230) had a TEP, with 99% of TEPs recording resuscitation status. However, other sections were not well documented (patient capacity 57% completion and personal priorities 45% completion, respectively). Only 11.9% of TEPs documented consultant involvement. Furthermore, only 44% of TEPs with a do not attempt resuscitation (DNACPR) decision were uploaded. Following this, we added reminders to computer monitors explaining how to upload TEP decisions to EPRO, which increased EPRO uploads to 74%. CONCLUSION Communication of TEPs needs improving across healthcare settings. This project showed that the use of a physical reminder can greatly improve communication of treatment escalation decisions. Furthermore, this intervention has inspired future projects aiming at making communication more sustainable through the use of discharge summaries.
Collapse
Affiliation(s)
- Oliver King
- Salisbury NHS Foundation Trust, Salisbury, UK, Address for correspondence: Dr Oliver King, Salisbury NHS Foundation Trust, Salisbury, UK. E-mail:
| | | | - Alice Evans
- Wyong Hospital, Hamlyn Terrace, NSW, Australia
| | | | - Elin Hughes
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | | | | | | |
Collapse
|
22
|
Kaminski A. Let's Talk About Dying: An Educational Pilot Program to Improve Providers' Competency in End-Of-Life Discussions. Am J Hosp Palliat Care 2022:10499091221127994. [PMID: 36154272 DOI: 10.1177/10499091221127994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Advance care planning (ACP) conversations occur infrequently due to lack of provider confidence-level, education, and workplace support for gaining skills in initiating goals of care and end-of-life discussions. METHODS A 3-month quality improvement project was carried out between October 2021 to January 2022 using a short, accessible virtual presentation on provider initiation of goals of care conversations. A pre-test/post-test design was implemented using the End-of-Life Professional Caregiver Survey and frequency of ACP documentation of surgical intensive care unit providers. RESULTS Over the study period, 17 providers reviewed the virtual presentation. The End-of-Life Professional Caregiver Survey sum score increased significantly from pre-to post-test (P < .001) reflecting increased provider confidence in initiating goals of care conversations. There was also significant increase in ACP documentation from pre-intervention to the third and final monthly cycle. DISCUSSION Structured education increased ICU providers confidence in having goals of care conversations and improved the frequency of ACP documentation.
Collapse
Affiliation(s)
- Ashley Kaminski
- School of Nursing, 7712University of Connecticut, Storrs, CT, USA
| |
Collapse
|
23
|
Booij JA, van de Haterd JC, Huttjes SN, van Deijck RH, Koopmans RT. Short- and Long-Term Mortality and Mortality Risk Factors among Nursing Home Patients after COVID-19 Infection. J Am Med Dir Assoc 2022; 23:1274-1278. [PMID: 35809633 PMCID: PMC9212799 DOI: 10.1016/j.jamda.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/15/2022] [Accepted: 06/11/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To assess short- and long-term mortality and risk factors in nursing home patients with COVID-19 infection. DESIGN Retrospective 2-center cohort study. SETTING AND PARTICIPANTS Dutch nursing home patients with clinically suspected COVID-19 infection confirmed by reverse transcription-polymerase chain reaction testing. METHODS Data were gathered between March 2020 and November 2020 using electronic medical records, including demographic characteristics, comorbidities, medical management, and symptoms on the first day of suspected COVID-19 infection. Mortality at 30 days and 6 months was assessed using multivariate logistic regression models and Kaplan-Meier analysis. At 6 months, a subgroup analysis was performed to estimate the mortality risk between COVID-negative patients and patients who survived COVID-19. Risk factors for mortality were assessed through multivariate logistic regression models. RESULTS A total of 321 patients with suspected COVID-19 infection were included, of whom 134 tested positive. Sixty-two patients in the positive group died at 30 days, with a short-term mortality rate of 2.9 (95% CI 1.7-5.3). Risk factors were fatigue (OR 2.6, 95% CI 1.3-6.2) and deoxygenation (OR 2.9, 95% CI 1.3-7.6). At 6 months, the mortality risk was 2.1 (95% CI 1.3-3.7). Risk factors for 6-month mortality were shortness of breath (OR 2.7, 95% CI 1.3-7.0), deoxygenation (OR 2.5, 95% CI 1.1-6.5) and medical management (OR 4.5, 95% CI 1.7-25.8). However, among patients who survived COVID-19 infection, the long-term mortality risk was not sustained (OR 1.0, 95% CI 0.4-2.7). CONCLUSIONS AND IMPLICATIONS Overall, COVID-19 infection increases short- and long-term mortality risk among nursing home patients. However, this study shows that surviving COVID-19 infection does not lead to increased mortality in the long term within this population. Therefore, advanced care planning should focus on quality of life among nursing home patients after COVID-19 infection.
Collapse
Affiliation(s)
- Johannes A. Booij
- De Zorggroep, Region Venlo (EBC), Venlo, the Netherlands,Address correspondence to Johannes A. Booij, MD, De Zorggroep, region Venlo (EBC), 5900 AR Venlo, the Netherlands
| | - Julie C.H.Q. van de Haterd
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - Raymond T.C.M. Koopmans
- Department of Primary and Community Care: Center for Family Medicine, Geriatric Care, and Public Health, Radboud University Medical Center, Nijmegen, the Netherlands,De Waalboog, Joachim en Anna, Center for Specialized Geriatric Care, Nijmegen, the Netherlands
| |
Collapse
|
24
|
Beetham B, Fasola C, Howard F. Preferred Place of Death Discussions: Are They Informing and Empowering Patients and their Family Caregivers? Omega (Westport) 2022:302228221115587. [PMID: 35861425 DOI: 10.1177/00302228221115587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Factors influencing preferred place of death (PPoD) are variable between individuals. However, there is little understanding of how these preferences are formed and how consistent they are in the final months of life. In particular, the expectation and responsibility of family caregivers to provide unpaid caregiving support to their dying loved one in the home is often overlooked. There is a need for clinicians to take an individualised approach to PPoD conversations that is inclusive of the needs of both the patient and the family caregiver. More Good Deaths - A Change Programme responds to this gap in care by advancing the skills of clinicians having PPoD conversations with patients and their family caregivers. This paper describes the programme, providing insight into its benefits to advanced care planning and communication, as well as to our newest service - Cottage Hospice.
Collapse
Affiliation(s)
- Bryony Beetham
- Hospice in the Weald, Tunbridge Wells, UK
- Cicely Saunders Institute of Palliative Care and Rehabilitation, King's College London, London, UK
| | | | - Faith Howard
- Hospice in the Weald, Tunbridge Wells, UK
- School of Health Sciences, University of Surrey, Guildford, UK
| |
Collapse
|
25
|
Attivissimo LA, Friedman MI, Williams M, Rimar A, Nouryan C, Patel V, Kozikowski A, Zhang M, Pekmezaris R. Goals of care conversation education program: An intervention to help health care professionals break bad news to patients with advanced illness. Gerontol Geriatr Educ 2022; 43:407-417. [PMID: 33627035 DOI: 10.1080/02701960.2021.1893171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The purpose of the study was to measure the effectiveness of communication skills intervention results for healthcare professionals. A multi-site pretest-posttest survey assessing the efficacy of a Goals of Care conversation education program. The program aimed to educate healthcare professionals concerning having Goals of Care conversations with patients and families. This research was implemented in a large healthcare organization in the Northeastern United States. This study found significant differences between pretests and posttests across professions, palliative care specialty, degree types, and years of experience in the participant's self-reported ability and comfort levels in having conversations about Goals of Care with patients and families. Providing education on Goals of Care was effective in improving the knowledge and comfort of health care professionals with conducting advanced illness conversations.
Collapse
Affiliation(s)
| | - M Isabel Friedman
- Department of Clinical Transformation, Northwell, Lake Success, New York, USA
| | - Myia Williams
- Department of Medicine, Northwell Health, Manhasset, New York, USA
| | - Alexander Rimar
- Department of Medicine, Long Island Jewish Medical Center, Queens, New York, USA
| | - Christian Nouryan
- Department of Medicine, Northwell Health, Manhasset, New York, USA
- Department of Medicine, The Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Vidhi Patel
- Department of Medicine, Northwell Health, Manhasset, New York, USA
| | - Andrzej Kozikowski
- Department of Medicine, Northwell Health, Manhasset, New York, USA
- Department of Medicine, The Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Meng Zhang
- Department of Medicine, The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Renee Pekmezaris
- Department of Medicine, Northwell Health, Manhasset, New York, USA
- Department of Medicine, The Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| |
Collapse
|
26
|
Trillig AU, Ljuslin M, Mercier J, Harrisson M, Vayne-Bossert P. "I Am Not the Same Man…": A Case Report of Management of Post-COVID Refractory Dyspnea. J Palliat Med 2022; 25:1606-1609. [PMID: 35271384 DOI: 10.1089/jpm.2021.0605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The SARS-CoV-2 pandemic brings with it a significant number of post-COVID symptoms, including persistent dyspnea and neuropsychological sequelae. The palliative approach in the treatment of these refractory symptoms is effective and widely applicable in different settings. We report the case of a patient with refractory dyspnea admitted to a specialized palliative care unit with a very poor prognosis. The application of different tools of the palliative approach proved to be effective: a detailed advanced care planning and open communication, the respect for the patient's wishes and optimal use of his resources-the salutogenesis- an adaptation of the rhythm of care to that of the patient. The patient was then discharged for rehabilitation, and finally returned home.
Collapse
Affiliation(s)
| | - Michael Ljuslin
- Palliative Care Unit, University Hospital Geneva, Geneva, Switzerland
| | - Jérôme Mercier
- Physiotherapy Team, Palliative Care Unit, University of Geneva, University Hospital Geneva, Geneva, Switzerland
| | - Maya Harrisson
- Physiotherapy Team, Palliative Care Unit, University of Geneva, University Hospital Geneva, Geneva, Switzerland
| | | |
Collapse
|
27
|
Law AC, Stevens JP, Choi E, Shen C, Mehta AB, Yeh RW, Walkey AJ. Days out of Institution after Tracheostomy and Gastrostomy Placement in Critically Ill Older Adults. Ann Am Thorac Soc 2022; 19:424-32. [PMID: 34388080 DOI: 10.1513/AnnalsATS.202106-649OC] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Rationale: Tracheostomy and gastrostomy tubes are frequently placed during critical illness for long-term life support, with most placed in older adults. Large knowledge gaps exist regarding outcomes expressed as most important to patients. Objectives: To determine the number of days alive and out of institution (DAOIs) and mortality after tracheostomy and gastrostomy placement during critical illness and to evaluate associations between health states before critical illness and outcomes. Methods: In this retrospective cohort study of Medicare beneficiaries admitted to an intensive care unit (ICU) who received a tracheostomy, gastrostomy, or both, we determined the number of DAOIs after procedure date; 90-day, 6-month, and 1-year mortality; hospital discharge destination; and hospital length of stay. We used claims from the year before admission to define eight mutually exclusive pre-ICU health states (permutations of one or more of cancer, chronic organ failure, frail, and robust) and assessed their association with DAOIs in 90 days and 1-year mortality. Results: Among 3,365 patients who received a tracheostomy, 6,709 patients who received a gastrostomy tube, and 3,540 patients who received both procedures, the median number of DAOIs in the first 90 days after placement was 3 (interquartile range, 0-46), 12 (0-61), and 0 (0-37), respectively. Over half died within 180 days. One-year mortality was 62%, 60%, and 64%, respectively. When compared with the robust state, all other pre-ICU health states were associated with loss of DAOIs and increased 1-year mortality; however, between the seven non-robust pre-ICU health states, there were no differences in outcomes. Conclusions: Medicare beneficiaries with prior comorbidity who received tracheostomy, gastrostomy tube, or both during critical illness spent few DAOIs and had high short- and long-term mortality.
Collapse
|
28
|
Epler K, Lenhan B, O'Callaghan T, Painter N, Troost J, Barrett J, Jacobson E. If Your Heart Were to Stop: Characterization and Comparison of Code Status Orders in Adult Patients Admitted with COVID-19. J Palliat Med 2021; 25:888-896. [PMID: 34967678 DOI: 10.1089/jpm.2021.0486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Aim: Our aim is to characterize code status documentation for patients hospitalized with novel coronavirus 2019 (COVID-19) during the first peak of the pandemic, when prognosis, resource availability, and provider safety were uncertain. Methods: This retrospective cohort study was performed at a single tertiary academic medical center. Adult patients admitted between March 1, 2020 and October 31, 2020 who tested positive for COVID-19 were included. Demographic and hospital outcome data were collected. Code status orders during this admission and prior admissions were trended. Data were analyzed with multivariable analysis to identify predictors of code status choice. Results: A total of 720 patients were included. The majority (70%) were full code and 12% were in do-not-attempt resuscitation (DNAR) status on admission; by discharge, 20% were DNAR. Age (p < 0.001), time in the intensive care unit (ICU) (p < 0.001), and having Medicaid (p = 0.04) compared to private insurance were predictors of DNAR. Fourteen percent had no code status order. Older age (p < 0.001), time in the ICU (p = 0.01), and admission to a teaching service (p < 0.001) were associated with having an order. Of patients with a prior admission (n = 227), 33.5% previously had no code status order and 44.5% had a different code status for their COVID-19 admission. Of those with a change, most transitioned to less aggressive resuscitation preferences. Conclusions: Most patients hospitalized with COVID-19 in our study elected to be full code. Almost half of patients with prepandemic admissions had a different code status during their COVID-19 admission, with a trend toward less aggressive resuscitation preference.
Collapse
Affiliation(s)
- Katharine Epler
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Blair Lenhan
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Thomas O'Callaghan
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Natalia Painter
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jonathan Troost
- Michigan Institute for Clinical and Health Research, Ann Arbor, Michigan, USA
| | - Julie Barrett
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Emily Jacobson
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| |
Collapse
|
29
|
Lee HTS, Yang CL, Chen TR, Leu SV, Hu WY. "We Want to Sign It, But We Can't Do It": Results From a Qualitative Pilot Study of Experiences Related to Advance Directives Among Families of Older Residents in a Long-term Care Facility. J Hosp Palliat Nurs 2021; 23:551-556. [PMID: 34282074 PMCID: PMC8560144 DOI: 10.1097/njh.0000000000000793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study aimed to clarify the experiences of family members of older adult residents regarding the signing of an advance directive in the context of a Chinese culture. Twenty family members of older residents in a long-term care facility participated in face-to-face interviews, and the researchers conducted a thematic analysis of observation field notes and interview transcripts. A content analysis of the interviews revealed 4 themes concerning the refusal to sign advance directives: resident decision, group decision, not entitled to decide, and random decision. Health providers may serve as mediators and pass on the residents' views regarding their end-of-life care to their families after holding discussions with residents and their families separately to ensure that an agreeable decision regarding the modes and objectives of EOL care is reached and that such a decision respects the right of the patient to choose.
Collapse
|
30
|
Deschasse G, Bloch F, Drumez E, Charpentier A, Visade F, Delecluse C, Loggia G, Lescure P, Attier-Żmudka J, Bloch J, Gaxatte C, Van Den Berghe W, Puisieux F, Beuscart JB. Development of a predictive score for mortality at 3- and 12-month after discharge from an acute geriatric unit as a trigger for advanced care planning. J Gerontol A Biol Sci Med Sci 2021; 77:1665-1672. [PMID: 34375411 DOI: 10.1093/gerona/glab217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is a need for a mortality score that can be used to trigger advanced care planning among older patients discharged from acute geriatric units (AGUs). OBJECTIVE To develop a prognostic score for 3- and 12-month mortality after discharge from an AGU, based on a comprehensive geriatric assessment, in-hospital events, and the exclusion of patients already receiving palliative care. METHODS DAMAGE is a French multicentre, prospective, cohort study. The broad inclusion criteria ensured that the cohort is representative of patients treated in an AGU. The DAMAGE participants underwent a comprehensive geriatric assessment, a daily clinical check-up, and follow-up visits 3 and 12 months after discharge. Multivariable logistic regression models were used to develop a prognostic score for the derivation and validation subsets. RESULTS 3509 patients were assessed and 3112 were included. The patient population was very older and frail or dependant, with a high proportion of deaths at 3 months (n=455, 14.8%) and at 12 months (n=1014, 33%). The score predicted an individual risk of mortality ranging from 1% to 80% at 3 months and between 5% and 93% at 12 months, with an area under the receiving operator characteristic curve in the validation cohort of 0.728 at 3 months and 0.733 at 12 months. CONCLUSIONS Our score predicted a broad range of risks of death after discharge from the AGU. Having this information at the time of hospital discharge might trigger a discussion on advanced care planning and end-of-life care with very old, frail patients.
Collapse
Affiliation(s)
- Guillaume Deschasse
- CHU Amiens-Picardie, Department of Geriatrics, Amiens, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | - Frédéric Bloch
- CHU Amiens-Picardie, Department of Geriatrics, Amiens, France
| | - Elodie Drumez
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,CHU Lille, Department of Biostatistics, Lille, France
| | | | - Fabien Visade
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,Lille Catholic Hospitals, Geriatrics Department, Lille, France
| | | | - Gilles Loggia
- Normandie Univ, UNICAEN, INSERM, COMETE, Caen, France.,Department of Geriatrics, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Pascale Lescure
- Department of Geriatrics, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Jadwiga Attier-Żmudka
- Geriatric department, General Hospital of Saint-Quentin, Saint-Quentin, France.,CHIMERE EA 7516 team research, Jules Verne University, Amiens, France
| | | | | | | | | | - Jean-Baptiste Beuscart
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,CHU Lille, Department of Geriatrics, Lille, France
| |
Collapse
|
31
|
Kurpershoek E, Hillen MA, Medendorp NM, de Bie RMA, de Visser M, Dijk JM. Advanced Care Planning in Parkinson's Disease: In-depth Interviews With Patients on Experiences and Needs. Front Neurol 2021; 12:683094. [PMID: 34393972 PMCID: PMC8355553 DOI: 10.3389/fneur.2021.683094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/28/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction: Advance care planning (ACP) is an iterative process of discussing the needs, wishes, and preferences of patients regarding disease-specific and end-of-life issues. There is ample evidence that ACP improves the quality of life and promotes the autonomy of patients with cancer and motor neuron disease who have a high disease burden and shortened life expectancy. In Parkinson's disease (PD) though, knowledge about the experiences and preferences of patients regarding ACP is scarce, despite the major disease burden associated with PD. Aim: This study aims to explore the experiences, needs, and preferences of PD patients regarding the content and timing of ACP. Methods: In-depth interviews were conducted with a purposively selected sample of patients diagnosed with PD. Using a semi-structured topic list, the participants were asked about their prospects for a future living with PD and with whom they wanted to discuss this. Qualitative analysis was performed in parallel with data collection using a data-driven constant comparative approach. The transcribed interviews were coded and analyzed by two researchers using MAXQDA software. Results: Of all 20 patients (13 males; age 47–82; disease duration 1–27 years), most expressed a wish to talk about ACP with a healthcare provider, enabling them to anticipate the uncertain future. The majority of patients preferred their healthcare provider to initiate the discussion on ACP, preferably at an early stage of the disease. Nearly all patients expressed the wish to receive more information regarding the long-term impact of PD, although, the preferred timing varied between patients. They also perceived that their neurologist was primarily focused on medication and had little time to address their need for a more holistic approach toward living with PD. Conclusion: Our results suggest that PD patients are in need of discussing ACP with their healthcare provider (HCP), even in the early stages of the disease. In addition, PD patients perceive a lack of information on their disease course and miss guidance on available supportive care. We recommend HCPs to inquire the information requirements and preferences of patients regarding ACP regularly, starting soon after diagnosis.
Collapse
Affiliation(s)
- Elisabeth Kurpershoek
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Medical Psychology, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Niki M Medendorp
- Department of Medical Psychology, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Rob M A de Bie
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marianne de Visser
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Joke M Dijk
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
32
|
Nicholson B. Advanced care planning: The concept over time. Nurs Forum 2021; 56:1024-1028. [PMID: 34263448 DOI: 10.1111/nuf.12631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/22/2021] [Accepted: 06/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The process of advanced care planning (ACP) assists patients to clarify goals for the end of life. DESIGN The concept analysis used the Walker and Avant approach to analyze the concept of ACP. DATA SOURCES Dictionary definitions, historical documents, position statements and database searches were performed in PubMed to yield 187 articles which were reviewed for use of the concept. Additional sources were reviewed for relevance of the concept over time. RESULTS The historical progression of the concept of ACP in the literature has progressed from a legal concept to a prominent concept in the medical literature. CONCLUSION This analysis aims to improve clarity of the concept of ACP. The article offers provides details of necessary components of these important discussions to improve nurse's awareness of the ACP process. Conceptual understanding will help nurses be better equipped to disseminate information regarding ACP with patients and families.
Collapse
Affiliation(s)
- Bridget Nicholson
- Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| |
Collapse
|
33
|
Heckman GA, Boscart V, Quail P, Keller H, Ramsey C, Vucea V, King S, Bains I, Choi N, Garland A. Applying the Knowledge-to-Action Framework to Engage Stakeholders and Solve Shared Challenges with Person-Centered Advance Care Planning in Long-Term Care Homes. Can J Aging 2021;:1-11. [PMID: 33583447 DOI: 10.1017/S0714980820000410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
As they near the end of life, long term care (LTC) residents often experience unmet needs and unnecessary hospital transfers, a reflection of suboptimal advance care planning (ACP). We applied the knowledge-to-action framework to identify shared barriers and solutions to ultimately improve the process of ACP and improve end-of-life care for LTC residents. We held a 1-day workshop for LTC residents, families, directors/administrators, ethicists, and clinicians from Manitoba, Alberta, and Ontario. The workshop aimed to identify: (1) shared understandings of ACP, (2) barriers to respecting resident wishes, and (3) solutions to better respect resident wishes. Plenary and group sessions were recorded and thematic analysis was performed. We identified four themes: (1) differing provincial frameworks, (2) shared challenges, (3) knowledge products, and 4) ongoing ACP. Theme 2 had four subthemes: (i) lacking clarity on substitute decision maker (SDM) identity, (ii) lacking clarity on the SDM role, (iii) failing to share sufficient information when residents formulate care wishes, and (iv) failing to communicate during a health crisis. These results have informed the development of a standardized ACP intervention currently being evaluated in a randomized trial in three Canadian provinces.
Collapse
|
34
|
Gul S, Freund M, Sanson-Fisher RW, Clapham M, Webster PJ. Prevalence and predictors of mortality for older adults referred to hospital avoidance program. Geriatr Gerontol Int 2021; 21:321-326. [PMID: 33533161 DOI: 10.1111/ggi.14133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/02/2021] [Accepted: 01/06/2021] [Indexed: 11/28/2022]
Abstract
AIM Following discharge from a hospital avoidance program, to examine the prevalence of patient mortality, demographic characteristics associated with risk of mortality up to 33 months, patient demographic and health characteristics associated with mortality within 1 year. METHODS A retrospective data linkage study of older adults with mean age of 80.5 years discharged from a hospital avoidance program between January 2017 and January 2018. The prevalence of death at 3, 6, 12, 18 and 33 months was calculated. Patient demographic and health characteristics associated with participant mortality within 12 (n = 195) and 33 (n = 185) months of discharge was examined using Cox multivariable regression for patients with complete health characteristic data. RESULTS The mortality prevalence was 17% at 6 months and cumulative prevalence at 1 year, 18 months and 33 months post-discharge were 24%, 29% and 36% respectively. Characteristics associated with mortality within 12 months of discharge were lower cognition, increased burden of comorbidity, decreased physical function, weight <55 kg and male sex. The same variables were associated with death up to 33 months as well as age, interaction between household arrangement and time, and albumin. CONCLUSIONS The establishment of potential risk indicators allows greater specificity for identifying older people at risk of dying in the next 12 months and an opportunity to discuss their advanced care planning. Geriatr Gerontol Int 2021; ••: ••-••.
Collapse
Affiliation(s)
- Shahzad Gul
- Geriatrics Department, John Hunter Hospital, Local Health Distract, New Lambton, New South Wales, Australia
| | - Megan Freund
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.,Priority Research Centre for Health Behaviour, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Robert W Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.,Priority Research Centre for Health Behaviour, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Matthew Clapham
- Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Penelope J Webster
- Geriatrics Department, John Hunter Hospital, Local Health Distract, New Lambton, New South Wales, Australia.,Community Acute Post-Acute Care, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| |
Collapse
|
35
|
Liao CT, Chang WT, Yu WL, Toh HS. Management of acute cardiovascular events in patients with COVID-19. Rev Cardiovasc Med 2021; 21:577-581. [PMID: 33388002 DOI: 10.31083/j.rcm.2020.04.140] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 11/06/2022] Open
Abstract
The pandemic of coronavirus disease 2019 (COVID-19) caused by the newly discovered virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), had been noticed to have high morbidity and mortality. Apart from pneumonia, COVID-19 can also cause damage to the cardiovascular system, and co-occurring with cardiovascular injury leads to a poorer prognosis. Besides, amid the pandemic of COVID-19, the management of critical cardiovascular events needs to further account for the highly infectious coronavirus, prompt and optimal treatments, clinician's safety, and healthcare provider's capacity. This review article aims to provide more comprehensive and appropriate guidance for the management of critical cardiovascular disease, including ST-segment elevation myocardial infarction (STEMI), non-STEMI acute coronary syndrome, cardiogenic shock, acute heart failure, cardiopulmonary resuscitation, and advanced care planning, during the COVID-19 epidemic.
Collapse
Affiliation(s)
- Chia-Te Liao
- Department of Cardiology, Chi Mei Medical Center, 71004, Tainan, Taiwan.,Department of Public Health, College of Medicine, National Cheng Kung University, 70101, Tainan, Taiwan.,Department of Electrical Engineer, Southern Taiwan University of Science and Technology, 71005, Tainan, Taiwan
| | - Wei-Ting Chang
- Department of Cardiology, Chi Mei Medical Center, 71004, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, 70101, Tainan, Taiwan.,Department of Biotechnology, Southern Taiwan University of Science and Technology, 71005, Tainan, Taiwan
| | - Wen-Liang Yu
- Department of Intensive Care Medicine, Chi Mei Medical Center, 71004, Tainan, Taiwan.,Department of Medicine, School of Medicine, College of Medicine, Taipei Medical University, 110, Taipei, Taiwan
| | - Han Siong Toh
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, 70101, Tainan, Taiwan.,Department of Intensive Care Medicine, Chi Mei Medical Center, 71004, Tainan, Taiwan
| |
Collapse
|
36
|
Carney MT, Williams M, Zhang M, Kozikowski A, Dolgin J, Kahn A, Walerstein S, Kessler M, Pekmezaris R. Impact of a community health conversation upon advance care planning attitudes and preparation intentions. Gerontol Geriatr Educ 2021; 42:82-95. [PMID: 32223366 DOI: 10.1080/02701960.2020.1739670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background: Advance care planning conversations and preparations do not occur as frequently as they should. Framing advance care planning as a health behavior and an opportunity for community engagement can help improve community-dwellers' intentions to have discussions and preparations regarding facing serious illness, death and dying.Methods: A multi-setting confidential pre/post paper survey assessing advance care planning discussions and preparation intentions was given to community-dwelling citizens residing in the New York metropolitan area. Survey items were adapted from a previous end of life survey to include questions on chronic illnesses, important conversations, comfort levels and concerns about end of life. The intervention was a 1-hour presentation on advance care planning (importance, laws, effective communication and audience questions)Results: Our study found significant interest in discussing advanced care planning across age groups. There were significant changes for participant intentions regarding: having conversations with loved ones, a health care proxy or similar document and none; as well as differences in participant intentions for discussions with caregiver, family, friends, primary physician and no-one.Conclusion: Educating individuals on the importance of advance care planning may be effective in changing community dwellers' intentions to start the conversation and put advanced care planning measures in place.Abbreviations: ACP: Advance Care Planning; CHAT: Conversations Health and Treatments; EoL: End of Life; HCP: Health Care Proxy; MOLST: Medical Orders for Life-Sustaining Treatments; PCP: Primary Care Physician.
Collapse
Affiliation(s)
- Maria T Carney
- Division of Geriatric and Palliative Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Myia Williams
- Department of Medicine, Northwell Health, Manhasset, New York, USA
| | - Meng Zhang
- Biostatistics Unit, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York, USA
| | | | - Janet Dolgin
- Maurice A. Deane School of Law, Hofstra University, Hempstead, New York, USA
| | - Adam Kahn
- Maurice A. Deane School of Law, Hofstra University, Hempstead, New York, USA
| | - Steve Walerstein
- Department of Medicine, Northwell Health, Manhasset, New York, USA
| | - Melissa Kessler
- Maurice A. Deane School of Law, Hofstra University, Hempstead, New York, USA
| | - Renee Pekmezaris
- Department of Medicine, Northwell Health, Manhasset, New York, USA
| |
Collapse
|
37
|
Abstract
AIM/PURPOSE This integrative review addresses whether the presence and timing of advanced care planning (ACP) with or without a palliative care (PC) consultation affect place of death and use of high-intensity medical care at end-of-life (EOL) in adolescent and young adult and adult cancer patients receiving hematopoietic stem cell transplant (HSCT) therapy. METHODS AND RESULTS A literature search was completed in the Scopus and PubMed databases. The search was not restricted by date but was restricted to English language. A total of 1,616 articles were found, and after exclusion of duplicates and irrelevance, 79 articles were available to review. After reviewing inclusion and exclusion criteria, 9 articles related to ACP with HSCT were found, and 4 were eliminated after further review, resulting in 5 viable articles for review related to EOL outcomes. EOL outcomes reviewed were place of death and high-intensity medical care. Factors noted to influence these measures included the presence or absence of ACP, the timing of ACP, and PC consultation. Overall survival also emerged as an EOL outcome affected by ACP. CONCLUSION Although there have been many barriers identified to ACP discussions in the HSCT population, the findings from the integrative literature review support the use of early ACP with patients who have hematologic malignancies undergoing HSCT to address patient EOL goals and reduce healthcare utilization at the EOL. The data also suggest that identification of patients who would most benefit from early engagement in ACP may positively impact outcomes.
Collapse
Affiliation(s)
- Alexandra Cooper
- 4002The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joyce E Dains
- 4002The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
38
|
Schultz KL, Brasel KJ, Zonies DH, Cook MR. Effective Palliative Care in the Trauma Setting. Am Surg 2020; 86:1441-1444. [PMID: 33153269 DOI: 10.1177/0003134820960047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 55-year-old man undergoes emergent exploratory laparotomy and splenectomy following a motorcycle collision. Following surgery, he is found to have a traumatic brain injury requiring decompressive craniectomy and intracranial pressure monitoring. The patient then continues to have complications throughout his hospital course. Using the American College of Surgeons Trauma Quality Improvement Program guidelines, the surgical team has early and ongoing primary palliative care discussions to foster communication and determine goals of care for the patient. As the patient deteriorates, the surgical team continues meeting with the patient's surrogate decision makers to discuss the best case and worst case scenarios regarding the patient's prognosis and expected quality of life.
Collapse
Affiliation(s)
- Kristen L Schultz
- Department of Surgery, Ringgold ID: 6684Oregon Health and Science University, OR, USA
| | - Karen J Brasel
- Department of Surgery, Ringgold ID: 6684Oregon Health and Science University, OR, USA
| | - David H Zonies
- Department of Surgery, Ringgold ID: 6684Oregon Health and Science University, OR, USA
| | - Mackenzie R Cook
- Department of Surgery, Ringgold ID: 6684Oregon Health and Science University, OR, USA
| |
Collapse
|
39
|
Abdel-Rahman EM, Metzger M, Blackhall L, Asif M, Mamdouhi P, MacIntyre K, Casimir E, Ma JZ, Balogun RA. Association between Palliative Care Consultation and Advance Palliative Care Rates: A Descriptive Cohort Study in Patients at Various Stages in the Continuum of Chronic Kidney Disease. J Palliat Med 2020; 24:536-544. [PMID: 32996797 DOI: 10.1089/jpm.2020.0153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Background: Despite evidence that advance care planning (ACP) benefits patients with serious illnesses, there is a dearth of information about "who" is referred for palliative care (PC) consultation, the rate of PC consultation, and the outcomes of referrals in patients with advanced chronic kidney disease/end-stage kidney disease (aCKD/ESKD). Objectives: (1) To describe patient characteristics associated with PC consultations and (2) to determine the frequency and outcome of PC consultation on documented ACP discussions for patients with aCKD/ESKD. Methodology/Design: This is retrospective observational electronic health record cohort review. Settings: University of Virginia (UVA) hospital, clinics, and dialysis units. Participants: Patients were studied along two time intervals. Time period January 1, 2015 to June 30, 2017 included all patients admitted to UVA during that time period with estimated glomerular filtration rate (eGFR) <60 mL/minute. Time period January 1, 2018 to March 31, 2019 included two cohorts: patients with eGFR <15 mL/minute who had died during study period excluding those who withdrew from dialysis and those who were dialysis dependent and withdrew from dialysis. Results: Aside from higher rates of PC consultation in patients with heart failure, none of the demographic and comorbidity data studied affected whether or not a patient is referred to PC in patients with aCKD/ESKD. PC consultation rates were low among all patients studied: 14.7% in patients with eGFR <60 mL/minute, 28.9% in dialysis patients withdrawing from dialysis, and 57.1% in terminally ill patients with eGFR <15 mL/minute. In all cohorts, PC consultations were associated with improved ACP. Conclusion: PC consultation is significantly associated with better end-of-life outcomes with more completion of ACP and hospice referral in patients with aCKD/ESKD. PC consultation rates remain low. Even in terminally ill patients with more aCKD, >40% were never seen by PC. Until policies and curricula better prepare nephrologists to independently address ACP, collaboration between nephrologists and PC specialists is recommended.
Collapse
Affiliation(s)
| | - Maureen Metzger
- School of Nursing, University of Virginia, Charlottesville, Virginia, USA
| | - Leslie Blackhall
- Section of Palliative Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Mohammad Asif
- Mary Washington Health Care, Fredericksburg, Virginia, USA
| | | | - Kara MacIntyre
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Ernst Casimir
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jennie Z Ma
- Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| |
Collapse
|
40
|
Gonzalez-Jaramillo V, Sobanski P, Calvache JA, Arenas-Ochoa LF, Franco OH, Hunziker L, Eychmüller S, Maessen M. Unmet device reprogramming needs at the end of life among patients with implantable cardioverter defibrillator: A systematic review and meta-analysis. Palliat Med 2020; 34:1019-1029. [PMID: 32588755 PMCID: PMC7388150 DOI: 10.1177/0269216320929548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Use of implantable cardioverter defibrillators is increasingly common. As patients approach the end of life, it is appropriate to deactivate the shock function. AIM To assess the prevalence of implantable cardioverter defibrillator reprogramming to deactivate the shock function at the end of life and the prevalence of advance directives among this population. DESIGN Following a previously established protocol available in PROSPERO, we performed a narrative synthesis of our findings and used the logit transformation method to perform our quantitative synthesis. DATA SOURCES We searched seven bibliographic databases (Embase, Cochrane Central register of controlled Trials, Medline-Ovid, Web-of-Science, Scopus, PsychInfo, and CINAHL) and additional sources until April 2019. RESULTS Of the references we identified, 14 were included. We found a pooled prevalence of implantable cardioverter defibrillator reprogramming at the end of life of 28% (95% confidence interval, 22%-36%) with higher reprogramming rates after the recommendations for managing the device at the end of life were published. Among patients with advance directives, the pooled prevalence of advance directives that explicitly mentioned the device was 1% (95% confidence interval, 1%-3%). CONCLUSIONS The prevalence of implantable cardioverter defibrillator reprogramming and advance directives that explicitly mentioned the device was very low. Study data suggested reprogramming decisions were made very late, after the patient experienced multiple shocks. Patient suffering could be ameliorated if physicians and other healthcare professionals adhere to clinical guidelines for the good management of the device at the end of life and include deactivating the shock function in the discussion that leads to the advance directive.
Collapse
Affiliation(s)
| | - Piotr Sobanski
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Spital Schwyz, Schwyz, Switzerland
| | - Jose A Calvache
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia.,Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Oscar H Franco
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Lukas Hunziker
- Department of Cardiology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Steffen Eychmüller
- University Center for Palliative Care, Inselspital University Hospital Bern, Bern, Switzerland
| | - Maud Maessen
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,University Center for Palliative Care, Inselspital University Hospital Bern, Bern, Switzerland
| |
Collapse
|
41
|
Krechowicz R, Gupta M, Gratton V, Hickey C, Thompson LH, Kyeremanteng K. Case Discussions in Advanced Care Planning. Am J Hosp Palliat Care 2020; 38:366-370. [PMID: 32787564 DOI: 10.1177/1049909120948495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Advanced care planning (ACP) provides an opportunity for individuals to explore and document their values concerning medical care decisions prior to an acute event. This manuscript explores the value of ACP and compares and contrasts 2 ACP models currently in practice. METHODS This hypothetical case describes an elderly, frail patient with end-stage chronic obstructive pulmonary disease who is also a high user of health care resources. A new palliative care-led outpatient ACP clinic model is described using this example. RESULTS Using the ACP clinic model in this case reveals how different a patient's end of life experience may be when proper, proactive planning measures are in place. With proper education and discussion around this patient and family's wishes pertaining to the end of his life, this man was able to change his plan of care from aggressive resuscitation treatment in hospital to a peaceful palliative experience at home. CONCLUSIONS In this case description, the valuable role of ACP in preserving quality of life for patients, increasing satisfaction with care, and decreasing distress among family members during a medical event is demonstrated.
Collapse
Affiliation(s)
- Regine Krechowicz
- Department of Medicine, 153006University of Ottawa, Ottawa, Ontario, Canada
| | - Melini Gupta
- Department of Medicine, 153006University of Ottawa, Ottawa, Ontario, Canada
| | - Valerie Gratton
- Department of Medicine, 153006University of Ottawa, Ottawa, Ontario, Canada.,551435Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Carly Hickey
- 60378Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Laura H Thompson
- 10055Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kwadwo Kyeremanteng
- Division of Palliative Care, 153006Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Critical Care, 153006Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
42
|
Prell T, Siebecker F, Lorrain M, Tönges L, Warnecke T, Klucken J, Wellach I, Buhmann C, Wolz M, Lorenzl S, Herbst H, Eggers C, Mai T. Specialized Staff for the Care of People with Parkinson's Disease in Germany: An Overview. J Clin Med 2020; 9:E2581. [PMID: 32784969 DOI: 10.3390/jcm9082581] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022] Open
Abstract
Access to specialized care is essential for people with Parkinson´s disease (PD). Given the growing number of people with PD and the lack of general practitioners and neurologists, particularly in rural areas in Germany, specialized PD staff (PDS), such as PD nurse specialists and Parkinson Assistants (PASS), will play an increasingly important role in the care of people with PD over the coming years. PDS have several tasks, such as having a role as an educator or adviser for other health professionals or an advocate for people with PD to represent and justify their needs. PD nurse specialists have been established for a long time in the Netherlands, England, the USA, and Scandinavia. In contrast, in Germany, distinct PDS models and projects have been established. However, these projects and models show substantial heterogeneity in terms of access requirements, education, theoretical and practical skills, principal workplace (inpatient vs. outpatient), and reimbursement. This review provides an overview of the existing forms and regional models for PDS in Germany. PDS reimbursement concepts must be established that will foster an implementation throughout Germany. Additionally, development of professional roles in nursing and more specialized care in Germany is needed.
Collapse
|
43
|
Dishman SE, Driggers KE, Johnson LS, Olsen CH, Ryan AB, McLawhorn MM, Chung KK. Perceptions of ICU Care Following Do-Not-Resuscitate Orders: A Military Perspective. Crit Care Explor 2020; 2:e0153. [PMID: 32766553 DOI: 10.1097/CCE.0000000000000153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although do-not-resuscitate orders only prohibit cardiopulmonary resuscitation in the case of cardiac arrest, the common initiation of this code status in the context of end-of-life care may lead providers to draw premature conclusions about other goals of care. The aim of this study is to identify concerns regarding care quality in the setting of do-not-resuscitate orders within the Department of Defense and compare differences in perceptions between members of the critical care team. Design A cross sectional observational study was conducted. Setting This study took place in the setting of critical care within the Department of Defense. Subjects All members of the Uniformed Services Section of the Society of Critical Care Medicine were invited to participate. Interventions A validated 31-question survey exploring the perceptions of care quality in the setting of do-not-resuscitate status was distributed. Measurements and Main Results Exploratory factor analysis was used to categorically group survey questions, and average factor scores were compared between respondent groups using t tests. Responses to individual questions were also analyzed between comparison groups using Fisher exact tests. Factor analysis revealed no significant differences between respondents of different training backgrounds; however, those with do-not-resuscitate training were more likely to agree that active treatment would be pursued (p = 0.024) and that trust and communication would be maintained (p = 0.005). Although 38% of all respondents worry that quality of care will decrease, 93% agree that life-prolonging treatments should be offered. About a third of providers wrongly believed that a do-not-resuscitate order must be reversed prior to an operation. Conclusions Although providers across training backgrounds held similar concerns about decreased care quality in the ICU, there is wide belief that the routine and noninvasive interventions are offered as indicated. Those with do-not-resuscitate training were more likely to believe that standards of care continued to be met after code status change.
Collapse
|
44
|
Abstract
Dementia has been described as the biggest health and social care challenge of this century; its impact on dental care cannot be ignored. Dementia affects cognitive ability and decision making, so it is important that oral healthcare professionals are conversant with current mental capacity legislation and issues that may be raised when treatment planning for patients living with the condition. This second article in the series considers the impact of dementia on dental care provision and covers a range of issues which are relevant to both general and specialist practice. These include assessment of capacity, use of different treatment modalities, such as sedation and general anaesthesia, and the factors that may be relevant when deciding to offer treatment or to refer to a secondary care setting for dental treatment. Advanced care planning is detailed to support general dental practitioners considering the longer-term wishes of their patients with an early diagnosis of dementia.
Collapse
Affiliation(s)
- Andrew Geddis-Regan
- NIHR Doctoral Research Fellow, Specialist in Special Care Dentistry, School of Dental Sciences, Newcastle University
| | - Kathryn Kerr
- Health Education England Regional Dental Adviser Workforce Transformation and Continuing Registration
| | - Charlotte Curl
- Consultant in Special Care Dentistry, Dental Care Group, King's College Hospital NHS Foundation Trust, London
| |
Collapse
|
45
|
Audigé M, Gillam L, Stark Z. Treatment limitation and advance planning: Hospital-wide audit of paediatric death. J Paediatr Child Health 2020; 56:893-899. [PMID: 31898378 DOI: 10.1111/jpc.14771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/14/2019] [Accepted: 12/19/2019] [Indexed: 11/30/2022]
Abstract
AIM To examine paediatric deaths following withdrawal or withholding of medical treatment (WWMT) from a hospital-wide perspective and identify changes over a 10 year period. METHODS A retrospective review of medical records was conducted for all paediatric inpatient deaths at the Royal Children's Hospital, Melbourne from April 2015 to April 2016, and results were compared to 2007 data from our centre. χ2 tests were used for comparisons. RESULTS A total of 101 deaths occurred in the inpatient setting in 2015-2016. Most deaths followed WWMT (88/101, 87%) and occurred in children with pre-existing chronic conditions (85/101, 85%). There was a shift to earlier discussions with parents regarding WWMT compared to 10 years prior. Cases where discussions began prior to the last admission increased from 4 to 19% (P = 0.004). There was increased paediatric palliative care (PPC) involvement (10 vs. 37%, P < 0.001), and a slightly greater proportion of children died outside of intensive care (16 vs. 22%, P = 0.25). In 2015-2016, subgroup analysis showed that children who died as inpatients but outside of intensive care were 76% more likely to have PPC involved than those who died in intensive care (P < 0.001). Their families were 51% more likely to have discussed WWMT with medical staff before the last admission (P < 0.001). CONCLUSIONS The last decade has seen an increase in PPC involvement and advance discussions around WWMT at our centre. Both of these are associated with death outside of intensive care.
Collapse
Affiliation(s)
- Manon Audigé
- Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The Royal Children's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lynn Gillam
- Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Zornitza Stark
- Department of Paediatrics, The Royal Children's Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| |
Collapse
|
46
|
Prell T, Siebecker F, Lorrain M, Eggers C, Lorenzl S, Klucken J, Warnecke T, Buhmann C, Tönges L, Ehret R, Wellach I, Wolz M. Recommendations for Standards of Network Care for Patients with Parkinson's Disease in Germany. J Clin Med 2020; 9:jcm9051455. [PMID: 32414071 PMCID: PMC7290836 DOI: 10.3390/jcm9051455] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/09/2020] [Accepted: 05/09/2020] [Indexed: 02/07/2023] Open
Abstract
Although our understanding of Parkinson’s disease (PD) has improved and effective treatments are available, caring for people with PD remains a challenge. The large heterogeneity in terms of motor symptoms, nonmotor symptoms, and disease progression makes tailored individual therapy and individual timing of treatment necessary. On the other hand, only limited resources are available for a growing number of patients, and the high quality of treatment cannot be guaranteed across the board. At this point, networks can help to make better use of resources and improve care. The working group PD Networks and Integrated Care, part of the German Parkinson Society, is entrusted to convene clinicians, therapists, nurses, researchers, and patients to promote the development of PD networks. This article summarizes the work carried out by the working group PD Networks and Integrated Care in the development of standards of network care for patients with PD in Germany.
Collapse
Affiliation(s)
- Tino Prell
- Department of Neurology, Jena University Hospital, 07740 Jena, Germany
- Center for Healthy Ageing, Jena University Hospital, 07740 Jena, Germany
- Correspondence:
| | | | - Michael Lorrain
- Nervenarztpraxis Gerresheim-Pempelfort, 40477 Düsseldorf, Germany;
| | - Carsten Eggers
- Department of Neurology, University Hospital Marburg, 35037 Marburg, Germany;
| | - Stefan Lorenzl
- Professorship for Palliative Care, Paracelsus Medical University, 5020 Salzburg, Austria;
- Department of Palliative Medicine, Ludwig-Maximilians-University Munich, 81377 Munich, Germany
- Department of Neurology, Klinikum Agatharied, 83734 Hausham, Germany
| | - Jochen Klucken
- Department of Molecular Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany;
- Medical Valley-Digital Health Application Center GmbH, 96047 Bamberg, Germany
- Fraunhofer Institute for Integrated Circuits, 91058 Erlangen, Germany
| | - Tobias Warnecke
- Department of Neurology, University of Muenster, 48149 Münster, Germany;
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Lars Tönges
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44801 Bochum, Germany;
| | | | - Ingmar Wellach
- Office for Neurology and Psychiatry Hamburg Walddörfer, Wiesenkamp 22 c, 22359 Hamburg, Germany;
- Department of Neurology, Ev. Amalie, Sieveking Hospital, 22359 Hamburg, Germany
| | - Martin Wolz
- Department of Neurology, Elblandklinikum Meißen, 01662 Meißen, Germany;
| |
Collapse
|
47
|
Harrington L, Price K, Edmonds P. From paper to paperless: Do electronic systems ensure safe and effective communication and documentation of DNACPR decisions? Clin Med (Lond) 2020; 20:329-333. [PMID: 32414725 PMCID: PMC7354023 DOI: 10.7861/clinmed.2019-0450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION An electronic resuscitation system, implemented in 2015, within electronic patient records (EPR) at King's College Hospital NHS Foundation Trust was studied, aiming to review and improve decision documentation and communication. METHOD The study (January 2018 - June 2018) included all gerontology inpatients with electronic do not attempt cardiopulmonary resuscitation (e-DNACPR) decisions. Cases were identified weekly, followed by retrospective analysis of discharges. Amendments to the electronic system and improvements were implemented between cycles. CYCLE 1: One-hundred and thirty-three patients were included; 85% had an e-DNACPR form; 86% of all forms had senior doctor involvement; 68% evidenced patient/relative discussion; 13% documented multidisciplinary team (MDT) discussion. INTERVENTIONS A mandatory 'named nurse' field was added to the form and trust-wide education programme implemented. CYCLE 2: One-hundred and twenty-six patients were included; 100% had an e-DNACPR form; 93% evidenced senior doctor involvement; 71% evidenced patient/relative discussion; 57% documented MDT discussion. CONCLUSION Changes to the process and trust-wide education resulted in more robust documentation and communication.
Collapse
Affiliation(s)
- Laura Harrington
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Polly Edmonds
- King's College Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
48
|
McKinnon M, Donnelly F, Perry J. Experiences of Post Anaesthetic Unit Recovery Nurse facilitating Advanced Directives in the immediate postanaesthetic period: A phenomenological study. J Adv Nurs 2020; 76:1708-1716. [PMID: 32189370 DOI: 10.1111/jan.14357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/14/2020] [Accepted: 03/09/2020] [Indexed: 11/29/2022]
Abstract
AIMS The aims of this study were to develop an understanding of the lived experience of the Post Anaesthetic Unit Recovery Nurse facilitating Advanced Directives and implications for patient-centred care. DESIGN Interpretive phenomenological analysis. METHODS Homogenized purposive sampling of six Registered Nurses using in-depth semi-structured interviews. Interviews were conducted between June-July 2018. Analysis was performed using interpretive phenomenology analysis. RESULTS Post Anaesthetic Recovery Nurses experienced a 'Grey Zone' when facilitating Advanced Directives postanaesthetic. The 'Grey Zone' is defined through four themes; The 'Trigger' of the anaesthetic characterized by physiological instability; 'Confusion and Frustration' featuring balancing of roles as a clinician and advocate during patient decline; 'Consistent Paternalism' by medical staff in the consideration of Advanced Directives; and 'Disempowerment' where nurses faced issues of advocacy, personal distress, a lack of literature or protocols, and handover of information. CONCLUSION The lived experience of nurses facilitating Advanced Directives postanaesthetic may be distressing. Further research is required to understand the implications of Advanced Directives following an anaesthetic. Education and development of protocols are recommended to optimize patient-centred care. IMPACT Post Anaesthetic Unit Recovery Nurses experienced a 'Grey Zone' when facilitating Advanced Directives, defined through four themes. Advanced Directives may appear to be clear, however, the anaesthetic may trigger physiological instability leading to confusion and frustration in interpretation and application of Advanced Directives. Confusion and Frustration were experienced while the attitudes of Consistent Paternalism were encountered when advocating for patient wishes, resulting in Disempowerment. Post Anaesthetic Unit Recovery Nurses may become empowered through acknowledging and describing the 'Grey Zone'.
Collapse
Affiliation(s)
- Majella McKinnon
- Adelaide Nursing School, The University of Adelaide, Adelaide, SA, Australia
| | - Frank Donnelly
- Adelaide Nursing School, The University of Adelaide, Adelaide, SA, Australia
| | - Josephine Perry
- Adelaide Nursing School, The University of Adelaide, Adelaide, SA, Australia
| |
Collapse
|
49
|
Shepherd-Banigan M, James HJ, Smith VA, Plassman BL, Jutkowitz E, Belanger E, Van Houtven CH. Drivers of Long-Term Care Considerations by Persons With Cognitive Impairment. J Appl Gerontol 2020; 40:648-660. [PMID: 32028815 DOI: 10.1177/0733464820903908] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Consideration of place of care is the first step in long-term care (LTC) planning and is critical for patients diagnosed with Alzheimer's disease; yet, drivers of consideration of place of care are unknown. We apply machine learning algorithms to cross-sectional data from the CARE-IDEAS (Caregivers' Reactions and Experience: Imaging Dementia-Evidence for Amyloid Scanning) study (n = 869 dyads) to identify drivers of patient consideration of institutional, in-home paid, and family care. Although decisions about LTC are complex, important drivers included whether patients consulted with a financial planner about LTC, patient demographics, loneliness, and geographical proximity of family members. Findings about consulting with a financial planner match literature showing that perceived financial constraints limit the range of choices in LTC planning. Well-documented drivers of institutionalization, such as care partner burden, were not identified as important variables. By understanding which factors drive patients to consider each type of care, clinicians can guide patients and their families in LTC planning.
Collapse
Affiliation(s)
- Megan Shepherd-Banigan
- Durham Veterans Affairs (VA) Medical Center, Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC, USA.,Department of Population Health Sciences, Duke School of Medicine, Durham, NC, USA
| | - Hailey J James
- Department of Population Health Sciences, Duke School of Medicine, Durham, NC, USA.,Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, USA
| | - Valerie A Smith
- Durham Veterans Affairs (VA) Medical Center, Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC, USA.,Department of Population Health Sciences, Duke School of Medicine, Durham, NC, USA
| | - Brenda L Plassman
- Department of Population Health Sciences, Duke School of Medicine, Durham, NC, USA
| | - Eric Jutkowitz
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
| | - Emmanuelle Belanger
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
| | - Courtney H Van Houtven
- Durham Veterans Affairs (VA) Medical Center, Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC, USA.,Department of Population Health Sciences, Duke School of Medicine, Durham, NC, USA
| |
Collapse
|
50
|
Shi ZY, Li XL, Tang MY, Peng YY. Investigation and Analysis of Undergraduate Nursing Students' Attitudes Toward Advanced Care Planning and Their Willingness to Implement. Am J Hosp Palliat Care 2020; 37:613-618. [PMID: 32022578 DOI: 10.1177/1049909120902123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE The purpose of this study is to understand the attitude of undergraduate nursing students toward advanced care planning (ACP) and their willingness to implement ACP and to analyze its influencing factors, so as to provide evidence-based basis for life and death education and ACP-related training in colleges and universities. METHODS A total of 312 nursing undergraduates from a university in Chengdu (China) were surveyed by using general information questionnaire, attitude scale of ACP, and willingness questionnaire to implement ACP. RESULTS The scores of undergraduate nursing students' attitude toward ACP were 24.97 ± 2.75, and the scores of total willingness to ACP were 79.26 ± 9.70. Univariate analysis and multivariate linear regression analysis showed that religious belief, grade, family relationship, and family discussion of death were the factors influencing the willingness of nursing students to carry out ACP. CONCLUSIONS The attitude of undergraduate nursing students toward ACP tended to be positive, but their cognition of ACP was misunderstood, and their willingness to implement ACP needed to be improved. To improve the awareness and implementating willingness of undergraduate nursing students to ACP, it was recommended that colleges and universities carried out systematic standardized life and death education courses and ACP-related training.
Collapse
Affiliation(s)
- Zheng-Yan Shi
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Xiao-Ling Li
- Department of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Meng-Yan Tang
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Yao-Yao Peng
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|