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Goins RT, Haozous EA, Anderson E, Winchester B. Cultural tailoring advance care planning for an American Indian community: make your wishes about you. ETHNICITY & HEALTH 2024:1-16. [PMID: 39292977 DOI: 10.1080/13557858.2024.2401830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/03/2024] [Indexed: 09/20/2024]
Abstract
BACKGROUND Advance care planning empowers people by allowing them some control over certain healthcare decisions in the event they are unable. Yet, advance care planning rates in the American Indian and Alaska Native populations are low. Thus, we culturally tailored the Make Your Wishes About You (MY WAY), an intervention to improve advance care planning access and completion for American Indian peoples. METHODS In partnership with an American Indian Tribe, the project took a community-based participatory orientation and relied on a Community Advisory Board and a Professional Advisory Board. The culturally tailoring was a 15-step process. These steps allowed us to ensure that the tailoring reflects community-specific norms and preferences, greater reliance on visual images and local idioms of expression, more appropriate attention to family roles, and inclusion of spiritual elements. RESULTS A four-phase cultural tailoring framework emerged with each phase centering around listening, learning, and analyzing with tailoring occurring between each phase. A culturally tailored MY WAY was created, which was delivered in a manner that reflected Tribal citizenss' preferences. Materials included Tribal language, local idioms of expression, attention to family roles, and appropriate inclusion of spiritual elements. The materials were rated high on a content validity index by the advisory board members. CONCLUSION There is a growing interest in tailoring existing evidence-based programs with relatively little in the literature offering guidance. By sharing our efforts and experiences in culturally tailoring an advance care planning program for an American Indian Tribe, we hope that it will serve useful for future efforts in ensuring that evidence-based programming reaches those in greatest need. While this project was rooted in the core Indigenous values of community, ceremony or spirituality, language, and place it also lends itself to broader translation across different populations.
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Affiliation(s)
- R Turner Goins
- College of Health and Human Sciences, Western Carolina University, Cullowhee, North Carolina, USA
| | - Emily A Haozous
- Pacific Institute of Research and Evaluation, Albuquerque, New Mexico, USA
| | - Elizabeth Anderson
- Pacific Institute of Research and Evaluation, Chapel Hill, North Carolina, USA
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Bonares M, Stilos K, Peters M, Huynh L, Selby D. Start of the COVID-19 Pandemic and Palliative Care Unit Utilization: A Retrospective Cohort Study. J Pain Symptom Manage 2024:S0885-3924(24)00902-3. [PMID: 39084410 DOI: 10.1016/j.jpainsymman.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/12/2024] [Accepted: 07/17/2024] [Indexed: 08/02/2024]
Abstract
CONTEXT People with noncancer diagnoses have poorer access to palliative care units (PCUs) or hospices compared to those with cancer diagnoses. The COVID-19 pandemic disrupted how specialist palliative care services were delivered and utilized. OBJECTIVE To determine the association between the start of the COVID-19 pandemic and PCU/hospice utilization in hospitalized individuals with cancer and noncancer diagnoses with specialist palliative care needs. METHODS Retrospective cohort study using routinely collected data. Percentages of individuals experiencing each disposition from hospital, including discharge to PCU/hospice, were calculated monthly for the total, cancer, and noncancer cohorts and were analyzed descriptively. Hospitalized individuals with specialist palliative care needs at a single academic hospital in Toronto, Canada from January 1, 2017, to September 31, 2022 (pandemic start was defined as April 1, 2020). RESULTS The cohort comprised 4349 individuals (median age=78 years; 52.4% female); 3065 (70.5%) and 1284 (29.5%) had cancer and noncancer diagnoses, respectively. Among individuals with noncancer diagnoses, the most significant absolute changes were a 13.0%-decrease in in-hospital deaths (prepandemic=49.6%; postpandemic=36.6%) and a 11.6%-increase in discharges to PCU/hospice (prepandemic=35.6%; postpandemic=47.3%). Among individuals with cancer, the most significant absolute changes were a 12.8%-increase in discharges home with formal care (prepandemic=2.3%; postpandemic=15.1%) and a 7.0%-decrease in in-hospital deaths (prepandemic=29.1%; postpandemic=22.0%). CONCLUSION Despite historically poor PCU/hospice access, the COVID-19 pandemic created circumstances that may have enabled unprecedented utilization in individuals with noncancer diagnoses in our cohort.
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Affiliation(s)
- Michael Bonares
- Division of Palliative Medicine (M.B., K.S., M.P., L.H., D.S.), Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Palliative Medicine (M.B., D.S.), Department of Medicine, University of Toronto, Toronto, ON, Canada; Sunnybrook Research Institute (M.B.), Toronto, ON, Canada.
| | - Kalli Stilos
- Division of Palliative Medicine (M.B., K.S., M.P., L.H., D.S.), Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Madison Peters
- Division of Palliative Medicine (M.B., K.S., M.P., L.H., D.S.), Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lise Huynh
- Division of Palliative Medicine (M.B., K.S., M.P., L.H., D.S.), Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Palliative Care (L.H.), Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Debbie Selby
- Division of Palliative Medicine (M.B., K.S., M.P., L.H., D.S.), Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Palliative Medicine (M.B., D.S.), Department of Medicine, University of Toronto, Toronto, ON, Canada
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3
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Wu MP, Hsiaog SH, Huang TC, Chu DC, Liu CY. Impacts of COVID-19 pandemic prevention measures to the palliative care in Taiwan. Front Public Health 2024; 12:1411185. [PMID: 39118972 PMCID: PMC11309006 DOI: 10.3389/fpubh.2024.1411185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/11/2024] [Indexed: 08/10/2024] Open
Abstract
Background Prevention measures for palliative care and the provision of discharge planning services for inpatients in Taiwan before and during the COVID-19 pandemic had not been investigated. This study was aimed to investigate the factors associated with heightened palliative care needs and increased mortality rates. Methods This research adopts a retrospective case-control study design. The investigation encompasses patients admitted before the pandemic (from January 1, 2019, to May 31, 2019) and during the COVID-19 pandemic (from January 1, 2020, to May 31, 2020). The case group consisted of 231 end-of-life inpatients during the pandemic, control group was composed of the pool of inpatients with pre-pandemic and matched with cases by sex and age in a 1:1 ratio. Results The results showed that the prevalence of respiratory failure symptoms (p = 0.004), residing in long-term care facilities (p = 0.017), palliative care needs assessment scores (p = 0.010), as well as the provision of guidance for nasogastric tube feeding (p = 0.002), steam inhalation (p = 0.003), turning and positioning (p < 0.001), percussion (p < 0.001), passive range of motion (p < 0.001), and blood pressure measurement (p < 0.001). Furthermore, the assessment of the necessity for assistive devices, including hospital beds, also exhibited statistically significant variations (p < 0.001). Further investigation of the factors associated with high palliative care needs and the risk of mortality for both the case and control groups. Risk factors for high palliative care needs encompassed assessments of daily activities of living, the presence of pressure ulcers, and the receipt of guidance for ambulation. Risk factors for mortality encompassed age, a diagnosis of cancer, palliative care needs assessment scores, and the provision of guidance for disease awareness. Conclusion This research highlights the heightened risk of COVID-19 infection among end-of-life inpatients during the COVID-19 pandemic. The findings of this study may advance care planning to alleviate avoidable suffering. To meet the needs of inpatients during pandemic, healthcare professionals should undergo comprehensive palliative care training and receive policy support.
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Affiliation(s)
- Meng-Ping Wu
- Department of Nursing, Taipei City Hospital, Taipei City, Taiwan
- College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan
- Department of Psychology and Counseling, University of Taipei, Taipei City, Taiwan
| | | | - Tsun-Cheng Huang
- Administrative Deputy Superintendent Office, Taipei City Hospital, Taipei City, Taiwan
| | | | - Chieh-Yu Liu
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan
- Department of Research and Development, Taipei City Hospital, Taipei City, Taiwan
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Slotman E, Weijzen F, Fransen HP, van Hoeve JC, Huijben AMT, Kuip EJM, Jager A, Kunst PWA, van Laarhoven HWM, Tol J, Tjan-Heijnen VCG, Raijmakers NJH, van der Linden YM, Siesling S. Continuity of care for patients with de novo metastatic cancer during the COVID-19 pandemic: A population-based observational study. Int J Cancer 2024; 154:1786-1793. [PMID: 38268393 DOI: 10.1002/ijc.34857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 01/26/2024]
Abstract
During the COVID-19 pandemic recommendations were made to adapt cancer care. This population-based study aimed to investigate possible differences between the treatment of patients with metastatic cancer before and during the pandemic by comparing the initial treatments in five COVID-19 periods (weeks 1-12 2020: pre-COVID-19, weeks 12-20 2020: 1st peak, weeks 21-41 2020: recovery, weeks 42-53 2020: 2nd peak, weeks 1-20 2021: prolonged 2nd peak) with reference data from 2017 to 2019. The proportion of patients receiving different treatment modalities (chemotherapy, hormonal therapy, immunotherapy or targeted therapy, radiotherapy primary tumor, resection primary tumor, resection metastases) within 6 weeks of diagnosis and the time between diagnosis and first treatment were compared by period. In total, 74,208 patients were included. Overall, patients were more likely to receive treatments in the COVID-19 periods than in previous years. This mainly holds for hormone therapy, immunotherapy or targeted therapy and resection of metastases. Lower odds were observed for resection of the primary tumor during the recovery period (OR 0.87; 95% CI 0.77-0.99) and for radiotherapy on the primary tumor during the prolonged 2nd peak (OR 0.84; 95% CI 0.72-0.98). The time from diagnosis to the start of first treatment was shorter, mainly during the 1st peak (average 5 days, p < .001). These findings show that during the first 1.5 years of the COVID-19 pandemic, there were only minor changes in the initial treatment of metastatic cancer. Remarkably, time from diagnosis to first treatment was shorter. Overall, the results suggest continuity of care for patients with metastatic cancer during the pandemic.
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Affiliation(s)
- Ellis Slotman
- Technical Medical Centre, Department of Health Technology and Services Research, University of Twente, Enschede, Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
- Netherlands Association for Palliative Care, Utrecht, Netherlands
| | - Feike Weijzen
- Technical Medical Centre, Department of Health Technology and Services Research, University of Twente, Enschede, Netherlands
| | - Heidi P Fransen
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
- Netherlands Association for Palliative Care, Utrecht, Netherlands
| | - Jolanda C van Hoeve
- Technical Medical Centre, Department of Health Technology and Services Research, University of Twente, Enschede, Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | - Auke M T Huijben
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, Netherlands
| | - Evelien J M Kuip
- Department of Medical Oncology and Department of Anesthesiology, Pain and Palliative Care, Radboud Medical Center, Nijmegen, Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Peter W A Kunst
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
- Department of Pulmonology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Hanneke W M van Laarhoven
- Medical Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jolien Tol
- Department of Internal Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Vivianne C G Tjan-Heijnen
- Department of Medical Oncology, Research Institute GROW, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Natasja J H Raijmakers
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
- Netherlands Association for Palliative Care, Utrecht, Netherlands
| | - Yvette M van der Linden
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, Netherlands
- Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, Netherlands
| | - Sabine Siesling
- Technical Medical Centre, Department of Health Technology and Services Research, University of Twente, Enschede, Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
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Ouchi K, Prachanukool T, Aaronson EL, Lakin JR, Higuchi M, Liu SW, Kennedy M, Revette AC, Chary AN, Kaithamattam J, Lee B, Neville TH, Hasdianda MA, Sudore R, Schonberg MA, Tulsky JA, Block SD. The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study. Acad Emerg Med 2024; 31:18-27. [PMID: 37814372 PMCID: PMC10794002 DOI: 10.1111/acem.14818] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. METHODS We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews. RESULTS Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. CONCLUSIONS Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Thidathit Prachanukool
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Emily L. Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R. Lakin
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Masaya Higuchi
- Division of Palliative Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shan W. Liu
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anita N. Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jenson Kaithamattam
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Brandon Lee
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Thanh H. Neville
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Mohammad A. Hasdianda
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Susan D. Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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6
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van de Wiel M, van Ierssel S, Verbrugghe W, Mertens V, Janssens A. Do-Not-ResuscitateDecision-Making during the COVID-19 Pandemic in a Teaching Hospital: Lessons Learned for the Future. J Aging Res 2023; 2023:2771149. [PMID: 38152565 PMCID: PMC10752667 DOI: 10.1155/2023/2771149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 12/29/2023] Open
Abstract
Method A cross-sectional survey study was conducted between February 2021 and April 2021 for all doctors and doctors in training, working in the Antwerp University Hospital during the COVID-19 pandemic. Results 127 doctors participated in this study. The familiarity with the different scores used in the triage during the COVID-10 pandemic was 51% for the Clinical Frailty Scale (CFS) and 20% for the Charlson Comorbidity Index (CCI). Participants indicated that their DNR decision is based on various aspects such as clinical assessment, comorbidities, patient's wishes, age, prognosis, and functional state. Conclusion The familiarity with the different scores used during triage assessments is low. The total clinical picture of the patient is needed to make a considered decision, and this total picture of the patient seems to be well encompassed by frailty measurement (CFS). Although many participants indicated that the different scores do not offer much added value compared to their clinical assessment, it can help guide DNR decisions, especially for doctors in training.
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Affiliation(s)
- Mick van de Wiel
- Antwerp University Hospital (UZA), Department of Thoracic Oncology, Drie Eikenstraat 655, Edegem 2650, Belgium
| | - Sabrina van Ierssel
- Antwerp University Hospital (UZA), Department of General Internal Medicine, Infectious Diseases and Tropical Medicine, Edegem 2650, Belgium
| | - Walter Verbrugghe
- Antwerp University Hospital (UZA), Department of Intensive Care, Edegem 2650, Belgium
| | - Veerle Mertens
- Antwerp University Hospital (UZA), Department of Geriatrics, Edegem 2650, Belgium
| | - Annelies Janssens
- Antwerp University Hospital (UZA), Department of Thoracic Oncology, Drie Eikenstraat 655, Edegem 2650, Belgium
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Murray GF, Lakin JR, Paasche-Orlow MK, Tulsky JA, Volandes A, Davis AD, Zupanc SN, Carney MT, Burns E, Martins-Welch D, LaVine N, Itty JE, Fix GM. Structural Barriers to Well-grounded Advance Care Planning for the Seriously Ill: a Qualitative Study of Clinicians' and Administrators' Experiences During a Pragmatic Trial. J Gen Intern Med 2023; 38:3558-3565. [PMID: 37488368 PMCID: PMC10713958 DOI: 10.1007/s11606-023-08320-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/03/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Advance Care Planning (ACP) comprises an iterative communication process aimed at understanding patients' goals, values, and preferences in the context of considering and preparing for future medical treatments and decision making in serious illness. The COVID pandemic heightened patients' and clinicians' awareness of the need for ACP. OBJECTIVE Our goal was to explore the experiences of clinicians and administrators in the context of an intervention to improve ACP during the COVID pandemic. DESIGN Qualitative interview study. PARTICIPANTS Clinicians and administrators across five sites that participated in the ACP-COVID trial. APPROACH We conducted semi-structured, qualitative interviews examining the context and approach to ACP. Interviews were analyzed using template analysis to systematically organize the data and facilitate review across the categories and participants. Templates were developed with iterative input and line-by-line review by the analytic team, to reach consensus. Findings were then organized into emergent themes. KEY RESULTS Across 20 interviews (4 administrators, 16 clinicians) we identified three themes related to how participants thought about ACP: (1) clinicians have varying views of what constitutes ACP; (2) the health system critically shapes ACP culture and norms; and (3) the centrality of clinicians' affective experience and own needs related to ACP. Varying approaches to ACP include a forms-focused approach; a discussion-based approach; and a parental approach. System features that shape ACP norms are (1) the primacy of clinician productivity measures; (2) the role of the EHR; and (3) the culture of quality improvement. CONCLUSIONS Despite high organizational commitment to ACP, we found that the health system channeled clinicians' ACP efforts narrowly on completion of forms, in tension with the ideal of well-grounded ACP. This resulted in a state of moral distress that risks undermining confidence in the process of ACP and may increase risk of harm for patients, family/caregivers, and providers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Genevra F Murray
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA
| | - Joshua R Lakin
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Michael K Paasche-Orlow
- Tufts University School of Medicine, Division of General Internal Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - James A Tulsky
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Section of General Internal Medicine, Boston, MA, USA
- ACP Decisions, Waban, MA, USA
| | | | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maria T Carney
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Edith Burns
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Diana Martins-Welch
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Nancy LaVine
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jennifer E Itty
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Gemmae M Fix
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, Bedford VA Healthcare System, Bedford, MA, USA
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8
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Abdollahpour S, Akbari A, Khadivzadeh T. Novel Memories of Motherhood: Childbirth Lived Experiences of Mothers with Coronavirus Disease 2019 (COVID-19). J Caring Sci 2023; 12:248-254. [PMID: 38250003 PMCID: PMC10799269 DOI: 10.34172/jcs.2023.31929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/30/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction The critical coronavirus pandemic presents a global challenge with dimensions yet unknown, underscoring the essential need to comprehend the lived experiences, especially for vulnerable groups. This study delves into the childbirth experiences of mothers dealing with coronavirus disease 2019 (COVID-19). Methods Employing hermeneutic phenomenology, this qualitative research was conducted at Mashhad University of Medical Sciences (Iran). Purposeful sampling involved 16 mothers with maximum variation. Unstructured telephone interviews collected data, analyzed using the Diekelman approach. Results Unveiling the theme "Novel Memories of Motherhood," four central themes emerged: "The Missing Link in Quality Care," "Coronavirus Stigma," "A lonely mother in quarantine," and "Cascade of Psychological Trauma." Conclusion COVID-19 acts as an intervening factor, distorting routine care and delivery programs. The focus for service providers attending to mothers in labor should extend beyond physical care, encompassing the elimination of coronavirus-related stigma and prioritizing psychological attention. This holistic approach is crucial for maintaining quality care standards.
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Affiliation(s)
- Sedigheh Abdollahpour
- Reproductive Health, Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Azam Akbari
- Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Talat Khadivzadeh
- Reproductive Health, Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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9
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Pankratz L, Gill G, Pirzada S, Papineau K, Reynolds K, Riviere CL, Bolton JM, Hensel JM, Olafson K, Kredentser MS, El-Gabalawy R, Hiebert T, Chochinov HM. "It took so much of the humanness away": Health care professional experiences providing care to dying patients during COVID-19. DEATH STUDIES 2023; 48:706-718. [PMID: 37938174 DOI: 10.1080/07481187.2023.2266639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
COVID-19 has affected healthcare in profound and unprecedented ways, distorting the experiences of patients and healthcare professionals (HCPs) alike. One area that has received little attention is how COVID-19 affected HCPs caring for dying patients. The goal of this study was to examine the experiences of HCPs working with dying patients during the COVID-19 pandemic. Between July 2020-July 2021, we recruited HCPs (N = 25) across Canada. We conducted semi-structured interviews, using a qualitative study design rooted in constructivist grounded theory methodology. The core themes identified were the impact of the pandemic on care utilization, the impact of infection control measures on provision of care, moral distress in the workplace, impact on psychological wellbeing, and adaptive strategies to help HCPs manage emotions and navigate pandemic imposed changes. This is the first Canadian study to qualitatively examine the experiences of HCPs providing care to dying patients during the COVID-19 pandemic. Implications include informing supportive strategies and shaping policies for HCPs providing palliative care.
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Affiliation(s)
- Lily Pankratz
- Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gagan Gill
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Salina Pirzada
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kelsey Papineau
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kristin Reynolds
- Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Christian La Riviere
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James M Bolton
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jennifer M Hensel
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kendiss Olafson
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maia S Kredentser
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Renée El-Gabalawy
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Anesthesiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tim Hiebert
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harvey Max Chochinov
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
- CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, Manitoba, Canada
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Granrud MD, Grøndahl VA, Helgesen AK, Bååth C, Olsson C, Tillfors M, Melin-Johansson C, Österlind J, Larsson M, Hov R, Sandsdalen T. Health Care Personnel's Perspectives on Quality of Palliative Care During the COVID-19 Pandemic - A Cross-Sectional Study. J Multidiscip Healthc 2023; 16:2893-2903. [PMID: 37790989 PMCID: PMC10543989 DOI: 10.2147/jmdh.s419442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 08/29/2023] [Indexed: 10/05/2023] Open
Abstract
Purpose The provision of high-quality palliative care is challenging, especially during a pandemic like COVID-19. The latter entailed major consequences for health care systems and health care personnel (HCP) in both specialist and community health care services, in Norway and worldwide. The aim of this study was to explore how the HCP perceived the quality of palliative care in nursing homes, medical care units, and intensive care units during the COVID-19 pandemic. Methods This study had a cross-sectional design. A total of 290 HCP from Norway participated in the study (RR = 25.8%) between October and December 2021. The questionnaire comprised items concerning respondents' demographics and quality of care, the latter measured by the short form of the Quality from the Patient's Perspective-Palliative Care instrument, adapted for HCP. The STROBE checklist was used. Results This study shows that the HCP scored subjective importance as higher in all dimensions, items and single items than their perception of the actual care received. This could indicate a need for improvement in all areas. Information about medication, opportunity to participate in decisions about medical and nursing care and continuity regarding receiving help from the same physician and nurse are examples of areas for improvement. Conclusion Study results indicate that HCP from nursing homes, medical care units, and intensive care units perceived that quality of palliative care provided was not in line with what they perceived to be important for the patient. This indicate that it was challenging to provide high-quality palliative care during the COVID-19 pandemic.
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Affiliation(s)
- Marie Dahlen Granrud
- Department of Social Sciences and Guidance, Faculty of Health and Social Sciences, Inland Norway University of Applied Sciences, Elverum, Norway
| | - Vigdis Abrahamsen Grøndahl
- Department of Nursing, Health and Laboratory Science, Faculty of Health, Welfare and Organization, Østfold University College, Halden, Norway
| | - Ann Karin Helgesen
- Department of Nursing, Health and Laboratory Science, Faculty of Health, Welfare and Organization, Østfold University College, Halden, Norway
| | - Carina Bååth
- Department of Nursing, Health and Laboratory Science, Faculty of Health, Welfare and Organization, Østfold University College, Halden, Norway
- Department of Health Sciences, Faculty of Health Science and Technology, Karlstad University, Karlstad, Sweden
| | - Cecilia Olsson
- Department of Health Sciences, Faculty of Health Science and Technology, Karlstad University, Karlstad, Sweden
- Department of Bachelor Education in Nursing, Lovisenberg Diaconal University College, Oslo, Norway
| | - Maria Tillfors
- Department of Social and Psychological Sciences, Faculty of Arts and Social Sciences, Karlstad University, Karlstad, Sweden
| | | | - Jane Österlind
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
| | - Maria Larsson
- Department of Health Sciences, Faculty of Health Science and Technology, Karlstad University, Karlstad, Sweden
| | - Reidun Hov
- Centre of Development of Institutional and Home Care Services, Innland (Hedmark), Hamar Municipality, Norway
| | - Tuva Sandsdalen
- Department of Health and Nursing Sciences, Faculty of Health and Social Sciences, Inland Norway University of Applied Sciences, Elverum, Norway
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11
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Younan S, Cardona M, Sahay A, Willis E, Ni Chroinin D. Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned. FRONTIERS IN HEALTH SERVICES 2023; 3:1242413. [PMID: 37780404 PMCID: PMC10541151 DOI: 10.3389/frhs.2023.1242413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023]
Abstract
Background The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice. Methods We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus. Results From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems. Conclusion The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.
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Affiliation(s)
- Sarah Younan
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, NSW, Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare, Bond University, Gold Coast, QLD, Australia
| | - Ashlyn Sahay
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Mackay, QLD, Australia
| | - Eileen Willis
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Mackay, QLD, Australia
| | - Danielle Ni Chroinin
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, UNSW, Sydney, NSW, Australia
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12
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Comer AR, Fettig L, Bartlett S, Sinha S, D'Cruz L, Odgers A, Waite C, Slaven JE, White R, Schmidt A, Petras L, Torke AM. Code status orders in hospitalized patients with COVID-19. Resusc Plus 2023; 15:100452. [PMID: 37662642 PMCID: PMC10470381 DOI: 10.1016/j.resplu.2023.100452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Background The COVID-19 pandemic created complex challenges regarding the timing and appropriateness of do-not-attempt cardiopulmonary resuscitation (DNACPR) and/or Do Not Intubate (DNI) code status orders. This paper sought to determine differences in utilization of DNACPR and/or DNI orders during different time periods of the COVID-19 pandemic, including prevalence, predictors, timing, and outcomes associated with having a documented DNACPR and/or DNI order in hospitalized patients with COVID-19. Methods A cohort study of hospitalized patients with COVID-19 at two hospitals located in the Midwest. DNACPR code status orders including, DNI orders, demographics, labs, COVID-19 treatments, clinical interventions during hospitalization, and outcome measures including mortality, discharge disposition, and hospice utilization were collected. Patients were divided into two time periods (early and late) by timing of hospitalization during the first wave of the pandemic (March-October 2020). Results Among 1375 hospitalized patients with COVID-19, 19% (n = 258) of all patients had a documented DNACPR and/or DNI order. In multivariable analysis, age (older) p =< 0.01, OR 1.12 and hospitalization early in the pandemic p = 0.01, OR 2.08, were associated with having a DNACPR order. Median day from DNACPR order to death varied between cohorts p => 0.01 (early cohort 5 days versus late cohort 2 days). In-hospital mortality did not differ between cohorts among patients with DNACPR orders, p = 0.80. Conclusions There was a higher prevalence of DNACPR and/or DNI orders and these orders were written earlier in the hospital course for patients hospitalized early in the pandemic versus later despite similarities in clinical characteristics and medical interventions. Changes in clinical care between cohorts may be due to fear of resource shortages and changes in knowledge about COVID-19.
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Affiliation(s)
- Amber R. Comer
- Indiana University School of Health and Human Science, United States
- Indiana University School of Medicine, United States
- American Medical Association, United States
| | - Lyle Fettig
- Indiana University School of Medicine, United States
| | | | - Shilpee Sinha
- Indiana University School of Medicine, United States
| | - Lynn D'Cruz
- Indiana University School of Health and Human Science, United States
| | - Aubrey Odgers
- Indiana University School of Health and Human Science, United States
| | - Carly Waite
- Indiana University School of Health and Human Science, United States
| | | | - Ryan White
- Indiana University School of Medicine, United States
| | | | - Laura Petras
- Indiana University School of Medicine, United States
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13
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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] [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.
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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
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14
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Nowels MA, Nowels D, Sheffler J, Lum HD. Characteristics of international primary care practices and physicians related to advance care planning: a cross-sectional survey study. BMC PRIMARY CARE 2023; 24:146. [PMID: 37452276 PMCID: PMC10347754 DOI: 10.1186/s12875-023-02103-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Primary care providers (PCPs) are well-situated to delivery primary palliative care such as advance care planning (ACP). The aim of this work is to identify practice characteristics, including features found in advanced primary care models (APCMs), that predict PCP engagement of patients in ACP. METHODS We analyzed characteristics of physician respondents and their practices associated with ACP conversations in older and sicker patients using data from 11 countries who participated in the 2015 Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations. The primary outcome was how routinely these ACP conversations are reported. We used a validated measure to describe practice-level characteristics of advanced primary care models. We conducted bivariate and multivariable analyses to determine PCP and practice characteristics associated with routinely engaging patients in ACP and with documenting patient preferences in medical records. RESULTS Respondents (N = 12,049) predominantly were older than 45 and did not view their jobs as high stress. PCPs reported routinely engaging patients in ACP work in practices with more APCM features. They are more likely to view their jobs as high stress, to work more hours, to practice in rural areas, and to work in smaller practices. Multivariable analyses showed that older PCP age, higher perceived stress of the job, practice location in rural areas, and increased number of APCM features were associated with more ACP conversations. Increased number of APCM features was also associated with higher odds of routinely recording patient preferences in their medical records. CONCLUSIONS In this international survey, physician and practice characteristics, including having features associated with APCMs, were associated with whether physicians routinely discuss ACP with patients who are older and sicker. Many features of APCMs may facilitate ACP discussions between PCPs and patients.
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Affiliation(s)
- Molly A Nowels
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA.
- Institute for Health, Health Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA.
| | - David Nowels
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Julia Sheffler
- Center for Translational Behavioral Science, Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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15
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Kim H, Flieger SP. Barriers to Effective Communication about Advance Care Planning and Palliative Care: A Qualitative Study. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2023; 26:42-50. [PMID: 37753510 PMCID: PMC10519725 DOI: 10.14475/jhpc.2023.26.2.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/18/2023] [Accepted: 02/25/2023] [Indexed: 09/28/2023]
Abstract
Purpose The purpose of this study was to identify barriers to effective conversations about advance care planning (ACP) and palliative care reported by health care and community-based service providers in Massachusetts, USA. Methods This qualitative research analyzed open-ended responses to two survey questions, inquiring about perceived barriers to having conversations about ACP and palliative care with patients and consumers. Data were collected between November 2017 and June 2019 from nine organizations in Massachusetts, including health care provider organizations, health insurers, community-based organizations, and a nursing education institution. Two researchers reviewed and coded the responses and identified common themes inductively. Results Across 142 responses, primary barriers to ACP included hesitation and lack of understanding and knowledge, discomfort and resistance among service providers, lack of staff knowledge, difficulties with follow-up, and differences in ACP policies across regions. Common barriers to palliative care were misconceptions about palliative care and lack of knowledge, service providers' lack of preparedness, and limited policy support and availability. Challenges relevant to both ACP and palliative care were fear and discomfort around serious illness discussions, lack of knowledge and awareness, discussions that occur too late, and cultural and language barriers. Conclusion Health care practitioners and community-based professionals reported consumer-, service provider-, and system-level barriers to facilitating conversations about ACP and palliative care with patients experiencing serious illness. There is a need for more tools and support to strengthen service providers' ACP and palliative care competencies and to promote a structured approach to health care planning conversations.
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Affiliation(s)
- Hyosin Kim
- College of Public Health & Human Sciences, Oregon State University, Corvallis, Boston, USA
- Tufts Center for Health Systems and Policy Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, USA
| | - Signe Peterson Flieger
- Tufts Center for Health Systems and Policy Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, USA
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16
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Ma JE, Lowe J, Berkowitz C, Kim A, Togo I, Musser RC, Fischer J, Shah K, Ibrahim S, Bosworth HB, Totten AM, Dolor R. Provider Interaction With an Electronic Health Record Notification to Identify Eligible Patients for a Cluster Randomized Trial of Advance Care Planning in Primary Care: Secondary Analysis. J Med Internet Res 2023; 25:e41884. [PMID: 37171856 DOI: 10.2196/41884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 02/17/2023] [Accepted: 03/21/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Advance care planning (ACP) improves patient-provider communication and aligns care to patient values, preferences, and goals. Within a multisite Meta-network Learning and Research Center ACP study, one health system deployed an electronic health record (EHR) notification and algorithm to alert providers about patients potentially appropriate for ACP and the clinical study. OBJECTIVE The aim of the study is to describe the implementation and usage of an EHR notification for referring patients to an ACP study, evaluate the association of notifications with study referrals and engagement in ACP, and assess provider interactions with and perspectives on the notifications. METHODS A secondary analysis assessed provider usage and their response to the notification (eg, acknowledge, dismiss, or engage patient in ACP conversation and refer patient to the clinical study). We evaluated all patients identified by the EHR algorithm during the Meta-network Learning and Research Center ACP study. Descriptive statistics compared patients referred to the study to those who were not referred to the study. Health care utilization, hospice referrals, and mortality as well as documentation and billing for ACP and related legal documents are reported. We evaluated associations between notifications with provider actions (ie, referral to study, ACP not documentation, and ACP billing). Provider free-text comments in the notifications were summarized qualitatively. Providers were surveyed on their satisfaction with the notification. RESULTS Among the 2877 patients identified by the EHR algorithm over 20 months, 17,047 unique notifications were presented to 45 providers in 6 clinics, who then referred 290 (10%) patients. Providers had a median of 269 (IQR 65-552) total notifications, and patients had a median of 4 (IQR 2-8). Patients with more (over 5) notifications were less likely to be referred to the study than those with fewer notifications (57/1092, 5.2% vs 233/1785, 13.1%; P<.001). The most common free-text comment on the notification was lack of time. Providers who referred patients to the study were more likely to document ACP and submit ACP billing codes (P<.001). In the survey, 11 providers would recommend the notification (n=7, 64%); however, the notification impacted clinical workflow (n=9, 82%) and was difficult to navigate (n=6, 55%). CONCLUSIONS An EHR notification can be implemented to remind providers to both perform ACP conversations and refer patients to a clinical study. There were diminishing returns after the fifth EHR notification where additional notifications did not lead to more trial referrals, ACP documentation, or ACP billing. Creation and optimization of EHR notifications for study referrals and ACP should consider the provider user, their workflow, and alert fatigue to improve implementation and adoption. TRIAL REGISTRATION ClinicalTrials.gov NCT03577002; https://clinicaltrials.gov/ct2/show/NCT03577002.
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Affiliation(s)
- Jessica E Ma
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, United States
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Jared Lowe
- Division of General Medicine & Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Callie Berkowitz
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Azalea Kim
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Ira Togo
- Duke Office of Clinical Research, Durham, NC, United States
| | - R Clayton Musser
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Jonathan Fischer
- Department of Community & Family Medicine, Duke University School of Medicine, Durham, NC, United States
- Duke Population Health Management Office, Durham, NC, United States
| | - Kevin Shah
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Salam Ibrahim
- Duke Health Performance Services, Duke University Health System, Durham, NC, United States
| | - Hayden B Bosworth
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Community & Family Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Psychiatry and Behavioral Services, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Annette M Totten
- Oregon Rural Practice Based Research Network, Oregon Health & Science University School of Medicine, Portland, OR, United States
| | - Rowena Dolor
- Division of General Medicine & Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
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Morioka N, Kashiwagi M, Machida A, Hanari K, Sugiyama T, Inokuchi R, Tamiya N. Japanese Local Governments' Dissemination Activities for Advance Care Planning: A Descriptive Analysis of a Nationwide Survey during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5408. [PMID: 37048022 PMCID: PMC10094607 DOI: 10.3390/ijerph20075408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/28/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023]
Abstract
This study aims to compare the awareness-raising activities between municipalities with and without focused anti-infection measures during the 2019 coronavirus disease (COVID-19) pandemic. Descriptive analysis was conducted using a nationwide self-administered questionnaire survey on municipalities' activities for residents and for healthcare providers and care workers (HCPs) in October 2022 in Japan. This study included 433 municipalities that had conducted awareness-raising activities before 2019 Fiscal Year. Workshops for residents were conducted in 85.2% of the municipalities, and they were more likely to be conducted in areas with focused anti-infection measures than those without measures (86.8% vs. 75.4%). Additionally, 85.9% of the municipalities were impacted by the pandemic; 50.1% canceled workshops, while 26.0% switched to a web-based style. Activities for HCPs were conducted in 55.2-63.7% of the municipalities, and they were more likely to be conducted in areas with focused anti-infection measures. A total of 50.6-62.1% of the municipalities changed their workshops for HCPs to a web-based style. Comparisons between areas with and without focused anti-infection measures indicated that the percentages of those impacted for all activities were not significantly different. In conclusion, awareness-raising activities in municipalities were conducted with new methods during the COVID-19 pandemic. Using information technology is essential to further promote such activities for residents.
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Affiliation(s)
- Noriko Morioka
- Department of Nursing Health Service Research, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo 1138510, Japan
| | - Masayo Kashiwagi
- Department of Nursing Health Service Research, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo 1138510, Japan
| | - Ako Machida
- Department of Nursing Health Service Research, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo 1138510, Japan
| | - Kyoko Hanari
- Health Services Research and Development Center, University of Tsukuba, Tsukuba 3058575, Japan
| | - Takehiro Sugiyama
- Health Services Research and Development Center, University of Tsukuba, Tsukuba 3058575, Japan
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo 1628655, Japan
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo 1628655, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba 3058575, Japan
| | - Ryota Inokuchi
- Health Services Research and Development Center, University of Tsukuba, Tsukuba 3058575, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba 3058575, Japan
| | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, Tsukuba 3058575, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba 3058575, Japan
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Zhukovsky DS, Heung Y, Enriquez P, Itzep N, Lu Z, Nortje N, Stanton P, Wong A, Bruera E. Just-in-Time Decision Making: Preliminary Findings of a Goals of Care Rapid Response Team. J Pain Symptom Manage 2023; 65:e337-e343. [PMID: 36496112 PMCID: PMC9729166 DOI: 10.1016/j.jpainsymman.2022.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 12/13/2022]
Abstract
CONTEXT The COVID-19 pandemic placed the issue of resource utilization front and center. Our comprehensive cancer center developed a Goals of Care Rapid Response Team (GOC RRT) to optimize resource utilization balanced with goal-concordant patient care. OBJECTIVES Primary study objective was to evaluate feasibility of the GOC RRT by describing the frequency of consultations that occurred from those requested. Secondary objectives included adherence to consultation processes in terms of core team member participation and preliminary efficacy in limiting care escalation. METHODS We conducted a retrospective chart review of patients referred to GOC RRT (3/23/2020-9/30/2020). Analysis was descriptive. Categorical variables were compared with Fisher's exact or Chi-Square tests and continuous variables with Mann-Whitney U tests. RESULTS A total of 89 patients were referred. Eighty-five percent (76 of 89) underwent a total of 95 consultations. Median (range) patient age was 61 (49, 69) years, 54% (48 of 89) male, 19% (17 of 89) Hispanic, 48% (43/89) White, 73% (65 of 89) married/partnered and 66% (59 of 89) Christian. Hematologic malignancies and solid tumors were evenly balanced (53% [47/89] vs. 47% [42 of 89, P = 0.199]). Most patients (82%, 73 of 89) had metastatic disease or relapsed leukemia. Seven percent (6 of 89) had confirmed COVID-19. Sixty-nine percent (61 of 89) died during the index hospitalization. There was no statistically significant difference in demographic or clinical characteristics among groups (no consultation, 1 consultation, >1 consultation). Core team members were present at 64% (61 of 95) of consultations. Care limitation occurred in 74% (56 of 76) of patients. CONCLUSION GOC RRT consultations were feasible and associated with care limitation. Adherence to core team participation was fair.
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Affiliation(s)
- Donna S Zhukovsky
- Palliative, Rehabilitation and Integrative Medicine (D.S.Z.,Y.H.,P.E.,Z.L.,P.S.,A.W. E.B.), Pediatrics (N.I.).
| | - Yvonne Heung
- Palliative, Rehabilitation and Integrative Medicine (D.S.Z.,Y.H.,P.E.,Z.L.,P.S.,A.W. E.B.), Pediatrics (N.I.)
| | - Parema Enriquez
- Palliative, Rehabilitation and Integrative Medicine (D.S.Z.,Y.H.,P.E.,Z.L.,P.S.,A.W. E.B.), Pediatrics (N.I.)
| | - Nelda Itzep
- Palliative, Rehabilitation and Integrative Medicine (D.S.Z.,Y.H.,P.E.,Z.L.,P.S.,A.W. E.B.), Pediatrics (N.I.)
| | - Zhanni Lu
- Palliative, Rehabilitation and Integrative Medicine (D.S.Z.,Y.H.,P.E.,Z.L.,P.S.,A.W. E.B.), Pediatrics (N.I.)
| | - Nico Nortje
- Critical Care Medicine-Section of Integrated Ethics (N.N.), The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Penny Stanton
- Palliative, Rehabilitation and Integrative Medicine (D.S.Z.,Y.H.,P.E.,Z.L.,P.S.,A.W. E.B.), Pediatrics (N.I.)
| | - Angelique Wong
- Palliative, Rehabilitation and Integrative Medicine (D.S.Z.,Y.H.,P.E.,Z.L.,P.S.,A.W. E.B.), Pediatrics (N.I.)
| | - Eduardo Bruera
- Palliative, Rehabilitation and Integrative Medicine (D.S.Z.,Y.H.,P.E.,Z.L.,P.S.,A.W. E.B.), Pediatrics (N.I.)
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Cinaroglu S. Does increasing the number of beds or health workers contribute to the rational use of scarce public health resources? Glob Health Med 2023; 5:23-32. [PMID: 36865894 PMCID: PMC9974230 DOI: 10.35772/ghm.2023.01006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/07/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023]
Abstract
Turkey makes substantial investments to increase the number of qualified beds in hospitals, the shortage in health professionals remains one of the main obstacles of the health system in the country. To address this research gap, the study aims to formulate a rational solution for the dilemma on whether to invest in beds or health professionals contribute to the rational use of scarce public health resources. Data for testing the model were derived from the Turkish Statistical Institute across 81 provinces in Turkey. The path analytic approach was used to determine the associations among hospital size, utilization/facility, health workforce, and indicators of health outcomes. The results point to a strong link between quantity of qualified beds, utilization of health services, and facility indicators, and health workforce. Rational use of scarce resources, optimal capacity planning, and increased quantity of health professionals will be beneficial for the sustainability of health care services.
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Affiliation(s)
- Songul Cinaroglu
- Address correspondence to:Songul Cinaroglu, Department of Health Care Management, Hacettepe University Faculty of Economics & Administrative Sciences, 06800, Ankara, Turkey. E-mail:
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Kim KM, Giannitrapani KF, Garcia A, Boothroyd D, Wu A, Van Cleve R, McCaa MD, Yefimova M, Aslakson RA, Morris AM, Shreve ST, Lorenz KA. Patient Characteristics Associated With Occurrence of Preoperative Goals-of-Care Conversations. JAMA Netw Open 2023; 6:e2255407. [PMID: 36757697 PMCID: PMC9912129 DOI: 10.1001/jamanetworkopen.2022.55407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 12/08/2022] [Indexed: 02/10/2023] Open
Abstract
Importance Communication about patients' goals and planned and potential treatment is central to advance care planning. Undertaking or confirming advance care plans is also essential to preoperative preparation, particularly among patients who are frail or will undergo high-risk surgery. Objective To evaluate the association between patient risk of hospitalization or death and goals-of-care conversations documented with a completed Life-Sustaining Treatment (LST) Decisions Initiative note among veterans undergoing surgery. Design, Setting, and Participants This retrospective cross-sectional study included 190 040 veterans who underwent operations between January 1, 2017, and February 28, 2020. Statistical analysis took place from November 1, 2021, to November 17, 2022. Exposure Patient risk of hospitalization or death, evaluated with a Care Assessment Need (CAN) score (range, 0-99, with a higher score representing a greater risk of hospitalization or death), dichotomized as less than 80 or 80 or more. Main Outcomes and Measures Preoperative LST note completion (30 days before or on the day of surgery) or no LST note completion within the 30-day preoperative period prior to or on the day of the index operation. Results Of 190 040 veterans (90.8% men; mean [SD] age, 65.2 [11.9] years), 3.8% completed an LST note before surgery, and 96.2% did not complete an LST note. In the groups with and without LST note completion before surgery, most were aged between 65 and 84 years (62.1% vs 56.7%), male (94.3% vs 90.7%), and White (82.2% vs 78.3%). Compared with patients who completed an LST note before surgery, patients who did not complete an LST note before surgery tended to be female (9.3% vs 5.7%), Black (19.2% vs 15.7%), married (50.2% vs 46.5%), and in better health (Charlson Comorbidity Index score of 0, 25.9% vs 15.2%); to have a lower risk of hospitalization or death (CAN score <80, 98.3% vs 96.9%); or to undergo neurosurgical (9.8% vs 6.2%) or urologic surgical procedures (5.9% vs 2.0%). Over the 3-year interval, unadjusted rates of LST note completion before surgery increased from 0.1% to 9.6%. Covariate-adjusted estimates of LST note completion indicated that veterans at a relatively elevated risk of hospitalization or death (CAN score ≥80) had higher odds of completing an LST note before surgery (odds ratio [OR], 1.29; 95% CI, 1.09-1.53) compared with those with CAN scores less than 80. High-risk surgery was not associated with increased LST note completion before surgery (OR, 0.93; 95% CI, 0.86-1.01). Veterans who underwent cardiothoracic surgery had the highest likelihood of LST note completion before surgery (OR, 1.35; 95% CI, 1.24-1.47). Conclusions and Relevance Despite increasing LST note implementation, a minority of veterans completed an LST note preoperatively. Although doing so was more common among veterans with an elevated risk compared with those at lower risk, improving proactive communication and documentation of goals, particularly among higher-risk veterans, is needed. Doing so may promote goal-concordant surgical care and outcomes.
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Affiliation(s)
- Kyung Mi Kim
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California
- Office of Research Patient Care Services, Stanford Health Care, Palo Alto, California
- Clinical Excellence Research Center, School of Medicine, Stanford University, Palo Alto, California
- Department of Social and Behavioral Sciences, School of Nursing, University of California San Francisco, San Francisco
| | - Karleen F. Giannitrapani
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California
- Primary Care and Population Health, School of Medicine, Stanford University, Palo Alto, California
- Quality Improvement Resource Center for Palliative Care, Stanford University, Palo Alto, California
| | - Ariadna Garcia
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California
- Quantitative Science Unit, School of Medicine, Stanford University, Palo Alto, California
| | - Derek Boothroyd
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California
- Quantitative Science Unit, School of Medicine, Stanford University, Palo Alto, California
| | - Adela Wu
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California
- Department of Neurosurgery, Stanford Health Care, Palo Alto, California
| | - Raymond Van Cleve
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California
| | - Matthew D. McCaa
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California
| | - Maria Yefimova
- Center for Nursing Excellence and Innovation, UCSF Health, San Francisco, California
- Department of Physiological Nursing, School of Nursing, University of California San Francisco, San Francisco
| | - Rebecca A. Aslakson
- Department of Anesthesiology, Larner College of Medicine, University of Vermont, Burlington
| | - Arden M. Morris
- Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California
- S-SPIRE Center, Department of Surgery, School of Medicine, Stanford University, Palo Alto, California
| | | | - Karl A. Lorenz
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California
- Primary Care and Population Health, School of Medicine, Stanford University, Palo Alto, California
- Quality Improvement Resource Center for Palliative Care, Stanford University, Palo Alto, California
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21
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Bennett FB, O'Conner-Von S. Continuous Commitment: Long-Term Care RNs' Experience Communicating With Residents and Their Families About End-of-Life Care Preferences. J Gerontol Nurs 2022; 48:29-36. [DOI: 10.3928/00989134-20221003-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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22
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Statler TM, Hsu FC, Silla L, Sheehan KN, Cowles A, Brooten JK, Omlor RL, Gabbard J. Occurrence of Advance Care Planning and Hospital Course in Patients Admitted for Coronavirus Disease 2019 (COVID-19) During the Pandemic. Am J Hosp Palliat Care 2022:10499091221123570. [PMID: 36018339 PMCID: PMC9420734 DOI: 10.1177/10499091221123570] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction The Coronavirus Disease 2019 (COVID-19) pandemic highlighted the importance
of understanding patients’ goals, values, and medical care preferences given
the high morbidity and mortality. We aimed to examine rates of advance care
planning (ACP) documentation along with hospital course differences in the
absence or presence of ACP among hospitalized patients with COVID-19. Methods This retrospective cohort study was performed at a single tertiary academic
medical center. All adults admitted between March 1, 2020, and June 30,
2020, for COVID-19 were included. Demographics, ACP documentation rates,
presence of ACP forms, palliative care consultation (PCC) rates, code
status, and hospital outcome data were collected. Data were analyzed with
multivariable analysis to identify predictors of ACP documentation. Results Among 356 patients (mean age 60.0, 153 (43%) female), 97 (27.2%) had
documented ACP and 20 (5.6%) had completed ACP forms. In patients with
documented ACP, 52.4% (n = 55) de-escalated care to do-not-resuscitate
(DNR)-limited or comfort measures. PCC occurred rarely (<8%), but 78% (n
= 21) of those consulted de-escalated care. Being admitted to the intensive
care unit (ICU) (OR = 11.1, 95% CI = 5.9-21.1), mechanical intubation (OR =
15.8, 95% CI = 7.4-32.1), and discharge location other than home (OR = 11.3,
95% CI = 5.7-22.7) were associated with ACP documentation. Conclusions This study found low ACP documentation and PCC rates in patients admitted for
COVID-19. PCC and completion of ACP were associated with higher rates of
care de-escalation. These results support the need for pro-active ACP and
PCC for patients admitted for serious illnesses, like COVID-19, to improve
goal-informed care.
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Affiliation(s)
- Tiffany M Statler
- Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Fang-Chi Hsu
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Laura Silla
- Department of Neurology, University of Utah Health, Salt Lake City, UT, USA
| | - Kristin N Sheehan
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Amy Cowles
- Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Justin K Brooten
- Department of Internal Medicine, Section on Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Rebecca L Omlor
- Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jennifer Gabbard
- Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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23
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Kotzé C, Roos JL. Ageism, human rights and ethical aspects of end-of-life care for older people with serious mental illness. Front Psychiatry 2022; 13:906873. [PMID: 35966471 PMCID: PMC9366006 DOI: 10.3389/fpsyt.2022.906873] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
There are many complex concepts to consider during end-of-life discussions and advance care planning, especially when vulnerable populations such as older individuals with serious mental illness are involved. This article aims to summarize some of these important concepts, such as the effects of ageism, preservation of human rights and dignity, supported or shared decision making and palliative approaches. It emerged from a study that found two thirds of 100 participants 60 years of age and older with serious mental illness had end-of-life decision-making capacity. This finding highlighted the individual and contextual nature of decision-making capacity, the importance of consideration of individual values and protection of human dignity during end-of-life care. Healthcare providers have a duty to initiate end-of-life and advance care discussions, to optimize decision-making capacity, and to protect autonomous decision-making. Chronological age or diagnostic categories should never be used as reasons for discrimination and all patients should receive end-of-life care in keeping with their preferences and values.
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Affiliation(s)
- Carla Kotzé
- Department of Psychiatry, Faculty of Health Sciences, School of Medicine, Weskoppies Psychiatric Hospital, University of Pretoria, Pretoria, South Africa
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24
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M A, Loubaris A, Y M, Es-Saad O, Labib S, Sbai H. Communication during covid area: The impact of creating a new communication center. Ann Med Surg (Lond) 2022; 78:103866. [PMID: 35637886 PMCID: PMC9131702 DOI: 10.1016/j.amsu.2022.103866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/20/2022] [Accepted: 05/22/2022] [Indexed: 11/28/2022] Open
Abstract
Background Since the breakout of COVID-19 pandemic, many ways have been proposed to improve the quality of communication between the medical staff patient and their families In our department of intensive care unit in tanger Morocco and due to the lack of resources we proposed to create a communication center near the hospital to keep the families updated. Objectives Explore the outcomes and the satisfaction of family members and intensive care unit physicians about the quality of communication through reception center during the restrictive measures imposed by COVID-19. Methods we have conducted a satisfaction survey with sample of 100 families and 35 members of ICU physician during the period between August and December 2021. Results We found that communications allowed families a better understanding of the clinical state of their patient, However it was inferior to the visit near bed visits, they also thought that it helps reduce the stress due to the lack of information. Physicians believed that the communication center improved the quality of care given to the patient and helped to reduce the tension with family and increased the trust link between then and family members. Conclusion The creation of reception center improved the relation between physicians and families and improved the quality care however it remains insufficient and other strategies should be considered including telecommunication and near bed visits specially in seriouslyç ill patients Since the breakout of COVID-19 pandemic, many ways have been proposed to improve the quality of communication between the medical stuff patient and their families. In our department of intensive care unit in tanger Morocco and due to the lack of resources we proposed to create a communication center neat to the hospital to keep the families updated. Our objective was to Explore the outcomes and the satisfaction of family members and IIntensive care unit physicians about the quality of communication through reception center during the restriction measures imposed by COVID-19.
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Affiliation(s)
- Aabdi M
- Intensive Care Unit, Tanger Tetouan Al Hoceima University Hospital Center, Faculty of Medicine and Pharmacy, Abdelmalek Essaâdi University, Tangier, Morocco
- Corresponding author. Anesthesiology and Intensive Care Unit Department, Tanger Tetouan Al hoceima University Hospital Center, Faculty of Medicine and Pharmacy, Abdelmalek Essaâdi University, Tangier, Morocco.
| | - A. Loubaris
- Intensive Care Unit, Tanger Tetouan Al Hoceima University Hospital Center, Faculty of Medicine and Pharmacy, Abdelmalek Essaâdi University, Tangier, Morocco
| | - Motiaa Y
- Intensive Care Unit, Tanger Tetouan Al Hoceima University Hospital Center, Faculty of Medicine and Pharmacy, Abdelmalek Essaâdi University, Tangier, Morocco
| | - O. Es-Saad
- Intensive Care Unit, Tanger Tetouan Al Hoceima University Hospital Center, Faculty of Medicine and Pharmacy, Abdelmalek Essaâdi University, Tangier, Morocco
| | - S. Labib
- Intensive Care Unit, Tanger Tetouan Al Hoceima University Hospital Center, Faculty of Medicine and Pharmacy, Abdelmalek Essaâdi University, Tangier, Morocco
| | - H. Sbai
- Intensive Care Unit, Tanger Tetouan Al Hoceima University Hospital Center, Faculty of Medicine and Pharmacy, Abdelmalek Essaâdi University, Tangier, Morocco
- Simulation Center for Medical Formation, Faculty of Medicine and Pharmacy, Abdelmalek Essaâdi University, Tangier, Morocco
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Principio de proporcionalidad terapéutica en la decisión de intubación orotraqueal y ventilación mecánica invasiva en paciente COVID-19 grave. ACTA COLOMBIANA DE CUIDADO INTENSIVO 2022. [PMCID: PMC7843031 DOI: 10.1016/j.acci.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
En medicina cuando se aplica el principio de proporcionalidad terapéutica se valoran los medios empleados y el fin previsible en cada paciente. Y se distingue entre tratamientos proporcionados o desproporcionados, valorando el beneficio y utilidad. Entre ellos su aplicación en el paciente COVID-19 grave que requiere intubación orotraqueal y ventilación mecánica invasiva. En ocasiones nos puede generar el dilema ético de proceder a realizar dicho procedimiento y no encontrar beneficio alguno, sino al contrario generar sufrimiento, dolor y prolongación de su posible agonía. Teniendo el deber ético en estos casos de no abandonar sino acompañar a través de los cuidados paliativos, siempre informando al familiar sobre la decisión que se tome. El analizar este principio de proporcionalidad terapéutica y su aplicación en las unidades de cuidado intensivo requiere de una conciencia moral por parte del grupo que tiene la responsabilidad de la toma de la decisiòn y dirimir el dilema ético que se presente. Recordando que a los pacientes que requieran intubación orotraqueal se les deben ofrecer todas las medidas requeridas en ventilación mecánica invasiva y no invasiva para mejoría de la hipoxemia. Se presenta un análisis y reflexión sobre el principio de proporcionalidad terapéutica y su fundamentación ética al igual que una revisión sistemática de la literatura médica relacionada con pacientes con COVID-19 en insuficiencia respiratoria aguda. Y se establecen unas consideraciones científicas y éticas a tener en cuenta en el paciente COVID-19. El principio de proporcionalidad terapéutica ante la decisión de intubación orotraqueal debe fundamentarse en un juicio de proporcionalidad, que garantice que se han hecho y utilizado todos los medios previsibles para evitar la intubación orotraqueal y como único fin útil para beneficiar al paciente será la ventilación mecánica invasiva.
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Barnato AE, Johnson GR, Birkmeyer JD, Skinner JS, O'Malley AJ, Birkmeyer NJO. Advance Care Planning and Treatment Intensity Before Death Among Black, Hispanic, and White Patients Hospitalized with COVID-19. J Gen Intern Med 2022; 37:1996-2002. [PMID: 35412179 PMCID: PMC9002036 DOI: 10.1007/s11606-022-07530-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/29/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Black and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access. OBJECTIVE To examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19. DESIGN Retrospective cohort analysis of manually abstracted electronic medical records. PATIENTS 7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020 MAIN MEASURES: Advance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR). KEY RESULTS Adjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9-1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6-1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)). CONCLUSIONS Hospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death.
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Affiliation(s)
- Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH, USA
| | | | - John D Birkmeyer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Sound Physicians, Tacoma, WA, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Economics, Dartmouth College, Hanover, NH, USA
| | - Allistair James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Nancy J O Birkmeyer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
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Boddaert MS, Douma J, Dijxhoorn AFQ, Héman RACL, van der Rijt CCD, Teunissen SSCM, Huijgens PC, Vissers KCP. Development of a national quality framework for palliative care in a mixed generalist and specialist care model: A whole-sector approach and a modified Delphi technique. PLoS One 2022; 17:e0265726. [PMID: 35320315 PMCID: PMC8942240 DOI: 10.1371/journal.pone.0265726] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 03/07/2022] [Indexed: 11/19/2022] Open
Abstract
In a predominantly biomedical healthcare model focused on cure, providing optimal, person-centred palliative care is challenging. The general public, patients, and healthcare professionals are often unaware of palliative care’s benefits. Poor interdisciplinary teamwork and limited communication combined with a lack of early identification of patients with palliative care needs contribute to sub-optimal palliative care provision. We aimed to develop a national quality framework to improve availability and access to high-quality palliative care in a mixed generalist-specialist palliative care model. We hypothesised that a whole-sector approach and a modified Delphi technique would be suitable to reach this aim. Analogous to the international AGREE guideline criteria and employing a whole-sector approach, an expert panel comprising mandated representatives for patients and their families, various healthcare associations, and health insurers answered the main question: ‘What are the elements defining high-quality palliative care in the Netherlands?’. For constructing the quality framework, a bottleneck analysis of palliative care provision and a literature review were conducted. Six core documents were used in a modified Delphi technique to build the framework with the expert panel, while stakeholder organisations were involved and informed in round-table discussions. In the entire process, preparing and building relationships took one year and surveying, convening, discussing content, consulting peers, and obtaining final consent from all stakeholders took 18 months. A quality framework, including a glossary of terms, endorsed by organisations representing patients and their families, general practitioners, elderly care physicians, medical specialists, nurses, social workers, psychologists, spiritual caregivers, and health insurers was developed and annexed with a summary for patients and families. We successfully developed a national consensus-based patient-centred quality framework for high-quality palliative care in a mixed generalist-specialist palliative care model. A whole-sector approach and a modified Delphi technique are feasible structures to achieve this aim. The process we reported may guide other countries in their initiatives to enhance palliative care.
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Affiliation(s)
- Manon S. Boddaert
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
- Center of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
- * E-mail:
| | - Joep Douma
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
- Palliactief, Dutch Society for Professionals in Palliative Care, Delft, the Netherlands
| | - Anne-Floor Q. Dijxhoorn
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
- Center of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Carin C. D. van der Rijt
- Palliactief, Dutch Society for Professionals in Palliative Care, Delft, the Netherlands
- Department of Medical Oncology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | | | - Peter C. Huijgens
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Kris C. P. Vissers
- Palliactief, Dutch Society for Professionals in Palliative Care, Delft, the Netherlands
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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Katamreddy A, Ye AM, Vorchheimer DA, Hardoon I, Faillace RT, Taub CC. Exploring the Changes in Code Status During the COVID-19 Pandemic and the Implications for Future Pandemic Care. Am J Hosp Palliat Care 2022; 39:1364-1370. [PMID: 35452316 PMCID: PMC9038937 DOI: 10.1177/10499091221092699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective: We aim to explore patterns of inpatient code status during the COVID-19 pandemic compared with a similar timeframe the previous year, as well as utilization of palliative care services. Methods: This is a retrospective cohort study using data from the Montefiore Health system of all inpatient admissions between March 15-May 31, 2019 and March 15-May 31, 2020. Univariate logistic regression was performed with full code status as the outcome. All statistically significant variables were included in the multivariable logistic regression. Results: The total number of admissions declined during the pandemic (16844 vs 11637). A lower proportion of patients had full code status during the pandemic (85.1% vs 94%, P < .001) at the time of discharge/death. There was a 20% relative increase in the number of palliative care consultations during the pandemic (12.2% vs 10.5%, P < .001). Intubated patients were less often full code (66.5% vs 82.2%, P < .001) during the pandemic. Although a lower portion of COVID-19 positive patients had a full code status compared with non-COVID patients (77.6% vs 92.4%, P<.001), there was no statistically significant difference in code status at death (38.3% vs 38.3%, P = .96). Conclusions: The proportion of full code patients was significantly lower during the pandemic. Age and COVID status were the key determinants of code status during the pandemic. There was a higher demand for palliative care services during the pandemic.
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Affiliation(s)
- Adarsh Katamreddy
- Department of Medicine, 24502Albert Einstein College of Medicine/Jacobi Medicine Center, Bronx, NY, USA
| | | | - David A Vorchheimer
- Division of Cardiovascular Disease, Department of Medicine, 384397Albert Einstein College of Medicine/Montefiore Medicine Center, Bronx, NY, USA
| | - Isaac Hardoon
- Palliative Care, Department of Family and Social Medicine, 12285Albert Einstein College of Medicine/ Montefiore Medicine Center, Bronx, NY, USA
| | - Robert T Faillace
- Department of Medicine, 24502Albert Einstein College of Medicine/Jacobi Medicine Center, Bronx, NY, USA
| | - Cynthia C Taub
- Division of Cardiovascular Disease, Department of Medicine, 384397Albert Einstein College of Medicine/Montefiore Medicine Center, Bronx, NY, USA
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Azizi B, Tilburgs B, van Hout HPJ, van der Heide I, Verheij RA, Achterberg WP, van der Steen JT, Joling KJ. Occurrence and Timing of Advance Care Planning in Persons With Dementia in General Practice: Analysis of Linked Electronic Health Records and Administrative Data. Front Public Health 2022; 10:653174. [PMID: 35392479 PMCID: PMC8980429 DOI: 10.3389/fpubh.2022.653174] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Advance care planning (ACP) is a process of communication in which patients and family caregivers discuss preferences for future care with the healthcare team. For persons with dementia, it is crucial to timely engage in ACP. Therefore, we study ACP in dementia using electronic health record data. This study aims to determine how often ACP conversations are recorded, analyze time from dementia diagnosis until the first recorded conversation and time from the first recorded conversation to death, and analyze which factors are associated with the timing of ACP. Methods Electronic records of 15,493 persons with dementia in Dutch general practice between 2008 and 2016 were linked to national administrative databases. ACP conversations and indicators of health deficits to determine frailty were obtained from electronic records coded with the International Classification of Primary Care. Socio-demographic characteristics were derived from the national population registry managed by Statistics Netherlands. Date of death was derived from the Personal Records Database (2008–2018). Results ACP was recorded as such as 22 (95% CI, 20–23) first conversations per 1,000 person-years of follow-up. The hazard ratio (HR) for the first conversation increased every year after dementia diagnosis, from 0.01 in the first year to 0.07 in the 7th and 8th year after diagnosis. Median time from a first conversation to death was 2.57 years (95% CI, 2.31–2.82). Migrant status [non-Western vs. Western (HR 0.31, 95% CI, 0.15–0.65)] was significantly associated with a longer time from dementia diagnosis to the first conversation. Being pre-frail (HR 2.06, 95% CI, 1.58–2.69) or frail (HR 1.40, 95% CI, 1.13–1.73) vs. non-frail was significantly associated with a shorter time from dementia diagnosis to the first ACP conversation. Conclusion ACP conversations in Dutch general practice were rare for persons with dementia, or was rarely recorded as such. In particular among persons with a non-Western migration background and those who are non-frail, it started long after diagnosis. We advise further research into public health and practical strategies to engage persons with dementia with a non-Western migration background and non-frail persons early in the disease trajectory in ACP.
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Affiliation(s)
- Bahar Azizi
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Bram Tilburgs
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Science, Nijmegen, Netherlands
| | - Hein P. J. van Hout
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Iris van der Heide
- Nivel, Netherlands Institute for Health Services Research, Utrecht, Netherlands
| | - Robert A. Verheij
- Nivel, Netherlands Institute for Health Services Research, Utrecht, Netherlands
- Tilburg School of Social and Behavioral Sciences (TRANZO), Tilburg University, Tilburg, Netherlands
| | - Wilco P. Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Jenny T. van der Steen
| | - Karlijn J. Joling
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Evans S, Elder P, Shoulder R, Sundaralingam A, Kewalramani N, Porter B, Flight W, Hardinge M, Rahman NM, Miller M. What can we Learn from Patients who Died from Covid-19 Following Escalation to a Respiratory High Dependency Unit for Trial of Non-Invasive Respiratory Support? J Palliat Care 2022; 37:310-316. [PMID: 35138202 PMCID: PMC9344193 DOI: 10.1177/08258597221078381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background: Covid-19 infection is associated with significant risk of death, particularly in older, comorbid patients. Emerging evidence supports use of non-invasive respiratory support (CPAP and high-flow nasal oxygen [HFNO]) in this context, but little is known about its use in patients receiving end-of-life care. Methods: This was a retrospective study of 33 patients who died of Covid-19 on the Respiratory High Dependency Unit at the John Radcliffe Hospital, Oxford between 28/03/20 and 20/05/20. Data was sourced via retrospective review of electronic patient records and drug charts. Results: Patients dying from Covid-19 on the Respiratory HDU were comorbid with median Charlson Comorbidity Index 5 (IQR 4-6); median age 78 (IQR 72-85). Respiratory support was trialled in all but one case with CPAP being the most common form of first line respiratory support (84.8%) however, was only tolerated in 44.8% of patients. Median time to death was 10.7 days from symptom onset (IQR 7.5-14.6) and 4.9 days from hospital admission (IQR 3.1-8.3). 48.5% of patients remained on respiratory support at the time of death. Conclusions: End-of-life care for patients with Covid-19 remains a challenge. Patients tend to be frail and comorbid with a rapid disease trajectory. Non-Invasive Respiratory Support may play a key role in symptom management in select patients, however, further work is needed in order to identify patients who will most benefit from Respiratory Support and those for whom withdrawal may prevent unnecessary distress at the end of life or potential prolongation of suffering.
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Affiliation(s)
- S Evans
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - P Elder
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Shoulder
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Sundaralingam
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N Kewalramani
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - B Porter
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - W Flight
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Hardinge
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N M Rahman
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK.,Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - M Miller
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Abken ES, Perkins MM, Bender AA. Assisted Living Administrators' Approaches to Advance Care Planning. J Appl Gerontol 2022; 41:391-400. [PMID: 33504248 PMCID: PMC8313630 DOI: 10.1177/0733464820988803] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This project examined administrator processes, barriers, and facilitators for conducting advance care planning in assisted living. METHOD Data from qualitative interviews with 27 administrators from seven diverse assisted living communities in the metropolitan Atlanta area were linked with descriptive and administrative data collected from each site and analyzed using thematic analysis. RESULTS Although administrators generally contended with a lack of staff training and stakeholders' reluctance to discuss advance care planning and end-of-life care, important facilitators of advance care planning in some assisted living communities included periodic follow-up discussions of residents' wishes and successfully educating consumers about the importance of planning. Three study communities whose administrators discussed planning with residents and informal caregivers during regular care plan meetings had more advance care planning documents on file. DISCUSSION These findings demonstrate the potential for nonmedical organizations, such as assisted living, to successfully promote advance care planning among their members.
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Affiliation(s)
| | - Molly M. Perkins
- Emory University
- Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center
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Wahidie D, Altinok K, Yılmaz-Aslan Y, Brzoska P. [Strategies, guidelines and recommendations for coping with the COVID-19 pandemic in palliative and hospice care facilities. Results of a scoping review]. Z Gerontol Geriatr 2022; 55:151-156. [PMID: 35061068 PMCID: PMC8780045 DOI: 10.1007/s00391-022-02016-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 12/17/2021] [Indexed: 11/13/2022]
Abstract
Hintergrund Palliativ- und Hospizeinrichtungen sind durch die COVID-19-Pandemie besonderen Herausforderungen ausgesetzt. Gründe dafür sind insbesondere das hohe Alter und bestehende Vorerkrankungen der Patienten sowie ein körperlich naher Kontakt zwischen Mitarbeitern und Patienten. Ziel der Arbeit Ziel der vorliegenden Studie ist es, bestehende Strategien, Richtlinien und Empfehlungen zum Umgang mit den Herausforderungen der COVID-19-Pandemie in der Palliativ- und Hospizversorgung zu ermitteln, die in Deutschland und anderen Ländern zum Einsatz kommen. Material und Methoden Im Rahmen eines Scoping Reviews wurden die Datenbanken PubMed, CINAHL, Web of Science und PsycInfo durchsucht. Zusätzlich wurde „graue Literatur“ über Google Search und Google Scholar recherchiert. Eingeschlossen wurden alle deutsch- und englischsprachigen Artikel im Zeitraum Januar 2020 bis August 2021, die sich auf die stationäre Palliativ- und Hospizversorgung beziehen. Ergebnisse Insgesamt wurden 51 Veröffentlichungen in die Analyse aufgenommen. Die identifizierten Maßnahmen lassen sich 10 verschiedenen Kategorien zuordnen: Maßnahmen zur Infektionskontrolle, strukturelle Maßnahmen, Besuchsregelungen, Kommunikationsstrukturen, Schulung und Aufklärung, psychosoziale Unterstützungsmaßnahmen, spezifische Überlegungen für Menschen mit Demenz, vorausschauende Pflegeplanung, Abschiednahme sowie Maßnahmen nach dem Tod. Diskussion Bei der Bewältigung der COVID-19-Pandemie dominieren insbesondere Maßnahmen zur Ermöglichung der Kommunikation zwischen Patienten, Mitarbeitern und Angehörigen, psychosoziale Unterstützungsmaßnahmen, strukturelle Maßnahmen und Empfehlungen zur Schulung und Aufklärung aller Beteiligten. Strategien zur Palliativversorgung von Menschen mit Demenz in Pandemiezeiten sowie zu Abschiednahme und Trauerbewältigung von Hinterbliebenen finden weniger Beachtung. Zusatzmaterial online Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00391-022-02016-8) enthalten.
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Affiliation(s)
- Diana Wahidie
- Fakultät für Gesundheit/Department für Humanmedizin, Lehrstuhl für Versorgungsforschung, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Deutschland
| | - Kübra Altinok
- Fakultät für Gesundheit/Department für Humanmedizin, Lehrstuhl für Versorgungsforschung, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Deutschland
| | - Yüce Yılmaz-Aslan
- Fakultät für Gesundheit/Department für Humanmedizin, Lehrstuhl für Versorgungsforschung, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Deutschland.,Fakultät für Gesundheitswissenschaften, AG3 Epidemiologie & International Public Health, Universität Bielefeld, Bielefeld, Deutschland.,Fakultät für Gesundheitswissenschaften, AG6 Versorgungsforschung und Pflegewissenschaft, Universität Bielefeld, Bielefeld, Deutschland
| | - Patrick Brzoska
- Fakultät für Gesundheit/Department für Humanmedizin, Lehrstuhl für Versorgungsforschung, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Deutschland.
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Yen YF, Hu HY, Chou YC, Chen CC, Ho CY. Utilization of Palliative Care Screening Tool to Early Identify Patients with COVID-19 Needing Palliative Care: A Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031054. [PMID: 35162078 PMCID: PMC8834527 DOI: 10.3390/ijerph19031054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/01/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023]
Abstract
There are very few programs that identify patients with coronavirus disease 2019 (COVID-19) who need palliative care. This cohort study presents a model to use a validated palliative care screening tool (PCST) to systematically identify hospitalized patients with COVID-19 in need of palliative care. In this prospective study, we consecutively recruited patients with COVID-19 admitted to Taipei City Hospital between 1 January and 30 July 2021. Patients’ palliative care needs were determined by using the PCST. Advance care planning (ACP) and advance directives (AD) were systemically provided for all patients with a PCST score ≥ 4. Of 897 patients, 6.1% had a PCST score ≥ 4. During the follow-up period, 106 patients died: 75 (8.9%) with a PCST score < 4 and 31 (56.4%) with a PCST score ≥ 4. The incidence of mortality was 2.08 and 0.58/100 person-days in patients with PCST scores ≥ 4 and <4, respectively. After controlling for other covariates, a PCST score ≥ 4 was associated with a higher risk of mortality in patients with COVID-19 (adjusted HR = 2.08; 95% CI: 1.22–3.54; p < 0.001). During hospitalization, 55 patients completed an ACP discussion with their physicians, which led to 15 of them completing the AD. Since hospitalized patients with COVID-19 had a high mortality rate, it is imperative to implement a comprehensive palliative care program to early identify patients needing palliative care and promotion of AD and ACP.
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Affiliation(s)
- Yung-Feng Yen
- Section of Infectious Diseases, Taipei City Hospital, Yangming Branch, Taipei 112, Taiwan
- Institute of Public Health, National Yang-Ming Chiao Tung University, Taipei 112, Taiwan;
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei 112, Taiwan;
- Department of Education and Research, Taipei City Hospital, Taipei 106, Taiwan;
- Department of Psychology and Counseling, University of Taipei, Taipei 100, Taiwan
- Correspondence: (Y.-F.Y.); (C.-Y.H.)
| | - Hsiao-Yun Hu
- Institute of Public Health, National Yang-Ming Chiao Tung University, Taipei 112, Taiwan;
- Department of Education and Research, Taipei City Hospital, Taipei 106, Taiwan;
- Department of Psychology and Counseling, University of Taipei, Taipei 100, Taiwan
| | - Yi-Chang Chou
- Department of Education and Research, Taipei City Hospital, Taipei 106, Taiwan;
| | - Chu-Chieh Chen
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei 112, Taiwan;
| | - Chin-Yu Ho
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Family Medicine, Taipei City Hospital, Yangming Branch, Taipei 112, Taiwan
- Department of Psychology, Soochow University, Taipei 100, Taiwan
- General Education Center, University of Taipei, Taipei 100, Taiwan
- Correspondence: (Y.-F.Y.); (C.-Y.H.)
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Liberman T, Roofeh R, Chin J, Chin K, Razack B, Aquilino J, Herod SH, Amato T. Remote Advance Care Planning in the Emergency Department During COVID-19 Disaster: Program Development and Initial Evaluation. J Emerg Nurs 2022; 48:22-31. [PMID: 34649729 PMCID: PMC8481094 DOI: 10.1016/j.jen.2021.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The coronavirus disease 2019 pandemic caused an unprecedented surge of patients presenting to emergency departments and forced hospitals to adapt to provide care to patients safely and effectively. The purpose here was to disseminate a novel program developed under disaster conditions to address advance care planning communications. METHODS A program development and initial evaluation was conducted for the Remote Goals of Care program, which was created for families to communicate patient goals of care and reduce responsibilities of those in the emergency department. RESULTS This program facilitated 64 remote goals of care conversation, with 72% of conversations taking place remotely with families of patients who were unable to participate. These conversations included discussions of patient preferences for care, including code status, presence of caregivers or surrogates, understanding of diagnosis and prognosis, and hospice care. Initially, this program was available 24 hours per day, 7 days per week, with gradual reduction in hours as needs shifted. Seven nurses who were unable to work in corona-positive environments but were able to continue working remotely were utilized. Lessons learned include the need for speed and agility of response and the benefit of established relationships between traditionally siloed specialties. Additional considerations include available technology for patients and families and expanding the documentation abilities for remote nurses. A logic model was developed to support potential program replication at other sites. DISCUSSION Upon initial evaluation, Remote Goals of Care Program was well received and demonstrated promise in decanting the responsibility of goals of care discussions from the emergency department to a calmer, remote setting. In future iterations, additional services and technology adjustments can be made to make this program more accessible to more patients and families. Other facilities may wish to replicate our Remote Goals of Care Program described here.
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Limitation of life-sustaining treatment and patient involvement in decision-making: a retrospective study of a Danish COVID-19 patient cohort. Scand J Trauma Resusc Emerg Med 2021; 29:173. [PMID: 34930420 PMCID: PMC8686092 DOI: 10.1186/s13049-021-00984-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/29/2021] [Indexed: 12/29/2022] Open
Abstract
Background The coronavirus (COVID-19) pandemic and the risk of an extensive overload of the healthcare systems have elucidated the need to make decisions on the level of life-sustaining treatment for patients requiring hospitalisation. The purpose of the study was to investigate the proportion and characteristics of COVID-19 patients with limitation of life-sustaining treatment decisions and the degree of patient involvement in the decisions. Methods A retrospective observational descriptive study was conducted in three Danish regional hospitals, looking at all patients ≥ 18 years of age admitted in 2020 with COVID-19 as the primary diagnosis. Lists of hospitalised patients admitted due to COVID-19 were extracted. The data registration included age, gender, comorbidities, including mental state, body mass index, frailty, recent hospital admissions, COVID-19 life-sustaining treatment, ICU admission, decisions on limitations of life-sustaining treatment before and during current hospitalisation, hospital length of stay, and hospital mortality. Results A total of 476 patients were included. For 7% (33/476), a decision about limitation of life-sustaining treatment had been made prior to hospital admission. At the time of admission, one or more limitations of life-sustaining treatment were registered for 16% (75/476) of patients. During the admission, limitation decisions were made for an additional 11 patients, totaling 18% (86/476). For 40% (34/86), the decisions were either made by or discussed with the patient. The decisions not made by patients were made by physicians. For 36% (31/86), no information was disclosed about patient involvement. Conclusions Life-sustaining treatment limitation decisions were made for 18% of a COVID-19 patient cohort. Hereof, more than a third of the decisions had been made before hospital admission. Many records lacked information on patient involvement in the decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00984-1.
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Dhont S, Callens R, Stevens D, Bauters F, De Bleecker JL, Derom E, Van Braeckel E. Myotonic dystrophy type 1 as a major risk factor for severe COVID-19? Acta Neurol Belg 2021; 121:1761-1765. [PMID: 33052531 PMCID: PMC7556549 DOI: 10.1007/s13760-020-01514-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/28/2020] [Indexed: 01/05/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is challenging health care systems worldwide. People with myotonic dystrophy type 1 (DM1) represent a high-risk population during infectious disease outbreaks, little is known about the potential impact of COVID-19 on patients with DM1. We studied the clinical course of COVID‐19 in three hospitalized patients with myotonic dystrophy type 1 or Steinert’s disease, between April 1, 2020‐April 30‐2020. All three had advanced Steinert’s disease receiving non-invasive nocturnal home ventilatory support. Two of them lived in a residential care centre. Two patients had a limited respiratory capacity, whereas one patient had a rather preserved functional capacity but more comorbidities. Two out of three patients were obese, none of them had diabetes mellitus. Two patients received hydroxychloroquine. Despite maximal supportive care with oxygen therapy, antibiotics, intensive respiratory physiotherapy and non-invasive positive pressure ventilation, all three patients eventually died due to COVID-19. Our case series of three patients with DM1 admitted for COVID-19 confirms that they are at high risk for severe disease and poor outcome. Clinical trials are needed to define best practices and determinants of outcomes in this unique population.
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Chojecka D, Pytlos J, Zawadka M, Andruszkiewicz P, Szarpak Ł, Dzieciątkowski T, Jaguszewski MJ, Filipiak KJ, Gąsecka A. How to Maintain Safety and Maximize the Efficacy of Cardiopulmonary Resuscitation in COVID-19 Patients: Insights from the Recent Guidelines. J Clin Med 2021; 10:jcm10235667. [PMID: 34884368 PMCID: PMC8658351 DOI: 10.3390/jcm10235667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Since December 2019, the novel coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has remained a challenge for governments and healthcare systems all around the globe. SARS-CoV-2 infection is associated with increased rates of hospital admissions and significant mortality. The pandemic increased the rate of cardiac arrest and the need for cardiopulmonary resuscitation (CPR). COVID-19, with its pathophysiology and detrimental effects on healthcare, influenced the profile of patients suffering from cardiac arrest, as well as the conditions of performing CPR. To ensure both the safety of medical personnel and the CPR efficacy for patients, resuscitation societies have published modified guidelines addressing the specific reality of the COVID-19 pandemic. In this review, we briefly describe the transmission and pathophysiology of COVID-19, present the challenges of CPR in SARS-CoV-2-infected patients, summarize the current recommendations regarding the algorithms of basic life support (BLS), advanced life support (ALS) and pediatric life support, and discuss other aspects of CPR in COVID-19 patients, which potentially affect the risk-to-benefit ratio of medical procedures and therefore should be considered while formulating further recommendations.
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Affiliation(s)
- Dominika Chojecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (D.C.); (J.P.)
| | - Jakub Pytlos
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (D.C.); (J.P.)
| | - Mateusz Zawadka
- 2nd Department of Anesthesia and Intensive Care, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.Z.); (P.A.)
| | - Paweł Andruszkiewicz
- 2nd Department of Anesthesia and Intensive Care, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.Z.); (P.A.)
| | - Łukasz Szarpak
- Department of Clinical Sciences, Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland;
- Department of Clinical Sciences, Maria Sklodowska-Curie Medical Academy in Warsaw, 00-136 Warsaw, Poland;
| | - Tomasz Dzieciątkowski
- Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | | | - Krzysztof Jerzy Filipiak
- Department of Clinical Sciences, Maria Sklodowska-Curie Medical Academy in Warsaw, 00-136 Warsaw, Poland;
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (D.C.); (J.P.)
- Correspondence:
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Westerduin D, Dujardin J, Schuurmans J, Engels Y, Wichmann AB. Making complex decisions in uncertain times: experiences of Dutch GPs as gatekeepers regarding hospital referrals during COVID-19-a qualitative study. BMC Med Ethics 2021; 22:158. [PMID: 34847897 PMCID: PMC8631560 DOI: 10.1186/s12910-021-00725-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 11/11/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND General practitioners often act as gatekeeper, authorizing patients' access to hospital care. This gatekeeping role became even more important during the current COVID-19 crisis as uncertainties regarding COVID-19 made estimating the desirability of hospital referrals (for outpatient or inpatient hospitalization) complex, both for COVID and non-COVID suspected patients. This study explored Dutch general practitioners' experiences and ethical dilemmas faced in decision making about hospital referrals in times of the COVID-19 pandemic. METHODS Semi-structured interviews with Dutch general practitioners working in the Netherlands were conducted. Participants were recruited via purposive sampling. Thematic analysis was conducted using content coding. RESULTS Fifteen interviews were conducted, identifying four themes: one overarching regarding (1) COVID-19 uncertainties, and three themes about experienced ethical dilemmas: (2) the patients' self-determination vs. the general practitioners' paternalism, (3) the general practitioners' duty of care vs. the general practitioners' autonomy rights, (4) the general practitioners' duty of care vs. adequate care provision. CONCLUSIONS Lack of knowledge about COVID-19, risks to infect loved ones, scarcity of hospital beds and loneliness of patients during hospital admission were central in dilemmas experienced. When developing guidelines for future crises, this should be taken into account.
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Affiliation(s)
- Dieke Westerduin
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke Dujardin
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Schuurmans
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anne B Wichmann
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
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Seino Y, Aizawa Y, Kogetsu A, Kato K. Ethical and Social Issues for Health Care Providers in the Intensive Care Unit during the Early Stages of the COVID-19 Pandemic in Japan: a Questionnaire Survey. Asian Bioeth Rev 2021; 14:115-131. [PMID: 34804220 PMCID: PMC8590925 DOI: 10.1007/s41649-021-00194-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/09/2021] [Accepted: 10/12/2021] [Indexed: 11/26/2022] Open
Abstract
This questionnaire-based observational study was conducted in July 2020 with the aim of understanding the ethical and social issues faced by health care providers (HCPs) registered with the Japanese Society of Intensive Care Medicine in intensive care units (ICUs) during the coronavirus disease (COVID-19) pandemic. There were 200 questionnaire respondents, and we analyzed the responses of 189 members who had been involved in COVID-19 treatment in ICUs. The ethical and social issues that HCPs recognized during the pandemic were difficulties in the decision-making process with patients' families, limitations of life-sustaining treatment, lack of palliative care, and inadequate mental support for patients' families and HCPs. Regarding decision-making on issues of clinical ethics during the pandemic, more than half of the respondents thought they had failed to provide sufficient palliative care to patients and responded that they experienced moral distress. The free-text responses on moral distress revealed issues such as unusual treatment and care, restricted visits, challenging situations for HCPs, and psychological burden. Additionally, 38.1% of respondents experienced episodes of social prejudice or discrimination and 4.7% experienced a shortage of medical resources. Our study result shows that the moral distress of HCPs was caused by difficulties in patient-centered decision-making and insufficient medical care to patients and their families. These were caused mainly by a lack of communication due to the stronger implementation of infection control measures. We believe that it is important to address ethical and social issues during a pandemic in order to provide appropriate medical care and prevent burnout among HCPs. Supplementary Information The online version contains supplementary material available at 10.1007/s41649-021-00194-y.
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Affiliation(s)
- Yusuke Seino
- Department of Biomedical Ethics and Public Policy, Graduate School of Medicine, Osaka University, Suita, Osaka Japan
| | - Yayoi Aizawa
- Department of Biomedical Ethics and Public Policy, Graduate School of Medicine, Osaka University, Suita, Osaka Japan
| | - Atsushi Kogetsu
- Department of Biomedical Ethics and Public Policy, Graduate School of Medicine, Osaka University, Suita, Osaka Japan
| | - Kazuto Kato
- Department of Biomedical Ethics and Public Policy, Graduate School of Medicine, Osaka University, Suita, Osaka Japan
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Briedé S, van Goor HMR, de Hond TAP, van Roeden SE, Staats JM, Oosterheert JJ, van den Bos F, Kaasjager KAH. Code status documentation at admission in COVID-19 patients: a descriptive cohort study. BMJ Open 2021; 11:e050268. [PMID: 34758991 PMCID: PMC8587534 DOI: 10.1136/bmjopen-2021-050268] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 10/26/2021] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES The COVID-19 pandemic pressurised healthcare with increased shortage of care. This resulted in an increase of awareness for code status documentation (ie, whether limitations to specific life-sustaining treatments are in place), both in the medical field and in public media. However, it is unknown whether the increased awareness changed the prevalence and content of code status documentation for COVID-19 patients. We aim to describe differences in code status documentation between infectious patients before the pandemic and COVID-19 patients. SETTING University Medical Centre of Utrecht, a tertiary care teaching academic hospital in the Netherlands. PARTICIPANTS A total of 1715 patients were included, 129 in the COVID-19 cohort (a cohort of COVID-19 patients, admitted from March 2020 to June 2020) and 1586 in the pre-COVID-19 cohort (a cohort of patients with (suspected) infections admitted between September 2016 to September 2018). PRIMARY AND SECONDARY OUTCOME MEASURES We described frequency of code status documentation, frequency of discussion of this code status with patient and/or family, and content of code status. RESULTS Frequencies of code status documentation (69.8% vs 72.7%, respectively) and discussion (75.6% vs 73.3%, respectively) were similar in both cohorts. More patients in the COVID-19 cohort than in the before COVID-19 cohort had any treatment limitation as opposed to full code (40% vs 25%). Within the treatment limitations, 'no intensive care admission' (81% vs 51%) and 'no intubation' (69% vs 40%) were more frequently documented in the COVID-19 cohort. A smaller difference was seen in 'other limitation' (17% vs 9%), while 'no resuscitation' (96% vs 92%) was comparable between both periods. CONCLUSION We observed no difference in the frequency of code status documentation or discussion in COVID-19 patients opposed to a pre-COVID-19 cohort. However, treatment limitations were more prevalent in patients with COVID-19, especially 'no intubation' and 'no intensive care admission'.
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Affiliation(s)
- Saskia Briedé
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Harriet M R van Goor
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Titus A P de Hond
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sonja E van Roeden
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Judith M Staats
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frederiek van den Bos
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Karin A H Kaasjager
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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A Duty to Plan: Proactive Goals of Care Conversations with Seriously Ill Veterans Who Test Positive for COVID-19. J Gen Intern Med 2021; 36:3636-3638. [PMID: 33950344 PMCID: PMC8097105 DOI: 10.1007/s11606-021-06837-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/19/2021] [Accepted: 04/20/2021] [Indexed: 11/05/2022]
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Chou TJ, Wu YR, Tsai JS, Cheng SY, Yao CA, Peng JK, Chiu TY, Huang HL. Telehealth-Based Family Conferences with Implementation of Shared Decision Making Concepts and Humanistic Communication Approach: A Mixed-Methods Prospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010801. [PMID: 34682545 PMCID: PMC8535301 DOI: 10.3390/ijerph182010801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/10/2021] [Accepted: 10/12/2021] [Indexed: 01/14/2023]
Abstract
Smartphone-enabled, telehealth-based family conferences represent an attractive and safe alternative to deliver communication during the COVID-19 pandemic. However, some may fear that the therapeutic relationship might be filtered due to a lack of direct human contact. The study aims to explore whether shared decision-making model combining VALUE (Value family statements, Acknowledge emotions, Listen, Understand the patient as a person, Elicit questions) and PLACE (Prepare with intention, Listen intently and completely, Agree on what matters most, Connect with the patient’s story, Explore emotional cues) framework can help physicians respond empathetically to emotional cues and foster human connectedness in a virtual context. Twenty-five virtual family conferences were conducted in a national medical center in Taiwan. The expression of verbal emotional distress was noted in 20% of patients and 20% of family members, while nonverbal distress was observed in 24% and 28%, respectively. On 10-point Likert scale, the satisfaction score was 8.7 ± 1.5 toward overall communication and 9.0 ± 1.1 on meeting the family’s needs. Adopting SDM concepts with VALUE and PLACE approaches helps physicians foster connectedness in telehealth family conferences. The model has high participant satisfaction scores and may improve healthcare quality among the pandemic.
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Affiliation(s)
- Tzu-Jung Chou
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
| | - Yu-Rui Wu
- Department of Family Medicine, Taitung Christian Hospital, Taitung 950, Taiwan;
| | - Jaw-Shiun Tsai
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
- New Southbound Health Center, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Shao-Yi Cheng
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
- New Southbound Health Center, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Chien-An Yao
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
| | - Jen-Kuei Peng
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
- New Southbound Health Center, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Tai-Yuan Chiu
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
- New Southbound Health Center, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Hsien-Liang Huang
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
- New Southbound Health Center, National Taiwan University Hospital, Taipei 100, Taiwan
- Correspondence: ; Tel.: +886-2-2312-3456 (ext. 66832)
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Catalisano G, Ippolito M, Marino C, Giarratano A, Cortegiani A. Palliative Care Principles and Anesthesiology Clinical Practice: Current Perspectives. J Multidiscip Healthc 2021; 14:2719-2730. [PMID: 34611408 PMCID: PMC8486274 DOI: 10.2147/jmdh.s240563] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background Palliative care is a person-centered approach aiming to relieve patient’s health-related suffering and it is often needed when caring for critically ill patients to manage symptoms and identify goals of care. Aim To describe the integration of palliative care principles in anesthesiology clinical practice, within and outside the ICU and to analyze the additional challenges that COVID-19 pandemic is posing in this context. Methods For the purpose of this review, PubMed database was searched for studies concerning palliative care and end of life care, in contexts involving anesthesiologists and intensivists, published in the last 5 years. Results Anesthesiologists and intensivists integrate palliative care within their daily practice providing symptoms management as well as family counseling. High-quality communicational skills are fundamental for anesthesiologists and intensivists especially when interfacing with surrogate decision makers in the ICU or with patients in the preoperative setting while discussing goals of care. Coronavirus disease 2019 (COVID-19) pandemic has challenged many aspects of palliative care delivery: reduced family presence within the ICU, communication with families through phone calls or video calls, patient–physician relationship mediated by bulky personal protective equipment and healthcare workers physical and psychological distress due to the increased workload and limitations in resources are some of the most evident. Conclusion Anesthesiologists and intensivists are increasingly facing challenging clinical situations where principles and practice of palliative care have to be applied. In this sense, increasing knowledge on palliative care and providing specific training would allow to deliver high-quality symptom management, family counseling and end of life guidance in critical care settings. COVID-19 pandemic sets additional difficulties to palliative care delivery.
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Affiliation(s)
- Giulia Catalisano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Claudia Marino
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
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Hughes K, Achauer S, Baker EF, Knowles HC, Clayborne EP, Goett RR, Moussa M. Addressing end-of-life care in the chronically ill: Conversations in the emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12569. [PMID: 34632450 PMCID: PMC8486416 DOI: 10.1002/emp2.12569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 11/23/2022] Open
Abstract
Patients present to the emergency department in various stages of chronic illness. Advance directives (ADs) aid emergency physicians in making treatment decisions, but only a minority of Americans have completed an AD, and the percentage of those who have discussed their end-of-life wishes may be even lower. This article addresses the use of common ADs and roadblocks to their use from the perspectives of families, patients, and physicians. Cases to examine new approaches to optimizing end-of-life conversations in patients who are chronically ill, such as the Improving Palliative Care in Emergency Medicine Project, a decision-making framework that opens discussion for patients to gain understanding and determine preferences, and the Brief Negotiated Interview, a 7-minute, scripted, motivational interview that determines willingness for behavior change and initiates care planning, are used.
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Affiliation(s)
- Katarina Hughes
- University of Toledo College of Medicine and Life SciencesToledoOhioUSA
| | - Samantha Achauer
- University of Toledo College of Medicine and Life SciencesToledoOhioUSA
| | | | | | - Elizabeth P. Clayborne
- Department of Emergency MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | | | - Mohamad Moussa
- Emergency MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOhioUSA
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van der Smissen D, van der Heide A, Sudore RL, Rietjens JAC, Korfage IJ. Measuring advance care planning behavior in Dutch adults: translation, cultural adaptation and validation of the Advance Care Planning Engagement Survey. BMC Med Res Methodol 2021; 21:194. [PMID: 34563115 PMCID: PMC8467154 DOI: 10.1186/s12874-021-01389-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 08/21/2021] [Indexed: 11/28/2022] Open
Abstract
Background Advance care planning (ACP) enables people to define, discuss, and record preferences for treatment and care. Measures of ACP behavior are lacking in the Netherlands. We aimed to translate, culturally adapt and validate the 34-item ACP Engagement Survey into Dutch. Methods Following validation guidelines, we tested content validity, internal consistency, reproducibility, construct validity, interpretability and criterion validity among persons with and without chronic disease. Results Forward-backward translation indicated the need of only minor adaptations. Two hundred thirty-two persons completed baseline and retest surveys; 121 were aged ≥60 years. Persons with chronic disease (n = 151) considered the survey more valuable than those without (66 vs. 59, p < 0.001, scale of 20–100), indicating good content validity. Internal consistency (Cronbach’s alpha: 0.97) and reproducibility (intraclass correlation: 0.88) were good. Total ACP Engagement was higher among persons with chronic disease than those without (2.9 vs. 2.4, p < 0.01, scale of 1 to 5), indicating good psychometric support for construct validity and interpretability. Positive correlations of the ACP Engagement Survey and the General Self-Efficacy survey indicated good criterion validity (p < 0.05). Conclusions This study provided good psychometric support for the validity and reliability of the Dutch 34-item ACP Engagement Survey. This instrument can be used to assess involvement in ACP in adults with and without chronic disease. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01389-5.
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Affiliation(s)
- Doris van der Smissen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands.
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA.,Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - Judith A C Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
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Vranas KC, Plinke W, Bourne D, Kansagara D, Lee RY, Kross EK, Slatore CG, Sullivan DR. The influence of POLST on treatment intensity at the end of life: A systematic review. J Am Geriatr Soc 2021; 69:3661-3674. [PMID: 34549418 DOI: 10.1111/jgs.17447] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. METHODS We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life). RESULTS Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes. CONCLUSION We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.
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Affiliation(s)
- Kelly C Vranas
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Wesley Plinke
- Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Donald Bourne
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Devan Kansagara
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Christopher G Slatore
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Donald R Sullivan
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
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Aker N, West E, Davies N, Moore KJ, Sampson EL, Nair P, Kupeli N. Challenges faced during the COVID-19 pandemic by family carers of people living with dementia towards the end of life. BMC Health Serv Res 2021; 21:996. [PMID: 34548067 PMCID: PMC8454696 DOI: 10.1186/s12913-021-07019-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/31/2021] [Indexed: 01/10/2023] Open
Abstract
Background People living with dementia account for a large proportion of deaths due to COVID-19. Family carers are faced with making significant and emotive decisions during the pandemic, including decisions about end of life. We aimed to explore the challenges faced by family carers of people living with dementia during the first wave of the COVID-19 pandemic in England, as reported by charity telephone support line staff, who were able to objectively discuss a range of different experiences of many different carers who call the helpline. In particular, we focussed on key concerns and areas of decision making at the end of life. Methods We conducted a qualitative study using semi-structured interviews with eight telephone support line staff from two UK based charities who support carers of people living with dementia and those at the end of life. Interviews were conducted in the first wave of the pandemic in England in May–June 2020. Results An overarching theme of uncertainty and reactivity during a crisis was identified, and within this, five main themes were identified: concerns about care transitions, uncertainty in engaging support and help, pandemic-motivated care planning, maintaining the wellbeing of the person living with dementia, and trust, loss of agency and confusion. Conclusions Family carers may be reluctant to seek support because of fear of what may happen to their relative, which may include hospitalisation and becoming ill with COVID-19, care home placement, or not being able to be with a relative at the end of life. In some cases, a lack of trust has developed, and instead carers are seeking support from alternative services they trust such as nationally known charities.This study was used to inform the development of a decision aid to support family carers making decisions about care for their relative with dementia during the pandemic, who the lack the capacity to make their own decisions.
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Affiliation(s)
- Narin Aker
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Emily West
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK.,Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.,National Ageing Research Institute, Parkville, Victoria, Australia
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.,Barnet, Enfield and Haringey Mental Health Liaison Service, North Middlesex University Hospital NHS Trust, London, UK
| | - Pushpa Nair
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
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Smolin B, Raz-Pasteur A, Mashiach T, Zaidani H, Levi L, Strizevsky A, King DA, Dwolatzky T. Mechanical ventilation for older medical patients in a large tertiary medical care center. Eur Geriatr Med 2021; 13:253-265. [PMID: 34542845 PMCID: PMC8450715 DOI: 10.1007/s41999-021-00557-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022]
Abstract
Aim The aim of the study is to determine the factors influencing the outcomes of older ventilated medical patients in a large tertiary medical center. Findings Of 554 older patients (mean age 79 years) who underwent mechanical ventilation for the first time during the study period in-hospital mortality was 64.1% and overall 6-months survival was 26%. A combination of age 85 years and older, poor functional status prior to ventilation, and associated morbidity were the strongest negative predictors of survival after discharge from the hospital. Message The identification of factors predicting poor survival of mechanical ventilation will assist policy makers in clinical decision-making particularly at times of limited health resources. Background The development of technologies for the prolongation of life has resulted in an increase in the number of older ventilated patients in internal medicine and chronic care wards. Our study aimed to determine the factors influencing the outcomes of older ventilated medical patients in a large tertiary medical center. Methods We performed a prospective observational cohort study including all newly ventilated medical patients aged 65 years and older over a period of 18 months. Data were acquired from computerized medical records and from an interview of the medical personnel initiating mechanical ventilation. Results A total of 554 patients underwent mechanical ventilation for the first time during the study period. The average age was 79 years, and 80% resided at home. Following mechanical ventilation, 8% died in the emergency room, and the majority of patients (351; 63%) were hospitalized in internal medicine wards. In-hospital mortality was 64.1%, with 48% dying during the first week of hospitalization. Overall 6-months survival was 26%. We found that a combination of age 85 years and older, functional status prior to ventilation, and associated morbidity (diabetes with target organ injury and/or oncological solid organ disease) were the strongest negative predictors of survival after discharge from the hospital. Conclusion Mechanical ventilation at older age is associated with poor survival and it is possible to identify factors predicting survival. In the midst of the COVID-19 pandemic, the findings of this study may help in the decision-making process regarding mechanical ventilation for older people.
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Affiliation(s)
- Bella Smolin
- Internal Medicine Division, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ayelet Raz-Pasteur
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Internal Medicine Ward "A", Rambam Health Care Campus, Haifa, Israel
| | - Tatiana Mashiach
- Epidemiology and Statistics Unit, Rambam Health Care Campus, Haifa, Israel
| | - Hisam Zaidani
- Internal Medicine Division, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Leon Levi
- Medical Administration, Rambam Health Care Campus, Haifa, Israel
| | | | - Daniel A King
- Pulmonary and Respiratory Intensive Care Division, Meir Medical Center, Kfar Saba, Israel
| | - Tzvi Dwolatzky
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel. .,Pulmonary and Respiratory Intensive Care Division, Meir Medical Center, Kfar Saba, Israel. .,Geriatric Unit, Rambam Health Care Campus, 8 Ha'Aliyah Street, Box 9602, 3109601, Haifa, Israel.
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Latifi M, Anvari Tafti M, Davari Dolatabadi N, Rafiei Z, Allahbakhshian Farsani L. E-Health: The Impact of Social Network on Self Care Behavior in Heart Failure Patients toward COVID-19 Epidemic. Adv Biomed Res 2021; 10:15. [PMID: 34476223 PMCID: PMC8378447 DOI: 10.4103/abr.abr_195_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/03/2020] [Accepted: 12/19/2020] [Indexed: 11/04/2022] Open
Abstract
Background Patients with heart failure are one of the high-risk groups for coronary artery. Distance education of self-care behaviors can be effective in preventing the disease. The aim of this study was to investigate the effect of social networks in explaining the awareness of cardiovascular patients' self-care behaviors toward COVID-19. Materials and Methods In the present survey study, 227 patients with a history of heart failure were selected from Shahid Rajaei Hospital in Tehran by the available sampling method (May to July 2020). Data collection tools were the standard European Self-Care Behavior Questionnaire for heart failure and the Dorty Elizabeth Orem self-care model. Data were analyzed using SPSS Version 22. Results The results of the Pearson correlation coefficient showed a positive and relatively strong linear relationship between the variable of the degree of persistence in the use of networks with the eight dimensions of self-care behavior except psychological emotion control (r = -0.39, P = 0.315). Furthermore, a significant weak inverse relationship between the dimension of "cooperation with physicians and treatment staff" (r = -0.22, P = 0.129). Moreover, psychological support (r = -0/034, P = 0.446) was observed with the use of networks. Multivariate regression analysis revealed that the type of activity and participation in networks has a greater share and effect in increasing the score of self-care behavior of 0.55. Conclusions Since the use of networks has a positive effect on patients' self-care behavior, the use of these networks is recommended as a community-based approach in the health system and to improve health and health outcomes.
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Affiliation(s)
- Masoomeh Latifi
- PhD in Information Sciences and Knowledge Studies, Cardiovascular Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Motahare Anvari Tafti
- Department of Emergency Medicine, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Nasrin Davari Dolatabadi
- Associate Professor of Health Information Management, Department of Health Information Technology, School of Allied Medical Sciences, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Zahra Rafiei
- Department of Critical Care Nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Leili Allahbakhshian Farsani
- PhD in Knowledge and Information Sciences, Vice Chancellor for Research and Technology, Isfahan University of Medical Sciences, Isfahan, Iran
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50
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Soosaipillai G, Wu A, Dettorre GM, Diamantis N, Chester J, Moss C, Aguilar-Company J, Bower M, Sng CCT, Salazar R, Brunet J, Jones E, Mesia R, Jackson A, Mukherjee U, Sita-Lumsden A, Seguí E, Ottaviani D, Carbó A, Benafif S, Würstlein R, Carmona C, Chopra N, Cruz CA, Swallow J, Saoudi N, Felip E, Galazi M, Garcia-Fructuoso I, Lee AJX, Newsom-Davis T, Wong YNS, Sureda A, Maluquer C, Ruiz-Camps I, Cabirta A, Prat A, Loizidou A, Gennari A, Ferrante D, Tabernero J, Russell B, Van Hemelrijck M, Dolly S, Hulbert-Williams NJ, Pinato DJ. Specialist palliative and end-of-life care for patients with cancer and SARS-CoV-2 infection: a European perspective. Ther Adv Med Oncol 2021; 13:17588359211042224. [PMID: 34497669 PMCID: PMC8419540 DOI: 10.1177/17588359211042224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 08/09/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Specialist palliative care team (SPCT) involvement has been shown to improve symptom control and end-of-life care for patients with cancer, but little is known as to how these have been impacted by the COVID-19 pandemic. Here, we report SPCT involvement during the first wave of the pandemic and compare outcomes for patients with cancer who received and did not receive SPCT input from multiple European cancer centres. METHODS From the OnCovid repository (N = 1318), we analysed cancer patients aged ⩾18 diagnosed with COVID-19 between 26 February and 22 June 2020 who had complete specialist palliative care team data (SPCT+ referred; SPCT- not referred). RESULTS Of 555 eligible patients, 317 were male (57.1%), with a median age of 70 years (IQR 20). At COVID-19 diagnosis, 44.7% were on anti-cancer therapy and 53.3% had ⩾1 co-morbidity. Two hundred and six patients received SPCT input for symptom control (80.1%), psychological support (54.4%) and/or advance care planning (51%). SPCT+ patients had more 'Do not attempt cardio-pulmonary resuscitation' orders completed prior to (12.6% versus 3.7%) and during admission (50% versus 22.1%, p < 0.001), with more SPCT+ patients deemed suitable for treatment escalation (50% versus 22.1%, p < 0.001). SPCT involvement was associated with higher discharge rates from hospital for end-of-life care (9.7% versus 0%, p < 0.001). End-of-life anticipatory prescribing was higher in SPCT+ patients, with opioids (96.3% versus 47.1%) and benzodiazepines (82.9% versus 41.2%) being used frequently for symptom control. CONCLUSION SPCT referral facilitated symptom control, emergency care and discharge planning, as well as high rates of referral for psychological support than previously reported. Our study highlighted the critical need of SPCTs for patients with cancer during the pandemic and should inform service planning for this population.
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Affiliation(s)
| | - Anjui Wu
- Cancer Division, University College London Hospitals, London, UK
- UCL Cancer Institute, Fitzrovia, London, UK
| | - Gino M Dettorre
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | | | - John Chester
- Medical Oncology, School of Medicine, Cardiff University, Cardiff, UK
- Medical Oncology, Velindre Cancer Centre, Cardiff, UK
| | - Charlotte Moss
- Translational Oncology and Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Juan Aguilar-Company
- Medical Oncology, Vall d’Hebron University Hospital and Institute of Oncology (VHIO), Barcelona, Spain
- Infectious Diseases, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Mark Bower
- Department of Oncology and National Centre for HIV Malignancy, Chelsea & Westminster Hospital, London, UK
| | | | - Ramon Salazar
- Department of Medical Oncology, ICO L’Hospitalet, Oncobell Program (IDIBELL), CIBERONC. Hospitalet de Llobregat, Spain
| | - Joan Brunet
- Department of Medical Oncology, Catalan Institute of Oncology, University Hospital Josep Trueta, Girona, Spain
| | - Eleanor Jones
- Medical Oncology, Guy’s and St Thomas’ NHS Foundation Trust (GSTT), London, UK
| | - Ricard Mesia
- Department of Medical Oncology, Catalan Institute of Oncology, Badalona, Spain
| | | | - Uma Mukherjee
- Medical Oncology, Barts Health NHS Trust, London, UK
| | - Ailsa Sita-Lumsden
- Medical Oncology, Guy’s and St Thomas’ NHS Foundation Trust (GSTT), London, UK
| | - Elia Seguí
- Department of Medical Oncology, Hospital Clinic, Barcelona, Spain
| | - Diego Ottaviani
- Cancer Division, University College London Hospitals, London, UK
| | - Anna Carbó
- Department of Medical Oncology, Catalan Institute of Oncology, University Hospital Josep Trueta, Girona, Spain
| | - Sarah Benafif
- Cancer Division, University College London Hospitals, London, UK
| | - Rachel Würstlein
- Department of Gynaecology and Obstetrics, Breast Centre and Gynaecological Cancer Centre and CCC Munich, University Hospital Munich, Munich, Germany
| | - Carme Carmona
- Department of Medical Oncology, Catalan Institute of Oncology, University Hospital Josep Trueta, Girona, Spain
| | - Neha Chopra
- Cancer Division, University College London Hospitals, London, UK
| | | | - Judith Swallow
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - Nadia Saoudi
- Medical Oncology, Vall d’Hebron University Hospital and Institute of Oncology (VHIO), Barcelona, Spain
| | - Eudald Felip
- Department of Medical Oncology, Catalan Institute of Oncology, Badalona, Spain
| | - Myria Galazi
- Cancer Division, University College London Hospitals, London, UK
| | - Isabel Garcia-Fructuoso
- Department of Medical Oncology, Catalan Institute of Oncology, University Hospital Josep Trueta, Girona, Spain
| | - Alvin J. X. Lee
- Cancer Division, University College London Hospitals, London, UK
| | - Thomas Newsom-Davis
- Department of Oncology and National Centre for HIV Malignancy, Chelsea & Westminster Hospital, London, UK
| | | | - Anna Sureda
- Haematology Department, ICO Hospitalet, Hospitalet de Llobregat, IDIBELL, Universitat de Barcelona, Spain
| | - Clara Maluquer
- Haematology Department, ICO Hospitalet, Hospitalet de Llobregat, IDIBELL, Universitat de Barcelona, Spain
| | - Isabel Ruiz-Camps
- Infectious Diseases, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Alba Cabirta
- Department of Haematology, Vall d’Hebron University Hospital and Institute of Oncology (VHIO), Barcelona, Spain
| | - Aleix Prat
- Department of Medical Oncology, Hospital Clinic, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumours, IDIBAPS, Barcelona, Spain
| | - Angela Loizidou
- Department of Infectious Diseases, Internal Medicine, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Alessandra Gennari
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale and Maggiore della Carità Hospital, Novara, Italy
| | - Daniela Ferrante
- Department of Translational Medicine, Unit of Cancer Epidemiology, CPO-Piemonte, University of Eastern Piedmont, Novara, Italy
| | - Josep Tabernero
- Medical Oncology, Vall d’Hebron University Hospital and Institute of Oncology (VHIO), Barcelona, Spain
| | - Beth Russell
- Translational Oncology and Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Mieke Van Hemelrijck
- Translational Oncology and Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
- Medical Oncology, Guy’s and St Thomas’ NHS Foundation Trust (GSTT), London, UK
| | - Saoirse Dolly
- Medical Oncology, Guy’s and St Thomas’ NHS Foundation Trust (GSTT), London, UK
| | - Nicholas J Hulbert-Williams
- Professor of Behavioural Medicine, Centre for Contextual Behavioural Science, School of Psychology, University of Chester, Chritchley Building, Parkgate Road, Chester, Cheshire, CH1 4BJ, UK
| | - David J Pinato
- Department of Surgery and Cancer, Clinical Senior Lecturer and Consultant Medical Oncologist, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
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