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Oshow F, Shah J, Ali SK. Religious, Cultural, and Sex Influences on Advance Care Directives in Patients Admitted to a Tertiary Care Center in Kenya. J Pain Symptom Manage 2024; 67:12-19.e1. [PMID: 37709176 DOI: 10.1016/j.jpainsymman.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Advance care directives (AD) are instructions from patients regarding the care they would prefer if they could not make medical decisions in the future. It is widely recognized that racial and ethnic as well as sex differences, particularly in the West, can influence AD. However, to the best of our knowledge, there is limited understanding of how these factors impact AD in sub-Saharan Africa. METHODS This prospective cross-sectional study was conducted at the Aga Khan University Hospital, Nairobi. We enrolled patients above the age of 18 years who were admitted to the general medical wards. The data were collected using a structured questionnaire that consisted of questions based on demographics and AD. Descriptive statistics were used to summarize the data, including frequencies and percentages, as well as medians and interquartile ranges. RESULTS The study involved 286 participants, with a median age of 44.0 years (IQR: 37.0 - 52.0). Roughly half of the participants were male (51.7%), and the majority identified themselves as Christians (77.3%) and of African ethnicity (78.3%). Upon further analysis, it was discovered that only 35.3% had an awareness of AD. Notably, individuals from the Hindu religion and Asian ethnicity demonstrated significantly higher knowledge of AD. Furthermore, more males reported having a living will and believed that AD are crucial for patients who could not make independent medical decisions compared to females. CONCLUSION This study indicated a lower awareness and knowledge of AD among the participants. Hindus and Asians exhibited higher levels of awareness regarding AD. Considering the diverse religious and cultural backgrounds in our setting, there is a pressing need for strategies to increase awareness surrounding AD.
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Affiliation(s)
- Fariah Oshow
- Department of Internal Medicine (FO, JS), Aga Khan University, Nairobi, Kenya
| | - Jasmit Shah
- Department of Internal Medicine (FO, JS), Aga Khan University, Nairobi, Kenya; Brain and Mind Institute (JS), Aga Khan University, Nairobi, Kenya
| | - Sayed K Ali
- Department of Internal Medicine (FO, JS), Aga Khan University, Nairobi, Kenya.
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Buiar PG, Goldim JR. Barriers to the composition and implementation of advance directives in oncology: a literature review. Ecancermedicalscience 2019; 13:974. [PMID: 31921345 PMCID: PMC6946425 DOI: 10.3332/ecancer.2019.974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Indexed: 12/21/2022] Open
Abstract
The advance directive (AD) is an important resource in oncology and all areas of medicine directly involved in the care of palliative patients. It provides people with the right to have their living wills honoured when they cannot respond by themselves. Despite their importance, ADs are still underused in most countries due to multiple factors. The objective of this review is to better categorise the barriers and difficulties that could impair the composition and implementation of ADs, allowing direct efforts against these obstacles. After the literature review, we believe that there would be five steps in the trajectory of an AD (discussion, composition, registration, access and implementation) and that all those steps can be affected by factors involving the health systems and professionals, the patient themselves and relatives or caregivers.
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Affiliation(s)
- Pedro Grachinski Buiar
- Medical Oncology Department, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0001-5144-1197
| | - José Roberto Goldim
- Bioethics Division, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0003-2127-6594
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Moreno-Alonso D, Porta-Sales J, Monforte-Royo C, Trelis-Navarro J, Sureda-Balarí A, Fernández De Sevilla-Ribosa A. Palliative care in patients with haematological neoplasms: An integrative systematic review. Palliat Med 2018; 32:79-105. [PMID: 29130387 DOI: 10.1177/0269216317735246] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Palliative care was originally intended for patients with non-haematological neoplasms and relatively few studies have assessed palliative care in patients with haematological malignancies. AIM To assess palliative care interventions in managing haematological malignancies patients treated by onco-haematology departments. DESIGN Integrative systematic review with data extraction and narrative synthesis (PROSPERO #: CRD42016036240). DATA SOURCES PubMed, CINAHL, Cochrane, Scopus and Web-of-Science were searched for articles published through 30 June 2015. Study inclusion criteria were as follows: (1) published in English or Spanish and (2) containing data on palliative care interventions in adults with haematological malignancies. RESULTS The search yielded 418 articles; 99 met the inclusion criteria. Six themes were identified: (1) end-of-life care, (2) the relationship between onco-haematology and palliative care departments and referral characteristics, (3) clinical characteristics, (4) experience of patients/families, (5) home care and (6) other themes grouped together as 'miscellany'. Our findings indicate that palliative care is often limited to the end-of-life phase, with late referral to palliative care. The symptom burden in haematological malignancies patients is more than the burden in non-haematological neoplasms patients. Patients and families are generally satisfied with palliative care. Home care is seldom used. Tools to predict survival in this patient population are lacking. CONCLUSION Despite a growing interest in palliative care for haematological malignancies patients, the evidence base needs to be strengthened to expand our knowledge about palliative care in this patient group. The results of this review support the need to develop closer cooperation and communication between the palliative care and onco-haematology departments to improve patient care.
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Affiliation(s)
- Deborah Moreno-Alonso
- 1 Palliative Care Service, Institut Catala d' Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Josep Porta-Sales
- 1 Palliative Care Service, Institut Catala d' Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Cristina Monforte-Royo
- 2 Nursing, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain
| | - Jordi Trelis-Navarro
- 1 Palliative Care Service, Institut Catala d' Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Sureda-Balarí
- 3 Clinical Haematology Service, Institut Catala d' Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
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Lee B, Na S, Park M, Ham S, Kim J. Home Return After Surgery in Patients Aged over 85 Years is Associated with Preoperative Albumin Levels, the Type of Surgery, and APACHE II Score. World J Surg 2016; 41:919-926. [DOI: 10.1007/s00268-016-3830-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Do-not-resuscitate orders in cancer patients: a review of literature. Support Care Cancer 2016; 25:677-685. [PMID: 27771786 DOI: 10.1007/s00520-016-3459-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
Discussing do-not-resuscitate (DNR) orders is part of daily hospital practice in oncology departments. Several medical factors and patient characteristics are associated with issuing DNR orders in cancer patients. DNR orders are often placed late in the disease process. This may be a cause for disagreements between doctors and between doctors and patients and may cause for unnecessary treatments and admissions. In addition, DNR orders on itself may influence the rest of the medical treatment for patients. We present recommendations for discussing DNR orders and medical futility in practice through shared decision-making. Prospective studies are needed to investigate in which a patient's cardiopulmonary resuscitation (CPR) is futile and whether or not DNR orders influence the medical care of patients.
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Liang YH, Wei CH, Hsu WH, Shao YY, Lin YC, Chou PC, Cheng AL, Yeh KH. Do-not-resuscitate consent signed by patients indicates a more favorable quality of end-of-life care for patients with advanced cancer. Support Care Cancer 2016; 25:533-539. [PMID: 27704261 DOI: 10.1007/s00520-016-3434-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 09/26/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE Do-not-resuscitate (DNR) consent is crucial in end-of-life (EOL) care for patients with advanced cancer. However, DNR consents signed by patients (DNR-P) and surrogates (DNR-S) reflect differently on patient autonomy and awareness. METHODS This retrospective study enrolled advanced cancer patients treated at National Taiwan University Hospital, Hsin-Chu Branch between 2012 and 2014. Patients who signed DNR consent at other hospitals were excluded; the remaining patients were subsequently classified into DNR-S and DNR-P groups. RESULTS We enrolled 1495 patients. The most prevalent primary cancers were hepato-biliary-pancreatic (26.9 %), lung (16.3 %), and colorectal (14.0 %) cancers. We classified 965 (64.5 %) and 530 (35.5 %) patients into the DNR-S and DNR-P groups, respectively. Significant differences were observed between both groups regarding gender (p = 0.002), age (p < 0.001), and the Eastern Cooperative Oncology Group performance (p < 0.001) and educational (p < 0.001) status levels. The median survival times after DNR consent signature were 5.0 days (95 % confidence interval [CI] 4.4-5.6 days) and 14.0 days (95 % CI 12.1-15.9 days) in the DNR-S and DNR-P groups, respectively (p < 0.001). The median good death evaluation (GDE) scores were 5.4 (95 % CI 4.9-6.0) and 13.7 (95 % CI 12.7-14.6) in the DNR-S and DNR-P groups, respectively (p < 0.001). Univariate and multivariate analyses revealed that DNR-S was an independent factor for significantly low GDE scores (i.e., poor EOL care quality). CONCLUSION The DNR concept is emerging; however, the DNR-P percentage remains low (35.6 %) in patients with advanced cancer. DNR-P significantly improves the EOL care quality.
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Affiliation(s)
- Yi-Hsin Liang
- Department of Oncology, National Taiwan University Hospital, No. 7, Chung-Shan South Rd, Taipei, 10002, Taiwan.,Department of Oncology, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan.,Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Chih-Hsin Wei
- Department of Oncology, National Taiwan University Hospital, No. 7, Chung-Shan South Rd, Taipei, 10002, Taiwan
| | - Wen-Hui Hsu
- Department of Nursing, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Yu-Yun Shao
- Department of Oncology, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan.,Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Ya-Chin Lin
- Department of Nursing, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Pei-Chun Chou
- Department of Nursing, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Ann-Lii Cheng
- Department of Oncology, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan.,Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei City, Taiwan.,Department of Internal Medicine, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan.,Center for Comparative Effectiveness Research, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan
| | - Kun-Huei Yeh
- Department of Oncology, National Taiwan University Hospital, No. 7, Chung-Shan South Rd, Taipei, 10002, Taiwan. .,Department of Oncology, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan. .,Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei City, Taiwan. .,Center for Comparative Effectiveness Research, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei City, Taiwan.
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7
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Do-not-resuscitate orders and related factors among family surrogates of patients in the emergency department. Support Care Cancer 2015; 24:1999-2006. [DOI: 10.1007/s00520-015-2971-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 09/28/2015] [Indexed: 12/21/2022]
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A. Mayer P, Daly BJ. CPR and hospice: Incompatible goals, irreconcilable differences. PROGRESS IN PALLIATIVE CARE 2015. [DOI: 10.1179/1743291x14y.0000000098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Bhatia HL, Patel NR, Choma NN, Grande J, Giuse DA, Lehmann CU. Code status and resuscitation options in the electronic health record. Resuscitation 2014; 87:14-20. [PMID: 25447035 DOI: 10.1016/j.resuscitation.2014.10.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/30/2014] [Accepted: 10/20/2014] [Indexed: 11/25/2022]
Abstract
AIM The advance discussion and documentation of code-status is important in preventing undesired cardiopulmonary resuscitation and related end of life interventions. Code-status documentation remains infrequent and paper-based, which limits its usefulness. This study evaluates a tool to document code-status in the electronic health records at a large teaching hospital, and analyzes the corresponding data. METHODS Encounter data for patients admitted to the Medical Center were collected over a period of 12 months (01-APR-2012-31-MAR-2013) and the code-status attribute was tracked for individual patients. The code-status data were analyzed separately for adult and pediatric patient populations. We considered 131,399 encounters for 83,248 adult patients and 80,778 encounters for 55,656 pediatric patients in this study. RESULTS 71% of the adult patients and 30% of the pediatric patients studied had a documented code-status. Age and severity of illness influenced the decision to document code-status. Demographics such as gender, race, ethnicity, and proximity of primary residence were also associated with the documentation of code-status. CONCLUSION Absence of a recorded code-status may result in unnecessary interventions. Code-status in paper charts may be difficult to access in cardiopulmonary arrest situations and may result in unnecessary and unwanted interventions and procedures. Documentation of code-status in electronic records creates a readily available reference for care providers.
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Affiliation(s)
- Haresh L Bhatia
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, United States.
| | - Neal R Patel
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Neesha N Choma
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Jonathan Grande
- Informatics Center, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Dario A Giuse
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, United States; Informatics Center, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Christoph U Lehmann
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
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Hwang IC, Keam B, Kim YA, Yun YH. Factors Related to the Differential Preference for Cardiopulmonary Resuscitation Between Patients With Terminal Cancer and That of Their Respective Family Caregivers. Am J Hosp Palliat Care 2014; 33:20-6. [PMID: 25138648 DOI: 10.1177/1049909114546546] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
There is little information regarding concordance between preferences for end-of-life care of terminally ill patients with cancer and those of their family caregivers. A cross-sectional exploration of cardiopulmonary resuscitation (CPR) preference in 361 dyads was conducted. Patients or family caregivers who were willing to approve CPR were compared with dyads who did not support CPR. The patient's quality of life was more associated with family caregiver's willingness than patient's willingness. A patient was more likely to prefer CPR than their caregiver in dyads of females and emotionally stable patients. A family caregiver showed stronger support for CPR if the patient had controlled pain or stable health and the family caregiver had not been counseled for CPR. Communications should be focused on these individuals to improve the planning of end-of-life care.
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Affiliation(s)
- In Cheol Hwang
- Department of Family Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Ae Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Young Ho Yun
- Department of Biomedical Science and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Azad AA, Siow SF, Tafreshi A, Moran J, Franco M. Discharge Patterns, Survival Outcomes, and Changes in Clinical Management of Hospitalized Adult Patients with Cancer with a Do-Not-Resuscitate Order. J Palliat Med 2014; 17:776-81. [DOI: 10.1089/jpm.2013.0554] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Arun A. Azad
- Joint Austin-Ludwig Oncology Unit, Austin Health, Melbourne, Australia
| | - Sue-Faye Siow
- Joint Austin-Ludwig Oncology Unit, Austin Health, Melbourne, Australia
| | - Ali Tafreshi
- Joint Austin-Ludwig Oncology Unit, Austin Health, Melbourne, Australia
| | - Juli Moran
- Palliative Care Services, Austin Health, Melbourne, Australia
| | - Michael Franco
- Monash Cancer Centre, Monash Health, Melbourne, Australia
- Monash University, Melbourne, Australia
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Kao CY, Wang HM, Tang SC, Huang KG, Jaing TH, Liu CY, Liu KH, Shen WC, Wu JH, Hung YS, Hsu HC, Chen JS, Liau CT, Lin YC, Su PJ, Hsieh CH, Chou WC. Predictive factors for do-not-resuscitate designation among terminally ill cancer patients receiving care from a palliative care consultation service. J Pain Symptom Manage 2014; 47:271-82. [PMID: 23856097 DOI: 10.1016/j.jpainsymman.2013.03.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/27/2013] [Accepted: 03/29/2013] [Indexed: 11/25/2022]
Abstract
CONTEXT Since the development of palliative care in the 1980s, "do not resuscitate" (DNR) has been promoted worldwide to avoid unnecessary resuscitation in terminally ill cancer patients. OBJECTIVES This study aimed to evaluate the effect of a palliative care consultation service (PCCS) on DNR designation and to identify a subgroup of patients who would potentially benefit from care by the PCCS with respect to DNR designation. METHODS In total, 2995 terminally ill cancer patients (with a predicted life expectancy of less than six months by clinician estimate) who received care by the PCCS between January 2006 and December 2010 at a single medical center in Taiwan were selected. Among these, the characteristics of 2020 (67.4%) patients who were not designated as DNR at the beginning of care by the PCCS were retrospectively analyzed to identify variables pertinent to DNR designation. RESULTS A total of 1301 (64%) of 2020 patients were designated as DNR at the end of care by the PCCS. Male gender and primary liver cancer were characteristics more predominantly found among DNR-designated patients who also had worse performance status, higher prevalence of physical distress, and shorter intervals from palliative care referral to death than did patients without DNR designation. On univariate analysis, a higher probability of DNR designation was associated with male gender, duration of care by the PCCS of more than 14 days, patients' prognostic awareness, family's diagnostic and prognostic awareness, and high Palliative Prognostic Index (PPI) scores. On multivariate analysis, duration of care by the PCCS, patients' prognostic awareness, family's diagnostic and prognostic awareness, and a high PPI score constituted independent variables predicting DNR-designated patients at the end of care by the PCCS. CONCLUSION DNR designation was late in terminally ill cancer patients. DNR-designated cancer patient indicators were high PPI scores, patients' prognostic awareness, family's diagnostic and prognostic awareness, and longer durations of care by the PCCS.
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Affiliation(s)
- Chen-Yi Kao
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Hung-Ming Wang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Shu-Chuan Tang
- Department of Nursing, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Kuan-Gen Huang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Tang-Her Jaing
- Division of Hematology and Oncology, Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Chien-Ying Liu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Keng-Hao Liu
- Department of Surgery, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Wen-Chi Shen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Jin-Hou Wu
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Yu-Shin Hung
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Hung-Chih Hsu
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Chi-Ting Liau
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Yung-Chang Lin
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Po-Jung Su
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China.
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Royall DR, Salazar R, Palmer RF. Latent variables may be useful in pain's assessment. Health Qual Life Outcomes 2014; 12:13. [PMID: 24479724 PMCID: PMC3918175 DOI: 10.1186/1477-7525-12-13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 12/17/2013] [Indexed: 12/27/2022] Open
Abstract
Background Unobserved “latent” variables have the potential to minimize “measurement error” inherent to any single clinical assessment or categorical diagnosis. Objectives To demonstrate the potential utility of latent variable constructs in pain’s assessment. Design We created two latent variables representing depressive symptom-related pain (Pd) and its residual, “somatic” pain (Ps), from survey questions. Setting The Hispanic Established Population for Epidemiological Studies in the Elderly (H-EPESE) project, a longitudinal population-based cohort study. Participants Community dwelling elderly Mexican-Americans in five Southwestern U.S. states. The data were collected in the 7th HEPESE wave in 2010 (N = 1,078). Measurements Self-reported pain, Center for Epidemiological Studies Depression Scale (CES-D) scores, bedside cognitive performance measures, and informant-rated measures of basic and instrumental Activities of Daily Living. Results The model showed excellent fit [χ2 = 20.37, DF = 12; p = 0.06; Comparative fit index (CFI) = 0.998; Root mean statistical error assessment (RMSEA) = 0.025]. Ps was most strongly indicated by self-reported pain-related physician visits (r = 0.48, p ≤0.001). Pd was most strongly indicated by self-reported pain-related sleep disturbances (r = 0.65, p <0.001). Both Pd and Ps were significantly independently associated with chronic pain (> one month), regional pain and pain summed across selected regions. Pd alone was significantly independently associated with self-rated health, life satisfaction, self-reported falls, Life-space, nursing home placement, the use of opiates, and a variety of sleep related disturbances. Ps was associated with the use of NSAIDS. Neither construct was associated with declaration of a resuscitation preference, mode of resuscitation preference declaration, or with opting for a “Do Not Resuscitate” (DNR) order. Conclusion This analysis illustrates the potential of latent variables to parse observed data into “unbiased” constructs with unique predictive profiles. The latent constructs, by definition, are devoid of measurement error that affects any subset of their indicators. Future studies could use such phenotypes as outcome measures in clinical pain management trials or associate them with potential biomarkers using powerful parametric statistical methods.
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Affiliation(s)
- Donald R Royall
- Department of Psychiatry, The University of Texas Health Science Center At San Antonio, 7703 Floyd Curl Drive MC 7792, San Antonio, TX 78229, USA.
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Rhondali W, Perez-Cruz P, Hui D, Chisholm GB, Dalal S, Baile W, Chittenden E, Bruera E. Patient-physician communication about code status preferences: a randomized controlled trial. Cancer 2013; 119:2067-73. [PMID: 23564395 DOI: 10.1002/cncr.27981] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 10/31/2012] [Accepted: 11/08/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Code status discussions are important in cancer care, but the best modality for such discussions has not been established. The objective of this study was to determine the impact of a physician ending a code status discussion with a question (autonomy approach) versus a recommendation (beneficence approach) on patients' do-not-resuscitate (DNR) preference. METHODS Patients in a supportive care clinic watched 2 videos showing a physician-patient discussion regarding code status. Both videos were identical except for the ending: one ended with the physician asking for the patient's code status preference and the other with the physician recommending DNR. Patients were randomly assigned to watch the videos in different sequences. The main outcome was the proportion of patients choosing DNR for the video patient. RESULTS A total of 78 patients completed the study, and 74% chose DNR after the question video, whereas 73% chose DNR after the recommendation video. Median physician compassion score was very high and not different for both videos. All 30 of 30 patients who had chosen DNR for themselves and 30 of 48 patients who had not chosen DNR for themselves chose DNR for the video patient (100% versus 62%). Age (odds ratio = 1.1/year) and white ethnicity (odds ratio = 9.43) predicted DNR choice for the video patient. CONCLUSIONS Ending DNR discussions with a question or a recommendation did not impact DNR choice or perception of physician compassion. Therefore, both approaches are clinically appropriate. All patients who chose DNR for themselves and most patients who did not choose DNR for themselves chose DNR for the video patient. Age and race predicted DNR choice.
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Affiliation(s)
- Wadih Rhondali
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Pentz RD, Flamm AL. Code status discussion: just have one. Cancer 2013; 119:1938-40. [PMID: 23564437 DOI: 10.1002/cncr.27983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 12/19/2012] [Indexed: 12/21/2022]
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Sacco J, Carr DRD, Viola D. The Effects of the Palliative Medicine Consultation on the DNR Status of African Americans in a Safety-Net Hospital. Am J Hosp Palliat Care 2012; 30:363-9. [DOI: 10.1177/1049909112450941] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To examine the effectiveness of palliative medicine consultation on completion of advance directives/do-not-resuscitate (DNR) orders by racial/ethnic minorities. Method: A sample of 1999 seriously ill African American and Hispanic inpatients was obtained from the Palliative Medicine Consultation database (n = 2972). Associations between race/ethnicity and diagnosis and documentation of DNR status on admission and discharge were examined. Results: Cancer was the primary diagnosis, 34.5%. Among patients with a consultation, 98% agreed to discuss advance directives; 65% of African Americans and 70% of Hispanics elected DNR status. Inpatient deaths were 46%; 74% of decedents agreed to DNR orders. Discharged patients referred to hospice were 29%. Conclusion: Palliative medicine consultations resulted in timely completion of DNR orders and were positively associated with DNR election and hospice enrollment.
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Affiliation(s)
- Joseph Sacco
- Palliative Medicine Consultation Service/Hospice Inpatient Unit, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Dana R. Deravin Carr
- Department of Health Policy and Management, School of Health Sciences and Practice, New York Medical College, Valhalla, NY, USA
| | - Deborah Viola
- Center for Long Term Care Research & Policy, School of Health Sciences and Practice, New York Medical College, Valhalla, NY, USA
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Fu S, Barber FD, Naing A, Wheler J, Hong D, Falchook G, Piha-Paul S, Tsimberidou A, Howard A, Kurzrock R. Advance care planning in patients with cancer referred to a phase I clinical trials program: the MD Anderson Cancer Center experience. J Clin Oncol 2012; 30:2891-6. [PMID: 22778314 DOI: 10.1200/jco.2011.38.0758] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with advanced malignancies referred for early clinical trials have a short life expectancy. We designed this survey to ascertain the status of advance care planning in this population. PATIENTS AND METHODS Patients who were seen in a phase I clinic were asked to anonymously complete an investigator-designed survey. RESULTS Of 435 individuals approached, 215 (49%) returned completed or partially completed surveys, whereas many others stated that they wanted to avoid the topic, because they had come to the phase I clinic for cancer therapy. Most patients (n = 149; 69%) were still hopeful about their future. Approximately 42% of patients (n = 90) reported having a living will, 46% had a medical power of attorney (n = 98), and 19% had a do-not-resuscitate (DNR) order (n = 40). Approximately 20% of participants (n = 43) had not discussed advance care planning. Fifty-nine percent of patients wanted to discuss advance care planning with their physician. Having a DNR order in place was significantly more common in individuals who had a living will and/or a medical power of attorney. CONCLUSION Although most patients referred to a phase I clinic remained optimistic, many had discussed a living will, medical power of attorney, and/or DNR order with their physician, family, and/or attorney. However, a significant minority had not addressed this issue with anyone, and many refused to take a survey on the topic. More than half of the patients wanted to discuss these matters with their physician. These observations suggest that extra effort to address advance care planning is needed for these patients.
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Affiliation(s)
- Siqing Fu
- Department of Investigational Cancer Therapeutics, Unit 0455, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
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Ethnicity, race, and advance directives in an inpatient palliative care consultation service. Palliat Support Care 2012; 11:5-11. [DOI: 10.1017/s1478951512000417] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:Although race and ethnic background are known to be important factors in the completion of advance directives, there is a dearth of literature specifically investigating the effect of race and ethnicity on advance directive completion rate after palliative care consultation (PCC).Method:A chart review of all patients seen by the PCC service in an academic hospital over a 9-month period was performed. Data were compiled using gender, race, ethnicity, religion, and primary diagnosis. For this study, advance directives were defined as: “Do Not Resuscitate” (DNR) and/or “Do Not Intubate” (DNI).Results:Of the 400 medical records reviewed, 57% of patients were female and 71.3% documented their religion as Christian. The most common documented diagnosis was cancer (39.5%). Forty-seven percent reported their race as white. White patients completed more advance directives than did nonwhite patients both before (25.67% vs. 12.68%) and after (59.36% vs. 40.84%) PCC. There was a significantly higher proportion of whites who signed an advance directive after a PCC than of nonwhites (p = 0.021); of the 139 whites who did not have an advance directive at admission, 63 signed an advance directive after a PCC compared with 186/60 nonwhites (45% vs. 32%, respectively, p = 0.021). Further analysis revealed that African Americans differed from whites in the likelihood of advance directive execution rates pre-PCC, but not post-PCC.Significance of results:This study demonstrates the impact of a PCC on the completion of advance directives, on both whites and nonwhites. The PCC Intervention significantly reduced differences between whites and African Americans in completing advance directives, which have been consistently documented in the end-of-life literature.
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Bailey FA, Allen RS, Williams BR, Goode PS, Granstaff S, Redden DT, Burgio KL. Do-Not-Resuscitate Orders in the Last Days of Life. J Palliat Med 2012; 15:751-9. [DOI: 10.1089/jpm.2011.0321] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- F. Amos Bailey
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama and Atlanta, Georgia
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rebecca S. Allen
- Department of Psychology/CMHA, University of Alabama, Tuscaloosa, Alabama
| | - Beverly R. Williams
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama and Atlanta, Georgia
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patricia S. Goode
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama and Atlanta, Georgia
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shanette Granstaff
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama and Atlanta, Georgia
- Department of Biostatistics, University of Alabama, Tuscaloosa, Alabama
| | - David T. Redden
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama and Atlanta, Georgia
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kathryn L. Burgio
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama and Atlanta, Georgia
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Wentlandt K, Burman D, Swami N, Hales S, Rydall A, Rodin G, Lo C, Zimmermann C. Preparation for the end of life in patients with advanced cancer and association with communication with professional caregivers. Psychooncology 2011; 21:868-76. [DOI: 10.1002/pon.1995] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 04/09/2011] [Accepted: 04/13/2011] [Indexed: 11/08/2022]
Affiliation(s)
- Kirsten Wentlandt
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
| | - Debika Burman
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute; Princess Margaret Hospital, University Health Network; Toronto Canada
| | - Nadia Swami
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute; Princess Margaret Hospital, University Health Network; Toronto Canada
| | - Sarah Hales
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
| | - Anne Rydall
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute; Princess Margaret Hospital, University Health Network; Toronto Canada
| | - Gary Rodin
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute; Princess Margaret Hospital, University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
| | - Christopher Lo
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
| | - Camilla Zimmermann
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute; Princess Margaret Hospital, University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
- Division of Medical Oncology and Haematology, Department of Medicine; University of Toronto; Toronto Canada
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Ismail A, Long J, Moiemen N, Wilson Y. End of life decisions and care of the adult burn patient. Burns 2010; 37:288-93. [PMID: 21074332 DOI: 10.1016/j.burns.2010.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 08/17/2010] [Accepted: 08/20/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Despite advancements in the provision of burn care, there is still a significant cohort of patients who fail to respond to therapy or for whom treatment is deemed futile. The decision to withdraw support from, or to implement a Do-Not-Resuscitate (DNAR) order in, such patients can be challenging. Our aims were to review the withdrawal of life-sustaining treatment, issuing of DNAR orders and end of life care in burn patient deaths. METHODS A retrospective case notes review was undertaken, for all burn in-patient deaths from 1st April 2001 to 31st December 2007. RESULTS Following exclusions, 63 patients were included in our study, with a median age of 56 years (21-94). End of life decisions in younger patients (under 65 years) were more often due to burn severity. In those over 65 years, reasons were due to co-morbidities, and these decisions were made late in the patient's admission. In 34% of patients, end of life care was not comprehensively documented. CONCLUSION A coherent, decisive approach should be adopted and adhered to by all members of the multi-disciplinary team, with clear, standardised documentation in place.
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Affiliation(s)
- A Ismail
- West Midlands Regional Burns Service, Queen Elizabeth Hospital, Birmingham B15 2WB, UK.
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