Practitioner Bias as an Explanation for Low Rates of Palliative Care Among Patients with Advanced Dementia

Palliative Care and End-of-Life Outcomes in Patients Considered for Liver Transplantation: A Single-Center Experience in the US Midwest

Introduction: Previous research has shown limited palliative care (PC) utilization among patients evaluated for liver transplantation (LT) despite the cohort's significant symptom burden, high frequency of hospitalization and risk of rapid decompensation. Our aim was to evaluate patient characteristics and end-of-life (EOL) outcomes (i.e. ICU utilization, code status, advance care planning) associated with the use of PC services in patients who were evaluated for LT. Methods: We performed a single-center cross-sectional study comprised of 223 deceased patients evaluated for LT between 1/1/2017 and 12/31/2021. We evaluated demographic characteristics and EOL outcomes for differences between patients who received PC consultation and those who did not. EOL outcomes associated with PC use were assessed using logistic and linear regression analysis adjusted for patient demographics. Results: Patients who received PC consultation were younger (mean 57 vs. 61; P = 0.048), had higher Model for end-stage Liver Disease (MELD) scores (27.5 vs. 22; P = 0.001), higher rates of hepatic encephalopathy (96% vs. 84%, P = 0.005), and were more frequently declined for LT (77% vs. 57%; P = 0.008). Patients who received PC services were less likely to die in the ICU (OR = 0.07 [0.02-0.18]) and were more likely to have documented advance care planning (OR = 3.16 [1.47-6.97]), family meetings (OR = 6.58 [2.72-17.08]), and goals-of-care discussions (OR = 14.83 [4.39-69.29]). Conclusion: For patients being evaluated for LT, PC utilization differed based on demographics, disease complications and severity, and transplant status. Those who received PC services had higher quality EOL care planning and fewer ICU admissions.

Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings

Introduction

Palliative care (PC) delivery for persons with advanced dementia (AD) remains low, particularly in acute-care settings. Studies have shown that cognitive biases and moral characteristics can influence patient care through their effect on the thinking patterns of healthcare workers (HCWs). This study aimed to determine whether cognitive biases, including representativeness, availability, and anchoring, are associated with treatment approaches, ranging from palliative to aggressive care in acute medical situations, for persons with AD.

Methods

Three hundred fifteen HCWs participated in this study: 159 physicians and 156 nurses from medical and surgical wards in two hospitals. The following questionnaires were administered: a socio-demographic questionnaire; the Moral Sensitivity Questionnaire; the Professional Moral Courage Scale; a case scenario of a person with AD presenting with pneumonia, with six possible interventions ranging from PC to aggressive care (referring to life-prolonging interventions), each given a score from (-1) (palliative) to 3 (aggressive), the sum of which is the "Treatment Approach Score;" and 12 items assessing perceptions regarding PC for dementia. Those items, the moral scores, and professional orientation (medical/surgical) were classified into the three cognitive biases.

Results

The following aspects of cognitive biases were associated with the Treatment Approach Score: representativeness-agreement with the definition of dementia as a terminal disease and appropriateness of PC for dementia; availability-perceived organizational support for PC decisions, apprehension regarding response to PC decisions by seniors or family, and apprehension regarding a lawsuit following PC; and anchoring-perceived PC appropriateness by colleagues, comfort with end-of-life conversations, guilt feelings following the death of a patient, stress, and avoidance accompanying care. No association was found between moral characteristics and the treatment approach. In a multivariate analysis, the predictors of the care approach were: guilt feelings about the death of a patient, apprehension regarding senior-level response, and PC appropriateness for dementia.

Conclusion

Cognitive biases were associated with the care decisions for persons with AD in acute medical conditions. These findings provide insight into the potential effects of cognitive biases on clinical decisions, which may explain the disparity between treatment guidelines and the deficiency in the implementation of palliation for this population.

Biases in bioethics: a narrative review

Given that biases can distort bioethics work, it has received surprisingly little and fragmented attention compared to in other fields of research. This article provides an overview of potentially relevant biases in bioethics, such as cognitive biases, affective biases, imperatives, and moral biases. Special attention is given to moral biases, which are discussed in terms of (1) Framings, (2) Moral theory bias, (3) Analysis bias, (4) Argumentation bias, and (5) Decision bias. While the overview is not exhaustive and the taxonomy by no means is absolute, it provides initial guidance with respect to assessing the relevance of various biases for specific kinds of bioethics work. One reason why we should identify and address biases in bioethics is that it can help us assess and improve the quality of bioethics work.

Do Perceptions about Palliative Care Affect Emergency Decisions of Health Personnel for Patients with Advanced Dementia?

Decision analysis regarding emergency medical treatment in patients with advanced dementia has seldom been investigated. We aimed to examine the preferred medical treatment in emergency situations for patients with advanced dementia and its association with perceptions of palliative care. We conducted a survey of 159 physicians and 156 nurses from medical and surgical wards in two tertiary hospitals. The questionnaire included two case scenarios of patients with advanced dementia presenting gastrointestinal bleeding (scenario I) or pneumonia (scenario II) with a list of possible interventions and 11 items probing perceptions towards palliative care. Low burden interventions such as laboratory tests and intravenous administration of antibiotics/blood were preferred. Palliative measures such as analgesia/sedation were chosen by about half of the participants and invasive intervention by 41.6% (gastroscopy in scenario I) and 37.1% (intubation/mechanical ventilation in scenario II). Medical ward staff had a more palliative approach than surgical ward staff in scenario I, and senior staff had a more palliative approach than junior staff in scenario II. Most participants (90.4%) agreed that palliative care was appropriate for patients with advanced dementia. Stress in caring for patients with advanced dementia was reported by 24.5% of participants; 33.1% admitted fear of lawsuit, 33.8% were concerned about senior-level responses, and 69.7% were apprehensive of family members' reaction to palliative care. Perceptions of health care workers towards palliative care were associated with preferred treatment choice for patients with advanced dementia, mainly in scenario II. Attitudes and apprehensions regarding palliative care in these situations may explain the gap between positive attitudes towards palliative care and the chosen treatment approach. Acquainting emergency care practitioners with the benefits of palliative care may impact their decisions when treating this population.

No Terminally Ill Patients with Non-cancer Received Palliative Care Services During Hospital Admission: A Cross-Sectional Study

BACKGROUND

Terminally ill patients admitted to a hospital with noncancer conditions may miss palliative care (PC) service opportunities. This study aimed to examine the utilization of PC services among these hospitalized patients.

METHODS

We conducted a cross-sectional study using the electronic medical records of noncancer patients admitted to internal medicine wards, intensive care units (ICUs), and cardiac intensive care units (CICUs). The patients meeting the Supportive and Palliative Care Indicators Tool (SPICT) criteria needed PC, and the patients who had advanced care plans or received PC consultations received PC services. We reported the proportions of patients with PC needs and PC services and their associated factors with the crude and adjusted odds ratios.

RESULTS

Of 459 patients, 49.9% were female, and 92.6% were discharged alive. The mean age was 63 years old, and the average length of stay was 10 days. Additionally, 61.7% needed PC according to the SPICT criteria, but none of these patients received PC services. Patients with dementia/frailty, kidney disease, and heart disease had the highest rate of PC underutilization (100%, 96.8%, and 91.3%, respectively). Age, number of discharge medications, and length of stay were associated with needing PC, but some associations disappeared after the subgroup analysis.

CONCLUSION

None of the terminally ill noncancer patients in our study received PC services. The patients with dementia/frailty, kidney disease, and heart disease underutilized the services. A long length of stay and many discharge medications were associated with the PC needs and can be used to assess the PC needs.