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de Lasa C, Mesfin E, Tajirian T, Chessex C, Lo B, Sockalingam S. Increasing resuscitation status-related goals of care discussions for older adults with severe mental illness in a Canadian mental health setting: a retrospective study. BMJ Open Qual 2024; 13:e002798. [PMID: 39532386 PMCID: PMC11555105 DOI: 10.1136/bmjoq-2024-002798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 10/21/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Older adults with severe mental illness, including advanced dementia (AD), within geriatric admission units (GAU) often prioritise comfort care, avoiding life-prolonging procedures including cardiopulmonary resuscitation (CPR). Pre-2019, hospital policy lacked a resuscitation status order (RSO) incorporating distinct do-not-resuscitate levels. Providers entered 'NO CPR' orders in the electronic health record (EHR), necessitating transfers for non-CPR medical issues, contradicting patient preferences. METHODS The study aimed for a 75% increase in resuscitation status-related (RSR) goals of care discussion (GOCD) completion rates within 1 week of GAU admission or transfer by December 2022. We implemented an EHR RSO, updated hospital policy and provided staff education. A 4-year GAU retrospective chart review assessed RSR GOCD frequency, completion time, documentation quality and discrepancies. Additionally, an environmental scan identified contributing factors to RSR GOCD. RESULTS Among 431 reviewed charts, the mean RSR GOCD completion rate was 13.9%; taking 39.5 days, with extreme outliers removed, the mean of time to completion was 15 days. Subgroup analysis highlighted a significant difference in RSR GOCD completion rates for AD (41.6%) compared with non-AD patients (16.3%). Discrepancy rates in charts with RSR GOCD were substantial: documentation without a corresponding RSO (66.7%), RSO without documentation (26.1%) and discordant resuscitation status between documentation and RSO (7.2%). Documentation quality varied: 32.9% lacked context, 20.7% had limited context, while 46.3% provided comprehensive context. Barriers to RSR GOCD included the absence of an EHR documentation tool and clear triggers. CONCLUSION RSR GOCD completion rates were lower and took longer than anticipated, highlighting improvement opportunities. AD subgroup analysis indicated provider awareness of RSR GOCD importance in this population. Discrepancies and documentation quality issues pose risks to patient-centred care. Collaborative stakeholder efforts are imperative for developing system-based informatics solutions, ensuring timely, comprehensive and patient-centred RSR GOCD.
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Affiliation(s)
- Cristina de Lasa
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elnathan Mesfin
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Tania Tajirian
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Caroline Chessex
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brian Lo
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Sanjeev Sockalingam
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Abuhammad S, Muflih S, Alzoubi KH, Gharaibeh B. Nursing and PharmD Undergraduate Students' Attitude Toward the "Do Not Resuscitate" Order for Children with Terminally Ill Diseases. J Multidiscip Healthc 2021; 14:425-434. [PMID: 33658789 PMCID: PMC7917390 DOI: 10.2147/jmdh.s298384] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/28/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Nurses and Doctor of Pharmacy (pharmD) must communicate and properly documented the do not resuscitate orders for terminally ill children and their relatives. They also have to offer excellent care including more family support, assisting the child with terminally ill disease in passing on peacefully, and preventing unnecessary cardiopulmonary resuscitation. This research was aimed to survey attitudes of nursing and pharmD undergraduate students about the "do not resuscitate" order for children with terminally ill diseases. METHODS A cross-sectional correlational design was used to study the correlation between attitude toward DNR and demographic variables. More than 400 nursing and pharmD students from Jordan University of Science and Technology were recruited in this study. All the participating students were e-mailed information regarding the study, including the web survey link. RESULTS The results showed that there was a significant difference in perception toward do not resuscitate order between nursing and pharmD students (p ≤ 0.05). The pharmD students had more positive attitude toward do not resuscitate than the nursing students. Approximately, 60% of the nursing and pharmD students would disclose the need for the do not resuscitate order for children with terminally ill diseases Demographic variables were not associated with the perception toward do not resuscitate orders (p ≥ 0.05). CONCLUSION This study showed that Jordanian nursing and pharmD students are willing to learn more about different aspects of do not resuscitate orders for terminally ill children. Analyzing their responses to many items showed their misconception about do not resuscitate orders for terminally ill children.
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Affiliation(s)
- Sawsan Abuhammad
- Department of Maternal and Child Health, Jordan University of Science and Technology, Irbid, 22110, Jordan,Correspondence: Sawsan Abuhammad Email
| | - Suhaib Muflih
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Besher Gharaibeh
- Department of Adult Health, Jordan University of Science and Technology, Irbid, 22110, Jordan
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Munroe JL, Douglas SL, Chaplin T. The Documentation of Goals of Care Discussions at a Canadian Academic Hospital. Cureus 2020; 12:e9560. [PMID: 32905552 PMCID: PMC7473609 DOI: 10.7759/cureus.9560] [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] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Patient-centered care is a core principle of the Canadian healthcare system. In order to facilitate patient-centered care, the documentation of a patient's medical goals and expectations is important, especially in the event of acute decompensation when an informed conversation with the patient may not be possible. The 'Goals of Care Discussion Form (GCF)' at Kingston Health Sciences Centre (KHSC) documents goals of care discussions between patients and healthcare providers. All patients admitted to the Internal Medicine service are expected to have this form completed within 24 hours of admission. Formal measurement of form completion at our center has not previously been done, though anecdotally this form is often incomplete. The purpose of this study is to quantify the rate of completion and assess quality of documentation of the GCF at KHSC. METHODS This prospective chart review took place between August 25, 2018, and March 25, 2019. Charts were reviewed for the presence of a completed GCF, and the quality of notation was assessed, as appropriate. Given there are no existing tools for assessing the quality of a document such as the GCF, authors TC and JM created one de novo for this study. Extracted data included the amount of time elapsed between admission and completion of the GCF, whether the 'yes/no cardiopulmonary resuscitation (CPR)' order in the patient's chart aligned with their wishes as outlined on the GCF, and whether or not a patient's GCF was uploaded to the hospital's electronic medical record (EMR). RESULTS Two hundred sixteen charts were reviewed. Of these, 136 (63.0%) had a complete GCF. The mean GCF quality score was 3.4/7 (95% CI [3.2, 3.6]). The mean time elapsed from admission to the completion of the GCF was 1.5 days (95% CI [0.6, 2.4]). There were 130 charts with both a complete GCF and a 'yes/no CPR' order, and of these, 20 (15.4%) showed a discrepancy. Eighty-six (63.2%) of the completed GCFs were uploaded to the EMR. DISCUSSION AND CONCLUSIONS The rate of GCF completion at KHSC is noticeably higher than expected based on the previous literature. However, our assessment of the quality of completion indicates that there is room for improvement. Most concerning, discrepancies were found between the 'yes/no CPR' order in a patient's chart and their stated wishes on the GCF. Furthermore, less than two-thirds of completed GCFs were found to have been uploaded to the hospital's EMR. Given the emphasis on patient-centered care in the Canadian healthcare system, our findings suggest that improvement initiatives are needed with respect to documenting goals of care discussions with patients.
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A comparative study on decision and documentation of refraining from resuscitation in two medical home care units in Sweden. BMC Palliat Care 2019; 18:80. [PMID: 31623585 PMCID: PMC6798351 DOI: 10.1186/s12904-019-0472-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/24/2019] [Indexed: 11/13/2022] Open
Abstract
Background A decision to refrain from cardiopulmonary resuscitation (CPR) in the case of cardiac arrest is recommended in terminally ill patients to avoid unnecessary suffering at time of death. The aim of this study was to describe the frequency of decisions and documentation of “do not attempt cardiopulmonary resuscitation” (DNACPR) in two Medical Home Care Units in Stockholm. Unit A had written guidelines about how to document CPR-decisions in the medical records, including a requirement for a decision to be taken (CPR: yes/no) while Unit B had no such requirement. Method The medical records for all patients in palliative phase of their disease at the two Units were reviewed. Data was collected on documentation of decisions about CPR (yes/no), DNACPR-decisions and documentation regarding whether the patient or next-of-kin had been informed about the DNACPR-decision. Results In the two Units, 316 and 219 patients in palliative phase were identified. In Unit A 100% of the patients had a CPR-decision (yes/no) compared to 79% in Unit B (p < 0.001). There was no statistically significant difference in DNACPR-decisions between the two Units, 43 and 37%. Documentation about informing the patient regarding the decision was significantly higher in Unit A, 53% compared to 14% at Unit B (p < 0.001). Documentation about informing the next-of-kin was also significantly higher at Unit A; 42% compared to 6% at Unit B (p < 0.001). Conclusion Less than 50% of patients in palliative phase had a decision of DNACPR in two Medical Home Care Units in Stockholm. The presence of written guidelines and a requirement for a CPR-decision did not increase the frequency of DNACPR-decisions but was associated with a higher frequency of documentation of decisions and of information given to both the patients and the next-of-kin.
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Tíscar-González V, Gea-Sánchez M, Blanco-Blanco J, Moreno-Casbas MT, Peter E. The advocacy role of nurses in cardiopulmonary resuscitation. Nurs Ethics 2019; 27:333-347. [PMID: 31113269 DOI: 10.1177/0969733019843634] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The decision whether to initiate cardiopulmonary resuscitation may sometimes be ethically complex. While studies have addressed some of these issues, along with the role of nurses in cardiopulmonary resuscitation, most have not considered the importance of nurses acting as advocates for their patients with respect to cardiopulmonary resuscitation. RESEARCH OBJECTIVE To explore what the nurse's advocacy role is in cardiopulmonary resuscitation from the perspective of patients, relatives, and health professionals in the Basque Country (Spain). RESEARCH DESIGN An exploratory critical qualitative study was conducted from October 2015 to March 2016. Thematic analysis was used to analyse the data. PARTICIPANTS Four discussion groups were held: one with patients and relatives (n = 8), two with nurses (n = 7 and n = 6, respectively), and one with physicians (n = 5). ETHICAL CONSIDERATIONS Approval was obtained from the Basque Country Clinical Research Ethics Committee. FINDINGS Three significant themes were identified: (a) accompanying patients during end of life in a context of medical dominance, (b) maintaining the pact of silence, and (c) yielding to legal uncertainty and concerns. DISCUSSION The values and beliefs of the actors involved, as well as pre-established social and institutional rules reduced nurses' advocacy to that of intermediaries between the physician and the family within the hospital environment. On the contrary, in primary health care, nurses participated more actively within the interdisciplinary team. CONCLUSION This study provides key information for the improvement and empowerment for ethical nursing practice in a cardiac arrest, and provides the perspective of patients and relatives, nurses and physicians.
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Affiliation(s)
| | | | - Joan Blanco-Blanco
- University of Lleida, Spain; Biomedical Research Institute of Lleida, Spain
| | - María Teresa Moreno-Casbas
- Instituto de Salud Carlos III, Spain; Centro de Investigación Biomédica en Red sobre Fragilidad y Envejecimiento Saludable (CIBERFES), Spain
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Pettersson M, Höglund AT, Hedström M. Perspectives on the DNR decision process: A survey of nurses and physicians in hematology and oncology. PLoS One 2018; 13:e0206550. [PMID: 30462673 PMCID: PMC6248939 DOI: 10.1371/journal.pone.0206550] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/15/2018] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION In cancer care, do-not-resuscitate (DNR) decisions are made frequently; i.e., decisions not to start the heart in the event of a cardiac arrest. A DNR decision can be a complex process involving nurses and physicians with a wide variety of experiences and perspectives. Previous studies have shown different perceptions of the DNR decision process among nurses and physicians, e.g. concerning patient involvement and information. DNR decisions have also been reported to be unclear and documentation inconsistent. OBJECTIVE The aim was to investigate how important and how likely to happen nurses and physicians considered various aspects of the DNR decision process, regarding participation, information and documentation, as well as which attributes they found most important in relation to DNR decisions. METHODS A descriptive correlational study using a web survey was conducted, including 132 nurses and 84 physicians working in hematology and oncology. RESULTS Almost half of the respondents reported it not likely that the patient would be involved in the decision on DNR, and 21% found it unimportant to inform patients of the DNR decision. Further, 57% reported that providing information to the patient was important, but only 21% stated that this was likely to happen. There were differences between nurses and physicians, especially regarding participation by and information to patients and relatives. The attributes deemed most important for both nurses and physicians pertained more to medical viewpoints than to ethical values, but a difference was found, as nurses chose patient autonomy as the most important value, while physicians rated non-maleficence as the most important value in relation to DNR decisions. CONCLUSION Nurses and physicians need to be able to talk openly about their different perspectives on DNR decisions, so that they can develop a deeper understanding of the decisions, especially in cases where they disagree. They should also be aware that what they think is important is not always likely to happen. The organization needs to support such discussions through providing an environment that allows ethical discussions on regular basis. Patients and relatives will also benefit from receiving the same information from all caregivers.
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Affiliation(s)
- Mona Pettersson
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Anna T. Höglund
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Mariann Hedström
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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Turnbull AE, Sahetya SK, Colantuoni E, Kweku J, Nikooie R, Curtis JR. Inter-Rater Agreement of Intensivists Evaluating the Goal Concordance of Preference-Sensitive ICU Interventions. J Pain Symptom Manage 2018; 56:406-413.e3. [PMID: 29902555 PMCID: PMC6456035 DOI: 10.1016/j.jpainsymman.2018.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/01/2018] [Accepted: 06/03/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Goal-concordant care has been identified as an important outcome of advance care planning and shared decision-making initiatives. However, validated methods for measuring goal concordance are needed. OBJECTIVES To estimate the inter-rater reliability of senior critical care fellows rating the goal concordance of preference-sensitive interventions performed in intensive care units (ICUs) while considering patient-specific circumstances as described in a previously proposed methodology. METHODS We identified ICU patients receiving preference-sensitive interventions in three adult ICUs at Johns Hopkins Hospital. A simulated cohort was created by randomly assigning each patient one of 10 sets of goals and preferences about limiting life support. Critical care fellows then independently reviewed patient charts and answered two questions: 1) Is this patient's goal achievable? and 2) Will performing this intervention help achieve the patient's goal? When the answer to both questions was yes, the intervention was rated as goal concordant. Inter-rater agreement was summarized by estimating intraclass correlation coefficient using mixed-effects models. RESULTS Six raters reviewed the charts of 201 patients. Interventions were rated as goal concordant 22%-92% of the time depending on the patient's goal-limitation combination. Percent agreement between pairs of raters ranged from 59% to 86%. The intraclass correlation coefficient for ratings of goal concordance was 0.50 (95% CI 0.31-0.69) and was robust to patient age, gender, ICU, severity of illness, and lengths of stay. CONCLUSION Inter-rater agreement between intensivists using a standardized methodology to evaluate the goal concordance of preference-sensitive ICU interventions was moderate. Further testing is needed before this methodology can be recommended as a clinical research outcome.
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Affiliation(s)
- Alison E Turnbull
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, USA; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
| | - Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, USA; Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Josephine Kweku
- Department of Anesthesiology and Critical Care, Anne Arundel Medical Center, Annapolis, Maryland, USA
| | - Roozbeh Nikooie
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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