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Golmohammadi M, Ebadi A, Ashrafizadeh H, Rassouli M, Barasteh S. Factors related to advance directives completion among cancer patients: a systematic review. BMC Palliat Care 2024; 23:3. [PMID: 38166983 PMCID: PMC10762918 DOI: 10.1186/s12904-023-01327-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients. METHODS A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior. RESULTS Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics". CONCLUSION The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.
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Affiliation(s)
- Mobina Golmohammadi
- Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hadis Ashrafizadeh
- Student Research Committee, Faculty of Nursing, Dezful University of Medical Sciences, Dezful, Iran
| | - Maryam Rassouli
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Salman Barasteh
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
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Baumann SM, Kruse NJ, Kliem PSC, Amacher SA, Hunziker S, Dittrich TD, Renetseder F, Grzonka P, Sutter R. Translation of patients' advance directives in intensive care units: are we there yet? J Intensive Care 2023; 11:53. [PMID: 37968692 PMCID: PMC10648602 DOI: 10.1186/s40560-023-00705-z] [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: 09/13/2023] [Accepted: 11/08/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVES This review examined studies regarding the implementation and translation of patients' advance directives (AD) in intensive care units (ICUs), focusing on practical difficulties and obstacles. METHODS The digital PubMed and Medline databases were screened using predefined keywords to identify relevant prospective and retrospective studies published until 2022. RESULTS Seventeen studies from the United States, Europe, and South Africa (including 149,413 patients and 1210 healthcare professionals) were identified. The highest prevalence of ADs was described in a prospective study in North America (49%), followed by Central Europe (13%), Asia (4%), Australia and New Zealand (4%), Latin America (3%), and Northern and Southern Europe (2.6%). While four retrospective studies reported limited effects of ADs, four retrospective studies, one survey and one systematic review indicated significant effects on provision of intensive care, higher rates of do-not-resuscitate orders, and care withholding in patients with ADs. Four of these studies showed shorter ICU stays, and lower treatment costs in patients with ADs. One prospective and two retrospective studies reported issues with loss, delayed or no transmission of ADs. One survey revealed that 91% of healthcare workers did not regularly check for ADs. Two retrospective studies and two survey revealed that the implementation of directives is further challenged by issues with their applicability, phrasing, and compliance by the critical care team and family members. CONCLUSIONS Although ADs may improve intensive- and end-of-life care, insufficient knowledge, lack of awareness, poor communication between healthcare providers and patients or surrogates, lack of standardization of directives, as well as ethical and legal concerns challenge their implementation.
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Affiliation(s)
- Sira M Baumann
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Natalie J Kruse
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Paulina S C Kliem
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Simon A Amacher
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Sabina Hunziker
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Tolga D Dittrich
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Fabienne Renetseder
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Pascale Grzonka
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland.
- Department of Clinical Research, University of Basel, Basel, Switzerland.
- Medical Faculty, University of Basel, Basel, Switzerland.
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Tooba R, Rose S, Modlin C, Liang C, Mascha EJ, Perez-Protto S. Using Preanesthesia Clinic Visits to Improve Advance Directives Completion: An Interrupted Time Series Analysis. Anesth Analg 2023; 137:906-916. [PMID: 37450641 DOI: 10.1213/ane.0000000000006533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Advance directives documentation can increase the likelihood that patient's wishes are respected if they become incapacitated. Unfortunately, completion rates are suboptimal overall, and disparities may exist, especially for vulnerable groups. We assessed whether implementing an initiative to standardize advance directives discussions during preanesthesia visits was associated with changes in rates of advance directives completion over time, and whether the association depends on race, insurance type, or income. METHODS We conducted a before-after interrupted time series evaluation between January 1, 2015 and June 30, 2019 in a single-center, outpatient preanesthesia clinic. Participants were adults who visited the preanesthesia clinic at Cleveland Clinic and had >1 comorbidity before a noncardiac surgery of either medium or high risk. The intervention in March of 2017 consisted of training staff to help patients complete and witness advance directives documents during visits. We measured advance directives completion, by race, payor, and income (using the 2019 Federal Poverty Line). We assessed the confounder-adjusted association between intervention (pre versus post) and proportion of patients completing advanced directives over time using segmented regression to compare slopes between periods and assess changes at start of the intervention. We used similar models to assess whether changes depended on race, insurance type, or income level. RESULTS We included 26,368 visits from 22,430 patients. We analyzed financial status for 16,788 visits from 14,274 patients who had address data. There were 11,242 (43%) visits preintervention and 15,126 (57%) visits postintervention. Crude completion rates for advance directives increased from 29% to 78%, with odds of completion an estimated 18 times higher than preintervention (odds ratio [95% CI] of 18 [16-21]; P < 0.001). Regarding race, Black patients had lower completion rates preintervention than White patients, although the gap steadily closed after the intervention ( P = .001). Postintervention, both race groups immediately increased, with no difference in amount of increase ( P = .17) or postintervention change in slope difference ( P = .17). Regarding insurance, patients with Medicaid had lower preintervention completion rates than those with private. Intervention was associated with increases in both groups, but the difference in slopes ( P = .43) or proportions ( P = .23) between the groups did not change after intervention. Regarding the Federal Poverty Line, the completion rate gap between those below (<100%) and above (139%-400%) narrowed by approximately half (0.51: 95% CI, 0.27-0.98; P = .04). CONCLUSIONS Standardizing advance directives discussions during preanesthesia visits was associated with more patients completing advance directives, particularly in vulnerable patient groups.
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Affiliation(s)
- Rubabin Tooba
- From the Department of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas
| | - Susannah Rose
- Center for Bioethics and Safety, Quality and Patient Experience, Clinical Transformation, Cleveland Clinic, Cleveland, Ohio
| | | | - Chen Liang
- Departments of Quantitative Health and Sciences
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward J Mascha
- Departments of Quantitative Health Sciences
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Silvia Perez-Protto
- Departments of Intensive Care & Resuscitation
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Levoy K, Sullivan SS, Chittams J, Myers RL, Hickman SE, Meghani SH. Don't Throw the Baby Out With the Bathwater: Meta-Analysis of Advance Care Planning and End-of-life Cancer Care. J Pain Symptom Manage 2023; 65:e715-e743. [PMID: 36764411 PMCID: PMC10192153 DOI: 10.1016/j.jpainsymman.2023.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/27/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
CONTEXT There is ongoing discourse about the impact of advance care planning (ACP) on end-of-life (EOL) care. No meta-analysis exists to clarify ACP's impact on patients with cancer. OBJECTIVE To investigate the association between, and moderators of, ACP and aggressive vs. comfort-focused EOL care outcomes among patients with cancer. METHODS Five databases were searched for peer-reviewed observational/experimental ACP-specific studies that were published between 1990-2022 that focused on samples of patients with cancer. Odds ratios were pooled to estimate overall effects using inverse variance weighting. RESULTS Of 8,673 articles, 21 met criteria, representing 33,541 participants and 68 effect sizes (54 aggressive, 14 comfort-focused). ACP was associated with significantly lower odds of chemotherapy, intensive care, hospital admissions, hospice use fewer than seven days, hospital death, and aggressive care composite measures. ACP was associated with 1.51 times greater odds of do-not-resuscitate orders. Other outcomes-cardiopulmonary resuscitation, emergency department admissions, mechanical ventilation, and hospice use-were not impacted. Tests of moderation revealed that the communication components of ACP produced greater reductions in the odds of hospital admissions compared to other components of ACP (e.g., documents); and, observational studies, not experimental, produced greater odds of hospice use. CONCLUSION This meta-analysis demonstrated mixed evidence of the association between ACP and EOL cancer care, where tests of moderation suggested that the communication components of ACP carry more weight in influencing outcomes. Further disease-specific efforts to clarify models and components of ACP that work and matter to patients and caregivers will advance the field.
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Affiliation(s)
- Kristin Levoy
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana.
| | - Suzanne S Sullivan
- School of Nursing (S.S.S.), University at Buffalo, State University of New York, Buffalo, New York
| | - Jesse Chittams
- BECCA (Biostatistics, Evaluation, Collaboration, Consultation & Analysis) Lab, Office of Nursing Research (J.C.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Ruth L Myers
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana
| | - Susan E Hickman
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences (S.H.M.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics (S.H.M.), University of Pennsylvania, Philadelphia, Pennsylvania
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Haines KL, Nguyen BP, Antonescu I, Freeman J, Cox C, Krishnamoorthy V, Kawano B, Agarwal S. Insurance Status and Ethnicity Impact Health Disparities in Rates of Advance Directives in Trauma. Am Surg 2023; 89:88-97. [PMID: 33877932 DOI: 10.1177/00031348211011115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Advanced directives (ADs) provide a framework from which families may understand patient's wishes. However, end-of-life planning may not be prioritized by everyone. This analysis aimed to determine what populations have ADs and how they affected trauma outcomes. METHODS Adult trauma patients recorded in the American College of Surgeons Trauma Quality Improvement Program (TQIP) from 2013-2015 were included. The primary outcome was presence of an AD. Secondary outcomes included mortality, length of stay (LOS), mechanical ventilation, ICU admission/LOS, withdrawal of life-sustaining measures, and discharge disposition. Multivariable logistic regression models were developed for outcomes. RESULTS 44 705 patients were included in the analyses. Advanced directives were present in 1.79% of patients. The average age for patients with ADs was 77.8 ± 10.7. African American (odds ratio (OR) .53, confidence intervals [CI] .36-.79) and Asian (OR .22, CI .05-.91) patients were less likely to have ADs. Conversely, Medicaid (OR 1.70, CI 1.06-2.73) and Medicare (OR 1.65, CI 1.25-2.17) patients were more likely to have ADs as compared to those with private insurance. The presence of ADs was associated with increased hospital mortality (OR 2.84, CI 2.19-3.70), increased transition to comfort measures (OR 2.87, CI 2.08-3.95), and shorter LOS (CO -.74, CI -1.26-.22). Patients with ADs had an increased odds of hospice care (OR 4.24, CI 3.18-5.64). CONCLUSION Advanced directives at admission are uncommon, particularly among African Americans and Asians. The presence of ADs was associated with increased mortality, use of mechanical ventilation, admission to the ICU, withdrawal of life-sustaining measures, and hospice. Future research should target expansion of ADs among minority populations to alleviate disparities in end-of-life treatment.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Benjamin P Nguyen
- Department of Surgery, 20868Kaweah Delta Health Care District, Medical Center, Visalia, CA, USA
| | - Ioana Antonescu
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Jennifer Freeman
- Department of Surgery, 3402TCU and UNTHSC School of Medicine, Fort Worth, TX, USA
| | - Christopher Cox
- Division of Pulmonary Critical Care, Department of Medicine, 22957Duke University Medical Center, Durham, NC, USA
| | - Vijay Krishnamoorthy
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Brad Kawano
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
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Allner M, Gostian M, Balk M, Rupp R, Allner C, Mantsopoulos K, Ostgathe C, Iro H, Hecht M, Gostian AO. Advance directives in patients with head and neck cancer - status quo and factors influencing their creation. Palliat Care 2022; 21:47. [PMID: 35395940 PMCID: PMC8991502 DOI: 10.1186/s12904-022-00932-5] [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] [Received: 07/05/2021] [Accepted: 03/10/2022] [Indexed: 12/24/2022] Open
Abstract
Background Advance Care Planning including living wills and durable powers of attorney for healthcare is a highly relevant topic aiming to increase patient autonomy and reduce medical overtreatment. Data from patients with head and neck cancer (HNC) are not currently available. The main objective of this study was to survey the frequency of advance directives (AD) in patients with head and neck cancer. Methods In this single center cross-sectional study, we evaluated patients during their regular follow-up consultations at Germany’s largest tertiary referral center for head and neck cancer, regarding the frequency, characteristics, and influencing factors for the creation of advance directives using a questionnaire tailored to our cohort. The advance directives included living wills, durable powers of attorney for healthcare, and combined directives. Results Four hundred and forty-six patients were surveyed from 07/01/2019 to 12/31/2019 (response rate = 68.9%). The mean age was 62.4 years (SD 11.9), 26.9% were women (n = 120). 46.4% of patients (n = 207) reported having authored at least one advance directive. These documents included 16 durable powers of attorney for healthcare (3.6%), 75 living wills (16.8%), and 116 combined directives (26.0%). In multivariate regression analysis, older age (OR ≤ 0.396, 95% CI 0.181–0.868; p = 0.021), regular medication (OR = 1.896, 95% CI 1.029–3.494; p = 0.040), and the marital status (“married”: OR = 2.574, 95% CI 1.142–5.802; p = 0.023; and “permanent partnership”: OR = 6.900, 95% CI 1.312–36.295; p = 0.023) emerged as significant factors increasing the likelihood of having an advance directive. In contrast, the stage of disease, the therapeutic regimen, the ECOG status, and the time from initial diagnosis did not correlate with the presence of any type of advance directive. Ninety-one patients (44%) with advance directives created their documents before the initial diagnoses of head and neck cancer. Most patients who decide to draw up an advance directive make the decision themselves or are motivated to do so by their immediate environment. Only 7% of patients (n = 16) actively made a conscious decision not create an advance directive. Conclusion Less than half of head and neck cancer patients had created an advance directive, and very few patients have made a conscious decision not to do so. Older and comorbid patients who were married or in a permanent partnership had a higher likelihood of having an appropriate document. Advance directives are an essential component in enhancing patient autonomy and allow patients to be treated according to their wishes even when they are unable to consent. Therefore, maximum efforts are advocated to increase the prevalence of advance directives, especially in head and neck cancer patients, whose disease often takes a crisis-like course. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00932-5.
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Affiliation(s)
- Moritz Allner
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany.
| | - Magdalena Gostian
- Department of Anesthesiology, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
| | - Matthias Balk
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Robin Rupp
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Clarissa Allner
- Emergency Medical Center, Department of Internal Medicine, Klinikum Fürth, Fürth, Germany
| | - Konstantinos Mantsopoulos
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), Erlangen-Nürnberg, Germany
| | - Heinrich Iro
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Markus Hecht
- Department of Radiation Oncology, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), Erlangen-Nürnberg, Germany
| | - Antoniu-Oreste Gostian
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
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Salazar MM, DeCook LJ, Butterfield RJ, Zhang N, Sen A, Wu KL, Vanness DJ, Khera N. End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation. J Palliat Med 2021; 25:97-105. [PMID: 34705545 DOI: 10.1089/jpm.2021.0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Patients receiving allogeneic hematopoietic cell transplantation (HCT) have high morbidity and mortality risk, but literature is limited on factors associated with end-of-life (EOL) care intensity. Objectives: Describe EOL care in patients after allogeneic HCT and examine association of patient and clinical characteristics with intense EOL care. Design: Retrospective chart review. Setting/Subjects: A total of 113 patients who received allogeneic HCT at Mayo Clinic Arizona between 2013 and 2017 and died before November 2019. Measurements: A composite EOL care intensity measure included five markers: (1) no hospice enrollment, (2) intensive care unit (ICU) stay in the last month, (3) hospitalization >14 days in last month, (4) chemotherapy use in the last two weeks, and (5) cardiopulmonary resuscitation, hemodialysis, or mechanical ventilation in the last week of life. Multivariable logistic regression modeling assessed associations of having ≥1 intensity marker with sociodemographic and disease characteristics, palliative care consultation, and advance directive documentation. Results: Seventy-six percent of patients in our cohort had ≥1 intensity marker, with 43% receiving ICU care in the last month of life. Median hospital stay in the last month of life was 15 days. Sixty-five percent of patients died in hospice; median enrollment was 4 days. Patients with higher education were less likely to have ≥1 intensity marker (odds ratio 0.28, p = 0.02). Patients who died >100 days after HCT were less likely to have ≥1 intensity marker than patients who died ≤100 days of HCT (p = 0.04). Conclusions: Death within 100 days of HCT and lower educational attainment were associated with higher likelihood of intense EOL care.
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Affiliation(s)
- Marisa M Salazar
- Mayo Clinic Alix School of Medicine, Mayo Clinic College of Science and Medicine, Scottsdale, Arizona, USA
| | - Lori J DeCook
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Nan Zhang
- Department of Biostatistics, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Kelly L Wu
- Division of General Internal Medicine, Center for Palliative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - David J Vanness
- Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Nandita Khera
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Stachulski F, Siegerink B, Bösel J. Dying in the Neurointensive Care Unit After Withdrawal of Life-Sustaining Therapy: Associations of Advance Directives and Health-Care Proxies With Timing and Treatment Intensity. J Intensive Care Med 2020; 36:451-458. [PMID: 32089041 DOI: 10.1177/0885066620906795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Critically ill patients require a careful approach for prognosis and decision-making. The German health legislation aims to strengthen the role of advance directives (ADs) and health-care proxies (HCPs). Their impact within a dedicated neurocritical care setting is unknown. This study aimed to assess the practice of withdrawal or withholding of life-sustaining therapy (WOLST) in a German neurointensive care unit (NICU) focusing on whether AD or HCP is associated with timing and treatment intensity. METHODS Data on patients who died after WOLST at a dedicated NICU of a German university hospital, from 2010 to 2013, were retrospectively analyzed. RESULTS Of 400 deceased patients, 310 (77.5%) died after initiation of WOLST. Among them, 68 (21.9%) were identified to have AD or HCP or both (AD + HCP). WOLST patients with AD, HCP, or AD + HCP were older than those without (median age: 77 vs 72 years, P < .001) but did not show any other distinct baseline features. There was no difference in the specific neurocritical care measures between the groups. Poisson regression analysis showed no significant difference in the probability of time-dependent WOLST initiation between those with and without AD/HCP, after adjusting for age and sex (adjusted incidence rate ratio, 1.10; 95% confidence interval, 0.94-1.28; P = .244). CONCLUSIONS In this single-center study of mainly cerebrovascular NICU patients, AD or HCP was neither associated with an earlier WOLST nor associated with a difference in treatment intensity before WOLST. Further prospective studies should assess the emerging concept of advance care planning in neurocritical care.
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Affiliation(s)
- Frank Stachulski
- Department of Neurology, German Allied Forces Hospital Berlin, Germany
| | - Bob Siegerink
- Center for Stroke Research (CSB), 14903Charité Universitätsmedizin Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Kassel General Hospital, Kassel, Germany.,Department of Neurology, 9144University Hospital Heidelberg, Germany
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10
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Trevino KM, Rutherford SC, Marte C, Ouyang DJ, Martin P, Prigerson HG, Leonard JP. Illness Understanding and Advance Care Planning in Patients with Advanced Lymphoma. J Palliat Med 2019; 23:832-837. [PMID: 31633432 PMCID: PMC7249459 DOI: 10.1089/jpm.2019.0311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: The prognosis of an aggressive lymphoma can change dramatically following failure of first-line treatment. This sudden shift is challenging for the promotion of illness understanding and advance care planning (ACP). Yet, little is known about illness understanding and ACP in patients with aggressive lymphomas. Objective: To examine illness understanding, rates of engagement in ACP, and reasons for lack of ACP engagement in patients with advanced B cell lymphomas. Design: Cross-sectional observational study. Setting/Subjects: Patients (n = 27) with aggressive B cell lymphomas that relapsed after first- or second-line treatment treated at a single urban academic medical center. Measurements: Participants were administered structured surveys by trained staff to obtain self-report measures of illness understanding (i.e., aggressiveness, terminality, curability) and ACP (i.e., discussions of care preferences, completion of advance directives). Results: The majority of patients reported discussing curability (92.6%), prognosis (77.8%), and treatment goals (88.9%) with their medical team. Yet, less than one-third of patients reported being terminally ill (29.6%) and having incurable disease (22.2%). Most patients had a health care proxy (81.5%) and had decided about do-not-resuscitate status (63%), but the majority had not completed a living will (65.4%) or discussed their care preferences with others (55.6%). Conclusions: The accuracy of lymphoma patients' illness understanding following first-line treatment is difficult to determine due to the potential for cure following transplant. However, this study suggests that a large proportion of patients with advanced B cell lymphomas may underestimate the severity of their illness, despite discussing illness severity with their medical team. Providing patients with information on prognosis, and the ACP process may increase engagement in ACP.
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Affiliation(s)
- Kelly M Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sarah C Rutherford
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Medicine, NewYork Presbyterian Hospital, New York, New York, USA
| | - Chrystal Marte
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel Jie Ouyang
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Medicine, NewYork Presbyterian Hospital, New York, New York, USA
| | - Peter Martin
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Medicine, NewYork Presbyterian Hospital, New York, New York, USA
| | - Holly G Prigerson
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Medicine, NewYork Presbyterian Hospital, New York, New York, USA
| | - John P Leonard
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Medicine, NewYork Presbyterian Hospital, New York, New York, USA
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11
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Escudero-Acha P, Peñasco Y, Rodriguez-Borregan JC, Cuenca Fito E, Ferreira Freire L, González-Castro A. [Concordance between the oncologist and the intensivist in the decisions of aggressive measures in cancer patients]. Med Intensiva 2019; 45:246-247. [PMID: 31630915 DOI: 10.1016/j.medin.2019.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/31/2019] [Accepted: 08/22/2019] [Indexed: 11/26/2022]
Affiliation(s)
- P Escudero-Acha
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Y Peñasco
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España; Servicio de Oncología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - J C Rodriguez-Borregan
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España; Servicio de Oncología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - E Cuenca Fito
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - L Ferreira Freire
- Servicio de Oncología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - A González-Castro
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España.
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12
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Khandelwal N, Long AC, Lee RY, McDermott CL, Engelberg RA, Curtis JR. Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals. THE LANCET RESPIRATORY MEDICINE 2019; 7:613-625. [PMID: 31122895 DOI: 10.1016/s2213-2600(19)30170-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA.
| | - Ann C Long
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
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13
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McPherson K, Carlos WG, Emmett TW, Slaven JE, Torke AM. Limitation of Life-Sustaining Care in the Critically Ill: A Systematic Review of the Literature. J Hosp Med 2019; 14:303-310. [PMID: 30794145 PMCID: PMC6625435 DOI: 10.12788/jhm.3137] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 12/03/2018] [Indexed: 12/21/2022]
Abstract
When life-sustaining treatments (LST) are no longer effective or consistent with patient preferences, limitations may be set so that LSTs are withdrawn or withheld from the patient. Many studies have examined the frequency of limitations of LST in intensive care unit (ICU) settings in the past 30 years. This systematic review describes variation and patient characteristics associated with limitations of LST in critically ill patients in all types of ICUs in the United States. A comprehensive search of the literature was performed by a medical librarian between December 2014 and April 2017. A total of 1,882 unique titles and abstracts were reviewed, 113 were selected for article review, and 36 studies were fully reviewed. Patient factors associated with an increased likelihood of limiting LST included white race, older age, female sex, poor preadmission functional status, multiple comorbidities, and worse illness severity score. Based on several large, multicenter studies, there was a trend toward a higher frequency of limitation of LST over time. However, there is large variability between ICUs in the proportion of patients with limitations and on the proportion of deaths preceded by a limitation. Increases in the frequency of limitations of LST over time suggests changing attitudes about aggressive end-of-life-care. Limitations are more common for patients with worse premorbid health and greater ICU illness severity. While some differences in the frequency of limitations of LST may be explained by personal factors such as race, there is unexplained wide variability between units.
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Affiliation(s)
- Katie McPherson
- Division of Pulmonary and Critical Care Medicine, University of Colorado, Denver Colorado
| | - W Graham Carlos
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas W Emmett
- Ruth Lilly Medical Library at Indiana University School of Medicine, Indianapolis, Indiana
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alexia M Torke
- Indiana University Center for Aging Research, Indianapolis Indiana
- Daniel F. Evans Center for Spiritual and Religious Values in Healthcare and Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, Indiana
- Corresponding Author: Alexia M Torke, MD, MS; E-mail: ; Telephone: 317-274-9221; Twitter: @AlexiaMTorke
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14
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Krishnappa V, Hein W, DelloStritto D, Gupta M, Raina R. Palliative care for acute kidney injury patients in the intensive care unit. World J Nephrol 2018; 7:148-154. [PMID: 30596033 PMCID: PMC6305526 DOI: 10.5527/wjn.v7.i8.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/25/2018] [Accepted: 12/05/2018] [Indexed: 02/06/2023] Open
Abstract
Patients with acute kidney injury (AKI) in the intensive care unit (ICU) are often suitable for palliative care due to the high symptom burden. The role of palliative medicine in this patient population is not well defined and there is a lack of established guidelines to address this issue. Because of this, patients in the ICU with AKI deprived of the most comprehensive or appropriate care. The reasons for this are multifactorial including lack of palliative care training among nephrologists. However, palliative care in these patients can help alleviate symptoms, improve quality of life, and decrease suffering. Palliative care physicians can determine the appropriateness and model of palliative care. In addition to shared decision-making, advance directives should be established with patients early on, with specific instructions regarding dialysis, and those advance directives should be respected.
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Affiliation(s)
- Vinod Krishnappa
- Northeast Ohio Medical University, Rootstown, OH 44272, United States
- Department of Nephrology, Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH 44302, United States
| | - William Hein
- Northeast Ohio Medical University, Rootstown, OH 44272, United States
| | | | - Mona Gupta
- Department of Hospice and Palliative Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General/Akron Nephrology Associates and Akron Children's Hospital, Akron, OH 44307, United States
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15
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Abstract
OBJECTIVES We quantified the 28-day mortality effect of preexisting do-not-resuscitate orders in ICUs. DESIGN Longitudinal, retrospective study of patients admitted to five ICUs at a tertiary university medical center (Beth Israel Deaconess Medical Center, BIDMC, Boston, MA) between 2001 and 2008. INTERVENTION None. PATIENTS Two cohorts were defined: patients with do not resuscitate advance directives on day 1 of ICU admission and a control group comprising patients with no limitations of level of care on ICU day 1 (full code). MEASUREMENTS AND MAIN RESULTS The primary outcome was mortality at 28 days after ICU admission. Of 19,007 ICU patients, 1,239 patients (6.5%) had a do-not-resuscitate order on the first day of ICU admission and survived 48 hours in the ICU. We matched those do-not-resuscitate patients with 2,402 patients with full-code status. Twenty-eight day and 1-year mortality were both significantly higher in the do-not-resuscitate group (33.9% vs 18.4% and 60.7% vs 40.2%; p < 0.001, respectively). CONCLUSION Do-not-resuscitate status is an independent risk factor for ICU mortality. This may reflect severity of illness not captured by other clinical factors, but the perceptions of the treating team related to do-not-resuscitate status could also be causally responsible for increased mortality in patients with do-not-resuscitate status.
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16
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Leung AK, To MJ, Luong L, Vahabi ZS, Gonçalves VL, Song J, Hwang SW. The Effect of Advance Directive Completion on Hospital Care Among Chronically Homeless Persons: a Prospective Cohort Study. J Urban Health 2017; 94:43-53. [PMID: 28028678 PMCID: PMC5359166 DOI: 10.1007/s11524-016-0105-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Advance care planning is relevant for homeless individuals because they experience high rates of morbidity and mortality. The impact of advance directive interventions on hospital care of homeless individuals has not been studied. The objective of this study was to determine if homeless individuals who complete an advance directive through a shelter-based intervention are more likely to have information from their advance directive documented and used during subsequent hospitalizations. The advance directive included preferences for life-sustaining treatments, resuscitation, and substitute decision maker(s). A total of 205 homeless men from a homeless shelter for men in Toronto, Canada, were enrolled in the study and offered an opportunity to complete an advance directive with the guidance of a trained counselor from April to June 2013. One hundred and three participants chose to complete an advance directive, and 102 participants chose to not complete an advance directive. Participants were provided copies of their advance directives. In addition, advance directives were electronically stored, and hospitals within a 1.0-mile radius of the shelter were provided access to the database. A prospective cohort study was performed using chart reviews to ascertain the documentation, availability, and use of advance directives, end-of-life care preferences, and medical treatments during hospitalizations over a 1-year follow-up period (April 2013 to June 2014) after the shelter-based advance directive intervention. Chart reviewers were blinded as to whether participants had completed an advance directive. The primary outcome was documentation or use of an advance directive during any hospitalization. The secondary outcome was documentation of end-of-life care preferences, without reference to an advance directive, during any hospitalization. After unblinding, charts were studied to determine whether advance directives were available, hospital care was consistent with patient preferences as documented in advance directives, and hospital resource utilization during admission. During the 1-year follow-up period, 38 participants who completed an advance directive and 37 participants who did not complete an advance directive had at least one hospitalization (36.9 vs. 36.2 %, p = 0.93). Participants who completed an advance directive were significantly more likely to have documentation or use of an advance directive in hospital, compared to participants who did not complete an advance directive (9.7 vs. 2.9 %, p = 0.047). Without reference to an advance directive, documentation of end-of-life care preferences occurred in 30.1 vs. 30.4 % of participants, respectively (p = 0.96), most often due to documentation of code status. There were no significant differences in resource utilization between admitted patients who completed and did not complete an advance directive. In conclusion, homeless men who complete an advance directive through a shelter-based intervention are more likely to have their detailed care preferences documented or used during subsequent hospitalizations.
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Affiliation(s)
- Alexander K Leung
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.
| | - Matthew J To
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
| | - Linh Luong
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
| | - Zahra Syavash Vahabi
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
| | - Victor L Gonçalves
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
| | - John Song
- Center for Bioethics, University of Minnesota, Minneapolis, MN, USA
| | - Stephen W Hwang
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.,Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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17
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Needle J, Smith AR. The Impact of Advance Directives on End-of-Life Care for Adolescents and Young Adults Undergoing Hematopoietic Stem Cell Transplant. J Palliat Med 2016; 19:300-5. [PMID: 26895198 DOI: 10.1089/jpm.2015.0327] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Little is known about the role of advance directives (AD) in end-of-life (EOL) care for adolescents and young adults (AYA) undergoing hematopoietic stem cell transplant (HSCT). OBJECTIVE The study objective was to describe the frequency, type, and influence of AD on the use of life-sustaining treatment (LST) in AYA patients undergoing HSCT. METHODS We performed a retrospective chart review of 96 patients aged 14-26 undergoing HSCT between April 2011 and January 2015 at the University of Minnesota. LST was defined as the use of positive pressure ventilation (PPV), dialysis, or CPR. RESULTS Of the 96 patients, survival was 72.9%, and 23% had an AD. Of the 26 patients who died, 13 (50%) had an AD. Among the 19 patients who died in the ICU, there was no significant difference in PPV, dialysis, withholding or withdrawing of LST, or timing of do not resuscitate (DNR) orders between those with ADs preferring LST (n = 5), those naming proxies only (n = 4), and those without ADs (n = 10). Patients with ADs expressing preference for LST were significantly more likely to receive CPR than those with proxies or those without ADs (p = 0.02). CONCLUSION A minority of AYA patients undergoing HSCT had ADs. Patients received care that was strongly associated with their preferences. With the exception of CPR, the use of LST did not differ between those with ADs and those without.
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Affiliation(s)
- Jennifer Needle
- 1 Department of Pediatrics, Division of Critical Care, University of Minnesota , Minneapolis, Minnesota
| | - Angela R Smith
- 2 Department of Pediatrics, Division of Pediatric Blood and Marrow Transplant, University of Minnesota , Minneapolis, Minnesota
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18
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Leder N, Schwarzkopf D, Reinhart K, Witte OW, Pfeifer R, Hartog CS. The Validity of Advance Directives in Acute Situations. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:723-9. [PMID: 26568176 PMCID: PMC4647312 DOI: 10.3238/arztebl.2015.0723] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/24/2015] [Accepted: 06/24/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nearly every fourth person in Germany has an advance directive that is to be used in certain medical situations. It is questionable, however, whether advance directives truly influence important treatment decisions in the intensive care unit. We studied the extent to which doctors and patients' relatives agree on the applicability of advance directives in the acute setting. METHODS A prospective study was carried out by questionnaire among the physicians and relatives of 50 patients with advance directives who were hospitalized on four different multidisciplinary intensive care units. The answers of 25 residents in training, 14 senior physicians, and 19 relatives were analyzed both quantitatively and qualitatively. The extent of agreement was assessed by means of Gwet's AC1 with linear weighting. RESULTS In most of the advance directives, the conditions under which they were meant to apply were stated in broad, general terms in prewritten blocks of text. 23 of the 50 patients (46%) died. All relatives stated that they were very familiar with the patients' wishes; 18 of 19 were legally responsible for decision-making. In assessing whether the advance directive was applicable to the situation at hand, the strength of agreement between physicians and relatives as well as between the two groups of physicians was only fair and non-significant (0.35; 95% confidence interval [CI]: -0.01 to 0.71; p = 0.059 and 0.24; 95% CI: -0.03 to 0.50; p = 0.079). The relatives found the advance directives more useful than the doctors did (median, 5 vs. 3 [p = 0.018] on a Likert scale ranging from 0 [not useful at all] to 5 [very useful]) and favored their literal application (median, 5 vs. 4 [p = 0.018] on a Likert scale ranging from 0 [favoring the doctor's interpretation] to 5 [favoring literal application]). 30 days after the decision, 13 relatives (68%) felt that the patient's wishes had been fully complied with. CONCLUSION These groups' clearly differing assessments of the applicability of advance directives imply that the currently most common types of advance directive are not suitable for use in intensive care. In order to support patients' relatives in their role as surrogate participants in decision-making, improved advance directives should be developed, and their implementation should be incorporated into the training and continuing medical education of intensive-care physicians.
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Affiliation(s)
- Nadja Leder
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital
- Center for Sepsis Control and Care (CSCC), Jena University Hospital
| | | | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital
- Center for Sepsis Control and Care (CSCC), Jena University Hospital
| | - Otto W Witte
- Department of Neurology, Jena University Hospital
| | | | - Christiane S Hartog
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital
- Center for Sepsis Control and Care (CSCC), Jena University Hospital
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19
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Shvartzman P, Reuven Y, Halperin M, Menahem S. Advance Directives-The Israeli Experience. J Pain Symptom Manage 2015; 49:1097-101. [PMID: 25637243 DOI: 10.1016/j.jpainsymman.2014.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 11/27/2014] [Accepted: 12/20/2014] [Indexed: 10/24/2022]
Abstract
CONTEXT A major step in end-of-life care was achieved in December 2005 when the Israeli parliament passed the "Dying Patient Law." The law (§31-§36) allows a competent person, even if he/she is healthy, to leave written instructions known as advance medical directives (AD), in which they explain their wishes in detail with respect to future medical treatment should it be determined that they are an incompetent terminally ill patient, as defined by the provisions of that law. OBJECTIVES The aims were to characterize the group of individuals that completes ADs, characterize the content of recorded ADs, and analyze trends associated with them. METHODS We performed a cross-sectional study of the entire population that signed ADs in Israel from 2007 to September 2010. All computerized AD forms were retrieved from the Ministry of Health's database. A descriptive analysis of trends, characteristics, and authorized procedures relating to the population of AD signatories was done. RESULTS There was an increase in the number of ADs signed during the study period (1167 signatories). About 90% of the AD signatories were 65 years of age or older and 95% were healthy at the time they completed the AD. In an end-stage condition, the mean number of procedures declined was 16.6 ± 4.7 of 19. In a non-end-stage condition, the corresponding mean number was 12.7 ± 3.7 of 15. CONCLUSION There is a need to increase awareness in the general population of the option to prepare ADs. Family physicians, oncologists, and geriatricians should be more involved in this process.
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Affiliation(s)
- Pesach Shvartzman
- Department of Family Medicine and Palliative Care Unit, Clalit Health Services, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Palliative Clalit Health Services - Southern District Care Unit, Beer-Sheva, Israel.
| | - Yonatan Reuven
- Department of Family Medicine and Palliative Care Unit, Clalit Health Services, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | | | - Sasson Menahem
- Department of Family Medicine and Palliative Care Unit, Clalit Health Services, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Palliative Clalit Health Services - Southern District Care Unit, Beer-Sheva, Israel
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20
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Wallace SK, Waller DK, Tilley BC, Piller LB, Price KJ, Rathi N, Haque S, Nates JL. Place of Death among Hospitalized Patients with Cancer at the End of Life. J Palliat Med 2015; 18:667-76. [PMID: 25927588 DOI: 10.1089/jpm.2014.0389] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The majority of hospital deaths in the United States occur after ICU admission. The characteristics associated with the place of death within the hospital are not known for patients with cancer. OBJECTIVE The study objective was to identify patient characteristics associated with place of death among hospitalized patients with cancer who were at the end of life. METHODS A retrospective cohort study design was implemented. Subjects were consecutive patients hospitalized between 2003 and 2007 at a large comprehensive cancer center in the United States. Multinomial logistic regression analysis was used to identify patient characteristics associated with place of death (ICU, hospital following ICU, hospital without ICU) among hospital decedents. RESULTS Among 105,157 hospital discharges, 3860 (3.7%) died in the hospital: 42% in the ICU, 14% in the hospital following an ICU stay, and 44% in the hospital without ICU services. Individuals with the following characteristics had an increased risk of dying in the ICU: nonlocal residence, newly diagnosed hematologic or nonmetastatic solid tumor malignancies, elective admission, surgical or pediatric services. A palliative care consultation on admission was associated with dying in the hospital without ICU services. CONCLUSIONS Understanding existing patterns of care at the end of life will help guide decisions about resource allocation and palliative care programs. Patients who seek care at dedicated cancer centers may elect more aggressive care; thus the generalizability of this study is limited. Although dying in a hospital may be unavoidable for patients who have uncontrolled symptoms that cannot be managed at home, palliative care consultations with patients and their families in advance regarding end-of-life preferences may prevent unwanted admission to the ICU.
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Affiliation(s)
- Susannah K Wallace
- 1 Clinical Analytics and Informatics Department, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Dorothy K Waller
- 2 Division of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center School of Public Health , Houston, Texas
| | - Barbara C Tilley
- 3 Division of Biostatistics, The University of Texas Health Science Center School of Public Health , Houston, Texas
| | - Linda B Piller
- 2 Division of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center School of Public Health , Houston, Texas
- 3 Division of Biostatistics, The University of Texas Health Science Center School of Public Health , Houston, Texas
| | - Kristen J Price
- 4 Critical Care Department, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Nisha Rathi
- 4 Critical Care Department, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Sajid Haque
- 4 Critical Care Department, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Joseph L Nates
- 4 Critical Care Department, The University of Texas MD Anderson Cancer Center , Houston, Texas
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21
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Rao J, Fu Q, Wu Q, Yu S. Comparison of the Treatments of Patients With Cancer in Their Last 6 Months Between ICU and Cancer Center. Am J Hosp Palliat Care 2015; 33:245-51. [PMID: 25552304 DOI: 10.1177/1049909114565018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To investigate the treatments of patients with cancer in their last 6 months of life in intensive care unit (ICU) and Cancer Center. METHOD A prospective study was conducted on patients with cancer who died between January 2010 and July 2013 in the ICU and the Cancer Center (55 and 161 cases, respectively) of Tongji Hospital, Wuhan, China. The differences were compared by Chi-square test or Fisher test. RESULTS The differences in the treatments of patients with cancer between 2 groups were statistically significant. The proportion of patients with cancer who accepted blood transfusion (except albumin) was significantly higher in the ICU than in the Cancer Center. CONCLUSION Patients with cancer in the ICU were more likely to receive active treatments and less palliative and hospice care at the end of life than patients in the Cancer Center.
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Affiliation(s)
- Jie Rao
- Cancer Center of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Qiang Fu
- Cancer Center of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Qiansheng Wu
- Department of Bile-Pancreatic Surgery of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Shiying Yu
- Cancer Center of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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22
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Are written advance directives helpful to guide end-of-life therapy in the intensive care unit? A retrospective matched-cohort study. J Crit Care 2014; 29:128-33. [PMID: 24331948 DOI: 10.1016/j.jcrc.2013.08.024] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 08/28/2013] [Accepted: 08/31/2013] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose of the study was to determine whether treatment preferences in patients' advance directives (ADs) are associated with life-supporting treatments received during end-of-life care in the intensive care unit (ICU). MATERIAL AND METHODS This is a retrospective cohort study, including patients who died in 4 ICUs of a university hospital in Germany. Patients with ADs were matched with 2 patients each without ADs using propensity scores. RESULTS Sixty-four (13%) of 477 patients had ADs, written a median of 109 weeks before admission. Five categories of applicability conditions were identified, most of them difficult to interpret in the ICU (eg, "advanced brain impairment" or "imminent death"). Advance directives contained a number of treatment refusals. Specifically, 63 of 64 refused "life-sustaining measures." Compared to patients without ADs, patients with ADs were less likely to receive cardiopulmonary resuscitation (9% vs 23%, P = .029) and more likely to have do-not-resuscitate orders (77% vs 56%, P = .007). Therapy-limiting decisions and ICU length of stay did not differ between those with or without ADs. CONCLUSIONS Patients with ADs are less likely to receive cardiopulmonary resuscitation but otherwise receive similar life-sustaining treatments compared to matched patients without ADs. More research is needed to explore reasons for potential noncompliance with patient preferences.
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Brinkman-Stoppelenburg A, Rietjens JAC, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med 2014; 28:1000-25. [PMID: 24651708 DOI: 10.1177/0269216314526272] [Citation(s) in RCA: 864] [Impact Index Per Article: 86.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advance care planning is the process of discussing and recording patient preferences concerning goals of care for patients who may lose capacity or communication ability in the future. Advance care planning could potentially improve end-of-life care, but the methods/tools used are varied and of uncertain benefit. Outcome measures used in existing studies are highly variable. AIM To present an overview of studies on the effects of advance care planning and gain insight in the effectiveness of different types of advance care planning. DESIGN Systematic review. DATA SOURCES We systematically searched PubMed, EMBASE and PsycINFO databases for experimental and observational studies on the effects of advance care planning published in 2000-2012. RESULTS The search yielded 3571 papers, of which 113 were relevant for this review. For each study, the level of evidence was graded. Most studies were observational (95%), originated from the United States (81%) and were performed in hospitals (49%) or nursing homes (32%). Do-not-resuscitate orders (39%) and written advance directives (34%) were most often studied. Advance care planning was often found to decrease life-sustaining treatment, increase use of hospice and palliative care and prevent hospitalisation. Complex advance care planning interventions seem to increase compliance with patients' end-of-life wishes. CONCLUSION The effects of different types of advance care planning have been studied in various settings and populations using different outcome measures. There is evidence that advance care planning positively impacts the quality of end-of-life care. Complex advance care planning interventions may be more effective in meeting patients' preferences than written documents alone. More studies are needed with an experimental design, in different settings, including the community.
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Affiliation(s)
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands
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Pfirstinger J, Kattner D, Edinger M, Andreesen R, Vogelhuber M. The impact of a tumor diagnosis on patients' attitudes toward advance directives. Oncology 2014; 87:246-56. [PMID: 25139124 DOI: 10.1159/000363508] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/05/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although advance care planning and the completion of advance directives (ADs) are important tools to avoid unwanted aggressive care once patients have lost their decision-making capacity, only a minority of cancer patients are admitted with completed ADs, and little is known about patients' wishes regarding AD consultations. METHODS For 1 year, every new patient admitted to the hematology/oncology outpatient clinic of the University Hospital Regensburg received a self-administered questionnaire comprising a self-evaluation of AD knowledge and questions about preferences regarding consultation partners and the time of consultation. Disease-related data were collected from medical records. Statistics were calculated with SPSS. RESULTS Of the 500 questionnaires handed out, 394 (75%) were evaluable and analyzed. Twenty-eight percent of the participants had completed an AD (living will or health care proxy). Ninety-two percent of the participants without ADs had never received a consultation offer from any professional involved. Only 20% perceived a clear relation between cancer and AD consultations. More than 50% of the participants without ADs were in favor of consultations 'now' or 'in a few weeks', while more than 40% objected to AD consultations. CONCLUSIONS Oncology patients have a large unmet demand for AD consultations. However, a relevant percentage of these patients object to AD consultations. Structured and early AD consultation offers should be made, and early discussions about indications for aggressive treatment should take place.
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Affiliation(s)
- Jochen Pfirstinger
- Department of Hematology and Medical Oncology, University Hospital Regensburg, Regensburg, Germany
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Fromme EK, Zive D, Schmidt TA, Cook JNB, Tolle SW. Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon. J Am Geriatr Soc 2014; 62:1246-51. [DOI: 10.1111/jgs.12889] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Erik K. Fromme
- Division of Hematology and Medical Oncology; Oregon Health & Science University; Portland Oregon
| | - Dana Zive
- Center for Policy and Research in Emergency Medicine; Oregon Health & Science University; Portland Oregon
| | - Terri A. Schmidt
- Department of Emergency Medicine; Oregon Health & Science University; Portland Oregon
| | - Jennifer N. B. Cook
- Department of Emergency Medicine; Oregon Health & Science University; Portland Oregon
| | - Susan W. Tolle
- Center for Ethics in Health Care; Division of General Internal Medicine and Geriatrics; Oregon Health & Science University; Portland Oregon
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Schmidt TA, Zive D, Fromme EK, Cook JNB, Tolle SW. Physician orders for life-sustaining treatment (POLST): lessons learned from analysis of the Oregon POLST Registry. Resuscitation 2014; 85:480-5. [PMID: 24407052 DOI: 10.1016/j.resuscitation.2013.11.027] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 09/18/2013] [Accepted: 11/03/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Physician Orders for Life-Sustaining Treatment (POLST) has become a common means of documenting patient treatment preferences. In addition to orders either for Attempt Resuscitation or Do Not Attempt Resuscitation, for patients not in cardiopulmonary arrest, POLST provides three levels of treatment: Full Treatment, Limited Interventions, and Comfort Measures Only. Oregon has an electronic registry for POLST forms completed in the state. We used registry data to examine the different combinations of treatment orders. METHODS AND RESULTS We analyzed data from forms signed and entered into the Oregon POLST Registry in 2012. The analysis included 31,294 POLST forms. The mean Registrant age was 76.7 years. 21,396 (68.4%) had Do Not Attempt Resuscitation (DNR) orders and 9900 (31.6%) had orders for "Attempt Resuscitation". The 6 order combinations were: Do Not Resuscitate (DNR)/Comfort Measures Only 10,769 (34.4%), DNR/Limited Interventions 9306 (29.7%), DNR/Full Treatment 1211 (3.9%), Attempt Cardiopulmonary Resuscitation (CPR)/Comfort Measures Only 11 (0.04%), Attempt CPR/Limited Interventions 2281 (7.3%), and Attempt CPR/Full Treatment 7473 (23.9%). CONCLUSIONS The most common order combinations were DNR/Comfort Measures Only, DNR/Limited Interventions and Attempt Resuscitation/Full Treatment. These three makes sense to health professionals. However, other order combinations that require interpretation at the time of a crisis were completed for about 10% of Registrants. These combinations need further investigation.
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Affiliation(s)
- Terri A Schmidt
- Department of Emergency Medicine, Oregon Health and Sciences University, United States.
| | - Dana Zive
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, United States
| | - Erik K Fromme
- Division of Hematology and Medical Oncology, Oregon Health & Science University, United States
| | - Jennifer N B Cook
- Department of Emergency Medicine, Oregon Health and Sciences University, United States
| | - Susan W Tolle
- Center for Ethics in Health Care, Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, United States
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Philippart F, Vesin A, Bruel C, Kpodji A, Durand-Gasselin B, Garçon P, Levy-Soussan M, Jagot JL, Calvo-Verjat N, Timsit JF, Misset B, Garrouste-Orgeas M. The ETHICA study (part I): elderly's thoughts about intensive care unit admission for life-sustaining treatments. Intensive Care Med 2013; 39:1565-73. [PMID: 23765236 DOI: 10.1007/s00134-013-2976-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 05/19/2013] [Indexed: 12/01/2022]
Abstract
PURPOSE To assess preferences among individuals aged ≥80 years for a future hypothetical critical illness requiring life-sustaining treatments. METHODS Observational cohort study of consecutive community-dwelling elderly individuals previously hospitalised in medical or surgical wards and of volunteers residing in nursing homes or assisted-living facilities. The participants were interviewed at their place of residence after viewing films of scenarios involving the use of non-invasive mechanical ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of invasive mechanical ventilation (RRT after IMV). Demographic, clinical, and quality-of-life data were collected. Participants chose among four responses regarding life-sustaining treatments: consent, refusal, no opinion, and letting the physicians decide. RESULTS The sample size was 115 and the response rate 87 %. Mean participant age was 84.8 ± 3.5 years, 68 % were female, and 81 % and 71 % were independent for instrumental activities and activities of daily living, respectively. Refusal rates among the elderly were 27 % for NIV, 43 % for IMV, and 63 % for RRT (after IMV). Demographic characteristics associated with refusal were married status for NIV [relative risk (RR), 2.9; 95 % confidence interval (95 %CI), 1.5-5.8; p = 0.002] and female gender for IMV (RR, 2.4; 95 %CI, 1.2-4.5; p = 0.01) and RRT (after IMV) (RR, 2.7; 95 %CI, 1.4-5.2; p = 0.004). Quality of life was associated with choices regarding all three life-sustaining treatments. CONCLUSIONS Independent elderly individuals were rather reluctant to accept life-sustaining treatments, especially IMV and RRT (after IMV). Their quality of life was among the determinants of their choices.
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Affiliation(s)
- F Philippart
- Medical-Surgical, Saint Joseph Hospital Network, 75014, Paris, France
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The Oregon Physician Orders for Life-Sustaining Treatment Registry: A Preliminary Study of Emergency Medical Services Utilization. J Emerg Med 2013; 44:796-805. [DOI: 10.1016/j.jemermed.2012.07.081] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 01/17/2012] [Accepted: 07/01/2012] [Indexed: 11/22/2022]
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Claure-Del Granado R, Mehta RL. Withholding and withdrawing renal support in acute kidney injury. Semin Dial 2011; 24:208-14. [PMID: 21517990 DOI: 10.1111/j.1525-139x.2011.00832.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Management of critically ill patients with acute kidney injury (AKI) is mainly limited to supportive therapy, with dialysis as one of the main components. Whether or not to offer dialysis and when to withdraw dialysis is a one of the many choices physicians face in daily clinical practice. Withholding or withdrawing renal replacement therapy is a complex decision and depends on many interacting factors, which are unique for each patient and their families and for the care team. An evidence-based guideline with nine specific recommendations for managing patients has been available however is infrequently employed to help clinical decision making. In this review, we discuss the important issues affecting decisions to withhold or withdraw dialysis in AKI patients and provide an approach for making these decisions for patient management.
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Affiliation(s)
- Rolando Claure-Del Granado
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
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Halpern NA, Pastores SM, Chou JF, Chawla S, Thaler HT. Advance directives in an oncologic intensive care unit: a contemporary analysis of their frequency, type, and impact. J Palliat Med 2011; 14:483-9. [PMID: 21417740 DOI: 10.1089/jpm.2010.0397] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Our objective was to provide a contemporary analysis of the prevalence, types, and impact of advance health care directives in critically ill cancer patients. METHODS We retrospectively reviewed all intensive care unit (ICU) admissions (January 1, 2006 to April 25, 2008) at an oncologic center and identified all patients who completed a living will (LW), or health care proxy (HCP), or neither prior to ICU admission. Demographics, clinical data, end-of-life (EOL) parameters and outcomes were compared among three groups: LWs, HCPs, and no LW or HCP. RESULTS Of 1,333 ICU admissions, 1,121 patients (84%) were included for analysis: 176 patients (15.7%) had LW, 534 (47.6%) had HCP and 411 (36.7%) had no LW or HCP. Patients with LW were significantly more likely to be older and white as compared to patients with HCP alone, or no LW or HCP. There were no significant demographic differences between patients with HCP or no LW or HCP. Patients with HCP alone, or no LW or HCP, were significantly more likely to have Medicaid than patients with LW. There were no differences noted in ICU care, EOL management, or outcomes among the three groups. CONCLUSIONS The prevalence of LWs in patients admitted to our oncologic ICU is low. More than half of the remaining patients had designated HCPs. Older age and white race were associated with the presence of LWs. However, the presence of LWs or HCPs did not influence ICU care, EOL management or outcomes at our institution.
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Affiliation(s)
- Neil A Halpern
- Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine, New York, New York, USA.
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Mancini ME, Soar J, Bhanji F, Billi JE, Dennett J, Finn J, Ma MHM, Perkins GD, Rodgers DL, Hazinski MF, Jacobs I, Morley PT. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S539-81. [PMID: 20956260 DOI: 10.1161/circulationaha.110.971143] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Soar J, Mancini ME, Bhanji F, Billi JE, Dennett J, Finn J, Ma MHM, Perkins GD, Rodgers DL, Hazinski MF, Jacobs I, Morley PT. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010; 81 Suppl 1:e288-330. [PMID: 20956038 PMCID: PMC7184565 DOI: 10.1016/j.resuscitation.2010.08.030] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol,United Kingdom.
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Abstract
This article discusses end-of-life issues in critically ill cancer patients. Since the majority of deaths will occur after limiting or withdrawing life support, focus should be given to ensuring that multidisciplinary family meetings are convened to discuss end-of-life decision making. Throughout the process of transitioning from cure to comfort care, it is essential to support the patient and the patient's family cultural beliefs and spiritual values, and to ensure good pain and symptom management. The use of protocols facilitates a smooth transition and potentially reduces variability between health care providers. Integrating measures into the ICU routine that will help health care providers cope with the care of a dying patient is recommended to avoid moral distress or emotional burnout.
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Affiliation(s)
- Susan Gaeta
- Department of Critical Care Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box # 0112, Houston, TX 77030, USA.
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Quality of End‐of‐Life Care Between Medical Oncologists and Other Physician Specialists for Taiwanese Cancer Decedents, 2001–2006. Oncologist 2009; 14:1232-41. [DOI: 10.1634/theoncologist.2009-0095] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Tang ST, Wu SC, Hung YN, Chen JS, Huang EW, Liu TW. Determinants of aggressive end-of-life care for Taiwanese cancer decedents, 2001 to 2006. J Clin Oncol 2009; 27:4613-8. [PMID: 19704067 DOI: 10.1200/jco.2008.20.5096] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess the association between aggressiveness of end-of-life (EOL) care and patient demographics, disease characteristics, primary physician's specialty, hospital characteristics, and availability of health care resources at the hospital and regional levels in Taiwan for a cohort of 210,976 cancer decedents in 2001 to 2006. METHODS This retrospective cohort study examined administrative data. Aggressiveness of EOL care was examined by a composite measure adapted from Earle et al. Scores range from 0 to 6, with higher scores indicating more aggressive EOL care. RESULTS The mean composite score for aggressiveness of EOL care was 2.04 (mean) +/- 1.26 (standard deviation), increasing from 1.96 +/- 1.26 in 2001 to 2.10 +/- 1.26 in 2006. Each successive year of death significantly increased the composite score. Cancer decedents received more aggressive EOL care if they were male, younger, single, had a higher level of comorbidity, had more malignant and extensive diseases or hematologic malignancies, were cared for by oncologists, and received care in a hospital with a greater density of beds. CONCLUSION Controlling for patient demographics and cormorbidity burden, EOL care in Taiwan was more aggressive for patients with cancer with highly malignant and extensive diseases, for patients with oncologists as primary care providers, or in hospitals with abundant health care resources. Health policies should aim to ensure that all patients receive treatments that best meet their individual needs and interests and that resources are devoted to care that produces the greatest health benefits.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University, Graduate School of Nursing, 259 Wen-Hwa 1st Rd, Kwei-Shan, Tao-Yuan, Taiwan, 333, R.O.C.
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An update on advance directives in the medical record: findings from 1186 consecutive patients with unresectable exocrine pancreas cancer. J Gastrointest Cancer 2009; 39:100-3. [PMID: 19127451 DOI: 10.1007/s12029-008-9041-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Accepted: 12/10/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Terri Schiavo case and other recent events underscore the importance of advance directives. Yet, in the past, only a small subgroup has utilized them. This study from a large tertiary medical center was undertaken to assess current rates of advance directives among patients with incurable pancreas cancer. METHODS/RESULTS The medical records of 1,186 consecutive patients with unresectable pancreas cancer were reviewed over a 4-year span. Only 174 patients (15%) had an advance directive in the medical record. Older age and having cancer therapy at our institution were associated with a greater likelihood of having an advance directive with odds ratios (95% confidence intervals) of 8.26 (2.81, 24.93) and 2.86 (2.03, 4.02), respectively, in multivariate analyses. Importantly, 42 patients (24%) had a different person designated as their healthcare agent in their advanced directive than what appeared in the medical record as the "contact person." CONCLUSION These findings underscore the ongoing need to discuss advance directives with patients with incurable malignancies and to clarify patients' wishes when seemingly contradictory information appears in other parts of the medical record.
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Jox RJ, Michalowski S, Lorenz J, Schildmann J. Substitute decision making in medicine: comparative analysis of the ethico-legal discourse in England and Germany. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2008; 11:153-163. [PMID: 17987402 DOI: 10.1007/s11019-007-9112-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Accepted: 10/15/2007] [Indexed: 05/25/2023]
Abstract
Health care decision making for patients without decisional capacity is ethically and legally challenging. Advance directives (living wills) have proved to be of limited usefulness in clinical practice. Therefore, academic attention should focus more on substitute decision making by the next of kin. In this article, we comparatively analyse the legal approaches to substitute medical decision making in England and Germany. Based on the current ethico-legal discourse in both countries, three aspects of substitute decision making will be highlighted: (1) Should there be a legally predefined order of relatives who serve as health care proxies? (2) What should be the respective roles and decisional powers of patient-appointed versus court-appointed substitute decision-makers? (3) Which criteria should be determined by law to guide substitute decision-makers?
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Affiliation(s)
- Ralf J Jox
- Interdisciplinary Centre for Palliative Medicine, University Hospital Munich, Marchioninistrasse 15, Munich, Germany.
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Tillyard ARJ. Ethics review: 'Living wills' and intensive care--an overview of the American experience. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:219. [PMID: 17634087 PMCID: PMC2206532 DOI: 10.1186/cc5945] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Withdrawal and limitation of life support in the intensive care unit is common, although how this decision is reached can be varied and arbitrary. Inevitably, the patient is unable to participate in this discussion because their capacity is limited by the nature of the illness and the effects of its treatment. Physicians often discuss these decisions with relatives in an attempt to respect the patient's wishes despite evidence suggesting that the relatives may not correctly reflect the patient's desires. Advance decisions, commonly known as 'living wills', have been proposed as a way of facilitating the maintenance of an individual's autonomy when they become incapacitated. Others have argued that legalising advance decisions is euthanasia by the back door. In October 2007 in England and Wales, advance decisions will become legally binding as part of the 2005 Mental Capacity Act. This has been the case in the USA for many years. The purpose of the present review is to examine the published literature regarding the effect of advance decisions in relation to the provision of adult critical care.
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Patel SS, Holley JL. Withholding and withdrawing dialysis in the intensive care unit: benefits derived from consulting the renal physicians association/american society of nephrology clinical practice guideline, shared decision-making in the appropriate initiation of and withdrawal from dialysis. Clin J Am Soc Nephrol 2008; 3:587-93. [PMID: 18256375 DOI: 10.2215/cjn.04040907] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Despite advances in the technology of dialysis, mortality in patients who develop acute renal failure remains high. Scoring systems have been developed to improve the ability to define prognosis in seriously ill patients with acute renal failure but predicting outcomes for individual patients is uncertain. Decisions to withhold or withdraw dialysis in seriously ill patients are difficult for patients, families, and health care providers. The clinical practice guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, provides evidence-based recommendations to aid nephrologists in discussions and the process of medical decision-making about starting and stopping dialysis. Estimating prognosis and addressing the issues of advance directives and patient and family preferences through the process of shared decision-making can clarify appropriate strategies for clinical management and interventions. Time-limited trials of dialysis may be an invaluable tool in this process. Increasing nephrologists' awareness of the guideline may facilitate decision-making around the issues of withholding and withdrawing dialysis in part by clarifying patients and situations in which it may be appropriate to withhold or withdraw dialysis.
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Affiliation(s)
- Samir S Patel
- Division of Renal Diseases and Hypertension, George Washington University, 2150 Pennsylvania Avenue, NW, Suite 1-200, Washington, DC 20037, USA.
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Hahn J, Mandraka F, Fröhlich G. Ethische Aspekte in der Therapie kritisch kranker Tumorpatienten. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s00390-007-0819-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Barclay JS, Blackhall LJ, Tulsky JA. Communication Strategies and Cultural Issues in the Delivery of Bad News. J Palliat Med 2007; 10:958-77. [PMID: 17803420 DOI: 10.1089/jpm.2007.9929] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Good communication is a fundamental skill for all palliative care clinicians. Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. This article provides an overview of the evidence for communication strategies in delivering bad news and discussing advance care planning. In addition, it reviews the literature regarding cultural aspects of care for terminally ill patients and their families and offers strategies for engaging them. Through good communication practices, clinicians can help to avoid conflict and understand patients' desires for end of life care.
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Affiliation(s)
- Joshua S Barclay
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27705-3860, USA.
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Bernal EW, Marco CA, Parkins S, Buderer N, Thum SD. End-of-life decisions: family views on advance directives. Am J Hosp Palliat Care 2007; 24:300-7. [PMID: 17582028 DOI: 10.1177/1049909107302296] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A cross-sectional survey was administered to family members of patients who died at 1 of the 5 Catholic institutions comprising Mercy Health Partners, a health care system in Ohio, to determine their opinions about patient and family participation in decisions about end-of-life care. Among 165 respondents, 118 (86%) of 138 agreed that the family was encouraged to join in decisions and 133 (91%) of 146 that their family member's health care choices were followed. Most agreed that nurses answered their questions (93%, 141/151) and that the doctor communicated well with family members (83%, 128/155). Seventy percent (107/152) indicated that their family member had at least 1 advance directive. There were no differences in whether health care choices were followed when patients with formal advance directives (92%, 92/100) were compared with patients without formal advance directives (88%, 35/40). A unique survey instrument can be used to measure family perceptions and opinions of participation in decisions about end-of-life care.
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Affiliation(s)
- Ellen W Bernal
- Ethics, St. Vincent Mercy Medical Center, 2213 Cherry Street, Toledo, OH 43608, USA.
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Joffe S, Mello MM, Cook EF, Lee SJ. Advance Care Planning in Patients Undergoing Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2007; 13:65-73. [PMID: 17222754 DOI: 10.1016/j.bbmt.2006.08.042] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 08/30/2006] [Indexed: 11/19/2022]
Abstract
Few data are available on the prevalence of advance care planning (ACP) in patients undergoing hematopoietic cell transplantation (HCT). We surveyed adult patients pre-HCT to ascertain completion of various elements of ACP. We also reviewed medical records for documentation of discussions regarding ACP and for the presence of written advance directives. Evaluable surveys were returned by 155 of 335 patients (46%) who underwent HCT during the study period; we obtained permission for medical record review from 137 of these 155 survey respondents (88%). We found that 69% of the respondents reported having designated a health care proxy, 44% had completed a living will, 61% had prepared an estate will, and 63% had discussed their wishes regarding life support with family and friends. In contrast, only 16% had discussed their wishes regarding life support with their clinicians. Documentation of discussions between clinicians and patients regarding most elements of ACP was rare. Written advance directives were present in the charts of 54 patients (39%). ACP was more common in older, college-educated, and allogeneic transplant patients. Even though ACP was more prevalent among this sample than in the general population, its use still could be enhanced, given the high risks of decisional incapacity and death that HCT patients face.
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Affiliation(s)
- Steven Joffe
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA.
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Kelley CG, Lipson AR, Daly BJ, Douglas SL. Use of advance directives in the chronically critically ill. ACTA ACUST UNITED AC 2006; 8:42-7; quiz 48-9. [PMID: 16755231 DOI: 10.1097/00128488-200604000-00005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although it would be ideal that all patients have the presence of an advance directive documented in their medical chart, it is especially important in the chronically critically ill, a patient population with an in-hospital mortality rate of 40%. How has the documentation of advance directives in the medical chart of chronically critically ill patients changed from 1997 to 2003? This article describes the patient characteristics and patterns of death in chronically critically ill patients, with or without an advance directive, enrolled in 2 consecutive studies.
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Affiliation(s)
- Carol G Kelley
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio 44106-4904, USA.
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Affiliation(s)
- Barbara J. Daly
- Barbara J. Daly is an associate professor at Case Western Reserve University and the director of a clinical ethics program at University Hospitals of Cleveland, Cleveland, Ohio. She has worked extensively in critical care, both as a staff nurse and a nurse manager. Currently, she teaches and does clinical research related to end-of-life issues
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Watch LS, Saxton-Daniels S, Schermer CR. Who has life-sustaining therapy withdrawn after injury? ACTA ACUST UNITED AC 2006; 59:1320-6; discussion 1326-7. [PMID: 16394904 DOI: 10.1097/01.ta.0000196003.41799.41] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trauma scoring systems have been developed to help surgeons predict who will die after injury. However, some patients may not actually die of their injuries but may undergo withdrawal of life-sustaining therapy (WLST). The goal of this study was to determine which factors were associated with WLST among older patients who died. We hypothesized that patients with comorbid illnesses, higher injury severity scores (ISS), complications, and existing advanced directives (AD) would be more likely to have WLST and that patients having WLST would receive more medication for symptom relief in the 24 hours before death. METHODS Data were collected via a retrospective chart review of patients age 55 years and older admitted to the intensive care unit after injury who subsequently died. In addition to demographic and injury information, documentation of family discussions regarding care wishes and formal ADs were evaluated. Patients dying despite curative attempts were compared with those who died after WLST by Student's t test and chi test where appropriate. RESULTS In a 3-year period, of 330 patients age 55 and older admitted to the intensive care unit, 66 (20%) died. Complete records were available for 64 patients. More than half of those who died (n = 35, 54.7%) had WLST. ADs were available for 15 patients (23.4%), and 11 (17.2%) patients had expressed to their families desires to not undergo aggressive curative care. Family discussions were documented for 50 (78%) cases. Comorbid illnesses were present in 46 (71.9%) patients and 35 (54.7%) developed at least one complication. Among people with ADs, 73% had WLST versus 49% of people without ADs (p = 0.09). WLST was independent of comorbid illnesses (p = 0.3), complications (p = 0.8), age (p = 0.5), and ISS (p = 0.2). Patients for whom there was documentation of a family discussion were more likely to have WLST than those without (91.4% versus 62.1%, p = 0.005). Morphine and benzodiazepine dosing in the 24 hours preceding death were greater in the WLST group than the curative therapy group (p = 0.02 and p = 0.05, respectively). CONCLUSIONS Expected associations with WLST such as age, ISS, comorbidities, and complications were not present in this population. Although trends may exist regarding patient wishes and ADs, larger studies are needed to corroborate these findings. Given the percentage of patients having supportive care withdrawn, trauma registries and scoring systems should include WLST.
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Affiliation(s)
- Libby S Watch
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico, USA
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Abstract
Family's needs and considerations are an essential component of intensive care unit (ICU) care. Family satisfaction is related to clinician communication and decision making. Indeed, timely, honest communication is vital to the psychosocial health and satisfaction of the family. Conflict often arises within the family and between the family and the clinicians, over decision making. Again, good communication skills are critical to family satisfaction with decision making and comfort with the care received. Family members have numerous psychosocial changes, and may experience depression,anxiety, or anticipatory grief while their family member is dying in the ICU. Awareness of these conditions, providing support to the families, and allowing family access to the dying individual can assist with meeting the family's desire to see their family member have a peaceful death.
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Affiliation(s)
- Karin T Kirchhoff
- School of Nursing, Clinical Science Center K6/358, 600 Highland Avenue, Madison, WI 53792-2455, USA.
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Elger BS, Chevrolet JC. Attitudes of health care workers towards waking a terminally ill patient in the intensive care unit for treatment decisions. Intensive Care Med 2003; 29:487-90. [PMID: 12557077 DOI: 10.1007/s00134-002-1612-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2002] [Accepted: 11/05/2002] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We examined whether health care workers would wake an intubated patient whose preferences are not known, and whether attitudes are influenced by how health care workers themselves would like to be treated if they were in the patient's place. DESIGN, SETTING, AND SUBJECTS Convenience sample of 90 participants at a postgraduate lecture to anesthesiologists and related professions. Participants filled out questionnaires after a case presentation followed by two commentaries, one arguing against, the other for waking a 49-year-old intubated patient suffering from a large, intratracheal, poorly differentiated metastatic squamous cell carcinoma of the lungs. The patient was not aware of the diagnosis and poor prognosis and had not expressed any preferences. RESULTS Participants were almost equally divided between the two alternatives. Significant differences were found between professions concerning the willingness not to wake the patient (19.8% of nurses vs. 45% of physicians and others). There was a strong correlation between the preferences of the health care worker for her-/himself and what he/she would do if in charge of the patient. CONCLUSIONS Our study shows that attitudes of health care workers towards waking and informing an intubated patient in the intensive care unit about a hopeless situation differ. Educational programs should ensure that physicians and nurses, especially when discussing and deciding withdrawal of vital support, are aware of theses differences and realize that their own behavior can be influenced by their own preferences if themselves in the patient's situation.
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Affiliation(s)
- Bernice S Elger
- Unité de Droit Médical et d'Ethique Clinique, Institut Universitaire de Médecine Légale, 9 av. de Champel, 1211 Geneva 4, Switzerland.
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