1
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Berry-Kilgour NAH, Paulin JR, Psirides A, Pegg TJ. Survey of hospital practitioners: common understanding of cardiopulmonary resuscitation definition and outcomes. Intern Med J 2023; 53:2050-2056. [PMID: 36878854 DOI: 10.1111/imj.16046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 02/12/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) is internationally defined as chest compressions and rescue breaths, and is a subset of resuscitation. First used for out-of-hospital cardiac arrest, CPR is now frequently used for in-hospital cardiac arrest (IHCA) with different causes and outcomes. AIMS This paper aims to describe clinical understanding of the role of in-hospital CPR and perceived outcomes for IHCA. METHODS An online survey of a secondary care staff involved in resuscitation was conducted, focussing on definitions of CPR, features of do-not-attempt-CPR conversations with patients and clinical case scenarios. Data were analysed using a simple descriptive approach. RESULTS Of 652 responses, 500 were complete and used for analysis. Two hundred eleven respondents were senior medical staff covering acute medical disciplines. Ninety-one percent of respondents agreed or strongly agreed that defibrillation is part of CPR, and 96% believed CPR for IHCA included defibrillation. Responses to clinical scenarios were dissonant, with nearly half of respondents demonstrating a pattern of underestimating survival and subsequently showing a desire to offer CPR in similar scenarios with poor outcomes. This was unaffected by seniority and level of resuscitation training. CONCLUSIONS The common use of CPR in hospital reflects the broader definition of resuscitation. Recapturing the CPR definition for clinicians and patients as only chest compressions and rescue breaths may allow clinicians to better discuss individualised resuscitation care to aide meaningful shared decision-making around patient deterioration. This may involve reframing current in-hospital algorithms and uncoupling CPR from wider resuscitative measures.
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Affiliation(s)
| | | | | | - Tammy J Pegg
- Te Whatu Ora, Nelson Marlborough, Nelson, New Zealand
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2
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Moreno S, Medina-Rico M, Osorio Clavijo K, Rodríguez NA, Vicuña Jiménez VM, Calvache JA, de Vries E. End of Life in Patients With Advanced Non-curable Cancer: Patient Considerations Around the Moment of Death. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231190240. [PMID: 37470363 DOI: 10.1177/00302228231190240] [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: 07/21/2023]
Abstract
There is limited knowledge regarding Colombian patients with advanced cancer preferences regarding their final moments, place of death, and post-death wishes. To better understand these preferences, we conducted 23 in-depth interviews with patients between the ages of 28 and 78 receiving treatment at two academic hospitals and the National Cancer Institute. While many participants desired a peaceful death, few were comfortable discussing the topic of death directly. Some younger participants expressed an interest in euthanasia but had not received any guidance or support. While several participants preferred a home death, some expressed a desire to die in a hospital due to better symptom control. Additionally, when discussing post-death wishes, some participants expressed frustration about being unable to have these conversations with their loved ones and their preferences for funeral arrangements. Socioeconomic and geographical factors significantly impacted the wishes and preferences expressed, with many individuals hesitant to initiate difficult conversations.
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Affiliation(s)
- Socorro Moreno
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Mauricio Medina-Rico
- Department of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana Bogota, Colombia
| | - Katalina Osorio Clavijo
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogota, Colombia
| | | | | | - Jose A Calvache
- Department of Anesthesiology, Universidad de Cauca, Popayan, Colombia
| | - Esther de Vries
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogota, Colombia
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3
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Modes ME, Engelberg RA, Nielsen EL, Brumback LC, Neville TH, Walling AM, Curtis JR, Kross EK. Seriously Ill Patients' Prioritized Goals and Their Clinicians' Perceptions of Those Goals. J Pain Symptom Manage 2022; 64:410-418. [PMID: 35700932 PMCID: PMC9482939 DOI: 10.1016/j.jpainsymman.2022.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 05/25/2022] [Accepted: 06/07/2022] [Indexed: 12/27/2022]
Abstract
CONTEXT Seriously ill patients whose prioritized healthcare goals are understood by their clinicians are likely better positioned to receive goal-concordant care. OBJECTIVES To examine the proportion of seriously ill patients whose prioritized healthcare goal is accurately perceived by their clinician and identify factors associated with accurate perception. METHODS Secondary analysis of a multicenter cluster-randomized trial of outpatients with serious illness and their clinicians. Approximately two weeks after a clinic visit, patients reported their current prioritized healthcare goal- extending life over relief of pain and discomfort, or relief of pain and discomfort over extending life - and clinicians reported their perception of their patients' current prioritized healthcare goal; matching these items defined accurate perception. RESULTS Of 252 patients with a prioritized healthcare goal, 60% had their goal accurately perceived by their clinician, 27% were cared for by clinicians who perceived prioritization of the alternative goal, and 13% had their clinician answer unsure. Patients who were older (OR 1.03 per year; 95%CI 1.01, 1.05), had stable goals (OR 2.52; 95%CI 1.26, 5.05), and had a recent goals-of-care discussion (OR 1.78, 95%CI 1.00, 3.16) were more likely to have their goals accurately perceived. CONCLUSION A majority of seriously ill outpatients are cared for by clinicians who accurately perceive their patients' prioritized healthcare goals. However, a substantial portion are not and may be at higher risk for goal-discordant care. Interventions that facilitate goals-of-care discussions may help align care with goals, as recent discussions were associated with accurate perceptions of patients' prioritized goals.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary and Critical Care Medicine (M.E.M), Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Ruth A Engelberg
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Lyndia C Brumback
- Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA; Department of Biostatistics (L.C.B.), University of Washington, Seattle, Washington, USA
| | - Thanh H Neville
- Division of Pulmonary (T.H.N.), Critical Care, and Sleep Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research (A.M.W.), University of California Los Angeles, Los Angeles, California, USA; Center for the Study of Healthcare Innovation (A.M.W.), Implementation and Policy, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California, USA
| | - J Randall Curtis
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities (J.R.C.), University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA
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4
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Alzayer H, Geraghty AM, Sebastian KK, Panesar H, Reddan DN. Dialysis Patients’ Preferences on Resuscitation: A Cross-Sectional Study Design. Can J Kidney Health Dis 2022; 9:20543581221113383. [PMID: 35923181 PMCID: PMC9340425 DOI: 10.1177/20543581221113383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/08/2022] [Indexed: 11/30/2022] Open
Abstract
Background: End-stage kidney disease is associated with a 10- to 100-fold increase in
cardiovascular mortality compared with age-, sex-, and race-matched
population. Cardiopulmonary resuscitation (CPR) in this cohort has poor
outcomes and leads to increased functional morbidity. Objective: The aim of this study is to assess patients’ preferences toward CPR and
advance care planning (ACP). Design: cross-sectional study design. Setting: Two outpatient dialysis units. Patients: Adults undergoing dialysis for more than 3 months were included. Exclusion
criteria were severe cognitive impairment or non-English-speaking
patients. Measurements: A structured interview with the use of Willingness to Accept Life-Sustaining
Treatment (WALT) tool. Methods: Demographic data were collected, and baseline Montreal Cognitive Assessment,
Patient Health Questionnaire–9, Duke Activity Status Index, Charlson
comorbidity index, and WALT instruments were used. Descriptive analysis,
chi-square, and t test were performed along with
probability plot for testing hypotheses. Results: Seventy participants were included in this analysis representing a 62.5%
response rate. There was a clear association between treatment burden,
anticipated clinical outcome, and the likelihood of that outcome with
patient preferences. Low-burden treatment with expected return to baseline
was associated with 98.5% willingness to accept treatment, whereas
high-burden treatment with expected return to baseline was associated with
94.2% willingness. When the outcome was severe functional or cognitive
impairment, then 45.7% and 28.5% would accept low-burden treatment,
respectively. The response changed based on the likelihood of the outcome.
In terms of resuscitation, more than 75% of the participants would be in
favor of receiving CPR and mechanical ventilation at their current health
state. Over 94% of patients stated they had never discussed ACP, whereas
59.4% expressed their wish to discuss this with their primary
nephrologist. Limitations: Limited generalizability due to lack of diversity. Unclear decision stability
due to changes in health status and patients’ priorities. Conclusions: ACP should be incorporated in managing chronic kidney disease (CKD) to
improve communication and encourage patient involvement.
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Affiliation(s)
- Husam Alzayer
- Department of Nephrology, University Hospital Galway, Ireland
- Royal College of Surgeons in Ireland, Dublin
| | | | - Kuruvilla K. Sebastian
- Department of Renal Medicine, Cork University Hospital, Ireland
- Department of Medicine, National University of Ireland, Galway
- Royal College of Physicians of Ireland, Dublin
| | - Hardarsh Panesar
- Department of Renal Medicine, Cork University Hospital, Ireland
- Western University, London, ON, Canada
| | - Donal N. Reddan
- Department of Nephrology, University Hospital Galway, Ireland
- Royal College of Physicians of Ireland, Dublin
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5
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Modes ME, Heckbert SR, Engelberg RA, Nielsen EL, Curtis JR, Kross EK. Patient-Reported Receipt of Goal-Concordant Care Among Seriously Ill Outpatients-Prevalence and Associated Factors. J Pain Symptom Manage 2020; 60:765-773. [PMID: 32389606 PMCID: PMC7508896 DOI: 10.1016/j.jpainsymman.2020.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Goal-concordant care is an important indicator of high-quality care in serious illness. OBJECTIVES To estimate the prevalence of patient-reported receipt of goal-concordant care among seriously ill outpatients and identify factors associated with the absence of patient-reported goal concordance. METHODS Analysis of enrollment surveys from a multicenter cluster-randomized trial of outpatients with serious illness. Patients reported their prioritized health care goal and the focus of their current medical care; these items were matched to define receipt of goal-concordant care. RESULTS Of 405 patients with a prioritized health care goal, 58% reported receipt of goal-concordant care, 17% goal-discordant care, and 25% were uncertain of the focus of their care. Patient-reported receipt of goal concordance differed by patient goal. For patients who prioritized extending life, 86% reported goal-concordant care, 2% goal-discordant care, and 12% were uncertain of the focus of their care. For patients who prioritized relief of pain and discomfort, 51% reported goal-concordant care, 21% goal-discordant care, and 28% were uncertain of the focus of their care. Patients who prioritized a goal of relief of pain and discomfort were more likely to report goal-discordant care than patients who prioritized a goal of extending life (relative risk ratio 22.20; 95% CI 4.59, 107.38). CONCLUSION Seriously ill outpatients who prioritize a goal of relief of pain and discomfort are less likely to report receipt of goal-concordant care than patients who prioritize extending life. Future interventions designed to improve receipt of goal-concordant care should focus on identifying patients who prioritize relief of pain and discomfort and promoting care aligned with that goal.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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6
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Bernacki GM, Engelberg RA, Curtis JR, Kurella Tamura M, Brumback LC, Lavallee DC, Vig EK, O’Hare AM. Cardiopulmonary Resuscitation Preferences of People Receiving Dialysis. JAMA Netw Open 2020; 3:e2010398. [PMID: 32833017 PMCID: PMC7445594 DOI: 10.1001/jamanetworkopen.2020.10398] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Whether the cardiopulmonary resuscitation (CPR) preferences of patients receiving dialysis align with their values and other aspects of end-of-life care is not known. OBJECTIVE To describe the CPR preferences of patients receiving dialysis and how these preferences are associated with their responses to questions about other aspects of end-of-life care. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey study of a consecutive sample of patients receiving dialysis at 31 nonprofit dialysis facilities in 2 US metropolitan areas (Seattle, Washington, and Nashville, Tennessee) between April 22, 2015, and October 2, 2018. Analyses for this article were conducted between December 2018 and April 2020. EXPOSURES Participants were asked to respond to the question "If you had to decide right now, would you want CPR if your heart were to stop beating?" Those who indicated they would probably or definitely want CPR were categorized as preferring CPR. MAIN OUTCOMES AND MEASURES This study examined the association between preference for CPR and other treatment preferences, engagement in advance care planning, values, desired place of death, expectations about prognosis, symptoms, and palliative care needs. RESULTS Of the 1434 individuals invited to complete the survey, 1009 agreed to participate, and 876 were included in the analytic cohort (61.1%). The final cohort had a mean (SD) age of 62.6 (14.0) years; 492 (56.2%) were men, and 528 (60.3%) were White individuals. Among 738 of 876 participants (84.2%) who indicated that they would definitely or probably want CPR (CPR group), 555 (75.2%) wanted mechanical ventilation vs 13 of 138 (9.4%) of those who did not want CPR (do not resuscitate [DNR] group) (P < .001). A total of 249 of 738 participants (33.7%) in the CPR group vs 84 of 138 (60.9%) in the DNR group had documented treatment preferences (P < .001). In terms of values about future care, 171 participants (23.2%) in the CPR group vs 5 of 138 (3.6%) in the DNR group valued life prolongation (P < .001); 320 in the CPR group (43.4%) vs 109 of 138 in the DNR group (79.0%) valued comfort (P < .001); and 247 participants (33.5%) in the CPR group vs 24 of 138 (17.4%) in the DNR group were unsure about their wishes for future care (P < .001). In the CPR group, 207 (28.0%) had thought about stopping dialysis vs 62 of 138 (44.9%) in the DNR group (P < .001), and 181 (24.5%) vs 58 of 138 (42.0%) had discussed stopping dialysis (P = .001). No statistically significant associations were observed between CPR preference and documentation of a surrogate decision maker, thoughts or discussion of hospice, preferred place of death, expectations about prognosis, reported symptoms, or palliative care needs. CONCLUSIONS AND RELEVANCE The CPR preferences of patients receiving dialysis were associated with some, but not all, other aspects of end-of-life care. How participants responded to questions about these other aspects of end-of-life care were not always aligned with their CPR preference. More work is needed to integrate discussions about code status with bigger picture conversations about patients' values, goals, and preferences for end-of-life care.
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Affiliation(s)
- Gwen M. Bernacki
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ruth A. Engelberg
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - J. Randall Curtis
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Manjula Kurella Tamura
- Department of Medicine, Stanford University Medical Center, Palo Alto, California
- Division of Nephrology, Geriatric Research, Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
| | | | | | - Elizabeth K. Vig
- Department of Medicine, University of Washington, Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
- Geriatrics, VA Puget Sound Health Care System, Seattle, Washington
| | - Ann M. O’Hare
- Department of Medicine, University of Washington, Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
- Kidney Research Institute, University of Washington, Seattle
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7
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Baker EF, Marco CA. Advance directives in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:270-275. [PMID: 33000042 PMCID: PMC7493570 DOI: 10.1002/emp2.12021] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/23/2019] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
Abstract
Advance directives are documents to convey patients' preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient-centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.
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Affiliation(s)
- Eileen F. Baker
- University of Toledo College of Medicine and Life SciencesToledoOhio
- Riverwood Emergency Services, Inc.PerrysburgOhio
| | - Catherine A. Marco
- Department of Emergency MedicineWright State University Boonshoft School of MedicineDaytonOhio
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8
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Dorsett M, Cooper RJ, Taira BR, Wilkes E, Hoffman JR. Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emerg Med J 2019; 37:240-245. [PMID: 31874920 DOI: 10.1136/emermed-2019-209031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/25/2019] [Accepted: 12/09/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Maia Dorsett
- Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Richelle J Cooper
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Breena R Taira
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Erin Wilkes
- Kaiser Permanente LAMC, Los Angeles, California, USA
| | - Jerome R Hoffman
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
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9
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Pollak KI, Gao X, Beliveau J, Griffith B, Kennedy D, Casarett D. Pilot Study to Improve Goals of Care Conversations Among Hospitalists. J Pain Symptom Manage 2019; 58:864-870. [PMID: 31422103 DOI: 10.1016/j.jpainsymman.2019.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Many hospitalized patients receive care that is not concordant with their goals. Teaching communication skills that better align goals and treatment can improve the care that patients receive. OBJECTIVE To develop and test an innovative approach that encourages hospitalists to engage in goals of care (GOC) conversations with their patients. METHODS We recruited 14 hospitalists and randomized half to receive electronic health record alerts for patients who might benefit most from a goals-of-care conversation, as well as communication coaching. The coaching required an initial meeting, then audio recording of two GOC conversations and feedback from the coach. Outcomes were the presence of GOC conversations (primary), the quality of the GOC conversations, physician perceptions of the intervention, and hospital metrics (e.g., 30-day readmissions, referrals to palliative care). RESULTS We did not increase the frequency of GOC conversations but did improve the quality of the conversations. Patients of physicians who received the intervention had fewer 30-day readmission rates and were less likely to die 90 days after admission than patients of physicians in the control arm. Patients of intervention physicians also had fewer palliative care consults than patients of control physicians. CONCLUSIONS Teaching hospitalists to have GOC conversations translated into better skills and outcomes for patients. This pilot study shows promise and should be tested in a larger trial.
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Affiliation(s)
- Kathryn I Pollak
- Cancer Control and Populations Sciences, Duke Cancer Institute, Durham, North Carolina, USA; Department of Population Health Sciences, Duke School of Medicine, Durham, North Carolina, USA.
| | - Xiaomei Gao
- Cancer Control and Populations Sciences, Duke Cancer Institute, Durham, North Carolina, USA
| | - Jessica Beliveau
- Department of Medicine, Duke School of Medicine, Durham, North Carolina, USA
| | - Brian Griffith
- Department of Medicine, Duke School of Medicine, Durham, North Carolina, USA
| | - Danielle Kennedy
- Cancer Control and Populations Sciences, Duke Cancer Institute, Durham, North Carolina, USA
| | - David Casarett
- Cancer Control and Populations Sciences, Duke Cancer Institute, Durham, North Carolina, USA; Department of Medicine, Duke School of Medicine, Durham, North Carolina, USA
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10
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Walling AM, Sudore RL, Bell D, Tseng CH, Ritchie C, Hays RD, Gibbs L, Rahimi M, Sanz J, Wenger NS. Population-Based Pragmatic Trial of Advance Care Planning in Primary Care in the University of California Health System. J Palliat Med 2019; 22:72-81. [PMID: 31486723 PMCID: PMC6916115 DOI: 10.1089/jpm.2019.0142] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction: Varying intensity of advance care planning (ACP) interventions at the population level has not been compared among seriously ill patients in primary care. This project will implement, test, and disseminate real-world scalable ACP interventions among primary care clinics across three University of California Health systems. The three ACP interventions are (1) distribution of an advance directive (AD) with targeted ACP messaging, (2) the AD, messaging, plus prompting patients to engage with the Prepare For Your Care website (PREPARE), and (3) the AD, messaging, PREPARE, plus Care Coordinator engagement with patients and clinicians. Methods: We will identify a population cohort of seriously ill primary care patients and implement the ACP interventions using electronic health record (EHR) patient portals and postal mailings. Forty-five clinics across the three health systems will be cluster randomized to one of the three ACP interventions. The primary outcome for the population cohort is AD or Physician Orders for Life-Sustaining Treatment documentation in the EHR. A subset of the population cohort will be surveyed to assess patient-centered outcomes, including care consistent with goals at baseline, 12 months, and 24 months. Caregivers will be interviewed if patients are unable to be surveyed or die. ACP documentation, goal concordant care, and among decedents, health care utilization will be compared among intervention arms. Study Implementation: Challenges and Contributions: The project is guided by a Study Advisory Group and Community Advisory Groups at each site to ensure rigorous patient-centered methods and consistency of implementation. Intervention fidelity will be evaluated using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. Challenges to implementation of this three-site health system trial and to intervention fidelity stem from site/clinic/system cultures, increasing attention to end-of-life care from payers and regulators, and growing pressures by health systems to implement ACP interventions. Stakeholder engagement is required to ensure consistent interventions across sites.
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Affiliation(s)
- Anne M. Walling
- Department of Medicine, University of California, Los Angeles, California
- VA Greater Los Angeles Health System, Los Angeles, California
| | - Rebecca L. Sudore
- Department of Medicine, University of California, San Francisco, California
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Doug Bell
- Department of Medicine, University of California, Los Angeles, California
| | - Chi-Hong Tseng
- Department of Medicine, University of California, Los Angeles, California
| | - Christine Ritchie
- Department of Medicine, University of California, San Francisco, California
| | - Ron D. Hays
- Department of Medicine, University of California, Los Angeles, California
| | - Lisa Gibbs
- Departments of Medicine and Family Medicine, University of California, Irvine, California
| | - Maryam Rahimi
- Departments of Medicine and Family Medicine, University of California, Irvine, California
| | - Javier Sanz
- Department of Medicine, University of California, Los Angeles, California
| | - Neil S. Wenger
- Department of Medicine, University of California, Los Angeles, California
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11
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Prater LC, Wickizer T, Bose-Brill S. Examining Age Inequalities in Operationalized Components of Advance Care Planning: Truncation of the ACP Process With Age. J Pain Symptom Manage 2019; 57:731-737. [PMID: 30610891 DOI: 10.1016/j.jpainsymman.2018.12.338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 12/21/2018] [Accepted: 12/25/2018] [Indexed: 12/21/2022]
Abstract
CONTEXT Opportunities for patients to receive unnecessary, costly, and potentially harmful care near the end of life abound. Advance care planning (ACP) can help to make this vulnerable period better for patients, caregivers, and providers. OBJECTIVE The objective of this study was to determine whether older age predicted the presence of certain forms of retrievable ACP documentation in the electronic health record (EHR) in a large sample of hospice-referred patients. METHODS This was a retrospective analysis of medical-record data on 3595 patients referred to hospice between January 1, 2013 and December 31, 2015. EHR documentation of an ACP note in the problem list, presence of a scanned advance directive, and the presence of a verified do-not-resuscitate order were the outcome measures. Logistic regression was used to assess the effect of age, education, race, gender, cancer diagnosis, dementia diagnosis, palliative encounter, and death on the outcome variables. RESULTS Our results suggest that when we control for prognosis, patients over age 70 years may experience gaps in ACP communication. We found that as patients age, the odds of having documentation of a conversation (odds ratio [OR] = 0.56; P < 0.001) or scanned advance directive decreased (OR = 0.63; P < 0.001), while the odds of having a verified do-not-resuscitate order increased (OR = 1.42; P < 0.001). CONCLUSION The results of this study may imply some degree of unilateral and physician-driven decision making for end-of-life care among older adults. Collaborative efforts between an interdisciplinary medical team should focus on developing policies to address this potential disparity between younger and older adults at the end of life.
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Affiliation(s)
- Laura C Prater
- Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
| | - Thomas Wickizer
- College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Seuli Bose-Brill
- Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Modes ME, Engelberg RA, Downey L, Nielsen EL, Curtis JR, Kross EK. Did a Goals-of-Care Discussion Happen? Differences in the Occurrence of Goals-of-Care Discussions as Reported by Patients, Clinicians, and in the Electronic Health Record. J Pain Symptom Manage 2019; 57:251-259. [PMID: 30391656 PMCID: PMC6348015 DOI: 10.1016/j.jpainsymman.2018.10.507] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 01/06/2023]
Abstract
CONTEXT Goals-of-care discussions are associated with improved end-of-life care for patients and therefore may be used as a process measure in quality improvement, research, and reimbursement programs. OBJECTIVES To examine three methods to assess occurrence of a goals-of-care discussion-patient report, clinician report, and documentation in the electronic health record (EHR)-at a clinic visit for seriously ill patients and determine whether each method is associated with patient-reported receipt of goal-concordant care. METHODS We conducted a secondary analysis of a multicenter cluster-randomized trial, with 494 patients and 124 clinicians caring for them. Self-reported surveys collected from patients and clinicians two weeks after a clinic visit assessed occurrence of a goals-of-care discussion. Documentation of a goals-of-care discussion was abstracted from the EHR. Patient-reported receipt of goal-concordant care was assessed by survey two weeks after the visit. RESULTS Fifty-two percent of patients reported occurrence of a goals-of-care discussion at the clinic visit; clinicians reported occurrence of a discussion at 66% of visits. EHR documentation occurred in 42% of visits (P < 0.001 for each compared with other two). Patients who reported occurrence of a goals-of-care discussion at the visit were more likely to report receipt of goal-concordant care than patients who reported no discussion (β 0.441, 95% CI 0.190-0.692; P = 0.001). Neither occurrence of a discussion by clinician report nor by EHR documentation was associated with goal-concordant care. CONCLUSION Different approaches to assess goals-of-care discussions give differing results, yet each may have advantages. Patient report is most likely to correlate with patient-reported receipt of goal-concordant care.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA; Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA.
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13
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Scarberry K, Ponsky L, Cherullo E, Larchian W, Bodner D, Cooney M, Ellis R, Maclennan G, Johnson B, Tabayoyong W, Abouassaly R. Evaluating the impact of the genitourinary multidisciplinary tumour board: Should every cancer patient be discussed as standard of care? Can Urol Assoc J 2018; 12:E403-E408. [PMID: 29787374 DOI: 10.5489/cuaj.5150] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION We sought to prospectively evaluate the effectiveness of the multidisciplinary tumour board (MTB) on altering treatment plans for genitourinary (GU) cancer patients. METHODS All GU cancer patients seen at our tertiary care hospital are discussed at MTB. We prospectively collected data on adult patients discussed over a continuous, 20-month period. Physicians completed a survey prior to MTB to document their opinion on the likelihood of change in their patient's treatment plan. Logistic regression was used to asses for factors associated with a change by the MTB, including patient age or sex, malignancy type, the predicted treatment plan, and the provider's years of experience or fellowship training. RESULTS A total of 321 cancer patients were included. Patients were primarily male (84.4%) with a median age of 67 (range 20-92) years old. Prostate (38.9%), bladder (31.8%), and kidney cancer (19.6%) were the most common malignancies discussed. A change in management plan following MTB was observed in 57 (17.8%) patients. The physician predicted a likely change in six (10.5%) of these patients. Multivariate logistic regression did not determine physician prediction to be associated with treatment plan change, and the only significant variable identified was a plan to discuss multiple treatment options with a patient (odds ratio 2.46; 95% confidence interval 1.09-9.54). CONCLUSIONS Routine discussion of all urologic oncology cases at MTB led to a change in treatment plan in 17.8% of patients. Physicians cannot reliably predict which patients have their treatment plan altered. Selectively choosing patients to be presented likely undervalues the impact of a multidisciplinary approach to care.
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Affiliation(s)
- Kyle Scarberry
- Urology Institute, University Hospitals Cleveland Medical Center.,Case Western Reserve University School of Medicine
| | - Lee Ponsky
- Urology Institute, University Hospitals Cleveland Medical Center.,Case Western Reserve University School of Medicine
| | - Edward Cherullo
- Urology Institute, University Hospitals Cleveland Medical Center.,Case Western Reserve University School of Medicine
| | - William Larchian
- Urology Institute, University Hospitals Cleveland Medical Center.,Case Western Reserve University School of Medicine
| | - Donald Bodner
- Urology Institute, University Hospitals Cleveland Medical Center.,Case Western Reserve University School of Medicine
| | - Matthew Cooney
- Case Western Reserve University School of Medicine.,Division of Hematology/Oncology, University Hospitals Cleveland Medical Center
| | - Rodney Ellis
- Case Western Reserve University School of Medicine.,Department of Radiation Oncology, University Hospitals Cleveland Medical Center
| | - Gregory Maclennan
- Case Western Reserve University School of Medicine.,Department of Pathology, University Hospitals Cleveland Medical Center; Cleveland, OH, United States
| | - Ben Johnson
- Urology Institute, University Hospitals Cleveland Medical Center.,Case Western Reserve University School of Medicine
| | - William Tabayoyong
- Urology Institute, University Hospitals Cleveland Medical Center.,Case Western Reserve University School of Medicine
| | - Robert Abouassaly
- Urology Institute, University Hospitals Cleveland Medical Center.,Case Western Reserve University School of Medicine
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Ethier JL, Paramsothy T, You JJ, Fowler R, Gandhi S. Perceived Barriers to Goals of Care Discussions With Patients With Advanced Cancer and Their Families in the Ambulatory Setting: A Multicenter Survey of Oncologists. J Palliat Care 2018; 33:125-142. [PMID: 29607704 DOI: 10.1177/0825859718762287] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Earlier goals of care (GOC) discussions in patients with advanced cancer are associated with less aggressive end-of-life care including decreased use of medical technologies. Unfortunately, conversations often occur late in the disease trajectory when patients are acutely unwell. Here, we evaluate practitioner perspectives of patient, family, physician, and external barriers to early GOC discussions in the ambulatory oncology setting. METHODS A previously published survey to assess barriers to GOC discussions among clinicians on inpatient medical wards was modified for the ambulatory oncology setting and distributed to oncologists from 12 centers in Ontario, Canada. Physicians were asked to rank the importance of various barriers to having GOC discussions (1 = extremely unimportant to 7 = extremely important). RESULTS Questionnaires were completed by 30 (24%) of 127 physicians. Respondents perceived patient- and family-related factors as the most important barriers to GOC discussions. Of these, patient difficulty accepting prognosis or desire for aggressive treatment were perceived as most important. Patients' inflated expectation of treatment benefit was also considered an important barrier to discontinuing active cancer-directed therapy. While physician barriers were ranked lower than patient-related factors, clinicians' self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Patient's refusal for referral was the most highly rated barrier to early palliative care referral. Most respondents were nonetheless very or extremely willing to initiate (90%) or lead (87%) GOC discussions. CONCLUSION Oncologists ranked patient- and family-related factors as the most important barriers to GOC discussions, while clinicians' self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Further work is required to assess patient preferences and perceptions and develop targeted interventions.
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Affiliation(s)
- Josee-Lyne Ethier
- 1 Department of Medical Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Thivaher Paramsothy
- 2 Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - John J You
- 3 Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,4 Department Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Robert Fowler
- 5 Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,6 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sonal Gandhi
- 2 Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Putman MS, Tak HJ, Curlin FA, Yoon JD. Quality of Life and Recommendations for Further Care. Crit Care Med 2017; 44:1996-2002. [PMID: 27441902 DOI: 10.1097/ccm.0000000000001846] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Physician recommendations for further medical treatment or palliative treatment only at the end of life may influence patient decisions. Little is known about the patient characteristics that affect physician-assessed quality of life or how such assessments are related to subsequent recommendations. DESIGN, SETTING, AND SUBJECTS A 2010 mailed survey of practicing U.S. physicians (1,156/1,878 or 62% of eligible physicians responded). MEASUREMENTS AND MAIN RESULTS Measures included an end of life vignette with five experimentally varied patient characteristics: setting, alimentation, pain, cognition, and communication. Physicians rated vignette patient quality of life on a scale from 0 to 100 and indicated whether they would recommend continuing full medical treatment or palliative treatment only. Cognitive deficits and alimentation had the greatest impacts on recommendations for further care, but pain and communication were also significant (all p < 0.001). Physicians who recommended continuing full medical treatment rated quality of life three times higher than those recommending palliative treatment only (40.41 vs 12.19; p < 0.01). Religious physicians were more likely to assess quality of life higher and to recommend full medical treatment. CONCLUSIONS Physician judgments about quality of life are highly correlated with recommendations for further care. Patients and family members might consider these biases when negotiating medical decisions.
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Affiliation(s)
- Michael S Putman
- 1Department of Medicine, The University of Chicago, Chicago, IL. 2Department of Health Services Research and Administration, University of Nebraska Medical Center, Omaha, NE. 3Duke University, Trent Center for Bioethics, Humanities, and History of Medicine, Durham, NC. 4MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL
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Kraus CK, Marco CA. Shared decision making in the ED: ethical considerations. Am J Emerg Med 2016; 34:1668-72. [DOI: 10.1016/j.ajem.2016.05.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/19/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022] Open
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17
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Hiraoka E, Homma Y, Norisue Y, Naito T, Kataoka Y, Hamada O, Den Y, Takahashi O, Fujitani S. What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective. Int J Gen Med 2016; 9:213-20. [PMID: 27418851 PMCID: PMC4935165 DOI: 10.2147/ijgm.s105302] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Japan has no official guidelines for do-not-resuscitate (DNR) orders. Therefore, we investigated the effect of DNR orders on physician decision making in relation to performing noncardiopulmonary resuscitation (CPR) and CPR procedures. Methods A case-scenario-based questionnaire that included a case of advanced cancer, a case of advanced dementia, and a case of nonadvanced heart failure was administered to physicians. The questions determined whether physicians would perform different non-CPR procedures and CPR procedures in the presence or absence of DNR orders. The number of non-CPR procedures each physician would perform and the number of physicians who would perform each non-CPR and CPR procedure in the absence and presence of DNR ocrders were compared. Physicians from three Japanese municipal acute care hospitals participated. Results We analyzed 111 of 161 (69%) questionnaires. Physicians would perform significantly fewer non-CPR procedures in the presence of DNR orders than in the absence of DNR orders for all three case scenarios (median [interquartile range] percentages: Case 1: 72% [45%–90%] vs 100% [90%–100%]; Case 2: 55% [36%–72%] vs 91% [63%–100%]; Case 3: 78% [55%–88%] vs 100% [88%–100%]). Fewer physicians would perform non-CPR and CPR procedures in the presence of DNR orders than in the absence of DNR orders. However, considerable numbers of physicians would perform electric shock treatment for ventricular fibrillation in the presence of DNR orders (Case 1: 26%; Case 2: 16%; Case 3: 20%). Conclusion DNR orders affect physician decision making about performing non-CPR procedures. Although some physicians would perform CPR for ventricular fibrillation in the presence of DNR orders, others would not. Therefore, a consensus definition for DNR orders should be developed in Japan, otherwise DNR orders may cause harm.
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Affiliation(s)
| | | | - Yasuhiro Norisue
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | | | | | | | - Yo Den
- Department of Internal Medicine
| | - Osamu Takahashi
- Department of Internal Medicine, St Luke's International Hospital, Tokyo, Japan
| | - Shigeki Fujitani
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
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Caruso D, Carter WE, Cifu DX, Carne W. Survival of patients with spinal cord injury after cardiac arrest in Department of Veterans Affairs hospital: Pilot study. ACTA ACUST UNITED AC 2015; 51:1103-8. [PMID: 25436984 DOI: 10.1682/jrrd.2013.05.0119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 03/25/2014] [Indexed: 11/05/2022]
Abstract
Survivability characteristics after cardiopulmonary resuscitation in the population with spinal cord injury (SCI) are unclear but may be useful for advanced care planning discussions with patients. Retrospective evaluation from records of all SCI patients over 10 yr at a Department of Veterans Affairs medical center who experienced in-hospital cardiac arrest was performed. Demographic data and other common measurements were recorded. Thirty-six male subjects were identified, and only two patients survived to discharge (5.5% survival rate), both of whom were admitted for nonacute issues and were asymptomatic shortly before the cardiac arrest. The mean age at the time of cardiopulmonary arrest was 62.4 yr, with a mean time from cardiac arrest to death of 3.02 d. No significant demographic parameters were identified. Overall, SCI likely portends worse outcome for acutely ill patients in the situation of a cardiac arrest. Conclusions are limited by sample size.
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Roze des Ordons AL, Sharma N, Heyland DK, You JJ. Strategies for effective goals of care discussions and decision-making: perspectives from a multi-centre survey of Canadian hospital-based healthcare providers. BMC Palliat Care 2015; 14:38. [PMID: 26286394 PMCID: PMC4544790 DOI: 10.1186/s12904-015-0035-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 08/10/2015] [Indexed: 12/21/2022] Open
Abstract
Background Communication gaps impact the quality of patient care. Previous research has focused on communication barriers rather than seeking solutions. Our aim was to identify strategies for effective communication and decision-making about goals of care for medical interventions in serious illness, from the perspectives of hospital-based healthcare providers. Methods A cross-sectional survey composed of closed- and open-ended questions about goals of care communication and decision-making was administered to healthcare providers in 13 centres in six Canadian provinces. We analyzed a portion of the open-ended survey questions, specifically (1) suggestions for overcoming barriers encountered in discussing goals of care, and (2) currently effective practices. Thematic content analysis was used to analyze responses to the open-ended questions. Results Of the 1,256 respondents to the larger survey, 468 responded to the open-ended questions (37 %), including 272 of 512 nurses (53 %), 153 of 484 internal medicine trainees (32 %), and 43 of 260 attending physicians (17 %). Responses to each of the two questions were similar, generating a common set of themes and subthemes. Effective strategies and ideas for improving communication and decision-making about goals of care clustered under five themes: patient and family factors, communication between healthcare providers and patients, interprofessional collaboration, education, and resources. Subthemes highlighted core elements of shared decision-making. Conclusions Translating our findings into multifaceted interventions that consider patient and family factors, address knowledge gaps, optimize resource utilization, and facilitate communication and collaboration between patients, families and healthcare providers may improve communication and decision-making about goals of care. Electronic supplementary material The online version of this article (doi:10.1186/s12904-015-0035-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amanda L Roze des Ordons
- Department of Critical Care Medicine and Division of Palliative Medicine, University of Calgary, South Health Campus, 4448 Front St SE, Calgary, AB, T3M 1M4, Canada.
| | - Nishan Sharma
- W21C (Ward of the 21st Century), Cumming School of Medicine, University of Calgary, GD01 TRW Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | - Daren K Heyland
- Critical Care Programme, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - John J You
- Departments of Medicine and Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Room HSC-2C8, Hamilton, ON, L8S 4K1, Canada.
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Marco CA, Michael S, Bleyer J, Post A. Do-not-resuscitate orders among trauma patients. Am J Emerg Med 2015; 33:1770-2. [PMID: 26371832 DOI: 10.1016/j.ajem.2015.08.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 08/11/2015] [Accepted: 08/14/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Do-not-resuscitate (DNR) orders are an important means to communicate end-of-life wishes. Previous studies have demonstrated variable prevalence of DNR orders among hospitalized trauma patients. OBJECTIVE This study was conducted to identify the prevalence and type of DNR orders among trauma patients and to identify associations of DNR orders with injury severity, length of stay, and whether CPR was performed in cases of cardiac arrest. METHODS In this retrospective study, medical records were reviewed for 263 trauma patients at Miami Valley Hospital in Dayton, Ohio, in 2014 with a DNR order. RESULTS Among 3394 trauma patients in 2014, 263 (8%) patients had a DNR order. Participants were 43% male and 57% female. The mean age was 76 (range, 16-90+) years. The most common mechanisms of injury included fall (n = 214, 81.4%) and motor vehicle collision (n = 16, 6.1%). Most DNR orders in this patient population were instituted during the hospitalization (n = 176, 67%). The most common types of advance directives included DNR order (n = 224, 85.2%), living will (n = 124, 47.2%), and durable power of health care attorney (n = 126, 47.9%). A minority of patients died during hospitalization (n = 100, 38.0%). Among patients who were deceased, 14 (14.0%) had CPR performed. CONCLUSIONS Among trauma patients with DNR orders, most DNR orders were instituted during the hospital admission. Most deceased patients with DNR orders did not have CPR performed during the hospital stay.
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Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, 3525 Southern Blvd, Kettering, OH 45429.
| | - Scarlett Michael
- Department of Emergency Medicine, 3525 Southern Blvd, Kettering, OH 45429
| | - Jamie Bleyer
- Department of Emergency Medicine, 3525 Southern Blvd, Kettering, OH 45429
| | - Alina Post
- Wright State University Boonshoft School of Medicine, 3640 Colonel Glenn Hw, Dayton, OH 45435
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Sharma RK, Breu AC. Making progress with code status documentation. J Hosp Med 2015; 10:553-4. [PMID: 25873559 PMCID: PMC4516597 DOI: 10.1002/jhm.2349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 02/25/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Rashmi K. Sharma
- Division of Hospital Medicine, Northwestern University, Chicago, Illinois
- Address for correspondence and reprint requests: Rashmi K. Sharma, MD, Division of Hospital Medicine, Northwestern University, 211 E. Ontario St., 07-734, Chicago, IL 60611; Telephone: 312-926-0096; Fax: 312-926-4588;
| | - Anthony C. Breu
- Department of Medical Services, VA Boston Healthcare System, West Roxbury, Massachusetts
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Brimblecombe C, Crosbie D, Lim WK, Hayes B. The Goals of Patient Care project: implementing a proactive approach to patient-centred decision-making. Intern Med J 2015; 44:961-6. [PMID: 24942613 DOI: 10.1111/imj.12511] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 06/11/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients in the later stages of their lives risk being harmed by futile or unwanted interventions if realistic care goals and patient values are not recognised. Doctors have difficulty discussing and informing patients' healthcare goals. AIMS To review implementation of a Goals of Patient Care (GOPC) summary in medical inpatients and its applicability in emergency medical response (EMR) situations. METHODS Single-centre cross-sectional study of adult medical inpatients and adult inpatients requiring EMR at a Victorian general hospital. MEASURES presence and content of GOPC summary, secondary review of decision-making and discussion documentation, patient characteristics; EMR precipitants and outcomes. RESULTS GOPC were documented for 82 of 101 patients. One had an existing advance directive, and six had records of a patient-appointed substitute decision-maker. For patients with GOPC, 80 had life-prolonging treatment aims, with a varying degree of treatment limitation in 48. Discussion with patient or substitute decision-maker was evident in 43 cases. GOPC were documented prior to nine of 23 EMR. The EMR triggered a GOPC modification in three instances. CONCLUSIONS Introduction of a routine GOPC summary encourages consideration of goals of care for most medical inpatients. Few have pre-existing records of their wishes, and there are opportunities for improvement in this regard. Doctors may still have difficulty determining goals of care, and discussion of GOPC with patients and families may not be clearly documented. Most patients requiring EMR do not have prior GOPC review, and the role of the summary in these situations remains unclear.
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Affiliation(s)
- C Brimblecombe
- Department of Palliative and Supportive Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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A video to improve patient and surrogate understanding of cardiopulmonary resuscitation choices in the ICU: a randomized controlled trial. Crit Care Med 2015; 43:621-9. [PMID: 25479118 DOI: 10.1097/ccm.0000000000000749] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine if a video depicting cardiopulmonary resuscitation and resuscitation preference options would improve knowledge and decision making among patients and surrogates in the ICU. DESIGN Randomized, unblinded trial. SETTING Single medical ICU. PATIENTS Patients and surrogate decision makers in the ICU. INTERVENTIONS The usual care group received a standard pamphlet about cardiopulmonary resuscitation and cardiopulmonary resuscitation preference options plus routine code status discussions with clinicians. The video group received usual care plus an 8-minute video that depicted cardiopulmonary resuscitation, showed a simulated hospital code, and explained resuscitation preference options. MEASUREMENTS AND MAIN RESULTS One hundred three patients and surrogates were randomized to usual care. One hundred five patients and surrogates were randomized to video plus usual care. Median total knowledge scores (0-15 points possible for correct answers) in the video group were 13 compared with 10 in the usual care group, p value of less than 0.0001. Video group participants had higher rates of understanding the purpose of cardiopulmonary resuscitation and resuscitation options and terminology and could correctly name components of cardiopulmonary resuscitation. No statistically significant differences in documented resuscitation preferences following the interventions were found between the two groups, although the trial was underpowered to detect such differences. A majority of participants felt that the video was helpful in cardiopulmonary resuscitation decision making (98%) and would recommend the video to others (99%). CONCLUSIONS A video depicting cardiopulmonary resuscitation and explaining resuscitation preference options was associated with improved knowledge of in-hospital cardiopulmonary resuscitation options and cardiopulmonary resuscitation terminology among patients and surrogate decision makers in the ICU, compared with receiving a pamphlet on cardiopulmonary resuscitation. Patients and surrogates found the video helpful in decision making and would recommend the video to others.
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Abstract
BACKGROUND Demographic change has also caused changes in perioperative intensive care because the proportion of geriatric patients who must undergo surgical procedures is increasing. With the current preoperative assessment instruments, it is still not possible to identify high-risk patients of this collective or to make a reliable prognosis concerning postoperative course. MATERIALS AND METHODS In addition to pain control, important aspects to minimize complications in postoperative intensive care include adequate oxygenation, adequate fluid management, an adequate supply of energy and nutrients, good control of blood sugar levels, and early mobilization of patients. RESULTS The perioperative intensive care treatment of geriatric patients requires the readiness to engage in interdisciplinary collaboration because only with this close dialog can the treatment results be sustained.
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Thurston A, Wayne DB, Feinglass J, Sharma RK. Documentation quality of inpatient code status discussions. J Pain Symptom Manage 2014; 48:632-8. [PMID: 24681110 PMCID: PMC4177509 DOI: 10.1016/j.jpainsymman.2013.11.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 11/20/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
Abstract
CONTEXT Accurate documentation of inpatient code status discussions (CSDs) is important because of frequent patient care handoffs. OBJECTIVES To examine the quality of inpatient CSD documentation and compare documentation quality across physician services. METHODS This was a retrospective study of patients hospitalized between January 1 and June 30, 2011 with a new or canceled do-not-resuscitate (DNR) order at least 24 hours after hospital admission. We developed a chart abstraction tool to assess the documentation of five quality elements: 1) who the DNR discussion was held with, 2) patient goals/values, 3) prognosis, 4) treatment options and resuscitation outcomes, and 5) health care power of attorney (HCPOA). RESULTS We identified 379 patients, of whom 235 (62%) had a note documenting a CSD. After excluding patients lacking a note from their primary service, 227 remained for analysis. Sixty-three percent of notes contained documentation of who the discussion was held with. Patient goals/values were documented in 43%, discussion of prognosis in 14%, treatment options and resuscitation outcomes in 40%, and HCPOA in 29%. Hospitalists were more likely than residents to document who the discussion was held with (P < 0.001) and patient goals/values (P < 0.001), whereas internal medicine residents were more likely to document HCPOA (P = 0.04). The mean number of elements documented for hospitalists was 2.40, followed by internal medicine residents at 2.07, and non-internal medicine trainees at 1.30 (P < 0.001). CONCLUSION Documentation quality of inpatient CSDs was poor. Our findings highlight the need to improve the quality of resident and attending CSD documentation.
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Affiliation(s)
- Andrew Thurston
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Diane B Wayne
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Joseph Feinglass
- Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, Illinois, USA
| | - Rashmi K Sharma
- Division of Hospital Medicine, Northwestern University, Chicago, Illinois, USA.
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Jorns LJ, Roche Green AR, Shannon RP. Tucker. J Palliat Med 2014; 17:864. [DOI: 10.1089/jpm.2013.0504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lainie J. Jorns
- Department of Family Medicine, Mayo Clinic, Jacksonville, Florida
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Bernal DR, Uribe CC. [Limitations on Therapeutic Efforts: Much More than not Doing]. ACTA ACUST UNITED AC 2014; 42:97-107. [PMID: 26572716 DOI: 10.1016/s0034-7450(14)60090-1] [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: 11/19/2012] [Accepted: 01/10/2013] [Indexed: 10/25/2022]
Abstract
The term LTE (Limitations on Therapeutic Efforts) refers to the withholding or withdrawing of medical treatment to a patient (either with or without capacity to decide) who does not clinically benefit from it. Although some countries already have legislation and official documents to formalize it, there are several reasons limiting the dissemination and acceptance of this proposal. One is the fact that physicians and health institutions consider this issue as the sole responsibility of patients; another reason is that physicians and the community in general believe the discussion refers just to elderly and terminal patients. It is necessary an academic approach on LTE from both, physicians and the community in general, to promote a sound ethical reflection so as to assist patients and their relatives in the hard task of becoming autonomous to decide and plan their futures.
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Abstract
OBJECTIVES Although studies have shown regional and interhospital variability in the intensity of end-of-life care, few data are available assessing variability in specific aspects of palliative care in the ICU across hospitals or interhospital variability in family and nurse ratings of this care. Recently, relatively high family satisfaction with ICU end-of-life care has prompted speculation that ICU palliative care has improved over time, but temporal trends have not been documented. DESIGN/SETTING Retrospective cohort study of consecutive patients dying in the ICU in 13 Seattle-Tacoma-area hospitals between 2003 and 2008. MEASUREMENTS We examined variability over time and among hospitals in satisfaction and quality of dying assessed by family, quality of dying assessed by nurses, and chart-based indicators of palliative care. We used regression analyses adjusting for patient, family, and nurse characteristics. MAIN RESULTS Medical charts were abstracted for 3,065 of 3,246 eligible patients over a 55-month period. There were significant differences between hospitals for all chart-based indicators (p < 0.001), family satisfaction (p < 0.001), family-rated quality of dying (p = 0.03), and nurse-rated quality of dying (p = 0.003). There were few significant changes in these measures over time, although we found a significant increase in pain assessments in the last 24 hours of life (p < 0.001) as well as decreased documentation of family conferences (p < 0.001) and discussion of prognosis (p = 0.020) in the first 72 hours in the ICU. CONCLUSIONS We found significant interhospital variation in ratings and delivery of palliative care, consistent with prior studies showing variation in intensity of care at the end of life. We did not find evidence of temporal changes in most aspects of palliative care, family satisfaction, or nurse/family ratings of the quality of dying. With the possible exception of pain assessment, there is little evidence that the quality of palliative care has improved over the time period studied.
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Ahluwalia SC, Chuang FL, Antonio ALM, Malin JL, Lorenz KA, Walling AM. Documentation and discussion of preferences for care among patients with advanced cancer. J Oncol Pract 2013; 7:361-6. [PMID: 22379417 DOI: 10.1200/jop.2011.000364] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2011] [Indexed: 12/25/2022] Open
Abstract
PURPOSE We sought to describe the documentation, frequency, and timing of discussions about patient preferences for care and to examine patterns of palliative care and hospice use among patients with advanced cancer. METHODS We prospectively abstracted the medical records of 118 patients receiving care at a Veterans Administration (VA) facility from diagnosis of stage IV disease to 12 months postdiagnosis or death. We used univariate statistics to describe the type and frequency of documentation of patient preferences and palliative care/hospice referral. We calculated the time from diagnosis to the first documentation of preferences and the time from first documentation to death. We compared documentation of patient preferences between decedents and nondecedents using χ(2) tests. RESULTS The majority of patients (81%) had some documentation of their care preferences recorded, although decedents were significantly more likely to have had their preferences documented than nondecedents (96% v 60%; P < .000). Most (53%) patients did not have a formal advance directive documented in the medical record. The mean time from diagnosis to the first documentation of preferences was approximately 2 months. More than half of all patients (53%) and almost three-quarters of decedents (73%) had a palliative care consultation. CONCLUSION Despite high rates of preference documentation, there remains room for improvement. Providers may need to be helped to identify patients earlier in their trajectory for appropriate palliative care services, and future work should focus on developing useful alternatives to advance directives for adequately documenting patient preferences.
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Affiliation(s)
- Sangeeta C Ahluwalia
- Center for the Study of Healthcare Provider Behavior, Veterans Administration Greater Los Angeles Healthcare System; Veterans Administration Greater Los Angeles Healthcare System; Cedars-Sinai Medical Center; University of California, Los Angeles (UCLA) School of Public Health; Geffen School of Medicine at UCLA, Los Angeles, CA
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Temel JS, Greer JA, Gallagher ER, Jackson VA, Lennes IT, Muzikansky A, Park ER, Pirl WF. Electronic Prompt to Improve Outpatient Code Status Documentation for Patients With Advanced Lung Cancer. J Clin Oncol 2013; 31:710-5. [DOI: 10.1200/jco.2012.43.2203] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Rates of documentation of end-of-life care preferences in the medical record remain low, even among patients with incurable malignancies. We therefore conducted a two-phase study to develop and assess the effect of electronic prompts to encourage oncology clinicians to document code status in the outpatient electronic health record (EHR) of patients with advanced lung cancers. Patients and Methods To determine the optimal delivery, content, and timing of the electronic prompt, we first facilitated focus groups with oncology clinicians at an affiliated medical center. Given this feedback, we developed e-mail reminders timed to the start of each new chemotherapy regimen. Between July 2009 and January 2011, 102 eligible patients with incurable lung cancer were approached, and 100 agreed to participate. We compared e-mail prompt participants (EPPs) with a cohort of 100 consecutive historical controls who began therapy for incurable lung cancer at least 1 year before the start of this study. The primary outcome measure was clinician documentation of code status in the EHR. Results EPPs were similar to historical controls, with no significant differences in demographic or clinical characteristics. At 1-year follow-up, 33.7% (n = 33/98) of EPPs had a code status documented in the outpatient EHR compared with 14.5% (n = 12/83) of historical controls (P = .003). Mean time to code status documentation was significantly shorter in EPPs (8.6 months [95% CI, 7.6 to 9.5]) compared with controls (10.5 months [95% CI, 9.8 to 11.3]; P = .004). Conclusion e-mail prompts may improve the rate and timing of code status documentation in the EHR and warrant further investigation.
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Affiliation(s)
| | | | | | | | - Inga T. Lennes
- All authors: the Massachusetts General Hospital, Boston, MA
| | | | - Elyse R. Park
- All authors: the Massachusetts General Hospital, Boston, MA
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Wenger NS, Citko J, O'Malley K, Diamant A, Lorenz K, Gonzalez V, Tarn DM. Implementation of Physician Orders for Life Sustaining Treatment in nursing homes in California: evaluation of a novel statewide dissemination mechanism. J Gen Intern Med 2013; 28:51-7. [PMID: 22878851 PMCID: PMC3539039 DOI: 10.1007/s11606-012-2178-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 05/21/2012] [Accepted: 06/25/2012] [Indexed: 11/04/2022]
Abstract
BACKGROUND Implementing Physician Orders for Life Sustaining Treatment (POLST) forms aims to improve communication of life-sustaining treatment preferences across care venues. California enabled this clinical tool in 2009, and a novel intervention of community coalitions was undertaken to advance POLST in localities around the state. Coalitions engaged facilities, including nursing homes (NHs), to foster POLST adoption. Eighteen months after introduction of POLST, we studied POLST implementation in California NHs. METHODS NHs randomly selected in coalition and non-coalition areas were mailed surveys about POLST preparation and use in 2010. Coalitions identified which NHs they worked with. RESULTS Of 546 NHs surveyed, 143 (52 %) in coalition areas and 141 (52 %) in non-coalition areas responded. In 82 % of responding NHs, staff received POLST education and 59 % of NHs reported having a formal policy on handling POLST. Two-thirds of NHs had admitted a resident with a POLST, and 15 % of newly admitted residents over the past month had a POLST (range 0-100 %). Eighty-one percent of NHs had completed a POLST with a resident. Fifty-four percent of residents were estimated to have a POLST (range 0-100 %) (coalition area NHs 60 % vs. non- coalition area NHs 48 %, p = 0.02). Within coalition areas, NHs that had worked with coalitions were more likely to have completed a POLST with a resident after admission than NHs that had not worked with coalitions. Few NHs (7 %) reported difficulty following POLST orders, but 38 % noted difficulty involving physicians in POLST completion. CONCLUSION Less than 2 years after introduction, many California nursing homes report using POLST, although some NHs reported no experience. A novel community coalition intervention facilitated POLST implementation.
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Affiliation(s)
- Neil S Wenger
- UCLA Division of General Internal Medicine and Health Services Research, 911 Broxton Plaza #309, Los Angeles, CA 90024, USA.
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Affiliation(s)
- Alexander K Smith
- Department of Medicine, Division of Geriatrics, University of California, 4150 Clement St (181 G), San Francisco, CA 94941, USA,
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Papadimos TJ, Maldonado Y, Tripathi RS, Kothari DS, Rosenberg AL. An overview of end-of-life issues in the intensive care unit. Int J Crit Illn Inj Sci 2012; 1:138-46. [PMID: 22229139 PMCID: PMC3249847 DOI: 10.4103/2229-5151.84801] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.
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Affiliation(s)
- Thomas J Papadimos
- Department of Anesthesiology, Division of Critical Care Medicine, The Ohio State University Medical Center, Columbus OH 43210, USA
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Fernandez R, Deutsch AL, Janairo MP, Compton SA. Development of a content valid tool for assessing end-of-life communication in acute care settings. J Palliat Med 2012; 15:381-7. [PMID: 22500476 DOI: 10.1089/jpm.2011.0427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Current recommendations throughout the literature require that physicians demonstrate proficiency in handling end-of-life care issues. However, current training and assessment tools are not easily translated to acutely decompensating emergency department patients with whom the practitioner is not familiar. Without these tools, robust assessment of physician performance cannot occur. OBJECTIVE To develop a content valid instrument to measure the critical care communication skills of emergency physicians in order to facilitate education and assessment of end-of-life communication skills in a time-sensitive acute care setting. METHODS A two-step modified Delphi methodology with emergency medicine palliative care subject matter experts was used. First, an extensive review of the literature was conducted to elucidate broad communication domains important to end-of-life care. Next, subject matter experts were asked open-ended questions to ascertain critical skills and behaviors that characterized these broad domains. Finally, both questions and domains were ranked as to their importance and relevance to end-of-life communication in an emergency department setting. RESULTS Literature review identified five domains of end-of-life care: (1) seek information, (2) assess life values, (3) educate family, (4) extend care in a consistent manner, and (5) respond to family questions and concerns. Within each domain, the expert panel identified subdomains with related behavioral examples that were consistently rated as important to end-of-life care for emergency practitioners. CONCLUSION The resulting assessment tool provides a list of skill domains with specific descriptors and clear behavioral examples that can be used as both a teaching and assessment tool. This represents an essential first step that will allow further validation of the assessment tool, ultimately producing a valid and reliable measure of physician skill in emergency medicine end-of-life care.
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Affiliation(s)
- Rosemarie Fernandez
- Division of Emergency Medicine, University of Washington School of Medicine and Wayne State University School of Medicine, Department of Emergency Medicine.
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Marco CA, Moskop JC, Schears RM, Stankus JL, Bookman KJ, Padela AI, Baine J, Bryant E. The ethics of health care reform: impact on emergency medicine. Acad Emerg Med 2012; 19:461-8. [PMID: 22506951 DOI: 10.1111/j.1553-2712.2012.01313.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The recent enactment of the Patient Protection and Affordable Care Act (ACA) of 2010, and the ongoing debate over reform of the U.S. health care system, raise numerous important ethical issues. This article reviews basic provisions of the ACA; examines underlying moral and policy issues in the U.S. health care reform debate; and addresses health care reform's likely effects on access to care, emergency department (ED) crowding, and end-of-life care. The article concludes with several suggested actions that emergency physicians (EPs) should take to contribute to the success of health care reform in America.
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Gehlbach TG, Shinkunas LA, Forman-Hoffman VL, Thomas KW, Schmidt GA, Kaldjian LC. Code status orders and goals of care in the medical ICU. Chest 2011; 139:802-809. [PMID: 21292755 PMCID: PMC3198491 DOI: 10.1378/chest.10-1798] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 12/02/2010] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care. METHODS We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders. RESULTS Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents' average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status (P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care. CONCLUSIONS Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients' code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.
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Affiliation(s)
- Thomas G Gehlbach
- Division of Pulmonary and Critical Care Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Laura A Shinkunas
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Valerie L Forman-Hoffman
- Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Karl W Thomas
- Division of Pulmonary and Critical Care Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Gregory A Schmidt
- Division of Pulmonary and Critical Care Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Lauris C Kaldjian
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, IA; Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.
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Walling AM, Ettner SL, Barry T, Yamamoto MC, Wenger NS. Missed opportunities: use of an end-of-life symptom management order protocol among inpatients dying expected deaths. J Palliat Med 2011; 14:407-12. [PMID: 21388254 DOI: 10.1089/jpm.2010.0328] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND When a patient is expected to die, the ideal plan of care focuses on comfort. Prior investigation of application of one institution's end-of-life symptom management order (ESMO) protocol suggested that comfort measures were often instituted too late and sometimes not at all. We studied patient factors associated with missed opportunities for use of an ESMO protocol and protocol adherence in order to identify areas for quality improvement. METHODS We abstracted the terminal hospitalization medical record for all adult decedents hospitalized for at least 3 days between April 2005 and April 2006 (n = 496) at a university medical center. Detailed information was collected about ESMO use and opiate titration at the end of life. Among patients expected to die, we used multivariate logistic regression to evaluate factors associated with whether patients were placed on the ESMO protocol prior to death. RESULTS Half of patients who died received ESMO protocol care (n = 248). All had documentation of a do-not-resuscitate (DNR) order (a requirement of the protocol). An opiate drip was used for 95% of patients placed on the ESMO protocol and it was titrated up at least once for 67% of those patients. Patients had a mean of 4 opiate titrations, but for only a mean of 2.2 was a justification documented (symptom documentation is required for each titration per the protocol). In a multivariable regression accounting for other demographic, clinical and provider variables, uninsured patients (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.06-0.62), patients admitted from a nursing home (RR 0.57, 95% CI 0.30-0.99), and patients considered for transplant (RR 0.60, 95% CI 0.40-0.85) were significantly less likely to be placed on the ESMO protocol prior to death. CONCLUSIONS Evaluation of implementation of a standardized order set can identify areas for quality improvement and missed opportunities for use.
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Affiliation(s)
- Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA.
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Kelley AS, Ettner SL, Morrison RS, Du Q, Wenger NS, Sarkisian CA. Determinants of medical expenditures in the last 6 months of life. Ann Intern Med 2011; 154:235-42. [PMID: 21320939 PMCID: PMC4126809 DOI: 10.7326/0003-4819-154-4-201102150-00004] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND End-of-life medical expenditures exceed costs of care during other years, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs. OBJECTIVE To identify patient-level determinants of Medicare expenditures at the end of life and to determine the contributions of these factors to expenditure variation while accounting for regional characteristics. It was hypothesized that race or ethnicity, social support, and functional status are independently associated with treatment intensity and controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation. DESIGN Using data from the Health and Retirement Study, Medicare claims, and The Dartmouth Atlas of Health Care, relationships were modeled between expenditures and patient and regional characteristics. SETTING United States, 2000 to 2006. PARTICIPANTS 2394 Health and Retirement Study decedents aged 65.5 years or older. MEASUREMENTS Medicare expenditures in the last 6 months of life were estimated in a series of 2-level multivariable regression models that included patient, regional, and patient and regional characteristics. RESULTS Decline in function (rate ratio [RR], 1.64 [95% CI, 1.46 to 1.83]); Hispanic ethnicity (RR, 1.50 [CI, 1.22 to 1.85]); black race (RR, 1.43 [CI, 1.25 to 1.64]); and certain chronic diseases, including diabetes (RR, 1.16 [CI, 1.06 to 1.27]), were associated with higher expenditures. Nearby family (RR, 0.90 [CI, 0.82 to 0.98]) and dementia (RR, 0.78 CI, 0.71 to 0.87]) were associated with lower expenditures, and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (RR, 1.09 [CI, 1.06 to 1.14]) and hospital beds per capita (RR, 1.01 [CI, 1.00 to 1.02]), were associated with higher expenditures. Patient characteristics explained 10% of overall variance and retained statistically significant relationships with expenditures after regional characteristics were controlled for. LIMITATION The study limitations include the decedent sample, proxy informants, and a large proportion of unexplained variation. CONCLUSION Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics. PRIMARY FUNDING SOURCE The Brookdale Foundation.
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Affiliation(s)
- Amy S Kelley
- Mount Sinai School of Medicine, New York, New York 10029, USA.
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Kaldjian LC, Broderick A. Developing a Policy for Do Not Resuscitate Orders Within a Framework of Goals of Care. Jt Comm J Qual Patient Saf 2011; 37:11-9. [DOI: 10.1016/s1553-7250(11)37002-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kelley AS, Morrison RS, Wenger NS, Ettner SL, Sarkisian CA. Determinants of treatment intensity for patients with serious illness: a new conceptual framework. J Palliat Med 2010; 13:807-13. [PMID: 20636149 DOI: 10.1089/jpm.2010.0007] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Research during the past few decades has greatly advanced our understanding of the cost, quality, and variability of medical care at the end of life. The current health-care policy debate has focused considerable attention on the unsustainable rate of spending and wide regional variation associated with medical treatments in the last year of life. New initiatives aim to standardize quality and reduce over-utilization at the end of life. We argue, however, that focusing exclusively on medical treatment at the end of life is not likely to lead to effective health-care policy reform or reduce costs. Specifically, end-of-life policy initiatives face the challenges of political feasibility, inaccurate prognostication, and gaps in the existing literature. OBJECTIVES With the ultimate aim of improving the quality and efficiency of care, we propose a research and policy agenda guided by a new conceptual framework of factors associated with treatment intensity for patients with serious and complicated medical illness. This model not only expands the population of interest to include all adults with serious illness, but also provides a blueprint for the thorough investigation of the diverse and interconnected determinants of treatment intensity. CONCLUSIONS The new conceptual framework presented in this paper can be used to develop future research and policy initiatives designed to improve the quality and efficiency of care for adults with serious illness.
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Affiliation(s)
- Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Loertscher LL, Beckman TJ, Cha SS, Reed DA. Code status discussions: agreement between internal medicine residents and hospitalized patients. TEACHING AND LEARNING IN MEDICINE 2010; 22:251-256. [PMID: 20936570 DOI: 10.1080/10401334.2010.512537] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Medical residents frequently participate in code status discussions, yet their competency in this role has not been evaluated. PURPOSE The objective is to determine the quality of code status discussions from the perspective of both resident and patient. METHODS We conducted a cross-sectional survey of consecutive pairs of hospitalized patients and admitting residents at Mayo Clinic in March 2007. We measured perceptions of occurrence and content of code status discussions, admission volume, and demographic information. RESULTS Among the 41 matched pairs, residents and patients agreed that a code status conversation occurred in 63% of cases. Agreement was more likely if residents performed less than 4 admissions (p= .02). Patients reported the inclusion of specific discussion components, such as resuscitation procedures (7%) and outcomes (0%), less frequently than residents (71% and 27%, respectively, p< .001). CONCLUSIONS Residents and patients demonstrated poor agreement on the occurrence and components of code status conversations. Residency programs should identify ways to enhance residents' competency in eliciting patients' code status preferences and provide adequate time for code status discussions.
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Walling AM, Asch SM, Lorenz KA, Roth CP, Barry T, Kahn KL, Wenger NS. The quality of care provided to hospitalized patients at the end of life. ACTA ACUST UNITED AC 2010; 170:1057-63. [PMID: 20585072 DOI: 10.1001/archinternmed.2010.175] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Patients in American hospitals receive intensive medical treatments. However, when lifesaving treatments are unsuccessful, patients often die in the hospital with distressing symptoms while receiving burdensome care. Systematic measurement of the quality of care planning and symptom palliation is needed. METHODS Medical records were abstracted using 16 Assessing Care of Vulnerable Elders quality indicators within the domains of end-of-life care and pain management designed to measure the quality of the dying experience for adult decedents (n = 496) hospitalized for at least 3 days between April 2005 and April 2006 at a university medical center recognized for providing intensive care for the seriously ill. RESULTS Over half of the patients (mean age, 62 years; 47% were women) were admitted to the hospital with end-stage disease, and 28% were 75 years or older. One-third of the patients required extubation from mechanical ventilation prior to death, and 15% died while receiving cardiopulmonary resuscitation. Overall, patients received recommended care for 70% of applicable indicators (range, 25%-100%). Goals of care were addressed in a timely fashion for patients admitted to the intensive care unit approximately half of the time, whereas pain assessments (94%) and treatments for pain (95%) and dyspnea (87%) were performed with fidelity. Follow-up for distressing symptoms was performed less well than initial assessment, and 29% of patients extubated in anticipation of death had documented dyspnea assessments. CONCLUSION A practical, medical chart-based assessment identified discrete deficiencies in care planning and symptom palliation that can be targeted to improve care for patients dying in the hospital.
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Affiliation(s)
- Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90024, USA.
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Garrett DD, Tuokko H, Stajduhar KI, Lindsay J, Buehler S. Planning for End-of-Life Care: Findings from the Canadian Study of Health and Aging. Can J Aging 2010. [DOI: 10.3138/cja.27.1.11] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RÉSUMÉLes étapes utilisées pour l'officialisation des préférences en matière de soins en fin de vie et les facteurs en rapport avec ces étapes sont flous dans la documentation. À l'aide des données de la troisième phase de l'Étude sur la santé et le vieillissement au Canada (ESVC-3), nous avons examiné les relations entre les prédicteurs démographiques et en matière de santé, et les trois résultats (à savoir si les participants avaient réfléchi à leurs préférences de fin de vie, s'ils en avaient discuté, ou s'ils les avaient officialisées), et s'il y avait des relations entre les trois résultats. La région de résidence au Canada, le sexe féminin, et davantage d'années de scolarité étaient des facteurs associés à des personnes ayant réfléchi à leurs préférences. La région de résidence, le sexe féminin, et le manque de déficience cognitive étaient associés aux discussions en matière de préférences, et la région de résidence et le fait de ne pas avoir de conjoint étaient associés au dépôt de documents officiels. Les résidents de l'Ontario étaient les plus enclins à avoir réfléchi à leurs préférences, à en avoir discuté, et à les avoir officialisées, tandis que les résidents des Maritimes étaient les moins enclins à y avoir pensé et à avoir agi en conséquence. Enfin, avoir réfléchi à leurs préférences était associé au fait d'en discuter, et y avoir réfléchi et en avoir discuté étaient chacun associés à l'officialisation des préférences. Ces résultats correspondent au postulat que l'exécution du mandat (directive par procuration) est un processus comportant plusieurs étapes. Avoir une meilleure idée de ce processus peut se révéler utile lors de l'élaboration d'interventions visant à promouvoir la planification des soins en fin de vie.
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Wagner GJ, Riopelle D, Steckart J, Lorenz KA, Rosenfeld KE. Provider communication and patient understanding of life-limiting illness and their relationship to patient communication of treatment preferences. J Pain Symptom Manage 2010; 39:527-34. [PMID: 20171827 DOI: 10.1016/j.jpainsymman.2009.07.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 07/30/2009] [Accepted: 08/03/2009] [Indexed: 10/19/2022]
Abstract
Medical decision making in the context of serious illness ideally involves a patient who understands his or her condition and prognosis and can effectively formulate and communicate his or her care preferences. To understand the relationships among these care processes, we analyzed baseline interview data from veterans enrolled in a randomized controlled trial of a palliative care intervention. Participants were 400 inpatient veterans admitted with a physician-estimated risk of one-year mortality more than 25%; 260 (65%) had cancer as the primary diagnosis. Patients who believed that they had a life-limiting illness (89% of sample) reported that their provider had communicated this to them more frequently than those who did not share that belief (78% vs. 22%, P<0.001). Over half (53%) of the participants reported discussing their care preferences with their providers and 66% reported such discussions with their family; 35% had a living will. In multivariate analysis, greater functional impairment was associated with patients having discussed their care preferences with providers (P<0.05), whereas patient understanding of prognosis (P<0.05), better quality of life (P<0.01), and not being African American (P<0.05) were associated with patients having discussed their care preferences with family; higher education (P<0.001), and not being African American (P<0.01) were associated with having a living will. Patients with poor understanding of prognosis are less likely to discuss care preferences with family members, suggesting the importance of provider communication with patients regarding prognosis. Because functional decline may prompt physicians to discuss prognosis with patients, patients with relatively preserved function may particularly need such communication.
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Chakrabarti B, Sulaiman MI, Davies L, Calverley PMA, Warburton CJ, Angus RM. A study of patient attitudes in the United Kingdom toward ventilatory support in chronic obstructive pulmonary disease. J Palliat Med 2010; 12:1029-35. [PMID: 19663712 DOI: 10.1089/jpm.2009.0160] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Informed patient choice is central to modern clinical care but there is a paucity of data about how patients respond to information regarding complex therapies. This qualitative study aimed to understand the attitudes of patients with chronic obstructive pulmonary disease (COPD) toward acute ventilatory support and assess how aids to decision making regarding ventilation affect patients' views of therapy. METHODS A standardized five-stage interview process was used to explore attitudes toward noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) in 50 stable COPD patients. RESULTS Eighty-six percent found demonstration of NIV helpful in decision making compared to 24% with the photographic aid (p < 00.001). Although 96% were willing to receive NIV after a verbal description of the technique, only 76% consented when a photographic aid was shown. When NIV was demonstrated, willingness rose to 84%. While 60% were willing to receive IMV following a verbal description, this decreased to 58% following explanation of alternative treatments to IMV. Patients willing to receive IMV were younger (67 versus 76 years p = 0.016) and had a better functional status (NEADL index 20 versus 15 units p = 0.03). Only 34% had heard of advanced directives of care (ADCs), none had ever issued one but 48% expressed an interest in doing so following explanation of this process. CONCLUSION COPD patients would find both explanation and demonstration of NIV useful in an outpatient setting. Worsening functional status along with advanced age was associated with reduced willingness to receive invasive ventilatory support. Awareness of ADCs was found to be low although almost half of the patients expressed interest in the uptake of ADCs following explanation of the process.
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Affiliation(s)
- Biswajit Chakrabarti
- Clinical Sciences Centre, University of Liverpool, University Hospital Aintree, Liverpool, United Kingdom
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Janjan N, Lutz ST, Bedwinek JM, Hartsell WF, Ng A, Pieters RS, Ratanatharathorn V, Silberstein EB, Taub RJ, Yasko AW, Rettenmaier A. Therapeutic guidelines for the treatment of bone metastasis: a report from the American College of Radiology Appropriateness Criteria Expert Panel on Radiation Oncology. J Palliat Med 2009; 12:427-31. [PMID: 19416037 DOI: 10.1089/jpm.2009.9632] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Bone metastases remain a therapeutic challenge because of the diversity of the problems they cause, the relative paucity of data regarding their treatment, and the necessity for management by a multidisciplinary palliative care team. The American College of Radiology convened an Appropriateness Criteria Expert Panel on Radiation Oncology for the treatment of bone metastasis to create representative clinical case scenarios and then rank the appropriate use of treatment modalities as well as the most reasonable radiotherapy dose schema and treatment planning methods. Here we present both the resulting Appropriateness Criteria and the rationale for making these decisions. The treatment recommendations are placed within the larger framework of the role of radiation in palliative care by discussing the efficiency of palliative radiotherapy schedules, cost effectiveness issues, and the need for additional research regarding the proper multidisciplinary care of patients with symptomatic bone metastasis.
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Affiliation(s)
- Nora Janjan
- University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
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Savory EA, Marco CA. End-of-life issues in the acute and critically ill patient. Scand J Trauma Resusc Emerg Med 2009; 17:21. [PMID: 19386133 PMCID: PMC2678074 DOI: 10.1186/1757-7241-17-21] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Accepted: 04/22/2009] [Indexed: 11/24/2022] Open
Abstract
The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.
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Affiliation(s)
- Eric A Savory
- University of Toledo College of Medicine, Mail Stop 1114, 3045 Arlington Avenue, Toledo, Ohio 43614, USA
| | - Catherine A Marco
- Professor, Department of Surgery, Emergency Medicine, Director of Medical Ethics Curriculum, University of Toledo College of Medicine, Mail Stop 1114, 3045 Arlington Avenue, Toledo, Ohio 43614, USA
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Anesthesiologist Management of Perioperative Do-Not-Resuscitate Orders: A Simulation-Based Experiment. Simul Healthc 2009; 4:70-6. [DOI: 10.1097/sih.0b013e31819e137b] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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