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Halpern NA, Tan KS, Bothwell LA, Boyce L, Dulu AO. Defining Intensivists: A Retrospective Analysis of the Published Studies in the United States, 2010-2020. Crit Care Med 2024; 52:223-236. [PMID: 38240506 PMCID: PMC11256975 DOI: 10.1097/ccm.0000000000005984] [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] [Indexed: 01/23/2024]
Abstract
OBJECTIVES The Society of Critical Care Medicine last published an intensivist definition in 1992. Subsequently, there have been many publications relating to intensivists. Our purpose is to assess how contemporary studies define intensivist physicians. DESIGN Systematic search of PubMed, Embase, and Web of Science (2010-2020) for publication titles with the terms intensivist, and critical care or intensive care physician, specialist, or consultant. We included studies focusing on adult U.S. intensivists and excluded non-data-driven reports, non-U.S. publications, and pediatric or neonatal ICU reports. We aggregated the study title intensivist nomenclatures and parsed Introduction and Method sections to discern the text used to define intensivists. Fourteen parameters were found and grouped into five definitional categories: A) No definition, B) Background training and certification, C) Works in ICU, D) Staffing, and E) Database related. Each study was re-evaluated against these parameters and grouped into three definitional classes (single, multiple, or no definition). The prevalence of each parameter is compared between groups using Fisher exact test. SETTING U.S. adult ICUs and databases. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 657 studies, 105 (16%) met inclusion criteria. Within the study titles, 17 phrases were used to describe an intensivist; these were categorized as intensivist in 61 titles (58%), specialty intensivist in 30 titles (29%), and ICU/critical care physician in 14 titles (13%). Thirty-one studies (30%) used a single parameter (B-E) as their definition, 63 studies (60%) used more than one parameter (B-E) as their definition, and 11 studies (10%) had no definition (A). The most common parameter "Works in ICU" (C) in 52 studies (50%) was more likely to be used in conjunction with other parameters rather than as a standalone parameter (multiple parameters vs single-parameter studies; 73% vs 17%; p < 0.0001). CONCLUSIONS There was no consistency of intensivist nomenclature or definitions in contemporary adult intensivist studies in the United States.
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Affiliation(s)
- Neil A Halpern
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lilly A Bothwell
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lindsay Boyce
- MSK Library, Technology Division, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alina O Dulu
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
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Palmer JA, Mccullough M, Wormwood J, Soylemez Wiener R, Mesfin N, Still M, Xu CS, Linsky AM. Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19. PLoS One 2023; 18:e0291542. [PMID: 37713379 PMCID: PMC10503769 DOI: 10.1371/journal.pone.0291542] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/31/2023] [Indexed: 09/17/2023] Open
Abstract
Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians' involvement in patients' end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19's catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians' demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents' demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during "peak-Covid," and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53-7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18-0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22-0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care.
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Affiliation(s)
- Jennifer A. Palmer
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
| | - Megan Mccullough
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Medical Center, Bedford, Massachusetts, United States of America
- University of Massachusetts, Lowell, Massachusetts, United States of America
| | - Jolie Wormwood
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Medical Center, Bedford, Massachusetts, United States of America
- University of New Hampshire, Durham, New Hampshire, United States of America
| | - Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Nathan Mesfin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Michael Still
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Chris S. Xu
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Amy M. Linsky
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, United States of America
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Mesfin N, Wormwood J, Wiener RS, Still M, Xu CS, Palmer J, Linsky AM. Impact of the COVID-19 Pandemic on Providing Recommendations During Goals-of-Care Conversations: A Multisite Survey. J Palliat Med 2023; 26:951-959. [PMID: 36944150 PMCID: PMC10398728 DOI: 10.1089/jpm.2022.0394] [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] [Accepted: 01/05/2023] [Indexed: 03/23/2023] Open
Abstract
Background: Goals-of-care conversations (GoCCs) are essential for individualized end-of-life care. Shared decision-making (SDM) that elicits patients' goals and values to collaboratively make life sustaining treatment (LST) decisions is best practice. However, it is unknown how the COVID-19 pandemic onset and associated changes to care delivery, stress on providers, and clinical uncertainty affected SDM and recommendation-making during GoCCs. Aim: To assess providers' attitudes and behaviors related to GoCCs during the COVID-19 pandemic and identify factors associated with provision of LST recommendations. Design: Survey of United States Veterans Health Administration (VA) health care providers. Setting/Participants: Health care providers from 20 VA facilities with high COVID-19 caseloads early in the pandemic who had authority to place LST orders and practiced in select specialties (n = 3398). Results: We had 323 respondents (9.5% adjusted response rate). Most were age ≥50 years (51%), female (63%), non-Hispanic white (64%), and had ≥1 GoCC per week during peak-COVID-19 (78%). Compared with pre-COVID-19, providers believed it was less appropriate and felt less comfortable giving an LST recommendation during peak-COVID-19 (p < 0.001). One-third (32%) reported either "never" or "rarely" giving an LST recommendation during GoCCs at peak-COVID-19. In adjusted regression models, being a physician and discussing patients' goals and values were positively associated with giving an LST recommendation (B = 0.380, p = 0.031 and B = 0.400, p < 0.001, respectively) at peak-COVID-19. Conclusion: Providers who discuss patients' preferences and values are more likely to report giving a recommendation; both behaviors are markers of SDM during GoCCs. Our findings suggest potential areas for training in conducting patient-centered GoCCs.
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Affiliation(s)
- Nathan Mesfin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jolie Wormwood
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- University of New Hampshire, Durham, New Hampshire, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michael Still
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Chris S. Xu
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Jennifer Palmer
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Amy M. Linsky
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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Ajzenberg H, Dainty KN, O'Connor E. Recommendation-making in the emergency department: A qualitative study of how Canadian emergency physicians guide treatment decisions about resuscitation in critically ill patients. J Am Coll Emerg Physicians Open 2023; 4:e12962. [PMID: 37229184 PMCID: PMC10204169 DOI: 10.1002/emp2.12962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/06/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
Study Objective Emergency physicians are frequently responsible for making time-sensitive decisions around the provision of life-sustaining treatment. These decisions can involve goals of care or code status discussion, which will often substantially alter a patient's care pathway. A central part of these conversations that has received relatively little attention are recommendations for care. By proposing a best course of action or treatment via a recommendation, a clinician can ensure that their patients receive care that is concordant with their values. The objective of this study is to explore emergency physicians' attitudes toward recommendations about resuscitation in critically ill patients in the emergency department (ED). Methods We recruited Canadian emergency physicians via multiple recruitment strategies to ensure maximum variation sampling. Semi-structured qualitative interviews were conducted until thematic saturation occurred. Participants were asked about their perspectives and experiences with respect to recommendation-making in critically ill patients and to identify areas for improvement in this process in the ED. We used a qualitative descriptive approach and thematic analysis to identify themes around recommendation-making in the ED for critically ill patients. Results Sixteen emergency physicians agreed to participate. We identified four themes and multiple subthemes. Major themes included identification of the roles and responsibilities of the emergency physician (EP) with respect to making a recommendation, the logistics or process of making a recommendation, barriers to making a recommendation, and how to improve recommendation-making and goals of care conversations in the ED. Conclusion Emergency physicians provided a range of perspectives on the role of recommendation-making in critically ill patients in the ED. Several barriers to the inclusion of a recommendation were identified and many physicians provided ideas on how to improve goals of care conversations, the recommendation-making process, and ensure that critically ill patients receive care that is concordant with their values.
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Affiliation(s)
- Henry Ajzenberg
- Division of Emergency MedicineUniversity of TorontoTorontoOntarioCanada
| | - Katie N. Dainty
- North York General Hospital, Institute of Health Policy Management and EvaluationUniversity of TorontoTorontoOntarioCanada
| | - Erin O'Connor
- Divisions of Emergency Medicine and Palliative MedicineDepartment of MedicineUniversity of TorontoTorontoOntarioCanada
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Ge C, Goss AL, Crawford S, Goostrey K, Buddadhumaruk P, Shields AM, Hough CL, Lo B, Carson SS, Steingrub J, White DB, Muehlschlegel S. Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods Study. Crit Care Explor 2022; 4:e0640. [PMID: 35224505 PMCID: PMC8863127 DOI: 10.1097/cce.0000000000000640] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Withdrawal-of-life-sustaining treatments (WOLST) rates vary widely among critically ill neurologic patients (CINPs) and cannot be solely attributed to patient and family characteristics. Research in general critical care has shown that clinicians prognosticate to families with high variability. Little is known about how clinicians disclose prognosis to families of CINPs, and whether any associations exist with WOLST. OBJECTIVES Primary: to demonstrate feasibility of audio-recording clinician-family meetings for CINPs at multiple centers and characterize how clinicians communicate prognosis during these meetings. Secondary: to explore associations of 1) clinician, family, or patient characteristics with clinicians' prognostication approaches and 2) prognostication approach and WOLST. DESIGN SETTING AND PARTICIPANTS Forty-three audio-recorded clinician-family meetings during which prognosis was discussed from seven U.S. centers for 39 CINPs with 88 family members and 27 clinicians. MAIN OUTCOMES AND MEASURES Two investigators qualitatively coded transcripts using inductive methods (inter-rater reliability > 80%) to characterize how clinicians prognosticate. We then applied univariate and multivariable multinomial and binomial logistic regression. RESULTS Clinicians used four distinct prognostication approaches: Authoritative (21%; recommending treatments without discussing values and preferences); Informational (23%; disclosing just the prognosis without further discussions); advisory (42%; disclosing prognosis followed by discussion of values and preferences); and responsive (14%; eliciting values and preferences, then disclosing prognosis). Before adjustment, prognostication approach was associated with center (p < 0.001), clinician specialty (neurointensivists vs non-neurointensivists; p = 0.001), patient age (p = 0.08), diagnosis (p = 0.059), and meeting length (p = 0.03). After adjustment, only clinician specialty independently predicted prognostication approach (p = 0.027). WOLST decisions occurred in 41% of patients and were most common under the advisory approach (56%). WOLST was more likely in older patients (p = 0.059) and with more experienced clinicians (p = 0.07). Prognostication approach was not independently associated with WOLST (p = 0.198). CONCLUSIONS AND RELEVANCE It is feasible to audio-record sensitive clinician-family meetings about CINPs in multiple ICUs. We found that clinicians prognosticate with high variability. Our data suggest that larger studies are warranted in CINPs to examine the role of clinicians' variable prognostication in WOLST decisions.
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Affiliation(s)
- Connie Ge
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Adeline L Goss
- Department of Internal Medicine, Division of Neurology, Highland Hospital, Oakland, CA
| | - Sybil Crawford
- Department of Graduate School of Nursing, University of Massachusetts Tan Chingfen Graduate School of Nursing, Worcester, MA
| | - Kelsey Goostrey
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
| | | | - Anne-Marie Shields
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Catherine L Hough
- Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, Oregon Health Sciences University, Portland, OR
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Shannon S Carson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jay Steingrub
- Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
- Department of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, MA
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA
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Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol. Ann Am Thorac Soc 2021; 18:336-346. [PMID: 32936675 DOI: 10.1513/annalsats.202002-088sd] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).
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Harter TD, Sterenson EL, Borgert A, Rasmussen C. Perceptions of Medical Providers on Morality and Decision-Making Capacity in Withholding and Withdrawing Life-Sustaining Treatment and Suicide. AJOB Empir Bioeth 2021; 12:227-238. [PMID: 33719891 DOI: 10.1080/23294515.2021.1887961] [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: 10/21/2022]
Abstract
BACKGROUND This study attempts to understand if medical providers beliefs about the moral permissibility of honoring patient-directed refusals of life-sustaining treatment (LST) are tied to their beliefs about the patient's decision-making capacity. The study aims to answer: 1) does concern about a patient's treatment decision-making capacity relate to beliefs about whether it is morally acceptable to honor a refusal of LST, 2) are there differences between provider types in assessments of decision-making capacity and the moral permissibility to refuse LST, and 3) do provider demographics impact beliefs about decision-making capacity and the moral permissibility to refuse LST. Methods: A mixed-methods survey using Likert assessment and vignette-based questions was administered to medical providers within a single health system in the upper Midwest (N = 714) to assess their perspectives on the moral acceptance and decision-making capacity in cases of withholding and withdrawing treatment and suicide. Results: Behavioral health providers report accepting of the moral permissibility of suicide (91.2%) more than either medical providers (77.2%) or surgeons (74.4%) (n = 283). Decision-making capacity was questioned more in the vignettes of the patients refusing life-saving surgery (36%) and voluntarily starvation (40.8%) than in the vignette of the patient requesting to deactivate a pacemaker (13%) (n = 283). Behavioral health providers were more concerned about the capacity to refuse life-saving surgery (55.9%) than medical providers (33.8%) or surgeons (23.1%) (n = 283). Conclusions: Respondents endorse the moral permissibility of persons to withhold or withdraw from treatment regardless of motive. Clinical concerns about a patient's treatment decision-making capacity do not strongly correlate to views about the moral permissibility of honoring refusals of LST. Different provider types appear to have different thresholds for when to question treatment decision-making capacity. Behavioral health providers tend to question treatment decision-making capacity to refuse LST more than non-behavioral health providers.
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Affiliation(s)
- Thomas D Harter
- Department of Bioethics and Humanities, Gundersen Health System, La Crosse, Wisconsin, USA
| | - Erin L Sterenson
- Department of Psychiatry, Allina Health System, Minneapolis, Minnesota, USA
| | - Andrew Borgert
- Department of Medical Research, Gundersen Health System, La Crosse, Wisconsin, USA
| | - Cary Rasmussen
- Department of Medical Research, Gundersen Health System, La Crosse, Wisconsin, USA
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Vink EE, Azoulay E, Caplan A, Kompanje EJO, Bakker J. Time-limited trial of intensive care treatment: an overview of current literature. Intensive Care Med 2018; 44:1369-1377. [PMID: 30136140 DOI: 10.1007/s00134-018-5339-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 07/23/2018] [Indexed: 12/12/2022]
Abstract
In critically ill patients, it is frequently challenging to identify who will benefit from admission to the intensive care unit and life-sustaining interventions when the chances of a meaningful outcome are unclear. In addition, the acute illness not only affects the patients but also family members or surrogates who often are overwhelmed and unable to make thoughtful decisions. In these circumstances, a time-limited trial (TLT) of intensive care treatment can be helpful. A TLT is an agreement to initiate all necessary treatments or treatments with clearly delineated limitations for a certain period of time to gain a more realistic understanding of the patient's chances of a meaningful recovery or to ascertain the patient's wishes and values. In this article, we discuss current research on different aspects of TLTs in the intensive care unit. We propose how and when to use TLTs, discuss how much time should be taken for a TLT, give an overview of the potential impact of TLTs on healthcare resources, describe ethical challenges concerning TLTs, and discuss how to evaluate a TLT.
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Affiliation(s)
- Eva E Vink
- Department of Pulmonology and Critical Care, Langone Medical Center-Bellevue Hospital, New York University, New York, NY, USA.,Department of Intensive Care Adults, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Elie Azoulay
- Service de Reanimation Medicale, Hopital Saint-Louis et Universite Paris 7, Assistance Publique, Hospitaux de Paris, Paris, France
| | - Arthur Caplan
- Division of Medical Ethics, School of Medicine, New York University, New York, NY, USA
| | - Erwin J O Kompanje
- Department of Intensive Care Adults, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan Bakker
- Department of Pulmonology and Critical Care, Langone Medical Center-Bellevue Hospital, New York University, New York, NY, USA. .,Department of Intensive Care Adults, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Division of Pulmonary, Allergy and Critical Care, University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY, USA. .,Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile. .,Department of Pulmonary and Critical Care, New York University, 462 First avenue, New York, NY, 10016, USA.
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Suwanabol PA, Kanters AE, Reichstein AC, Wancata LM, Dossett LA, Rivet EB, Silveira MJ, Morris AM. Characterizing the Role of U.S. Surgeons in the Provision of Palliative Care: A Systematic Review and Mixed-Methods Meta-Synthesis. J Pain Symptom Manage 2018; 55:1196-1215.e5. [PMID: 29221845 DOI: 10.1016/j.jpainsymman.2017.11.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT The provision of palliative care varies appropriately by clinical factors such as patient age and severity of disease and also varies by provider practice and specialty. Surgical patients are persistently less likely to receive palliative care than their medical counterparts for reasons that are not clear. OBJECTIVES We sought to characterize surgeon-specific determinants of palliative care in seriously ill and dying patients. METHODS We performed a systematic review of the literature focused on surgery and palliative care within PubMed, CINAHL, EMBASE, Scopus, and Ovid Medline databases from January 1, 2000 through December 31, 2016 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quantitative and qualitative studies with primary data evaluating surgeons' attitudes, knowledge, and behaviors or experiences in care for seriously ill and dying patients were selected for full review by at least two study team members based on predefined inclusion criteria. Data were extracted based on a predetermined instrument and compared across studies using thematic analysis in a meta-synthesis of qualitative and quantitative findings. RESULTS A total of 2589 abstracts were identified and screened, and 35 articles (26 quantitative and nine qualitative) fulfilled criteria for full review. Among these, 17 articles explored practice and attitudes of surgeons regarding palliative and end-of-life care, 11 articles assessed training in palliative care, five characterized surgical decision making, one described behaviors of surgeons caring for seriously ill and dying patients, and one explicitly identified barriers to use of palliative care. Four major themes across studies affected receipt of palliative care for surgical patients: 1) surgeons' experience and knowledge, 2) surgeons' attitudes, 3) surgeons' preferences and decision making for treatment, and 4) perceived barriers. CONCLUSIONS Among the articles reviewed, surgeons overall demonstrated insight into the benefits of palliative care but reported limited knowledge and comfort as well as a multitude of challenges to introducing palliative care to their patients. These findings indicate a need for wider implementation of strategies that allow optimal integration of palliative care with surgical decision making.
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Affiliation(s)
| | - Arielle E Kanters
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ari C Reichstein
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Lauren M Wancata
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily B Rivet
- Department of Surgery and Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Maria J Silveira
- Department of Surgery, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Arden M Morris
- S-SPIRE Center and Department of Surgery, Stanford University, Stanford, California, USA
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11
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Rationale and Design of the Randomized Evaluation of Default Access to Palliative Services (REDAPS) Trial. Ann Am Thorac Soc 2018; 13:1629-39. [PMID: 27348271 DOI: 10.1513/annalsats.201604-308ot] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The substantial nationwide investment in inpatient palliative care services stems from their great promise to improve patient-centered outcomes and reduce costs. However, robust experimental evidence of these benefits is lacking. The Randomized Evaluation of Default Access to Palliative Services (REDAPS) study is a pragmatic, stepped-wedge, cluster randomized trial designed to test the efficacy and costs of specialized palliative care consultative services for hospitalized patients with advanced chronic obstructive pulmonary disease, dementia, or end-stage renal disease, as well as the overall effectiveness of ordering such services by default. Additional aims are to identify the types of services that are most beneficial and the types of patients most likely to benefit, including comparisons between ward and intensive care unit patients. We hypothesize that patient-centered outcomes can be improved without increasing costs by simply changing the default option for palliative care consultation from opt-in to opt-out for patients with life-limiting illnesses. Patients aged 65 years or older are enrolled at 11 hospitals using an integrated electronic health record. As a pragmatic trial designed to enroll between 12,000 and 15,000 patients, eligibility is determined using a validated, electronic health record-based algorithm, and all outcomes are captured via the electronic health record and billing systems data. The time at which each hospital transitions from control, opt-in palliative care consultation to intervention, opt-out consultation is randomly assigned. The primary outcome is a composite measure of in-hospital mortality and length of stay. Secondary outcomes include palliative care process measures and clinical and economic outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT02505035).
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Berger JT. The Limits of Surrogates’ Moral Authority and Physician Professionalism:Can the Paradigm of Palliative Sedation Be Instructive? Hastings Cent Rep 2017; 47:20-23. [DOI: 10.1002/hast.665] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Prochaska MT, Sulmasy DP. Recommendations to Surrogates at the End of Life: A Critical Narrative Review of the Empirical Literature and a Normative Analysis. J Pain Symptom Manage 2015; 50:693-700. [PMID: 26025276 DOI: 10.1016/j.jpainsymman.2015.05.004] [Citation(s) in RCA: 7] [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: 12/19/2014] [Revised: 05/11/2015] [Accepted: 05/21/2015] [Indexed: 11/17/2022]
Abstract
Physician recommendations have historically been a part of shared decision making. Recent literature has challenged the idea that physician recommendations should be part of shared decision making at the end of life, particularly the making of recommendations to surrogates of incapacitated patients. Close examination of the studies and the available data on surrogate preferences for decisional authority at the end of life, however, provide an empirical foundation for a style of shared decision making that includes a physician recommendation. Moreover, there are independent ethical reasons for arguing that physician recommendations enhance rather than detract from shared decision making.
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Affiliation(s)
- Micah T Prochaska
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Daniel P Sulmasy
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA; MacLean Center for Clinical and Medical Ethics, The University of Chicago, Chicago, Illinois, USA; The Divinity School, The University of Chicago, Chicago, Illinois, USA.
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Rousseau A, Rozenberg P, Ravaud P. Assessing Complex Emergency Management with Clinical Case-Vignettes: A Validation Study. PLoS One 2015; 10:e0138663. [PMID: 26383261 PMCID: PMC4575125 DOI: 10.1371/journal.pone.0138663] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 09/02/2015] [Indexed: 12/31/2022] Open
Abstract
Objective To evaluate whether responses to dynamic case-vignettes accurately reflect actual practices in complex emergency situations. We hypothesized that when obstetricians were faced with vignette of emergency situation identical to one they previously managed, they would report the management strategy they actually used. On the other hand, there is no reason to suppose that their response to a vignette based on a source case managed by another obstetrician would be the same as the actual management. Methods A multicenter vignette-based study was used in 7 French maternity units. We chose the example of severe postpartum hemorrhage (PPH) to study the use of case-vignettes for assessing the management of complex situations. We developed dynamic case-vignettes describing incidents of PPH in several steps, using documentation in patient files. Vignettes described the postpartum course and included multiple-choice questions detailing proposed clinical care. Each participating obstetrician was asked to evaluate 4 case-vignettes: 2 directly derived from cases they previously managed and 2 derived from other obstetricians’ cases. We compared the final treatment decision in vignette responses to those documented in the source-case by the overall agreement and the Kappa coefficient, both for the cases the obstetricians previously managed and the cases of others. Results Thirty obstetricians participated. Overall agreement between final treatment decisions in case-vignettes and documented care for cases obstetricians previously managed was 82% (Kappa coefficient: 0.75, 95% CI [0.62–0.88]). Overall agreement between final treatment decisions in case-vignettes and documented care in vignettes derived from other obstetricians’ cases was only 48% (Kappa coefficient: 0.30, 95% CI [0.12–0.48]). Final agreement with documented care was significantly better for cases based on their own previous cases than for others (p<0.001). Conclusions Dynamic case-vignettes accurately reflect actual practices in complex emergency situations. Therefore, they can be used to assess the quality of management in these situations.
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Affiliation(s)
- Anne Rousseau
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
- INSERM U1153 Research Unit, Paris Descartes-Sorbonne Paris Cité University, Paris, France
- * E-mail:
| | - Patrick Rozenberg
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
- Research unit EA 7285, Versailles-St Quentin University, Saint Quentin en Yvelines, France
| | - Philippe Ravaud
- INSERM U1153 Research Unit, Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre d’Epidémiologie Clinique, Hôpital Hôtel-Dieu, Paris, France
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Halpern SD, Becker D, Curtis JR, Fowler R, Hyzy R, Kaplan LJ, Rawat N, Sessler CN, Wunsch H, Kahn JM. An Official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine Policy Statement: The Choosing Wisely® Top 5 List in Critical Care Medicine. Am J Respir Crit Care Med 2014; 190:818-26. [DOI: 10.1164/rccm.201407-1317st] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Contrasting patient, family, provider, and societal goals at the end of life complicate decision making and induce variability of care after trauma. J Trauma Acute Care Surg 2014; 77:262-7. [PMID: 25058252 DOI: 10.1097/ta.0000000000000304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND End-of-life (EoL) decision making during critical illness and injury is important in facilitating compassionate care that is congruent with patient, family, and societal expectations. Herein, we evaluate factors that may effect and induce variability in practitioner EoL decision making, particularly years in practice, use of advance directives (ADs), and cost. METHODS An anonymous, online survey was offered to all active members of the Eastern Association for the Surgery of Trauma (n = 1,359) in June 2012. Demographic information and a series of questions dealing with common potentially influential factors were included. Responses were 5-point Likert scale based. RESULTS A total of 375 responses (27.6%) were received. Ninety-two percent of the respondents were physicians, 70% were male, and 77% were from Level 1 trauma centers. Of respondents, 65.8% rely on family to make EoL decisions most or all of the time, while 80.7% feel family members are rarely or only sometimes in appropriate emotional states to make such choices. A significant number of practitioners felt comfortable making decisions without family input at all, more so with experienced practitioners as compared with those in practice for less than 15 years (38.2% and 24.1% respectively, p < 0.01).Of the practitioners, 59.6% rely on ADs most or all of the time, only 61.1% agree or strongly agree that ADs are useful, and only 56.3% feel families follow their loved one's ADs most or all of the time. A patient's family support or ability to pay for aftercare was rarely or never considered important by 80.1% of the practitioners, despite 85.1% reporting that quality of life postillness/injury was important most or all of the time. CONCLUSION Practitioner comfort and motivation to influence EoL decision making varies with experience level. ADs are not uniformly perceived to be helpful, and costs are uncommonly considered. To improve EoL quality, these factors need to be considered. LEVEL OF EVIDENCE Care management study, level IV.
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Abstract
PURPOSE OF REVIEW Decisions to limit life-sustaining therapy (DLLST) in the ICU are used to uphold patients' autonomy, protect them from non-beneficial treatment and fairly distribute resources. The institution of these decisions is complex, with a variety of qualitative and quantitative data published. This review aims to summarize the main issues and review the contemporary research findings on this subject. RECENT FINDINGS DLLST are used in a variety of clinical and non-clinical situations, before and after ICU admission, and are not always part of end-of-life management. There are many dilemmas and barriers that beset their institution. Many ICU physicians feel inadequately trained to carry them out and they are frequently a source of conflict. A variety of strategies have been examined to improve their institution, including advanced directives, intensive communication strategies and family information leaflets, many of which have improved patient and family-centred outcomes. SUMMARY There are a number of uncertainties that beset the institution of DLLST in the ICU; however, a variety of research has improved our ability to understand and implement them. This review frames some of the dilemmas and discusses some of the procedural strategies that have been used to improve outcomes.
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Affiliation(s)
- Deborah Cook
- From the Departments of Medicine, Clinical Epidemiology, and Biostatistics, McMaster University, Hamilton, ON (D.C.), and the Department of Medicine, Dalhousie University, Halifax, NS (G.R.) - both in Canada
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Shah RD, Rasinski KA, Alexander GC. The Influence of Surrogate Decision Makers on Clinical Decision Making for Critically Ill Adults. J Intensive Care Med 2013; 30:278-85. [PMID: 24362444 DOI: 10.1177/0885066613516597] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 10/22/2013] [Indexed: 11/15/2022]
Abstract
PURPOSE Intensive care unit patients rarely have decisional capacity and often surrogates make clinical decisions on their behalf. Little is known about how surrogate characteristics may influence end-of-life decision making for these patients. This study sought to determine how surrogate characteristics impact physicians' approach to end-of-life decision making. METHODS From March 2011 to August 2011, a survey was fielded to 1000 randomly sampled critical care physicians using a modified Dillman approach. The survey included a hypothetical vignette to examine how physicians' approach varied based on patient age, patient-surrogate relationship, surrogate-staff relationship, basis for surrogate's stated preferences, and surrogate's understanding of patient's condition. Outcomes included physicians' beliefs regarding (1) appropriateness of cardiopulmonary resuscitation (CPR); (2) appropriate locus of decision making for the patient; (3) degree to which a physician would try to influence a surrogate if disagreement was present; and (4) physician strategies to discussing end-of-life with surrogates. RESULTS Of 922 eligible physicians, 608 (66%) participated. Across all vignettes, CPR was felt to be less appropriate and surrogates less likely to be given priority with an older rather than younger patient (15% vs 63% and 50% vs 65%, both P values <.001). Cardiopulmonary resuscitation was considered less appropriate when the surrogate-patient relationship was not close (34% vs 44%, P = .03) and the surrogate's understanding was poor (34% vs 43%, P = .05). No other surrogate characteristics examined yielded statistically significant associations. CONCLUSION Some surrogate characteristics may modify clinicians' beliefs and practices regarding end-of-life care, suggesting the nuances of the surrogate-physician relationship and clinical decision making for critically ill patients.
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Affiliation(s)
- Raj D Shah
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - Kenneth A Rasinski
- Chicago Consortium for School Research, University of Chicago, Chicago, IL, USA
| | - G Caleb Alexander
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Department of Medicine, Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD, USA Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Department of Pharmacy Practice, University of Illinois at Chicago School of Pharmacy, Chicago, IL, USA
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The luck of the draw: physician-related variability in end-of-life decision-making in intensive care. Intensive Care Med 2013; 39:1128-32. [DOI: 10.1007/s00134-013-2871-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 02/02/2013] [Indexed: 10/27/2022]
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Recent Literature Feature Editor: Paul C. Rousseau. J Palliat Med 2013. [DOI: 10.1089/jpm.2013.9526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Recent Literature Feature Editor: Paul C. Rousseau. J Palliat Med 2013. [DOI: 10.1089/jpm.2013.9533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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