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Mead G. Shared decision making in older people after severe stroke. Age Ageing 2024; 53:afae017. [PMID: 38364821 DOI: 10.1093/ageing/afae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Indexed: 02/18/2024] Open
Abstract
Stroke is a major cause of death and lifelong disability. Although stroke treatments have improved, many patients are left with life-changing deficits. Shared decision making and consent are fundamental to good medical practice. This is challenging because stroke often causes mental incapacity, prior views might not be known and prognosis early after stroke is often uncertain. There are no large trials of shared decision making after severe stroke, so we need to rely on observational data to inform practice. Core ethical principles of autonomy, beneficence, non-maleficence and justice must underpin our decision making. 'Surrogate' decision makers will need to be involved if a patient lacks capacity, and prior expressed views and values and beliefs need to be taken into account in decision making. Patients and surrogates often feel shocked at the sudden nature of stroke, and experience grief including anticipatory grief. Health care professionals need to acknowledge these feelings and provide support, be clear about what decisions need to be made and provide sufficient information about the stroke, and the risks and benefits of treatments being considered. Shared decision making can be emotionally difficult for health care professionals and so working in a supportive environment with compassionate leadership is important. Further research is needed to better understand the nature of grief and what sort of psychological support would be most helpful. Large randomised trials of shared decision making are also needed.
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Affiliation(s)
- Gillian Mead
- Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh EH16 4SA, UK
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McGlinchey MP, Faulkner-Gurstein R, Sackley CM, McKevitt C. Factors guiding therapist decision making in the rehabilitation of physical function after severely disabling stroke - an ethnographic study. Disabil Rehabil 2024; 46:672-684. [PMID: 36734838 DOI: 10.1080/09638288.2023.2172463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 01/20/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Whilst strong evidence supports rehabilitation to improve outcomes post-stroke, there is limited evidence to guide rehabilitation in the most severely disabled group. In an era of evidence-based practice, the aim of the study was to understand what factors guide physiotherapists (PTs) and occupational therapists (OTs) to select particular interventions in the rehabilitation of physical function after severely disabling stroke. MATERIAL AND METHODS An ethnographic study was undertaken over an 18-month period involving five London, UK stroke services. Seventy-nine primary participants (30 PTs, 22 OTs, and 27 stroke survivors) were recruited to the study. Over 400 h of observation, 52 semi-structured interviews were conducted. Study data were analysed through thematic analysis. RESULTS Key factors guiding therapist decision making were clinical expertise, professional role, stroke survivors' clinical presentation, therapist perspectives about stroke recovery, and clinical guidelines. Research evidence, stroke survivors' treatment preferences, organisational type, and pathway design were less influential factors. Therapy practice did not always address the physical needs of severely disabled stroke survivors. CONCLUSIONS Multiple factors guided therapist decision making after severely disabling stroke. Alternative ways of therapist working should be considered to address the physical needs of severely disabled stroke survivors more fully.Implications for rehabilitationMultiple factors guide therapist decision making after severely disabling stroke, some of which result in the use of interventions that do not fully address stroke survivors' clinical needs.Therapists should critically reflect upon their personal beliefs and attitudes about severely disabling stroke to reduce potential sources of bias on decision making.Therapists should consider the timing and intensity of therapy delivery as well as their treatment approach to optimise outcomes after severely disabling stroke.
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Affiliation(s)
- Mark P McGlinchey
- Neurorehabilitation Service, Integrated Local Services, Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Rachel Faulkner-Gurstein
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Catherine M Sackley
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Christopher McKevitt
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Bainbridge L, Briffa K, Burton E, Hill KD, Fary R. Physiotherapists' decision-making about transition to independent walking in hospital after stroke: a qualitative study. Disabil Rehabil 2023:1-9. [PMID: 37578096 DOI: 10.1080/09638288.2023.2245757] [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: 02/28/2023] [Revised: 07/30/2023] [Accepted: 08/03/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE Physiotherapists working in hospitals have a key role in decisions about when a person with stroke is safe to walk independently. The aim of this study was to explore the factors influencing decision-making of physiotherapists in this situation. METHODS A qualitative design with semi-structured interviews and reflexive thematic analysis was used. Fifteen physiotherapists with recent experience working in inpatient stroke rehabilitation participated. RESULTS Multiple factors influence decision-making about walking independence after stroke in hospitals. Four themes were identified: (1) Assessment of walking safety involves observation of walking function and consideration of complex individual factors; (2) Perspectives on risk vary, and influence whether a person is considered safe to walk; (3) Institutional culture involves background pressures that may influence decision-making; and (4) Physiotherapists adopt a structured, individualised mobility progression to manage risk. Physiotherapists consistently use observation of walking and understanding of attention and perception in this decision-making. There can sometimes be a conflict between goals of independence and of risk avoidance, and decisions are made by personal judgements. CONCLUSIONS Decision-making about independent walking for people in a hospital after a stroke is complex. Improved guidance about clinical assessment of capacity and determining acceptable risk may enable physiotherapists to engage more in shared decision-making.IMPLICATIONS FOR REHABILITATIONRegaining independence in walking after a stroke comes with the potential risk of falls.Assessment of walking safety should be specific to the complexity of the situation and consider perception and cognition.Benefits of activity and autonomy, and the risk of falls need to be considered in decisions about walking independence.Patients with the capacity to understand consequences and accept risk can be active participants in determining what is sufficiently safe.
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Affiliation(s)
- Liz Bainbridge
- Curtin School of Allied Health, Curtin University, Perth, Australia
| | - Kathy Briffa
- Curtin School of Allied Health, Curtin University, Perth, Australia
| | - Elissa Burton
- Curtin School of Allied Health, Curtin University, Perth, Australia
- enAble Institute, Curtin University, Perth, Australia
| | - Keith D Hill
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, Monash University, Melbourne, Australia
| | - Robyn Fary
- Curtin School of Allied Health, Curtin University, Perth, Australia
- enAble Institute, Curtin University, Perth, Australia
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Diegoli H, Magalhães PSC, Makdisse MRP, Moro CHC, França PHC, Lange MC, Longo AL. Real-World Populational-Based Quality of Life and Functional Status After Stroke. Value Health Reg Issues 2023; 36:76-82. [PMID: 37054502 DOI: 10.1016/j.vhri.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/24/2022] [Accepted: 02/14/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVES This study aimed to describe health-related quality of life (HRQoL) 3 months and 1 year after stroke, compare HRQoL between dependent (modified Rankin scale [mRS] 3-5) and independent (mRS 0-2) patients, and identify factors predictive of poor HRQoL. METHODS Patients with a first ischemic stroke or intraparenchymal hemorrhage from the Joinville Stroke Registry were analyzed retrospectively. Using the 5-level version of the EuroQol-5D questionnaire, HRQoL was calculated for all patients 3 months and 1 year after stroke, stratified by mRS score (0-2 or 3-5). One-year HRQoL predictors were examined using univariate and multivariate analyses. RESULTS Three months after a stroke, data from 884 patients were analyzed; 72.8% were categorized as mRS 0-2 and 27.2% as mRS 3-5, and the mean HRQoL was 0.670 ± 0.256. At 1-year follow-up, 705 patients were evaluated; 75% were classified as mRS 0-2 and 25% as mRS 3-5, and the mean HRQoL was 0.71 ± 0.249. An increase in HRQoL was observed between 3 months and 1 year (mean difference 0.024, P < .0001), both in patients with 3-month mRS 0-2 (0.013, P = .027) and mRS 3-5 (0.052, P < .0001). Increasing age, female sex, hypertension, diabetes, and a high mRS were associated with poor HRQoL at 1 year. CONCLUSIONS This study described the HRQoL after a stroke in a Brazilian population. This analysis shows that the mRS was highly associated with HRQoL after stroke. Age, sex, diabetes, and hypertension were also associated with HRQoL, although not independently of mRS.
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Affiliation(s)
| | | | | | - Carla H C Moro
- Joinville Stroke Registry, City Hall of Joinville, Joinville, SC, Brazil
| | - Paulo H C França
- Post-Graduation Program in Health and Environment, University of the Region of Joinville, Joinville, SC, Brazil
| | - Marcos C Lange
- Federal University of Paraná, Clinical Hospital, Curitiba, PR, Brazil
| | - Alexandre L Longo
- Joinville Stroke Registry, City Hall of Joinville, Joinville, SC, Brazil
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Schuster L, Essig F, Daneshkhah N, Herm J, Hellwig S, Endres M, Dirnagl U, Hoffmann F, Michalski D, Pfeilschifter W, Urbanek C, Petzold GC, Rizos T, Kraft A, Haeusler KG. Ability of patients with acute ischemic stroke to recall given information on intravenous thrombolysis: Results of a prospective multicenter study. Eur Stroke J 2023; 8:241-250. [PMID: 37021170 PMCID: PMC10069168 DOI: 10.1177/23969873221143856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/20/2022] [Indexed: 01/09/2023] Open
Abstract
Introduction: Intravenous thrombolysis (IVT) is an on label treatment for selected patients with acute ischemic stroke (AIS). As major bleeding or allergic shock may occur, the need to ensure patients’ informed consent for IVT is a matter of debate. Patients and methods: Prospective investigator-initiated multi-center observational study to assess the ability of AIS patients to recall information, provided by a physician during a standardized educational talk (SET) on IVT use. The recall of 20 pre-defined items was assessed in AIS after 60–90 min ( n = 93) or 23–25 h ( n = 40) after SET. About 40 patients with subacute stroke, 40 non-stroke patients, and 23 relatives of AIS patients served as controls, and were surveyed 60–90 min after SET. Results: Within 60–90 min after SET, AIS patients (median age 70 years, 31% female, median NIHSS score on admission 3 points) who were considered capable to provide informed consent recalled 55% (IQR 40%–66.7%) of the provided SET items. In multivariable linear regression analysis recapitulation by AIS patients was associated with their educational level (β = 6.497, p < 0.001), self-reported excitement level (β = 1.879, p = 0.011) and NIHSS score on admission (β = −1.186, p = 0.001). Patients with subacute stroke (70 years, 40% female, median NIHSS = 2) recalled 70% (IQR 55.7%–83.6%), non-stroke patients (75 years, 40% female) 70% (IQR 60%–78.7%), and AIS relatives (58 years, 83% female) 70% (IQR 60%–85%). Compared to subacute stroke patients, AIS patients less often recalled the frequency of IVT-related bleeding (21% vs 43%), allergic shock (15% vs 39%), and bleeding-related morbidity and mortality (44% vs 78%). AIS patients recalled 50% (IQR 42.3%–67.5%) of the provided items 23–25 h after SET. Conclusion: AIS patients eligible for IVT remember about half of all SET-items after 60–90 min or 23–25 h, respectively. The fact that the recapitulation of IVT-associated risks is particularly poor should be given special consideration.
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Affiliation(s)
- Luzie Schuster
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Fabian Essig
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Naeimeh Daneshkhah
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Juliane Herm
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Germany
| | - Simon Hellwig
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany
| | - Ulrich Dirnagl
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- QUEST Center, Berlin Institute of Health (BIH), Berlin, Germany
| | - Frank Hoffmann
- Department of Neurology, Martha-Maria Hospital, Halle/Saale, Germany
| | | | - Waltraud Pfeilschifter
- Department of Neurology, University of Frankfurt, Frankfurt/Main, Germany
- Department of Neurology, Hospital Lüneburg, Lüneburg, Germany
| | - Christian Urbanek
- Department of Neurology, Hospital Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University of Bonn, Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Timolaos Rizos
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Andrea Kraft
- Department of Neurology, Martha-Maria Hospital, Halle/Saale, Germany
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Hou T, Qiao W, Song S, Guan Y, Zhu C, Yang Q, Gu Q, Sun L, Liu S. The Use of Machine Learning Techniques to Predict Deep Vein Thrombosis in Rehabilitation Inpatients. Clin Appl Thromb Hemost 2023; 29:10760296231179438. [PMID: 37365805 DOI: 10.1177/10760296231179438] [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: 06/28/2023] Open
Abstract
BACKGROUND Rehabilitation is crucial to recovering patients' dysfunction, improving their life quality, and promoting an early return to their family and society. In China, most patients in rehabilitation units are patients transferred from neurology, neurosurgery, and orthopedics, and most of these patients face problems such as continuously bedridden or varying degrees of limb dysfunction, all of which are risk factors for deep venous thrombosis. The formation of deep venous thrombosis can delay the recovery process and result in significant morbidity, mortality, and higher healthcare costs, so early detection and individualized treatment are needed. Machine learning algorithms can help develop more precise prognostic models, which can be of great significance in the development of rehabilitation training programs. In this study, we aimed to develop a model of deep venous thrombosis for inpatients in the Department of Rehabilitation Medicine at the Affiliated Hospital of Nantong University using machine learning methods. METHODS We analyzed and compared 801 patients in the Department of Rehabilitation Medicine using machine learning. Support vector machine, logistic regression, decision tree, random forest classifier, and artificial neural network were used to build models. RESULTS Artificial neural network was the better predictor than other traditional machine learnings. D-dimer levels, bedridden time, Barthel Index, and fibrinogen degradation products were common predictors of adverse outcomes in these models. CONCLUSIONS Risk stratification can help healthcare practitioners to achieve improvements in clinical efficiency and specify appropriate rehabilitation training programs.
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Affiliation(s)
- Tingting Hou
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Graduate School of Dalian Medical University, Dalian, Liaoning Province, China
| | - Wei Qiao
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Graduate School of Dalian Medical University, Dalian, Liaoning Province, China
| | - Sijin Song
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Graduate School of Dalian Medical University, Dalian, Liaoning Province, China
| | - Yingchao Guan
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Graduate School of Dalian Medical University, Dalian, Liaoning Province, China
| | - Chunyang Zhu
- School of Sciences, Nantong University, Nantong, Jiangsu Province, China
| | - Qing Yang
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Graduate School of Dalian Medical University, Dalian, Liaoning Province, China
| | - Qi Gu
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong, China
| | - Li Sun
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong, China
| | - Su Liu
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong, China
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7
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Prick JCM, Zonjee VJ, van Schaik SM, Dahmen R, Garvelink MM, Brouwers PJAM, Saxena R, Keus SHJ, Deijle IA, van Uden-Kraan CF, van der Wees PJ, Van den Berg-Vos RM. Experiences with information provision and preferences for decision making of patients with acute stroke. PATIENT EDUCATION AND COUNSELING 2022; 105:1123-1129. [PMID: 34462248 DOI: 10.1016/j.pec.2021.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/23/2021] [Accepted: 08/21/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The aim of this study was to gain insight into experiences of patients with acute stroke regarding information provision and their preferred involvement in decision-making processes during the initial period of hospitalisation. METHODS A sequential explanatory design was used in two independent cohorts of patients with stroke, starting with a survey after discharge from hospital (cohort 1) followed by observations and structured interviews during hospitalisation (cohort 2). Quantitative data were analysed descriptively. RESULTS In total, 72 patients participated in this study (52 in cohort 1 and 20 in cohort 2). During hospitalisation, the majority of the patients were educated about acute stroke and their treatment. Approximately half of the patients preferred to have an active role in the decision-making process, whereas only 21% reported to be actively involved. In cohort 2, 60% of the patients considered themselves capable to carefully consider treatment options. CONCLUSIONS Active involvement in the acute decision-making process is preferred by approximately half of the patients with acute stroke and most of them consider themselves capable of doing so. However, they experience a limited degree of actual involvement. PRACTICE IMPLICATIONS Physicians can facilitate patient engagement by explicitly emphasising when a decision has to be made in which the patient's opinion is important.
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Affiliation(s)
- J C M Prick
- Department of Neurology, OLVG, Amsterdam, The Netherlands; Santeon, Utrecht, The Netherlands.
| | - V J Zonjee
- Department of Neurology, OLVG, Amsterdam, The Netherlands
| | - S M van Schaik
- Department of Neurology, OLVG, Amsterdam, The Netherlands
| | - R Dahmen
- Amsterdam Rehabilitation Research Center/Reade, Amsterdam, The Netherlands
| | - M M Garvelink
- Department of Value Based Healthcare, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - P J A M Brouwers
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - R Saxena
- Department of Neurology, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - S H J Keus
- Department of Quality and Improvement, OLVG, Amsterdam, The Netherlands
| | - I A Deijle
- Department of Quality and Improvement, OLVG, Amsterdam, The Netherlands
| | | | - P J van der Wees
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R M Van den Berg-Vos
- Department of Neurology, OLVG, Amsterdam, The Netherlands; Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
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Deutsch JE, Gill-Body KM, Schenkman M. Updated Integrated Framework for Making Clinical Decisions Across the Lifespan and Health Conditions. Phys Ther 2022; 102:6497836. [PMID: 35079823 DOI: 10.1093/ptj/pzab281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 09/16/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022]
Abstract
The updated Integrated Framework for Clinical Decision Making responds to changes in evidence, policy, and practice since the publication of the first version in 2008. The original framework was proposed for persons with neurological health conditions, whereas the revised framework applies to persons with any health condition across the lifespan. In addition, the revised framework (1) updates patient-centered concepts with shared clinical decision-making; (2) frames the episode of care around the patient's goals for participation; (3) explicitly describes the role of movement science; (4) reconciles movement science and International Classification of Function language, illustrating the importance of each perspective to patient care; (5) provides a process for movement analysis of tasks; and (6) integrates the movement system into patient management. Two cases are used to illustrate the application of the framework: (1) a 45-year-old male bus driver with low back pain whose goals for the episode of care are to return to work and recreational basketball; and (2) a 65-year-old female librarian with a fall history whose goals for the episode of care are to return to work and reduce future falls. The framework is proposed as a tool for physical therapist education and to guide clinical practice for all health conditions across the lifespan.
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Affiliation(s)
- Judith E Deutsch
- Rivers Lab, Department of Rehabilitation and Movement Science, School of Health Professions, Rutgers University, Newark, New Jersey, USA
| | | | - Margaret Schenkman
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Sugimori H, Mori K, Yasaka M. [Antithrombotic therapy considering risk of falls and bleeding in the elderly]. Nihon Ronen Igakkai Zasshi 2022; 59:305-311. [PMID: 36070904 DOI: 10.3143/geriatrics.59.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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10
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Gaboury I, Tousignant M, Corriveau H, Menear M, Le Dorze G, Rochefort C, Vachon B, Rochette A, Gosselin S, Michaud F, Bollen J, Dean S. Effects of Telerehabilitation on Patient Adherence to a Rehabilitation Plan: Protocol for a Mixed Methods Trial. JMIR Res Protoc 2021; 10:e32134. [PMID: 34709196 PMCID: PMC8587325 DOI: 10.2196/32134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/03/2021] [Accepted: 09/03/2021] [Indexed: 01/30/2023] Open
Abstract
Background Strong evidence supports beginning stroke rehabilitation as soon as the patient’s medical status has stabilized and continuing following discharge from acute care. However, adherence to rehabilitation treatments over the rehabilitation phase has been shown to be suboptimal. Objective The aim of this study is to assess the impact of a telerehabilitation platform on stroke patients’ adherence to a rehabilitation plan and on their level of reintegration into normal social activities, in comparison with usual care. The primary outcome is patient adherence to stroke rehabilitation (up to 12 weeks), which is hypothesized to influence reintegration into normal living. Secondary outcomes for patients include functional recovery and independence, depression, adverse events related to telerehabilitation, use of services (up to 6 months), perception of interprofessional shared decision making, and quality of services received. Interprofessional collaboration as well as quality of interprofessional shared decision making will be measured with clinicians. Methods In this interrupted time series with a convergent qualitative component, rehabilitation teams will be trained to develop rehabilitation treatment plans that engage the patient and family, while taking advantage of a telerehabilitation platform to deliver the treatment. The intervention will be comprised of 220 patients who will take part in stroke telerehabilitation with an interdisciplinary group of clinicians (telerehabilitation group) versus face-to-face standard of care (control group: n=110 patients). Results Our Research Ethics Board approved the study in June 2020. Data collection for the control group is underway, with another year planned before we begin the intervention phase. Conclusions This study will contribute to the minimization of both knowledge and practice gaps, while producing robust, in-depth data on the factors related to the effectiveness of telerehabilitation in a stroke rehabilitation continuum. Findings will inform best practice guidelines regarding telecare services and the provision of telerehabilitation, including recommendations for effective interdisciplinary collaboration regarding stroke rehabilitation. Trial Registration ClinicalTrials.gov NCT04440215; https://clinicaltrials.gov/ct2/show/NCT04440215 International Registered Report Identifier (IRRID) DERR1-10.2196/32134
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Affiliation(s)
- Isabelle Gaboury
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Longueuil, QC, Canada
| | - Michel Tousignant
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Hélène Corriveau
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Matthew Menear
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Guylaine Le Dorze
- School of Audiology and Speech Therapy, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Christian Rochefort
- School of Nursing, Faculty of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Brigitte Vachon
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Annie Rochette
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, QC, Canada
| | - Sylvie Gosselin
- Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - François Michaud
- Department of Electrical and Computer Engineering, Faculty of Engineering, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jessica Bollen
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
| | - Sarah Dean
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
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Mc Lernon S, Werring D, Terry L. Clinicians' Perceptions of the Appropriateness of Neurocritical Care for Patients with Spontaneous Intracerebral Hemorrhage (ICH): A Qualitative Study. Neurocrit Care 2021; 35:162-171. [PMID: 33263147 PMCID: PMC7707900 DOI: 10.1007/s12028-020-01145-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/30/2020] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Clinicians working in intensive care frequently report perceptions of inappropriate care (PIC) situations. Intracerebral haemorrhage (ICH) is associated with high rates of mortality and morbidity. Prognosticating after ICH is complex and may be influenced by clinicians' subjective impressions and biases, which may, in turn, influence decision making regarding the level of care provided. The aim of this study was to qualitatively explore perceptions of neurocritical care in relation to the expected functional outcome for ICH patients. DESIGN Qualitative study using semi-structured interviews with neurocritical care doctors and nurses. SETTING Neurocritical care (NCC) department in a UK neuroscience tertiary referral center. SUBJECTS Eleven neurocritical care nurses, five consultant neurointensivists, two stroke physicians, three neurosurgeons. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS We conducted 21 semi-structured interviews and identified five key themes: (1) prognostic uncertainty (2) subjectivity of good versus poor outcome (3) perceived inappropriate care (PIC) situations (including for frail elderly patients) (4) challenging nature of decision-making (5) clinician distress. CONCLUSIONS Caring for severely affected ICH patients in need of neurocritical care is challenging, particularly with frail elderly patients. Awareness of the challenges could facilitate interventions to improve decision-making for this group of stroke patients and their families, as well as measures to reduce the distress on clinicians who care for this patient group. Our findings highlight the need for effective interdisciplinary shared decision making involving the family, taking into account patients' previously expressed values and preferences and incorporating these into bespoke care planning.
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Affiliation(s)
- Siobhan Mc Lernon
- School of Health and Social Care, London South Bank University, 103 Borough Road, London, SE1 OAA UK
| | - David Werring
- Stroke Research Centre, UCL Institute of Neurology, First Floor, Russell Square House, 10-12 Russell Square, London, WC1B 5EH UK
| | - Louise Terry
- School of Health and Social Care, London South Bank University, 103 Borough Road, London, SE1 OAA UK
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12
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Mason B, Boyd K, Doubal F, Barber M, Brady M, Cowey E, Visvanathan A, Lewis S, Gallacher K, Morton S, Mead GE. Core Outcome Measures for Palliative and End-of-Life Research After Severe Stroke: Mixed-Method Delphi Study. Stroke 2021; 52:3507-3513. [PMID: 34266306 PMCID: PMC8547585 DOI: 10.1161/strokeaha.120.032650] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Stroke is the second commonest cause of death worldwide and a leading cause of severe disability, yet there are no published trials of palliative care in stroke. To design and evaluate palliative care interventions for people with stroke, researchers need to know what measurable outcomes matter most to patients and families, stroke professionals, and other service providers. Methods: A multidisciplinary steering group of professionals and laypeople managed the study. We synthesized recommendations from respected United Kingdom and international consensus documents to generate a list of outcome domains and then performed a rapid scoping literature review to identify potential outcome measures for use in future trials of palliative care after stroke. We then completed a 3-round, online Delphi survey of professionals, and service users to build consensus about outcome domains and outcome measures. Finally, we held a stakeholder workshop to review and finalize this consensus. Results: We generated a list of 36 different outcome domains from 4 key policy documents. The rapid scoping review identified 43 potential outcome measures that were used to create a shortlist of 16 measures. The 36 outcome domains and 16 measures were presented to a Delphi panel of diverse healthcare professionals and lay service users. Of 48 panelists invited to take part, 28 completed all 3 rounds. Shared decision-making and quality of life were selected as the most important outcome domains for future trials of palliative care in stroke. Additional comments highlighted the need for outcomes to be feasible, measurable, and relevant beyond the initial, acute phase of stroke. The stakeholder workshop endorsed these results. Conclusions: Future trials of palliative care after stroke should include pragmatic outcome measures, applicable to the evolving patient and family experiences after stroke and be inclusive of shared decision-making and quality of life.
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Affiliation(s)
- Bruce Mason
- Usher Institute (B.M., K.B., S.L., S.M, G.E.M)
| | - Kirsty Boyd
- Usher Institute (B.M., K.B., S.L., S.M, G.E.M)
| | | | - Mark Barber
- University of Edinburgh, University Hospital, Monklands, NHS Lanarkshire (M. Barber)
| | - Marian Brady
- Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University (M. Brady)
| | - Eileen Cowey
- Nursing & Health Care School, University of Glasgow (E.C.)
| | | | - Steff Lewis
- Usher Institute (B.M., K.B., S.L., S.M, G.E.M)
| | - Katie Gallacher
- Institute of Health and Wellbeing, University of Glasgow (K.G.)
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The Experiences of Couples Affected by Stroke and Nurses Managing Patient Rehabilitation: A Descriptive Study in Singapore. J Nurs Res 2021; 28:e113. [PMID: 32568954 DOI: 10.1097/jnr.0000000000000392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Stroke in a family affects both patients and their spousal caregivers. Despite advances in the medical management of stroke, less is known about the social and cultural factors that impact couples regarding stroke recovery. PURPOSE The purpose of this study was to explore the experiences of stroke from the perspectives of couples affected by stroke and the nurses managing patient rehabilitation. METHODS An interpretive descriptive study was conducted. Purposive sampling was used to enroll 17 participants, comprising eight nurses, five spousal caregivers, and four stroke survivors. Individual, in-depth interviews were performed at a rehabilitation hospital in Singapore in June 2018. RESULTS The primary theme was the diverse meanings of stroke recovery attributed to limited conversations about the care decisions made by couples and rehabilitation nurses. The second theme was the challenges in nursing responsibilities that hindered the recovery of patients with stroke. CONCLUSIONS/IMPLICATIONS FOR PRACTICE The meaning of recovery differs between patients and their informal and formal care providers. This issue should be explored in patient-provider conversations, as these conversations highlight the values and preferences that affect the stroke recovery trajectory. Enhancing shared decision making by patients, spousal caregivers, and healthcare providers during the stroke trajectory may promote the alignment of values that are critical to the stroke recovery experience. Further research into whether and how to incorporate shared decision making in rehabilitation hospital settings as an interventional component is warranted to better support stroke survivors before discharge.
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14
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Visvanathan A, Graham C, Dennis M, Lawton J, Doubal F, Mead G, Whiteley W. Predicting specific abilities after disabling stroke: Development and validation of prognostic models. Int J Stroke 2021; 16:935-943. [PMID: 33402051 PMCID: PMC8554496 DOI: 10.1177/1747493020982873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Predicting specific abilities (e.g. walk and talk) to provide a functional profile six months after disabling stroke could help patients/families prepare for the consequences of stroke and facilitate involvement in treatment decision-making. Aim To develop new statistical models to predict specific abilities six months after stroke and test their performance in an independent cohort of patients with disabling stroke. Methods We developed models to predict six specific abilities (to be independent, walk, talk, eat normally, live without major anxiety/depression, and to live at home) using data from seven large multicenter stroke trials with multivariable logistic regression. We included 13,117 participants recruited within three days of hospital admission. We assessed model discrimination and derived optimal cut-off values using four statistical methods. We validated the models in an independent single-center cohort of patients (n = 403) with disabling stroke. We assessed model discrimination and calibration and reported the performance of our models at the statistically derived cut-off values. Results All six models had good discrimination in external validation (AUC 0.78–0.84). Four models (predicting to walk, eat normally, live without major anxiety/depression, live at home) calibrated well. Models had sensitivities between 45.0 and 97.9% and specificities between 21.6 and 96.5%. Conclusions We have developed statistical models to predict specific abilities and demonstrated that these models perform reasonably well in an independent cohort of disabling stroke patients. To aid decision-making regarding treatments, further evaluation of our models is required.
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Affiliation(s)
- Akila Visvanathan
- Centre for Clinical Brain Sciences, Chancellor's Building, The University of Edinburgh, Edinburgh, UK
| | - Catriona Graham
- Edinburgh Clinical Research Facility, The University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, Chancellor's Building, The University of Edinburgh, Edinburgh, UK
| | - Julia Lawton
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, Chancellor's Building, The University of Edinburgh, Edinburgh, UK
| | - Gillian Mead
- Centre for Clinical Brain Sciences, Chancellor's Building, The University of Edinburgh, Edinburgh, UK
| | - William Whiteley
- Centre for Clinical Brain Sciences, Chancellor's Building, The University of Edinburgh, Edinburgh, UK
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15
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Opoku S, Eliason C, Akpalu A. Why Me?: A Qualitative Study on the Experiences of Young Stroke Survivors in the Accra Metropolis of Ghana, West Africa. J Patient Exp 2020; 7:1788-1796. [PMID: 33457644 PMCID: PMC7786678 DOI: 10.1177/2374373520967505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Young stroke survivors are affected gravely when diagnosed with stroke between the ages of 18 to 45 years. The psychological and social effects of young stroke require stringent coping factors geared toward recovery and regeneration of self. A qualitative exploratory design was used to explore coping experiences and purposive sampling technique was employed to recruit 10 participants. Data were collected using tape recorded interviews which lasted between 45 minutes to 1 hour 30 minutes and guided by a semistructured interview guide which was informed by the research objectives and literature review. Thematic content analysis was used to analyze the transcribed data and 6 themes namely: psychological disruption, disruption to social identity, spiritual practices and beliefs, self-determination, support, and herbal medicine were derived. These themes gave insight into how these young stroke victims experienced and coped with physical signs and symptoms which negatively impacted their activities of daily living and resulted in social isolation, fear, anxiety, depression, guilt, and suicidal ideations. Provision of continuity of care for young adults living with stroke is highly recommended.
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Affiliation(s)
- Sussana Opoku
- Department of Nursing, Narh-Bita College, Tema, Ghana
| | | | - Albert Akpalu
- University of Ghana, School of Medical Sciences, Accra, Ghana
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16
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Scrutinio D, Ricciardi C, Donisi L, Losavio E, Battista P, Guida P, Cesarelli M, Pagano G, D'Addio G. Machine learning to predict mortality after rehabilitation among patients with severe stroke. Sci Rep 2020; 10:20127. [PMID: 33208913 PMCID: PMC7674405 DOI: 10.1038/s41598-020-77243-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/02/2020] [Indexed: 12/23/2022] Open
Abstract
Stroke is among the leading causes of death and disability worldwide. Approximately 20–25% of stroke survivors present severe disability, which is associated with increased mortality risk. Prognostication is inherent in the process of clinical decision-making. Machine learning (ML) methods have gained increasing popularity in the setting of biomedical research. The aim of this study was twofold: assessing the performance of ML tree-based algorithms for predicting three-year mortality model in 1207 stroke patients with severe disability who completed rehabilitation and comparing the performance of ML algorithms to that of a standard logistic regression. The logistic regression model achieved an area under the Receiver Operating Characteristics curve (AUC) of 0.745 and was well calibrated. At the optimal risk threshold, the model had an accuracy of 75.7%, a positive predictive value (PPV) of 33.9%, and a negative predictive value (NPV) of 91.0%. The ML algorithm outperformed the logistic regression model through the implementation of synthetic minority oversampling technique and the Random Forests, achieving an AUC of 0.928 and an accuracy of 86.3%. The PPV was 84.6% and the NPV 87.5%. This study introduced a step forward in the creation of standardisable tools for predicting health outcomes in individuals affected by stroke.
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Affiliation(s)
| | - Carlo Ricciardi
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy. .,Department of Advanced Biomedical Sciences, University Hospital of Naples "Federico II", Naples, Italy.
| | - Leandro Donisi
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy.,Department of Advanced Biomedical Sciences, University Hospital of Naples "Federico II", Naples, Italy
| | | | | | - Pietro Guida
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Mario Cesarelli
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy.,Department of Electrical Engineering and Information Technology, University of Naples "Federico II", Naples, Italy
| | - Gaetano Pagano
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
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17
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Visvanathan A, Whiteley W, Mead G, Lawton J, Doubal FN, Dennis M. Reporting “specific abilities” after major stroke to better describe prognosis. J Stroke Cerebrovasc Dis 2020; 29:104993. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/23/2022] Open
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18
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Visvanathan A, Mead GE, Dennis M, Whiteley WN, Doubal FN, Lawton J. The considerations, experiences and support needs of family members making treatment decisions for patients admitted with major stroke: a qualitative study. BMC Med Inform Decis Mak 2020; 20:98. [PMID: 32487145 PMCID: PMC7268726 DOI: 10.1186/s12911-020-01137-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2020] [Indexed: 12/01/2022] Open
Abstract
Background Treatment decision-making by family members on behalf of patients with major stroke can be challenging because of the shock of the diagnosis and lack of knowledge of the patient’s treatment preferences. We aimed to understand how, and why, family members made certain treatment decisions, and explored their information and support needs. Method Semi-structured interviews with family members (n = 24) of patients with major stroke, within 2 weeks of hospital admission. Data were analysed thematically. Results Families’ approach to treatment decision-making lay on a spectrum according to the patient’s state of health pre-stroke (i.e. patient’s prior experience of illness and functional status) and any views expressed about treatment preferences in the event of life-threatening illness. Support and information needs varied according to where they were on this spectrum. At one extreme, family members described deciding not to initiate life-extending treatments from the outset because of the patients’ deteriorating health and preferences expressed pre-stroke. Information from doctors about poor prognosis was merely used to confirm this decision. In the middle of the spectrum were family members of patients who had been moderately independent pre-stroke. They described the initial shock of the diagnosis and how they had initially wanted all treatments to continue. However, once they overcame their shock, and had gathered relevant information, including information about poor prognosis from doctors, they decided that life-extending treatments were no longer appropriate. Many reported this process to be upsetting and expressed a need for psychological support. At the other end of the spectrum were family members of previously independent patients whose preferences pre-stroke had not been known. Family members described feeling extremely distressed at such an unexpected situation and wanting all treatments to continue. They described needing psychological support and hope that the patient would survive. Conclusion The knowledge that family members’ treatment decision-making approaches lay on a spectrum depending on the patient’s state of health and stated preferences pre-stroke may allow doctors to better prepare for discussions regarding the patient’s prognosis. This may enable doctors to provide information and support that is tailored towards family members’ needs.
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Affiliation(s)
- A Visvanathan
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK.
| | - G E Mead
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - M Dennis
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - W N Whiteley
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - F N Doubal
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - J Lawton
- Usher Institute, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
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19
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Frey I, De Boer ME, Dronkert L, Pols AJ, Visser MC, Hertogh CMPM, Depla MFIA. Between Choice, Necessity, and Comfort: Deciding on Tube Feeding in the Acute Phase After a Severe Stroke. QUALITATIVE HEALTH RESEARCH 2020; 30:1114-1124. [PMID: 32418501 PMCID: PMC7322925 DOI: 10.1177/1049732320911370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This is an ethnographic study of decision-making concerning tube feeding in the acute phase after a severe stroke. It is based on 6 months of ethnographic research in three stroke units in the Netherlands, where the decision-making on life-sustaining treatment was studied in 16 cases of severe stroke patients. Data were collected through participant observation and interviews. For this article, the analysis was narrowed down to the decision whether or not the patient should receive tube feeding. The data on tube feeding were assembled and coded according to different modes of dealing with this decision in clinical practice, which we refer to as "repertoires." We discerned three different repertoires: choice, necessity, and comfort. Each repertoire structures clinical practice differently: It implies distinctive ethical imperatives, central concerns, sources of information, and temporalities. We hope our findings can improve decision-making by uncovering its underlying logics in clinical practice.
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Affiliation(s)
- Isabel Frey
- Vrije Universiteit Amsterdam, Amsterdam,
The Netherlands
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20
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Orav K, Moullaali TJ, Sandset EC, Doubal F, Whiteley W. Inspiring New Researchers in Stroke: The ESO Edinburgh Stroke Research Workshop. Stroke 2019; 50:e316-e318. [PMID: 31610766 DOI: 10.1161/strokeaha.119.026936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kateriine Orav
- From the Department of Neurology and Neurosurgery, Tartu University Hospital, Estonia (K.O.)
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh (T.J.M., F.D., W.W.)
| | | | - Fergus Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh (T.J.M., F.D., W.W.)
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh (T.J.M., F.D., W.W.)
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21
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Visvanathan A, Mead G, Dennis M, Whiteley W, Doubal F, Lawton J. Maintaining hope after a disabling stroke: A longitudinal qualitative study of patients' experiences, views, information needs and approaches towards making treatment decisions. PLoS One 2019; 14:e0222500. [PMID: 31518369 PMCID: PMC6743774 DOI: 10.1371/journal.pone.0222500] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 09/01/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Some treatments after a disabling stroke increase the likelihood patients will survive longer but with significant disability. Patients and doctors should make collaborative decisions regarding these treatments. However, this can be challenging. To better understand treatment decision-making in acute disabling stroke, we explored the experiences, views and needs of stroke survivors in hospital and six months later. METHODS Fifteen patients who had a disabling stroke were interviewed within a week of their diagnosis; eleven were re-interviewed six months later. Data were analysed thematically and longitudinally. RESULTS Patients' functional abilities prior to their stroke and need for hope of functional recovery appeared to impact on their involvement in decision-making. In the early period post stroke, patients who were functionally independent pre- stroke described being emotionally devastated and ill-prepared for the consequences of stroke. They appeared unaware that treatments offered might extend their life but with significant disability and took all treatments in the hope of functional recovery. Those who were dependent pre-stroke appeared to be more stoic, had considered treatment implications and decided against such treatments. At follow-up, all patients had varying unmet psychological needs which appeared to contribute to poor quality of life. In the early period post stroke, patients looked for various ways to cultivate and maintain hope of functional recovery. While patients continued to look for hope at six months, they also reported wishing they had been given realistic information in the early period after stroke in order to prepare for the consequences. CONCLUSION Stroke survivors may benefit from psychological support. A collaborative approach towards treatment decision-making may not be realistic in all patients especially when they may be emotionally distressed and looking to maintain a positive outlook. Communication strategies to balance maintaining hope without providing false hope may be appropriate. Patients' information needs may need reassessed at different time points.
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Affiliation(s)
- Akila Visvanathan
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
- * E-mail:
| | - Gillian Mead
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Martin Dennis
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - William Whiteley
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Julia Lawton
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, United Kingdom
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22
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Exploring the experiences of individuals with an insertable cardiac monitor: Making the decision for device insertion. Heart Lung 2019; 49:86-91. [PMID: 31399224 DOI: 10.1016/j.hrtlng.2019.07.004] [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: 01/18/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Little is known about the decision-making process for insertable cardiac monitors (ICM) in those with suspected arrhythmias. OBJECTIVE The purpose of this qualitative study was to describe how individuals make a decision to insert an ICM. METHODS A qualitative descriptive design was used. Data were analyzed using content analysis and constant comparison. NVivo 10 was used for data grouping and patterns. RESULTS Participants (N = 12) ranged in age from 41to 95. Most (n = 7) had the device inserted because of syncope or atrial fibrillation (AF), and others (n = 5) for cryptogenic stroke. Three categories emerged: pre-decision, definitive decision, and deliberated decision. Event symptoms, including physical, cognitive and emotional, and trust emerged as factors in decision-making. CONCLUSIONS Those who perceived their experience as life-threatening, trusted the healthcare provider and assented to the ICM insertion. Conversely, those who perceived symptoms as episodic, used other strategies to resolve symptoms prior to making the decision for insertion.
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