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Muthu M, Dalal S, George M, Clavijo CS, Lenz C, Nortje N. The importance of facilitating goal-concordant care (GCC) in a pandemic: the MD Anderson Experience with hospitalized COVID-19-positive patients. Support Care Cancer 2023; 31:661. [PMID: 37906311 DOI: 10.1007/s00520-023-08135-1] [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: 05/23/2023] [Accepted: 10/20/2023] [Indexed: 11/02/2023]
Abstract
PURPOSE Provider-patient communication (PPC) about goals of care (GOC) facilitates goal-concordant care (GCC) delivery. Hospital resource limitations imposed during the pandemic made it vital to deliver GCC to a patient cohort with COVID-19 and cancer. We aimed to evaluate the implementation of a real-time goals of care intervention and to make recommendations for future pandemics with similar clinical scenarios. METHODS This is a retrospective cohort study, of all COVID-19 positive patients admitted to The University of Texas MD Anderson Cancer Center between March of 2020 and January of 2021. The cohort included the following: (1) patients 18 years of age or older; (2) positive COVID-19 infection; (3) requiring hospitalization. Medical records were reviewed and all patient data including demographics, comorbidities, and outcomes were collected and analyzed in the Syntropy platform, Palantir Foundry, as part of the institutional Data-Driven Determinants of COVID-19 Oncology Discovery Effort (D3CODE) protocol. A multidisciplinary GOC task force developed processes for ease of conducting GOC-PPC and implemented structured documentation. We looked at ACP documentation pre- and post-implementation alongside demographics, length of stay (LOS), 30-day readmission rate and mortality. RESULTS There were 494 unique patients identified, 53% male, 61.5% Caucasian, 16.8% African American, and 3.2% Asian. Active cancer was identified in 84.6% patients, of which 65.6% were solid tumors and 34.4% hematologic malignancies. LOS was 9 days with a 30-day readmission rate of 15% and inpatient mortality of 14%. Inpatient ACP note documentation was significantly higher post-implementation as compared to pre-implementation (90% vs 8%, P<0.05). We saw sustained ACP documentation throughout the pandemic suggesting effective processes. CONCLUSIONS The implementation of institutional structured processes for GOC-PPC resulted in rapid sustainable adoption of ACP documentation for COVID-19-positive cancer patients. This was highly beneficial for this population during the pandemic, as it demonstrated the role of agile processes in care delivery models, which will be beneficial in the future when rapid implementation is needed.
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Affiliation(s)
- Mayoora Muthu
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Shalini Dalal
- Department of Palliative & Supportive Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina George
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cesar Simbaqueba Clavijo
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caitlin Lenz
- Department of Clinical Informatics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nico Nortje
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Nutrition and Dietetics, University of the Western Cape, Cape Town, South Africa
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Muthu M, Dalal S, George M, Clavijo CS, Lenz C, Nortje N. The Importance of Facilitating Goal-Concordant Care (GCC) in a Pandemic: The MD Anderson Experience with hospitalized COVID-19 positive patients. RESEARCH SQUARE 2023:rs.3.rs-2968661. [PMID: 37398052 PMCID: PMC10312944 DOI: 10.21203/rs.3.rs-2968661/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Purpose Provider-patient communication (PPC) about goals of care (GOC) facilitates goal-concordant care (GCC) delivery. Hospital resource limitations imposed during the pandemic made it vital to deliver GCC to a patient cohort with COVID-19 and cancer. Our aim was to understand the population and adoption of GOC-PPC along with structured documentation in the form of an Advance Care Planning (ACP) note. Methods A multidisciplinary GOC task force developed processes for ease of conducting GOC-PPC and implemented structured documentation. Data were obtained from multiple electronic medical record elements, with each source identified, data integrated and analyzed. We looked at PPC and ACP documentation pre and post implementation alongside demographics, length of stay (LOS), 30-day readmission rate and mortality. Results 494 unique patients were identified, 52% male, 63% Caucasian, 28% Hispanic, 16% African American and 3% Asian. Active cancer was identified in 81% patients, of which 64% were solid tumors and 36% hematologic malignancies. LOS was 9 days with a 30-day readmission rate of 15% and inpatient mortality of 14%. Inpatient ACP note documentation was significantly higher post-implementation as compared to pre-implementation (90% vs 8%, P < 0.05). We saw sustained ACP documentation throughout the pandemic suggesting effective processes. Conclusions The implementation of institutional structured processes for GOC-PPC resulted in rapid sustainable adoption of ACP documentation for COVID-19 positive cancer patients. This was highly beneficial for this population during the pandemic, as it demonstrated the role of agile processes in care delivery models, which will be beneficial in the future when rapid implementation is needed.
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Affiliation(s)
| | | | | | | | - Caitlin Lenz
- The University of Texas MD Anderson Cancer Center
| | - Nico Nortje
- The University of Texas MD Anderson Cancer Center
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Bhadelia A, Oldfield LE, Cruz JL, Singh R, Finkelstein EA. Identifying Core Domains to Assess the "Quality of Death": A Scoping Review. J Pain Symptom Manage 2022; 63:e365-e386. [PMID: 34896278 DOI: 10.1016/j.jpainsymman.2021.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/18/2021] [Accepted: 11/28/2021] [Indexed: 01/13/2023]
Abstract
CONTEXT There is growing recognition of the value to patients, families, society, and health systems in providing healthcare, including end-of-life care, that is consistent with both patient preferences and clinical guidelines. OBJECTIVES Identify the core domains and subdomains that can be used to evaluate the performance of end-of-life care within and across health systems. METHODS PubMed/MEDLINE (NCBI), PsycINFO (ProQuest), and CINAHL (EBSCO) databases were searched for peer-reviewed journal articles published prior to February 22, 2020. The SPIDER tool was used to determine search terms. A priori criteria were followed with independent review to identify relevant articles. RESULTS A total of 309 eligible articles were identified out of 2728 discrete results. The articles represent perspectives from the broader health system (11), patients (70), family and informal caregivers (65), healthcare professionals (43), multiple viewpoints (110), and others (10). The most common condition of focus was cancer (103) and the majority (245) of the studies concentrated on high-income country contexts. The review identified five domains and 11 subdomains focused on structural factors relevant to end-of-life care at the broader health system level, and two domains and 22 subdomains focused on experiential aspects of end-of-life care from the patient and family perspectives. The structural health system domains were: 1) stewardship and governance, 2) resource generation, 3) financing and financial protection, 4) service provision, and 5) access to care. The experiential domains were: 1) quality of care, and 2) quality of communication. CONCLUSION The review affirms the need for a people-centered approach to managing the delicate process and period of accepting and preparing for the end of life. The identified structural and experiential factors pertinent to the "quality of death" will prove invaluable for future efforts aimed to quantify health system performance in the end-of-life period.
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Affiliation(s)
- Afsan Bhadelia
- Department of Global Health and Population (A.B.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
| | | | - Jennifer L Cruz
- Department of Social and Behavioral Sciences (J.L.C.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ratna Singh
- Lien Centre for Palliative Care (R.S., E.A.F.), Duke-NUS Medical School, Singapore, Singapore
| | - Eric A Finkelstein
- Lien Centre for Palliative Care (R.S., E.A.F.), Duke-NUS Medical School, Singapore, Singapore
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Juárez-Villegas LE, Altamirano-Bustamante MM, Zapata-Tarrés MM. Decision-Making at End-of-Life for Children With Cancer: A Systematic Review and Meta-Bioethical Analysis. Front Oncol 2021; 11:739092. [PMID: 34722289 PMCID: PMC8554195 DOI: 10.3389/fonc.2021.739092] [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] [Received: 07/10/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background Evidence shows that medical education includes a variety of basic and clinical skills. Ethical and human values are not typically considered in medical school curricula, and this is evident in medical practice in certain scenarios such as decision-making at pediatric cancer patients' end of life. Methods This study explores a bioethical approach to address complex decision-making at the end of life in children and adolescents with cancer. We are a cross-functional group of scientists from several academic disciplines who conducted a systematic review of the literature using our newly developed meta-bioethical analysis and synthesis of findings. The search was carried out in five databases, resulting in 10 research papers. Following quality screening, seven articles were ultimately selected for further analysis. Results Our focus is on the state of the art to better understand the bioethical deliberation at the end of life in pediatric oncology. Here, we report a systematic review that includes (i) classification of the screened articles by the type of decision-making they use, ii) the system values that are at the core of the decision-making at the end of life, and iii) bioethical and ethical discernment queries. We conclude with a discussion regarding the best practices of ethical discernment and decision-making at the end of life.This study highlights the need to develop more research to better understand the influence and origin of these multidimensional factors determining critical decisions that define the quality of life of patients in a highly sensitive moment. Conclusion We conclude that personal aspects of the physician define their actions more than knowledge or organized structure. It is thus necessary that pediatric oncologists receive ethics and humanistic education.
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Affiliation(s)
- Luis Enrique Juárez-Villegas
- Department of Hematology-Oncology, Hospital Infantil de Mexico Federico Gómez, Mexico City, Mexico.,Master and Doctorate Program in Medical and Health Sciences, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Myriam M Altamirano-Bustamante
- Master and Doctorate Program in Medical and Health Sciences, Universidad Nacional Autónoma de México, Mexico City, Mexico.,Metabolic Diseases Research Unit, Cross-functional Bioethics Group, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Davis J, Asuncion M, Rabello J, Silangcruz C, van Dyk E. A Qualitative Review of Occupational Therapists' Listening Behaviors and Experiences When Caring for Patients in Palliative or Hospice Care. OTJR-OCCUPATION PARTICIPATION AND HEALTH 2012. [DOI: 10.3928/15394492-20121012-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Listening behaviors and experiences of occupational therapists working with patients in palliative or hospice care were investigated. Because the U.S. Government's Healthy People 2020 mandates better listening in health care, this research is timely. A qualitative design using semi-structured interviews and member checks provided researchers with rich text that revealed patterns and themes associated with listening behaviors, listening experiences, and listening training of occupational therapists working in palliative and hospice care. Participants were selected using typical case and snowball sampling. Six participants from two distinct geographic regions of the United States agreed to be interviewed. Interviews revealed four themes: working within the OT Practice Framework, key listening behaviors used in this context, listening barriers and challenges, and clinical competence and training needed prior to working with this population. This small sample size represents only a fraction of the occupational therapists working in palliative or hospice care, yet provides a foundation for further research and underscores the importance of listening behaviors.
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Alexander SJ. An intense and unforgettable experience: the lived experience of malignant wounds from the perspectives of patients, caregivers and nurses. Int Wound J 2011; 7:456-65. [PMID: 20673255 DOI: 10.1111/j.1742-481x.2010.00715.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Malignant wounds occur infrequently, but are typically described as devastating and overwhelming. However, there has been little formalised research, and the vast majority of existing malignant wound literature comprises reports of health care professionals from their management of the physical symptoms. Few studies have investigated the lived experience from the perspectives of patients and nurses and none have investigated the experiences of lay caregivers caring for a patient with a malignant wound. As a result, there has been little mention in existing literature of the non physical issues associated with malignant wounds or how they might be addressed. The purpose of this study was to address this gap in knowledge by investigating the lived experience of malignant wounds from the perspectives of those living it. In-depth interviews were conducted with patients, caregivers and nurses. The data were analysed thematically within a hermeneutic phenomenological methodology to show four themes: (i) malodour; (ii) new mode of being-in-the-world; (iii) still room for hope and (iv) enduring memories. Although this study confirmed previous findings that malodour was one of the worst aspects of malignant wounds, it was significant that the other three themes occurred in the previously largely overlooked psychosocial domain.
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Affiliation(s)
- Susan J Alexander
- Faculty of Sciences, Engineering & Health, CQ University, Locked Bag 3333, Bundaberg, Qld, Australia.
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Gunaratnam Y. Cultural vulnerability and professional narratives. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2011; 7:338-349. [PMID: 22150178 DOI: 10.1080/15524256.2011.623464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In this article the author draws upon research with palliative care professionals in the United Kingdom to discuss the value of a stance of cultural vulnerability in intercultural care. Cultural vulnerability recognizes the reality, but also the ethical value of uncertainty and not-knowing in care. Attentiveness to professional narratives is advocated as vital in the development of greater understanding of cultural vulnerability and its effects. The role of cultural identifications and the politics of racism in social work narratives is given specific attention.
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Affiliation(s)
- Yasmin Gunaratnam
- Department of Sociology, Goldsmiths College, University of London, New Cross, London, UK.
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Bingley AF, Thomas C, Brown J, Reeve J, Payne S. Developing narrative research in supportive and palliative care: the focus on illness narratives. Palliat Med 2008; 22:653-8. [PMID: 18612032 DOI: 10.1177/0269216308089842] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The phenomenon of the 'illness narrative' is well-documented, in the last 25 years, of increasing interest to researchers in health and social sciences. Personal stories about the experience of facing the end of life also have an established history of particular relevance for palliative care clinicians. In this article, we review and describe a range of narrative analysis approaches that may be of use in palliative care. In particular, we distinguish between qualitative analysis applied to narratives and narrative analysis as a method. We discuss the potential benefits and challenges in the use of narrative research methods as a means to deepen our understanding of patient, carer and health professionals' experience, and to support improvements in end of life care policy and practice.
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Affiliation(s)
- A F Bingley
- International Observatory on End of Life Care, Institute for Health Research, Lancaster University, Lancaster, UK
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Abstract
The aspiration to design and conduct high-quality research in palliative care has been an important but elusive goal. The article evaluates the nature of research methodologies presented in published research within the broad remit of palliative care. A systematic search of the Medline database between 1997 and 2006, using the keywords 'palliative care' or 'end-of-life care' and 'research methodology', identified over 318 publications. A bibliometric analysis indicates an incremental increase in published outputs per year, from 27 countries, with articles widely distributed across 108 journals. The heterogeneity of the research methodologies and the journals publishing them, present challenges in defining what constitutes 'high quality'. We argue that although this diversity leads to a lack of coherence for a single disciplinary paradigm for palliative care, there is a greater acknowledgement of the differing epistemological and theoretical frameworks used by researchers. This could be regarded as enriching our understanding of what it means to be dying in contemporary society.
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Affiliation(s)
- S A Payne
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK.
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Rousseau PC. Recent Literature. J Palliat Med 2006. [DOI: 10.1089/jpm.2006.9.1023] [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
Affiliation(s)
- Paul C. Rousseau
- Department of Geriatrics and Extended Care, VA Medical Center, Phoenix, AZ 85012
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