Ceilings of treatment: a qualitative study in the emergency department

Shared decision making with older people on treatment escalation planning for acute deterioration in the emergency medical setting: a UK-based qualitative study of patient perspectives (STREAMS-P)

BACKGROUND

Shared decision making (SDM) in treatment escalation planning (TEP) involves patients and clinicians determining together a contingency for future health deterioration. Patients' role in health-care decision making is subject to ongoing debate. This study aimed to understand the perspectives of older patients in the UK on SDM in TEP for the acute hospital setting.

METHODS

In this qualitative study, we recruited older adults with varying levels of frailty and diverse ethnicity via primary care in an Inner London borough. We excluded individuals who did not have the capacity to make TEP decisions, could not be interviewed in English, or whose main chronic clinical problem was cancer or an established severe single organ failure. We used purposive stratified sampling to capture a variety of age, frailty, and ethnicity. We conducted semistructured interviews from March 31 to Dec 19, 2023, and audiorecorded them. We then performed a reflexive thematic analysis.

FINDINGS

We conducted 27 interviews with 32 participants. Participants were aged 63-101 years, clinical frailty ranged from none to severe and was distributed across age groups, and 19 participants were female and 13 participants were male. We identified four themes from the interviews: (1) Focusing on a Natural Life Lived Well, which reflects participants' ideas around expected life and death trajectory; (2) Making Sense of an Unfamiliar Medical Narrative, where detailed planning for medical intervention was not expected; (3) My Body, My Decision, in which there was emphasis on retaining control over health-care decisions; and (4) Expert, Imperfect Doctors in an Essential, Imperfect System, in which the context of decision making involving health-care professionals in a stretched UK health service was considered.

INTERPRETATION

Patients did not immediately perceive the relevance of detailed planning for future treatment, but nonetheless showed determination to be final arbiters on health-care decisions. Viewed in the context of increasing emphasis on patient autonomy, future steps include public education on possibilities and limitations for intensive medical intervention, clinician reflection on approaches to TEP conversations and policy-level deliberation to define expectations for patient involvement in TEP decisions.

FUNDING

HCA International and NIHR Imperial Biomedical Research Centre.

The social experience of uncertainty: a qualitative analysis of emergency department care for suspected pneumonia for the design of decision support

BACKGROUND

This study sought to understand the process of clinical decision-making for suspected pneumonia by emergency departments (ED) providers in Veterans Affairs (VA) Medical Centers. The long-term goal of this work is to create clinical decision support tools to reduce unwarranted variation in diagnosis and treatment of suspected pneumonia.

METHODS

Semi-structured qualitative interviews were conducted with 16 ED clinicians from 9 VA facilities demonstrating variation in antibiotic and hospitalization decisions. Interviews of ED providers focused on understanding decision making for provider-selected pneumonia cases and providers' organizational contexts.

RESULTS

Thematic analysis identified four salient themes: i) ED decision-making for suspected pneumonia is a social process; ii) the "diagnosis drives treatment" paradigm is poorly suited to pneumonia decision-making in the ED; iii) The unpredictability of the ED requires deliberate and effortful information management by providers in CAP decision-making; and iv) the emotional stakes and high uncertainty of pneumonia care drive conservative decision making.

CONCLUSIONS

Ensuring CDS reflects the realities of clinical work as a socially organized process with high uncertainty may ultimately improve communication between ED and admitting providers, continuity of care and patient outcomes.

Effect of patient gender on the decision of ceiling of care: an European study of emergency physicians' treatment decisions in simulated cases

BACKGROUND AND IMPORTANCE

Gender bias in healthcare can significantly influence clinical decision-making, potentially leading to disparities in treatment outcomes. This study addresses the impact of patient gender on the decision-making process for establishing a ceiling of care in emergency medicine, particularly the decision to limit tracheal intubation.

OBJECTIVE

To determine whether patient gender influences emergency physicians' decisions regarding the recommendation for tracheal intubation in critically ill patients.

DESIGN

A European survey-based study was conducted using a standardized clinical scenario to assess physicians' decisions in a controlled setting.

SETTINGS AND PARTICIPANTS

The survey targeted European emergency physicians over a 2-week period in April 2024. A total of 3423 physicians participated, with a median age of 40 years and a distribution of 46% women. Physicians were presented with a clinical vignette of a 75-year-old patient in acute respiratory distress. The vignettes were randomized to vary only by the patient's gender (woman/man) and level of functional status: (1) can grocery shop alone, (2) cannot grocery shop alone but can bathe independently, or (3) cannot perform either task independently.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was the recommendation for intubation, with secondary analyses exploring the influence of patient functional status levels. Multivariable logistic regression was used to adjust for potential confounders, including physician gender, age, experience, and practice setting.

MAIN RESULTS

A total of 3423 physicians responded, mostly from France, Spain, Italy, and the UK (1,532, 494, 247, and 245 respectively). Women patients were less likely to be intubated compared to male patients [67.9% vs. 71.7%; difference 3.81%; 95% confidence interval (CI), 0.7-6.9%]. The likelihood of recommending intubation decreased with lower levels of patient functional status. Women physician gender was also associated with a reduced likelihood of recommending intubation.

CONCLUSION

This study suggests a significant gender-based disparity in emergency care decision-making, with women patients being less likely to receive recommendations for intubation. However, these results should be interpreted with caution due to potential limitations in the representativity of respondents and the uncertain applicability of survey responses to real-life clinical practice.

Shared decision-making with older people on TReatment Escalation planning for Acute deterioration in the emergency Medical Setting: a qualitative study of Clinicians' perspectives (STREAMS-C)

BACKGROUND

Shared decision-making (SDM) is increasingly expected in healthcare systems prioritising patient autonomy. Treatment escalation plans (TEPs) outline contingency for medical intervention in the event of patient deterioration. This study aimed to understand clinicians' perspectives on SDM in TEP for older patients in the acute medical setting.

METHODS

This was a qualitative study following a constructivist approach. Semistructured interviews with vignettes were conducted with 26 consultant and registrar doctors working in emergency medicine, general internal medicine, intensive care medicine and palliative care medicine. Reflexive thematic analysis was performed.

RESULTS

There were three themes: 'An unequal partnership', 'Options without equipoise' and 'Decisions with shared understanding'. Clinicians' expertise in synthesising complex, uncertain clinical information was contrasted with perceived patient unfamiliarity with future health planning and medical intervention. There was a strong sense of morality underpinning decision-making and little equipoise about appropriate TEP decisions. Communication around the TEP was important, and clinicians sought control over the high-stakes decision whilst avoiding conflict and achieving shared understanding.

CONCLUSIONS

Clinicians take responsibility for securing a 'good' TEP decision for older patients in the acute medical setting. They synthesise clinical data with implicit ethical reasoning according to their professional predictions of qualitative and quantitative success following medical intervention. SDM is seldom considered a priority for this context. Nonetheless, avoidance of conflict, preserving the clinical relationship and shared understanding with the patient and family are important.

Variation in Hospital Performance for General Surgery in Younger and Older Adults: A Retrospective Cohort Study

OBJECTIVE

To compare hospital surgical performance in older and younger patients.

BACKGROUND

In-hospital mortality after surgical procedures varies widely among hospitals. Prior studies suggest that failure-to-rescue rates drive this variation for older adults, but the generalizability of these findings to younger patients remains unknown.

METHODS

We performed a retrospective cohort study of patients ≥18 years undergoing one of 10 common and complex general surgery operations in 16 states using the Healthcare Cost and Utilization Projects State Inpatient Databases (2016-2018). Patients were split into 2 populations: patients with Medicare ≥65 (older adult) and non-Medicare <65 (younger adult). Hospitals were sorted into quintiles using risk-adjusted in-hospital mortality rates for each age population. Correlations between hospitals in each mortality quintile across age populations were calculated. Complication and failure-to-rescue rates were compared across the highest and lowest mortality quintiles in each age population.

RESULTS

We identified 579,582 patients treated in 732 hospitals. The mortality rate was 3.6% among older adults and 0.7% among younger adults. Among older adults, high- relative to low-mortality hospitals had similar complication rates (32.0% vs 29.8%; P = 0.059) and significantly higher failure-to-rescue rates (16.0% vs 4.0%; P < 0.001). Among younger adults, high-relative to low-mortality hospitals had higher complications (15.4% vs 12.1%; P < 0.001) and failure-to-rescue rates (8.3% vs 0.7%; P < 0.001). The correlation between observed-to-expected mortality ratios in each age group was 0.385 ( P < 0.001).

CONCLUSIONS

High surgical mortality rates in younger patients may be driven by both complication and failure-to-rescue rates. There is little overlap between low-mortality hospitals in the older and younger adult populations. Future work must delve into the root causes of this age-based difference in hospital-level surgical outcomes.

Development and validation of a model to predict ceiling of care in COVID-19 hospitalized patients

BACKGROUND

Therapeutic ceiling of care is the maximum level of care deemed appropiate to offer to a patient based on their clinical profile and therefore their potential to derive benefit, within the context of the availability of resources. To our knowledge, there are no models to predict ceiling of care decisions in COVID-19 patients or other acute illnesses. We aimed to develop and validate a clinical prediction model to predict ceiling of care decisions using information readily available at the point of hospital admission.

METHODS

We studied a cohort of adult COVID-19 patients who were hospitalized in 5 centres of Catalonia between 2020 and 2021. All patients had microbiologically proven SARS-CoV-2 infection at the time of hospitalization. Their therapeutic ceiling of care was assessed at hospital admission. Comorbidities collected at hospital admission, age and sex were considered as potential factors for predicting ceiling of care. A logistic regression model was used to predict the ceiling of care. The final model was validated internally and externally using a cohort obtained from the Leeds Teaching Hospitals NHS Trust. The TRIPOD Checklist for Prediction Model Development and Validation from the EQUATOR Network has been followed to report the model.

RESULTS

A total of 5813 patients were included in the development cohort, of whom 31.5% were assigned a ceiling of care at the point of hospital admission. A model including age, COVID-19 wave, chronic kidney disease, dementia, dyslipidaemia, heart failure, metastasis, peripheral vascular disease, chronic obstructive pulmonary disease, and stroke or transient ischaemic attack had excellent discrimination and calibration. Subgroup analysis by sex, age group, and relevant comorbidities showed excellent figures for calibration and discrimination. External validation on the Leeds Teaching Hospitals cohort also showed good performance.

CONCLUSIONS

Ceiling of care can be predicted with great accuracy from a patient's clinical information available at the point of hospital admission. Cohorts without information on ceiling of care could use our model to estimate the probability of ceiling of care. In future pandemics, during emergency situations or when dealing with frail patients, where time-sensitive decisions about the use of life-prolonging treatments are required, this model, combined with clinical expertise, could be valuable. However, future work is needed to evaluate the use of this prediction tool outside COVID-19.

Perspectives of healthcare professionals and older patients on shared decision-making for treatment escalation planning in the acute hospital setting: a systematic review and qualitative thematic synthesis

Background

Shared Decision-Making (SDM) between patients and clinicians is increasingly considered important. Treament Escalation Plans (TEP) are individualised documents outlining life-saving interventions to be considered in the event of clinical deterioration. SDM can inform subjective goals of care in TEP but it remains unclear how much it is considered beneficial by patients and clinicians. We aimed to synthesise the existing knowledge of clinician and older patient (generally aged ≥65 years) perspectives on patient involvement in TEP in the acute setting.

Methods

Systematic database search was performed in MEDLINE, EMBASE, PsycInfo and CINAHL databases as well as grey literature from database inception to June 8, 2023, using the Sample (older patients, clinicians, acute setting; studies relating to patients whose main diagnosis was cancer or single organ failure were excluded as these conditions may have specific TEP considerations), Phenomenon of Interest (Treatment Escalation Planning), Design (any including interview, observational, survey), Evaluation (Shared Decision-Making), Research type (qualitative, quantitative, mixed methods) tool. Primary data (published participant quotations, field notes, survey results) and descriptive author comments were extracted and qualitative thematic synthesis was performed to generate analytic themes. Quality assessment was made using the Critical Appraisal Skills Programme and Mixed Methods Appraisal Tools. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) approach was used to assess overall confidence in each thematic finding according to methodology, coherence, adequacy and relevance of the contributing studies. The study protocol was registered on PROSPERO, CRD42022361593.

Findings

Following duplicate exclusion there were 1916 studies screened and ultimately 13 studies were included, all from European and North American settings. Clinician-orientated themes were: treatment escalation is a medical decision (high confidence); clinicians want the best for their patients amidst uncertainty (high confidence); involving patients and families in decisions is not always meaningful and can involve conflict (high confidence); treatment escalation planning exists within the clinical environment, organisation and society (moderate confidence). Patient-orientated themes were: patients' relationships with Treatment Escalation Planning are complex (low confidence); interactions with doctors are important but communication is not always easy (moderate confidence); patients are highly aware of their families when considering TEP (moderate confidence).

Interpretation

Based on current evidence, TEP decisions appear dominated by clinicians' perspectives, motivated by achieving the best for patients and challenged by complex decisions, communication and environmental factors; older patients' perspectives have seldom been explored, but their input on decisions may be modest. Presenting the context and challenge of SDM during professional education may allow reflection and a more nuanced approach. Future research should seek to understand what approach to TEP decision-making patients and clinicians consider to be optimum in the acute setting so that a mutually acceptable standard can be defined in policy.

Funding

HCA International and the NIHR Imperial Biomedical Research Centre.

The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review

Decisions in end-of-life care are influenced by several factors, many of which are not identified by the decision maker. These influencing factors modify important decisions in this scenario, such as in decisions to adapt to therapeutic support. This presented scoping review aims to map the factors that influence end-of-life care decisions for adult and older adult patients, by a scoping review. The review was carried out in 19 databases, with the keyword 'clinical decision-making' AND 'terminal care' OR 'end-of-life care' and its analogues, including publications from 2017 to 2022. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The search resulted in 3474 publications, where the presence of influencing factors in end-of-life decision-making for adults and the elderly was applied as a selection criterion. Fifty-four (54) of them were selected, which means 1.5% of all the results. Among the selected publications, 89 influencing factors were found, distributed in 54 (60.6%) factors related to the health team, 18 (20.2%) to patients, 10 (11.2%) related to family or surrogates and 7 (7.8%) factors related to the decision environment. In conclusion, we note that the decision-making in end-of-life care is complex, mainly because there is an interaction of different characters (health team, patient, family, or surrogates) with a plurality of influencing factors, associated with an environment of uncertainty and that result in a critical outcome, with a great repercussion for the end of life, making it imperative the recognition of these factors for more competent and safe decision-making.

Teto terapêutico e a adequação do tratamento no Serviço de Urgência – estudo retrospectivo

Introdução: no Serviço de Urgência vive-se um antagonismo constante pela sua natureza direcionada para a patologia aguda e a prestação de cuidados paliativos de qualidade. O nosso estudo tem como objetivo avaliar se a definição de teto terapêutico leva a diferenças na adequação da marcha diagnóstica e terapêutica instituída.Material e métodos: análise retrospetiva descritiva monocêntrica dos doentes que morreram nos primeiros seis meses de 2018 no serviço de urgência do Hospital do Espírito Santo de Évora.Resultados: compararam-se os três grupos de doentes o que não foi definido qualquer teto terapêutico, com o grupo em que iniciaram medidas paliativas e o grupo em que se tomou a Decisão de Não Reanimar. Verificou-se que não existem diferenças significativa entre as idades, o local de residência e as comorbilidades e, com exceção da demência (p= 0,006), existe sim uma diferença no grau de dependência nas atividades da vida diária (p<0,001). Verificou-se que não existem diferenças entre número ou tipo de exames complementares de diagnóstico, mas há algumas diferenças na terapêutica instituída já que no grupo dos doentes em cuidados paliativos a terapêutica com morfina (p<0,001), butilescopolamina (p=0,001) e paracetamol (p=0,004) foi mais frequente. A ventilação invasiva só ocorreu no grupo de doentes sem definição de teto terapêutico (p<0,001), enquanto a oxigénioterapia foi mais frequente nos grupos em Decisão de Não Reanimar ou em cuidados paliativos (p<0,001).Discussão e conclusão: os médicos do serviço de urgência reconhecem que os seus doentes estão em final de vida, adequando parcialmente a terapêutica com vista ao controlo de sintomas, dor e secreções. 

The management and diagnosis of rhabdomyolysis-induced acute kidney injury: a case study

Rhabdomyolysis is characterised by a rapid dissolution of damaged or injured skeletal muscle that can be the result of a multitude of mechanisms. It can range in severity from mild to severe, leading to multi-organ failure and death. Rhabdomyolysis causes muscular cellular breakdown, which can cause fatal electrolyte imbalances and metabolic acidosis, as myoglobin, creatine phosphokinase, lactate dehydrogenase and other electrolytes move into the circulation; acute kidney injury can follow as a severe complication. This article reflects on the case of a person who was diagnosed with rhabdomyolysis and acute kidney injury after a fall at home. Understanding the underpinning mechanism of rhabdomyolysis and the associated severity of symptoms may improve early diagnosis and treatment initiation.

Cognitive biases, environmental, patient and personal factors associated with critical care decision making: A scoping review

PURPOSE

Cognitive biases and factors affecting decision making in critical care can potentially lead to life-threatening errors. We aimed to examine the existing evidence on the influence of cognitive biases and factors on decision making in critical care.

MATERIALS AND METHODS

We conducted a scoping review by searching MEDLINE for articles from 2004 to November 2020. We included studies conducted in physicians that described cognitive biases or factors associated with decision making. During the study process we decided on the method to summarize the evidence, and based on the obtained studies a descriptive summary of findings was the best fit.

RESULTS

Thirty heterogenous studies were included. Four main biases or factors were observed, e.g. cognitive biases, personal factors, environmental factors, and patient factors. Six (20%) studies reported biases associated with decision making comprising omission-, status quo-, implicit-, explicit-, outcome-, and overconfidence bias. Nineteen (63%) studies described personal factors, twenty-two (73%) studies described environmental factors, and sixteen (53%) studies described patient factors.

CONCLUSIONS

The current evidence on cognitive biases and factors is heterogenous, but shows they influence clinical decision. Future studies should investigate the prevalence of cognitive biases and factors in clinical practice and their impact on clinical outcomes.

The BOAST recommendations for care of the older or frail orthopaedic trauma patient

Safe and effective care for the elderly or physiologically frail patient in cases of trauma requires a multidisciplinary perioperative approach. This article expands upon the British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines for the management of the older or frail orthopaedic trauma patient. Optimisation of the patient is key to a successful surgical outcome, because these patients often have significant comorbidities involving bone health, nutrition, cognitive function and cardiovascular stability. This article discusses the evidence base for tailoring the management of these patients and the importance of doing so in an ageing population. It considers the requisite preoperative procedures and investigations, guidelines for specific cases such as comatose patients or those with complex fractures, and ceiling of care discussions, and then focuses on the postoperative period, including physiotherapy, rehabilitation goals and medical management.

Covid-19: avaliação remota em Atenção Primária à Saúde

O que você precisa saber? A maioria dos pacientes com Covid-19 podem ser manejados remotamente com aconselhamento de manejo de sintomas e autoisolamento; Apesar da maioria das consultas poderem ser feitas por telefone, a imagem de vídeo fornece pistas adicionais visuais e a presença terapêutica do profissional de saúde para o paciente; Falta de ar é um sintoma preocupante, embora, hoje, não há ferramenta validada para avaliá-la remotamente;Aconselhamento sobre rede de segurança para o paciente é crucial, uma vez que, alguns pacientes deterioram muito a sua condição de saúde em 2 semanas, mais comumente por pneumonia.