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Driggers KE, Keenan LM, Alcover KC, Atkin M, Irby K, Kovacs M, McLawhorn MM, Mir-Kasimov M, Sabbahi WZ, Sellman J, Johnson LS. Unintended Consequences of Code Status in the Intensive Care Unit: What Happens After a Do-Not-Resuscitate Order Is Placed? A Retrospective Cohort Study. J Palliat Med 2024; 27:508-514. [PMID: 38574337 DOI: 10.1089/jpm.2023.0289] [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] [Indexed: 04/06/2024] Open
Abstract
Background: Some clinicians suspect that patients with do-not-resuscitate (DNR) orders receive less aggressive care. Extrapolation from code status to goals of care could cause significant harm. This study asked the question: Do DNR orders in the intensive care unit (ICU) lead to a decrease in invasive interventions? Methods: This was a retrospective cohort study of ICU patients from three teaching hospitals. All ICU patients were assessed for inclusion. Exclusion criteria were medical futility and death, comfort care, or ICU discharge <48 hours after DNR initiation. Five hundred thirty-six patients met inclusion criteria. One hundred forty-five were included in the final analysis. Primary outcomes were occurrence of invasive interventions after DNR initiation-surgical operation, central line, ventilation, dialysis, or other procedure. Secondary outcomes were antibiotic administration, blood transfusion, mortality, and discharge location. Results: Patients with DNR orders underwent fewer surgical operations (14.5% vs. 31.1%, p = 0.002), but more central lines (42.1% vs. 23.0%, p = 0.009), ventilator use (49.0% vs. 18.9%, p < 0.001), and dialysis (20.0% vs. 4.1%, p = 0.002), compared with patients without DNR orders. Transfusions and antibiotic use decreased similarly over admission for both groups (transfusions: β = 1.25; p = 0.59; and antibiotics: β = 1.44; p = 0.27). Mortality and hospice discharges were higher for DNR patients (p < 0.001.). Conclusions: DNR status did not decrease the number of nonoperative interventions patients received as compared with full code counterparts. Although differences in populations existed, patients with DNR orders were likely to receive a similar number of invasive interventions. This finding suggests that providers do not wholesale limit these options for patients with code status limitations.
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Affiliation(s)
- Kathryn E Driggers
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Lynn M Keenan
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Pulmonary and Critical Care Medicine, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Karl C Alcover
- Department of Medicine, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Megan Atkin
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kathleen Irby
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Monique Kovacs
- Pulmonary and Critical Care Medicine, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Melissa M McLawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - Mustafa Mir-Kasimov
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Pulmonary and Critical Care Medicine, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Wesam Z Sabbahi
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jeffrey Sellman
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Pulmonary and Critical Care Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Laura S Johnson
- Department of Medicine, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Surgery, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC, USA
- Walter L. Ingram Burn Center at Grady Memorial Hospital, Atlanta, Georgia, USA
- Department of Surgery, Emory Universiy School of Medicine, Atlanta, Georgia, USA
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Gupta S, Chen BJ, Suolang D, Cooper R, Faigle R. Advance directives among community-dwelling stroke survivors. PLoS One 2023; 18:e0292484. [PMID: 37847705 PMCID: PMC10581473 DOI: 10.1371/journal.pone.0292484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/21/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE Advance directives (ADs) are integral to health care, allowing patients to specify surrogate decision-makers and treatment preferences in case of loss of capacity. The present study sought to identify determinants of ADs among stroke survivors. METHODS In this cross-sectional study (Care Attitudes and Preferences in Stroke Survivors [CAPriSS]), community-dwelling stroke survivors were surveyed on ADs; validated scales were used to query palliative care knowledge and attitudes towards life-sustaining treatments. Logistic regression was used to determine variables associated with ADs. RESULTS Among 562 community-dwelling stroke survivors who entered the survey after screening questions confirmed eligibility, 421 (74.9%) completed survey components with relevant variables of interest. The median age was 69 years (IQR 58-75 years); 53.7% were male; and 15.0% were Black. Two hundred and fifty-one (59.6%) respondents had ADs. Compared to stroke survivors without ADs, those with ADs were more likely to be older (median age 72 vs. 61 years; p<0.001), White (91.2% vs. 75.9%, p<0.001), and male (58.6% vs. 46.5%, p = 0.015), and reported higher education (p<0.001) and income (p = 0.011). Ninety-eight (23.3%) participants had "never heard of palliative care". Compared to participants without ADs, participants with ADs had higher Palliative Care Knowledge Scale (PaCKS) scores (median 10 [IQR 5-12] vs. 7 [IQR 0-11], p<0.001), and lower scores on the Attitudes Towards Life-Sustaining Treatments Scale (indicating a more negative attitude towards life-sustaining treatments; median 23 [IQR 18-28] vs. 29 [IQR 24-35], p<0.001). Multivariable logistic regression identified age (OR 1.62 per 10 year increase, 95% CI 1.30-2.02; p<0.001), prior advance care planning discussion with a physician (OR 1.73, 95% CI 1.04-2.86; p = 0.034), PaCKS scores (OR 1.06 per 1 point increase, 95% CI 1.01-1.12; p = 0.018), and Attitudes Towards Life-Sustaining Treatments Scale scores (OR 0.91 per 1 point increase, 95% CI 0.88-0.95; p<0.001) as variables independently associated with ADs. CONCLUSIONS Age, prior advance care planning discussion with a physician, palliative care knowledge, and attitudes towards life-sustaining treatments were independently associated with ADs.
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Affiliation(s)
- Soumya Gupta
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Bridget J. Chen
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Deji Suolang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Rachel Cooper
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Yeh HL, Hsieh FI, Lien LM, Kuo WH, Jeng JS, Sun Y, Wei CY, Yeh PY, Yip HT, Lin CL, Huang N, Hsu KC. Patient and hospital characteristics associated with do-not-resuscitate/do-not-intubate orders: a cross-sectional study based on the Taiwan stroke registry. BMC Palliat Care 2023; 22:138. [PMID: 37715158 PMCID: PMC10503153 DOI: 10.1186/s12904-023-01257-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Previous studies of do-not-resuscitate (DNR) or do-not-intubate (DNI) orders in stroke patients have primarily been conducted in North America or Europe. However, characteristics associated with DNR/DNI orders in stroke patients in Asia have not been reported. METHODS Based on the Taiwan Stroke Registry, this nationwide cross-sectional study enrolled hospitalized stroke patients from 64 hospitals between 2006 and 2020. We identified characteristics associated with DNR/DNI orders using a two-level random effects model. RESULTS Among the 114,825 patients, 5531 (4.82%) had DNR/DNI orders. Patients with acute ischemic stroke (AIS) had the highest likelihood of having DNR/DNI orders (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.61-1.93), followed by patients with intracerebral hemorrhage (ICH), and patients with subarachnoid hemorrhage (SAH) had the lowest likelihood (aOR 0.53, 95% CI 0.43-0.66). From 2006 to 2020, DNR/DNI orders increased in all three types of stroke. In patients with AIS, women were significantly more likely to have DNR/DNI orders (aOR 1.23, 95% CI 1.15-1.32), while patients who received intravenous alteplase had a lower likelihood (aOR 0.74, 95% CI 0.65-0.84). Patients with AIS who were cared for by religious hospitals (aOR 0.55, 95% CI 0.35-0.87) and patients with SAH who were cared for by medical centers (aOR 0.40, 95% CI 0.17-0.96) were significantly less likely to have DNR/DNI orders. CONCLUSIONS In Taiwan, DNR/DNI orders increased in stroke patients between 2006 and 2020. Hospital characteristics were found to play a significant role in the use of DNR/DNI orders.
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Affiliation(s)
- Hsu-Ling Yeh
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Fang-I Hsieh
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Wen-Hua Kuo
- Institute of Science, Technology, and Society, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center, Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu Sun
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Cheng-Yu Wei
- Department of Exercise and Health Promotion, College of Kinesiology and Health, Chinese Culture University, Taipei, Taiwan
| | - Po-Yen Yeh
- Department of Neurology, St. Martin de Porres Hospital, Chiayi City, Taiwan
| | - Hei-Tung Yip
- Management office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, No. 155, Section 2, Li-Nong Street, Taipei 112, Taipei, Taiwan.
| | - Kai-Cheng Hsu
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
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Driggers KE, Dishman SE, Chung KK, Olsen CH, Ryan AB, McLawhorn MM, Johnson LS. Perceptions of care following initiation of do-not-resuscitate orders. J Crit Care 2022; 69:154008. [DOI: 10.1016/j.jcrc.2022.154008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 01/29/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022]
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Jain V, Farooqui A, Roman Casul YA, Nagaraja N. Clinical and Imaging Features Associated with the Utilization of Comfort Measures Only in Acute Ischemic Stroke. J Palliat Med 2022; 25:405-412. [PMID: 34704842 PMCID: PMC8968838 DOI: 10.1089/jpm.2021.0294] [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: 01/22/2023] Open
Abstract
Objectives: Up to 10% of acute ischemic stroke (AIS) patients can die in the first 30 days. Older age and a higher National Institutes of Health Stroke Scale (NIHSS) score are associated with transition to comfort measures only (CMO) in AIS. There are insufficient data on specific stroke etiology, infarct location, or vascular territory for the association of AIS with the use of CMO. We therefore evaluated the clinical and imaging factors associated with utilization of CMO and their outcomes. Methods: AIS patients seen in an academic comprehensive stroke center in the United States between July 1, 2015, and June 30, 2016, were subgrouped based on the use of CMO orders (CMO vs. non-CMO) during hospitalization. Clinical, laboratory, and imaging data were analyzed. Multivariable logistic regression analysis was performed, adjusting for pertinent covariates. Results: The study consisted of 296 patients, 27 (9%) patients were transitioned to CMO. Compared with non-CMO patients, those with CMO were older (mean ± standard deviation: 66 ± 15 vs. 75 ± 11 years, p = 0.002). Hemorrhagic transformation of AIS was more likely in CMO (17% vs. 41%, p = 0.0030) compared with non-CMO patients. On multivariate analysis, severe stroke measured by the NIHSS score (odds ratio [OR] = 1.2; 95% confidence interval [CI] = 1.1-1.4), infarction of the insular cortex (OR = 12.9; 95% CI = 1.4-118.4), and presence of cerebral edema with herniation (OR = 9.4; 95% CI = 2.5-35.5) were associated with transition to CMO. Conclusions: The presence of severe stroke, infarction of the insular cortex, and cerebral edema with herniation were associated with utilization of CMO in AIS. Impairment of multiple neurological functions served by the insular cortex could play a role in transition to CMO.
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Affiliation(s)
- Varun Jain
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Amreen Farooqui
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Yoram A. Roman Casul
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA.,Address correspondence to: Nandakumar Nagaraja, MD, MS, FAHA, Department of Neurology, Penn State Health, Milton S. Hershey Medical Center, 30 Hope Drive, Suite 2800, PO Box 859, Hershey, PA 17033, USA
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Avidan A, Sprung CL, Schefold JC, Ricou B, Hartog CS, Nates JL, Jaschinski U, Lobo SM, Joynt GM, Lesieur O, Weiss M, Antonelli M, Bülow HH, Bocci MG, Robertsen A, Anstey MH, Estébanez-Montiel B, Lautrette A, Gruber A, Estella A, Mullick S, Sreedharan R, Michalsen A, Feldman C, Tisljar K, Posch M, Ovu S, Tamowicz B, Demoule A, DeKeyser Ganz F, Pargger H, Noto A, Metnitz P, Zubek L, de la Guardia V, Danbury CM, Szűcs O, Protti A, Filipe M, Simpson SQ, Green C, Giannini AM, Soliman IW, Piras C, Caser EB, Hache-Marliere M, Mentzelopoulos SD. Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study. THE LANCET RESPIRATORY MEDICINE 2021; 9:1101-1110. [PMID: 34364537 DOI: 10.1016/s2213-2600(21)00261-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING None.
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Affiliation(s)
- Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Joerg C Schefold
- Inselspital, Department of Intensive Care Medicine, University of Bern, Bern, Switzerland
| | - Bara Ricou
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany, and Klinik Bavaria, Kreischa, Germany
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ulrich Jaschinski
- Department of Anesthesiology and Critical Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Suzana M Lobo
- Intensive Care Division, São José do Rio Preto School of Medicine, São Jose do Rio Preto, São Paulo, Brazil
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - Olivier Lesieur
- Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
| | - Manfred Weiss
- Clinic of Anaesthesiology and Intensive Care Medicine, University Hospital Medical School, Ulm, Germany
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Hans-Henrik Bülow
- Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark
| | - Maria G Bocci
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Annette Robertsen
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | | | | | - Alexandre Lautrette
- Medical Intensive Care Unit, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Anastasiia Gruber
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Angel Estella
- Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain
| | | | - Roshni Sreedharan
- Department of General Anesthesiology, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrej Michalsen
- Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany
| | - Charles Feldman
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kai Tisljar
- Intensive Care Unit, University Hospital and University of Basel, Basel, Switzerland
| | - Martin Posch
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Steven Ovu
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara Tamowicz
- Faculty of Health Sciences, Poznan University of Medical Sciences, Poznań, Poland
| | - Alexandre Demoule
- Service de Médecine intensive- Réanimation, AP-HP Sorbonne Université, Site Pitié-Salpêtrière, and UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, Paris, France
| | - Freda DeKeyser Ganz
- Hadassah Hebrew University School of Nursing and Jerusalem College of Technology, Faculty of Life and Health Sciences, Jerusalem, Israel
| | - Hans Pargger
- Intensive Care Unit, University Hospital and University of Basel, Basel, Switzerland
| | - Alberto Noto
- Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", Division of Anesthesia and Intensive Care, University of Messina, Messina, Italy
| | - Philipp Metnitz
- Department of General Anaesthesiology, Emergency and Intensive Care Medicine, LKH-University Hospital of Graz, Graz, Austria
| | - Laszlo Zubek
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Veronica de la Guardia
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Orsolya Szűcs
- 1st Department of Surgery and Interventional Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Alessandro Protti
- Department of Anesthesia, Intensive Care, and Emergency Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Filipe
- Department of Anesthesiology and Critical Care Medicine, DPC Hospital Budapest, Semmelweis University, Budapest, Hungary
| | - Steven Q Simpson
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas, Kansas City, KS, USA
| | - Cameron Green
- Department of Intensive Care, Peninsula Health, Melbourne, VIC, Australia
| | - Alberto M Giannini
- Division of Pediatric Anesthesia and Intensive Care, ASST-Spedali Civili, Brescia, Italy
| | - Ivo W Soliman
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Eliana B Caser
- Department of Internal Medicine, University Federal do Espírito Santo, Espírito Santo, Brazil
| | - Manuel Hache-Marliere
- Department of Critical Care Medicine, CEDIMAT, Santo Domingo, Dominican Republic, and Department of Internal Medicine, Jacobi Medical Center-AECOM, Bronx, NY, USA
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
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Kelly PA, Baker KA, Hodges KM, Vuong EY, Lee JC, Lockwood SW. Original Research: Nurses' Perspectives on Caring for Patients with Do-Not-Resuscitate Orders. Am J Nurs 2021; 121:26-36. [PMID: 33350694 DOI: 10.1097/01.naj.0000731652.86224.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Confusion about what a do-not-resuscitate (DNR) order means, including its misinterpretation as "do not treat," has been extensively documented in the literature. Yet there is a paucity of research concerning nurses' perspectives on DNR orders. PURPOSE AND DESIGN This mixed-methods study was designed to explore nurses' perspectives on the meaning and interpretation of DNR orders in relation to caring for hospitalized adults with such orders. METHODS Direct care nurses on three units in a large urban hospital were asked to respond online to a case study by indicating how they would prioritize care based on the patient's DNR designation. These nurses were then invited to participate in open-ended interviews with a nurse researcher. Interviews were audiotaped, transcribed, and analyzed. FINDINGS A total of 35 nurses responded to the case study survey. The majority chose to prioritize palliative care, despite no indication that any plan of care was in place. Thirteen nurses also completed a one-on-one interview. Analysis of interview data revealed this overarching theme: varying interpretations of DNR orders among nurses were common, resulting in unintended consequences. Participants also reported perceived variances among health care team members, patients, and family members. Such misinterpretations resulted in shifts in care, varying responses to deteriorating status, tension, and differences in role expectations for health care team members. CONCLUSIONS Nurses have opportunities to address misconceptions about care for patients with DNR orders through practice, education, advocacy and policy, and research.
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Affiliation(s)
- Patricia A Kelly
- Patricia A. Kelly is a research and evidence-based practice translationist at Texas Health Presbyterian Hospital Dallas, where Karen M. Hodges is a direct care nurse and Joyce C. Lee is a nurse manager. Kathy A. Baker is an associate professor and director of nursing research and scholarship at Texas Christian University Harris College of Nursing and Health Sciences, Fort Worth, where Suzy W. Lockwood is a professor and associate dean of nursing and nurse anesthesia. Ellen Y. Vuong is a clinical educator at Texas Health Resources University, Arlington. Funding for transcription services was provided by the Texas Health Resources Foundation. Contact author: Patricia A. Kelly, . The authors have disclosed no potential conflicts of interest, financial or otherwise
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Sutter R, Meyer-Zehnder B, Baumann SM, Marsch S, Pargger H. Advance Directives in the Neurocritically Ill: A Systematic Review. Crit Care Med 2020; 48:1188-1195. [PMID: 32697490 DOI: 10.1097/ccm.0000000000004388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the frequency of advance directives or directives disclosed by healthcare agents and their influence on decisions to withdraw/withhold life-sustaining care in neurocritically ill adults. DATA SOURCES PubMed, Embase, and Cochrane databases. STUDY SELECTION Screening was performed using predefined search terms to identify studies describing directives of neurocritically ill patients from 2000 to 2019. The review was registered prior to the screening process (International Prospective Register of Systematic Reviews identification number 149185). DATA EXTRACTION Data were collected using standardized forms. Primary outcomes were the frequency of directives and associated withholding/withdrawal of life-sustaining care. DATA SYNTHESIS Out of 721 articles, 25 studies were included representing 35,717 patients. The number of studies and cohort sizes increased over time. A median of 39% (interquartile range, 14-72%) of patients had directives and/or healthcare agents. The presence of directives was described in patients with stroke, status epilepticus, neurodegenerative disorders, neurotrauma, and neoplasms, with stroke patients representing the largest subgroup. Directives were more frequent among patients with neurodegenerative disorders compared with patients with other illnesses (p = 0.043). In reference to directives, care was adapted in 71% of European, 50% of Asian, and 42% of American studies, and was withheld or withdrawn more frequently over time with a median of 58% (interquartile range, 39-89%). Physicians withheld resuscitation in reference to directives in a median of 24% (interquartile range, 22-70%). CONCLUSIONS Studies regarding the use and translation of directives in neurocritically ill patients are increasing. In reference to directives, care was adapted in up to 71%, withheld or withdrawn in 58%, and resuscitation was withheld in every fourth patient, but the quality of evidence regarding their effects on critical care remains weak and the risk of bias high. The limited number of patients having directives is worrisome and studies aiming to increase the use and translation of directives are scarce. Efforts need to be made to increase the perception, use, and translation of directives of the neurocritically ill.
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Affiliation(s)
- Raoul Sutter
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | | | | | - Stephan Marsch
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Hans Pargger
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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9
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Abstract
Although do-not-resuscitate orders only prohibit cardiopulmonary resuscitation in the case of cardiac arrest, the common initiation of this code status in the context of end-of-life care may lead providers to draw premature conclusions about other goals of care. The aim of this study is to identify concerns regarding care quality in the setting of do-not-resuscitate orders within the Department of Defense and compare differences in perceptions between members of the critical care team. Design A cross sectional observational study was conducted. Setting This study took place in the setting of critical care within the Department of Defense. Subjects All members of the Uniformed Services Section of the Society of Critical Care Medicine were invited to participate. Interventions A validated 31-question survey exploring the perceptions of care quality in the setting of do-not-resuscitate status was distributed. Measurements and Main Results Exploratory factor analysis was used to categorically group survey questions, and average factor scores were compared between respondent groups using t tests. Responses to individual questions were also analyzed between comparison groups using Fisher exact tests. Factor analysis revealed no significant differences between respondents of different training backgrounds; however, those with do-not-resuscitate training were more likely to agree that active treatment would be pursued (p = 0.024) and that trust and communication would be maintained (p = 0.005). Although 38% of all respondents worry that quality of care will decrease, 93% agree that life-prolonging treatments should be offered. About a third of providers wrongly believed that a do-not-resuscitate order must be reversed prior to an operation. Conclusions Although providers across training backgrounds held similar concerns about decreased care quality in the ICU, there is wide belief that the routine and noninvasive interventions are offered as indicated. Those with do-not-resuscitate training were more likely to believe that standards of care continued to be met after code status change.
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10
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Chang YC, Fang YT, Chen HC, Lin CY, Chang YP, Chen YM, Huang CH, Huang KT, Chang HC, Su MC, Wang YH, Wang CC, Lin MC, Fang WF. Effect of do-not-resuscitate orders on patients with sepsis in the medical intensive care unit: a retrospective, observational and propensity score-matched study in a tertiary referral hospital in Taiwan. BMJ Open 2019; 9:e029041. [PMID: 31209094 PMCID: PMC6589004 DOI: 10.1136/bmjopen-2019-029041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine whether do-not-resuscitate (DNR) orders affect outcomes in patients with sepsis admitted to intensive care unit (ICU). DESIGN This is a retrospective observational study. PARTICIPANTS We enrolled 796 consecutive adult intensive care patients at Kaohsiung Chang Gung Memorial Hospital, a 2700-bed tertiary teaching hospital in southern Taiwan. A total of 717 patients were included. MAIN MEASURES Clinical factors such as age, gender and other clinical factors possibly related to DNR orders and hospital mortality were recorded. KEY RESULTS There were 455 patients in the group without DNR orders and 262 patients in the group with DNR orders. Within the DNR group, patients were further grouped into early (orders signed on intensive care day 1, n=126) and late (signed after day 1, n=136). Patients in the DNR group were older and more likely to have malignancy than the group without DNR orders. Mortality at days 7, 14 and 28, as well as intensive care and hospital mortality, were all worse in these patients even after propensity-score matching. There were higher Charlson Comorbidity Index in the emergency room, but better outcomes in those with early-DNR orders compared with late-DNR orders. CONCLUSIONS DNR orders may predict worse outcomes for patients with sepsis admitted to medical ICUs. The survival rate in the early-DNR order group was not inferior to the late-DNR order group.
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Affiliation(s)
- Ya-Chun Chang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Tang Fang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hung-Cheng Chen
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chiung-Yu Lin
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Ping Chang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Mu Chen
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chi-Han Huang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Tung Huang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Huang-Chih Chang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mao-Chang Su
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yi-Hsi Wang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chin-Chou Wang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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11
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Hill J, Gerace A, Oster C, Ullah S. Resuscitation status in psychogeriatric and general medical inpatients aged 65 years and older: a retrospective comparison study. AUST HEALTH REV 2018; 43:432-440. [PMID: 30103850 DOI: 10.1071/ah18004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 02/04/2018] [Indexed: 11/23/2022]
Abstract
Objective The aims of the present study were to establish rates of resuscitation order documentation of patients aged ≥65 years from both psychogeriatric and general medical units and to compare patients on predictors of resuscitation status, particularly examining the effect of depression. Methods A retrospective case note audit of psychogeriatric (n=162) and general medical (n=135) unit admissions within a tertiary teaching hospital was performed. Multivariate logistic regression was used to determine significant clinical and demographic predictors of resuscitation status. Results Resuscitation orders were documented in more psychogeriatric (94.4%) than general medical (48.1%) files. Depression did not significantly predict resuscitation status in either group. Having undergone competency assessment significantly predicted resuscitation status for the total sample and separately for psychogeriatric and medical patients. Older age (overall sample), poorer prognosis (overall sample), living in residential care (overall sample and medical group) and self-consenting to resuscitation status (overall sample and medical group) significantly predicted resuscitation status. Conclusions Resuscitation orders were more frequently documented on the psychogeriatric unit. Further prospective analysis is needed of how resuscitation orders are made before depression is discounted as a predictor of end-of-life decision-making. What is known about the topic? Despite increased community, media and research attention to end-of-life decision-making, resuscitation preferences of older patients are often poorly documented. Existing research into patient clinical and demographic factors that influence end-of-life decision-making have largely focused on general medical rather than psychogeriatric settings. There is a need to investigate rates of resuscitation documentation in psychogeriatric and general medical units and specific factors associated with having a 'do not attempt resuscitation' order in place, particularly the effect of current depression on decision-making. What does this paper add? Resuscitation orders were more frequently documented on the psychogeriatric than medical unit. Depression was not a significant predictor of resuscitation status in either group of patients. Although having undergone a competency assessment, older age and poorer prognosis predicted not being for resuscitation for the total sample, living in residential care and self-consenting to resuscitation status predicted not being for resuscitation for the overall sample and the medical group specifically. What are the implications for practitioners? This paper suggests that the need for clinicians to ensure documentation of preferences is a focus of day-to-day work with older patients. Clinicians should consider patient competency in end-of-life decision-making and how factors associated with depression, such as helplessness, may be more closely related to resuscitation decision-making in older patients.
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Affiliation(s)
- Jo Hill
- Older Persons Mental Health Services, Repatriation General Hospital, 216 Daws Road, Daw Park, SA 5041, Australia
| | - Adam Gerace
- College of Nursing and Health Sciences, Flinders University of South Australia, GPO Box 2100, Adelaide, SA 5001, Australia.
| | - Candice Oster
- College of Nursing and Health Sciences, Flinders University of South Australia, GPO Box 2100, Adelaide, SA 5001, Australia.
| | - Shahid Ullah
- College of Nursing and Health Sciences, Flinders University of South Australia, GPO Box 2100, Adelaide, SA 5001, Australia.
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12
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Thompson MP, Zhao X, Bekelis K, Gottlieb DJ, Fonarow GC, Schulte PJ, Xian Y, Lytle BL, Schwamm LH, Smith EE, Reeves MJ. Regional Variation in 30-Day Ischemic Stroke Outcomes for Medicare Beneficiaries Treated in Get With The Guidelines-Stroke Hospitals. Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.117.003604. [PMID: 28798017 DOI: 10.1161/circoutcomes.117.003604] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 07/06/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND We explored regional variation in 30-day ischemic stroke mortality and readmission rates and the extent to which regional differences in patients, hospitals, healthcare resources, and a quality of care composite care measure explain the observed variation. METHODS AND RESULTS This ecological analysis aggregated patient and hospital characteristics from the Get With The Guidelines-Stroke registry (2007-2011), healthcare resource data from the Dartmouth Atlas of Health Care (2006), and Medicare fee-for-service data on 30-day mortality and readmissions (2007-2011) to the hospital referral region (HRR) level. We used linear regression to estimate adjusted HRR-level 30-day outcomes, to identify HRR-level characteristics associated with 30-day outcomes, and to describe which characteristics explained variation in 30-day outcomes. The mean adjusted HRR-level 30-day mortality and readmission rates were 10.3% (SD=1.1%) and 13.1% (SD=1.1%), respectively; a modest, negative correlation (r=-0.17; P=0.003) was found between one another. Demographics explained more variation in readmissions than mortality (25% versus 6%), but after accounting for demographics, comorbidities accounted for more variation in mortality compared with readmission rates (17% versus 7%). The combination of hospital characteristics and healthcare resources explained 11% and 16% of the variance in mortality and readmission rates, beyond patient characteristics. Most of the regional variation in mortality (65%) and readmission (50%) rates remained unexplained. CONCLUSIONS Thirty-day mortality and readmission rates vary substantially across HRRs and exhibit an inverse relationship. While regional variation in 30-day outcomes were explained by patient and hospital factors differently, much of the regional variation in both outcomes remains unexplained.
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Affiliation(s)
- Michael P Thompson
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.).
| | - Xin Zhao
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Kimon Bekelis
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Daniel J Gottlieb
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Gregg C Fonarow
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Phillip J Schulte
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Ying Xian
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Barbara L Lytle
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Lee H Schwamm
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Eric E Smith
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Mathew J Reeves
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
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13
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Patel K, Sinvani L, Patel V, Kozikowski A, Smilios C, Akerman M, Kiszko K, Maiti S, Hajizadeh N, Wolf‐Klein G, Pekmezaris R. Do‐Not‐Resuscitate Orders in Older Adults During Hospitalization: A Propensity Score–Matched Analysis. J Am Geriatr Soc 2018; 66:924-929. [DOI: 10.1111/jgs.15347] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Karishma Patel
- Division of Hospital Medicine, Department of MedicineNorthwell HealthManhasset New York
| | - Liron Sinvani
- Division of Hospital Medicine, Department of MedicineNorthwell HealthManhasset New York
| | - Vidhi Patel
- Division of Health Services Research, Department of MedicineCenter for Health Innovations and Outcomes ResearchManhasset New York
| | - Andrzej Kozikowski
- Division of Health Services Research, Department of MedicineCenter for Health Innovations and Outcomes ResearchManhasset New York
| | - Christopher Smilios
- Division of Health Services Research, Department of MedicineCenter for Health Innovations and Outcomes ResearchManhasset New York
| | | | - Kinga Kiszko
- Division of Hospital Medicine, Department of MedicineNorthwell HealthManhasset New York
| | - Sutapa Maiti
- Division of Hospital Medicine, Department of MedicineNorthwell HealthManhasset New York
| | - Negin Hajizadeh
- Division of Health Services Research, Department of MedicineCenter for Health Innovations and Outcomes ResearchManhasset New York
| | - Gisele Wolf‐Klein
- Division of Hospital Medicine, Department of MedicineNorthwell HealthManhasset New York
- Division of Geriatric and Palliative Medicine, Department of MedicineNorthwell HealthManhasset New York
| | - Renee Pekmezaris
- Division of Health Services Research, Department of MedicineCenter for Health Innovations and Outcomes ResearchManhasset New York
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14
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Singh T, Peters SR, Tirschwell DL, Creutzfeldt CJ. Palliative Care for Hospitalized Patients With Stroke: Results From the 2010 to 2012 National Inpatient Sample. Stroke 2017; 48:2534-2540. [PMID: 28818864 PMCID: PMC5571885 DOI: 10.1161/strokeaha.117.016893] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Substantial variability exists in the use of life-prolonging treatments for patients with stroke, especially near the end of life. This study explores patterns of palliative care utilization and death in hospitalized patients with stroke across the United States. METHODS Using the 2010 to 2012 nationwide inpatient sample databases, we included all patients discharged with stroke identified by International Classification of Diseases-Ninth Revision codes. Strokes were subclassified as ischemic, intracerebral, and subarachnoid hemorrhage. We compared demographics, comorbidities, procedures, and outcomes between patients with and without a palliative care encounter (PCE) as defined by the International Classification of Diseases-Ninth Revision code V66.7. Pearson χ2 test was used for categorical variables. Multivariate logistic regression was used to account for hospital, regional, payer, and medical severity factors to predict PCE use and death. RESULTS Among 395 411 patients with stroke, PCE was used in 6.2% with an increasing trend over time (P<0.05). We found a wide range in PCE use with higher rates in patients with older age, hemorrhagic stroke types, women, and white race (all P<0.001). Smaller and for-profit hospitals saw lower rates. Overall, 9.2% of hospitalized patients with stroke died, and PCE was significantly associated with death. Length of stay in decedents was shorter for patients who received PCE. CONCLUSIONS Palliative care use is increasing nationally for patients with stroke, especially in larger hospitals. Persistent disparities in PCE use and mortality exist in regards to age, sex, race, region, and hospital characteristics. Given the variations in PCE use, especially at the end of life, the use of mortality rates as a hospital quality measure is questioned.
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Affiliation(s)
- Tarvinder Singh
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle.
| | - Steven R Peters
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| | - David L Tirschwell
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| | - Claire J Creutzfeldt
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
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15
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Pinto P, Brown T, Khilkin M, Chuang E. Patient Outcomes After Palliative Care Consultation Among Patients Undergoing Therapeutic Hypothermia. Am J Hosp Palliat Care 2017; 35:570-573. [PMID: 28789562 DOI: 10.1177/1049909117724779] [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: 11/16/2022] Open
Abstract
OBJECTIVES To compare the clinical outcomes of patients who did and did not receive palliative care consultation among those who experienced out-of-hospital cardiac arrest and underwent therapeutic hypothermia. METHODS We identified patients at a single academic medical center who had undergone therapeutic hypothermia after out-of-hospital cardiac arrest between 2009 and 2013. We performed a retrospective chart review for demographic data, hospital and critical care length of stay, and clinical outcomes of care. RESULTS We reviewed the charts of 62 patients, of which 35 (56%) received a palliative care consultation and 27 (44%) did not. Palliative care consultation occurred an average of 8.3 days after admission. Patients receiving palliative care consultation were more likely to have a do-not-resuscitate (DNR) order placed (odds ratio: 2.3, P < .001). The mean length of stay in the hospital was similar for patients seen by palliative care or not (16.7 vs 17.1 days, P = .90). Intensive care length of stay was also similar (11.3 vs 12.6 days, P = .55). CONCLUSIONS Palliative care consultation was underutilized and utilized late in this cohort. Palliative consultation was associated with DNR orders but did not affect measures of utilization such as hospital and intensive care length of stay.
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Affiliation(s)
- Priya Pinto
- 1 Division of Palliative Medicine and Bioethics, Winthrop University Hospital, Mineola, NY, USA
| | - Tartania Brown
- 2 Wyckoff Hospital, MJHS Hospice and Palliative Care, Brooklyn, NY, USA
| | - Michael Khilkin
- 3 Department of Critical Care Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Elizabeth Chuang
- 4 Hospice and Palliative Medicine, Department of Family and Social Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
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16
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Prabhakaran S, Cox M, Lytle B, Schulte PJ, Xian Y, Zahuranec D, Smith EE, Reeves M, Fonarow GC, Schwamm LH. Early transition to comfort measures only in acute stroke patients: Analysis from the Get With The Guidelines-Stroke registry. Neurol Clin Pract 2017; 7:194-204. [PMID: 28680764 DOI: 10.1212/cpj.0000000000000358] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/10/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Death after acute stroke often occurs after forgoing life-sustaining interventions. We sought to determine the patient and hospital characteristics associated with an early decision to transition to comfort measures only (CMO) after ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) in the Get With The Guidelines-Stroke registry. METHODS We identified patients with IS, ICH, or SAH between November 2009 and September 2013 who met study criteria. Early CMO was defined as the withdrawal of life-sustaining treatments and interventions by hospital day 0 or 1. Using multivariable logistic regression, we identified patient and hospital factors associated with an early (by hospital day 0 or 1) CMO order. RESULTS Among 963,525 patients from 1,675 hospitals, 54,794 (5.6%) had an early CMO order (IS: 3.0%; ICH: 19.4%; SAH: 13.1%). Early CMO use varied widely by hospital (range 0.6%-37.6% overall) and declined over time (from 6.1% in 2009 to 5.4% in 2013; p < 0.001). In multivariable analysis, older age, female sex, white race, Medicaid and self-pay/no insurance, arrival by ambulance, arrival off-hours, baseline nonambulatory status, and stroke type were independently associated with early CMO use (vs no early CMO). The correlation between hospital-level risk-adjusted mortality and the use of early CMO was stronger for SAH (r = 0.52) and ICH (r = 0.50) than AIS (r = 0.15) patients. CONCLUSIONS Early CMO was utilized in about 5% of stroke patients, being more common in ICH and SAH than IS. Early CMO use varies widely between hospitals and is influenced by patient and hospital characteristics.
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Affiliation(s)
- Shyam Prabhakaran
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Margueritte Cox
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Barbara Lytle
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Phillip J Schulte
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Ying Xian
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Darin Zahuranec
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Eric E Smith
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Mathew Reeves
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Gregg C Fonarow
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Lee H Schwamm
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
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Mahajan A, Patel A, Nadkarni G, Sidiropoulos C. Are hospitalized Parkinson’s disease patients more likely to carry a do-not-resuscitate order? J Clin Neurosci 2017; 37:57-58. [DOI: 10.1016/j.jocn.2016.10.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/16/2016] [Indexed: 10/20/2022]
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18
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Family discussions on life-sustaining interventions in neurocritical care. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:397-408. [PMID: 28187812 DOI: 10.1016/b978-0-444-63600-3.00022-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Approximately 20% of all deaths in the USA occur in the intensive care unit (ICU) and the majority of ICU deaths involves decision of de-escalation of life-sustaining interventions. Life-sustaining interventions may include intubation and mechanical ventilation, artificial nutrition and hydration, antibiotic treatment, brain surgery, or vasoactive support. Decision making about goals of care can be defined as an end-of-life communication and the decision-making process between a clinician and a patient (or a surrogate decision maker if the patient is incapable) in an institutional setting to establish a plan of care. This process includes deciding whether to use life-sustaining treatments. Therefore, family discussion is a critical element in the decision-making process throughout the patient's stay in the neurocritical care unit. A large part of care in the neurosciences intensive care unit is discussion of proportionality of care. This chapter provides a stepwise approach to hold these conferences and discusses ways to do it effectively.
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Nathaniel TI, Cochran T, Chaves J, Fulmer E, Sosa C, Yi S, Fredwall M, Sternberg S, Blackhurst D, Nelson A, Leacock R. Co-morbid conditions in use of recombinant tissue plasminogen activator (rt-PA) for the treatment of acute ischaemic stroke. Brain Inj 2016; 30:1261-5. [DOI: 10.1080/02699052.2016.1186840] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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20
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Alonso A, Ebert AD, Dörr D, Buchheidt D, Hennerici MG, Szabo K. End-of-life decisions in acute stroke patients: an observational cohort study. BMC Palliat Care 2016; 15:38. [PMID: 27044257 PMCID: PMC4820928 DOI: 10.1186/s12904-016-0113-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 03/23/2016] [Indexed: 11/11/2022] Open
Abstract
Background Crucial issues of modern stroke care include best practice end-of-life-decision (EOLD)-making procedures and the provision of high-quality palliative care for dying stroke patients. Methods We retrospectively analyzed records of those patients who died over a 4-year period (2011–2014) on our Stroke Unit concerning EOLD, focusing on the factors that most probably guided decisions to induce limitation of life-sustaining therapy and subsequently end-of-life-care procedures thereafter. Results Of all patients treated at our Stroke Unit, 120 (2.71 %) died. In 101 (86.3 %), a do-not-resuscitate-order (DNRO) was made during early treatment. A decision to withdraw/withhold further life supportive therapy was made in 40 patients (34.2 %) after a mean of 5.0 days (range 0–29). Overall patient death occurred after a mean time of 7.0 days (range 1–30) and 2.6 days after therapy restrictions. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke were possible indicators of decisions to therapeutic withdrawing/withholding. Proceedings of EOL care in these patients were heterogeneous; in most cases monitoring (95 %), medical procedures (90 %), oral medication (88 %), parenteral nutrition (98 %) and antibiotic therapy (86 %) were either not ordered or withdrawn, however IV fluids were continued in all patients. Conclusions A high percentage of stroke patients were rated as terminally ill and died in the course of caregiving. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke facilitated decisions to change therapeutic goals thus initiating end-of-life-care. However, there is further need to foster research on this field in order to ameliorate outcome prognostication, to understand the dynamics of EOLD-making procedures and to educate staff to provide high-quality patient-centred palliative care in stroke medicine. Electronic supplementary material The online version of this article (doi:10.1186/s12904-016-0113-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Angelika Alonso
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany.
| | - Anne D Ebert
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Dorothee Dörr
- Health Care Ethics Committee, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Michael G Hennerici
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
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Patel AA, Mahajan A, Benjo A, Jani VB, Annapureddy N, Agarwal SK, Simoes PK, Pakanati KC, Sinha V, Konstantinidis I, Pathak A, Nadkarni GN. A National Perspective of Do-Not-Resuscitate Order Utilization Predictors in Intracerebral Hemorrhage. Neurohospitalist 2016; 6:7-10. [PMID: 26753051 DOI: 10.1177/1941874415599577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Nontraumatic intracerebral hemorrhage (ICH) is associated with substantial morbidity and mortality. Do-not-resuscitate (DNR) orders are linked to poorer outcomes in patients with ICH, possibly due to less active management. Demographic, regional, and social factors, not related to ICH severity, have not been adequately looked at as significant predictors of DNR utilization. We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database in 2011 for adult ICH admissions and DNR status. We generated hierarchical 2-level multivariate regression models to estimate adjusted odds ratios. We analyzed 25 768 ICH hospitalizations, 18% of which (4620 hospitalizations) had DNR orders, corresponding to national estimates of 126 254 and 22 668, respectively. In multivariable regression, female gender, white or Hispanic/Latino ethnicity, no insurance coverage, and teaching hospitals were significantly associated with increased DNR utilization after adjusting for confounders. There was also significantly more interhospital variability in the lowest quartile of hospital volume. In conclusion, demographic factors and insurance status are significantly associated with increased DNR utilization, with more individual hospital variability in low-volume hospitals. The reasons for this are likely qualitative and linked to patient, provider, and hospital practices.
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Affiliation(s)
- Achint A Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Alexandre Benjo
- Division of Cardiology, Oschner Clinic Foundation, New Orleans, LA, USA
| | - Vishal B Jani
- Department of Neurology, Michigan State University, East Lansing, MI, USA
| | - Narender Annapureddy
- Division of Rheumatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shiv Kumar Agarwal
- Division of Cardiology, University of Arkansas Medical Sciences, Little Rock, AR, USA
| | - Priya K Simoes
- Department of Medicine, St. Luke's Roosevelt Medical Center at Mount Sinai, New York, NY, USA
| | | | - Vikash Sinha
- Division of Nephrology, University of Chicago, Chicago, IL, USA
| | | | - Ambarish Pathak
- Department of Public Health, New York Medical College, Valhalla, NY
| | - Girish N Nadkarni
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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22
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McAlister FA, Wang J, Donovan L, Lee DS, Armstrong PW, Tu JV. Influence of Patient Goals of Care on Performance Measures in Patients Hospitalized for Heart Failure: An Analysis of the Enhanced Feedback For Effective Cardiac Treatment (EFFECT) Registry. Circ Heart Fail 2015; 8:481-8. [PMID: 25669939 DOI: 10.1161/circheartfailure.114.001712] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 02/09/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pay for performance programs compare metrics that are risk-adjusted, but goals of care are not considered in current models. We conducted this study to explore the associations between do not resuscitate (DNR) designations, quality of care, and outcomes. METHODS AND RESULTS Retrospective cohort study with chart review for inpatient quality metrics, 30 day mortality, and readmissions or death within 30 days of discharge in 96 Ontario hospitals participating in the Enhanced Feedback For Effective Cardiac Treatment (EFFECT) study in 2004/05. Of 8339 patients (mean age 77 years) with new heart failure, 1220 (15%) had DNR documented at admission (admission DNR, varying from 0% to 36% between hospitals) and 892 (11%) were switched from full resuscitation to DNR during their index hospitalization (later DNR). Death at 30 days was more common in patients with admission DNR (27%) or later DNR (35%) than full resuscitation (3%)-admission DNR was a stronger predictor (adjusted OR 8.6, 95% confidence interval 6.8-10.7) than any of the variables currently included in heart failure 30 day mortality risk models. Hospital-level rankings differed considerably if DNR patients were excluded: 22 of the 39 EFFECT hospitals in the top and bottom quintiles for 30 day mortality rates (the usual thresholds for rewards/penalties in current performance-based reimbursement schemes) would not have been in those same quintiles if admission DNR patients were excluded. CONCLUSIONS Alternate goals of care are frequent and important confounders in heart failure comparative studies. Philosophy of care discussions should be considered for inclusion as a potential quality of care indicator.
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Affiliation(s)
- Finlay A McAlister
- From the Division of General Internal Medicine (F.A.M.) and Canadian VIGOUR Centre (F.A.M., P.W.A.), Department of Medicine, University of Alberta, Edmonton, Canada; Institute for Clinical Evaluative Sciences (J.W., D.S.L., J.V.T.) and Division of Cardiology, Department of Medicine, Sunnybrook Schulich Heart Centre (L.D., J.V.T.), University of Toronto, Canada; and Peter Munk Cardiac Centre, Division of Cardiology, and Joint Department of Medical Imaging, University Health Network, Toronto, Canada (D.S.L.).
| | - Julie Wang
- From the Division of General Internal Medicine (F.A.M.) and Canadian VIGOUR Centre (F.A.M., P.W.A.), Department of Medicine, University of Alberta, Edmonton, Canada; Institute for Clinical Evaluative Sciences (J.W., D.S.L., J.V.T.) and Division of Cardiology, Department of Medicine, Sunnybrook Schulich Heart Centre (L.D., J.V.T.), University of Toronto, Canada; and Peter Munk Cardiac Centre, Division of Cardiology, and Joint Department of Medical Imaging, University Health Network, Toronto, Canada (D.S.L.)
| | - Linda Donovan
- From the Division of General Internal Medicine (F.A.M.) and Canadian VIGOUR Centre (F.A.M., P.W.A.), Department of Medicine, University of Alberta, Edmonton, Canada; Institute for Clinical Evaluative Sciences (J.W., D.S.L., J.V.T.) and Division of Cardiology, Department of Medicine, Sunnybrook Schulich Heart Centre (L.D., J.V.T.), University of Toronto, Canada; and Peter Munk Cardiac Centre, Division of Cardiology, and Joint Department of Medical Imaging, University Health Network, Toronto, Canada (D.S.L.)
| | - Douglas S Lee
- From the Division of General Internal Medicine (F.A.M.) and Canadian VIGOUR Centre (F.A.M., P.W.A.), Department of Medicine, University of Alberta, Edmonton, Canada; Institute for Clinical Evaluative Sciences (J.W., D.S.L., J.V.T.) and Division of Cardiology, Department of Medicine, Sunnybrook Schulich Heart Centre (L.D., J.V.T.), University of Toronto, Canada; and Peter Munk Cardiac Centre, Division of Cardiology, and Joint Department of Medical Imaging, University Health Network, Toronto, Canada (D.S.L.)
| | - Paul W Armstrong
- From the Division of General Internal Medicine (F.A.M.) and Canadian VIGOUR Centre (F.A.M., P.W.A.), Department of Medicine, University of Alberta, Edmonton, Canada; Institute for Clinical Evaluative Sciences (J.W., D.S.L., J.V.T.) and Division of Cardiology, Department of Medicine, Sunnybrook Schulich Heart Centre (L.D., J.V.T.), University of Toronto, Canada; and Peter Munk Cardiac Centre, Division of Cardiology, and Joint Department of Medical Imaging, University Health Network, Toronto, Canada (D.S.L.)
| | - Jack V Tu
- From the Division of General Internal Medicine (F.A.M.) and Canadian VIGOUR Centre (F.A.M., P.W.A.), Department of Medicine, University of Alberta, Edmonton, Canada; Institute for Clinical Evaluative Sciences (J.W., D.S.L., J.V.T.) and Division of Cardiology, Department of Medicine, Sunnybrook Schulich Heart Centre (L.D., J.V.T.), University of Toronto, Canada; and Peter Munk Cardiac Centre, Division of Cardiology, and Joint Department of Medical Imaging, University Health Network, Toronto, Canada (D.S.L.)
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Chao TH, Hsieh TJ, Wang V. "Do not resuscitate" orders among deceased patients who received acute neurological care: an observation analysis. Medicine (Baltimore) 2014; 93:e343. [PMID: 25546685 PMCID: PMC4602613 DOI: 10.1097/md.0000000000000343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
There were many reports about the "do not resuscitate" (DNR) order while practicing in the critical care units and conducting hospice affairs but limited in the neurological issues. This study investigated the possible flaws in the execution of the DNR order among patients who received acute neurological care in Taiwan. Over a 3-year period, we retrospectively reviewed the medical records of 77 deceased patients with neurological conditions for DNR orders. Registry and analysis works included demography, hospital courses, DNR data, and clinical usefulness of the lab and image examinations. Sixty-seven DNR orders were requested by the patients' families, and more than half were signed by the patients' children or grandchildren. The main DNR items were chest compression, cardiac defibrillation, and pacemaker use, although several DNR patients received resuscitation. The mean duration from the coding date to death was 7.6 days. Two-thirds of the patients with DNR requests remained in the intensive care unit, with a mean stay of 6.9 days. Several patients underwent regular roentgenography and blood tests on the day of their death, despite their DNR orders. Hospital courses and DNR items may be valuable information on dealing with the patients with DNR orders. The results of this study also suggest the public education about the DNR orders implemented for neurological illnesses.
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Affiliation(s)
- Tzu-Hao Chao
- From the School of Medicine, Fu Jen Catholic University (THC, VW); Department of Neurology (THC, VW), and Department of Family Medicine (TJH), Cardinal Tien, College of Medicine, Hospital, Xindian District, New Taipei City, Taiwan
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24
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Xian Y, Holloway RG, Smith EE, Schwamm LH, Reeves MJ, Bhatt DL, Schulte PJ, Cox M, Olson DM, Hernandez AF, Lytle BL, Anstrom KJ, Fonarow GC, Peterson ED. Racial/Ethnic differences in process of care and outcomes among patients hospitalized with intracerebral hemorrhage. Stroke 2014; 45:3243-50. [PMID: 25213344 DOI: 10.1161/strokeaha.114.005620] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although racial/ethnic differences in care are pervasive in many areas of medicine, little is known whether intracerebral hemorrhage (ICH) care processes or outcomes differ by race/ethnicity. METHODS We analyzed 123 623 patients with ICH (83 216 white, 22 147 black, 10 519 Hispanic, and 7741 Asian) hospitalized at 1199 Get With The Guidelines-Stroke hospitals between 2003 and 2012. Multivariable logistic regression with generalized estimating equation was used to evaluate the association among race, stroke performance measures, and in-hospital outcomes. RESULTS Relative to white patients, black, Hispanic, and Asian patients were significantly younger, but more frequently had more severe stroke (median National Institutes of Health Stroke Scale, 9, 10, 10, and 11, respectively; P<0.001). After adjustment for both patient and hospital-level characteristics, black patients were more likely to receive deep venous thrombosis prophylaxis, rehabilitation assessment, dysphagia screening, and stroke education, but less likely to have door to computed tomographic time ≤25 minutes and smoking cessation counseling than whites. Both Hispanic and Asian patients had higher odds of dysphagia screening but lower odds of smoking cessation counseling. In-hospital all-cause mortality was lower for blacks (23.0%), Hispanics (22.8%), and Asians (25.3%) than for white patients (27.6%). After risk adjustment, all minority groups had lower odds of death, of receiving comfort measures only or of being discharged to hospice. In contrast, they were more likely to exceed the median length of stay when compared with white patients. CONCLUSIONS Although individual quality indicators in ICH varied by race/ethnicity, black, Hispanic, and Asian patients with ICH had lower risk-adjusted in-hospital mortality than white patients with ICH.
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Affiliation(s)
- Ying Xian
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.).
| | - Robert G Holloway
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Eric E Smith
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Lee H Schwamm
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Mathew J Reeves
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Deepak L Bhatt
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Phillip J Schulte
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Margueritte Cox
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - DaiWai M Olson
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Adrian F Hernandez
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Barbara L Lytle
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Kevin J Anstrom
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Gregg C Fonarow
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Eric D Peterson
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
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Brinkman-Stoppelenburg A, Rietjens JAC, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med 2014; 28:1000-25. [PMID: 24651708 DOI: 10.1177/0269216314526272] [Citation(s) in RCA: 864] [Impact Index Per Article: 86.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advance care planning is the process of discussing and recording patient preferences concerning goals of care for patients who may lose capacity or communication ability in the future. Advance care planning could potentially improve end-of-life care, but the methods/tools used are varied and of uncertain benefit. Outcome measures used in existing studies are highly variable. AIM To present an overview of studies on the effects of advance care planning and gain insight in the effectiveness of different types of advance care planning. DESIGN Systematic review. DATA SOURCES We systematically searched PubMed, EMBASE and PsycINFO databases for experimental and observational studies on the effects of advance care planning published in 2000-2012. RESULTS The search yielded 3571 papers, of which 113 were relevant for this review. For each study, the level of evidence was graded. Most studies were observational (95%), originated from the United States (81%) and were performed in hospitals (49%) or nursing homes (32%). Do-not-resuscitate orders (39%) and written advance directives (34%) were most often studied. Advance care planning was often found to decrease life-sustaining treatment, increase use of hospice and palliative care and prevent hospitalisation. Complex advance care planning interventions seem to increase compliance with patients' end-of-life wishes. CONCLUSION The effects of different types of advance care planning have been studied in various settings and populations using different outcome measures. There is evidence that advance care planning positively impacts the quality of end-of-life care. Complex advance care planning interventions may be more effective in meeting patients' preferences than written documents alone. More studies are needed with an experimental design, in different settings, including the community.
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Affiliation(s)
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW Medical decision-making in stroke patients can be complex and often involves ethical challenges, from the perspective of healthcare providers as well as patients and their families. Awareness of these challenges and knowledge of current ethical topics in stroke may improve the quality of care provided to stroke patients. RECENT FINDINGS Predictive scores are increasingly available to estimate prognosis following stroke, though their usefulness in decision-making for individual patients remains unclear. Medical decisions requiring a surrogate decision-maker can be challenging; surrogates may also be susceptible to systematic biases in their decision-making. Variations in care are common and possibly related to under-utilization or over-utilization of resources. However, patient preferences may explain some of the variability as well. Early mortality may be related to patient and family preferences regarding life-sustaining measures rather than the provision of care that is not well tolerated or evidence-based. SUMMARY Ethical challenges are common in the care of stroke patients. An effective understanding of these topics is essential for clinicians to deliver patient-centered, preference-sensitive care.
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Holloway RG, Arnold RM, Creutzfeldt CJ, Lewis EF, Lutz BJ, McCann RM, Rabinstein AA, Saposnik G, Sheth KN, Zahuranec DB, Zipfel GJ, Zorowitz RD. Palliative and End-of-Life Care in Stroke. Stroke 2014; 45:1887-916. [DOI: 10.1161/str.0000000000000015] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kelly AG, Zahuranec DB, Holloway RG, Morgenstern LB, Burke JF. Variation in do-not-resuscitate orders for patients with ischemic stroke: implications for national hospital comparisons. Stroke 2014; 45:822-7. [PMID: 24523035 DOI: 10.1161/strokeaha.113.004573] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Decisions on life-sustaining treatments and the use of do-not-resuscitate (DNR) orders can affect early mortality after stroke. We investigated the variation in early DNR use after stroke among hospitals in California and the effect of this variation on mortality-based hospital classifications. METHODS Using the California State Inpatient Database from 2005 to 2011, ischemic stroke admissions for patients aged≥50 years were identified. Cases were categorized by the presence or the absence of DNR orders within the first 24 hours of admission. Multilevel logistic regression models with a random hospital intercept were used to predict inpatient mortality after adjusting for comorbidities, vascular risk factors, and demographics. Hospital mortality rank order was assigned based on this model and compared with the results of a second model that included DNR status. RESULTS From 355 hospitals, 252,368 cases were identified, including 33,672 (13.3%) with early DNR. Hospital-level-adjusted use of DNR varied widely (quintile 1, 2.2% versus quintile 5, 23.2%). Hospitals with higher early DNR use had higher inpatient mortality because inpatient mortality more than doubled from quintile 1 (4.2%) to quintile 5 (8.7%). Failure to adjust for DNR orders resulted in substantial hospital reclassification across the rank spectrum, including among high mortality hospitals. CONCLUSIONS There is wide variation in the hospital-level proportion of ischemic stroke patients with early DNR orders; this variation affects hospital mortality estimates. Unless the circumstances of early DNR orders are better understood, mortality-based hospital comparisons may not reliably identify hospitals providing a lower quality of care.
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Affiliation(s)
- Adam G Kelly
- From the Department of Neurology, University of Rochester Medical Center, NY (A.G.K., R.G.H.); and Stroke Program, University of Michigan Health Systems, Ann Arbor (D.B.Z., L.B.M., J.F.B.)
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Abstract
In face of any severe stroke, the questions for health professionals in charge of the patient are: will the handicap be acceptable for the patient? But can we predict an acceptable handicap for the patient? For his family? When we know that the cognitive disorders, consequences of severe stroke often modify, in a major way, the behaviour of these patients? Given these difficulties for estimate vital and functional prognosis and even more the quality of life of patients with severe stroke, collective reflexions between physicians and nurses are essential, reflexions taking into account preferences and values of patients. Use of resuscitation resources for severe stroke patients implies to offer them the best rehabilitation. So, questions about health pathways for severe stroke are essential: which structures for these patients, which technologies, which medical, medico-social and social supports, which human accompaniment the society can propose to the patients and to their family, so that they have an acceptable quality of life.
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Affiliation(s)
- F Woimant
- Service de neurologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; Agence régionale de santé Île-de-France, 35, rue de la Gare, 75019 Paris, France.
| | - Y Biteye
- Agence régionale de santé Île-de-France, 35, rue de la Gare, 75019 Paris, France
| | - P Chaine
- Service de neurologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - S Crozier
- Service des urgences cérébrovasculaires, groupe hospitalier Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
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