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Nakazawa Y, Miyashita M, Morita T, Okumura Y, Kizawa Y, Kawagoe S, Yamamoto H, Takeuchi E, Yamazaki R, Ogawa A. Dying Patients' Quality of Care for Five Common Causes of Death: A Nationwide Mortality Follow-Back Survey. J Palliat Med 2024; 27:1146-1155. [PMID: 38770675 DOI: 10.1089/jpm.2023.0645] [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: 05/22/2024] Open
Abstract
Background: The importance of high-quality care for terminal patients is being increasingly recognized; however, quality of care (QOC) and quality of death and dying (QOD) for noncancer patients remain unclear. Objectives: To clarify QOC and QOD according to places and causes of death. Design, Subjects: A nationwide mortality follow-back survey was conducted using death certificate data for cancer, heart disease, stroke syndrome, pneumonia, and kidney failure in Japan. The questionnaire was distributed to 115,816 bereaved family members between February 2019 and February 2020. Measurements included QOC, QOD, and symptoms during the last week of life. Analyses used generalized estimating equations adjusting for age, sex, and region. Results: Valid responses were returned by 62,576 (54.0%). Family-reported QOC and QOD by the place of death were significantly higher at home than in other places across all causes of death (for all combinations with hospital p < 0.01). In stroke syndrome and pneumonia, QOD significantly differed between hospital and home (stroke syndrome: 57.1 vs. 72.4, p < 0.001, effect size 0.77; pneumonia: 57.3 vs. 71.1, p < 0.001, effect size 0.78). No significant differences were observed in QOC and QOD between cancer and noncancer. The prevalence of symptoms was higher for cancer than for other causes of death. Conclusions: QOC and QOD were higher at home than in other places of death across all causes of death. The further expansion of end-of-life care options is crucial for improving QOC and QOD for all terminal patients.
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Affiliation(s)
- Yoko Nakazawa
- Division of Policy Evaluation, Institute for Cancer Control, National Cancer Center, Chuo-ku, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team and Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
- Research Association for Community Health, Hamamatsu, Japan
| | - Yasuyuki Okumura
- Initiative for Clinical Epidemiological Research, Machida, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative and Supportive Care, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | | | - Hiroshi Yamamoto
- Department of Respiratory Medicine, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Itabashi-ku, Japan
| | - Emi Takeuchi
- Division of Quality Assurance Programs, Institute for Cancer Control, National Cancer Center, Chuo-ku, Japan
| | - Risa Yamazaki
- Department of Medical Psychology, Graduate School of Medical Sciences, Kitasato University, Sagamihara, Japan
| | - Asao Ogawa
- Division of Psycho-Oncology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan
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Zhang H, Davies C, Stokes D, O'Donnell D. Shared Decision-Making for Patients with Stroke in Neurocritical Care: A Qualitative Meta-Synthesis. Neurocrit Care 2024:10.1007/s12028-024-02106-y. [PMID: 39192102 DOI: 10.1007/s12028-024-02106-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 08/12/2024] [Indexed: 08/29/2024]
Abstract
Decision-making for patients with stroke in neurocritical care is uniquely challenging because of the gravity and high preference sensitivity of these decisions. Shared decision-making (SDM) is recommended to align decisions with patient values. However, limited evidence exists on the experiences and perceptions of key stakeholders involved in SDM for neurocritical patients with stroke. This review aims to address this gap by providing a comprehensive analysis of the experiences and perspectives of those involved in SDM for neurocritical stroke care to inform best practices in this context. A qualitative meta-synthesis was conducted following the methodological guidelines of the Joanna Briggs Institute (JBI), using the thematic synthesis approach outlined by Thomas and Harden. Database searches covered PubMed, CIHAHL, EMBASE, PsycINFO, and Web of Science from inception to July 2023, supplemented by manual searches. After screening, quality appraisal was performed using the JBI Appraisal Checklist. Data analysis comprised line-by-line coding, development of descriptive themes, and creation of analytical themes using NVivo 12 software. The initial search yielded 7,492 articles, with 94 undergoing full-text screening. Eighteen articles from five countries, published between 2010 and 2023, were included in the meta-synthesis. These studies focused on the SDM process, covering life-sustaining treatments (LSTs), palliative care, and end-of-life care, with LST decisions being most common. Four analytical themes, encompassing ten descriptive themes, emerged: prognostic uncertainty, multifaceted balancing act, tripartite role dynamics and information exchange, and influences of sociocultural context. These themes form the basis for a conceptual model offering deeper insights into the essential elements, relationships, and behaviors that characterize SDM in neurocritical care. This meta-synthesis of 18 primary studies offers a higher-order interpretation and an emerging conceptual understanding of SDM in neurocritical care, with implications for practice and further research. The complex role dynamics among SDM stakeholders require careful consideration, highlighting the need for stroke-specific communication strategies. Expanding the evidence base across diverse sociocultural settings is critical to enhance the understanding of SDM in neurocritical patients with stroke.Trial registration This study is registered with PROSPERO under the registration number CRD42023461608.
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Affiliation(s)
- Hui Zhang
- Nursing Department, Jining No.1 People's Hospital, Health Road No.6, Rencheng District, Jining, 272000, China.
- School of Nursing, Midwifery, and Health Systems, University College Dublin, Dublin, Ireland.
| | - Carmel Davies
- School of Nursing, Midwifery, and Health Systems, University College Dublin, Dublin, Ireland
- Center for Interdisciplinary Research, Education, and Innovation in Health Systems, University College Dublin, Dublin, Ireland
| | - Diarmuid Stokes
- School of Nursing, Midwifery, and Health Systems, University College Dublin, Dublin, Ireland
| | - Deirdre O'Donnell
- School of Nursing, Midwifery, and Health Systems, University College Dublin, Dublin, Ireland
- Center for Interdisciplinary Research, Education, and Innovation in Health Systems, University College Dublin, Dublin, Ireland
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Jonsdottir G, Haraldsdottir E, Vilhjalmsson R, Sigurdardottir V, Hjaltason H, Klinke ME, Tryggvadottir GB, Jonsdottir H. Transition to end-of-life care in patients with neurological diseases in an acute hospital ward. BMC Neurol 2024; 24:253. [PMID: 39039445 PMCID: PMC11265032 DOI: 10.1186/s12883-024-03768-z] [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: 04/22/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Transitioning to end-of-life care and thereby changing the focus of treatment directives from life-sustaining treatment to comfort care is important for neurological patients in advanced stages. Late transition to end-of-life care for neurological patients has been described previously. OBJECTIVE To investigate whether previous treatment directives, primary medical diagnoses, and demographic factors predict the transition to end-of-life care and time to eventual death in patients with neurological diseases in an acute hospital setting. METHOD All consecutive health records of patients diagnosed with stroke, amyotrophic lateral sclerosis (ALS), and Parkinson's disease or other extrapyramidal diseases (PDoed), who died in an acute neurological ward between January 2011 and August 2020 were retrieved retrospectively. Descriptive statistics and multivariate Cox regression were used to examine the timing of treatment directives and death in relation to medical diagnosis, age, gender, and marital status. RESULTS A total of 271 records were involved in the analysis. Patients in all diagnostic categories had a treatment directive for end-of-life care, with patients with haemorrhagic stroke having the highest (92%) and patients with PDoed the lowest (73%) proportion. Cox regression identified that the likelihood of end-of-life care decision-making was related to advancing age (HR = 1.02, 95% CI: 1.007-1.039, P = 0.005), ischaemic stroke (HR = 1.64, 95% CI: 1.034-2.618, P = 0.036) and haemorrhagic stroke (HR = 2.04, 95% CI: 1.219-3.423, P = 0.007) diagnoses. End-of-life care decision occurred from four to twenty-two days after hospital admission. The time from end-of-life care decision to death was a median of two days. Treatment directives, demographic factors, and diagnostic categories did not increase the likelihood of death following an end-of-life care decision. CONCLUSIONS Results show not only that neurological patients transit late to end-of-life care but that the timeframe of the decision differs between patients with acute neurological diseases and those with progressive neurological diseases, highlighting the particular significance of the short timeframe of patients with the progressive neurological diseases ALS and PDoed. Different trajectories of patients with neurological diseases at end-of-life should be further explored and clinical guidelines expanded to embrace the high diversity in neurological patients.
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Affiliation(s)
- Gudrun Jonsdottir
- Faculty of Nursing and Midwifery, School of Health Sciences, University of Iceland, Reykjavik, 101, Iceland.
- Department of Hematology and Oncology, Landspitali, The National University Hospital of Iceland, Reykjavik, 101, Iceland.
| | - Erna Haraldsdottir
- Division of Nursing and Paramedic Science, Queen Margaret University, Edinburgh, EH216UU, Scotland
| | - Runar Vilhjalmsson
- Faculty of Nursing and Midwifery, School of Health Sciences, University of Iceland, Reykjavik, 101, Iceland
| | - Valgerdur Sigurdardottir
- Palliative Care Unit, Landspitali, The National University Hospital of Iceland, Reykjavik, 101, Iceland
| | - Haukur Hjaltason
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, 101, Iceland
- Department of Neurology, Landspitali, The National University Hospital of Iceland, Reykjavik, 101, Iceland
| | - Marianne Elisabeth Klinke
- Faculty of Nursing and Midwifery, School of Health Sciences, University of Iceland, Reykjavik, 101, Iceland
- Department of Neurology, Landspitali, The National University Hospital of Iceland, Reykjavik, 101, Iceland
| | | | - Helga Jonsdottir
- Faculty of Nursing and Midwifery, School of Health Sciences, University of Iceland, Reykjavik, 101, Iceland
- Respiratory Section, Division of Clinical Services, Landspitali, The National University Hospital of Iceland, Reykjavik, 101, Iceland
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Murray SA, Boyd K, Moine S, Kendall M, Macpherson S, Mitchell G, Amblàs-Novellas J. Using illness trajectories to inform person centred, advance care planning. BMJ 2024; 384:e067896. [PMID: 38428953 DOI: 10.1136/bmj-2021-067896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Affiliation(s)
- Scott A Murray
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Kirsty Boyd
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Sebastien Moine
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
- Health Education and Practices Laboratory, University of Paris 13, Bobigny, France
| | - Marilyn Kendall
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Stella Macpherson
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
- patient author, UK
| | | | - Jordi Amblàs-Novellas
- Central Catalonia Chronicity Research Group, Faculty of Medicine, University of Vic-Central University of Catalonia, 08500 Vic, Spain
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5
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Mead G. Shared decision making in older people after severe stroke. Age Ageing 2024; 53:afae017. [PMID: 38364821 DOI: 10.1093/ageing/afae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Indexed: 02/18/2024] Open
Abstract
Stroke is a major cause of death and lifelong disability. Although stroke treatments have improved, many patients are left with life-changing deficits. Shared decision making and consent are fundamental to good medical practice. This is challenging because stroke often causes mental incapacity, prior views might not be known and prognosis early after stroke is often uncertain. There are no large trials of shared decision making after severe stroke, so we need to rely on observational data to inform practice. Core ethical principles of autonomy, beneficence, non-maleficence and justice must underpin our decision making. 'Surrogate' decision makers will need to be involved if a patient lacks capacity, and prior expressed views and values and beliefs need to be taken into account in decision making. Patients and surrogates often feel shocked at the sudden nature of stroke, and experience grief including anticipatory grief. Health care professionals need to acknowledge these feelings and provide support, be clear about what decisions need to be made and provide sufficient information about the stroke, and the risks and benefits of treatments being considered. Shared decision making can be emotionally difficult for health care professionals and so working in a supportive environment with compassionate leadership is important. Further research is needed to better understand the nature of grief and what sort of psychological support would be most helpful. Large randomised trials of shared decision making are also needed.
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Affiliation(s)
- Gillian Mead
- Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh EH16 4SA, UK
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Swerts D, Araújo A, Vulcano P, Prado B, Miyake C, Docema R, Hwang H, Peres M. Neuropalliative care in a tertiary-level hospital. BMJ Support Palliat Care 2023:spcare-2023-004499. [PMID: 38123312 DOI: 10.1136/spcare-2023-004499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Palliative care in neurology is a recent specialty to improve the quality of life of patients with severe neurological diseases. This study aims to determine the frequency of neurological inpatients who had indication of palliative care, and evaluate the symptomatology, demographic profile, the need for supportive measures, advance directives for life and medical history of patients in a tertiary hospital in Brazil. METHODS This cross-sectional analytical study evaluated all patients admitted to the neurological semi-intensive care unit (ICU) at Hospital Israelita Albert Einstein with neurological conditions from February through August 2022. The Palliative Performance Scale (weight loss greater than 5% associated with body changes and a negative response to the question: 'Would you be surprised if the patient died within 1 year?') was used to indicate palliative care. Patients were divided into three groups: patients with palliative care needs (groupindication), patients without palliative care needs (groupwithout indication) and patients who received at least one assessment of a palliative care team (grouppalliative). Demographic data were analysed using the Χ2 test for qualitative and Kruskal-Wallis test for quantitative variables. RESULTS Of the 198 patients included in the study, 115 (58%) had palliative care needs. Only 6.9% received assessment by the palliative care team, and 9.56% had advance directives in their medical records. Patients in groupindication had a higher prevalence of symptoms, such as fatigue, depression, shortness of breath and lack of appetite, and required more supportive measures, such as oxygen therapy, enteral/parenteral nutrition, admissions at ICU and days in hospital. CONCLUSION Despite the high demand for palliative care in neurology, few patients receive this treatment, resulting in decreased quality of care. Therefore, greater integration and discussion of palliative care in neurology are needed.
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Affiliation(s)
- Diego Swerts
- Department of Neurology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Ana Araújo
- Department of Neurology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Polyana Vulcano
- Department of Neurology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Bernard Prado
- Palliative, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Caroline Miyake
- Department of Neurology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Rafael Docema
- Department of Neurology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Hye Hwang
- Department of Neurology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Mario Peres
- Department of Neurology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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7
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Creutzfeldt CJ, Abedini NC, Holloway RG. Neuropalliative Care for Stroke Providers. Stroke 2023; 54:e485-e487. [PMID: 37814954 DOI: 10.1161/strokeaha.123.040431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Claire J Creutzfeldt
- Department of Neurology (C.J.C.), University of Washington, Seattle
- Cambia Palliative Care Center of Excellence (C.J.C., N.C.A.), University of Washington, Seattle
| | - Nauzley C Abedini
- Cambia Palliative Care Center of Excellence (C.J.C., N.C.A.), University of Washington, Seattle
- Department of Medicine (N.C.A.), University of Washington, Seattle
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8
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Alhalabi MN, Khalaf IA, Zeilani RS, Bawadi HA, Musa AS, Nashwan AJ. Palliative care needs of Jordanian women's experience of living with stroke: a descriptive phenomenological study. BMC Palliat Care 2023; 22:106. [PMID: 37507696 PMCID: PMC10375733 DOI: 10.1186/s12904-023-01216-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Stroke is a prevalent neurological disease that can have a profound impact on women's physical, psychosocial, and spiritual well-being. In many cases, women living with stroke may have marginalized palliative care needs that are often not adequately addressed by healthcare providers. Unfortunately, the experience of women with stroke and their specific palliative care needs have been largely overlooked in research conducted in Jordan. AIM The purpose of this study is to examine the specific palliative care needs of women who have experienced a stroke and are currently living in Jordan. By conducting this research, we aim to identify the various physical, emotional, social, and spiritual needs of women with stroke and gain a better understanding of how these needs can be addressed through palliative care interventions. METHODS This research utilized a phenomenological descriptive study approach to explore the experiences of twelve women recruited from the outpatient clinic of rehabilitation centers. The data was collected through semi-structured interviews. The analysis was conducted using the method of Colaizzi (1978), which involves identifying significant statements, extracting meanings, and formulating an exhaustive description of the phenomenon under study. RESULTS The study findings uncovered three primary themes that reflect the palliative care needs of women who are currently living with stroke in Jordan, including (1) Spiritual practices, beliefs, and needs; (2) Coping with distressing symptoms; and (3) Managing the delivery of unfavorable news. DISCUSSION This study provides valuable insights into the experiences of Jordanian women living with stroke, highlighting the far-reaching consequences of this condition on various aspects of their lives. The findings reveal that stroke has a significant impact on women's physical, emotional, social, and spiritual well-being, with many facing unmet palliative care needs. By illuminating these challenges, our study underscores the importance of taking a holistic approach to stroke care that addresses the multifaceted needs of women living with stroke. Healthcare providers must consider these findings and integrate palliative care interventions into treatment plans to improve the quality of life of women living with stroke in Jordan. CONCLUSION This study provides valuable insights into the palliative care needs of women who have experienced a stroke. Our findings highlight the importance of addressing women's physical, psychosocial, and spiritual needs as part of a comprehensive approach to stroke care. We recommend integrating palliative care interventions into rehabilitation programs to improve the quality of life of women living with stroke in Jordan. By doing so, we can address the pain and complications that can arise from stroke, while also providing holistic support to address the emotional and spiritual impact of the illness. This approach has the potential to improve outcomes for women living with stroke and enhance their overall well-being.
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Affiliation(s)
- Marwa Nayef Alhalabi
- Department of Adult Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
| | - Inaam Abdulla Khalaf
- Department of Maternal and Child Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
| | - Ruqayya Sayed Zeilani
- Department of Adult Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
| | - Hala Ahmad Bawadi
- Department of Maternal and Child Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
| | - Ahmad S Musa
- Department of Adult Health Nursing, Faculty of Nursing, Al Al-Bayt University, Mafraq, Jordan
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Liu H, Cook A, Ding J, Lu H, Jiao J, Bai W, Johnson CE. Palliative care needs and specialist services post stroke: national population-based study. BMJ Support Palliat Care 2023:spcare-2023-004280. [PMID: 37500566 DOI: 10.1136/spcare-2023-004280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/07/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVES (1) To compare palliative care needs of patients admitted primarily with stroke and (2) to determine how the care needs of these patients affect their use of different types of specialist palliative care services. METHODS Observational study based on point-of-care data from the Australian Palliative Care Outcomes Collaboration. Multivariate logistic regression models were used to explore the association between patients' palliative care needs and use of community versus inpatient specialist palliative care services. RESULTS The majority of patients who had a stroke in this study population had mild or no symptom distress, but experienced a high degree of functional impairment and needed substantial help with basic tasks of daily living. A lower Australia-modified Karnofsky Performance Status score (OR=1.82, 95% CI 1.06 to 3.13) and occurrence of an 'unstable' palliative care phase (OR=28.34, 95% CI 9.03 to 88.94) were associated with use of inpatient versus community palliative care, but otherwise, no clear association was observed between the majority of symptoms and use of different care services. CONCLUSIONS Many people with stroke could potentially have been cared for and could have experienced the terminal phases of their condition in a community setting if more community support services were available for their families.
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Affiliation(s)
- Huiqin Liu
- Health Management Center, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Angus Cook
- School of Population and Global Health, University of Western Australia, Crawley, Western Australia, Australia
| | - Jinfeng Ding
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
- Yale School of Internal Medicine, New Haven, Connecticut, USA
| | - Hongwei Lu
- Health Management Center, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jingjing Jiao
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Wenhui Bai
- Department of Nursing, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Claire E Johnson
- AHSRI, University of Wollongong Faculty of Business, Wollongong, New South Wales, Australia
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Kluger BM, Hudson P, Hanson LC, Bužgovà R, Creutzfeldt CJ, Gursahani R, Sumrall M, White C, Oliver DJ, Pantilat SZ, Miyasaki J. Palliative care to support the needs of adults with neurological disease. Lancet Neurol 2023; 22:619-631. [PMID: 37353280 DOI: 10.1016/s1474-4422(23)00129-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/08/2023] [Accepted: 03/27/2023] [Indexed: 06/25/2023]
Abstract
Neurological diseases cause physical, psychosocial, and spiritual or existential suffering from the time of their diagnosis. Palliative care focuses on improving quality of life for people with serious illness and their families by addressing this multidimensional suffering. Evidence from clinical trials supports the ability of palliative care to improve patient and caregiver outcomes by the use of outpatient or home-based palliative care interventions for people with motor neuron disease, multiple sclerosis, or Parkinson's disease; inpatient palliative care consultations for people with advanced dementia; telephone-based case management for people with dementia in the community; and nurse-led discussions with decision aids for people with advanced dementia in long-term care. Unfortunately, most people with neurological diseases do not get the support that they need for their palliative care under current standards of healthcare. Improving this situation requires the deployment of routine screening to identify individual palliative care needs, the integration of palliative care approaches into routine neurological care, and collaboration between neurologists and palliative care specialists. Research, education, and advocacy are also needed to raise standards of care.
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Affiliation(s)
- Benzi M Kluger
- University of Rochester Medical Center, Rochester, NY, USA.
| | - Peter Hudson
- The University of Melbourne, Fitzroy, VIC, Australia; St Vincent's Hospital, Melbourne, Fitzroy, VIC, Australia; Vrije Universiteit Brussel, Brussel, Belgium
| | - Laura C Hanson
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Radka Bužgovà
- Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | | | - Roop Gursahani
- Hinduja Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Malenna Sumrall
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Charles White
- University of Rochester Medical Center, Rochester, NY, USA
| | | | - Steven Z Pantilat
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Keiser M, Buterakos R, Stutzky H, Moran L, Hewelt D. Evaluating the FRAIL Questionnaire as a Trigger for Palliative Care Consultation After Acute Stroke. J Hosp Palliat Nurs 2023; 25:124-128. [PMID: 36989192 DOI: 10.1097/njh.0000000000000940] [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: 03/30/2023]
Abstract
The American Heart Association and the American Stroke Association jointly released guidelines stating that all patients with a new diagnosis of stroke should receive palliative care consultation starting in the acute phase of care. The purpose of this project was to increase palliative care consultation rates for patients after an acute stroke by using a frailty score to trigger a palliative care consult. Provider education on palliative care and a 5-question fatigue, resistance, ambulation, illnesses, and loss of weight (FRAIL) questionnaire was delivered by a presentation, handouts, and a follow-up email using previously developed content. Patients included adults admitted to the neuroscience critical care unit of a Midwestern comprehensive stroke center with an admission diagnosis of acute stroke (n = 120). The charge nurse completed the FRAIL questionnaire as a screening tool to trigger a palliative care consult. A survey was also distributed to providers (n = 54) to understand their knowledge, thoughts, and feelings toward palliative care. There was an increase in patients who received palliative care consultation from 14.9% to 21.7% after implementation of the FRAIL questionnaire. Also, providers felt better able to provide symptom management to patients after acute stroke. Further research is necessary to determine if the FRAIL survey is an adequate trigger for palliative care consultation.
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12
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Schutz REC, Creutzfeldt CJ. Palliative care after stroke survival. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:3-11. [PMID: 36599514 DOI: 10.1016/b978-0-12-824535-4.00003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Stroke is a leading cause of both death and disability worldwide. While most research has focused on the first hours to days after acute stroke, much less is known about the experience of patients and their families living after a stroke. Stroke survivors have a high burden of physical and psychological symptoms such as pain, fatigue, and depression that are often not addressed in the postacute setting. Similarly, goals-of-care conversations that may have started during the acute hospitalization are often not followed up later. This chapter outlines the prevalence and management of common poststroke symptoms, approaches to postacute goals-of-care conversations, family needs after stroke, and provides an overview of stroke-specific hospice and end-of-life care aspects. We emphasize the need for research in each of these areas.
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Affiliation(s)
- Rachael E C Schutz
- Department of Neurology, University of Washington, Seattle, WA, United States
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Howard M, Hafid A, Webber C, Isenberg SR, Gayowsky A, Jones A, Scott M, Hsu AT, Conen K, Downar J, Manuel D, Tanuseputro P. Continuity of physician care over the last year of life for different cause-of-death categories: a retrospective population-based study. CMAJ Open 2022; 10:E971-E980. [PMID: 36347560 PMCID: PMC9648626 DOI: 10.9778/cmajo.20210294] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The mix of care provided by family physicians, specialists and palliative care physicians can vary by the illnesses leading to death, which may result in disruptions of continuity of care at the end of life. We measured continuity of outpatient physician care in the last year of life across differing causes of death and assessed factors associated with higher continuity. METHODS We conducted a retrospective descriptive study of adults who died in Ontario between 2013 and 2018, using linked provincial health administrative data. We calculated 3 measures of continuity (usual provider, Bice-Boxerman and sequential continuity), which range from 0 to 1, from outpatient physician visits over the last year of life for terminal illness, organ failure, frailty, sudden death and other causes of death. We used multivariable logistic regression models to evaluate associations between characteristics and a continuity score of 0.5 or greater. RESULTS Among the 417 628 decedents, we found that mean usual provider, Bice-Boxerman and sequential continuity indices were 0.37, 0.30 and 0.37, respectively, with continuity being the lowest for those with terminal illness (0.27, 0.23 and 0.33, respectively). Higher number of comorbidities, higher neighbourhood income quintile and all non-sudden death categories were associated with lower continuity. INTERPRETATION We found that continuity of physician care in the last year of life was low, especially in those with cancer. Further research is needed to validate measures of continuity against end-of-life health care outcomes.
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Affiliation(s)
- Michelle Howard
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont.
| | - Abe Hafid
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Colleen Webber
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Sarina R Isenberg
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Ana Gayowsky
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Aaron Jones
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Mary Scott
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Amy T Hsu
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Katrin Conen
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - James Downar
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Doug Manuel
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Peter Tanuseputro
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
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Nicholson CJ, Combes S, Mold F, King H, Green R. Addressing inequity in palliative care provision for older people living with multimorbidity. Perspectives of community-dwelling older people on their palliative care needs: A scoping review. Palliat Med 2022; 37:475-497. [PMID: 36002975 PMCID: PMC10074761 DOI: 10.1177/02692163221118230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Older people living with multimorbidity are projected to become the main recipients of palliative care in the coming decades, yet there is limited evidence regarding their expressed palliative care needs to inform person-centred care. AIM To understand the palliative care needs of community-dwelling people aged ⩾60 living with multimorbidity in the last 2 years of life. DESIGN A scoping review following Arksey and O'Malley. DATA SOURCES Three international electronic databases (CINAHL, Ovid Medline, PsycINFO) were searched from March 2018 to December 2021. Reference lists were hand searched. Eligible papers were those reporting empirical data on older people's needs. RESULTS From 985 potential papers, 28 studies were included, published between 2002 and 2020; sixteen quantitative, nine qualitative and three mixed methods. Data were extracted and presented under the holistic palliative care domains of need: physical, psychological, social, spiritual, and additionally practical needs. Different measurement tools (n = 29) were used, of which 20 were multidimensional. Primacy in reporting was given to physical needs, most commonly pain and function. Social and practical needs were often prioritised by older people themselves, including maintaining social connections and accessing and receiving individualised care. CONCLUSION Identifying the palliative care needs that matter most to older people with multimorbidity requires the recognition of their concerns, as well as their symptoms, across a continuum of living and dying. Available evidence is superficial. Supporting end of life provision for this growing and underserved population necessitates a shift to tailored multidimensional tools and community focussed integrated care services.
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Affiliation(s)
| | - Sarah Combes
- University of Surrey, Guildford, UK
- St Christopher's Hospice, London, UK
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15
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Swan S, Meade R, Cavers D, Kimbell B, Lloyd A, Carduff E. Factors influencing adult carer support planning for unpaid caregiving at the end of life in Scotland: Qualitative insights from triangulated interviews and focus groups. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:1422-1432. [PMID: 34427355 PMCID: PMC9290463 DOI: 10.1111/hsc.13472] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 02/24/2021] [Accepted: 05/18/2021] [Indexed: 06/13/2023]
Abstract
Caring for a relative or friend at the end of life can be rewarding but all-encompassing. These caregivers are often not identified, meaning their diverse needs remain unmet, and the lack of assessment, support and planning increases the likelihood of crisis and burnout. The Carers (Scotland) Act 2016 places responsibility on local authorities to implement such a plan, which will be fast-tracked for carers supporting someone at the end of life. Our research described the factors which might influence this planning, triangulating primary focus groups with 15 carers and secondary qualitative data from transcripts with 30 carers, all of whom who had looked after someone with a terminal illness. Analysis was iterative, and constant comparative analysis of the secondary data informed the primary focus groups. Three main themes were identified; 1. The importance of early identification as a carer to enable timely assessment and support. 2. Carers experience isolation and loneliness which limits opportunities for support. 3. Responding in a timely fashion to carer assessment and support is vital to avoid crises. This research confirms that identifying carers early in the illness trajectory, ideally at diagnosis, is vital to avoid carer burnout. Health and social care providers have a key role in identification and should ensure, where possible, that carer needs are dynamically assessed, supported and documented. Finally, caring does not end after death, it extends into bereavement. Thus, we need to consider system and cultural change to ensure the experiences and needs of carers are addressed and valued.
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Affiliation(s)
| | | | - Debbie Cavers
- Usher InstituteUniversity of EdinburghOld Medical SchoolEdinburghUK
| | - Barbara Kimbell
- Usher InstituteUniversity of EdinburghOld Medical SchoolEdinburghUK
| | - Anna Lloyd
- Usher InstituteUniversity of EdinburghOld Medical SchoolEdinburghUK
- St Columba's HospiceEdinburghUK
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16
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Palliative Care for Older Adults Hospitalized for Stroke From the Informal Caregivers' Perspectives. J Cardiovasc Nurs 2022; 38:E110-E119. [PMID: 37027138 DOI: 10.1097/jcn.0000000000000923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND International guidelines have promoted palliative care (PC) for stroke survivors, but definition and implementation have been less than ideal. This practice gap is more prominent in China, where discussion of death remains taboo. AIM The aim of this study was to explore the perspectives of PC among caregivers of hospitalized patients with stroke. DESIGN AND SETTING A descriptive qualitative study design was used. Seventeen in-depth interviews with bedside caregivers in a first-rank tertiary hospital (general hospital with bed capacity exceeding 500) in China were analyzed thematically. RESULTS "Promoting comfort" stands at the core of PC and was operationalized by "meeting physical care needs," "ensuring communication," "providing psychoemotional care," "providing cognitive stimulation," and "avoiding discussion on death and dying." Caregivers who took care of older adults for a long time have described the use of "cognitive stimulation" to promote patients' positive emotional and cognitive reactions. All interviewees avoided mentioning "death" to protect patients' feelings, because they believed discussion of death was hurtful. CONCLUSIONS The high care demand for patients with stroke is a defining feature of stroke PC and should be recognized in addition to its prognosis estimation to promote this concept. The healthcare system should integrate PC as part of the regular service for patients with severe stroke to shift the focus of care from survival to promotion of comfort. A discussion of the dying process requires sensitivity and should be approached in a discussion of advanced PC planning, which views death as a meaningful transition.
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17
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Morgan DD, Taylor RR, Ivy M, George S, Farrow C, Lee V. Contemporary occupational priorities at the end of life mapped against Model of Human Occupation constructs: A scoping review. Aust Occup Ther J 2022; 69:341-373. [PMID: 35199343 DOI: 10.1111/1440-1630.12792] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/21/2021] [Accepted: 01/12/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION People with end-of-life care needs are seen in an increasingly diverse range of health and community settings. Opportunity for continued occupational participation is highly valued by people at the end of life. This scoping review sought to identify the priorities and preferences for participation at the end of life and to map findings using the model of human occupation. METHODS A search strategy informed by the research question was developed in collaboration with a research librarian. Data sources used were Ovid Medline(R), CINAHL, Ovid Emcare, Scopus, Web of Science and PsychInfo. Studies that focused on clinician perspectives, clinical care, grief and loss, did not clearly identify end-stage diseases, <18 years and written in languages other than English were excluded. FINDINGS Forty-four studies were included with a total of 1,070 study participants. Inductively developed themes were mapped against the model of human occupation constructs of volition (personal causation, values, interests), habituation (habits of occupational performance and routine), performance capacity and the lived body within the physical, social and occupational environment. The majority of findings sat within the construct of volition, particularly around sense of personal capacity, self-efficacy and values. At the end of life, people prioritise ongoing engagement in valued occupations even if participation is effortful. As disease progresses, opportunity to exert influence and control over this participation and engagement increases in importance. Personal causation plays an important role in the experience of occupational participation at this time. CONCLUSION This review provides important insights into the occupational priorities of people at the end of life and the importance of supporting agency and volition at this time. The model of human occupation and its client-centred focus offer a framework for a more robust examination of ways to enhance volitional capacity and enable occupational participation for people at the end of life.
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Affiliation(s)
- Deidre D Morgan
- Research Centre for Palliative Care, Death and Dying (RePaDD), College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Renée R Taylor
- Director, Model of Human Occupation Clearinghouse, Department of Occupational Therapy, University of Illinois, Chicago, Illinois, USA
| | - Mack Ivy
- Rehabilitation Services, MD Anderson Cancer Center, Manvel, Texas, USA
| | - Stacey George
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Caroline Farrow
- SA Health, Northern Adelaide Palliative Care Service, Adelaide, South Australia, Australia
| | - Vincci Lee
- Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
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18
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Dawson B, McConvey K, Gofton TE. When to initiate palliative care in neurology. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:105-125. [PMID: 36055710 DOI: 10.1016/b978-0-323-85029-2.00011-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Life-limiting and life-threatening neurologic conditions often progress slowly. Patients live with a substantial symptom burden over a long period of time, and there is often a high degree of functional and cognitive impairment. Because of this, the most appropriate time to initiate neuropalliative care is often difficult to identify. Further challenges to the incorporation of neuropalliative care include communication barriers, such as profound dysarthria or language impairments, and loss of cognitive function and decision-making capacity that prevent shared decision making and threaten patient autonomy. As a result, earlier initiation of at least some components of palliative care is paramount to ensuring patient-centered care while the patient is still able to communicate effectively and participate as fully as possible in their medical care. For these reasons, neuropalliative care is also distinct from palliative care in oncology, and there is a growing evidence base to guide timely initiation and integration of neuropalliative care. In this chapter, we will focus on when to initiate palliative care in patients with life-limiting, life-threatening, and advanced neurologic conditions. We will address three main questions, which patients with neurologic conditions will benefit from initiation of palliative care, what aspects of neurologic illness are most amenable to neuropalliative care, and when to initiate neuropalliative care?
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Affiliation(s)
- Benjamin Dawson
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada
| | - Kayla McConvey
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada
| | - Teneille E Gofton
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada.
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Crocker TF, Brown L, Lam N, Wray F, Knapp P, Forster A. Information provision for stroke survivors and their carers. Cochrane Database Syst Rev 2021; 11:CD001919. [PMID: 34813082 PMCID: PMC8610078 DOI: 10.1002/14651858.cd001919.pub4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND A stroke is a sudden loss of brain function caused by lack of blood supply. Stroke can lead to death or physical and cognitive impairment and can have long lasting psychological and social implications. Research shows that stroke survivors and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues. OBJECTIVES The primary objective is to assess the effects of active or passive information provision for stroke survivors (people with a clinical diagnosis of stroke or transient ischaemic attack (TIA)) or their identified carers. The primary outcomes are knowledge about stroke and stroke services, and anxiety. SEARCH METHODS We updated our searches of the Cochrane Stroke Group Specialised Register on 28 September 2020 and for the following databases to May/June 2019: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5) and the Cochrane Database of Systematic Reviews (CDSR; 2019, Issue 5) in the Cochrane Library (searched 31 May 2019), MEDLINE Ovid (searched 2005 to May week 4, 2019), Embase Ovid (searched 2005 to 29 May 2019), CINAHL EBSCO (searched 2005 to 6 June 2019), and five others. We searched seven study registers and checked reference lists of reviews. SELECTION CRITERIA Randomised trials involving stroke survivors, their identified carers or both, where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone, or where the comparison was between active and passive information provision without other differences in treatment. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We categorised interventions as either active information provision or passive information provision: active information provision included active participation with subsequent opportunities for clarification and reinforcement; passive information provision provided no systematic follow-up or reinforcement procedure. We stratified analyses by this categorisation. We used GRADE methods to assess the overall certainty of the evidence. MAIN RESULTS We have added 12 new studies in this update. This review now includes 33 studies involving 5255 stroke-survivor and 3134 carer participants. Twenty-two trials evaluated active information provision interventions and 11 trials evaluated passive information provision interventions. Most trials were at high risk of bias due to lack of blinding of participants, personnel, and outcome assessors where outcomes were self-reported. Fewer than half of studies were at low risk of bias regarding random sequence generation, concealment of allocation, incomplete outcome data or selective reporting. The following estimates have low certainty, based on the quality of evidence, unless stated otherwise. Accounting for certainty and size of effect, analyses suggested that for stroke survivors, active information provision may improve stroke-related knowledge (standardised mean difference (SMD) 0.41, 95% confidence interval (CI) 0.17 to 0.65; 3 studies, 275 participants), may reduce cases of anxiety and depression slightly (anxiety risk ratio (RR) 0.85, 95% CI 0.68 to 1.06; 5 studies, 1132 participants; depression RR 0.83, 95% CI 0.68 to 1.01; 6 studies, 1315 participants), may reduce Hospital Anxiety and Depression Scale (HADS) anxiety score slightly, (mean difference (MD) -0.73, 95% CI -1.10 to -0.36; 6 studies, 1171 participants), probably reduces HADS depression score slightly (MD (rescaled from SMD) -0.8, 95% CI -1.27 to -0.34; 8 studies, 1405 participants; moderate-certainty evidence), and may improve each domain of the World Health Organization Quality of Life assessment short-form (WHOQOL-BREF) (physical, MD 11.5, 95% CI 7.81 to 15.27; psychological, MD 11.8, 95% CI 7.29 to 16.29; social, MD 5.8, 95% CI 0.84 to 10.84; environment, MD 7.0, 95% CI 3.00 to 10.94; 1 study, 60 participants). No studies evaluated positive mental well-being. For carers, active information provision may reduce HADS anxiety and depression scores slightly (MD for anxiety -0.40, 95% CI -1.51 to 0.70; 3 studies, 921 participants; MD for depression -0.30, 95% CI -1.53 to 0.92; 3 studies, 924 participants), may result in little to no difference in positive mental well-being assessed with Bradley's well-being questionnaire (MD -0.18, 95% CI -1.34 to 0.98; 1 study, 91 participants) and may result in little to no difference in quality of life assessed with a 0 to 100 visual analogue scale (MD 1.22, 95% CI -7.65 to 10.09; 1 study, 91 participants). The evidence is very uncertain (very low certainty) for the effects of active information provision on carers' stroke-related knowledge, and cases of anxiety and depression. For stroke survivors, passive information provision may slightly increase HADS anxiety and depression scores (MD for anxiety 0.67, 95% CI -0.37 to 1.71; MD for depression 0.39, 95% CI -0.61 to 1.38; 3 studies, 227 participants) and the evidence is very uncertain for the effects on stroke-related knowledge, quality of life, and cases of anxiety and depression. For carers, the evidence is very uncertain for the effects of passive information provision on stroke-related knowledge, and HADS anxiety and depression scores. No studies of passive information provision measured carer quality of life, or stroke-survivor or carer positive mental well-being. AUTHORS' CONCLUSIONS Active information provision may improve stroke-survivor knowledge and quality of life, and may reduce anxiety and depression. However, the reductions in anxiety and depression scores were small and may not be important. In contrast, providing information passively may slightly worsen stroke-survivor anxiety and depression scores, although again the importance of this is unclear. Evidence relating to carers and to other outcomes of passive information provision is generally very uncertain. Although the best way to provide information is still unclear, the evidence is better for strategies that actively involve stroke survivors and carers and include planned follow-up for clarification and reinforcement.
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Affiliation(s)
- Thomas F Crocker
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Lesley Brown
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Natalie Lam
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Faye Wray
- Academic Unit for Ageing and Stroke Research, University of Leeds, Bradford, UK
| | - Peter Knapp
- Department of Health Sciences, University of York and the Hull York Medical School, York, UK
| | - Anne Forster
- Academic Unit for Ageing and Stroke Research, University of Leeds, Bradford, UK
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20
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Mason B, Boyd K, Doubal F, Barber M, Brady M, Cowey E, Visvanathan A, Lewis S, Gallacher K, Morton S, Mead GE. Core Outcome Measures for Palliative and End-of-Life Research After Severe Stroke: Mixed-Method Delphi Study. Stroke 2021; 52:3507-3513. [PMID: 34266306 PMCID: PMC8547585 DOI: 10.1161/strokeaha.120.032650] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 05/14/2021] [Accepted: 06/10/2021] [Indexed: 11/23/2022]
Abstract
Background and Purpose Stroke is the second commonest cause of death worldwide and a leading cause of severe disability, yet there are no published trials of palliative care in stroke. To design and evaluate palliative care interventions for people with stroke, researchers need to know what measurable outcomes matter most to patients and families, stroke professionals, and other service providers. Methods A multidisciplinary steering group of professionals and laypeople managed the study. We synthesized recommendations from respected United Kingdom and international consensus documents to generate a list of outcome domains and then performed a rapid scoping literature review to identify potential outcome measures for use in future trials of palliative care after stroke. We then completed a 3-round, online Delphi survey of professionals, and service users to build consensus about outcome domains and outcome measures. Finally, we held a stakeholder workshop to review and finalize this consensus. Results We generated a list of 36 different outcome domains from 4 key policy documents. The rapid scoping review identified 43 potential outcome measures that were used to create a shortlist of 16 measures. The 36 outcome domains and 16 measures were presented to a Delphi panel of diverse healthcare professionals and lay service users. Of 48 panelists invited to take part, 28 completed all 3 rounds. Shared decision-making and quality of life were selected as the most important outcome domains for future trials of palliative care in stroke. Additional comments highlighted the need for outcomes to be feasible, measurable, and relevant beyond the initial, acute phase of stroke. The stakeholder workshop endorsed these results. Conclusions Future trials of palliative care after stroke should include pragmatic outcome measures, applicable to the evolving patient and family experiences after stroke and be inclusive of shared decision-making and quality of life.
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Affiliation(s)
- Bruce Mason
- Usher Institute (B.M., K.B., S.L., S.M, G.E.M)
| | - Kirsty Boyd
- Usher Institute (B.M., K.B., S.L., S.M, G.E.M)
| | | | - Mark Barber
- University of Edinburgh, University Hospital, Monklands, NHS Lanarkshire (M. Barber)
| | - Marian Brady
- Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University (M. Brady)
| | - Eileen Cowey
- Nursing & Health Care School (E.C.), University of Glasgow
| | | | - Steff Lewis
- Usher Institute (B.M., K.B., S.L., S.M, G.E.M)
| | - Katie Gallacher
- Institute of Health and Wellbeing (K.G.), University of Glasgow
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21
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Riesinger R, Altmann K, Lorenzl S. Involvement of Specialist Palliative Care in a Stroke Unit in Austria-Challenges for Families and Stroke Teams. Front Neurol 2021; 12:683624. [PMID: 34630274 PMCID: PMC8492896 DOI: 10.3389/fneur.2021.683624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: Severe stroke poses vast challenges. Appropriate goals of care according to individual preferences and values have to be developed under time restrictions—often impeded by limited ability to communicate and the need for decisions by surrogates. The aim of our study was to explore the decision-making process and the involvement of specialist palliative care in the acute phase of severe stroke. Methods: Twenty patients suffering from severe ischemic stroke treated in an Austrian acute inpatient stroke unit were included in a prospective study. Their families were interviewed with a questionnaire (FS-ICU 24), which covered satisfaction with care and decision-making. With a second questionnaire, decision-making processes within the stroke team were investigated. Results: A palliative approach and early integration of specialist palliative care in severe ischemic stroke results in individualized therapeutic goals, including withholding therapeutic or life-sustaining measures, especially in patients with pre-existing illness. Conclusions: Family members benefit from understandable and consistent information, emotional support, and a professional team identifying their needs. Stroke unit professionals need skills as well as knowledge and strategies in order to make decisions and provide treatment at the end-of-life, when there may be ethical or legal issues. Close cooperation with specialist palliative care services supports both treatment teams and families with communication and decision-making for patients with severe ischemic stroke.
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Affiliation(s)
- Renate Riesinger
- Department of Palliative Care, Hospital Barmherzige Schwestern, Ried im Innkreis, Austria
| | - Klaus Altmann
- Department of Neurology, Hospital Barmherzige Schwestern, Ried im Innkreis, Austria
| | - Stefan Lorenzl
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria.,Ludwig-Maximilians-University, Munich, Germany.,Department of Neurology, Klinikum Agatharied, Hausham, Germany
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22
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Cowey E, Schichtel M, Cheyne JD, Tweedie L, Lehman R, Melifonwu R, Mead GE. Palliative care after stroke: A review. Int J Stroke 2021; 16:632-639. [PMID: 33949268 PMCID: PMC8366189 DOI: 10.1177/17474930211016603] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care is an integral aspect of stroke unit care. In 2016, the American Stroke Association published a policy statement on palliative care and stroke. Since then there has been an expansion in the literature on palliative care and stroke. AIM Our aim was to narratively review research on palliative care and stroke, published since 2015. RESULTS The literature fell into three broad categories: (a) scope and scale of palliative care needs, (b) organization of palliative care for stroke, and (c) shared decision making. Most literature was observational. There was a lack of evidence about interventions that address specific palliative symptoms or improve shared decision making. Racial disparities exist in access to palliative care after stroke. There was a dearth of literature from low- and middle-income countries. CONCLUSION We recommend further research, especially in low- and middle-income countries, including research to explore why racial disparities in access to palliative care exist. Randomized trials are needed to address specific palliative care needs after stroke and to understand how best to facilitate shared decision making.
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Affiliation(s)
- Eileen Cowey
- Nursing & Health Care School, University of Glasgow, Glasgow, UK
| | - Markus Schichtel
- Institute of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Joshua D Cheyne
- Cochrane Stroke Group, Centre for Clinical Brain Sciences (CCBS), University of Edinburgh, Edinburgh, UK
| | | | - Richard Lehman
- Institute of Applied Health Research, Murray Learning Centre, University of Birmingham, Birmingham, UK
| | - Rita Melifonwu
- Life After Stroke Centre, Stroke Action Nigeria, Onitsha, Nigeria
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Levy SA, Pedowitz E, Stein LK, Dhamoon MS. Healthcare Utilization for Stroke Patients at the End of Life: Nationally Representative Data. J Stroke Cerebrovasc Dis 2021; 30:106008. [PMID: 34330019 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/20/2021] [Accepted: 07/10/2021] [Indexed: 10/20/2022] Open
Abstract
Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.
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Affiliation(s)
- Sarah A Levy
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
| | - Elizabeth Pedowitz
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, United States.
| | - Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
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24
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Connolly T, Coats H, DeSanto K, Jones J. The experience of uncertainty for patients, families and healthcare providers in post-stroke palliative and end-of-life care: a qualitative meta-synthesis. Age Ageing 2021; 50:534-545. [PMID: 33206952 DOI: 10.1093/ageing/afaa229] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Indexed: 01/14/2023] Open
Abstract
PURPOSE recent data show that there is limited evidence and guidance regarding the best practices for the integration of palliative care (PC) and end-of-life (EOL) post-stroke. The purpose of this meta-synthesis is to understand the PC/EOL experiences after a stroke. METHODS a meta-synthesis was conducted to answer the following research question-What are post-stroke PC/EOL experiences from the perspectives of patients, families and healthcare professionals (HCPs)? This approach was completed through two main phases-a systematic search and appraisal of the literature and reciprocal translation with interpretive triangulation of the extracted data. Databases searched were MEDLINE, EMBASE, PsycINFO, Joanna Briggs Institute and CINAHL databases (from their inception to April 2020). After data were extracted, a qualitative exploratory design was used to evaluate the PC/EOL in post-stroke experiences. RESULTS the search identified 696 studies. A total of 14 studies were included in this meta-synthesis as they satisfied our eligibility criteria. Uncertainty post-stroke was the overarching main theme that emerged across post-stroke PC/EOL experiences. Within this theme of uncertainty, opportunities to decrease uncertainty emerged from two interdependent themes-presence of cohesive communication and shared dynamic decision process for both families and HCPs. CONCLUSIONS to mitigate the degree of uncertainty post-stroke, HCPs should be present, provide clear direct communication and incorporate the value-based goals of care within their medical treatment plan. These findings suggest that future research is needed to focus on how PC approaches can be integrated into stroke care programmes.
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Affiliation(s)
- Teresa Connolly
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Heather Coats
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristen DeSanto
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jacqueline Jones
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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25
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Johnson PD, Ulrich A, Siv J, Taylor B, Tirschwell D, Creutzfeldt CJ. Planning After Stroke Survival: Advance Care Planning in the Stroke Clinic. J Am Heart Assoc 2020; 8:e011317. [PMID: 30995885 PMCID: PMC6512127 DOI: 10.1161/jaha.118.011317] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Stroke survivors have high rates of mortality and recurrent stroke. Stroke patients are often unable to participate in decision making, highlighting the need for advance care planning (ACP) in poststroke care. We sought to better understand experiences and perceptions around stroke risk and ACP in our stroke clinic. Methods and Results Clinic patients completed the Planning After Stroke Survival survey assessing (1) advance directive (AD) documentation and ACP conversations, (2) factors associated with ADs and ACP, (3) perceptions of stroke risk, and (4) ACP needs. We used a physician survey and the electronic medical record to assess clinical and demographic information. We collected 219 surveys (78% response rate). Forty‐five percent reported having completed ADs, although the correlation between patient report and EMS documentation of ADs was low. Most patients (73%) had discussed ACP, and 58% desired additional conversation. Predictors of completing ADs included age (≥65 years; odds ratio, 4.8; 95% CI, 2.3–10.1), white race (odds ratio, 3.1; 95% CI, 1.2–7.8), milder poststroke disability (modified Rankin Scale score ≤1; odds ratio, 2.9; 95% CI, 1.3–6.4), having previously discussed ACP with a physician (odds ratio, 4.8; 95% CI, 2.0–11.7), and discussing risk of stroke recurrence (odds ratio, 2.2; 95% CI, 1.1–4.5). Conclusions Stroke survivors had low AD completion rates and desired more conversations about stroke risk and ACP. Completed ADs were inconsistently documented in the electronic medical record. These findings provide guidance to improve ACP in our stroke clinic and may provide a model for others interested in enhancing ACP and ultimately goal‐concordant care.
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Affiliation(s)
- Paul D Johnson
- 1 Intermountain Medical Center Salt Lake City UT.,2 Harborview Medical Center University of Washington Seattle WA
| | - Angela Ulrich
- 2 Harborview Medical Center University of Washington Seattle WA
| | - Jenny Siv
- 2 Harborview Medical Center University of Washington Seattle WA
| | - Breana Taylor
- 2 Harborview Medical Center University of Washington Seattle WA
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26
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Visvanathan A, Whiteley W, Mead G, Lawton J, Doubal FN, Dennis M. Reporting “specific abilities” after major stroke to better describe prognosis. J Stroke Cerebrovasc Dis 2020; 29:104993. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/23/2022] Open
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Visvanathan A, Mead GE, Dennis M, Whiteley WN, Doubal FN, Lawton J. The considerations, experiences and support needs of family members making treatment decisions for patients admitted with major stroke: a qualitative study. BMC Med Inform Decis Mak 2020; 20:98. [PMID: 32487145 PMCID: PMC7268726 DOI: 10.1186/s12911-020-01137-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2020] [Indexed: 12/01/2022] Open
Abstract
Background Treatment decision-making by family members on behalf of patients with major stroke can be challenging because of the shock of the diagnosis and lack of knowledge of the patient’s treatment preferences. We aimed to understand how, and why, family members made certain treatment decisions, and explored their information and support needs. Method Semi-structured interviews with family members (n = 24) of patients with major stroke, within 2 weeks of hospital admission. Data were analysed thematically. Results Families’ approach to treatment decision-making lay on a spectrum according to the patient’s state of health pre-stroke (i.e. patient’s prior experience of illness and functional status) and any views expressed about treatment preferences in the event of life-threatening illness. Support and information needs varied according to where they were on this spectrum. At one extreme, family members described deciding not to initiate life-extending treatments from the outset because of the patients’ deteriorating health and preferences expressed pre-stroke. Information from doctors about poor prognosis was merely used to confirm this decision. In the middle of the spectrum were family members of patients who had been moderately independent pre-stroke. They described the initial shock of the diagnosis and how they had initially wanted all treatments to continue. However, once they overcame their shock, and had gathered relevant information, including information about poor prognosis from doctors, they decided that life-extending treatments were no longer appropriate. Many reported this process to be upsetting and expressed a need for psychological support. At the other end of the spectrum were family members of previously independent patients whose preferences pre-stroke had not been known. Family members described feeling extremely distressed at such an unexpected situation and wanting all treatments to continue. They described needing psychological support and hope that the patient would survive. Conclusion The knowledge that family members’ treatment decision-making approaches lay on a spectrum depending on the patient’s state of health and stated preferences pre-stroke may allow doctors to better prepare for discussions regarding the patient’s prognosis. This may enable doctors to provide information and support that is tailored towards family members’ needs.
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Affiliation(s)
- A Visvanathan
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK.
| | - G E Mead
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - M Dennis
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - W N Whiteley
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - F N Doubal
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - J Lawton
- Usher Institute, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
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28
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Joundi RA, Saposnik G, Martino R, Fang J, Kapral MK. Development and Validation of a Prognostic Tool for Direct Enteral Tube Insertion After Acute Stroke. Stroke 2020; 51:1720-1726. [PMID: 32397928 DOI: 10.1161/strokeaha.120.028949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- We aimed to create a novel prognostic risk score to estimate outcomes after direct enteral tube placement in acute stroke. Methods- We used the Ontario Stroke Registry and linked databases to obtain clinical information on all patients with direct enteral tube insertion after ischemic stroke or intracerebral hemorrhage from July 1, 2003 to June 30, 2010 (derivation cohort) and July 1, 2010 to March 31, 2013 (validation cohort). We used multivariable regression to assign scores to predictor variables for 3 outcomes after tube placement: favorable outcome (discharge modified Rankin Scale score 0-3 and alive at 90 days), poor outcome (discharge modified Rankin Scale score 5 or death at 90 days), and 30-day mortality. Results- Variables associated with a favorable outcome were younger age, preadmission independence, ischemic stroke rather than intracerebral hemorrhage, lower stroke severity, and a shorter time between stroke and tube placement. Variables associated with a poor outcome were older age, preadmission dependence, atrial fibrillation, greater stroke severity, and tracheostomy. Age, preadmission dependence, atrial fibrillation, cancer, chronic obstructive pulmonary disease, and shorter time to tube placement were associated with increased 30-day mortality. Using these variables, we created an online calculator to facilitate estimation of individual patient risk of favorable and poor outcomes. C-statistic in the validation cohort was 0.82 for favorable outcome, 0.65 for poor outcome, and 0.62 for 30-day mortality, and calibration was adequate. Conclusions- We developed risk scores to estimate outcomes after direct enteral tube insertion for acute dysphagic stroke. This information may be useful in discussions with patients and families when there is prognostic uncertainty surrounding outcomes with direct enteral tube placement after stroke.
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Affiliation(s)
- Raed A Joundi
- From the Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary (R.A.J.).,ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.)
| | - Gustavo Saposnik
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.).,Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), University of Toronto, Canada.,Institute of Health Policy, Management and Evaluation (G.S.), University of Toronto, Canada
| | - Rosemary Martino
- Department of Speech-Language Pathology (R.M.), University of Toronto, Canada.,Graduate Department of Rehabilitation Science (R.M.), University of Toronto, Canada.,Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Canada (R.M.)
| | - Jiming Fang
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.)
| | - Moira K Kapral
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.).,Division of General Internal Medicine, Department of Medicine (M.K.), University of Toronto, Canada.,Institute of Health Policy, Management, and Evaluation (M.K.), University of Toronto, Canada
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29
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Krishnamoorthy V, Hough CL, Vavilala MS, Komisarow J, Chaikittisilpa N, Lele AV, Raghunathan K, Creutzfeldt CJ. Tracheostomy After Severe Acute Brain Injury: Trends and Variability in the USA. Neurocrit Care 2020; 30:546-554. [PMID: 30919303 DOI: 10.1007/s12028-019-00697-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND/OBJECTIVE Severe acute brain injury (SABI) is responsible for 12 million deaths annually, prolonged disability in survivors, and substantial resource utilization. Little guidance exists regarding indication or optimal timing of tracheostomy after SABI. Our aims were to determine national trends in tracheostomy utilization among mechanically ventilated patients with SABI in the USA, as well as to examine factors associated with tracheostomy utilization following SABI. METHODS We conducted a population-based retrospective cohort study using the National Inpatient Sample from 2002 to 2011. We identified adult patients with SABI, defined as a primary diagnosis of stroke, traumatic brain injury or post-cardiac arrest who received mechanical ventilation for greater than 96 h. We analyzed trends in tracheostomy utilization over time and used multilevel mixed-effects logistic regression to analyze factors associated with tracheostomy utilization. RESULTS There were 94,082 hospitalizations for SABI during the study period, with 30,455 (32%) resulting in tracheostomy utilization. The proportion of patients with SABI who received a tracheostomy increased during the study period, from 28.0% in 2002 to 32.1% in 2011 (p < 0.001). Variation in tracheostomy utilization was noted based on patient and facility characteristics, including higher odds of tracheostomy in large hospitals (OR 1.34, 95% CI 1.18-1.53, p < 0.001, compared to small hospitals), teaching hospitals (OR 1.15, 95% CI 1.06-1.25, p = 0.001, compared to non-teaching hospitals), and urban hospitals (OR 1.60, 95% CI 1.33-1.92, p < 0.001, compared to rural hospitals). CONCLUSIONS Tracheostomy utilization has increased in the USA among patients with SABI, with wide variation by patient and facility-level factors.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, 2301 Erwin Rd., Durham, NC, 27710, USA. .,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA.
| | - Catherine L Hough
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | | | | | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University, 2301 Erwin Rd., Durham, NC, 27710, USA
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30
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Scholten EWM, Hillebregt CF, Ketelaar M, Visser-Meily JMA, Post MWM. Measures used to assess impact of providing care among informal caregivers of persons with stroke, spinal cord injury, or amputation: a systematic review. Disabil Rehabil 2019; 43:746-772. [PMID: 31366259 DOI: 10.1080/09638288.2019.1641847] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE (1) To identify measures used to evaluate the impact of caregiving among caregivers of persons with stroke, spinal cord injury, and amputation; and (2) to systematically evaluate their clinimetric properties reported in validation studies. MATERIALS AND METHODS Two separate systematic reviews (Embase, PsycINFO, CINAHL, Pubmed/Medline) were conducted. COSMIN guidelines were used to assess clinimetric properties and methodological quality of studies. RESULTS (1) 154 studies published between 2008 and May 2019 were included, in which 48 measures were used, mostly describing negative impact. Thirty measures were used only once and not further described. (2) In general, structural validity, internal consistency, and hypothesis testing were often investigated. Reliability, cross-cultural and criterion validity to a lesser extent, and scale development and content validity were rarely described. Tests of measurement error and responsiveness were exceptional. Most supporting evidence was found for the Zarit Burden Interview Short Form, Caregiver Burden Scale and Positive Aspects of Caregiving Questionnaire. CONCLUSIONS There is a wide variety of impact of caregiving measures. The present study provided a detailed overview of what is known about clinimetric characteristics of 18 different measures repeatedly used in research. The overview provides clinicians a guidance of appropriate measure selection. PROSPERO REGISTRATION CRD42018094796IMPLICATIONS FOR REHABILITATIONClinicians should be aware that information about measure development and clinimetric properties for most measures used to assess impact of informal caregiving is incomplete.Most supporting evidence was found for the Zarit Burden Interview Short Form, Caregiver Burden Scale and Positive Aspects of Caregiving Questionnaire.This overview of clinimetric properties provides clinicians guidance for selection of an appropriate measure.
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Affiliation(s)
- Eline W M Scholten
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Chantal F Hillebregt
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Marjolijn Ketelaar
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Johanna M A Visser-Meily
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.,Department of Rehabilitation, Physical Therapy Science & Sports, UMCU Utrecht Brain Center, University Medical Center, Utrecht, The Netherlands
| | - Marcel W M Post
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.,University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Department of Rehabilitation Medicine, Groningen, The Netherlands
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31
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Steigleder T, Kollmar R, Ostgathe C. Palliative Care for Stroke Patients and Their Families: Barriers for Implementation. Front Neurol 2019; 10:164. [PMID: 30894836 PMCID: PMC6414790 DOI: 10.3389/fneur.2019.00164] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/07/2019] [Indexed: 11/17/2022] Open
Abstract
Stroke is a leading cause of death, disability and is a symptom burden worldwide. It impacts patients and their families in various ways, including physical, emotional, social, and spiritual aspects. As stroke is potentially lethal and causes severe symptom burden, a palliative care (PC) approach is indicated in accordance with the definition of PC published by the WHO in 2002. Stroke patients can benefit from a structured approach to palliative care needs (PCN) and the amelioration of symptom burden. Stroke outcome is uncertain and outlook may change rapidly. Regarding these challenges, core competencies of PC include the critical appraisal of various treatment options, and openly and respectfully discussing therapeutic goals with patients, families, and caregivers. Nevertheless, PC in stroke has to date mainly been restricted to short care periods for dying patients after life-limiting complications. There is currently no integrated concept for PC in stroke care addressing the appropriate moment to initiate PC for stroke patients, and the question of how to screen for symptoms remains unanswered. Therefore, PC for stroke patients is often perceived as a stopgap in cases of unfavorable prognosis and very short survival times. In contrast, PC can provide much more for stroke patients and support a holistic approach, improve quality of life and ensure treatment according to the patient's wishes and values. In this short review we identify key aspects of PC in stroke care and current barriers to implementation. Additionally, we provide insights into our approach to PC in stroke care.
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Affiliation(s)
- Tobias Steigleder
- Department of Palliative Care, University Hospital Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Rainer Kollmar
- Department of Neurology and Neurointensive Care, Darmstadt Academic Hospital, Darmstadt, Germany
| | - Christoph Ostgathe
- Department of Palliative Care, University Hospital Erlangen-Nuremberg, Erlangen, Germany
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Chaturvedi SK. Commentary. Indian J Palliat Care 2019; 25:91-92. [PMID: 30820109 PMCID: PMC6388601 DOI: 10.4103/ijpc.ijpc_204_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Santosh K Chaturvedi
- Department of Mental Health Education, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Abstract
Neuropalliative care is a new and growing field within neurology that focuses on improving the quality of life of patients with serious neurologic illnesses. While specialty-level palliative care training is available to interested neurologists, all neurologists can strive to provide primary palliative care for their patients. In this review, we will describe the scope of neuropalliative care, define patient populations who may benefit from palliative care, and explore the communication and symptom management skills essential to palliative care delivery.
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Affiliation(s)
- K Brizzi
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - C J Creutzfeldt
- Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Wang Ambulatory Care Center, Boston, Massachusetts
- Department of Neurology, Harborview Medical Center, Seattle, Washington
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34
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Affiliation(s)
- Jessica Simon
- Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, Alta.
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35
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Doubal F, Cowey E, Bailey F, Murray SA, Borthwick S, Somerville M, Lerpiniere C, Reid L, Boyd K, Hynd G, Mead GE. The key challenges of discussing end-oflife stroke care with patients and families: a mixed-methods electronic survey of hospital and community healthcare professionals. J R Coll Physicians Edinb 2018; 48:217-224. [DOI: 10.4997/jrcpe.2018.305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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