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Paulik O, Whitaker R, Mesuria M, Wong D, Swanson K, Green H, Sikhosana N, Fernandez R. Implementation and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT™) in acute care. Australas J Ageing 2024. [PMID: 38558296 DOI: 10.1111/ajag.13308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/18/2024] [Accepted: 03/03/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES The Supportive and Palliative Care Indicators Tool (SPICT™) has been used to identify patients at risk of deteriorating and dying within 1 year. Early identification and integration of advance care planning (ACP) provides the opportunity for a better quality of life for patients. The aims of this study were to identify the number of patients who were SPICT™ positive; their mortality rates at 6 and 12 months of the SPICT™ assessment; and level of adherence to ACP documentation. METHODS A retrospective audit of the Supportive and Palliative Care database was conducted at an acute aged care precinct in a major metropolitan tertiary referral hospital in New South Wales, Australia. Data comprising demographics, clinical conditions, SPICT™ positivity and compliance with ACP documentation were collected. SPICT™-positive patients and mortality were tracked at 6 and 12 months, respectively. RESULTS Data from 153 patients were collected. The mean age of the patients was 84.1 (±7.8) years, and the length of hospital stay was 10 (±24.7) (range 1-269) days. Approximately 37% were from residential care, and 80% had family deciding on their care. About 15% died during hospitalisation, and 48% were discharged to a care facility. The ACP documentation showed various levels of completion. Mortality rates at 6 and 12 months were 36% and 39%, respectively. Most patients (99%) were SPICT™-positive, with indicators correlating with higher mortality rates at both follow-ups. CONCLUSIONS The study emphasises the critical need for addressing ACP and palliative care among older patients with life-limiting conditions. It underscores the importance of timely discussions, documentation, and cessation of futile interventions.
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Affiliation(s)
- Olivia Paulik
- St George Hospital, Sydney, New South Wales, Australia
| | | | | | - Debbie Wong
- St George Hospital, Sydney, New South Wales, Australia
| | - Katie Swanson
- St George Hospital, Sydney, New South Wales, Australia
| | - Heidi Green
- Australian Centre for Health Engagement, Evidence and Values (ACHEEV), School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Nqobile Sikhosana
- School of Nursing and Midwifery, University of Newcastle, Newcastle, New South Wales, Australia
| | - Ritin Fernandez
- School of Health Sciences, University of Newcastle, Newcastle, New South Wales, Australia
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Omoya O, De Bellis A, Breaden K. Experiences of Australian emergency doctors and nurses using advance care directives in the provision of care at the end of life. Emerg Med Australas 2024; 36:231-242. [PMID: 37940110 DOI: 10.1111/1742-6723.14343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/03/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE An advance care directive is a legal document outlining the wishes made by a person about treatment options. However, there is increasing evidence that an advance care directive that has previously been documented may not always benefit the current prognosis of the patient. Therefore, the aim of the present study was to explore the experiences of Australian emergency doctors and nurses concerning the use of previously documented advance care directives at the point of care for patients and their families. METHODS A qualitative study guided by a phenomenological interpretive approach was employed. Semi-structured interviews were conducted with ED doctors and nurses across Australia. Data were thematically analysed using a seven-stage data analysis framework. RESULTS An analysis of the interview data resulted in four major themes: (i) Benefits of Advance Care Directives; (ii) Knowledge and Awareness; (iii) Communication; and (iv) Availability of Advance Care Directive Information. CONCLUSIONS From the findings, advance care directives were believed to be beneficial in decision making when patients, families, and ED staff agreed with the decisions made. Advance care directives were often made a long time ago but were useful to start conversations around goals of care and end-of-life care relevant to the patient's current situation. Findings in the present study further reinforced that an advance care directive was beneficial when used alongside goals of care at the point of care in EDs.
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Affiliation(s)
- Oluwatomilayo Omoya
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Anita De Bellis
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Katrina Breaden
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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Sweeny AL, Alsaba N, Grealish L, May K, Huang YL, Ranse J, Denny KJ, Lukin B, Broadbent A, Burrows E, Ranse K, Sunny L, Khatri M, Crilly J. End-of-life care: A retrospective cohort study of older people who died within 48 hours of presentation to the emergency department. Emerg Med Australas 2024; 36:13-23. [PMID: 37914673 DOI: 10.1111/1742-6723.14331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/06/2023] [Accepted: 09/27/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES To describe the characteristics of, and care provided to, older people who died within 48 h of ED presentation. METHODS A descriptive retrospective cohort study of people 65 years and older presenting to two EDs in Queensland, Australia, between April 2018 and March 2019. Data from electronic medical records were collected and analysed. RESULTS Two hundred and ninety-five older people who died within 48 h of ED presentation were included. Nearly all arrived by ambulance (92%, n = 272) and 36% (n = 106) were from aged care facilities. Three-quarters (75%, n = 222) were triaged into the most urgent triage categories (i.e. Australasian Triage Scale; ATS 1/2). Fewer than half were previously independent with mobility (38%, n = 111) and activities of daily living (43%, n = 128). Sixty-one per cent (n = 181) had a pre-existing healthcare directive. Twenty-two per cent (n = 66) died in ED, most commonly due to pneumonia, intracerebral haemorrhage, cardiac arrest and/or sepsis. Over half had one or more ED visits (52%, n = 154) and/or hospital admissions (52%, n = 152) 6 months prior. CONCLUSIONS Identification of patients at end-of-life (EoL) is not always straightforward; consider recent reduction in independence and recent ED visits/hospital admissions. System-based strategies that span pre-hospital, ED and in-patient care are recommended to facilitate EoL pathway implementation and care continuity.
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Affiliation(s)
- Amy L Sweeny
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Nemat Alsaba
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Laurie Grealish
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Nursing and Midwifery Research Unit, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Katya May
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Ya-Ling Huang
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Health (Nursing), Southern Cross University, Gold Coast, Queensland, Australia
| | - Jamie Ranse
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Kerina J Denny
- Department of Intensive Care Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Bill Lukin
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane Residential Aged Care Assessment and Referral Service, Brisbane, Queensland, Australia
| | - Andrew Broadbent
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- Supportive and Specialist Palliative Care, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Erin Burrows
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Kristen Ranse
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Linda Sunny
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- Lyell McEwin and Modbury Hospitals, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Meghna Khatri
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
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Ellis-Smith C, Tunnard I, Dawkins M, Gao W, Higginson IJ, Evans CJ. Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools. BMC Palliat Care 2021; 20:168. [PMID: 34674695 PMCID: PMC8532380 DOI: 10.1186/s12904-021-00845-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022] Open
Abstract
Background Older people with multi-morbidities commonly experience an uncertain illness trajectory. Clinical uncertainty is challenging to manage, with risk of poor outcomes. Person-centred care is essential to align care and treatment with patient priorities and wishes. Use of evidence-based tools may support person-centred management of clinical uncertainty. We aimed to develop a logic model of person-centred evidence-based tools to manage clinical uncertainty in older people. Methods A systematic mixed-methods review with a results-based convergent synthesis design: a process-based iterative logic model was used, starting with a conceptual framework of clinical uncertainty in older people towards the end of life. This underpinned the methods. Medline, PsycINFO, CINAHL and ASSIA were searched from 2000 to December 2019, using a combination of terms: “uncertainty” AND “palliative care” AND “assessment” OR “care planning”. Studies were included if they developed or evaluated a person-centred tool to manage clinical uncertainty in people aged ≥65 years approaching the end of life and quality appraised using QualSyst. Quantitative and qualitative data were narratively synthesised and thematically analysed respectively and integrated into the logic model. Results Of the 17,095 articles identified, 44 were included, involving 63 tools. There was strong evidence that tools used in clinical care could improve identification of patient priorities and needs (n = 14 studies); that tools support partnership working between patients and practitioners (n = 8) and that tools support integrated care within and across teams and with patients and families (n = 14), improving patient outcomes such as quality of death and dying and satisfaction with care. Communication of clinical uncertainty to patients and families had the least evidence and is challenging to do well. Conclusion The identified logic model moves current knowledge from conceptualising clinical uncertainty to applying evidence-based tools to optimise person-centred management and improve patient outcomes. Key causal pathways are identification of individual priorities and needs, individual care and treatment and integrated care. Communication of clinical uncertainty to patients is challenging and requires training and skill and the use of tools to support practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00845-9.
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Affiliation(s)
- Clare Ellis-Smith
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.
| | - India Tunnard
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - Marsha Dawkins
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Guys & St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Wei Gao
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,King's College Hospital NHS Foundation Trust, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, UK
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Dignam C, Brown M, Thompson CH. Moving from "Do Not Resuscitate" Orders to Standardized Resuscitation Plans and Shared-Decision Making in Hospital Inpatients. Gerontol Geriatr Med 2021; 7:23337214211003431. [PMID: 33796631 PMCID: PMC7983414 DOI: 10.1177/23337214211003431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 02/19/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022] Open
Abstract
Not for Cardiopulmonary Resuscitation (No-CPR) orders, or the local equivalent, help prevent futile or unwanted cardiopulmonary resuscitation. The importance of unambiguous and readily available documentation at the time of arrest seems self-evident, as does the need to establish a patient’s treatment preferences prior to any clinical deterioration. Despite this, the frequency and quality of No-CPR orders remains highly variable, while discussions with the patient about their treatment preferences are undervalued, occur late in the disease process, or are overlooked entirely. This review explores the evolution of hospital patient No-CPR/Do Not Resuscitate decisions over the past 60 years. A process based on standardized resuscitation plans has been shown to increase the frequency and clarity of documentation, reduce stigma attached to the documentation of a No-CPR order, and support the delivery of medically appropriate and desired care for the hospital patient.
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Affiliation(s)
- Colette Dignam
- University of Adelaide, SA, Australia.,Royal Adelaide Hospital, SA, Australia
| | | | - Campbell H Thompson
- University of Adelaide, SA, Australia.,Royal Adelaide Hospital, SA, Australia
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Monchis M, Martin C, DiDiodato G. Evaluation of a program using a physician assistant and an electronic patient-provider communication tool to facilitate discussions about goals of care in older adults in hospital: a pilot study. CMAJ Open 2020; 8:E577-E584. [PMID: 32928879 PMCID: PMC7505521 DOI: 10.9778/cmajo.20200022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many patients receive unwanted, low-value, high-intensity care at the end of life because of poor communication with health care providers. Our aim was to evaluate the feasibility of using a physician assistant and an electronic tool to facilitate discussions about goals of care. METHOD We conducted a pilot study for the intervention (physician assistant-led discussion using an electronic tool) from Apr. 1 to Aug. 31, 2019. Patients aged 79 years or older admitted to the Royal Victoria Hospital (Barrie, Ontario) with either (i) no documented resuscitation preferences or (ii) a request for life-sustaining treatments in the event of a life-threatening illness were eligible for the intervention. The goal of this study was to complete more than 30 interventions. The primary outcomes included the proportion of consenting eligible patients, the time required and the proportion of patients changing their resuscitation preferences. RESULTS A total of 763 patients met the inclusion criteria, with 337 eligible for the intervention. Of these, 49 cases were contacted for consent, and 37 interventions were completed (75.5%, 95% confidence interval [CI] 61.1%-86.6%). On average, the intervention required 50 minutes (standard deviation 21) to complete. Overall, 31 interventions resulted in a change in resuscitation preferences (83.7%, 95% CI 68.0%-93.8%), with 22 patients choosing to forgo any access to life-sustaining treatments in the event of a life-threatening illness (59.4%, 95% CI 42.1%-75.2%). INTERPRETATION In this pilot study, the intervention was completed in a minority of eligible patients and required substantial time; however, it led to many changes in resuscitation preferences. Before designing a study to evaluate its impact, the intervention needs to be revised to make it more efficient to administer.
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Affiliation(s)
- Monica Monchis
- Department of Critical Care Medicine (Monchis, Martin, DiDiodato), Royal Victoria Regional Health Centre, Barrie, Ont.; Department of Health Research Methods, Evidence and Impact (DiDiodato), McMaster University, Hamilton, Ont
| | - Chris Martin
- Department of Critical Care Medicine (Monchis, Martin, DiDiodato), Royal Victoria Regional Health Centre, Barrie, Ont.; Department of Health Research Methods, Evidence and Impact (DiDiodato), McMaster University, Hamilton, Ont
| | - Giulio DiDiodato
- Department of Critical Care Medicine (Monchis, Martin, DiDiodato), Royal Victoria Regional Health Centre, Barrie, Ont.; Department of Health Research Methods, Evidence and Impact (DiDiodato), McMaster University, Hamilton, Ont.
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van de Schoot D. Should every patient have goals of care discussed in the emergency department? Yes. Emerg Med Australas 2020; 32:509-510. [PMID: 32394610 DOI: 10.1111/1742-6723.13527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/21/2020] [Indexed: 11/29/2022]
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Hanning J, Walker KJ, Horrigan D, Levinson M, Mills A. Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review. Emerg Med Australas 2019; 31:525-532. [DOI: 10.1111/1742-6723.13303] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/26/2019] [Accepted: 03/31/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Jennifer Hanning
- Emergency DepartmentCabrini Hospital Melbourne Victoria Australia
- Melbourne Medical SchoolThe University of Melbourne Melbourne Victoria Australia
| | - Katherine J Walker
- Emergency DepartmentCabrini Hospital Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | | | | | - Amber Mills
- Monash University Melbourne Victoria Australia
- Cabrini Institute Melbourne Victoria Australia
- Bolton Clarke Research Institute Melbourne Victoria Australia
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Abstract
Goals-of-care discussions aim to establish patient values for shared medical decision-making. These discussions are relevant towards end-of-life as patients may receive non-beneficial treatments if they have never discussed preferences for care. End-of-life care is provided in Emergency Departments (EDs) but little is known regarding ED-led goals-of-care discussions. We aimed to explore practitioner perspectives on goals-of-care discussions for adult ED patients nearing end-of-life. We report the qualitative component of a mixed methods study regarding a 'Goals-of-Care' form in an Australian ED. Eighteen out of 34 doctors who completed the form were interviewed. We characterised ED-led goals-of-care consultations for the first time. Emergency doctors perceive goals-of-care discussions to be relevant to their practice and occurring frequently. They aim to ensure appropriate care is provided prior to review by the admitting team, focusing on limitations of treatment and clarity in the care process. ED doctors felt they could recognise end-of-life and that ED visits often prompt consideration of end-of-life care planning. They wanted long-term practitioners to initiate discussions prior to patient deterioration. There were numerous interpretations of palliative care concepts. Standardisation of language, education, collaboration and further research is required to ensure Emergency practitioners are equipped to facilitate these challenging conversations.
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Affiliation(s)
- Michele Levinson
- a Department of Medicine , Monash University , Melbourne , Australia
| | - Katherine J Walker
- b Emergency Department , Cabrini , Melbourne , Australia.,c Department of Epidemiology and Preventive Medicine , Monash University , Melbourne , Australia
| | - Jennifer Hanning
- b Emergency Department , Cabrini , Melbourne , Australia.,d Melbourne Medical School , University of Melbourne , Melbourne , Australia
| | - William Dunlop
- b Emergency Department , Cabrini , Melbourne , Australia
| | - Edward Cheong
- b Emergency Department , Cabrini , Melbourne , Australia
| | - Amber Mills
- a Department of Medicine , Monash University , Melbourne , Australia.,e Bolton Clarke
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