Implementing Serious Illness Communication Processes in Primary Care: A Qualitative Study

PURPOSE

Primary care clinicians face barriers to engaging patients in conversations about prognosis, values, and goals ("serious illness conversations"). We introduced a structured, multi-component intervention, the Serious Illness Care Program (SICP), to facilitate conversations in the primary care setting. We present findings of a qualitative study to explore practical aspects of program implementation.

METHODS

We conducted semi-structured interviews of participating primary care physicians, nurse care coordinators, and social workers and coded transcripts to assess the activities used to integrate SICP into the workflow.

RESULTS

We conducted interviews with 14 of 46 clinicians from 6 primary care clinics, stopping with thematic saturation. Qualitative analysis revealed major themes around activities in the timing of the conversation (before, during, and after) and overarching insights about the program. Clinicians used a variety of strategies to adapt program components while preserving key program goals, including processes to generate accountability to ensure that conversations happen in busy clinical workflows. The interviews revealed changes to clinicians' mindset and norms, such as the recognition of the need to start conversations earlier in the illness course and the use of more expansive models of prognostic communication that address function and quality of life. Data also revealed indicators of sustainable behavior change and the spread of communication practices to patients outside the intended program scope.

CONCLUSION

SICP served as a framework for primary care clinicians to integrate serious illness communication into routine care. The shifts in processes employed by inter-professional clinicians revealed comprehensive models for prognostic communication and creative workflows to ensure that patients with complex illnesses had proactive, longitudinal, and patient-centered serious illness conversations and care planning.

Multiple line and polarization control in a far infrared laser with a compound grating resonator

Operating principles and the efficacy of two types of coupled laser resonator are described and their experimental verification presented: a compound mirror-grating-mirror resonator (MGM), and a mirror-grating-grating resonator (MGG). The coupling for both resonators is through the zero-order diffraction of the resonator's primary grating. The coupling mechanism makes it possible to obtain a particular wavelength and polarization from the resonators. Since the phase change of the radiation diffracted into both first order and zero order is different for the radiation polarized linearly parallel and linearly perpendicular to the direction of the grating lines, a different effective length of the secondary cavity exists for the two polarizations. In the case of the MGM resonator, the coupling is used to control the polarization properties of a single laser line. For the MGG resonator, the coupling is used so that two distinct laser lines can lase simultaneously. The MGG resonator also has a degree of control of the relative polarization of the two lines. The resonators are used to control the degree of the laser output coupling, output radiation polarization, and resonator bandwidth. The resonators were used for interaction studies between four pairs of water vapor lines (26.60-47.47, 26.60-47.70, 27.97-47.47, and 27.97-47.70, microm).

Carbon dioxide absorption of He-Ne laser radiation at 4.2 microm: characteristics of self and nitrogen broadened cases

A laser resonance absorption spectrometer is used to investigate the characteristics of both self and nitrogen collision broadened carbon dioxide in resonance with He-Ne laser radiation at 4.2 microm. The absorption coefficient in these broadening conditions has contributions from the R(28) to R(34) absorption lines of the nu(3) CO(2) spectrum. The Fletcher-Powell optimization method is used to reduce the raw absorption data and to find the best value average collision broadening coefficient and laser emission frequency for a Lorentzian line shape model of the contributing lines. Pure carbon dioxide absorption in a pressure range of from 0.0016 atm (1.25 Torr) to 0.33 atm (250 Torr) is described well by the model with an average self broadening coefficient of 0.084 +/- 0.008 cm(-1) atm(-1) for laser frequencies located at either 2370.591 +/- 0.020 cm(-1) or 2371.135 +/- 0.019 cm(-1). Nitrogen broadened carbon dioxide in the total pressure range of from 0.13 atm (100 Torr) to 1.18 atm (900 Torr) is characterized by the same model with the laser frequency at 2371.102 +/- 0.007 cm(-1) atm(-1). The average absorption coefficient for low concentrations of carbon dioxide in a 1-atm total pressure nitrogen environment has been determined experimentally as 9.90 +/- 1.49 cm(-1) atm(-1). All the listed results are at 296 K.

Pulsed and cw operation of helium-water vapor laser at 28 microm

The operating characteristics of a water vapor-helium laser working at 28 microm are presented. Comparison is made of power output in continuous and pulsed operation for various gas mixtures and discharge currents for the same laser cavity.

Laser Absorption Techniques for the Measurementof Atmospheric Water Vapor Concentration

A sensitive laser method with fast response time has been developed which is suitable for measuringatmospheric water vapor concentration. The method utilizes the absorption of 33.02 and 27.972 pm radiationfrom a water vapor laser. Experiments were carried out in a 2 m controlled atmosphere absorption cell atconditions corresponding to ground-level to high-altitude atmospheric pressures. Typically, an absorptionof 1% was produced in a 1 m path length by a water vapor pressure of 1.1 Pa at ground level and 2.2 Paat 5 km using 33.02 pm laser radiation. With 27,972 pm laser radiation the absorption is about a factor 50less and can be used when higher concentrations of water vapor are encountered. The response time of thedetecting apparatus can be less than a second and still achieve these sensitivities. Possibilities of building anairborne instrument for measuring water vapor concentration are discussed.

Absorption line parameter measurements using laser spectroscopy

An analytical method is described for obtaining the precise location of an absorption line and the pressure broadening coefficients due to self-broadening or foreign gas broadening from experimental measurements using a laser operating on a single line near the absorption line. These absorption line characteristics are obtained from the pressure dependence of the transmittance of the laser radiation for the gas of interest, the analysis involving a least squares fit to a family of Lorentz curves. The method includes a computer search for the region of best fit to the Lorentz profile and provides both the values of and errors in the above coefficients. The pressure broadening coefficient obtained is the same as for the more general Voigt curve. The method is applied to the absorption line of vinyl chloride near 27.972 microm and of methane near 3.392 microm and the results compared with a graphical fit to a Voigt profile. The self-broadening coefficients obtained were alpha = 0.15 x 10(-3) +/- 0.97 x 10(-4) cm(-1) Torr(-1) for vinyl chloride and alpha = 0.14 x 10(-3) +/- 0.46 x 10(-4) cm(-1) Torr(-1) for methane. The separation between the helium-neon laser line at 2947.903 cm(-1) and the methane absorption line at 2947.888 +/- 0.015 cm(-1) was found to be 0.21 x 10(-2) +/- 0.15 x 10(-2) cm(-1).

Excitation processes and relaxation rates in the pulsed water vapor laser

This paper presents an experimental study of time-resolved gain in H(2)O, H(2)O-He, and H(2)O-H(2) mixtures as a function of gas composition and excitation current. Utilizing the fast rising (~70 nsec) pulse from H(2)O-He laser as a probe, the amplifier gain was measured with a time resolution of about 100 nsec. The gain was observed to follow the excitation current pulse rather closely indicating that population inversion was established in times less than 100 nsec. This suggested that excitation was most likely by means of rapid cascading from higher levels and/or by direct electron impact. The gain was found to be describable by a two-level rate equation model containing one dominant relaxation rate and assuming immediate excitation of the levels involved by inelastic collisions with electrons. With pure H(2)O, the relaxation rate was proportional to pressure to within 10%, indicating that the upper level was de-excited primarily by c llisions with other H(2)O molecules. At a pressure of 1 Torr the relaxation rate in pure H(2)O was 0.35 +/- 0.05 for the 28-microm transition. The addition of small amounts of foreign gases was observed to increase this relaxation rate, consistent with the measured decrease in the amplifier gain. By subsequently increasing the water vapor pressure it was found possible to optimize the gain at an enhanced level over the pure H(2)O case. The peak gain obtained in water vapor at 1000 A was 0.34 m(-1). Under foreign gas addition this increased to 0.68 m(-l) for the same peak current. In this case the relaxation rate, as a function of the foreign gas (He or H(2)) pressure, remained constant to within 10%, suggesting that these gases at higher concentrations may enhance the system gain by altering the discharge conditions without appreciably collisionally de-exciting the upper laser level.

Analysis of gain measurements of a pulsed two-level laser system

A fast and convenient method for the extraction of basic constants from time resolved laser amplifier gain measurements is described. The method is based on the assumption of a two-level laser system having direct electron excitation of the levels involved. The experimentally measured pulsed discharge current waveforms and time resolved gain curves are analyzed by a digital computer and fitted to the above model.

Grating coupled compound resonators

A simple model, based on a simple boundary condition at the grating coupling surface, is constructed for a grating coupled cavity. The physical meaning of the boundary condition is discussed, and the gain factor and phase shift of the coupled resonator are studied in terms of the properties of the grating and the reflectivities of the mirrors.

A formulation of the infinite strip resonator problem

The geometrical theory of diffraction has been used to formulate the infinite strip resonator problem. The conditions of large mirror size and large separation of the end mirrors in the Fox and Li formulation can be removed under this alternative scheme. Diffraction losses and phase shifts are given for resonators of Fresnel number from 0.56 to 0.01.