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Choi S, Ko H. Factors affecting advance directives completion among older adults in Korea. Front Public Health 2024; 12:1329916. [PMID: 38371241 PMCID: PMC10869548 DOI: 10.3389/fpubh.2024.1329916] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/15/2024] [Indexed: 02/20/2024] Open
Abstract
Objective Advance directives (ADs) provide an opportunity for patients to enhance the quality of their end-of-life care and prepare for a dignified death by deciding treatment plans. The purpose of this study was to explore the multiple factors that influence the advance directives completion among older adults in South Korea. Methods This was a secondary analysis of a cross-sectional study of 9,920 older adults. The differences in ADs based on subjects' sociodemographic characteristics, health-related characteristics, and attitude toward death were tested using the chi-squared and t-test. A multinomial logistic regression model was used to identify the influencing factor of ADs. Results The number of chronic diseases, number of prescribed medications, depression, insomnia, suicide intention, and hearing, vision, or chewing discomfort were higher in the ADs group compared to the non-ADs group. The influencing factors of the signing of ADs included men sex, higher education level, exercise, death preparation education, lower awareness of dying-well, and experience of fracture. Conclusion Information dissemination regarding ADs should be promoted and relevant authorities should consider multiple options to improve the physical and psychological health of older adults, as well as their attitude toward death to increase the ADs completion rate.
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Affiliation(s)
| | - Hana Ko
- College of Nursing, Gachon University, Yeonsu-gu, Incheon, Republic of Korea
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Mathew T, Patel A, DiGrande K, Michelis ND, Mody B, Lombardo D. Improving Advance Care Planning for Hospitalized Patients With Heart Failure. Palliat Med Rep 2023; 4:339-343. [PMID: 38155912 PMCID: PMC10754343 DOI: 10.1089/pmr.2023.0035] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 12/30/2023] Open
Abstract
Advance care planning (ACP) is a valuable and proven approach for enhancing end-of-life communication and quality of life for individuals with heart failure (HF) and their family members. However, the adoption of ACP in practice is still lower than desired. According to University of California, Irvine Medical Center HF metrics, only 15.3% of hospitalized HF patients had completed ACP documentation before discharge, as recorded in the electronic medical record (EMR). This quality improvement project aimed to investigate whether the rate of ACP completion could be increased by utilizing EMR reminders to health care teams regarding individual patients. Personalized reminders were sent to providers for each hospitalized patient diagnosed with HF, who did not have existing ACP documentation in the EMR, to encourage completion of ACP documentation. Our findings have shown that, during the three-month intervention period, the average ACP completion rate was 21.0%. This represents a 5.7% absolute increase in ACP completion compared to the six months before our intervention (15.3%); a relative increase of 37.3%. Direct message reminders to providers prove to be an effective method for enhancing ACP completion among this specific patient group.
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Affiliation(s)
- Tobin Mathew
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
| | - Akash Patel
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
| | - Kyle DiGrande
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
| | - Nathalie De Michelis
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
| | - Behram Mody
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
| | - Dawn Lombardo
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
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3
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Cameron P, Jusela C. Unfolding Case Studies for Nursing Leadership. J Dr Nurs Pract 2023; 16:3-8. [PMID: 36918280 DOI: 10.1891/jdnp-2021-0018] [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] [Indexed: 03/16/2023]
Abstract
Background: The education of nursing students has changed radically during the COVID-19 pandemic, with more content being delivered virtually. With less face-to-face (F2F) contact with educators, content translation to real-world scenarios is diminished. Objective: To determine if an educational seminar using unfolding case studies will improve students' understanding of concepts. Method: A pilot study of senior-level nursing students of an intensive unfolding case study application was conducted to focus on concept application. Results: Pre- and post-tests were compared with the increase in understanding of the focused topics, delegation, advanced directives, and safety, which was statistically significant (t[55] = 6.92, p < .001). Conclusion: Using real-world clinical problems through case studies facilitates understanding concepts and developing critical thinking skills/problem-solving abilities. The results of this study provide an impetus for the use of unfolding case studies to help nursing students understand leadership concepts.
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Affiliation(s)
| | - Cheryl Jusela
- Oakland University School of Nursing, Rochester, Michigan, USA
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4
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Haines KL, Nguyen BP, Antonescu I, Freeman J, Cox C, Krishnamoorthy V, Kawano B, Agarwal S. Insurance Status and Ethnicity Impact Health Disparities in Rates of Advance Directives in Trauma. Am Surg 2023; 89:88-97. [PMID: 33877932 DOI: 10.1177/00031348211011115] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Advanced directives (ADs) provide a framework from which families may understand patient's wishes. However, end-of-life planning may not be prioritized by everyone. This analysis aimed to determine what populations have ADs and how they affected trauma outcomes. METHODS Adult trauma patients recorded in the American College of Surgeons Trauma Quality Improvement Program (TQIP) from 2013-2015 were included. The primary outcome was presence of an AD. Secondary outcomes included mortality, length of stay (LOS), mechanical ventilation, ICU admission/LOS, withdrawal of life-sustaining measures, and discharge disposition. Multivariable logistic regression models were developed for outcomes. RESULTS 44 705 patients were included in the analyses. Advanced directives were present in 1.79% of patients. The average age for patients with ADs was 77.8 ± 10.7. African American (odds ratio (OR) .53, confidence intervals [CI] .36-.79) and Asian (OR .22, CI .05-.91) patients were less likely to have ADs. Conversely, Medicaid (OR 1.70, CI 1.06-2.73) and Medicare (OR 1.65, CI 1.25-2.17) patients were more likely to have ADs as compared to those with private insurance. The presence of ADs was associated with increased hospital mortality (OR 2.84, CI 2.19-3.70), increased transition to comfort measures (OR 2.87, CI 2.08-3.95), and shorter LOS (CO -.74, CI -1.26-.22). Patients with ADs had an increased odds of hospice care (OR 4.24, CI 3.18-5.64). CONCLUSION Advanced directives at admission are uncommon, particularly among African Americans and Asians. The presence of ADs was associated with increased mortality, use of mechanical ventilation, admission to the ICU, withdrawal of life-sustaining measures, and hospice. Future research should target expansion of ADs among minority populations to alleviate disparities in end-of-life treatment.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Benjamin P Nguyen
- Department of Surgery, 20868Kaweah Delta Health Care District, Medical Center, Visalia, CA, USA
| | - Ioana Antonescu
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Jennifer Freeman
- Department of Surgery, 3402TCU and UNTHSC School of Medicine, Fort Worth, TX, USA
| | - Christopher Cox
- Division of Pulmonary Critical Care, Department of Medicine, 22957Duke University Medical Center, Durham, NC, USA
| | - Vijay Krishnamoorthy
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Brad Kawano
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
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Lehmann F, Schneider M, Bernstock JD, Bode C, Borger V, Ehrentraut SF, Gessler F, Potthoff AL, Putensen C, Schenk LM, Zimmermann J, Vatter H, Schuss P, Hadjiathanasiou A. Treatment-Limiting Decisions in Patients with Spontaneous Intracerebral Hemorrhage. Medicina (Kaunas) 2022; 58. [PMID: 35893103 DOI: 10.3390/medicina58080989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 11/27/2022]
Abstract
Background and Objectives: Treatment-limiting decisions (TLDs) are employed to actively withhold treatment/invasive interventions from patients in whom clinicians feel they would derive little to no benefit and/or suffer detrimental effects. Data regarding the employment of TLDs in patients with spontaneous intracerebral hemorrhage (ICH) remain sparse. Accordingly, this study sought to investigate both the prevalence of TLDs and factors driving TLDs in patients suffering from spontaneous ICH. Materials and Methods: This was a retrospective study of 249 consecutive patients with ICH treated from 2018−2019 at the Neurovascular Center of the University Hospital Bonn. Reasons deemed critical in the decision-making process with regard to TLD were ultimately extracted/examined via chart review of qualifying patients. Results: A total of 249 patients with ICH were included within the final analyses. During the time period examined, 49 patients (20%) had advanced directives in place, whereas in 53 patients (21%) consultation with relatives or acquaintances was employed before further treatment decisions. Overall, TLD ultimately manifested in 104 patients (42%). TLD was reached within 6 h after admission in 52 patients (50%). Congruent with severity of injury and expected outcomes, TLDs were more likely in patients with signs of cerebral herniation and an ICH score > 3 (p < 0.001). Conclusions: The present study examines details associated with TLDs in patients with spontaneous ICH. These data provide insight into key decisional processes and reinforce the need for further structured investigations in an effort to help guide patients and their families.
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Horton SM. Can African-Americans Be Encouraged to Become Active Participants in Advanced Care Planning? J Natl Black Nurses Assoc 2022; 33:22-28. [PMID: 38564488] [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] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
The purpose of this study was to encourage African-Americans to become active participants in advanced care planning through increased education and awareness. A quasi-experimental design was used in two local churches in Leon County. Thirty participants (N = 30) were African-Americans, 18 years of age and older, English speaking, from all socioeconomical levels, and from all educational backgrounds. The annotated 2003 Minnesota Survey was used to develop pre-survey and post-survey questions regarding advanced care planning. A paired t test was used to analyze the pre-survey and post-survey responses. The significant value was < 0.05, thus demonstrating a statistically significant difference in pre- and post-survey responses. The educational intervention on advanced directives indicated that all 30 participants would consider completing some form of advanced directive or discussing end-of-life care planning with either another person, a healthcare provider, or they would seek legal advice. African-Americans are more prone to chronic diseases. However, a systemic literature review describes how African-Americans were less likely to participate in advanced care planning and were less likely to receive end-of-life care than other ethnic groups. The 30-minute educational intervention encouraged African-Americans to participate in advanced care planning. Because the sample size was small, results cannot be generalized to all African-Americans. With increased educational opportunities, African-Americans may be encouraged to become active participants in advanced care planning. Advanced practice registered nurse providers should provide advanced care planning information to all patients, but especially to African-Americans. This study should be replicated in a wide variety of settings with larger numbers of participants. Further research is needed to discover additional methods of providing advanced care planning education to African-Americans.
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de Lasa C, Brown EE, Colman R, Rajji TK, Colman S. Invited letter: Integrated palliative care in a geriatric mental health setting during the COVID-19 pandemic. Int J Geriatr Psychiatry 2021; 37:10.1002/gps.5654. [PMID: 34792225 PMCID: PMC8646403 DOI: 10.1002/gps.5654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Cristina de Lasa
- Division of Medicine in PsychiatryCentre for Addiction and Mental HealthTorontoCanada
- Department of Family and Community MedicineUniversity of TorontoTorontoCanada
| | - Eric E. Brown
- Division of Adult Neurodevelopment and Geriatric PsychiatryCentre for Addiction and Mental HealthTorontoCanada
- Department of PsychiatryUniversity of TorontoTorontoCanada
| | - Rebecca Colman
- Divisions of Respirology and Division of Palliative MedicineDepartment of MedicineUniversity of TorontoTorontoCanada
- Temmy Latner Centre for Palliative CareSinai Health SystemTorontoCanada
| | - Tarek K. Rajji
- Division of Adult Neurodevelopment and Geriatric PsychiatryCentre for Addiction and Mental HealthTorontoCanada
- Department of PsychiatryUniversity of TorontoTorontoCanada
- Toronto Dementia Research AllianceUniversity of TorontoTorontoCanada
| | - Sarah Colman
- Division of Adult Neurodevelopment and Geriatric PsychiatryCentre for Addiction and Mental HealthTorontoCanada
- Department of PsychiatryUniversity of TorontoTorontoCanada
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8
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Meisenberg BR, Qureshi S, Somasekar MT, Ali Q, Karpman M, Rhule J. Covid-19 Mortality in an Acute Care Hospital: Association of Patient Factors With Decision to Forego the Intensive Care Unit. Am J Hosp Palliat Care 2021; 39:481-486. [PMID: 34184575 DOI: 10.1177/10499091211028849] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Public awareness of the large mortality toll of COVID-19 particularly among elderly and frail persons is high. This public awareness represents an enhanced opportunity for early and urgent goals-of-care discussions to reduce medically ineffective care. OBJECTIVE To assess the end-of-life experiences of hospitalized patients dying of COVID-19 with respect to identifying the clinical factors associated with utilization or non-utilization of the ICU. METHODS Retrospective cohort study of hospital outcomes using electronic medical records and individual chart review from March 15, 2020 to October 15, 2020 of every patient with a COVID-19 diagnosis who died or was admitted to hospice while hospitalized. Logistic regression multivariate analysis was used to identify the clinical and demographic factors associated with non-utilization of the ICU. RESULTS 133/749 (18%) of hospitalized COVID-19 patients died or were admitted to hospice as a result of COVID-19. Of the 133, 66 (49.6%) had no ICU utilization. In multivariate analysis, the significant patient factors associated with non-ICU utilization were increasing age, normal body mass index, and the presence of an advanced directive calling for limited life sustaining therapies. Race and residence at time of admission (home vs. facility) were significant only in the unadjusted analyses but not in adjusted. Gender was not significant in either form of analyses. CONCLUSION Goals of care discussions performed by an augmented palliative care team and other bedside clinicians had renewed urgency during COVID-19. Large percentages of patients and surrogates, perhaps motivated by public awareness of poor outcomes, opted not to utilize the ICU.
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Affiliation(s)
- Barry R Meisenberg
- Department of Medicine, Annapolis, MD, USA.,589981Luminis Health Research Institute, Luminis Health, Annapolis, MD, USA
| | - Sadaf Qureshi
- 589981Luminis Health Research Institute, Luminis Health, Annapolis, MD, USA
| | - Monika Thandalam Somasekar
- Department of Medicine, Annapolis, MD, USA.,589981Luminis Health Research Institute, Luminis Health, Annapolis, MD, USA
| | - Qurat Ali
- 589981Luminis Health Research Institute, Luminis Health, Annapolis, MD, USA
| | - Mitchell Karpman
- 589981Luminis Health Research Institute, Luminis Health, Annapolis, MD, USA
| | - Jane Rhule
- 589981Luminis Health Research Institute, Luminis Health, Annapolis, MD, USA
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9
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Levine OH, Dhesy-Thind SK, McConnell MM, Brouwers MC, Mukherjee SD. Code status communication training in postgraduate oncology programs: a needs assessment. Curr Oncol 2020; 27:e607-e613. [PMID: 33380876 PMCID: PMC7755451 DOI: 10.3747/co.27.6221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Discussions with patients with cancer about cardiopulmonary resuscitation directives (code status) are often led by residents. This study was carried out in Canada to identify current educational practices and gaps in training for this communication skill. Methods Canadian medical and radiation oncology residents and program directors (pds) were surveyed about teaching practices, satisfaction with current education, and barriers to teaching code status discussion skills. Relative frequencies of categorical and ordinal responses were calculated. Results Between November 2016 and February 2017, 95 (58.6%) of 162 residents and 17 (63%) of 27 pds completed surveys. Only 54.1% and 48.3% of medical and radiation oncology residents, respectively, had received any code status communication training before entering an oncology program. While 41% of residents expected to receive formal teaching on this topic during residency, 47.1% of pds endorsed inclusion of this topic in curricula. Only 20% of residents reported receiving formal evaluation of this skill while 41.2% of pds indicated that evaluations are provided. The importance of this communication skill in oncology was strongly supported. Among residents, 88% desired more training, and 82.3% of pds identified the need for new educational resources. Lack of time, resources, and evaluation tools were among the most commonly identified barriers to teaching. Conclusions Oncology residency pds and trainees feel that code status communication is important, but teaching and evaluation of this skill are limited. Barriers to teaching and skill-building have been identified. Further work is underway to develop novel educational resources for code status communication training.
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Affiliation(s)
- O H Levine
- Department of Oncology, McMaster University, Hamilton
| | | | - M M McConnell
- Department of Innovation in Medical Education, University of Ottawa, Ottawa
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa
| | - M C Brouwers
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON
| | - S D Mukherjee
- Department of Oncology, McMaster University, Hamilton
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10
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Schifeling CH, Shanbhag P, Johnson A, Atwater RC, Koljack C, Parnes BL, Vejar MM, Farro SA, Phimphasone-Brady P, Lum HD. Disparities in Video and Telephone Visits Among Older Adults During the COVID-19 Pandemic: Cross-Sectional Analysis. JMIR Aging 2020; 3:e23176. [PMID: 33048821 PMCID: PMC7674139 DOI: 10.2196/23176] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [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: 08/05/2020] [Revised: 10/01/2020] [Accepted: 10/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Telephone and video telemedicine appointments have been a crucial service delivery method during the COVID-19 pandemic for maintaining access to health care without increasing the risk of exposure. Although studies conducted prior to the pandemic have suggested that telemedicine is an acceptable format for older adults, there is a paucity of data on the practical implementation of telemedicine visits. Due to prior lack of reimbursement for telemedicine visits involving nonrural patients, no studies have compared telephone visits to video visits in geriatric primary care. OBJECTIVE This study aimed to determine (1) whether video visits had longer durations, more visit diagnoses, and more advance care planning discussions than telephone visits during the rapid implementation of telemedicine in the COVID-19 pandemic, and (2) whether disparities in visit type existed based on patient characteristics. METHODS We conducted a retrospective, cross-sectional analysis of patients seen at two geriatric clinics from April 23 to May 22, 2020. Approximately 25% of patients who had telephone and video appointments during this time underwent chart review. We analyzed patient characteristics, visit characteristics, duration of visits, number of visit diagnoses, and the presence of advance care planning discussion in clinical documentation. RESULTS Of the 190 appointments reviewed, 47.4% (n=90) were video visits. Compared to telephone appointments, videoconferencing was, on average, 7 minutes longer (mean 37.3 minutes, SD 10 minutes; P<.001) and had, on average, 1.2 more visit diagnoses (mean 5.7, SD 3; P=.001). Video and telephone visits had similar rates of advance care planning. Furthermore, hearing, vision, and cognitive impairment did not result in different rates of video or telephone appointments. Non-White patients, patients who needed interpreter services, and patients who received Medicaid were less likely to have video visits than White patients, patients who did not need an interpreter, and patients who did not receive Medicaid, respectively (P=.003, P=.01, P<.001, respectively). CONCLUSIONS Although clinicians spent more time on video visits than telephone visits, more than half of this study's older patients did not use video visits, especially if they were from racial or ethnic minority backgrounds or Medicaid beneficiaries. This potential health care disparity merits greater attention.
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Affiliation(s)
- Christopher H Schifeling
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Prajakta Shanbhag
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Angene Johnson
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Riannon C Atwater
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Claire Koljack
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Bennett L Parnes
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Maria M Vejar
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Samantha A Farro
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | | | - Hillary D Lum
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, United States.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO, United States
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11
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Yao JS, Dee EC, Milazzo C, Jurado J, Paguio JA. Covid-19 in dementia: an insidious pandemic. Age Ageing 2020; 49:713-715. [PMID: 32584402 PMCID: PMC7337638 DOI: 10.1093/ageing/afaa136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
- Jasper Seth Yao
- Hoboken University Medical Center, Hoboken, NJ 07030, USA
- Address correspondence to: Jasper Seth Yao. Tel: +639175369876 or +63287277619.
| | | | | | - Jerry Jurado
- Hoboken University Medical Center, Hoboken, NJ 07030, USA
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13
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Abstract
We propose that the palliative care team response will occur in two ways: first, communication and second, symptom management. Our experience with discussing goals of care with the family of a COVID-positive patient highlighted some expected and unexpected challenges. We describe these challenges along with recommendations for approaching these conversations. We also propose a framework for proactively mobilizing the palliative care workforce to aggressively address goals of care in all patients, with the aim of reducing the need for rationing of resources.
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Affiliation(s)
- Catherine Adams
- Community Hospice, Albany, New York, USA; St. Peter's Hospital Albany, New York, USA.
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14
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Fokin AA, Wycech J, Katz JK, Tymchak A, Teitzman RL, Koff S, Puente I. Palliative Care Consultations in Trauma Patients and Role of Do-Not-Resuscitate Orders: Propensity-Matched Study. Am J Hosp Palliat Care 2020; 37:1068-1075. [PMID: 32319314 DOI: 10.1177/1049909120919672] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To delineate characteristics of trauma patients associated with a palliative care consultation (PCC) and to analyze the role of do-not-resuscitate (DNR) orders and related outcomes. METHODS Retrospective study included 864 patients from 2 level one trauma centers admitted between 2012 and 2019. Level 1 trauma centers are designated for admission of the most severe injured patients. Palliative care consultation group of 432 patients who received PCC and were compared to matched control (MC) group of 432 patients without PCC. Propensity matching covariates included Injury Severity Score, mechanism of injury, gender, and hospital length of stay (HLOS). Analysis included patient demographics, injury parameters, intensive care unit (ICU) admissions, ICU length of stay (ICULOS), duration of mechanical ventilation, timing of PCC and DNR, and mortality. Palliative care consultation patients were further analyzed based on DNR status: prehospital DNR, in-hospital DNR, and no DNR (NODNR). RESULTS Palliative care consultation compared to MC patients were older, predominantly Caucasian, with more frequent traumatic brain injury (TBI), ICU admissions, and mechanical ventilation. The average time to PCC was 5.3 days. Do-not-resuscitate orders were significantly more common in PCC compared to MC group (71.5% vs 11.1%, P < .001). Overall mortality was 90.7% in PCC and 6.0% in MC (P < .001). In patients with DNR, mortality was 94.2% in PCC and 18.8% in MC. In-hospital DNR-PCC compared to NODNR-PCC patients had shorter ICULOS (5.0 vs 7.3 days, P = .04), HLOS (6.2 vs 13.2 days, P = .006), and time to discharge (1.0 vs 6.3 days, P = .04). CONCLUSIONS Advanced age, DNR order, and TBI were associated with a PCC in trauma patients and resulted in significantly higher mortality in PCC than in MC patients. Combination of DNR and PCC was associated with shorter ICULOS, HLOS, and time from PCC to discharge.
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Affiliation(s)
- Alexander A Fokin
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA
| | - Joanna Wycech
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL, USA
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA
| | - Alexander Tymchak
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA
| | | | - Susan Koff
- 535241TrustBridge Health, West Palm Beach, FL, USA
| | - Ivan Puente
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL, USA.,Department of Surgery, Herbert Wertheim College of Medicine, 306688Florida International University, Miami, FL, USA
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McKinnon M, Donnelly F, Perry J. Experiences of Post Anaesthetic Unit Recovery Nurse facilitating Advanced Directives in the immediate postanaesthetic period: A phenomenological study. J Adv Nurs 2020; 76:1708-1716. [PMID: 32189370 DOI: 10.1111/jan.14357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/07/2019] [Revised: 02/14/2020] [Accepted: 03/09/2020] [Indexed: 11/29/2022]
Abstract
AIMS The aims of this study were to develop an understanding of the lived experience of the Post Anaesthetic Unit Recovery Nurse facilitating Advanced Directives and implications for patient-centred care. DESIGN Interpretive phenomenological analysis. METHODS Homogenized purposive sampling of six Registered Nurses using in-depth semi-structured interviews. Interviews were conducted between June-July 2018. Analysis was performed using interpretive phenomenology analysis. RESULTS Post Anaesthetic Recovery Nurses experienced a 'Grey Zone' when facilitating Advanced Directives postanaesthetic. The 'Grey Zone' is defined through four themes; The 'Trigger' of the anaesthetic characterized by physiological instability; 'Confusion and Frustration' featuring balancing of roles as a clinician and advocate during patient decline; 'Consistent Paternalism' by medical staff in the consideration of Advanced Directives; and 'Disempowerment' where nurses faced issues of advocacy, personal distress, a lack of literature or protocols, and handover of information. CONCLUSION The lived experience of nurses facilitating Advanced Directives postanaesthetic may be distressing. Further research is required to understand the implications of Advanced Directives following an anaesthetic. Education and development of protocols are recommended to optimize patient-centred care. IMPACT Post Anaesthetic Unit Recovery Nurses experienced a 'Grey Zone' when facilitating Advanced Directives, defined through four themes. Advanced Directives may appear to be clear, however, the anaesthetic may trigger physiological instability leading to confusion and frustration in interpretation and application of Advanced Directives. Confusion and Frustration were experienced while the attitudes of Consistent Paternalism were encountered when advocating for patient wishes, resulting in Disempowerment. Post Anaesthetic Unit Recovery Nurses may become empowered through acknowledging and describing the 'Grey Zone'.
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Affiliation(s)
- Majella McKinnon
- Adelaide Nursing School, The University of Adelaide, Adelaide, SA, Australia
| | - Frank Donnelly
- Adelaide Nursing School, The University of Adelaide, Adelaide, SA, Australia
| | - Josephine Perry
- Adelaide Nursing School, The University of Adelaide, Adelaide, SA, Australia
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16
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Marmor M, Jonas A, Mirza A, Rad E, Wong H, Aslakson RA. Opportunities to Improve Utilization of Palliative Care Among Adults With Cystic Fibrosis: A Systematic Review. J Pain Symptom Manage 2019; 58:1100-1112.e1. [PMID: 31437475 DOI: 10.1016/j.jpainsymman.2019.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Individuals with cystic fibrosis (CF) frequently survive into adulthood, and many have multifaceted symptoms that impair quality of life. OBJECTIVE We conducted a systematic review to investigate opportunities to improve utilization of palliative care among adults with CF. METHODS We searched PubMed, Embase, Scopus, Web of Science, and CINAHL databases from inception until September 27, 2018, and reviewed references manually. Eligible articles were published in English, involved adults aged 18 years and older with CF, and contained original data regarding patient outcomes related to presence of advance care planning (ACP), symptom experience, and preferred and/or received end-of-life (EOL) care. RESULTS We screened 652 article abstracts and 32 full-text articles; 12 studies met inclusion criteria. All studies were published between 2000 and 2018. Pertinent findings include that although 43% to 65% of adults with CF had contemplated completing ACP, the majority only completed ACP during their terminal hospital admission. Patients also reported high prevalence of untreated symptoms, with adequate symptom control reported in 45% among those with dyspnea, 22% among those with pain, and 51% among those with anxiety and/or depression. Prevalence of in-hospital death ranged from 62% to 100%, with a third dying in the intensive care unit. The majority received antibiotics and preventative treatments during their terminal hospitalization. Finally, treatment from a palliative care specialist was associated with a higher prevalence of patient completion of advanced directives, decreased likelihood of death in intensive care unit, and decreased use of mechanical ventilation at EOL. CONCLUSION Adults with CF often have untreated symptoms, and many opportunities exist for palliative care specialists to improve ACP completion and quality of EOL care.
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Affiliation(s)
- Meghan Marmor
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, California, USA.
| | - Andrea Jonas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Alicia Mirza
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Elika Rad
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Hongnei Wong
- Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca A Aslakson
- Department of Medicine, Stanford University, Stanford, California, USA; Department of Anesthesiology, Stanford University, Stanford, California, USA
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17
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Abstract
Advance directives (ADs) allow individuals to legally determine their preferences for end-of-life (EOL) medical treatment and designate a health-care proxy to act on their behalf prior to losing the cognitive ability to make informed decisions for themselves. An interprofessional group of researchers (law, nursing, medicine, and social work) conducted an exploratory study to identify the differences in quality-of-life (QOL) language found within the AD state statutes from 50 US states and the District of Columbia. Data were coded using constant comparative analysis. Identified concepts were grouped into 2 focus areas for EOL discussions: communication/awareness of surroundings and activities of daily living. Language regarding communication/awareness of surroundings was present in the half of the statutes. Activities of daily living were addressed in only 18% of the statutes. Only 3 states (Arkansas, Nevada, and Tennessee) specifically addressed QOL. Patients are best served when professionals, regardless of discipline, can share and transform knowledge for patients in times of crisis and loss in ways that are empathetic and precise. Interprofessional collaborative practice (IPCP) comprises multiple health workers from different professional backgrounds working together with patients, families, and communities to deliver the highest quality of care. One of the major competencies of IPCP encompasses values and ethics. Interprofessional collaborative practice is offered as the means to deliver person-centered value-based care when facilitating these crucial dialogs and making recommendations for change.
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Affiliation(s)
- Terry Eggenberger
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL, USA
| | - Heather Howard
- Phyllis and Harvey Sandler School of Social Work, Florida Atlantic University, Boca Raton, FL, USA
| | | | - George Luck
- Hospice and Palliative Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
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18
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Saya A, Brugnoli C, Piazzi G, Liberato D, Di Ciaccia G, Niolu C, Siracusano A. Criteria, Procedures, and Future Prospects of Involuntary Treatment in Psychiatry Around the World: A Narrative Review. Front Psychiatry 2019; 10:271. [PMID: 31110481 PMCID: PMC6501697 DOI: 10.3389/fpsyt.2019.00271] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/10/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anna Saya
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Psychiatry and Clinical Psychology Unit, Department of Neurosciences, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Chiara Brugnoli
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Psychiatry and Clinical Psychology Unit, Department of Neurosciences, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Gioia Piazzi
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Psychiatry and Clinical Psychology Unit, Department of Neurosciences, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Daniela Liberato
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Psychiatry and Clinical Psychology Unit, Department of Neurosciences, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Gregorio Di Ciaccia
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Psychiatry and Clinical Psychology Unit, Department of Neurosciences, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Cinzia Niolu
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Psychiatry and Clinical Psychology Unit, Department of Neurosciences, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Alberto Siracusano
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Psychiatry and Clinical Psychology Unit, Department of Neurosciences, Fondazione Policlinico Tor Vergata, Rome, Italy
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19
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Abstract
Management of limited health-care resources has been of growing concern. Stewardship of health-care dollars and avoidance of low-value care is being increasingly recognized as a matter that affects all practitioners. This review aims to examine a particular pathological state with multifactorial origins: chronic critical illness (CCI). This condition exerts a large toll on society as well as individual patients and their families. Here, we offer a brief review as to the incidence/prevalence of CCI and suggestions for prevention. Emphasis should be placed on the importance of early, open communication among physicians and patients about their end-of-life decisions and advanced directives, so that decisions can be made wisely and with the patient's best interests in mind.
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Affiliation(s)
| | - William McGee
- 1 Baystate Medical Center, Springfield, MA, USA.,2 University of Massachusetts Medical School, Worcester, MA, USA
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20
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Abstract
En pédiatrie, la prise de décision médicale est compliquée par les variations importantes du développement physique et psychologique observées entre la naissance et l’adolescence. Les parents et les tuteurs sont les décideurs de facto au nom des nourrissons, mais par la suite, leur rôle et celui des patients deviennent de plus en plus complexe. Tout au long de l’enfance, les dispensateurs de soins (DdS), qui ne sont pas des décideurs en soi, ont un rôle important à jouer dans la prise de décision médicale. Le présent document de principes expose les principes éthiques de la prise de décision médicale pour les DdS qui participent aux soins des patients pédiatriques. Cette mise à jour porte sur la prise de décision individuelle dans le cadre de la relation entre le patient et le DdS et fournit plus de conseils en cas de mésententes.
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Affiliation(s)
- Kevin W Coughlin
- Société canadienne de pédiatrie, comité de bioéthique, Ottawa (Ontario)
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21
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Wooster M, Stassi A, Hill J, Kurtz J, Bonta M, Spalding MC. End-of-Life Decision-Making for Patients With Geriatric Trauma Cared for in a Trauma Intensive Care Unit. Am J Hosp Palliat Care 2018; 35:1063-1068. [PMID: 29366336 DOI: 10.1177/1049909117752670] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The geriatric trauma population is growing and fraught with poor physiological response to injury and high mortality rates. Our primary hypothesis analyzed how prehospital and in-hospital characteristics affect decision-making regarding continued life support (CLS) versus withdrawal of care (WOC). Our secondary hypothesis analyzed adherence to end-of-life decisions regarding code status, living wills, and advanced directives. MATERIALS AND METHODS We performed a retrospective review of patients with geriatric trauma at a level I and level II trauma center from January 1, 2007, to December 31, 2014. Two hundred seventy-four patients met inclusion criteria with 144 patients undergoing CLS and 130 WOC. RESULTS A total of 13 269 patients with geriatric trauma were analyzed. Insurance type and injury severity score (ISS) were found to be significant predictors of WOC ( P = .013/.045). Withdrawal of care patients had shorter time to palliative consultation and those with geriatrics consultation were 16.1 times more likely to undergo CLS ( P = .026). Twenty-seven (33%) patients who underwent CLS and 31 (24%) patients who underwent WOC had a living will, advanced directive, or DNR order ( P = .93). CONCLUSIONS Of the many hypothesized predictors of WOC, ISS was the only tangible independent predictor of WOC. We observed an apparent disconnect between the patient's wishes via living wills or advanced directives "in a terminal condition" and fulfillment during EOL decision-making that speaks to the complex nature of EOL decisions and further supports the need for a multidisciplinary approach.
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Affiliation(s)
- Meghan Wooster
- 1 Department of Surgery, Indiana University, Indianapolis, IN, USA
| | - Alyssa Stassi
- 2 Department of Surgery, Palmetto Health Richland, Columbia, SC, USA
| | - Joshua Hill
- 3 Department of Surgery, Grant Medical Center, Columbus, OH, USA
| | - James Kurtz
- 4 Heritage College of Osteopathic Medicine, Ohio University, Doctors Hospital, Columbus, OH, USA
| | - Marco Bonta
- 5 Department of Surgery, Riverside Methodist Medical Hospital, Columbus, OH, USA
| | - M Chance Spalding
- 3 Department of Surgery, Grant Medical Center, Columbus, OH, USA
- 4 Heritage College of Osteopathic Medicine, Ohio University, Doctors Hospital, Columbus, OH, USA
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22
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Nagarsheth NP, Gupta N, Gupta A, Moshier E, Gretz H, Shander A. Responses of advanced directives by Jehovah's Witnesses on a gynecologic oncology service. J Blood Med 2015; 6:17-23. [PMID: 25565911 PMCID: PMC4284050 DOI: 10.2147/jbm.s70981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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] [Indexed: 01/29/2023] Open
Abstract
Objectives To review the responses of advance directives signed by Jehovah’s Witness patients prior to undergoing surgery at a gynecologic oncology service. Study design A retrospective chart review of gynecologic oncology patients undergoing surgery at a bloodless surgery center from 1998–2007 was conducted. Demographic, pathologic, and clinical data were recorded. The proportion of patients who accepted and refused various blood-derived products was determined and was compared to previously published results from a similar study of labor and delivery unit patients. Results No gynecologic oncology patients agreed to accept transfusions of whole blood, red cells, white cells, platelets, or plasma under any circumstance, whereas 9.8% of pregnant patients accepted transfusion (P=0.0385). However, 98% of gynecologic oncology patients agreed to accept some blood products, including fractions such as albumin, immunoglobulins, and clotting factors, while only 39% of pregnant patients agreed (P<0.0001). In addition, all gynecologic oncology patients (100%) accepted intraoperative hemodilution, compared to 55% of pregnant patients (P<0.0001). Conclusion Our results confirm the commonly held belief that the majority of Jehovah’s Witness patients refuse to accept major blood components. However, Jehovah’s Witness patients at a gynecologic oncology service will accept a variety of blood-derived products (minor fractions) and interventions designed to optimize outcomes when undergoing transfusion-free surgery. Patients presenting to a gynecologic oncology service respond differently to advanced directives related to bloodless surgery, as compared to patients from an obstetrical service.
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Affiliation(s)
- Nimesh P Nagarsheth
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA ; Englewood Hospital and Medical Center, Englewood, NJ, USA
| | - Nikhil Gupta
- Department of Urology, North Shore - Long Island Jewish Health Service, New Hyde Park, NY, USA
| | - Arpeta Gupta
- Department of Endocrinology, Diabetes and Metabolism, St Luke's Hospital of Kansas City, Kansas City, MO, USA
| | - Erin Moshier
- Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA
| | - Herbert Gretz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA
| | - Aryeh Shander
- Department of Anesthesiology, Englewood Hospital and Medical Center, Englewood, NJ, USA
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Brink P. Examining Do-Not-Resuscitate Orders Among Newly Admitted Residents of Long-term Care Facilities. Palliat Care 2014; 8:1-6. [PMID: 25278762 PMCID: PMC4168846 DOI: 10.4137/pcrt.s13042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 11/21/2013] [Accepted: 11/25/2013] [Indexed: 11/06/2022] Open
Abstract
Do-not-resuscitate (DNR) orders are an important part of advance directives. To date, little is known about DNR orders in Ontario’s long-term care (LTC) facilities. The Canadian Institute for Health Information (CIHI) stated that in between 2011 and 2012, there were more than 32,000 discharges from Ontario’s LTC facilities, 44% of which resulted from death. This study examined DNR orders in LTC homes in Ontario. The sample includes all LTC residents receiving care between 2010 and 2012. Data provided by the CIHI were collected using the Canadian version of the Resident Assessment Instrument. The data included administrative assessments on health of 112,746 residents. The average age of LTC residents in this study was 84.5 years, and about 70% were female residents. Results showed that residents admitted from home were less likely to have a DNR order on file during assessment and three months later. Residents whose families were responsible for care were more likely to have DNR orders when admitted, but this effect was not found at three-month follow-up. Residents who were in end-stage diseases were more likely to have completed DNR orders upon admission to LTC facilities. The presence of a health condition (eg frailty, depression, heart condition, pulmonary or psychiatric condition) increased the likelihood of residents having DNR orders when admitted to LTC facilities. Residents whose conditions were deteriorating were more likely to have completed DNR orders before the three-month follow-up. In conclusion, this study represents an important step in identifying issues related to DNR orders in LTC facilities. The factors that influence whether residents have DNR orders on file upon admission depend on the presence of family members, whether the residents are designated as end-of-life cases (six months or less), older age, and health. Discussions about resuscitation are an important part of care plans.
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Affiliation(s)
- Peter Brink
- Department of Health Sciences, Lakehead University, Thunder Bay, Ontario, Canada
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24
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Ledoux M, Rhondali W, Monnin L, Thollet C, Gabon P, Filbet M. [ Advanced directives: nurses' and physicians' representations in 2012]. Bull Cancer 2013; 100:941-5. [PMID: 24077035 DOI: 10.1684/bdc.2013.1817] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In cancer patients, decision-making process is crucial and patient's involvement is described as a central component. In 2005, a new tool appears to convey patient's opinion even if he is not able to communicate anymore: advanced directives (AD). Unfortunately, their documentation is marginal. The objective of this study was to investigate nurses' and physicians' representations towards AD. A questionnaire had been sent to hospitals, public health facilities and liberal practitioners during February 2012. We collected responses from 42/251 physicians (17 %) and 80/198 nurses (40 %). Sixty percent of participants reported that they were not familiar with the legislative framework for AD. For physicians, main barriers were patient cognitive impairment (P = 0.004) and lack of information on the clinical situation (P = 0.004). For nurses, difficulties were toward end of life and prognosis discussion (P = 0.002), clinical situation evolution since AD documentation (P = 0.008), time frame for AD application (P < 0.001) and the fact that final decision is made by physician alone (P = 0.015). AD should be part of a good medical practice and literature has highlighted the benefit of AD on patient's quality of life. End of life discussion therefore requires dedicated time and specific training for physicians and nurses to improve the rate of patients with AD.
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Abstract
Most lawyers and bioethicists recommend that patients enact a durable power of attorney for health care designating somebody as their proxy decision maker should they become unable to make decisions. Most people choose family members as their agent. But what if a patient wants his or her doctor to be his or her proxy decision maker? Can the doctor be both physician and surrogate decision maker? Or should those roles necessarily be kept separate? We present a case in which those issues arose, and sought comments from Sabrina Derrington, a pediatric palliative care physician; Arthur Derse, an emergency department physician and lawyer; and Phil Black, a pulmonologist.
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Affiliation(s)
- Philip G Black
- Cystic Fibrosis Service,Children's Mercy Hospital, Kansas City, MO 64108, USA
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