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Tong HH, Creutzfeldt CJ, Hicks KG, Kross EK, Sharma RK, Jennerich AL. Questions From Family Members During the Dying Process And Moral Distress Experienced by ICU Nurses. J Pain Symptom Manage 2024; 67:402-410.e1. [PMID: 38342474 DOI: 10.1016/j.jpainsymman.2024.01.041] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND For a hospitalized patient, transitioning to comfort measures only (CMO) involves discontinuation of life-prolonging interventions with a goal of allowing natural death. Nurses play a pivotal role during the provision of CMO, caring for both the dying patient and their family. OBJECTIVE To examine the experiences of ICU nurses caring for patients receiving CMO. METHODS Between October 2020 and June 2021, nurses in the neuro- and medical-cardiac intensive care units at Harborview Medical Center in Seattle, WA, completed surveys about their experiences providing CMO. Surveys addressed involvement in discussions about CMO and questions asked by family members of dying patients. We also assessed nurses' moral distress related to CMO and used ordinal logistic regression to examine predictors of moral distress. RESULTS Surveys were completed by 82 nurses (response rate 44%), with 79 (96%) reporting experience providing CMO in the previous year. Most preferred to be present for discussions between physicians or advanced practice providers and family members about transitioning to CMO (89% most of the time or always); however, only 31% were present most of the time or always. Questions from family about time to death, changes in breathing, and medications to relieve symptoms were common. Most nurses reported moral distress at least some of the time when providing CMO (62%). Feeling well-prepared to answer specific questions from family was associated with less moral distress. CONCLUSION There is discordance between nurses' preferences for inclusion in discussions about the transition to CMO and their actual presence. Moral distress is common for nurses when providing CMO and feeling prepared to answer questions from family members may attenuate distress.
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Affiliation(s)
- Hao H Tong
- University of Pennsylvania, Division of Pulmonary, Allergy and Critical Care (H.H.T.), Philadelphia, Pennsylvania, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Department of Neurology (C.J.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA
| | - Katherine G Hicks
- Baylor College of Medicine, Section of Geriatrics and Palliative Medicine (K.G.H.), Houston, Texas, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA; Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington (E.K.K., A.L.J.), Seattle, Washington, USA
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA; University of Washington, Division of General Internal Medicine (R.K.S.), Seattle, Washington, USA
| | - Ann L Jennerich
- Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA; Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington (E.K.K., A.L.J.), Seattle, Washington, USA.
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Pollack LR, Nomitch JT, Downey L, Paul SR, Reed MJ, Uyeda AM, Kiker WA, Dotolo DG, Dzeng E, Lee RY, Engelberg RA, Kross EK. Mechanical Ventilation in Older Adults With Dementia: Opportunities to Promote Goal-Concordant Care. J Pain Symptom Manage 2024:S0885-3924(24)00741-3. [PMID: 38685288 DOI: 10.1016/j.jpainsymman.2024.04.021] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 02/07/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
CONTEXT Recent studies show increasing use of mechanical ventilation among people living with dementia. There are concerns that this trend may not be driven by patient preferences. OBJECTIVES To better understand decision-making regarding mechanical ventilation in people living with dementia. METHODS This was an electronic health record-based retrospective cohort study of older adults with dementia (n = 295) hospitalized at one of two teaching hospitals between 2015 and 2019 who were supported with mechanical ventilation (n = 191) or died without mechanical ventilation (n = 104). Multivariable logistic regression was used to examine associations between patient characteristics and mechanical ventilation use. RESULTS The median age was 78 years (IQR 71-86), 41% were female, 28% resided in a nursing home, and 58% had clinical markers of advanced dementia (dehydration, weight loss, mobility limitations, or pressure ulcers). Among patients supported with mechanical ventilation, 70% were intubated within 24 hours of presentation, including 31% intubated before hospital arrival. Younger age, higher illness acuity, and absence of a treatment-limiting Physician Orders for Life-Sustaining Treatment document were associated with mechanical ventilation use; nursing home residence and clinical markers of advanced dementia were not. Most patients (89%) had a documented goals of care discussion (GOCD) during hospitalization. CONCLUSION Future efforts to promote goal-concordant care surrounding mechanical ventilation use for people living with dementia should involve identifying barriers to goal-concordant care in pre-hospital settings, assessing the timeliness of in-hospital GOCD, and developing strategies for in-the-moment crisis communication across settings.
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Affiliation(s)
- Lauren R Pollack
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA.
| | - Jamie T Nomitch
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Sudiptho R Paul
- University of Washington School of Medicine (S.R.P.), Seattle, Washington, USA
| | - May J Reed
- Division of Geriatric Medicine (M.J.R.), University of Washington, Seattle, Washington, USA
| | - Alison M Uyeda
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Whitney A Kiker
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Danae G Dotolo
- Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Elizabeth Dzeng
- Department of Medicine (E.D.), University of California San Francisco, San Francisco, California, USA
| | - Robert Y Lee
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
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Triplette M, Kross EK, Snidarich M, Shahrir S, Hippe DS, Crothers K. An alternating-intervention pilot trial on the impact of an informational handout on patient-reported outcomes and follow-up after lung cancer screening. PLoS One 2024; 19:e0300352. [PMID: 38598511 PMCID: PMC11006146 DOI: 10.1371/journal.pone.0300352] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 02/20/2024] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION Lung cancer screening (LCS) can reduce lung cancer mortality; however, poor understanding of results may impact patient experience and follow-up. We sought to determine whether an informational handout accompanying LCS results can improve patient-reported outcomes and adherence to follow-up. STUDY DESIGN This was a prospective alternating intervention pilot trial of a handout to accompany LCS results delivery. SETTING/PARTICIPANTS Patients undergoing LCS in a multisite program over a 6-month period received a mailing containing either: 1) a standardized form letter of LCS results (control) or 2) the LCS results letter and the handout (intervention). INTERVENTION A two-sided informational handout on commonly asked questions after LCS created through iterative mixed-methods evaluation with both LCS patients and providers. OUTCOME MEASURES The primary outcomes of 1)patient understanding of LCS results, 2)correct identification of next steps in screening, and 3)patient distress were measured through survey. Adherence to recommended follow-up after LCS was determined through chart review. Outcomes were compared between the intervention and control group using generalized estimating equations. RESULTS 389 patients were eligible and enrolled with survey responses from 230 participants (59% response rate). We found no differences in understanding of results, identification of next steps in follow-up or distress but did find higher levels of knowledge and understanding on questions assessing individual components of LCS in the intervention group. Follow-up adherence was overall similar between the two arms, though was higher in the intervention group among those with positive findings (p = 0.007). CONCLUSIONS There were no differences in self-reported outcomes between the groups or overall follow-up adherence. Those receiving the intervention did report greater understanding and knowledge of key LCS components, and those with positive results had a higher rate of follow-up. This may represent a feasible component of a multi-level intervention to address knowledge and follow-up for LCS. TRIAL REGISTRATION ClinicalTrials.gov NCT05265897.
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Affiliation(s)
- Matthew Triplette
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Erin K. Kross
- Department of Medicine, University of Washington, Seattle, WA, United States of America
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA, United States of America
| | - Madison Snidarich
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, United States of America
| | - Shahida Shahrir
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Daniel S. Hippe
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, United States of America
| | - Kristina Crothers
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, United States of America
- Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America
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John M, Crooks CP, Matin N, Brown CE, Kross EK, Skerrett S, Johnson NJ, Wahlster S. Fixed, Dilated, and Cannulated - Medical Management of Elevated Intracranial Pressures due to a Large Intracranial Hemorrhage in a Patient on Veno-Venous Extracorporeal Membrane Oxygenation: Case Report. Neurohospitalist 2024; 14:199-203. [PMID: 38666276 PMCID: PMC11040625 DOI: 10.1177/19418744231221305] [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: 04/28/2024] Open
Abstract
A 40-year-old woman presented with mediastinitis, necrotizing pancreatitis, and severe acute respiratory distress syndrome with refractory acidemia (pH 7.14) and hypercapnia (PaCO2 115 mmHg), requiring veno-venous extracorporeal membrane oxygenation (ECMO). Eight hours after cannulation, and rapid correction of PaCO2 to 44 mmHg, she was found to have bilaterally fixed and dilated pupils. Imaging showed a 60 mL left-sided temporoparietal intracranial hemorrhage with surrounding edema, 8 mm midline shift, intraventricular hemorrhage, and impending herniation. Decompressive hemicraniectomy was not offered due to concern for medical instability. After receiving a dose of mannitol, her pupillary and motor exam improved. An intracranial pressure (ICP) monitor was placed to guide hyperosmolar therapy administration, hemodynamic targets, and sweep gas titration. On hospital day (HD) 5, her ICP monitor was removed. Follow-up imaging revealed resolution of mass effect and no brainstem injury. She was subsequently extubated (HD 9) and discharged home (HD 40). One year after hospitalization, she is living at home with minimal residual deficits. This case highlights the utility of targeted, medical ICP management and importance of assessing response to conservative therapies when considering prognosis in patients on ECMO with severe acute brain injury.
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Affiliation(s)
- Mira John
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - C. Patrick Crooks
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Nassim Matin
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Crystal E. Brown
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA, USA
| | - Erin K. Kross
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA, USA
| | - Shawn Skerrett
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicholas J. Johnson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
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5
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Lau N, Ramos KJ, Aitken ML, Goss CH, Barton KS, Kross EK, Engelberg RA. "We'll deal with it as it comes": A Qualitative Analysis of Romantic Partners' Dyadic Coping in Cystic Fibrosis. J Soc Pers Relat 2024; 41:689-705. [PMID: 38638205 PMCID: PMC11025702 DOI: 10.1177/02654075231190617] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Background Although cystic fibrosis (CF) is a progressive, life-limiting, genetic disease, recent advances have extended survival, allowing persons with CF the time and physical and mental health to form romantic relationships. Previous studies have shown the importance of dyadic coping to positive psychosocial functioning and relationship satisfaction for people with serious chronic illness and their romantic partners, but little work has been done with persons with CF and their partners. The present study examines dyadic coping processes in persons with CF and their romantic partners. Methods Sixteen adults with moderate to severe CF (Mage=42.3, 43.8% identified as cisgender male, 56.2% identified as cisgender female) and their romantic partners (Mage=43.8, 56.3% identified as cisgender male, 43.7% identified as cisgender female) participated in individual semi-structured interviews focused on topics related to quality of life, communication, and palliative care. We conducted a directed content analysis utilizing Berg and Upchurch's (2007) developmental-contextual theoretical model to examine dyadic coping processes in persons with CF and their romantic partners. Results Consistent with the developmental-contextual model of dyadic coping, couples described adapting to health and functional declines that occurred over time. Dyads were aligned in their appraisals of illness representation, illness ownership, and perspectives of illness as a shared stressor; they used shared coping mechanisms that included supportive and collaborative actions rather than uninvolved or controlling strategies. Conclusions We recommend family-based approaches to medical decision-making and goals of care conversations with persons with CF and their partners, aligning those approaches with supportive and collaborative coping configurations. This may improve psychosocial outcomes for patients and their partners.
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Affiliation(s)
- Nancy Lau
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Kathleen J. Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Moira L. Aitken
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Christopher H. Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Division of Pulmonary, Department of Pediatrics, University of Washington, Seattle, WA
| | - Krysta S. Barton
- Biostatistics Epidemiology and Analytics for Research (BEAR) Core, Seattle Children’s Research Institute, Seattle, WA
| | - Erin K. Kross
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
| | - Ruth A. Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
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Miles NL, Abedini NC, Harris MH, Engelberg RA, Kross EK, Creutzfeldt CJ. Goals-of-Care Conversations After Stroke Survival. Stroke 2024; 55:e44-e45. [PMID: 38189121 PMCID: PMC10922777 DOI: 10.1161/strokeaha.123.046119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Affiliation(s)
- Nancy L. Miles
- University of Washington School of Medicine, Seattle, WA
| | - Nauzley C. Abedini
- University of Washington School of Medicine, Seattle, WA
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle WA
| | - Mark H. Harris
- University of California, Irvine School of Medicine, Irvine, CA
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle WA
- University of Washington Department of Medicine, Seattle, WA
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle WA
- University of Washington Department of Medicine, Seattle, WA
| | - Claire J. Creutzfeldt
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle WA
- University of Washington Department of Neurology, Seattle, WA
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Andersen SK, Yang Y, Kross EK, Haas B, Geagea A, May TL, Hart J, Bagshaw SM, Dzeng E, Fischhoff B, White DB. Achieving Goals of Care Decisions in Chronic Critical Illness: A Multi-Institutional Qualitative Study. Chest 2024:S0012-3692(24)00161-2. [PMID: 38365177 DOI: 10.1016/j.chest.2024.02.015] [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: 08/21/2023] [Revised: 01/29/2024] [Accepted: 02/11/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Physicians, patients, and families alike perceive a need to improve how goals of care (GOC) decisions occur in chronic critical illness (CCI), but little is currently known about this decision-making process. RESEARCH QUESTION How do intensivists from various health systems facilitate decision-making about GOC for patients with CCI? What are barriers to, and facilitators of, this decision-making process? STUDY DESIGN AND METHODS We conducted semistructured interviews with a purposeful sample of intensivists from the United States and Canada using a mental models approach adapted from decision science. We analyzed transcripts inductively using qualitative description. RESULTS We interviewed 29 intensivists from six institutions. Participants across all sites described GOC decision-making in CCI as a complex, longitudinal, and iterative process that involved substantial preparatory work, numerous stakeholders, and multiple family meetings. Intensivists required considerable time to collect information on prior events and conversations, and to arrive at a prognostic consensus with other involved physicians prior to meeting with families. Many intensivists stressed the importance of scheduling multiple family meetings to build trust and relationships prior to explicitly discussing GOC. Physician-identified barriers to GOC decision-making included 1-week staffing models, limited time and cognitive bandwidth, difficulty eliciting patient values, and interpersonal challenges with care team members or families. Potential facilitators included scheduled family meetings at regular intervals, greater interprofessional involvement in decisions, and consistent messaging from care team members. INTERPRETATION Intensivists described a complex time- and labor-intensive group process to achieve GOC decision-making in CCI. System-level interventions that improve how information is shared between physicians and decrease logistical and relational barriers to timely and consistent communication are key to improving GOC decision-making in CCI.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada.
| | - Yanran Yang
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA; Global Health Research Center, Duke Kunshan University, Jiangsu, China
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
| | - Barbara Haas
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anna Geagea
- Division of Critical Care Medicine, Department of Medicine, North York General Hospital, Toronto, ON, Canada
| | - Teresa L May
- Department of Pulmonary and Critical Care, Maine Medical Center, Portland, ME
| | - Joanna Hart
- Palliative and Advanced Illness Research Center, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Elizabeth Dzeng
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA
| | - Douglas B White
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Pollack LR, Downey L, Nomitch JT, Lee RY, Engelberg RA, Weiss NS, Kross EK, Khandelwal N. Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure. Ann Am Thorac Soc 2024. [PMID: 38323911 DOI: 10.1513/annalsats.202308-694oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 02/05/2024] [Indexed: 02/08/2024] Open
Abstract
RATIONALE Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care. OBJECTIVE To identify risk factors, in particular whether an early goals of care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure. METHODS We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ≥48 hours mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (>=$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization. RESULTS Patients in the sample had a median age of 71 (IQR 62-79) years. About half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. Over half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had 50% lower risk of a high-cost hospitalization (RR 0.50, 95% CI 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU as compared to a medical ICU were associated with higher likelihood of high-cost hospitalization. CONCLUSIONS Early GOCD for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.
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Affiliation(s)
- Lauren R Pollack
- University of Washington Division of Pulmonary Critical Care and Sleep Medicine, 312769, Seattle, Washington, United States
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, United States;
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, United States
| | - Jamie T Nomitch
- University of Washington Division of Pulmonary Critical Care and Sleep Medicine, 312769, Seattle, Washington, United States
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, United States
| | - Robert Y Lee
- University of Washington Division of Pulmonary Critical Care and Sleep Medicine, 312769, Seattle, Washington, United States
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, United States
| | - Ruth A Engelberg
- University of Washington Division of Pulmonary Critical Care and Sleep Medicine, 312769, Seattle, Washington, United States
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, United States
| | - Noel S Weiss
- University of Washington Department of Epidemiology, 246474, Seattle, Washington, United States
| | - Erin K Kross
- University of Washington Division of Pulmonary Critical Care and Sleep Medicine, 312769, Medicine, Seattle, Washington, United States
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, United States
| | - Nita Khandelwal
- University of Washington Department of Anesthesiology & Pain Medicine, 228464, Seattle, Washington, United States
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, United States
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Kruser JM, Ashana DC, Courtright KR, Kross EK, Neville TH, Rubin E, Schenker Y, Sullivan DR, Thornton JD, Viglianti EM, Costa DK, Creutzfeldt CJ, Detsky ME, Engel HJ, Grover N, Hope AA, Katz JN, Kohn R, Miller AG, Nabozny MJ, Nelson JE, Shanawani H, Stevens JP, Turnbull AE, Weiss CH, Wirpsa MJ, Cox CE. Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2024; 21:187-199. [PMID: 38063572 PMCID: PMC10848901 DOI: 10.1513/annalsats.202310-925st] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.
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10
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Brown CE, Marshall AR, Cueva KL, Snyder CR, Kross EK, Young BA. Physician Perspectives on Addressing Anti-Black Racism. JAMA Netw Open 2024; 7:e2352818. [PMID: 38265801 PMCID: PMC10809013 DOI: 10.1001/jamanetworkopen.2023.52818] [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] [Received: 08/24/2023] [Accepted: 12/01/2023] [Indexed: 01/25/2024] Open
Abstract
Importance Uncertainty remains among clinicians regarding processes to address and resolve conflict around anti-Black racism. Objective To elicit clinicians' perceptions of their role in addressing concerns about anti-Black racism among Black patients with serious illness as well as their families. Design, Setting, and Participants In this qualitative study, one-on-one semistructured interviews were conducted with 21 physicians at an academic county hospital between August 1 and October 31, 2022. Participants were provided clinical scenarios where anti-Black racism was a concern of a patient with serious illness. Participants were asked open-ended questions about initial impressions, prior similar experiences, potential strategies to address patients' concerns, and additional resources to support these conversations. A framework based on restorative justice was used to guide qualitative analyses. Main Outcomes and Measures Perspectives on addressing anti-Black racism as described by physicians. Results A total of 21 medical subspecialists (mean [SD] age, 44.2 [7.8] years) participated in the study. Most physicians were women (14 [66.7%]), 4 were Asian (19.0%), 3 were Black (14.3%), and 14 were White (66.7%). Participants identified practices that are normalized in clinical settings that may perpetuate and exacerbate perceptions of anti-Black racism. Using provided scenarios and personal experiences, participants were able to describe how Black patients are harmed as a result of these practices. Last, participants identified strategies and resources for addressing Black patients' concerns and facilitating conflict resolution, but they stopped short of promoting personal or team accountability for anti-Black racism. Conclusions and Relevance In this qualitative study, physicians identified resources, skills, and processes that partially aligned with a restorative justice framework to address anti-Black racism and facilitate conflict resolution, but did not provide steps for actualizing accountability. Restorative justice and similar processes may provide space within a mediated setting for clinicians to repair harm, provide accountability, and facilitate racial healing.
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Affiliation(s)
- Crystal E. Brown
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - Arisa R. Marshall
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kristine L. Cueva
- Department of Medicine, Center for Health Workforce Studies, School of Medicine, University of Washington, Seattle
| | - Cyndy R. Snyder
- Department of Family Medicine, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Bessie A. Young
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Justice, Equity, Diversity, and Inclusion Center for Transformational Research, Office of Healthcare Equity, University of Washington, Seattle
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11
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Nomitch JT, Downey L, Pollack LR, Bayomy OF, Ramos KJ, Kross EK, Jennerich AL. Palliative Care Consultation and Family-Centered Outcomes in Patients With Unplanned Intensive Care Unit Admissions. J Palliat Med 2023. [PMID: 38150304 DOI: 10.1089/jpm.2023.0436] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
Context: Hospitalized patients who experience unplanned intensive care unit (ICU) admissions face significant challenges, and their family members have unique palliative care needs. Objectives: To identify predictors of palliative care consultation among hospitalized patients with unplanned ICU admissions and to examine the association between palliative care consultation and family outcomes. Methods: We conducted a prospective cohort study of patients with unplanned ICU admissions at two medical centers in Seattle, WA. This study was approved by the institutional review board at the University of Washington (STUDY00008182). Using multivariable logistic regression, we examined associations between patient characteristics and palliative care consultation. Family members completed surveys assessing psychological distress within 90 days of patient discharge. Adjusted ordinal probit or binary logistic regression models were used to identify associations between palliative care consultation and family symptoms of psychological distress. Results: In our cohort (n = 413 patients and 272 family members), palliative care was consulted for 24% of patients during hospitalization (n = 100), with the majority (93%) of these consultations occurring after ICU admission. Factors associated with palliative care consultation after ICU transfer included enrollment site (OR, 2.29; 95% CI: 1.17-4.50), Sequential Organ Failure Assessment score at ICU admission (OR, 1.12; 95% CI: 1.05-1.19), and reason for hospital admission (kidney dysfunction [OR, 7.02; 95% CI: 1.08-45.69]). There was no significant difference in family symptoms of depression or posttraumatic stress based on palliative care consultation status. Conclusions: For patients experiencing unplanned ICU admission, palliative care consultation often happened after transfer and was associated with illness severity, comorbid illness, and hospital site. Patient death was associated with family symptoms of psychological distress.
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Affiliation(s)
- Jamie T Nomitch
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Lauren R Pollack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Omar F Bayomy
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
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12
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Curtis JR, Lee RY, Brumback LC, Kross EK, Downey L, Torrence J, LeDuc N, Mallon Andrews K, Im J, Heywood J, Brown CE, Sibley J, Lober WB, Cohen T, Weiner BJ, Khandelwal N, Abedini NC, Engelberg RA. Intervention to Promote Communication About Goals of Care for Hospitalized Patients With Serious Illness: A Randomized Clinical Trial. JAMA 2023; 329:2028-2037. [PMID: 37210665 PMCID: PMC10201405 DOI: 10.1001/jama.2023.8812] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/05/2023] [Indexed: 05/22/2023]
Abstract
Importance Discussions about goals of care are important for high-quality palliative care yet are often lacking for hospitalized older patients with serious illness. Objective To evaluate a communication-priming intervention to promote goals-of-care discussions between clinicians and hospitalized older patients with serious illness. Design, Setting, and Participants A pragmatic, randomized clinical trial of a clinician-facing communication-priming intervention vs usual care was conducted at 3 US hospitals within 1 health care system, including a university, county, and community hospital. Eligible hospitalized patients were aged 55 years or older with any of the chronic illnesses used by the Dartmouth Atlas project to study end-of-life care or were aged 80 years or older. Patients with documented goals-of-care discussions or a palliative care consultation between hospital admission and eligibility screening were excluded. Randomization occurred between April 2020 and March 2021 and was stratified by study site and history of dementia. Intervention Physicians and advance practice clinicians who were treating the patients randomized to the intervention received a 1-page, patient-specific intervention (Jumpstart Guide) to prompt and guide goals-of-care discussions. Main Outcomes and Measures The primary outcome was the proportion of patients with electronic health record-documented goals-of-care discussions within 30 days. There was also an evaluation of whether the effect of the intervention varied by age, sex, history of dementia, minoritized race or ethnicity, or study site. Results Of 3918 patients screened, 2512 were enrolled (mean age, 71.7 [SD, 10.8] years and 42% were women) and randomized (1255 to the intervention group and 1257 to the usual care group). The patients were American Indian or Alaska Native (1.8%), Asian (12%), Black (13%), Hispanic (6%), Native Hawaiian or Pacific Islander (0.5%), non-Hispanic (93%), and White (70%). The proportion of patients with electronic health record-documented goals-of-care discussions within 30 days was 34.5% (433 of 1255 patients) in the intervention group vs 30.4% (382 of 1257 patients) in the usual care group (hospital- and dementia-adjusted difference, 4.1% [95% CI, 0.4% to 7.8%]). The analyses of the treatment effect modifiers suggested that the intervention had a larger effect size among patients with minoritized race or ethnicity. Among 803 patients with minoritized race or ethnicity, the hospital- and dementia-adjusted proportion with goals-of-care discussions was 10.2% (95% CI, 4.0% to 16.5%) higher in the intervention group than in the usual care group. Among 1641 non-Hispanic White patients, the adjusted proportion with goals-of-care discussions was 1.6% (95% CI, -3.0% to 6.2%) higher in the intervention group than in the usual care group. There was no evidence of differential treatment effects of the intervention on the primary outcome by age, sex, history of dementia, or study site. Conclusions and Relevance Among hospitalized older adults with serious illness, a pragmatic clinician-facing communication-priming intervention significantly improved documentation of goals-of-care discussions in the electronic health record, with a greater effect size in racially or ethnically minoritized patients. Trial Registration ClinicalTrials.gov Identifier: NCT04281784.
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Affiliation(s)
- J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Robert Y. Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | | | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Lois Downey
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Janaki Torrence
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Nicole LeDuc
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kasey Mallon Andrews
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Jennifer Im
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Joanna Heywood
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Crystal E. Brown
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - James Sibley
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
| | - William B. Lober
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle
| | - Trevor Cohen
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle
| | - Bryan J. Weiner
- Department of Health Systems and Population Health, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Nauzley C. Abedini
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
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13
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Crothers K, Shahrir S, Kross EK, Kava CM, Cole A, Wenger D, Triplette M. Patient and Clinician Recommendations to Improve Communication and Understanding of Lung Cancer Screening Results. Chest 2023; 163:707-718. [PMID: 36209835 DOI: 10.1016/j.chest.2022.09.038] [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: 05/25/2022] [Revised: 08/24/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Patient understanding of chest low-dose CT (LDCT) scan results for lung cancer screening (LCS) may impact outcomes. RESEARCH QUESTION What are patient- and clinician-identified gaps in understanding and communication of LCS results and how might communication be improved through a patient-oriented tool? STUDY DESIGN AND METHODS We performed a mixed-methods study of participants recruited from a multisite LCS program to understand knowledge gaps after receiving LCS results and to guide development of a commonly asked questions (CAQ) after LCS information sheet. Initial patient surveys assessed understanding and reactions to LCS results (n = 190). We then conducted patient interviews and focus group discussions (n = 31) to understand experiences receiving LDCT scan results and reactions to results letters and the proposed CAQ; we also interviewed clinicians (n = 6) for feedback on these resources. We summarized survey responses and used thematic analysis to identify major themes in focus groups and interviews. RESULTS Of 190 survey respondents (43% response rate), although 88% agreed that they "understood" their LCS results, only 55% reported understanding what a lung nodule is. Approximately two-thirds thought it was "very important" to receive more information regarding lung nodules and incidental lung and heart disease. In interviews and focus groups, although patients believed that brief results letters for normal LDCT scan results generally were acceptable, most found letters explaining abnormal LDCT scan and incidental findings to be concerning and not a substitute for discussion with their clinician. Nearly all patients expressed that the CAQ sheet provided helpful information on nodules, results reporting and incidental findings, and helped them form questions to ask their clinicians. INTERPRETATION We identified patient-reported information needs regarding LCS results and developed a CAQ information sheet that was refined with patient and clinician input. The CAQ may represent a simple and feasible way to improve LCS results reporting and to augment clinician-patient discussions.
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Affiliation(s)
- Kristina Crothers
- VA Puget Sound Healthcare System, University of Washington, Seattle, WA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washingon, Seattle, WA.
| | - Shahida Shahrir
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washingon, Seattle, WA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA
| | - Erin K Kross
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washingon, Seattle, WA; Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, WA
| | - Christine M Kava
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA
| | - Allison Cole
- Department of Family Medicine, University of Washington, Seattle, WA
| | - David Wenger
- Division of Pulmonary and Critical Care, Evergreen Healthcare, Kirkland, WA
| | - Matthew Triplette
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washingon, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
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14
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Lee RY, Kross EK, Torrence J, Li KS, Sibley J, Cohen T, Lober WB, Engelberg RA, Curtis JR. Assessment of Natural Language Processing of Electronic Health Records to Measure Goals-of-Care Discussions as a Clinical Trial Outcome. JAMA Netw Open 2023; 6:e231204. [PMID: 36862411 PMCID: PMC9982698 DOI: 10.1001/jamanetworkopen.2023.1204] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
IMPORTANCE Many clinical trial outcomes are documented in free-text electronic health records (EHRs), making manual data collection costly and infeasible at scale. Natural language processing (NLP) is a promising approach for measuring such outcomes efficiently, but ignoring NLP-related misclassification may lead to underpowered studies. OBJECTIVE To evaluate the performance, feasibility, and power implications of using NLP to measure the primary outcome of EHR-documented goals-of-care discussions in a pragmatic randomized clinical trial of a communication intervention. DESIGN, SETTING, AND PARTICIPANTS This diagnostic study compared the performance, feasibility, and power implications of measuring EHR-documented goals-of-care discussions using 3 approaches: (1) deep-learning NLP, (2) NLP-screened human abstraction (manual verification of NLP-positive records), and (3) conventional manual abstraction. The study included hospitalized patients aged 55 years or older with serious illness enrolled between April 23, 2020, and March 26, 2021, in a pragmatic randomized clinical trial of a communication intervention in a multihospital US academic health system. MAIN OUTCOMES AND MEASURES Main outcomes were natural language processing performance characteristics, human abstractor-hours, and misclassification-adjusted statistical power of methods of measuring clinician-documented goals-of-care discussions. Performance of NLP was evaluated with receiver operating characteristic (ROC) curves and precision-recall (PR) analyses and examined the effects of misclassification on power using mathematical substitution and Monte Carlo simulation. RESULTS A total of 2512 trial participants (mean [SD] age, 71.7 [10.8] years; 1456 [58%] female) amassed 44 324 clinical notes during 30-day follow-up. In a validation sample of 159 participants, deep-learning NLP trained on a separate training data set from identified patients with documented goals-of-care discussions with moderate accuracy (maximal F1 score, 0.82; area under the ROC curve, 0.924; area under the PR curve, 0.879). Manual abstraction of the outcome from the trial data set would require an estimated 2000 abstractor-hours and would power the trial to detect a risk difference of 5.4% (assuming 33.5% control-arm prevalence, 80% power, and 2-sided α = .05). Measuring the outcome by NLP alone would power the trial to detect a risk difference of 7.6%. Measuring the outcome by NLP-screened human abstraction would require 34.3 abstractor-hours to achieve estimated sensitivity of 92.6% and would power the trial to detect a risk difference of 5.7%. Monte Carlo simulations corroborated misclassification-adjusted power calculations. CONCLUSIONS AND RELEVANCE In this diagnostic study, deep-learning NLP and NLP-screened human abstraction had favorable characteristics for measuring an EHR outcome at scale. Adjusted power calculations accurately quantified power loss from NLP-related misclassification, suggesting that incorporation of this approach into the design of studies using NLP would be beneficial.
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Affiliation(s)
- Robert Y. Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Janaki Torrence
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kevin S. Li
- Division of Biomedical and Health Informatics, Department of Biomedical Informatics and Medical Education, University of Washington, Seattle
| | - James Sibley
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
| | - Trevor Cohen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Biomedical and Health Informatics, Department of Biomedical Informatics and Medical Education, University of Washington, Seattle
| | - William B. Lober
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Biomedical and Health Informatics, Department of Biomedical Informatics and Medical Education, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Health Systems and Population Health, University of Washington, Seattle
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15
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Uyeda AM, Lee RY, Pollack LR, Paul SR, Downey L, Brumback LC, Engelberg RA, Sibley J, Lober WB, Cohen T, Torrence J, Kross EK, Curtis JR. Predictors of Documented Goals-of-Care Discussion for Hospitalized Patients With Chronic Illness. J Pain Symptom Manage 2023; 65:233-241. [PMID: 36423800 PMCID: PMC9928787 DOI: 10.1016/j.jpainsymman.2022.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 11/04/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022]
Abstract
CONTEXT Goals-of-care discussions are important for patient-centered care among hospitalized patients with serious illness. However, there are little data on the occurrence, predictors, and timing of these discussions. OBJECTIVES To examine the occurrence, predictors, and timing of electronic health record (EHR)-documented goals-of-care discussions for hospitalized patients. METHODS This retrospective cohort study used natural language processing (NLP) to examine EHR-documented goals-of-care discussions for adults with chronic life-limiting illness or age ≥80 hospitalized 2015-2019. The primary outcome was NLP-identified documentation of a goals-of-care discussion during the index hospitalization. We used multivariable logistic regression to evaluate associations with baseline characteristics. RESULTS Of 16,262 consecutive, eligible patients without missing data, 5,918 (36.4%) had a documented goals-of-care discussion during hospitalization; approximately 57% of these discussions occurred within 24 hours of admission. In multivariable analysis, documented goals-of-care discussions were more common for women (OR=1.26, 95%CI 1.18-1.36), older patients (OR=1.04 per year, 95%CI 1.03-1.04), and patients with more comorbidities (OR=1.11 per Deyo-Charlson point, 95%CI 1.10-1.13), cancer (OR=1.88, 95%CI 1.72-2.06), dementia (OR=2.60, 95%CI 2.29-2.94), higher acute illness severity (OR=1.12 per National Early Warning Score point, 95%CI 1.11-1.14), or prior advance care planning documents (OR=1.18, 95%CI 1.08-1.30). Documentation of these discussions was less common for racially or ethnically minoritized patients (OR=0.823, 95%CI 0.75-0.90). CONCLUSION Among hospitalized patients with serious illness, documented goals-of-care discussions identified by NLP were more common among patients with older age and increased burden of acute or chronic illness, and less common among racially or ethnically minoritized patients. This suggests important disparities in goals-of-care discussions.
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Affiliation(s)
- Alison M Uyeda
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Robert Y Lee
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Lauren R Pollack
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Sudiptho R Paul
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Lois Downey
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Lyndia C Brumback
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biostatistics, University of Washington (L.C.B.), Seattle, Washington, USA
| | - Ruth A Engelberg
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - James Sibley
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biomedical Informatics and Medical Education, University of Washington (J.S., W.B.L., T.C.), Seattle, Washington, USA
| | - William B Lober
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biomedical Informatics and Medical Education, University of Washington (J.S., W.B.L., T.C.), Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington (W.B.L.), Seattle, Washington, USA
| | - Trevor Cohen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biomedical Informatics and Medical Education, University of Washington (J.S., W.B.L., T.C.), Seattle, Washington, USA
| | - Janaki Torrence
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Erin K Kross
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - J Randall Curtis
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA.
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Kiker WA, Cheng S, Pollack LR, Creutzfeldt CJ, Kross EK, Curtis JR, Belden KA, Melamed R, Armaignac DL, Heavner SF, Christie AB, Banner-Goodspeed VM, Khanna AK, Sili U, Anderson HL, Kumar V, Walkey A, Kashyap R, Gajic O, Domecq JP, Khandelwal N. Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19. J Pain Symptom Manage 2022; 64:359-369. [PMID: 35764202 PMCID: PMC9233554 DOI: 10.1016/j.jpainsymman.2022.06.014] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/19/2022] [Accepted: 06/21/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT The COVID-19 pandemic has highlighted variability in intensity of care. We aimed to characterize intensity of care among hospitalized patients with COVID-19. OBJECTIVES Examine the prevalence and predictors of admission code status, palliative care consultation, comfort-measures-only orders, and cardiopulmonary resuscitation (CPR) among patients hospitalized with COVID-19. METHODS This cross-sectional study examined data from an international registry of hospitalized patients with COVID-19. A proportional odds model evaluated predictors of more aggressive code status (i.e., Full Code) vs. less (i.e., Do Not Resuscitate, DNR). Among decedents, logistic regression was used to identify predictors of palliative care consultation, comfort measures only, and CPR at time of death. RESULTS We included 29,923 patients across 179 sites. Among those with admission code status documented, Full Code was selected by 90% (n = 15,273). Adjusting for site, Full Code was more likely for patients who were of Black or Asian race (ORs 1.82, 95% CIs 1.5-2.19; 1.78, 1.15-3.09 respectively, relative to White race), Hispanic ethnicity (OR 1.89, CI 1.35-2.32), and male sex (OR 1.16, CI 1.0-1.33). Of the 4951 decedents, 29% received palliative care consultation, 59% transitioned to comfort measures only, and 29% received CPR, with non-White racial and ethnic groups less likely to receive comfort measures only and more likely to receive CPR. CONCLUSION In this international cohort of patients with COVID-19, Full Code was the initial code status in the majority, and more likely among patients who were Black or Asian race, Hispanic ethnicity or male. These results provide direction for future studies to improve these disparities in care.
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Affiliation(s)
- Whitney A Kiker
- Division of Pulmonary, Critical Care and Sleep Medicine (W.A.K., L.R.P., E.K.K., J.R.C., ), University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA.
| | - Si Cheng
- Department of Biostatistics (S.C.), University of Washington, Seattle, WA, USA
| | - Lauren R Pollack
- Division of Pulmonary, Critical Care and Sleep Medicine (W.A.K., L.R.P., E.K.K., J.R.C., ), University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA
| | - Claire J Creutzfeldt
- Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA; Department of Neurology, Harborview Medical Center (C.J.C.), University of Washington, Seattle, WA, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care and Sleep Medicine (W.A.K., L.R.P., E.K.K., J.R.C., ), University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine (W.A.K., L.R.P., E.K.K., J.R.C., ), University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA
| | - Katherine A Belden
- Division of Infectious Diseases (K.A.B.), Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Roman Melamed
- Abbott Northwestern Hospital (R.M.), Allina Health, Minneapolis, MN, USA
| | - Donna Lee Armaignac
- Center for Advanced Analytics (D.L.A.), Baptist Health South Florida, Miami, FL, USA
| | - Smith F Heavner
- Department of Public Health Sciences (S.F.H.), Clemson University, Clemson, SC, USA
| | - Amy B Christie
- Department of Critical Care (A.B.C.), Atrium Health Navicent, Macon, GA, USA
| | - Valerie M Banner-Goodspeed
- Department of Anesthesia, Critical Care & Pain Medicine (V.M.B-G.), Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine (A.K.K.), Perioperative Outcomes and Informatics Collaborative (POIC), Wake Forest School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA; Outcomes Research Consortium (A.K.K.), Cleveland, OH, USA
| | - Uluhan Sili
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine (U.S.), Marmara University, Istanbul, Turkey
| | - Harry L Anderson
- Department of Surgery (H.L.A.), St Joseph Mercy Ann Arbor, Ann Arbor, MI, USA
| | - Vishakha Kumar
- Society of Critical Medicine (V.K.), Mount Prospect, IL, USA
| | - Allan Walkey
- The Pulmonary Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, and Evans Center of Implementation and Improvement Sciences, Department of Medicine (A.W.), Boston University School of Medicine, Boston, MA, USA
| | - Rahul Kashyap
- Division of Pulmonary and Critical Care Medicine (R.K., O.G.), Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine (R.K., O.G.), Mayo Clinic, Rochester, MN, USA
| | - Juan Pablo Domecq
- Division of Nephrology and Hypertension (J.P.D.), Mayo Clinic, Rochester, MN, USA; Department of Critical Care Medicine (J.P.D.), Mayo Clinic, Mankato, MN, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine (N.K.), University of Washington, Seattle, WA, USA
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Modes ME, Engelberg RA, Nielsen EL, Brumback LC, Neville TH, Walling AM, Curtis JR, Kross EK. Seriously Ill Patients' Prioritized Goals and Their Clinicians' Perceptions of Those Goals. J Pain Symptom Manage 2022; 64:410-418. [PMID: 35700932 PMCID: PMC9482939 DOI: 10.1016/j.jpainsymman.2022.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 05/25/2022] [Accepted: 06/07/2022] [Indexed: 12/27/2022]
Abstract
CONTEXT Seriously ill patients whose prioritized healthcare goals are understood by their clinicians are likely better positioned to receive goal-concordant care. OBJECTIVES To examine the proportion of seriously ill patients whose prioritized healthcare goal is accurately perceived by their clinician and identify factors associated with accurate perception. METHODS Secondary analysis of a multicenter cluster-randomized trial of outpatients with serious illness and their clinicians. Approximately two weeks after a clinic visit, patients reported their current prioritized healthcare goal- extending life over relief of pain and discomfort, or relief of pain and discomfort over extending life - and clinicians reported their perception of their patients' current prioritized healthcare goal; matching these items defined accurate perception. RESULTS Of 252 patients with a prioritized healthcare goal, 60% had their goal accurately perceived by their clinician, 27% were cared for by clinicians who perceived prioritization of the alternative goal, and 13% had their clinician answer unsure. Patients who were older (OR 1.03 per year; 95%CI 1.01, 1.05), had stable goals (OR 2.52; 95%CI 1.26, 5.05), and had a recent goals-of-care discussion (OR 1.78, 95%CI 1.00, 3.16) were more likely to have their goals accurately perceived. CONCLUSION A majority of seriously ill outpatients are cared for by clinicians who accurately perceive their patients' prioritized healthcare goals. However, a substantial portion are not and may be at higher risk for goal-discordant care. Interventions that facilitate goals-of-care discussions may help align care with goals, as recent discussions were associated with accurate perceptions of patients' prioritized goals.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary and Critical Care Medicine (M.E.M), Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Ruth A Engelberg
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Lyndia C Brumback
- Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA; Department of Biostatistics (L.C.B.), University of Washington, Seattle, Washington, USA
| | - Thanh H Neville
- Division of Pulmonary (T.H.N.), Critical Care, and Sleep Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research (A.M.W.), University of California Los Angeles, Los Angeles, California, USA; Center for the Study of Healthcare Innovation (A.M.W.), Implementation and Policy, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California, USA
| | - J Randall Curtis
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities (J.R.C.), University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA
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Sullivan DR, Iyer AS, Enguidanos S, Cox CE, Farquhar M, Janssen DJA, Lindell KO, Mularski RA, Smallwood N, Turnbull AE, Wilkinson AM, Courtright KR, Maddocks M, McPherson ML, Thornton JD, Campbell ML, Fasolino TK, Fogelman PM, Gershon L, Gershon T, Hartog C, Luther J, Meier DE, Nelson JE, Rabinowitz E, Rushton CH, Sloan DH, Kross EK, Reinke LF. Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement. Am J Respir Crit Care Med 2022; 206:e44-e69. [PMID: 36112774 PMCID: PMC9799127 DOI: 10.1164/rccm.202207-1262st] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.
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Curtis JR, Lee RY, Brumback LC, Kross EK, Downey L, Torrence J, Heywood J, LeDuc N, Mallon Andrews K, Im J, Weiner BJ, Khandelwal N, Abedini NC, Engelberg RA. Improving communication about goals of care for hospitalized patients with serious illness: Study protocol for two complementary randomized trials. Contemp Clin Trials 2022; 120:106879. [PMID: 35963531 PMCID: PMC10042145 DOI: 10.1016/j.cct.2022.106879] [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: 03/21/2022] [Revised: 07/26/2022] [Accepted: 08/06/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Although goals-of-care discussions are important for high-quality palliative care, this communication is often lacking for hospitalized older patients with serious illness. Electronic health records (EHR) provide an opportunity to identify patients who might benefit from these discussions and promote their occurrence, yet prior interventions using the EHR for this purpose are limited. We designed two complementary yet independent randomized trials to examine effectiveness of a communication-priming intervention (Jumpstart) for hospitalized older adults with serious illness. METHODS We report the protocol for these 2 randomized trials. Trial 1 has two arms, usual care and a clinician-facing Jumpstart, and is a pragmatic trial assessing outcomes with the EHR only (n = 2000). Trial 2 has three arms: usual care, clinician-facing Jumpstart, and clinician- and patient-facing (bi-directional) Jumpstart (n = 600). We hypothesize the clinician-facing Jumpstart will improve outcomes over usual care and the bi-directional Jumpstart will improve outcomes over the clinician-facing Jumpstart and usual care. We use a hybrid effectiveness-implementation design to examine implementation barriers and facilitators. OUTCOMES For both trials, the primary outcome is EHR documentation of a goals-of-care discussion within 30 days of randomization; additional outcomes include intensity of end-of-life care. Trial 2 also examines patient- or family-reported outcomes assessed by surveys targeting 3-5 days and 4-8 weeks after randomization including quality of goals-of-care communication, receipt of goal-concordant care, and psychological symptoms. CONCLUSIONS This novel study incorporates two complementary randomized trials and a hybrid effectiveness-implementation approach to improve the quality and value of care for hospitalized older adults with serious illness. CLINICAL TRIALS REGISTRATION STUDY00007031-A and STUDY00007031-B.
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Affiliation(s)
- J Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America.
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Lyndia C Brumback
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Lois Downey
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Janaki Torrence
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Joanna Heywood
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Nicole LeDuc
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Kasey Mallon Andrews
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Jennifer Im
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States of America
| | - Bryan J Weiner
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States of America; Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States of America
| | - Nauzley C Abedini
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
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Dzeng E, Merel SE, Kross EK. J. Randall Curtis's Legacy and Scientific Contributions to Palliative Care in Critical Care. J Pain Symptom Manage 2022; 63:e587-e593. [PMID: 35595372 DOI: 10.1016/j.jpainsymman.2022.02.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Elizabeth Dzeng
- Division of Hospital Medicine (E.D.), Department of Medicine, University of California, San Francisco, California, USA; Cicely Saunders Institute (E.D.), King's College London, London, UK.
| | - Susan E Merel
- Division of General Internal Medicine (S.E.M.), Department of Medicine, University of Washington, Seattle, Washington State, USA; Cambia Palliative Care Center of Excellence at UW Medicine (S.E.M., E.K.K.), Seattle, Washington State, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence at UW Medicine (S.E.M., E.K.K.), Seattle, Washington State, USA; Division of Pulmonary (E.K.K.), Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington State, USA
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Uyeda AM, Curtis JR, Engelberg RA, Brumback LC, Guo Y, Sibley J, Lober WB, Cohen T, Torrence J, Heywood J, Paul SR, Kross EK, Lee RY. Mixed-methods evaluation of three natural language processing modeling approaches for measuring documented goals-of-care discussions in the electronic health record. J Pain Symptom Manage 2022; 63:e713-e723. [PMID: 35182715 PMCID: PMC9124686 DOI: 10.1016/j.jpainsymman.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/05/2022] [Accepted: 02/07/2022] [Indexed: 01/02/2023]
Abstract
CONTEXT Documented goals-of-care discussions are an important quality metric for patients with serious illness. Natural language processing (NLP) is a promising approach for identifying goals-of-care discussions in the electronic health record (EHR). OBJECTIVES To compare three NLP modeling approaches for identifying EHR documentation of goals-of-care discussions and generate hypotheses about differences in performance. METHODS We conducted a mixed-methods study to evaluate performance and misclassification for three NLP featurization approaches modeled with regularized logistic regression: bag-of-words (BOW), rule-based, and a hybrid approach. From a prospective cohort of 150 patients hospitalized with serious illness over 2018 to 2020, we collected 4391 inpatient EHR notes; 99 (2.3%) contained documented goals-of-care discussions. We used leave-one-out cross-validation to estimate performance by comparing pooled NLP predictions to human abstractors with receiver-operating-characteristic (ROC) and precision-recall (PR) analyses. We qualitatively examined a purposive sample of 70 NLP-misclassified notes using content analysis to identify linguistic features that allowed us to generate hypotheses underpinning misclassification. RESULTS All three modeling approaches discriminated between notes with and without goals-of-care discussions (AUCROC: BOW, 0.907; rule-based, 0.948; hybrid, 0.965). Precision and recall were only moderate (precision at 70% recall: BOW, 16.2%; rule-based, 50.4%; hybrid, 49.3%; AUCPR: BOW, 0.505; rule-based, 0.579; hybrid, 0.599). Qualitative analysis revealed patterns underlying performance differences between BOW and rule-based approaches. CONCLUSION NLP holds promise for identifying EHR-documented goals-of-care discussions. However, the rarity of goals-of-care content in EHR data limits performance. Our findings highlight opportunities to optimize NLP modeling approaches, and support further exploration of different NLP approaches to identify goals-of-care discussions.
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Affiliation(s)
- Alison M Uyeda
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA
| | - J Randall Curtis
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Informatics (J.R.C., J.S., W.B.L.), University of Washington, Seattle, WA.
| | - Ruth A Engelberg
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Lyndia C Brumback
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biostatistics (L.C.B.), University of Washington, Seattle, WA
| | - Yue Guo
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biomedical Informatics and Medical Education (Y.G., W.B.L., T.C.), University of Washington, Seattle, WA
| | - James Sibley
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Informatics (J.R.C., J.S., W.B.L.), University of Washington, Seattle, WA
| | - William B Lober
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biomedical Informatics and Medical Education (Y.G., W.B.L., T.C.), University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Informatics (J.R.C., J.S., W.B.L.), University of Washington, Seattle, WA
| | - Trevor Cohen
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biomedical Informatics and Medical Education (Y.G., W.B.L., T.C.), University of Washington, Seattle, WA
| | - Janaki Torrence
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Joanna Heywood
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Sudiptho R Paul
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Erin K Kross
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Robert Y Lee
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
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22
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Rosenberg AR, Engelberg RA, Kross EK. Truths, Principles, Maxims, and Other Smart Things We Learned From J. Randall Curtis. J Pain Symptom Manage 2022; 63:e595-e600. [PMID: 34973352 DOI: 10.1016/j.jpainsymman.2021.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Abby R Rosenberg
- Department of Pediatrics (A.R.R.), Division of Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington State, USA; Palliative Care and Resilience Lab (A.R.R.), Seattle Children's Research Institute, Seattle, Washington State, USA; Cambia Palliative Care Center of Excellence at the University of Washington (A.R.R., R.E., E.K.K.), Seattle, Washington State, USA.
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence at the University of Washington (A.R.R., R.E., E.K.K.), Seattle, Washington State, USA; Department of Medicine (R.E., E.K.K.), Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, Washington State, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence at the University of Washington (A.R.R., R.E., E.K.K.), Seattle, Washington State, USA; Department of Medicine (R.E., E.K.K.), Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, Washington State, USA
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23
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McDermott CL, Coats H, Bernacki GM, Blakeney EAR, Brown CE, Lau N, Lee RY, Modes ME, Steineck A, Steiner JM, Taylor MR, Kross EK. What Does it Mean to be an Excellent Mentor? J. Randall "Randy" Curtis' Living Legacy. J Pain Symptom Manage 2022; 63:e657-e659. [PMID: 35595383 DOI: 10.1016/j.jpainsymman.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/21/2022]
Affiliation(s)
- Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Heather Coats
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Gwen M Bernacki
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Erin Abu-Rish Blakeney
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Crystal E Brown
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Nancy Lau
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Matthew E Modes
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Angela Steineck
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Jill M Steiner
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Mallory R Taylor
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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24
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Stapleton RD, Ford DW, Sterba KR, Nadig NR, Ades S, Back AL, Carson SS, Cheung KL, Ely J, Kross EK, Macauley RC, Maguire JM, Marcy TW, McEntee JJ, Menon PR, Overstreet A, Ritchie CS, Wendlandt B, Ardren SS, Balassone M, Burns S, Choudhury S, Diehl S, McCown E, Nielsen EL, Paul SR, Rice C, Taylor KK, Engelberg RA. Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients. J Pain Symptom Manage 2022; 63:e621-e632. [PMID: 35595375 PMCID: PMC9179950 DOI: 10.1016/j.jpainsymman.2022.03.009] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/06/2022] [Accepted: 03/09/2022] [Indexed: 01/27/2023]
Abstract
CONTEXT Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree. OBJECTIVES Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families. METHODS This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness. RESULTS Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending. CONCLUSIONS IA is a feasible and reasonable approach to CPR discussions in selected patient populations.
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Affiliation(s)
- Renee D Stapleton
- Pulmonary and Critical Medicine, HSRF 222 (R.D.S), University of Vermont Larner College of Medicine, Burlington, Vermont, USA.
| | - Dee W Ford
- Division Director and Professor, Pulmonary, Critical Care, and Sleep Medicine, CSB 816, MSC 630 (D.W.F.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine R Sterba
- Public Health Sciences (K.R.S.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nandita R Nadig
- Pulmonary and Critical Care Medicine Northwestern University Feinberg School of Medicine (N.R.N.), Chicago, Illinois, USA
| | - Steven Ades
- Hematology and Oncology (S.A.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Anthony L Back
- Department of Medicine (A.L.B.), University of Washington, Seattle, Washington, USA
| | - Shannon S Carson
- Pulmonary and Critical Care Medicine (S.S.C.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Katharine L Cheung
- Nephrology (K.L.C.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Janet Ely
- University of Vermont Cancer Center (J.E.), Burlington, Vermont, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care & Sleep Medicine, Co-Director of Cambia Palliative Care Center of Excellence at UW Medicine (E.K.K.), University of Washington, Seattle, Washington, USA
| | | | - Jennifer M Maguire
- Pulmonary and Critical Care Medicine (J.M.M.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Theodore W Marcy
- Pulmonary and Critical Care Medicine (T.W.M.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Jennifer J McEntee
- Internal Medicine and Pediatrics, Palliative Care and Hospice Medicine (J.J.M.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Prema R Menon
- Vertex Pharmaceuticals (P.R.M.), Boston, Massachusetts, USA
| | - Amanda Overstreet
- Geriatrics and Palliative Care (A.O.), Medical University of South Carolina, Charleston, SC
| | | | - Blair Wendlandt
- Pulmonary and Critical Care Medicine (B.W.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sara S Ardren
- University of Vermont Larner College of Medicine (S.S.A.), Burlington, Vermont, USA
| | - Michael Balassone
- Division of Pulmonary and Critical Care Medicine (M.B.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stephanie Burns
- University of Vermont Larner College of Medicine (S.B.), Burlington, Vermont, USA
| | - Summer Choudhury
- North Carolina Translational and Clinical Sciences Institute (S.C.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sandra Diehl
- University of Vermont Medical Center (S.D.), Burlington, Vermont, USA
| | - Ellen McCown
- Spiritual Care (E.M.), University of Washington Medical Center, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Cambia Palliative Care Center of Excellence at UW Medicine (E.L.N), University of Washington, Seattle, Washington, USA
| | - Sudiptho R Paul
- Pulmonary and Critical Care Medicine (S.R.P., C.R.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Colleen Rice
- Pulmonary and Critical Care Medicine (S.R.P., C.R.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Katherine K Taylor
- Pulmonary, Critical Care, and Sleep Medicine (K.K.T), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ruth A Engelberg
- Pulmonary, Critical Care & Sleep Medicine, Cambia Palliative Care Center of Excellence at UW Medicine (R.A.E.), University of Washington, Seattle, Seattle, Washington, USA
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25
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Lobo SM, Creutzfeldt CJ, Maia IS, Town JA, Amorim E, Kross EK, Çoruh B, Patel PV, Jannotta GE, Lewis A, Greer DM, Curtis JR, Sharma M, Wahlster S. Perceptions of Critical Care Shortages, Resource Use, and Provider Well-being During the COVID-19 Pandemic: A Survey of 1,985 Health Care Providers in Brazil. Chest 2022; 161:1526-1542. [PMID: 35150658 PMCID: PMC8828383 DOI: 10.1016/j.chest.2022.01.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/18/2022] [Accepted: 01/31/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Brazil has been disproportionately affected by COVID-19, placing a high burden on ICUs. RESEARCH QUESTION Are perceptions of ICU resource availability associated with end-of-life decisions and burnout among health care providers (HCPs) during COVID-19 surges in Brazil? STUDY DESIGN AND METHODS We electronically administered a survey to multidisciplinary ICU HCPs during two 2-week periods (in June 2020 and March 2021) coinciding with COVID-19 surges. We examined responses across geographical regions and performed multivariate regressions to explore factors associated with reports of: (1) families being allowed less input in decisions about maintaining life-sustaining treatments for patients with COVID-19 and (2) emotional distress and burnout. RESULTS We included 1,985 respondents (57% physicians, 14% nurses, 12% respiratory therapists, 16% other HCPs). More respondents reported shortages during the second surge compared with the first (P < .05 for all comparisons), including lower availability of intensivists (66% vs 42%), ICU nurses (53% vs 36%), ICU beds (68% vs 22%), and ventilators for patients with COVID-19 (80% vs 70%); shortages were highest in the North. One-quarter of HCPs reported that families were allowed less input in decisions about maintaining life-sustaining treatments for patients with COVID-19, which was associated with lack of intensivists (adjusted relative risk [aRR], 1.37; 95% CI, 1.05-1.80) and ICU beds (aRR, 1.71; 95% CI, 1.16-2.62) during the first surge and lack of N95 masks (aRR, 1.43; 95% CI, 1.10-1.85), noninvasive positive pressure ventilation (aRR, 1.56; 95% CI, 1.18-2.07), and oxygen concentrators (aRR, 1.50; 95% CI, 1.13-2.00) during the second surge. Burnout was higher during the second surge (60% vs 71%; P < .001), associated with witnessing colleagues at one's hospital contract COVID-19 during both surges (aRR, 1.55 [95% CI, 1.25-1.93] and 1.31 [95% CI, 1.11-1.55], respectively), as well as worries about finances (aRR, 1.28; 95% CI, 1.02-1.61) and lack of ICU nurses (aRR, 1.25; 95% CI, 1.02-1.53) during the first surge. INTERPRETATION During the COVID-19 pandemic, ICU HCPs in Brazil experienced substantial resource shortages, health care disparities between regions, changes in end-of-life care associated with resource shortages, and high proportions of burnout.
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Affiliation(s)
- Suzana M Lobo
- Intensive Care Department, Hospital de Base, São José do Rio Preto, São Paulo, Brazil; Associação de Medicina Intensiva Brasileira, Florianópolis, Santa Catarina, Brazil
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA; Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA
| | - Israel S Maia
- Department of Intensive Care Medicine, Hospital Nereu Ramos, Florianópolis, Santa Catarina, Brazil
| | - James A Town
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Başak Çoruh
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Pratik V Patel
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Gemi E Jannotta
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Ariane Lewis
- Departments of Neurology and Neurosurgery, New York University, New York, NY
| | - David M Greer
- Department of Neurology, Boston University, Boston, MA
| | - J Randall Curtis
- Department of Intensive Care Medicine, Hospital Nereu Ramos, Florianópolis, Santa Catarina, Brazil; Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA
| | - Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA; Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA; Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA.
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26
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Lee RY, Kross EK, Downey L, Paul SR, Heywood J, Nielsen EL, Okimoto K, Brumback LC, Merel SE, Engelberg RA, Curtis JR. Efficacy of a Communication-Priming Intervention on Documented Goals-of-Care Discussions in Hospitalized Patients With Serious Illness: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e225088. [PMID: 35363271 PMCID: PMC8976242 DOI: 10.1001/jamanetworkopen.2022.5088] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE High-quality goals-of-care communication is critical to delivering goal-concordant, patient-centered care to hospitalized patients with chronic life-limiting illness. However, implementation and documentation of goals-of-care discussions remain important shortcomings in many health systems. OBJECTIVE To evaluate the efficacy, feasibility, and acceptability of a patient-facing and clinician-facing communication-priming intervention to promote goals-of-care communication for patients hospitalized with serious illness. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial enrolled patients from November 6, 2018, to February 18, 2020. The setting was 2 hospitals in an academic health care system in Seattle, Washington. Participants included hospitalized adults with chronic life-limiting illness, aged 65 years or older and with markers of frailty, or aged 80 years or older. Data analysis was performed from August 2020 to August 2021. INTERVENTION Patients were randomized to usual care with baseline questionnaires (control) vs the Jumpstart communication-priming intervention. Patients or surrogates in the intervention group and their clinicians received patient-specific Jumpstart Guides populated with data from questionnaires and the electronic health records (EHRs) that were designed to prompt and guide a goals-of-care discussion. MAIN OUTCOMES AND MEASURES The primary outcome was EHR documentation of a goals-of-care discussion between randomization and hospital discharge. Additional outcomes included patient-reported or surrogate-reported goals-of-care discussions, patient-reported or surrogate-reported quality of communication, and intervention feasibility and acceptability. RESULTS Of 428 eligible patients, this study enrolled 150 patients (35% enrollment rate; mean [SD] age, 59.2 [13.6] years; 66 women [44%]; 132 [88%] by patient consent and 18 [12%] by surrogate consent). Seventy-five patients each were randomized to the intervention and control groups. Compared with the control group, the cumulative incidence of EHR-documented goals-of-care discussions between randomization and hospital discharge was higher in the intervention group (16 of 75 patients [21%] vs 6 of 75 patients [8%]; risk difference, 13% [95% CI, 2%-24%]; risk ratio, 2.67 [95% CI, 1.10-6.44]; P = .04). Patient-reported or surrogate-reported goals-of-care discussions did not differ significantly between groups (30 of 66 patients [45%] vs 36 of 66 patients [55%]), although the intrarater consistency of patient and surrogate reports was poor. Patient-rated or surrogate-rated quality of communication did not differ significantly between groups. The intervention was feasible and acceptable to patients, surrogates, and clinicians. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, a patient-facing and clinician-facing communication priming intervention for seriously ill, hospitalized patients promoted EHR-documented goals-of-care discussions before discharge with good feasibility and acceptability. Communication-priming interventions should be reexamined in a larger randomized clinical trial to better understand their effectiveness in the inpatient setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03746392.
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Affiliation(s)
- Robert Y. Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Lois Downey
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Sudiptho R. Paul
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- University of Washington School of Medicine, Seattle
| | - Joanna Heywood
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Elizabeth L. Nielsen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Kelson Okimoto
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- Department of Family Medicine, University of Washington, Seattle
| | - Lyndia C. Brumback
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Susan E. Merel
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
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Abedini NC, Merel SE, Hicks KG, Torrence J, Heywood J, Engelberg RA, Kross EK, Curtis JR. Applying Human-Centered Design to Refinement of the Jumpstart Guide, a Clinician- and Patient-Facing Goals-of-Care Discussion Priming Tool. J Pain Symptom Manage 2021; 62:1283-1288. [PMID: 34147577 PMCID: PMC8648905 DOI: 10.1016/j.jpainsymman.2021.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022]
Abstract
CONTEXT Human-centered design provides a framework to understand the needs of patients and clinicians who are the target of goals-of-care discussion priming tools. Few studies employ human-centered design to develop and refine their tools. OBJECTIVES To describe how human-centered design can be applied to the development and refinement of clinician- and patient-facing inpatient goals-of-care discussion guides (Jumpstart guides). METHODS Human-centered design was applied to the development and refinement of the inpatient Jumpstart guides in four phases: (1) discovering problems based on prior pilots, studies, and research team priorities; (2) further defining problems based on stakeholder and expert review of the current guides; (3) designing solutions based on consensus among stakeholders; and (4) validating solutions after research team review of stakeholder comments. RESULTS Five initial problems were identified by the research team in phase 1. After expert and stakeholder review in phase 2, 30 additional problems were identified related to Jumpstart guide format, structure, and content. In phase 3, stakeholders proposed solutions to these 35 problems and reached consensus on 32 of these. There was disagreement in 3 areas, including how to frame discussions around cardiopulmonary resuscitation and 2 perceived barriers to inpatient goals-of-care discussions. In phase 4, the research team reviewed all stakeholder input and reached final consensus on solutions to all of the identified problems. CONCLUSION Human-centered design is a useful tool for enhancing communication interventions in serious illness and can easily be integrated in future development and refinement of clinician- and patient-facing interventions to enhance goals-of-care discussions.
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Affiliation(s)
- Nauzley C Abedini
- Division of Gerontology and Geriatric Medicine, Department of Medicine (N.C.A.), University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., S.E.M., K.G.H., J.T., J.H., R.A.E., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Susan E Merel
- Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., S.E.M., K.G.H., J.T., J.H., R.A.E., E.K.K., J.R.C.), Seattle, Washington, USA; Division of General Internal Medicine, Department of Medicine (S.E.M., K.G.H.), University of Washington, Seattle, Washington, USA
| | - Katherine G Hicks
- Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., S.E.M., K.G.H., J.T., J.H., R.A.E., E.K.K., J.R.C.), Seattle, Washington, USA; Division of General Internal Medicine, Department of Medicine (S.E.M., K.G.H.), University of Washington, Seattle, Washington, USA
| | - Janaki Torrence
- Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., S.E.M., K.G.H., J.T., J.H., R.A.E., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (J.T., J.H., R.A.E., E.K.K., J.R.C.), University of Washington, Seattle, Washington, USA
| | - Joanna Heywood
- Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., S.E.M., K.G.H., J.T., J.H., R.A.E., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (J.T., J.H., R.A.E., E.K.K., J.R.C.), University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., S.E.M., K.G.H., J.T., J.H., R.A.E., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (J.T., J.H., R.A.E., E.K.K., J.R.C.), University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., S.E.M., K.G.H., J.T., J.H., R.A.E., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (J.T., J.H., R.A.E., E.K.K., J.R.C.), University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., S.E.M., K.G.H., J.T., J.H., R.A.E., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (J.T., J.H., R.A.E., E.K.K., J.R.C.), University of Washington, Seattle, Washington, USA
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Vranas KC, Plinke W, Bourne D, Kansagara D, Lee RY, Kross EK, Slatore CG, Sullivan DR. The influence of POLST on treatment intensity at the end of life: A systematic review. J Am Geriatr Soc 2021; 69:3661-3674. [PMID: 34549418 DOI: 10.1111/jgs.17447] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 04/30/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. METHODS We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life). RESULTS Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes. CONCLUSION We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.
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Affiliation(s)
- Kelly C Vranas
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Wesley Plinke
- Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Donald Bourne
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Devan Kansagara
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Christopher G Slatore
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Donald R Sullivan
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
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29
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Sharma M, Creutzfeldt CJ, Lewis A, Patel PV, Hartog C, Jannotta GE, Blissitt P, Kross EK, Kassebaum N, Greer DM, Curtis JR, Wahlster S. Health-care Professionals' Perceptions of Critical Care Resource Availability and Factors Associated With Mental Well-being During Coronavirus Disease 2019 (COVID-19): Results from a US Survey. Clin Infect Dis 2021; 72:e566-e576. [PMID: 32877508 PMCID: PMC7499503 DOI: 10.1093/cid/ciaa1311] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/31/2020] [Indexed: 11/29/2022] Open
Abstract
Background Assessing the impact of COVID-19 on intensive care unit (ICU) providers’ perceptions of resource availability and evaluating factors associated with emotional distress/burnout can inform interventions to promote provider well-being. Methods Between April 23-May 7, 2020, we electronically administered a survey to physicians, nurses, respiratory therapist (RTs) and advanced practice providers (APPs) caring for COVID-19 patients in the US. We conducted multivariate regression to assess associations between concerns, reported lack of resources and three outcomes: emotional distress/burnout (primary outcome), and two secondary outcomes: 1) fear that hospital is unable to keep providers safe, and 2) concern about transmitting COVID-19 to family/community. Results We included 1,651 respondents from all 50 states; 47% nurses, 25% physicians, 17% RTs, 11% APPS. Shortages of intensivists and ICU nurses were reported by 12% and 28% of providers, respectively. The largest supply restrictions reported were for powered air purifying respirators (PAPRs); (56% reporting restricted availability). Provider concerns included worries about transmitting COVID-19 to family/community (66%), emotional distress/burnout (58%), and insufficient personal protective equipment (PPE) (40%). After adjustment, emotional distress/burnout was significantly associated with insufficient PPE access (aRR: 1.43, 95% CI: 1.32 - 1.55), stigma from community (aRR: 1.32, 95% CI: 1.24 - 1.41), and poor communication with supervisors (aRR:1.13, 95% CI: 1.06 - 1.21). Insufficient PPE access was the strongest predictor of feeling that the hospital is unable to keep providers safe and worries about transmitting infection to families/communities. Conclusion Addressing insufficient PPE access, poor communication from supervisors, and community stigma may improve provider mental well-being during the COVID-19 pandemic.
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Affiliation(s)
- Monisha Sharma
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Cambia Health Foundation, Seattle, Washington, USA
| | - Ariane Lewis
- Departments of Neurology and Neurosurgery, New York University, New York, New York, USA
| | - Pratik V Patel
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Christiane Hartog
- Klinik für Anaesthesie und Operative Intensivmedizin, Charité Universitaetsmedizin Berlin, Berlin, Germany.,Klinik Bavaria Kreischa, Kreischa, Germany
| | - Gemi E Jannotta
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Patricia Blissitt
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Nicholas Kassebaum
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - David M Greer
- Department of Neurology, Boston University, Boston, Massachusetts, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Cambia Health Foundation, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA.,Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
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Schenker Y, Ellington L, Bell L, Kross EK, Rosenberg AR, Kutner JS, Bickel KE, Ritchie C, Kavalieratos D, Bekelman DB, Mooney KB, Fischer SM. The National Postdoctoral Palliative Care Research Training Collaborative: History, Activities, Challenges, and Future Goals. J Palliat Med 2021; 24:545-553. [PMID: 32955969 PMCID: PMC8182655 DOI: 10.1089/jpm.2020.0411] [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] [Indexed: 11/12/2022] Open
Abstract
Background: Palliative care-related postdoctoral training opportunities are critical to increase the quantity and quality of palliative care research. Objective: To describe the history, activities, challenges, and future goals of the National Postdoctoral Palliative Care Research Training Collaborative. Design: National web-based survey of participating program leaders. Measurements: Information about participating programs, trainees, challenges faced, and future goals. Results: Nine participating programs at academic institutions across the United States focus on diverse aspects of palliative care research. The majority of 73 current and former fellows are female (75%) and white (84%). In total, 38% of fellows (n = 28) have MD backgrounds, of whom less than half (n = 12) completed hospice and palliative medicine fellowships. An additional 38% of fellows (n = 28) have nursing PhD backgrounds and 23% (n = 17) have other diverse types of PhD backgrounds. Key challenges relate to recruiting diverse trainees, fostering a shared identity, effectively advocating for trainees, and securing funding. Future goals include expanding efforts to engage clinician and nonclinician scientists, fostering the pipeline of palliative care researchers through expanded mentorship of predoctoral and clinical trainees, increasing the number of postdoctoral palliative care training programs, and expanding funding support for career development grants. Conclusion: The National Postdoctoral Palliative Care Research Training Collaborative fills an important role in creating a community for palliative care research trainees and developing strategies to address shared challenges.
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Affiliation(s)
- Yael Schenker
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Lindsay Bell
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Abby R. Rosenberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Palliative Care and Resilience Laboratory, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jean S. Kutner
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kathleen E. Bickel
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Medicine, Veterans Affairs Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Christine Ritchie
- Center for Palliative Care, Harvard Medical School, Boston, Massachusetts, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - David B. Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Medicine, Veterans Affairs Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | | | - Stacy M. Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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Shen J, Crothers K, Kross EK, Petersen K, Melzer AC, Triplette M. Provision of Smoking Cessation Resources in the Context of In-Person Shared Decision-Making for Lung Cancer Screening. Chest 2021; 160:765-775. [PMID: 33745990 DOI: 10.1016/j.chest.2021.03.016] [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] [Received: 10/21/2020] [Revised: 03/04/2021] [Accepted: 03/06/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Lung cancer screening (LCS) is effective at reducing mortality for high-risk smokers. Mortality benefits go beyond early cancer detection, because shared decision-making (SDM) may present a "teachable moment" to reinforce cessation and provide resources. RESEARCH QUESTION How well is smoking cessation performed during LCS SDM encounters, and what patient and provider characteristics are associated with smoking cessation assistance? STUDY DESIGN AND METHODS This is a retrospective cohort study of current smokers participating in initial LCS SDM through a multisite program in Seattle, Washington, between 2015-2018. The LCS tracking database and electronic health record were reviewed for demographics, comorbidity data, and clinical encounter information. The primary outcome was provision of a smoking cessation resource, defined as referral to cessation resources, recommendation for nicotine replacement, or prescription for cessation medication. Participant and provider factor associations with the outcome were evaluated using χ2 testing and multivariable logistic regression. RESULTS Most of the 423 study participants were men (70%), with a median age of 61 (IQR, 58-66) years and median of 50 (41-72) pack-years of smoking. Only 26% of encounters had documentation consistent with SDM. Thirty-nine percent of participants received at least one smoking cessation resource, and only 5% received both counseling referrals and medication. In a multivariable model, the provision of any smoking cessation resource was half as likely in participants with higher levels of comorbidity (Charlson Index >2; OR, 0.53; 95% CI, 0.31-0.81), and half as likely if the ordering provider was not the patient's PCP or their specialist (OR, 0.55; 95% CI, 0.32-0.96). INTERPRETATION Overall provision of smoking cessation resources was moderate during SDM encounters for LCS, and lower in patients with more comorbidities and when not performed by the patient's PCP or specialist. Interventions are needed to improve smoking cessation counseling and resource utilization at the time of LCS encounters.
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Affiliation(s)
| | - Kristina Crothers
- University of Washington, Seattle, WA; Veterans Affairs Puget Sound Medical Center, Seattle, WA
| | - Erin K Kross
- University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
| | | | - Anne C Melzer
- Division of Pulmonary, Allergy and Critical Care, University of Minnesota, Minneapolis, MN; Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Matthew Triplette
- University of Washington, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA.
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32
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Rosenberg AR, Zhou C, Bradford MC, Barton K, Junkins CC, Taylor M, Kross EK, Curtis JR, Dionne-Odom JN, Yi-Frazier JP. Parent Perspectives after the PRISM-P Randomized Trial: A Mixed-Methods Analysis. J Palliat Med 2021; 24:1505-1515. [PMID: 33720787 DOI: 10.1089/jpm.2020.0720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 12/23/2022] Open
Abstract
Background: Parents experience high distress following their child's diagnosis of cancer. We previously tested two delivery models (group and one-on-one) of the "Promoting Resilience in Stress Management for Parents" (PRISM-P) intervention in a randomized trial: one-on-one delivery improved resilience and benefit finding at three months when compared to usual care (UC). Objective: The objective of this analysis was to evaluate quantitative and qualitative outcomes at six months. Design: In this single-center, phase 2, parallel, 1:1:1 randomized trial conducted December 2016 to December 2018, English-speaking parents with a 2-24 year-old child diagnosed with new cancer were randomly assigned to UC, one-on-one, or group PRISM-P, a brief, skill-based curriculum targeting stress management, goal setting, cognitive reframing, and meaning making. We collected parent-reported outcomes (resilience, benefit finding, and psychological distress) at baseline and three and six months. We applied linear mixed-effects regression models to examine six-month outcomes among all participants and conducted directed content analyses of exit interviews with the first 12 parents to complete each study arm. Results: The 94 participating parents were median aged 35-38 years and predominantly white, college-educated mothers. At six months, there was no statistically significant difference in parent-reported outcomes. Exit interviews (n = 36) suggested that PRISM-P was highly valued: 100% of interviewed recipients recommended it for other parents. Most suggested more coaching would help them retain skills, and almost all endorsed a combined one-on-one and group program. Conclusions: Although the PRISM-P benefits observed at three months were not sustained for six months, all interviewed parents found it valuable. Additional opportunities to strengthen and sustain resilience resources include longer follow-up, flexible format, and skill reinforcement. Trial Registration: NCT02998086.
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Affiliation(s)
- Abby R Rosenberg
- Palliative Care and Resilience Research Laboratory, Center for Clinical and Translational Research, Epidemiology, and Analytics in Research Program, Seattle Children's Research Institute, Seattle, Washington, USA.,Division of Hematology/Oncology and Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Chuan Zhou
- Division of General Pediatrics, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Biostatistics, Epidemiology, and Analytics in Research Program, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Miranda C Bradford
- Biostatistics, Epidemiology, and Analytics in Research Program, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Krysta Barton
- Palliative Care and Resilience Research Laboratory, Center for Clinical and Translational Research, Epidemiology, and Analytics in Research Program, Seattle Children's Research Institute, Seattle, Washington, USA.,Biostatistics, Epidemiology, and Analytics in Research Program, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Courtney C Junkins
- Palliative Care and Resilience Research Laboratory, Center for Clinical and Translational Research, Epidemiology, and Analytics in Research Program, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Mallory Taylor
- Palliative Care and Resilience Research Laboratory, Center for Clinical and Translational Research, Epidemiology, and Analytics in Research Program, Seattle Children's Research Institute, Seattle, Washington, USA.,Division of Hematology/Oncology and Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - J Nicholas Dionne-Odom
- Department of Acute, Chronic, and Continuing Care, University of Alabama at Birmingham School of Nursing, Birmingham, Alabama, USA
| | - Joyce P Yi-Frazier
- Palliative Care and Resilience Research Laboratory, Center for Clinical and Translational Research, Epidemiology, and Analytics in Research Program, Seattle Children's Research Institute, Seattle, Washington, USA
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Lee RY, Brumback LC, Lober WB, Sibley J, Nielsen EL, Treece PD, Kross EK, Loggers ET, Fausto JA, Lindvall C, Engelberg RA, Curtis JR. Identifying Goals of Care Conversations in the Electronic Health Record Using Natural Language Processing and Machine Learning. J Pain Symptom Manage 2021; 61:136-142.e2. [PMID: 32858164 PMCID: PMC7769906 DOI: 10.1016/j.jpainsymman.2020.08.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Goals-of-care discussions are an important quality metric in palliative care. However, goals-of-care discussions are often documented as free text in diverse locations. It is difficult to identify these discussions in the electronic health record (EHR) efficiently. OBJECTIVES To develop, train, and test an automated approach to identifying goals-of-care discussions in the EHR, using natural language processing (NLP) and machine learning (ML). METHODS From the electronic health records of an academic health system, we collected a purposive sample of 3183 EHR notes (1435 inpatient notes and 1748 outpatient notes) from 1426 patients with serious illness over 2008-2016, and manually reviewed each note for documentation of goals-of-care discussions. Separately, we developed a program to identify notes containing documentation of goals-of-care discussions using NLP and supervised ML. We estimated the performance characteristics of the NLP/ML program across 100 pairs of randomly partitioned training and test sets. We repeated these methods for inpatient-only and outpatient-only subsets. RESULTS Of 3183 notes, 689 contained documentation of goals-of-care discussions. The mean sensitivity of the NLP/ML program was 82.3% (SD 3.2%), and the mean specificity was 97.4% (SD 0.7%). NLP/ML results had a median positive likelihood ratio of 32.2 (IQR 27.5-39.2) and a median negative likelihood ratio of 0.18 (IQR 0.16-0.20). Performance was better in inpatient-only samples than outpatient-only samples. CONCLUSION Using NLP and ML techniques, we developed a novel approach to identifying goals-of-care discussions in the EHR. NLP and ML represent a potential approach toward measuring goals-of-care discussions as a research outcome and quality metric.
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Affiliation(s)
- Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Lyndia C Brumback
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - William B Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Patsy D Treece
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Elizabeth T Loggers
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - James A Fausto
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA.
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Modes ME, Heckbert SR, Engelberg RA, Nielsen EL, Curtis JR, Kross EK. Patient-Reported Receipt of Goal-Concordant Care Among Seriously Ill Outpatients-Prevalence and Associated Factors. J Pain Symptom Manage 2020; 60:765-773. [PMID: 32389606 PMCID: PMC7508896 DOI: 10.1016/j.jpainsymman.2020.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Goal-concordant care is an important indicator of high-quality care in serious illness. OBJECTIVES To estimate the prevalence of patient-reported receipt of goal-concordant care among seriously ill outpatients and identify factors associated with the absence of patient-reported goal concordance. METHODS Analysis of enrollment surveys from a multicenter cluster-randomized trial of outpatients with serious illness. Patients reported their prioritized health care goal and the focus of their current medical care; these items were matched to define receipt of goal-concordant care. RESULTS Of 405 patients with a prioritized health care goal, 58% reported receipt of goal-concordant care, 17% goal-discordant care, and 25% were uncertain of the focus of their care. Patient-reported receipt of goal concordance differed by patient goal. For patients who prioritized extending life, 86% reported goal-concordant care, 2% goal-discordant care, and 12% were uncertain of the focus of their care. For patients who prioritized relief of pain and discomfort, 51% reported goal-concordant care, 21% goal-discordant care, and 28% were uncertain of the focus of their care. Patients who prioritized a goal of relief of pain and discomfort were more likely to report goal-discordant care than patients who prioritized a goal of extending life (relative risk ratio 22.20; 95% CI 4.59, 107.38). CONCLUSION Seriously ill outpatients who prioritize a goal of relief of pain and discomfort are less likely to report receipt of goal-concordant care than patients who prioritize extending life. Future interventions designed to improve receipt of goal-concordant care should focus on identifying patients who prioritize relief of pain and discomfort and promoting care aligned with that goal.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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Lee RY, Modes ME, Sathitratanacheewin S, Engelberg RA, Curtis JR, Kross EK. Conflicting Orders in Physician Orders for Life-Sustaining Treatment Forms. J Am Geriatr Soc 2020; 68:2903-2908. [PMID: 32936447 DOI: 10.1111/jgs.16828] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 06/17/2020] [Revised: 08/17/2020] [Accepted: 08/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVES Many older persons with chronic illness use Physician Orders for Life-Sustaining Treatment (POLST) to document portable medical orders for emergency care. However, some POLSTs contain combinations of orders that do not translate into a cohesive care plan (eg, cardiopulmonary resuscitation [CPR] without intensive care, or intensive care without antibiotics). This study characterizes the prevalence and predictors of POLSTs with conflicting orders. DESIGN Retrospective cohort study. SETTING Large academic health system. PARTICIPANTS A total of 3,123 POLST users with chronic life-limiting illness who died between 2010 and 2015 (mean age = 69.7 years). MEASUREMENTS In a retrospective review of all POLSTs in participants' electronic health records, we describe the prevalence of POLSTs with conflicting orders for cardiac arrest and medical interventions, and use clustered logistic regression to evaluate potential predictors of conflicting orders. We also examine the prevalence of conflicts between POLST orders for antibiotics and artificial nutrition with orders for cardiac arrest or medical interventions. RESULTS Among 3,924 complete POLSTs belonging to 3,123 decedents, 209 (5.3%) POLSTs contained orders to "attempt CPR" paired with orders for "limited interventions" or "comfort measures only"; 745/3169 (23.5%) POLSTs paired orders to restrict antibiotics with orders to deliver non-comfort-only care; and, 170/3098 (5.5%) POLSTs paired orders to withhold artificial nutrition with orders to deliver CPR or intensive care. Among POLSTs with orders to avoid intensive care, orders to attempt CPR were more likely to be present in POLSTs completed earlier in the patient's illness course (adjusted odds ratio = 1.27 per twofold increase in days from POLST to death; 95% confidence interval = 1.18-1.36; P < .001). CONCLUSION Although most POLSTs are actionable by clinicians, 5% had conflicting orders for cardiac arrest and medical interventions, and 24% had one or more conflicts between orders for cardiac arrest, medical interventions, antibiotics, and artificial nutrition. These conflicting orders make implementation of POLST challenging for clinicians in acute care settings.
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Affiliation(s)
- Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Matthew E Modes
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Seelwan Sathitratanacheewin
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
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Wahlster S, Sharma M, Lewis AK, Patel PV, Hartog CS, Jannotta G, Blissitt P, Kross EK, Kassebaum NJ, Greer DM, Curtis JR, Creutzfeldt CJ. The Coronavirus Disease 2019 Pandemic's Effect on Critical Care Resources and Health-Care Providers: A Global Survey. Chest 2020; 159:619-633. [PMID: 32926870 PMCID: PMC7484703 DOI: 10.1016/j.chest.2020.09.070] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [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: 06/24/2020] [Revised: 08/28/2020] [Accepted: 09/07/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide. RESEARCH QUESTION How do regional differences and perceived lack of ICU resources affect critical care resource use and the well-being of HCPs? STUDY DESIGN AND METHODS Between April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout. RESULTS We included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction [ARR], 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46). INTERPRETATION Our findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.
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Affiliation(s)
- Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, WA; Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, WA; Department of Neurological Surgery, Harborview Medical Center, University of Washington, WA.
| | - Monisha Sharma
- Department of Global Health, University of Washington, WA
| | - Ariane K Lewis
- Departments of Neurology and Neurosurgery, New York University, NY
| | - Pratik V Patel
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, WA
| | - Christiane S Hartog
- Klinik für Anaesthesie und operative Intensivmedizin, Charité Universitaetsmedizin Berlin, Berlin; Klinik Bavaria Kreischa, Germany
| | - Gemi Jannotta
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, WA
| | - Patricia Blissitt
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, WA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, WA; Cambia Palliative Care Center of Excellence, University of Washington, WA
| | - Nicholas J Kassebaum
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, WA; Department of Global Health, University of Washington, WA
| | - David M Greer
- Department of Neurology, Boston University, Boston, MA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, WA; Cambia Palliative Care Center of Excellence, University of Washington, WA; Cambia Health Foundation
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, WA; Cambia Palliative Care Center of Excellence, University of Washington, WA; Cambia Health Foundation
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Affiliation(s)
- Robert Y Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
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Curtis JR, Kross EK, Stapleton RD. The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19). JAMA 2020; 323:1771-1772. [PMID: 32219360 DOI: 10.1001/jama.2020.4894] [Citation(s) in RCA: 175] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Renee D Stapleton
- Larner College of Medicine, Division of Pulmonary and Critical Care Medicine, University of Vermont, Burlington
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Haines KJ, McPeake J, Hibbert E, Boehm LM, Aparanji K, Bakhru RN, Bastin AJ, Beesley SJ, Beveridge L, Butcher BW, Drumright K, Eaton TL, Farley T, Firshman P, Fritschle A, Holdsworth C, Hope AA, Johnson A, Kenes MT, Khan BA, Kloos JA, Kross EK, Mactavish P, Meyer J, Montgomery-Yates A, Quasim T, Saft HL, Slack A, Stollings J, Weinhouse G, Whitten J, Netzer G, Hopkins RO, Mikkelsen ME, Iwashyna TJ, Sevin CM. Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness: The Thrive Collaboratives. Crit Care Med 2020; 47:1194-1200. [PMID: 31241499 DOI: 10.1097/ccm.0000000000003818] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them. DESIGN Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data. SETTING Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents. SUBJECTS Clinicians from 21 sites. MEASUREMENT AND MAIN RESULTS Ten enablers and nine barriers to implementation of "ICU follow-up clinics" were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of "peer support groups" were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising. CONCLUSIONS Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.
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Affiliation(s)
- Kimberley J Haines
- Department of Physiotherapy, Western Health, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Joanne McPeake
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Scotland, United Kingdom.,School of Medicine, Dentistry and Nursing, University of Glasgow, Scotland, United Kingdom
| | - Elizabeth Hibbert
- Department of Physiotherapy, Western Health, Melbourne, VIC, Australia
| | | | | | - Rita N Bakhru
- Wake Forest University School of Medicine, Department of Internal Medicine, Section of Pulmonary, Critical Care, Allergy and Immunology, Winston Salem, NC
| | - Anthony J Bastin
- Department of Peri-operative Medicine, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Sarah J Beesley
- Pulmonary Division, Department of Medicine, Intermountain Medical Center, Murray, UT.,Center for Humanizing Critical Care, Intermountain Health Care, Murray, UT.,Pulmonary Division, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Lynne Beveridge
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Scotland, United Kingdom
| | - Brad W Butcher
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kelly Drumright
- Tennessee Valley Healthcare System VA Medical Center, Nashville, TN
| | - Tammy L Eaton
- Palliative and Supportive Institute, UPMC Mercy, Pittsburgh, PA
| | - Thomas Farley
- School of Nursing, University of California San Francisco, San Francisco, CA
| | | | | | - Clare Holdsworth
- Department of Physiotherapy, Western Health, Melbourne, VIC, Australia
| | - Aluko A Hope
- Division of Critical Care Medicine, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY
| | | | - Michael T Kenes
- Department of Pharmacy, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Babar A Khan
- Indiana University School of Medicine Research Scientist, Regenstrief Institute Inc., Indianapolis, IN
| | - Janet A Kloos
- University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Erin K Kross
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Pamela Mactavish
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Scotland, United Kingdom
| | - Joel Meyer
- Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Ashley Montgomery-Yates
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Lexington, KY
| | - Tara Quasim
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Scotland, United Kingdom
| | - Howard L Saft
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Andrew Slack
- Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Joanna Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Gerald Weinhouse
- Department of Medicine, Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA
| | | | - Giora Netzer
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Health Care, Murray, UT.,Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, UT.,Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Theodore J Iwashyna
- Department of Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, MI.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Carla M Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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Lee RY, Engelberg RA, Curtis JR, Hough CL, Kross EK. Novel Risk Factors for Posttraumatic Stress Disorder Symptoms in Family Members of Acute Respiratory Distress Syndrome Survivors. Crit Care Med 2020; 47:934-941. [PMID: 30985448 DOI: 10.1097/ccm.0000000000003774] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Family members of ICU survivors report long-term psychologic symptoms of posttraumatic stress disorder. We describe patient- and family-member risk factors for posttraumatic stress disorder symptoms among family members of survivors of acute respiratory distress syndrome. DESIGN Prospective cohort study of family members of acute respiratory distress syndrome survivors. SETTING Single tertiary care center in Seattle, Washington. SUBJECTS From 2010 to 2015, we assembled an inception cohort of adult acute respiratory distress syndrome survivors who identified family members involved in ICU and post-ICU care. One-hundred sixty-two family members enrolled in the study, corresponding to 120 patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Family members were assessed for self-reported psychologic symptoms 6 months after patient discharge using the Posttraumatic Stress Disorder Checklist-Civilian Version, the Patient Health Questionnaire 9-item depression scale, and the Generalized Anxiety Disorder 7-item scale. The primary outcome was posttraumatic stress disorder symptoms, and secondary outcomes were symptoms of depression and anxiety. We used clustered multivariable logistic regression to identify patient- and family-member risk factors for psychologic symptoms. Posttraumatic stress disorder symptoms were present in 31% (95% CI, 24-39%) of family participants. Family member risk factors for posttraumatic stress disorder symptoms included preexisting mental health disorders (adjusted odds ratio, 3.22; 95% CI, 1.42-7.31), recent personal experience of serious physical illness (adjusted odds ratio, 3.07; 95% CI, 1.40-6.75), and female gender (adjusted odds ratio, 5.18; 95% CI, 1.74-15.4). Family members of previously healthy patients (Charlson index of zero) had higher frequency of posttraumatic stress disorder symptoms (adjusted odds ratio, 2.25; 95% CI, 1.06-4.77). Markers of patient illness severity were not associated with family posttraumatic stress disorder symptoms. CONCLUSIONS The prevalence of long-term posttraumatic stress disorder symptoms among family members of acute respiratory distress syndrome survivors is high. Family members with preexisting mental health disorders, recent experiences of serious physical illness, and family members of previously healthy patients are at increased risk for posttraumatic stress disorder symptoms.
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Affiliation(s)
- Robert Y Lee
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
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Lee RY, Brumback LC, Sathitratanacheewin S, Lober WB, Modes ME, Lynch YT, Ambrose CI, Sibley J, Vranas KC, Sullivan DR, Engelberg RA, Curtis JR, Kross EK. Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life. JAMA 2020; 323:950-960. [PMID: 32062674 PMCID: PMC7042829 DOI: 10.1001/jama.2019.22523] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. OBJECTIVES To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system. EXPOSURES POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. MAIN OUTCOMES AND MEASURES The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. RESULTS Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). CONCLUSIONS AND RELEVANCE Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.
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Affiliation(s)
- Robert Y. Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Lyndia C. Brumback
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Seelwan Sathitratanacheewin
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - William B. Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Bioinformatics and Medical Education, University of Washington, Seattle
| | - Matthew E. Modes
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Ylinne T. Lynch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | | | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Bioinformatics and Medical Education, University of Washington, Seattle
| | - Kelly C. Vranas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Donald R. Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Bioethics and Humanities, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
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Kross EK, Rosenberg AR, Engelberg RA, Curtis JR. Postdoctoral Research Training in Palliative Care: Lessons Learned From a T32 Program. J Pain Symptom Manage 2020; 59:750-760.e8. [PMID: 31775020 PMCID: PMC7029795 DOI: 10.1016/j.jpainsymman.2019.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 12/20/2022]
Abstract
Our aging population and advances in chronic disease management that prolong the time that patients live with a chronic illness have combined to create an enormous need for improved palliative care research across diverse diseases. In this article, we describe the structure and processes of a National Institutes of Health-funded T32 postdoctoral research fellowship at the University of Washington and our experiences in developing and implementing the program. We recognize a broad definition of palliative care research, including research focused on improving quality of life, minimizing symptoms, providing psychological and spiritual support, and improving communication about patients' values and goals of care, all in the context of a serious illness. We describe our four core principles for postdoctoral training in palliative care research, each with a number of specific approaches: 1) mastering a set of essential content and research skills; 2) structured mentoring and academic career development; 3) creating and supporting early success; and 4) interdisciplinary training and team science. In addition, we also describe our framework for the essential competencies necessary for a palliative care research training program, our methods for identification and selection of applicants, our outcomes to date, and our processes of continuous quality assessment and improvement. Our goal is to describe our successful postdoctoral research training program in palliative care to promote development of new programs and share information between programs to continue to build the field of collaborative and interdisciplinary palliative care research.
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Affiliation(s)
- Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Abby R Rosenberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Hematology/Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.
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Modes ME, Engelberg RA, Downey L, Nielsen EL, Lee RY, Curtis JR, Kross EK. Toward Understanding the Relationship Between Prioritized Values and Preferences for Cardiopulmonary Resuscitation Among Seriously Ill Adults. J Pain Symptom Manage 2019; 58:567-577.e1. [PMID: 31228534 PMCID: PMC6754772 DOI: 10.1016/j.jpainsymman.2019.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Prioritizing among potentially conflicting end-of-life values may help patients discriminate among treatments and allow clinicians to align treatments with values. OBJECTIVES To investigate end-of-life values that patients prioritize when facing explicit trade-offs and identify predictors of patients whose values and treatment preferences seem inconsistent. METHODS Analysis of surveys from a multi-center cluster-randomized trial of patients with serious illness. Respondents prioritized end-of-life values and identified cardiopulmonary resuscitation (CPR) preferences in two health states. RESULTS Of 535 patients, 60% prioritized relief of discomfort over extending life, 17% prioritized extending life over relief of discomfort, and 23% were unsure. Patients prioritizing extending life were most likely to prefer CPR, with 93% preferring CPR in current health and 67% preferring CPR if dependent on others, compared with 69% and 21%, respectively, for patients prioritizing relief of discomfort, and 78% and 33%, respectively, for patients unsure of their prioritized value (P < 0.001 for all comparisons). Among patients prioritizing relief of discomfort, preference for CPR in current health was less likely among older patients (odds ratio 0.958 per year; 95% CI 0.935, 0.981) and more likely with better self-perceived health (odds ratio 1.402 per level of health; 95% CI 1.090, 1.804). CONCLUSION Clinicians face challenges as they clarify patient values and align treatments with values. Patients' values predicted CPR preferences, but a substantial proportion of patients expressed CPR preferences that appeared potentially inconsistent with their primary value. Clinicians should question assumptions about relationships between values and CPR preferences. Further research is needed to identify ways to use values to guide treatment decisions.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Robert Y Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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Haines KJ, Sevin CM, Hibbert E, Boehm LM, Aparanji K, Bakhru RN, Bastin AJ, Beesley SJ, Butcher BW, Drumright K, Eaton TL, Farley T, Firshman P, Fritschle A, Holdsworth C, Hope AA, Johnson A, Kenes MT, Khan BA, Kloos JA, Kross EK, MacLeod-Smith BJ, Mactavish P, Meyer J, Montgomery-Yates A, Quasim T, Saft HL, Slack A, Stollings J, Weinhouse G, Whitten J, Netzer G, Hopkins RO, Mikkelsen ME, Iwashyna TJ, McPeake J. Key mechanisms by which post-ICU activities can improve in-ICU care: results of the international THRIVE collaboratives. Intensive Care Med 2019; 45:939-947. [PMID: 31165227 PMCID: PMC6611738 DOI: 10.1007/s00134-019-05647-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/24/2019] [Indexed: 12/27/2022]
Abstract
Objective To identify the key mechanisms that clinicians perceive improve care in the intensive care unit (ICU), as a result of their involvement in post-ICU programs. Methods Qualitative inquiry via focus groups and interviews with members of the Society of Critical Care Medicine’s THRIVE collaborative sites (follow-up clinics and peer support). Framework analysis was used to synthesize and interpret the data. Results Five key mechanisms were identified as drivers of improvement back into the ICU: (1) identifying otherwise unseen targets for ICU quality improvement or education programs—new ideas for quality improvement were generated and greater attention paid to detail in clinical care. (2) Creating a new role for survivors in the ICU—former patients and family members adopted an advocacy or peer volunteer role. (3) Inviting critical care providers to the post-ICU program to educate, sensitize, and motivate them—clinician peers and trainees were invited to attend as a helpful learning strategy to gain insights into post-ICU care requirements. (4) Changing clinician’s own understanding of patient experience—there appeared to be a direct individual benefit from working in post-ICU programs. (5) Improving morale and meaningfulness of ICU work—this was achieved by closing the feedback loop to ICU clinicians regarding patient and family outcomes. Conclusions The follow-up of patients and families in post-ICU care settings is perceived to improve care within the ICU via five key mechanisms. Further research is required in this novel area. Electronic supplementary material The online version of this article (10.1007/s00134-019-05647-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kimberley J Haines
- Department of Physiotherapy, Western Health, Sunshine Hospital, Melbourne, Australia.
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.
| | - Carla M Sevin
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth Hibbert
- Department of Physiotherapy, Western Health, Melbourne, VIC, Australia
| | - Leanne M Boehm
- School of Nursing, Vanderbilt University, Nashville, TN, USA
| | - Krishna Aparanji
- Critical Care Medicine, Springfield Clinic, Springfield, IL, USA
| | - Rita N Bakhru
- Section of Pulmonary, Critical Care, Allergy and Immunology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Anthony J Bastin
- Department of Peri-operative Medicine, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Sarah J Beesley
- Pulmonary Division, Department of Medicine, Intermountain Medical Center, Murray, UT, USA
- Center for Humanizing Critical Care, Intermountain Health Care, Murray, UT, USA
- Pulmonary Division, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Brad W Butcher
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Kelly Drumright
- Tennessee Valley Healthcare System VA Medical Center, Nashville, TN, USA
| | - Tammy L Eaton
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Thomas Farley
- School of Nursing, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Clare Holdsworth
- Department of Physiotherapy, Western Health, Melbourne, VIC, Australia
| | - Aluko A Hope
- Division of Critical Care Medicine, Albert Einstein College of Medicine of Yeshiva University, New York, USA
| | - Annie Johnson
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael T Kenes
- Department of Pharmacy, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Babar A Khan
- Indiana University School of Medicine Research Scientist, Regenstrief Institute Inc., Indianapolis, IN, USA
| | - Janet A Kloos
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | - Pamela Mactavish
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
| | - Joel Meyer
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ashley Montgomery-Yates
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Kentucky, USA
| | - Tara Quasim
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland, UK
| | - Howard L Saft
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Andrew Slack
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joanna Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gerald Weinhouse
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jessica Whitten
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN, USA
| | - Giora Netzer
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Maryland, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Health Care, Murray, UT, USA
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Murray, UT, USA
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT, USA
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Joanne McPeake
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK.
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland, UK.
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Taylor MR, Bradford MC, Junkins CC, Kross EK, Curtis JR, Yi-Frazier JP, Rosenberg AR. The promoting resilience in stress management (PRISM) intervention for parents of children with cancer: A randomized controlled trial. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10029 Background: Parents of children with cancer experience significant levels of distress, which may negatively impact surviving patients and family members. Positive psychology interventions have shown promise, but few address the well-being of parents. The objective of this study was to test the efficacy of a resilience intervention, Promoting Resilience in Stress Management-Parent (PRISM-P), among parents of children with cancer. Methods: This study was a phase 2, 1:1:1 RCT. Eligible participants were English-speaking parents of children 2-24 years-old receiving cancer-directed therapy at Seattle Children’s Hospital. PRISM-P is a skills-based program targeting resilience resources. Parents were randomized to usual care (UC), UC plus individual PRISM-P (1:1), or UC plus group PRISM-P (group). Parents completed surveys at baseline and 3 months measuring resilience (primary outcome, 10-item Connor Davidson Resilience Scale (CDRISC)) and other secondary outcomes including stress, social support, and benefit-finding. We performed an intention-to-treat analysis using unadjusted linear mixed-effects modeling to estimate PRISM effects on score change. With n = 25 per arm, we achieved 80% power to detect an effect size (CDRISC change) of 5.1 (Cohen’s d = 0.8) with a type 1 error rate of 0.05. Results: 107 parents enrolled. Of these, 94 (88%) completed baseline surveys and 77 (72%) completed 3 month surveys. Mean (SD) resilience score change in UC, 1:1 and group arms was -2 (3.5), 1 (5.3) and -1 (5.0), respectively. In mixed models, the estimated 1:1 PRISM benefit for resilience score change vs. UC was +2.8 (95% CI: 0.5,5.2, p = 0.02) while there was no evidence of a group benefit (beta 0.4, 95% CI: -2.1, 2.8, p = 0.76.). Models for secondary outcome score change found a PRISM advantage for benefit finding, where the 1:1 vs. UC difference was +0.5 (95% CI: 0.2, 0.8, p < 0.01) and the group vs. UC difference was +0.4 (0.0, 0.7, p = 0.05). Conclusions: Compared to UC, 1:1 PRISM-P was associated with improved resilience change, and both PRISM-P intervention arms were associated with greater benefit-finding. Future studies will explore larger scale efficacy and alternative delivery design. Clinical trial information: NCT02998086.
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Affiliation(s)
- Mallory R. Taylor
- Center for Clinical and Translationsal Research, Seattle Children’s Research Institute, Seattle, WA
| | - Miranda C. Bradford
- Children’s Core for Biomedical Statistics, Center for Clinical and Translationsal Research, Seattle Children’s Research Institute, Seattle, WA
| | - Courtney C. Junkins
- Center for Clinical and Translationsal Research, Seattle Children’s Research Institute, Seattle, WA
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
| | - Joyce P. Yi-Frazier
- Center for Clinical and Translationsal Research, Seattle Children's Research Institute, Seattle, WA
| | - Abby R. Rosenberg
- Center for Clinical and Translationsal Research, Seattle Children's Research Institute, Seattle, WA
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Turnbull AE, Bosslet GT, Kross EK. Aligning use of intensive care with patient values in the USA: past, present, and future. Lancet Respir Med 2019; 7:626-638. [PMID: 31122892 DOI: 10.1016/s2213-2600(19)30087-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/06/2019] [Accepted: 03/06/2019] [Indexed: 10/26/2022]
Abstract
For more than three decades, both medical professionals and the public have worried that many patients receive non-beneficial care in US intensive care units during their final months of life. Some of these patients wish to avoid severe cognitive and physical impairments, and protracted deaths in the hospital setting. Recognising when intensive care will not restore a person's health, and helping patients and families embrace goals related to symptom relief, interpersonal connection, or spiritual fulfilment are central challenges of critical care practice in the USA. We review trials from the past decade of interventions designed to address these challenges, and present reasons why evaluating, comparing, and implementing these interventions have been difficult. Careful scrutiny of the design and interpretation of past trials can show why improving goal concordant care has been so elusive, and suggest new directions for the next generation of research.
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Affiliation(s)
- Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Department of Epidemiology, Bloomberg School of Public Health, and Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Gabriel T Bosslet
- Division of Pulmonary, Allergy, Critical Care, Occupational, and Sleep Medicine, and Charles Warren Fairbanks Center for Medical Ethics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
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Affiliation(s)
- Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Kathryn I Pollak
- Cancer Control and Population Sciences, Duke Cancer Institute, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
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Modes ME, Engelberg RA, Downey L, Nielsen EL, Curtis JR, Kross EK. Did a Goals-of-Care Discussion Happen? Differences in the Occurrence of Goals-of-Care Discussions as Reported by Patients, Clinicians, and in the Electronic Health Record. J Pain Symptom Manage 2019; 57:251-259. [PMID: 30391656 PMCID: PMC6348015 DOI: 10.1016/j.jpainsymman.2018.10.507] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 01/06/2023]
Abstract
CONTEXT Goals-of-care discussions are associated with improved end-of-life care for patients and therefore may be used as a process measure in quality improvement, research, and reimbursement programs. OBJECTIVES To examine three methods to assess occurrence of a goals-of-care discussion-patient report, clinician report, and documentation in the electronic health record (EHR)-at a clinic visit for seriously ill patients and determine whether each method is associated with patient-reported receipt of goal-concordant care. METHODS We conducted a secondary analysis of a multicenter cluster-randomized trial, with 494 patients and 124 clinicians caring for them. Self-reported surveys collected from patients and clinicians two weeks after a clinic visit assessed occurrence of a goals-of-care discussion. Documentation of a goals-of-care discussion was abstracted from the EHR. Patient-reported receipt of goal-concordant care was assessed by survey two weeks after the visit. RESULTS Fifty-two percent of patients reported occurrence of a goals-of-care discussion at the clinic visit; clinicians reported occurrence of a discussion at 66% of visits. EHR documentation occurred in 42% of visits (P < 0.001 for each compared with other two). Patients who reported occurrence of a goals-of-care discussion at the visit were more likely to report receipt of goal-concordant care than patients who reported no discussion (β 0.441, 95% CI 0.190-0.692; P = 0.001). Neither occurrence of a discussion by clinician report nor by EHR documentation was associated with goal-concordant care. CONCLUSION Different approaches to assess goals-of-care discussions give differing results, yet each may have advantages. Patient report is most likely to correlate with patient-reported receipt of goal-concordant care.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA; Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA.
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McPeake J, Hirshberg EL, Christie LM, Drumright K, Haines K, Hough CL, Meyer J, Wade D, Andrews A, Bakhru R, Bates S, Barwise JA, Bastarache J, Beesley SJ, Boehm LM, Brown S, Clay AS, Firshman P, Greenberg S, Harris W, Hill C, Hodgson C, Holdsworth C, Hope AA, Hopkins RO, Howell DCJ, Janssen A, Jackson JC, Johnson A, Kross EK, Lamas D, MacLeod-Smith B, Mandel R, Marshall J, Mikkelsen ME, Nackino M, Quasim T, Sevin CM, Slack A, Spurr R, Still M, Thompson C, Weinhouse G, Wilcox ME, Iwashyna TJ. Models of Peer Support to Remediate Post-Intensive Care Syndrome: A Report Developed by the Society of Critical Care Medicine Thrive International Peer Support Collaborative. Crit Care Med 2019; 47:e21-e27. [PMID: 30422863 PMCID: PMC6719778 DOI: 10.1097/ccm.0000000000003497] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patients and caregivers can experience a range of physical, psychologic, and cognitive problems following critical care discharge. The use of peer support has been proposed as an innovative support mechanism. DESIGN We sought to identify technical, safety, and procedural aspects of existing operational models of peer support, among the Society of Critical Care Medicine Thrive Peer Support Collaborative. We also sought to categorize key distinctions between these models and elucidate barriers and facilitators to implementation. SUBJECTS AND SETTING Seventeen Thrive sites from the United States, United Kingdom, and Australia were represented by a range of healthcare professionals. MEASUREMENTS AND MAIN RESULTS Via an iterative process of in-person and email/conference calls, members of the Collaborative defined the key areas on which peer support models could be defined and compared, collected detailed self-reports from all sites, reviewed the information, and identified clusters of models. Barriers and challenges to implementation of peer support models were also documented. Within the Thrive Collaborative, six general models of peer support were identified: community based, psychologist-led outpatient, models-based within ICU follow-up clinics, online, groups based within ICU, and peer mentor models. The most common barriers to implementation were recruitment to groups, personnel input and training, sustainability and funding, risk management, and measuring success. CONCLUSIONS A number of different models of peer support are currently being developed to help patients and families recover and grow in the postcritical care setting.
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Affiliation(s)
- Joanne McPeake
- NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- University of Glasgow, Glasgow, United Kingdom
| | - Eliotte L Hirshberg
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Leeann M Christie
- Dell Children's Medical Centre, Austin, TX
- VA Tennessee Valley Healthcare System, Nashville, TN
| | | | - Kimberley Haines
- Western Health, Melbourne, VIC, Australia
- Australia and New Zealand Intensive Care Society Research Centre, Monash University, Melbourne, VIC, Australia
| | - Catherine L Hough
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Joel Meyer
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Dorothy Wade
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Rita Bakhru
- Pulmonary, Critical Care, Allergy & Immunologic Diseases, Wake Forest School of Medicine, Winston Salem, NC
| | | | - John A Barwise
- VA Tennessee Valley Healthcare System, Nashville, TN
- Vanderbilt University Medical Center, Nashville, TN
| | - Julie Bastarache
- VA Tennessee Valley Healthcare System, Nashville, TN
- Vanderbilt University Medical Center, Nashville, TN
| | - Sarah J Beesley
- Intermountain Medical Center, Division of Pulmonary and Critical Care, Murray, UT
- Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, UT
| | - Leanne M Boehm
- Vanderbilt University School of Nursing, Nashville, TN
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, TN
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | | | | | - Penelope Firshman
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Steven Greenberg
- Evanston Hospital, NorthShore University HealthSystem, University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Wendy Harris
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Carol Hodgson
- Australia and New Zealand Intensive Care Society Research Centre, Monash University, Melbourne, VIC, Australia
- Alfred Health, Melbourne, VIC, Australia
| | | | | | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT
- Intermountain Medical Center, Division of Pulmonary and Critical Care, Murray, UT
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, UT
| | - David C J Howell
- Critical Care Unit, University College London NHS Foundation Trust, London, United Kingdom
| | - Anna Janssen
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | - Erin K Kross
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Daniela Lamas
- Division of Pulmonary and Critical Care Medicine, Brigham & Women's Hospital, Boston, MA
| | | | - Ruth Mandel
- NorthShore University Health System - Evanston Hospital, Chicago, IL
| | | | - Mark E Mikkelsen
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine of the University of Pennsylvania, Pennsylvania, PA
| | - Megan Nackino
- University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Tara Quasim
- NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- University of Glasgow, Glasgow, United Kingdom
| | - Carla M Sevin
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Andrew Slack
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Rachel Spurr
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Mary Still
- Emory University Hospital (Emory Healthcare), Atlanta, GA
| | - Carol Thompson
- College of Nursing, University of Kentucky, Lexington, KY
| | - Gerald Weinhouse
- Division of Pulmonary and Critical Care Medicine, Brigham & Women's Hospital, Boston, MA
| | - M Elizabeth Wilcox
- Division of Respirology, Department of Medicine, Toronto Western Hospital, Toronto, ON, Canada
| | - Theodore J Iwashyna
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Long AC, Kross EK, Curtis JR. Family-centered outcomes during and after critical illness: current outcomes and opportunities for future investigation. Curr Opin Crit Care 2018; 22:613-620. [PMID: 27685849 DOI: 10.1097/mcc.0000000000000360] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Family-centered outcomes during and after critical illness assess issues that are most important to family members. An understanding of family-centered outcomes is necessary to support the provision of family-centered care and to foster development of interventions to improve care and communication in the ICU. RECENT FINDINGS Current family-centered outcomes in critical care include satisfaction with care, including end-of-life care, symptoms of psychological distress, and health-related quality of life. Novel measures include assessments of decisional conflict, decision regret, therapeutic alliance, and caregiver burden, as well as positive adaptations and resilience. SUMMARY Critical illness places a significant burden on family members. A wide variety of family-centered outcomes are available to guide improvements in care and communication. Future research should focus on developing sensitive and responsive measures that capture key elements of the family member experience during and after critical illness.
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Affiliation(s)
- Ann C Long
- aDivision of Pulmonary and Critical Care Medicine, Harborview Medical Center bCambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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