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Wood GJ, Clepp RK, Lee J, Twaddle ML, Ogunseitan A, Neagle J, Szmuilowicz E. Outcomes of a Multisite Mentored Implementation Approach to Promoting Goals of Care Conversations. J Pain Symptom Manage 2024:S0885-3924(24)00744-9. [PMID: 38697406 DOI: 10.1016/j.jpainsymman.2024.04.024] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/20/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
CONTEXT The Preference-Aligned Communication and Treatment (PACT) Project is a multisite quality improvement effort that has been shown to increase the frequency of goals of care (GOC) conversations in hospitalized patients with serious illness. OBJECTIVES To evaluate the effect of PACT on goal-discordant care and resource utilization. METHODS Hospitals enrolled in a multiyear mentored implementation quality improvement initiative to facilitate GOC conversations for seriously ill hospitalized patients. The primary outcome was the percentage of patients with care discordant with stated preferences, assessed by comparing documented wishes to Medicare claims data for patients who were admitted to intervention units and died over the study period. Secondary outcomes evaluated end-of-life resource utilization by comparing Medicare claims data for intervention patients with propensity score-matched controls. RESULTS In the 9 hospitals included in the study, 1347 intervention group patients were compared to 4019 in the control group. Rates of discordance between wishes and care were generally low in the intervention group. Compared to the control group, patients in the intervention group had lower costs (-976.05 dollars, P = 0.010), were less likely to be admitted to the ICU (OR 0.9, P = 0.005), less likely to be on a ventilator or undergo CPR or cardioversion, more likely to enroll in hospice (OR 1.81, P < 0.001) and had a longer hospice stay (3.35 more days, P = 0.041). CONCLUSION A multisite mentored implementation quality improvement intervention for seriously ill hospitalized patients resulted in care aligned with goals and decreased resource utilization at the end of life.
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Affiliation(s)
- Gordon J Wood
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Medical Education (G.J.W.), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Rebecca K Clepp
- Division of Pulmonary and Critical Care (R.K.C.), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jungwha Lee
- Department of Preventive Medicine (J.L.), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Martha L Twaddle
- Northwestern Lake Forest Hospital (M.L.T), Palliative Medicine and Supportive Care, Lake Forest, Illinois, USA
| | - Adeboye Ogunseitan
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jayson Neagle
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Eytan Szmuilowicz
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Szmuilowicz E, Clepp RK, Neagle J, Ogunseitan A, Twaddle M, Wood GJ. The PACT Project: Feasibility of a Multidisciplinary, Multi-Faceted Intervention to Promote Goals of Care Conversations. Am J Hosp Palliat Care 2024; 41:355-362. [PMID: 37272769 DOI: 10.1177/10499091231181557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Patients living with serious illness generally want their physicians to facilitate Goals of Care conversations (GoCc), yet physicians may lack time and skills to engage in these conversations in the outpatient setting. The problem may be addressed by supporting multiple members of the clinical team to facilitate GoCc with the patient while admitted to the hospital. METHODS A multi-modal training and mentored implementation program was developed. A group of 10 hospitals were recruited to participate. Each hospital selected a primary inpatient unit on which to start the intervention, then expanded to a secondary unit later in the project. The number of trained facilitators (champions) and the number of documented GoCc were tracked over time. RESULTS Nine of 10 hospitals completed the 3-year project. Most of the units were general medical-surgical units. Forty-eight champions were trained at the kick-off conference, attended primarily by nurses, physicians, and social workers. By the end of the project, 153 champions had been trained. A total of 51 087 patients were admitted to PACT units with 85.4% being screened for eligibility. Of the patients who were eligible, over 68% had documented GoCc. CONCLUSION A multifaceted quality improvement intervention focused on serious illness communication skills can support a diverse clinical workforce to facilitate inpatient GoCc over time.
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Affiliation(s)
- Eytan Szmuilowicz
- Department of Medicine, Northwestern Medicine, Chicago, IL, USA
- Section of Palliative Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Rebecca K Clepp
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jayson Neagle
- Department of Medicine, Northwestern Medicine, Chicago, IL, USA
- Section of Palliative Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Adeboye Ogunseitan
- Department of Medicine, Northwestern Medicine, Chicago, IL, USA
- Section of Palliative Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Martha Twaddle
- Department of Medicine, Northwestern Medicine, Chicago, IL, USA
- Palliative Medicine and Supportive Care, Northwestern Lake Forest Hospital, Lake Forest, IL, USA
| | - Gordon J Wood
- Department of Medicine, Northwestern Medicine, Chicago, IL, USA
- Section of Palliative Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
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Chiec L, Szmuilowicz E, Neagle J, Clepp K, Wood GJ. Identifying Patients in Need of Goals of Care Conversations: Reliability, Acceptability, and Prognostic Significance of the Preference-Aligned Communication and Treatment Conversation Trigger Tool for Patients with Cancer. J Palliat Med 2022; 25:1249-1253. [PMID: 35363050 DOI: 10.1089/jpm.2021.0401] [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: 11/13/2022] Open
Abstract
Background: Simple methods to help teams identify patients with goals of care (GOC) conversation needs are lacking. Objectives: To develop a tool to identify hospitalized patients who may benefit from GOC conversations. Methods: The Preference-Aligned Communication and Treatment (PACT) Conversation Trigger Tool was implemented as part of a quality improvement initiative in 10 Illinois hospitals and validated in a cohort of patients admitted to the coordinating site's oncology unit (n = 135). Results: The tool was reliable and acceptable to clinicians using it across sites. Thirty percent (n = 40) of patients screened at the coordinating site's oncology unit triggered positive. These patients were more likely to have a do-not-resuscitate order (43% vs. 11%) and palliative care consult (53% vs. 20%) and had lower mean survival time (125 vs. 248 days) than those who did not trigger (p < 0.001). Conclusions: The tool is reliable, acceptable, and can identify hospitalized oncology patients who may benefit from GOC conversations.
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Affiliation(s)
- Lauren Chiec
- Division of Hematology-Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Eytan Szmuilowicz
- Division of Hospital Medicine (Palliative Care), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jayson Neagle
- Division of Hospital Medicine (Palliative Care), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katie Clepp
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gordon J Wood
- Division of Hospital Medicine (Palliative Care), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Kruser TJ, Kruser JM, Gross JP, Moran M, Kaiser K, Szmuilowicz E, Kircher SM. Medical oncologist perspectives on palliative care reveal physician-centered barriers to early integration. Ann Palliat Med 2020; 9:2800-2808. [PMID: 32787372 PMCID: PMC7572896 DOI: 10.21037/apm-20-270] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 07/01/2020] [Indexed: 01/14/2023]
Abstract
Background: Early palliative care referral for patients with advanced cancer has demonstrable benefits but is underutilized. We sought to characterize medical oncologists’ perceptions about palliative care referral in their clinical practices. Methods: We conducted 4 focus groups with a national sample of medical oncologists to elicit perspectives about the optimal timing of and barriers to palliative care referral for patients with cancer. We used qualitative content analysis to uncover themes related to early integration of palliative care into standard oncologic practice. Results: Study participants readily acknowledged the evidence supporting early palliative care referral. However, medical oncologists identified patient-centered and physician-centered barriers to widespread adoption of early palliative care. Patient-centered barriers included patients’ and families’ perceptions or misperceptions of the role of palliative care. Additionally, physicians themselves described acting as a barrier to palliative care referral because they were concerned that palliative care physicians may interfere with the plan of care, or offer options that were not endorsed by the medical oncologist. Medical oncologists depicted themselves having authority over the timing of palliative care referral, and as granting limited autonomy to other clinical team members in counseling patients about advanced care planning. Conclusions: Medical oncologists are hesitant to adopt the practice of early palliative care referral because they are concerned that other physicians may disrupt a patient’s treatment plan. Physician-centered barriers may delay integration of palliative care, and future efforts to promote a collaborative approach to advanced care planning may improve patient-centered outcomes through access to early palliative care.
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Affiliation(s)
- Tim J Kruser
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Jacqueline M Kruser
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey P Gross
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Margaret Moran
- Medical Social Sciences, and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen Kaiser
- Medical Social Sciences, and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Eytan Szmuilowicz
- Division of Hospital Medicine (Palliative Care), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sheetal M Kircher
- Division of Hematology-Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Gradwohl K, Wood GJ, Clepp RK, Rivnay L, Szmuilowicz E. Preventing Readmissions Through Effective Partnerships—Communication and Palliative Care (PREP-CPC): A Multisite Intervention for Encouraging Goals of Care Conversations for Hospitalized Patients Facing Serious Illness. Am J Hosp Palliat Care 2020; 37:582-588. [DOI: 10.1177/1049909119891996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Despite evidence showing that goals of care (GOC) conversations increase the likelihood that patients facing a serious illness receive care that is concordant with their wishes, only a minority of at-risk patients receive the opportunity to engage in such conversations. Objective: The Preventing Readmissions through Effective Partnerships—Communication and Palliative Care (PREP-CPC) intervention was designed to increase the frequency of GOC conversations for hospitalized patients facing serious illness. Methods: The PREP-CPC employed a sequential, multicohort design using a yearlong mentored implementation approach to support nonpalliative care health-care professionals at participating hospitals to implement quality improvement projects focused on GOC conversations. Results: Over the 3-year study period, 134 clinicians from 29 hospital teams were trained to facilitate GOC conversations. After the kickoff conference, participants reported improvements in their confidence in facilitating GOC conversations. The hospital teams then instituted site-specific pilot interventions to promote GOC conversations, identifying essential elements required for ongoing improvement. Since projects varied by hospital, results did as well, but reported positive outcomes included increased GOC conversations, increased Practitioner Orders for Life-Sustaining Treatment form completion rates, new screening and documentation methods, and increased support from leadership. Conclusions: The PREP-CPC pilot successfully engaged a diverse set of hospitals to participate in quality improvement collaborative promoting primary palliative care and more frequent GOC conversations. This initiative revealed several lessons that should guide future interventions.
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Affiliation(s)
- Kelsey Gradwohl
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gordon J. Wood
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Section of Palliative Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Rebecca K. Clepp
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Liza Rivnay
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Eytan Szmuilowicz
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Section of Palliative Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
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Secunda K, Wirpsa MJ, Neely KJ, Szmuilowicz E, Wood GJ, Panozzo E, McGrath J, Levenson A, Peterson J, Gordon EJ, Kruser JM. Use and Meaning of "Goals of Care" in the Healthcare Literature: a Systematic Review and Qualitative Discourse Analysis. J Gen Intern Med 2020; 35:1559-1566. [PMID: 31637653 PMCID: PMC7210326 DOI: 10.1007/s11606-019-05446-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The specific phrase "goals of care" (GOC) is pervasive in the discourse about serious illness care. Yet, the meaning of this phrase is ambiguous. We sought to characterize the use and meaning of the phrase GOC within the healthcare literature to improve communication among patients, families, clinicians, and researchers. METHODS A systematic review of the English language healthcare literature indexed in MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus was performed in October of 2018. We searched for all publications with the exact phrase "goals of care" within the title or abstract; no limitations on publication date or format were applied; conference abstracts were excluded. We used qualitative, discourse analysis to identify key themes and generate an operational definition and conceptual model of GOC. RESULTS A total of 214 texts were included in the final analysis. Use of GOC increased over time with 87% of included texts published in the last decade (2009-2018). An operational definition emerged from consensus within the published literature: the overarching aims of medical care for a patient that are informed by patients' underlying values and priorities, established within the existing clinical context, and used to guide decisions about the use of or limitation(s) on specific medical interventions. Application of the GOC concept was described as important to the care of patients with serious illness, in order to (1) promote patient autonomy and patient-centered care, (2) avoid unwanted care and identify valued care, and (3) provide psychological and emotional support for patients and their families. DISCUSSION The use of the phrase "goals of care" within the healthcare literature is increasingly common. We identified a consensus, operational definition that can facilitate communication about serious illness among patients, families, and clinicians and provide a framework for researchers developing interventions to improve goal-concordant care.
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Affiliation(s)
- Katharine Secunda
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | - Kathy J Neely
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Eytan Szmuilowicz
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Gordon J Wood
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | - Joan McGrath
- Northwestern Memorial Hospital, Chicago, IL, USA
| | - Anne Levenson
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Jonna Peterson
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Galter Health Sciences Library and Learning Center, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Elisa J Gordon
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Surgery, Division of Transplantation, Northwestern University Feinberg School of Medicine, Chicago, USA.,Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, USA.,Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Jacqueline M Kruser
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA. .,Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, USA. .,Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, USA.
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Chuzi S, Grady KL, Ogunseitan A, Szmuilowicz E, Wilcox JE. Authors' Response. J Pain Symptom Manage 2019; 57:e11-e12. [PMID: 30552959 DOI: 10.1016/j.jpainsymman.2018.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 12/04/2018] [Accepted: 12/04/2018] [Indexed: 11/23/2022]
Affiliation(s)
- Sarah Chuzi
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Kathleen L Grady
- Department of Medicine, Division of Cardiology, Department of Surgery, Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Adeboye Ogunseitan
- Department of Medicine, Division of Hospital Medicine (Palliative Care), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Eytan Szmuilowicz
- Department of Medicine, Division of Hospital Medicine (Palliative Care), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jane E Wilcox
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Chuzi S, Hale S, Arnold J, Zhou A, Harap R, Grady KL, Rich JD, Yancy CW, Ogunseitan A, Szmuilowicz E, Wilcox JE. Pre-Ventricular Assist Device Palliative Care Consultation: A Qualitative Analysis. J Pain Symptom Manage 2019; 57:100-107. [PMID: 30315917 DOI: 10.1016/j.jpainsymman.2018.09.023] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/27/2018] [Accepted: 09/30/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION In 2013, the Centers for Medicare and Medicaid Services issued a mandate requiring that all patients undergoing destination therapy ventricular assist device (DT VAD) implantation have access to a palliative care team before surgery. Subsequently, many VAD programs implemented a mandatory preimplantation palliative care consultation for patients considering DT VAD. However, little is known about the quality of these consults. METHODS All patients undergoing DT VAD implantation at Northwestern Memorial Hospital from October 30, 2013 (the Centers for Medicare and Medicaid Services decision date), through March 1, 2018, were included. Palliative care consultation notes were qualitatively analyzed for elements of "palliative care assessment" and preparedness planning. RESULTS Sixty-eight preimplantation palliative care consultations were analyzed. Fifty-six percent of the consults occurred in the intensive care unit, and the median time from consult to VAD implant was six days. General palliative care elements were infrequently discussed. Furthermore, the elements of preparedness planning-device failure, post-VAD health-related quality of life, device complications, and progressive comorbidities-were discussed in only 10%, 54%, 49%, and 12% of consultations, respectively. CONCLUSIONS One-time preimplantation palliative care consultations at our institution do not lead to completion of preparedness planning or even general palliative care assessment. Further work is needed to determine the most effective way to integrate palliative care into preimplantation care.
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Affiliation(s)
- Sarah Chuzi
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Sarah Hale
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jason Arnold
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amy Zhou
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Rebecca Harap
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Kathleen L Grady
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Surgery, Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jonathan D Rich
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Clyde W Yancy
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Adeboye Ogunseitan
- Department of Medicine, Division of Hospital Medicine (Palliative Care), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eytan Szmuilowicz
- Department of Medicine, Division of Hospital Medicine (Palliative Care), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jane E Wilcox
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Kruser TJ, Kruser JM, Gross J, Moran M, Kaiser K, Szmuilowicz E, Kircher SM. Barriers to early integration of palliative care: A qualitative analysis of medical oncologist attitudes and practice patterns. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e22191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Tim J Kruser
- Northwestern University Lurie Cancer Center, Chicago, IL
| | - Jacqueline M Kruser
- Northwestern University Feinberg School of Medicine, Department of Medicine, Chicago, IL
| | | | - Margaret Moran
- Northwestern University Feinberg School of Medicine, Department of Medical Social Sciences, Chicago, IL
| | - Karen Kaiser
- Feinberg School of Medicine, Northwestern University, Chicago, IL
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Kruser T, Kruser J, Gross J, Moran M, Kaiser K, Szmuilowicz E, Kircher S. EP-1651: Radiation oncologists’ role in end-of-life care: a view from medical oncologists. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)31960-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Dans M, Smith T, Back A, Baker JN, Bauman JR, Beck AC, Block S, Campbell T, Case AA, Dalal S, Edwards H, Fitch TR, Kapo J, Kutner JS, Kvale E, Miller C, Misra S, Mitchell W, Portman DG, Spiegel D, Sutton L, Szmuilowicz E, Temel J, Tickoo R, Urba SG, Weinstein E, Zachariah F, Bergman MA, Scavone JL. NCCN Guidelines Insights: Palliative Care, Version 2.2017. J Natl Compr Canc Netw 2017; 15:989-997. [DOI: 10.6004/jnccn.2017.0132] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Sharma RK, Szmuilowicz E, Ogunseitan A, Jones SF, Montalvo JA, O'Leary KJ, Wayne DB. Evaluation of a Mastery Learning Intervention on Hospitalists' Code Status Discussion Skills. J Pain Symptom Manage 2017; 53:1066-1070. [PMID: 28063865 DOI: 10.1016/j.jpainsymman.2016.12.341] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 09/08/2016] [Revised: 11/29/2016] [Accepted: 12/27/2016] [Indexed: 10/20/2022]
Abstract
CONTEXT Although code status discussions (CSD) occur frequently in the hospital setting, discussions often lack content necessary for informed decision making. Simulation-based mastery learning (SBML) has been used to improve clinical skills among resident physicians and may provide a novel way to improve hospitalists' CSD skills. OBJECTIVES The objective of this pilot randomized controlled trial was to develop and evaluate a CSD SBML intervention for hospitalists. METHODS Twenty hospitalists were randomized to control vs. a CSD SBML intervention. Hospitalists conducted a baseline standardized patient encounter (pretest) that was scored using a 19-item CSD checklist and controls completed a repeat standardized patient encounter six months later (post-test). Intervention group hospitalists received at least one two-hour training session featuring deliberate practice and feedback and were expected to meet a minimum passing score (MPS) on the post-test of 84% set by an expert panel. RESULTS Only two of the 20 hospitalists met the MPS at pretest. Seventy percentage of intervention hospitalists achieved the MPS after a single training session. Post-test median checklist scores were higher for intervention hospitalists compared with controls (16.5 vs. 12.0, P = 0.0001). Intervention hospitalists were significantly more likely to ask about previous experiences with end-of-life decision making (70% vs. 20%, P = 0.03), explore values/goals (100% vs. 50%, P = 0.01), ask permission to make a recommendation regarding code status (60% vs. 0%, P = 0.003), and align recommendations with patient values/goals (90% vs. 40%, P = 0.02) than controls. CONCLUSION Few hospitalists demonstrated mastery of CSD skills at baseline; SBML was an effective way to improve these skills.
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Affiliation(s)
- Rashmi K Sharma
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA.
| | - Eytan Szmuilowicz
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Adeboye Ogunseitan
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sasha F Jones
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jessica A Montalvo
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kevin J O'Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Diane B Wayne
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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O’Mahony S, Levine S, Baron A, Johnson TJ, Ansari A, Leyva I, Marschke M, Szmuilowicz E, Deamant C. Palliative Workforce Development and a Regional Training Program. Am J Hosp Palliat Care 2016; 35:138-143. [DOI: 10.1177/1049909116685046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Aims: Our primary aims were to assess growth in the local hospital based workforce, changes in the composition of the workforce and use of an interdisciplinary team, and sources of support for palliative medicine teams in hospitals participating in a regional palliative training program in Chicago. Methods: PC program directors and administrators at 16 sites were sent an electronic survey on institutional and PC program characteristics such as: hospital type, number of beds, PC staffing composition, PC programs offered, start-up years, PC service utilization and sources of financial support for fiscal years 2012 and 2014. Results: The median number of consultations reported for existing programs in 2012 was 345 (IQR 109 – 2168) compared with 840 (IQR 320 – 4268) in 2014. At the same time there were small increases in the overall team size from a median of 3.2 full time equivalent positions (FTE) in 2012 to 3.3 FTE in 2013, with a median increase of 0.4 (IQR 0-1.0). Discharge to hospice was more common than deaths in the acute care setting in hospitals with palliative medicine teams that included both social workers and advanced practice nurses ( p < .0001). Conclusions: Given the shortage of palliative medicine specialist providers more emphasis should be placed on training other clinicians to provide primary level palliative care while addressing the need to hire sufficient workforce to care for seriously ill patients.
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Affiliation(s)
| | | | | | | | - Aziz Ansari
- Loyola University Hospital, Maywood, IL, USA
| | - Ileana Leyva
- Cadence Health Central Dupage Hospital, Winfield, IL, USA
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Levy M, Smith T, Alvarez-Perez A, Back A, Baker JN, Beck AC, Block S, Dalal S, Dans M, Fitch TR, Kapo J, Kutner JS, Kvale E, Misra S, Mitchell W, Portman DG, Sauer TM, Spiegel D, Sutton L, Szmuilowicz E, Taylor RM, Temel J, Tickoo R, Urba SG, Weinstein E, Zachariah F, Bergman MA, Scavone JL. Palliative Care Version 1.2016. J Natl Compr Canc Netw 2016; 14:82-113. [PMID: 26733557 DOI: 10.6004/jnccn.2016.0009] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Palliative Care provide interdisciplinary recommendations on palliative care for patients with cancer. The NCCN Guidelines are intended to provide guidance to the primary oncology team on the integration of palliative care into oncology. The NCCN Palliative Care Panel's recommendations seek to ensure that each patient experiences the best quality of life possible throughout the illness trajectory. Accordingly, the NCCN Guidelines outline best practices for screening, assessment, palliative care interventions, reassessment, and after-death care.
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15
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Minami CA, Yang AD, Szmuilowicz E. Negotiating the Tensions in Patient-Centered Care. JAMA 2015; 314:1167-8. [PMID: 26372586 DOI: 10.1001/jama.2015.10112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/14/2022]
Affiliation(s)
- Christina A Minami
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois2Northwestern Memorial Hospital, Chicago, Illinois3Center for Healthcare Studies, Feinberg School of Medicine
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois2Northwestern Memorial Hospital, Chicago, Illinois4Department of Surgery, Feinberg School of Medicine, Northwes
| | - Eytan Szmuilowicz
- Division of Hospital Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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16
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Sharma RK, Cameron KA, Chmiel JS, Von Roenn JH, Szmuilowicz E, Prigerson HG, Penedo FJ. Racial/Ethnic Differences in Inpatient Palliative Care Consultation for Patients With Advanced Cancer. J Clin Oncol 2015; 33:3802-8. [PMID: 26324373 DOI: 10.1200/jco.2015.61.6458] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [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
PURPOSE Inpatient palliative care consultation (IPCC) may help address barriers that limit the use of hospice and the receipt of symptom-focused care for racial/ethnic minorities, yet little is known about disparities in the rates of IPCC. We evaluated the association between race/ethnicity and rates of IPCC for patients with advanced cancer. PATIENTS AND METHODS Patients with metastatic cancer who were hospitalized between January 1, 2009, and December 31, 2010, at an urban academic medical center participated in the study. Patient-level multivariable logistic regression was used to evaluate the association between race/ethnicity and IPCC. RESULTS A total of 6,288 patients (69% non-Hispanic white, 19% African American, and 6% Hispanic) were eligible. Of these patients, 16% of whites, 22% of African Americans, and 20% of Hispanics had an IPCC (overall P < .001). Compared with whites, African Americans had a greater likelihood of receiving an IPCC (odds ratio, 1.21; 95% CI, 1.01 to 1.44), even after adjusting for insurance, hospitalizations, marital status, and illness severity. Among patients who received an IPCC, African Americans had a higher median number of days from IPCC to death compared with whites (25 v 17 days; P = .006), and were more likely than Hispanics (59% v 41%; P = .006), but not whites, to be referred to hospice. CONCLUSION Inpatient settings may neutralize some racial/ethnic differences in access to hospice and palliative care services; however, irrespective of race/ethnicity, rates of IPCC remain low and occur close to death. Additional research is needed to identify interventions to improve access to palliative care in the hospital for all patients with advanced cancer.
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Affiliation(s)
- Rashmi K Sharma
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY.
| | - Kenzie A Cameron
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Joan S Chmiel
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Jamie H Von Roenn
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Eytan Szmuilowicz
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Holly G Prigerson
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Frank J Penedo
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
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Abstract
COPD is a leading cause of morbidity and mortality worldwide. Patients suffer from refractory breathlessness, unrecognized anxiety and depression, and decreased quality of life. Palliative care improves symptom management, patient reported health-related quality of life, cost savings, and mortality though the majority of patients with COPD die without access to palliative care. There are many barriers to providing palliative care to patients with COPD including the difficulty in prognosticating a patient’s course causing referrals to occur late in a patient’s disease. Additionally, physicians avoid conversations about advance care planning due to unique communication barriers present with patients with COPD. Lastly, many health systems are not set up to provide trained palliative care physicians to patients with chronic disease including COPD. This review analyzes the above challenges, the available data regarding palliative care applied to the COPD population, and proposes an alternative approach to address the unmet needs of patients with COPD with proactive primary palliative care.
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Affiliation(s)
- Julia H Vermylen
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Eytan Szmuilowicz
- Section of Palliative Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ravi Kalhan
- Asthma and COPD Program, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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18
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Schroedl C, Yount S, Szmuilowicz E, Rosenberg SR, Kalhan R. Outpatient palliative care for chronic obstructive pulmonary disease: a case series. J Palliat Med 2014; 17:1256-61. [PMID: 24933590 DOI: 10.1089/jpm.2013.0669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) have well-documented symptoms that affect quality of life. Professional societies recommend palliative care for such patients, but the optimal way of delivering this care is unknown. OBJECTIVE To describe an outpatient palliative medicine program for patients with COPD. DESIGN Retrospective case series. SETTING/SUBJECTS Thirty-six patients with COPD followed in a United States academic outpatient palliative medicine clinic. MEASUREMENTS Descriptive analysis of sociodemographic data, disease severity and comorbidities, treatments, hospitalizations, mortality, topic discussion, and symptom assessment. RESULTS Thirty-six patients (representing 5% of the total number of patients with COPD seen in a specialty pulmonary clinic) were seen over 11 months and followed for 2 years. Seventy-seven percent of patients were Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 3-4 and 72% were on oxygen at home. No patients had documented advanced directives at the initial visit but documentation increased to 61% for those who had follow-up appointments. The most commonly documented topics included symptoms (100%), social issues (94%), psychological issues (78%), and advance care planning (75%). Of symptoms assessed, pain was the least prevalent (51.6%), and breathlessness and fatigue were the most prevalent (100%). Symptoms were often undertreated prior to the palliative care appointment. During the 3-year study period, there were 120 hospital admissions (median, 2) and 12 deaths (33%). CONCLUSIONS The patients with COPD seen in the outpatient palliative medicine clinic had many comorbid conditions, severe illness, and significant symptom burden. Many physical and psychological symptoms were untreated prior to the palliative medicine appointment. Whether addressing these symptoms through a palliative medicine intervention affects outcomes in COPD is unknown but represents an important topic for future research.
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Affiliation(s)
- Clara Schroedl
- 1 Asthma and COPD Program, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine , Chicago, Illinois
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19
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Ramchandran KJ, Shega JW, Von Roenn J, Schumacher M, Szmuilowicz E, Rademaker A, Weitner BB, Loftus PD, Chu IM, Weitzman S. A predictive model to identify hospitalized cancer patients at risk for 30-day mortality based on admission criteria via the electronic medical record. Cancer 2013; 119:2074-80. [PMID: 23504709 DOI: 10.1002/cncr.27974] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 10/25/2012] [Accepted: 11/16/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND This study sought to develop a predictive model for 30-day mortality in hospitalized cancer patients, by using admission information available through the electronic medical record. METHODS Observational cohort study of 3062 patients admitted to the oncology service from August 1, 2008, to July 31, 2009. Matched numbers of patients were in the derivation and validation cohorts (1531 patients). Data were obtained on day 1 of admission and included demographic information, vital signs, and laboratory data. Survival data were obtained from the Social Security Death Index. RESULTS The 30-day mortality rate of the derivation and validation samples were 9.5% and 9.7% respectively. Significant predictive variables in the multivariate analysis included age (P < .0001), assistance with activities of daily living (ADLs; P = .022), admission type (elective/emergency) (P = .059), oxygen use (P < .0001), and vital signs abnormalities including pulse oximetry (P = .0004), temperature (P = .017), and heart rate (P = .0002). A logistic regression model was developed to predict death within 30 days: Score = 18.2897 + 0.6013*(admit type) + 0.4518*(ADL) + 0.0325*(admit age) - 0.1458*(temperature) + 0.019*(heart rate) - 0.0983*(pulse oximetry) - 0.0123 (systolic blood pressure) + 0.8615*(O2 use). The largest sum of sensitivity (63%) and specificity (78%) was at -2.09 (area under the curve = -0.789). A total of 25.32% (100 of 395) of patients with a score above -2.09 died, whereas 4.31% (49 of 1136) of patients below -2.09 died. Sensitivity and positive predictive value in the derivation and validation samples compared favorably. CONCLUSIONS Clinical factors available via the electronic medical record within 24 hours of hospital admission can be used to identify cancer patients at risk for 30-day mortality. These patients would benefit from discussion of preferences for care at the end of life.
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Affiliation(s)
- Kavitha J Ramchandran
- Department of Medicine, Division of General Medical Disciplines and Division of Oncology, Stanford University, Stanford, CA 94305, USA.
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20
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Wayne DB, Moazed F, Cohen ER, Sharma RK, McGaghie WC, Szmuilowicz E. Code status discussion skill retention in internal medicine residents: one-year follow-up. J Palliat Med 2012; 15:1325-8. [PMID: 23045991 PMCID: PMC3509358 DOI: 10.1089/jpm.2012.0232] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [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] [Accepted: 08/03/2012] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Communicating with patients about goals of care is an important skill for internal medicine residents. However, many trainees are not competent to perform a code status discussion (CSD). A multimodality intervention improved skills in a group of first-year residents in 2011. How long these acquired CSD skills are retained is unknown. OBJECTIVE To study CSD skill retention one year after a multimodality intervention. DESIGN This was a longitudinal cohort study. SETTING/SUBJECTS Thirty-eight second-year internal medicine residents in a university-affiliated internal medicine residency program participated in the study. Nineteen completed the intervention and 19 served as controls. MEASUREMENTS Mean CSD clinical skills examination (CSE) scores using an 18-item checklist were compared after the intervention (2011) and one year later (2012). RESULTS Intervention group residents performed significantly better than residents in the control group (71.9% (standard deviation [SD]=16.0%) versus 54.7% (SD=17.1%; p<0.001) at one-year follow-up. Intervention group residents retained their CSD skills at one year as performance was 75.1% in 2011 and 71.9% in 2012 (p=0.46). Control group residents did not develop additional CSD skills as 2011 checklist performance was 53.2% and 2012 performance was 54.7% (p=0.78). CONCLUSIONS CSD skills taught in a rigorous curriculum are retained at one-year follow-up. Residents in the control group did not acquire new CSD skills despite an additional year of training and clinical experience. Further study is needed to link improved CSD skills to better patient care quality.
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Affiliation(s)
- Diane B Wayne
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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21
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Szmuilowicz E, Neely KJ, Sharma RK, Cohen ER, McGaghie WC, Wayne DB. Improving residents' code status discussion skills: a randomized trial. J Palliat Med 2012; 15:768-74. [PMID: 22690890 DOI: 10.1089/jpm.2011.0446] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Inpatient Code Status Discussions (CSDs) are commonly facilitated by resident physicians, despite inadequate training. We studied the efficacy of a CSD communication skills training intervention for internal medicine residents. METHODS This was a prospective, randomized controlled trial of a multimodality communication skills educational intervention for postgraduate year (PGY) 1 residents. Intervention group residents completed a 2 hour teaching session with deliberate practice of communication skills, online modules, self-reflection, and a booster training session in addition to assigned clinical rotations. Control group residents completed clinical rotations alone. CSD skills of residents in both groups were assessed 2 months after the intervention using an 18 item behavioral checklist during a standardized patient encounter. Average scores for intervention and control group residents were calculated and between-group differences on the CSD skills assessment were evaluated using two-tailed independent sample t tests. RESULTS Intervention group residents displayed higher overall scores on the simulated CSD (75.1% versus 53.2%, p<0.0001) than control group residents. The intervention group also displayed a greater number of key CSD communication behaviors and facilitated significantly longer conversations. The training, evaluation, and feedback sessions were rated highly. CONCLUSION A focused, multimodality curriculum can improve resident performance of simulated CSDs. Skill improvement lasted for at least 2 months after the intervention. Further studies are needed to assess skill retention and to set minimum performance standards.
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Affiliation(s)
- Eytan Szmuilowicz
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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22
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Ramchandran K, Shega J, Schumacher M, Rademaker A, Weitner BB, Szmuilowicz E, Weitzman SA. A predictive model to identify cancer patients at risk for in-hospital mortality based on admission criteria. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.6045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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23
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Neely D, Szmuilowicz E, Neely K. Postcards from our students--reflections on professionalism and ethics. J Hosp Med 2010; 5:496-9. [PMID: 20945476 DOI: 10.1002/jhm.858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- David Neely
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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24
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25
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26
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Affiliation(s)
- David Neely
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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27
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Szmuilowicz E, el-Jawahri A, Chiappetta L, Kamdar M, Block S. Improving Residents' End-of-Life Communication Skills with a Short Retreat: A Randomized Controlled Trial. J Palliat Med 2010; 13:439-52. [DOI: 10.1089/jpm.2009.0262] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Eytan Szmuilowicz
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Areej el-Jawahri
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laurel Chiappetta
- Data Development, Integration, Verification, and Analysis (DataD.I.V.A.), Pittsburgh, Pennsylvania
| | - Mihir Kamdar
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Susan Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Abstract
Symptom management requires an understanding of the likely cause of the symptom in the individual patient, comprehensive assessment, and evidence-based interventions. This article explores the management strategies for common symptoms encountered in palliative care practice. Stomatitis, xerostomia, dysphagia, nausea and vomiting, anorexia, constipation, dyspnea, and fatigue are among the symptoms reviewed.
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Affiliation(s)
- Constance Dahlin
- Palliative Care Service, Founders 604, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114-2696, USA.
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29
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Abstract
Limited data are available on the accuracy of various calibration methods used to estimate the size of cardiovascular structures during interventional pediatric cardiac catheterizations. The aim of this study was to evaluate, in an experimental model, several of these commonly used calibration methods. Thoracic box models were constructed in 4 sizes to simulate average chest sizes of infants, children, adolescents, and adults. Four anatomic positions were studied: aortic valve in posteroanterior projection, pulmonary valve in lateral projection, and isthmus in posteroanterior and lateral projections. The following calibration methods were examined: (1) a 5Fr pigtail catheter or a 1-cm radio-opaque marker catheter, placed at the level of the anatomic structure, (2) a body surface marker in multiple positions, and (3) a 1 x 1-cm radio-opaque rectilinear grid placed either at the center of the thorax or in an anatomic position. Three independent observers made size estimations. The most accurate method for size estimation, in all anatomic positions and for all box sizes, was the 1-cm radio-opaque marker catheter (mean error </=4%). The surface marker was moderately accurate in the smallest box (mean error 3% to 6%), but had a mean error as high as 33% in the adult-sized box. The 5Fr pigtail angiographic catheter overestimated the size of the structure by 3% to 13% (mean 7%). Intra- and interobserver differences in size estimations were not statistically significant. Among the size calibration methods used during pediatric cardiac catheterizations, catheters with radio-opaque markers within the structure of interest were the most accurate. The use of surface markers in larger patients may introduce significant error, risking a potentially inadequate or adverse outcome from the intervention.
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Affiliation(s)
- E Szmuilowicz
- Division of Pediatric Cardiology, Department of Pediatrics, University of California-San Diego, San Diego, California 92103-8445, USA
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