1
|
Horecki P, Deming J, Lagunas M, Brustad R, Okuno S, Manz J, Christensen S, Suhail Z. Improve Advance Care Planning: A Brief Report Discussing Goals of Care Interventions to Improve Communication Among Health Care Teams and Patients Maximizing the Use of the Electronic Health Record Tools. J Palliat Med 2024. [PMID: 38364111 DOI: 10.1089/jpm.2023.0580] [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: 02/18/2024] Open
Abstract
Introduction: A key element of advance care planning (ACP) is the goals of care (GOC) conversation between the provider and the patient. The value of meaningful GOC conversations for the patient, provider, and health care institution is well documented. However, if the GOC documentation is buried in the medical record, not well defined, or poorly documented, that value is squandered. The Improvement Process: Interventions were implemented with oncology physicians and nurse practitioners (NPs). These included education, system reform including improving the ease and consistency of documentation of ACP, and regular feedback. Results: Participants reported increased confidence in communication skills about GOC conversations postworkshops. Data results for the tracked metrics, health care power of attorney, code status, and GOC, all showed improvement. Conclusion: Physicians and NPs recognized the importance of GOC conversations as part of ACP. Considerable progress was made by focusing on GOC conversations, maximizing information technology, participating in coaching, and ongoing data monitoring.
Collapse
Affiliation(s)
- Patty Horecki
- Department of Experience Training, Education, and Coaching, Mayo Clinic Health System, NWWI, Eau Claire, Wisconsin, USA
| | - James Deming
- Department of Clinical Medicine, Palliative Care, Mayo Clinic Health System, NWWI, Eau Claire, Wisconsin, USA
| | - Meg Lagunas
- Department of Nursing, University of Wisconsin, Eau Claire, Eau Claire, Wisconsin, USA
| | - Rebecca Brustad
- Department of Quality, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott Okuno
- Department of Oncology, Mayo Clinic Health System, NWWI, Eau Claire, Wisconsin, USA
| | - James Manz
- Department of Spine, Neurological Surgery, Mayo Clinic Health System, NWWI, Eau Claire, Wisconsin, USA
| | - Sue Christensen
- Administration, Mayo Clinic Health System, NWWI, Eau Claire, Wisconsin, USA
| | - Zoha Suhail
- Department of Nursing, University of Wisconsin, Eau Claire, Eau Claire, Wisconsin, USA
| |
Collapse
|
2
|
Neugarten C, Baldeo R, Engel K, Wang D, Lamba S. Emergency Palliative Care: Hospice Patients in the Emergency Department. J Palliat Med 2023. [PMID: 38011634 DOI: 10.1089/jpm.2023.0280] [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: 11/29/2023] Open
Abstract
In this segment of the emergency department (ED) palliative care (PC) case series, we discuss a patient on hospice who presented to the ED for the management of acute symptoms and potential procedural intervention. Hospice patients frequently visit the ED and can challenge typical ED paradigms of care that often include resuscitative efforts and broad workups. Our patient had a history of advanced liver cancer, and his ED presentation was prompted by worsening abdominal pain from ascites requiring serial paracentesis. PC consultation was requested to help address the patient's symptoms and create a plan of care. The PC clinician played an important role in supporting aggressive symptom management, re-evaluating goals of care, addressing concerns about hospice, and facilitating changes in code status requested for a procedure.
Collapse
Affiliation(s)
- Carter Neugarten
- Section of Palliative Care, Departments of Internal Medicine and Emergency Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Ryan Baldeo
- Department of Internal Medicine, Division of Palliative Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Kirsten Engel
- Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David Wang
- Department of Palliative Medicine, Scripps Health, San Diego, California, USA
| | - Sangeeta Lamba
- Department of Emergency Medicine, New Jersey Medical School, Newark, New Jersey, USA
| |
Collapse
|
3
|
Molitch-Hou E, Zhang H, Gala P, Tate A. Impact of the COVID-19 Public Health Crisis and a Structured COVID Unit on Physician Behaviors in Code Status Ordering. Am J Hosp Palliat Care 2023:10499091231204943. [PMID: 37786255 PMCID: PMC10985045 DOI: 10.1177/10499091231204943] [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: 10/04/2023] Open
Abstract
Purpose: Code status orders are standard practice impacting end-of-life care for individuals. This study reviews the impact of a COVID unit on physician behaviors towards goal-concordant end-of-life care at an urban academic tertiary-care hospital. Methods: We conducted a retrospective cohort study of code status ordering on adult inpatients comparing the pre-pandemic period to patients who tested positive, negative and were not tested during the pandemic from January 1, 2019, to December 31, 2020. Results: We analyzed 59,471 unique patient encounters (n = 35,317 pre-pandemic and n = 24,154 during). 1,631 cases of COVID-19 were seen. The rate of code status orders among all inpatients increased from 22% pre-pandemic to 29% during the pandemic (P < .001). Code status orders increased for both patients who were COVID-negative (32% P < .001) and COVID-positive (65% P < .001). Being in a cohorted COVID unit increased code status ordering by an odds of 4.79 (P < .001). Compared to the pre-pandemic cohort, the COVID-positive cohort is less female (50% to 56% P < .001), more Black (66% to 61% P < .001), more Hispanic (6.5% to 5%) and less white (26% to 30% P < .001). Compared to Black patients, white patients had lower odds (.86) of code status ordering (P < .001). Other race/ethnicity categories were not significant. Conclusions: Code status ordering remains low. Compared to pre-pandemic rates, the frequency of orders placed significantly increased for all patients during the pandemic. The largest increase occurred in patients with COVID-19. This increase likely occurred due to protocols in the COVID unit and disease uncertainty.
Collapse
Affiliation(s)
- Ethan Molitch-Hou
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| | - Hui Zhang
- Center for Health and The Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Pooja Gala
- NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Alexandra Tate
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| |
Collapse
|
4
|
Kieffer SF, Tanaka T, Ogilvie AC, Gilbertson-White S, Hagiwara Y. Palliative Care and End-of-Life Outcomes in Patients Considered for Liver Transplantation: A Single-Center Experience in the US Midwest. Am J Hosp Palliat Care 2023; 40:1049-1057. [PMID: 36448659 DOI: 10.1177/10499091221142841] [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: 09/19/2023] Open
Abstract
Introduction: Previous research has shown limited palliative care (PC) utilization among patients evaluated for liver transplantation (LT) despite the cohort's significant symptom burden, high frequency of hospitalization and risk of rapid decompensation. Our aim was to evaluate patient characteristics and end-of-life (EOL) outcomes (i.e. ICU utilization, code status, advance care planning) associated with the use of PC services in patients who were evaluated for LT. Methods: We performed a single-center cross-sectional study comprised of 223 deceased patients evaluated for LT between 1/1/2017 and 12/31/2021. We evaluated demographic characteristics and EOL outcomes for differences between patients who received PC consultation and those who did not. EOL outcomes associated with PC use were assessed using logistic and linear regression analysis adjusted for patient demographics. Results: Patients who received PC consultation were younger (mean 57 vs. 61; P = 0.048), had higher Model for end-stage Liver Disease (MELD) scores (27.5 vs. 22; P = 0.001), higher rates of hepatic encephalopathy (96% vs. 84%, P = 0.005), and were more frequently declined for LT (77% vs. 57%; P = 0.008). Patients who received PC services were less likely to die in the ICU (OR = 0.07 [0.02-0.18]) and were more likely to have documented advance care planning (OR = 3.16 [1.47-6.97]), family meetings (OR = 6.58 [2.72-17.08]), and goals-of-care discussions (OR = 14.83 [4.39-69.29]). Conclusion: For patients being evaluated for LT, PC utilization differed based on demographics, disease complications and severity, and transplant status. Those who received PC services had higher quality EOL care planning and fewer ICU admissions.
Collapse
Affiliation(s)
- Sawyer F Kieffer
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Tomohiro Tanaka
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, IA, USA
| | - Amy C Ogilvie
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | | | - Yuya Hagiwara
- Division of General Internal Medicine, Department of Medicine, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
5
|
Petersile M, Devuni D. Palliative Care and Advanced Directive Practices at Liver Transplant Centers in the United States. J Palliat Med 2023; 26:1327-1332. [PMID: 37155706 DOI: 10.1089/jpm.2022.0556] [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: 05/10/2023] Open
Abstract
Introduction: Patients with cirrhosis have a decreased quality of life due to decompensations of their underlying disease. While liver transplantation (LT) has improved outcomes and quality of life for patients with cirrhosis, many patients die or are delisted before transplant. Despite high morbidity and mortality, palliative care (PC) services are underutilized for patients with cirrhosis. Methods: To evaluate current PC and advance care practices at LT centers, a survey was designed and sent to 115 U.S. LT centers. Results: Forty-two surveys were completed (37% response rate) with representation from all United Network for Organ Sharing regions. Nineteen institutions (46.3%) reported 100 or fewer waitlisted patients, while 22 (53.6%) reported more than 100. Twenty-five institutions (59.5%) reported 100 or fewer transplants performed in the last year and 17 (40.5%) reported more than 100. Nineteen transplant centers (45.2%) require patients to discuss advance directives as part of the LT evaluation, while 23 (54.8%) do not. Only 5 centers (12.2%) reported having a dedicated PC provider as part of their transplant team and only 2 reported requiring patients to meet with a PC provider as part of the LT evaluation process. Discussion: This study shows many LT centers do not engage their patients in advance directive discussions and highlights the underutilization of PC services in the LT evaluation process. Our results also show minimal advancement in the collaboration between PC and transplant hepatology over the last decade. Encouraging or requiring LT centers to hold advance directive discussions and incorporate PC providers into the transplant team is a recommended area for improvement.
Collapse
Affiliation(s)
- Matthew Petersile
- Department of Internal Medicine, Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - Deepika Devuni
- Department of Internal Medicine, Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| |
Collapse
|
6
|
Olds PK, Musinguzi N, Geisler BP, Sarin P, Haberer JE. Evaluating disparities in code status designation among patients admitted with COVID-19 at a quaternary care center early in the pandemic. Medicine (Baltimore) 2023; 102:e34447. [PMID: 37505119 PMCID: PMC10376097 DOI: 10.1097/md.0000000000034447] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/29/2023] Open
Abstract
The COVID-19 pandemic has highlighted disparities in outcomes by social determinants to health. It is unclear how much end-of-life discussions and a patient's decision about code status ("do not resuscitate," do not resuscitate, or "comfort measures only," [CMO] orders) might contribute to in hospital disparities in care, especially given know racial inequities in end-of-life care. Here, we looked at factors associated with code status orders at the end of hospitalization for patients with COVID-19. We conducted a retrospective chart review of all patients who presented to the Emergency Department of a large quaternary hospital between 8 March and 3 June 2020. We used logistic regression modeling to quantify the degree to which social determinants of health, including race, ethnicity, area deprivation index (ADI), English as a primary language, homelessness, and illicit substance use might impact the likelihood of a particular code status at the end-of a patient's hospitalization, while controlling for disease severity. Among social determinants to health, only white race (odds ratio [OR] 2.0; P = .03) and higher ADI (OR 1.2; P = .03) were associated with having a do not resuscitate or a CMO order. Additionally, we found that patients with white race (OR 2.9; P = .02) were more likely to carry a CMO order. Patient race and ADI were associated with different code status orders at the end of hospitalization. Differences in code status might have contributed to disparities in COVID-19 outcomes early in the pandemic, though further investigations are warranted.
Collapse
Affiliation(s)
- Peter K. Olds
- Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Nicholas Musinguzi
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Benjamin P. Geisler
- Massachusetts General Hospital/Harvard Medical School, Boston, MA
- Ludwig Maximilian University Munich, Munich, Germany
| | - Pankaj Sarin
- Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
| | | |
Collapse
|
7
|
Godage S, Rowe K, Hu FY, Bader AM, Cooper Z, Bernacki RE, Hepner DL, Allen MB. Preoperative Code Status Discussion Workflows: Targets for Improvement in Multidisciplinary Pathways. J Pain Symptom Manage 2023; 66:e35-e43. [PMID: 37023833 DOI: 10.1016/j.jpainsymman.2023.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/22/2023] [Accepted: 03/26/2023] [Indexed: 04/08/2023]
Abstract
CONTEXT Discussion of perioperative code status is an important element of preoperative care and a component of the American College of Surgeons' Geriatric Surgery Verification (GSV) program. Evidence suggests code status discussions (CSDs) are not routinely performed and are inconsistently documented. OBJECTIVES Because preoperative decision making is a complex process spanning multiple providers, this study aims to utilize process mapping to highlight challenges associated with CSDs and inform efforts to improve workflows and implement elements of the GSV program. METHODS Using process mapping, we detailed workflows relating to (CSDs) for patients undergoing thoracic surgery and a possible workflow for implementing GSV standards for goals and decision-making. RESULTS We generated process maps for outpatient and day-of-surgery workflows relating to CSDs. In addition, we generated a process map for a potential workflow to address limitations and integrate GSV Standards for Goals and Decision Making. CONCLUSION Process mapping highlighted challenges associated with the implementation of multidisciplinary care pathways and indicated a need for centralization and consolidation of perioperative code status documentation.
Collapse
Affiliation(s)
- Sashini Godage
- Harvard Medical School (S.G., K.R.), Boston, Massachusetts, USA
| | - Katie Rowe
- Harvard Medical School (S.G., K.R.), Boston, Massachusetts, USA; Harvard Business School (K.R.), Boston, Massachusetts, USA
| | - Frances Y Hu
- Department of Surgery (F.Y.H., Z.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Angela M Bader
- Center for Surgery and Public Health (A.M.B., Z.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Anesthesiology (A.M.B., D.L.H., M.B.A), Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zara Cooper
- Department of Surgery (F.Y.H., Z.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Center for Surgery and Public Health (A.M.B., Z.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care (R.E.B), Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (R.E.B), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David L Hepner
- Department of Anesthesiology (A.M.B., D.L.H., M.B.A), Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew B Allen
- Department of Anesthesiology (A.M.B., D.L.H., M.B.A), Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
8
|
Hamidi S, Zarnke S, Turcotte K, Silver SA. The Feasibility of a Transitional Care Unit for Patients Newly
Started on In-Center Hemodialysis: A Research Letter. Can J Kidney Health Dis 2023; 10:20543581231162235. [PMID: 36970567 PMCID: PMC10031589 DOI: 10.1177/20543581231162235] [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: 11/09/2022] [Accepted: 01/30/2023] [Indexed: 03/23/2023] Open
Abstract
Background: Patients with end-stage kidney disease face high mortality and morbidity
after dialysis initiation. Transitional care units (TCUs) are typically 4-
to 8-week structured multidisciplinary programs targeted toward patients
starting hemodialysis during this high-risk time in their care. The goals of
such programs are to provide psychosocial support, provide dialysis modality
education, and reduce risks of complications. Despite apparent benefits, the
TCU model may be challenging to implement, and the effect on patient
outcomes is unclear. Objective: To assess a newly created multidisciplinary TCUs’ feasibility for patients
newly started on hemodialysis. Design: Before-and-after study. Setting: Kingston Health Sciences Centre hemodialysis unit in Ontario, Canada. Patients: We considered all adult patients (age 18+) who initiated in-center
maintenance hemodialysis eligible for the TCU program, although patients on
infection control precautions and evening shifts were not able to receive
TCU care due to staffing limitations. Measurements: We defined feasibility as eligible patients completing the TCU program in a
timely fashion without additional need for space, no signal of harm, and
without explicit concerns from TCU staff or patients at weekly meetings. Key
outcomes at 6 months included mortality, proportion hospitalized, dialysis
modality, vascular access, initiation of transplant workup, and code
status. Methods: The TCU care consisted of 1:1 nursing and education until predefined clinical
stability and dialysis decisions were satisfied. We compared outcomes among
the pre-TCU cohort who initiated hemodialysis between June 2017 and May
2018, and TCU patients who initiated dialysis between June 2018 and March
2019. We summarized outcomes descriptively, along with unadjusted odds
ratios (ORs) and 95% confidence intervals (CIs). Results: We included 115 pre-TCU patients and 109 post-TCU patients, of whom 49/109
(45%) entered and completed the TCU. The most common reasons for not
participating in the TCU included evening hemodialysis shifts (18/60, 30%)
or contact precautions (18/60, 30%). The TCU patients completed the program
in a median of 35 (25-47) days. We observed no differences in mortality (9%
vs 8%; OR = 0.93, 95% CI = 0.28-3.13) or proportion hospitalized (38% vs
39%; OR = 1.02, 95% CI = 0.51-2.03) between the pre-TCU cohort and TCU
patients. There was also no difference in use of home dialysis (16% vs 10%;
OR = 1.67, 95% CI = 0.64-4.39), non-catheter access (32% vs 25%; OR = 1.44,
95% CI = 0.69-2.98), initiation of transplant workup (14% vs 12%; OR 1.67;
95% CI = 0.64-4.39), and choosing “do not resuscitate” (DNR) orders (22% vs
19%; OR = 1.22, 95% CI = 0.54-2.77). There was no negative patient or staff
feedback on the program. Limitations: Small sample size and potential for selection bias given inability to provide
TCU care for patients on infection control precautions or evening
shifts. Conclusions: The TCU accommodated a large number of patients, who completed the program in
a timely fashion. The TCU model was determined to be feasible at our center.
There was no difference in outcomes due to the small sample size. Future
work at our center is required to expand the number of TCU dialysis chairs
to evening shifts and evaluate the TCU model in prospective, controlled
studies.
Collapse
Affiliation(s)
- Shabnam Hamidi
- Division of Nephrology, Department of
Medicine, Queen’s University, Kingston, ON, Canada
- Kingston Health Sciences Centre, ON,
Canada
| | - Sasha Zarnke
- Division of Nephrology, Department of
Medicine, Queen’s University, Kingston, ON, Canada
| | | | - Samuel A. Silver
- Division of Nephrology, Department of
Medicine, Queen’s University, Kingston, ON, Canada
- Kingston Health Sciences Centre, ON,
Canada
- Samuel A. Silver, Division of Nephrology,
Department of Medicine, Queen’s University, 76 Stuart Street, 3-Burr 21-3-039,
Kingston, ON K7L 2V7, Canada.
| |
Collapse
|
9
|
Liu K, Hwang J, Chesteen K, Huth H, Zhu Y, Mixon A, Tillman S, Misra S, Karlekar M. A Retrospective Review of the Characteristics and Outcomes of Patients through an Integrated Palliative Care Model during the First Wave of the SARS-COV-2 Pandemic. J Palliat Med 2022; 25:1844-1849. [PMID: 36108157 DOI: 10.1089/jpm.2022.0006] [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: 01/04/2023] Open
Abstract
Background: The COVID-19 pandemic created surges of rapidly deteriorating patients straining health care necessitating the evaluation of novel models of palliative care (PC) integration to reduce patient suffering and hospital strain. Objective: To evaluate an integrated PC model's effect on code status change. Design: This is an observational retrospective study. Setting: Urban quaternary referral center in the southeastern United States from April 6th to August 20th, 2020. Patients: All patients admitted to our medical intensive care unit and stepdown unit were diagnosed with COVID-19. Measurements: Code status change, multivariate regression on patient characteristics. Results: In total, 79.7% (98/123) patients were full code at admission. After PC consultation, 33.3% (41/123) patients remained full code, 13.0% (16/123) were do not resuscitate (DNR), and 53.6% (66/123) changed to DNR/do not intubate (DNI). An ordinal logistic model determined that consultation location (odds ratio [OR] 3.35, p = 0.017) and patient age (OR 1.09, p < 0.001) were predictive of code status change to DNR/DNI. Conclusion: Within an integrated PC model, PC consultation was associated with code status change. The effect of an integrated PC model warrants further study in comparison with a traditional PC model in a similar patient cohort.
Collapse
Affiliation(s)
- Kevin Liu
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jane Hwang
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kim Chesteen
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Holly Huth
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yuwei Zhu
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amanda Mixon
- Vanderbilt University Medical Center, VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC) Tennessee, Nashville, Tennessee, USA
| | - Stacey Tillman
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sumathi Misra
- VA Geriatric Research Education and Clinical Center (GRECC) Tennessee, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mohana Karlekar
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
10
|
Statler TM, Hsu FC, Silla L, Sheehan KN, Cowles A, Brooten JK, Omlor RL, Gabbard J. Occurrence of Advance Care Planning and Hospital Course in Patients Admitted for Coronavirus Disease 2019 (COVID-19) During the Pandemic. Am J Hosp Palliat Care 2022:10499091221123570. [PMID: 36018339 PMCID: PMC9420734 DOI: 10.1177/10499091221123570] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction The Coronavirus Disease 2019 (COVID-19) pandemic highlighted the importance
of understanding patients’ goals, values, and medical care preferences given
the high morbidity and mortality. We aimed to examine rates of advance care
planning (ACP) documentation along with hospital course differences in the
absence or presence of ACP among hospitalized patients with COVID-19. Methods This retrospective cohort study was performed at a single tertiary academic
medical center. All adults admitted between March 1, 2020, and June 30,
2020, for COVID-19 were included. Demographics, ACP documentation rates,
presence of ACP forms, palliative care consultation (PCC) rates, code
status, and hospital outcome data were collected. Data were analyzed with
multivariable analysis to identify predictors of ACP documentation. Results Among 356 patients (mean age 60.0, 153 (43%) female), 97 (27.2%) had
documented ACP and 20 (5.6%) had completed ACP forms. In patients with
documented ACP, 52.4% (n = 55) de-escalated care to do-not-resuscitate
(DNR)-limited or comfort measures. PCC occurred rarely (<8%), but 78% (n
= 21) of those consulted de-escalated care. Being admitted to the intensive
care unit (ICU) (OR = 11.1, 95% CI = 5.9-21.1), mechanical intubation (OR =
15.8, 95% CI = 7.4-32.1), and discharge location other than home (OR = 11.3,
95% CI = 5.7-22.7) were associated with ACP documentation. Conclusions This study found low ACP documentation and PCC rates in patients admitted for
COVID-19. PCC and completion of ACP were associated with higher rates of
care de-escalation. These results support the need for pro-active ACP and
PCC for patients admitted for serious illnesses, like COVID-19, to improve
goal-informed care.
Collapse
Affiliation(s)
- Tiffany M Statler
- Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Fang-Chi Hsu
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Laura Silla
- Department of Neurology, University of Utah Health, Salt Lake City, UT, USA
| | - Kristin N Sheehan
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Amy Cowles
- Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Justin K Brooten
- Department of Internal Medicine, Section on Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Rebecca L Omlor
- Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jennifer Gabbard
- Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| |
Collapse
|
11
|
Baldor DJ, Smyrnios NA, Faris K, Guilarte-Walker Y, Celik U, Torres U. A Controlled Study in CPR-Survival in Propensity Score Matched Full-Code and Do-Not-Resuscitate ICU Patients. J Intensive Care Med 2022; 37:1363-1369. [PMID: 35815880 DOI: 10.1177/08850666221114052] [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: 11/15/2022]
Abstract
BACKGROUND Cardiopulmonary Resuscitation (CPR) causes significant injuries and increased cost among transiently resuscitated patients that do not survive their hospitalizations. Descriptive studies show zero and near-zero percent survival for CPR recipients with high Apache II scores. Despite these factors, no controlled studies exist in CPR to guide patient selection for CPR candidacy. Our objective was therefore to perform a controlled study in CPR to inform recommendations for CPR candidacy. We hypothesize that the protective effects of CPR decrease as illness severity increases, and that Full-Code status provides no survival benefit over Do-Not-Resuscitate (DNR) status for patients with the highest predicted mortality by Apache IV score. METHODS We performed propensity-score matched survival analyzes between Full-Code and DNR patients after stratifying by predicted mortality quartiles using Apache IV scores. Primary outcomes were mortality hazard ratios. Secondary outcomes were Median Survival Differences, ICU LOS, and tracheostomy rates. RESULTS Among 17,710 propensity-score matched ICU encounters, DNR status was associated with greater mortality in the first through third predicted mortality quartiles. There was no difference in survival outcomes in the fourth quartile (HR 0.99, p = .96). There was a stepwise decrease in the mortality hazard ratio for DNR patients as quartiles increased. CONCLUSION Full-Code status provides no survival benefit over DNR status in individuals with greater than 75% predicted mortality by Apache IV score. There is a stepwise decrease in survival benefit for Full-Code patients as predicted mortality increases. We propose that it is reasonable to consider a very high predicted mortality by Apache IV score a contraindication to CPR given the lack of survival benefit seen in these patients. Larger studies with similar methods should be performed to reinforce or refute these findings.
Collapse
Affiliation(s)
- Daniel J Baldor
- Department of General Surgery, The University of Massachusetts Chan School of Medicine, Worcester, MA, USA
| | - Nicholas A Smyrnios
- Division of Pulmonary, Allergy, and Critical Care Medicine, The University of Massachusetts Chan School of Medicine, Worcester, MA, USA
| | - Khaldoun Faris
- Division of Anesthesiology Critical Care Medicine, The University of Massachusetts Chan School of Medicine, Worcester, MA, USA
| | - Yurima Guilarte-Walker
- Department of Population and Quantitative Health Sciences, The University of Massachusetts Chan School of Medicine, Worcester, MA, USA
| | - Ugur Celik
- Center for Clinical and Translational Science, Research Informatics Core, The University of Massachusetts Chan School of Medicine, Worcester, MA, USA
| | - Ulises Torres
- George Washington University School of Medicine, Washington, DC, USA
| |
Collapse
|
12
|
Paddley B, Espin S, Indar A, Rose D, Bookey-Bassett S. Communication of Code Status Escalation for Nurses and Physicians in the Intensive Care Unit: A Case Study. Can J Nurs Res 2022; 55:176-184. [PMID: 35538849 DOI: 10.1177/08445621221099117] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Interprofessional teams working in the Intensive Care Unit (ICU) care for patients requiring varying degrees of life sustaining therapy. A patient's code status can help clinicians to understand the appropriate life support measures to deliver to patients in this setting. Members of the interprofessional team, such as physicians and nurses, can experience challenges related to communication when the code status is unclear. PURPOSE The purpose of this study was to explore how nurses and physicians in the ICU experience communication of code status escalations. METHODS A qualitative case study approach was used. Participants were physicians and nurses, working in the medical-surgical ICU of a large, urban academic hospital. Data were collected using semi-structured interviews, observations of health care rounds and a chart review. Data were analyzed using qualitative content analysis. RESULTS Thematic findings include: (1) engaging in an interprofessional discussion, (2) finding consistent documentation, (3) revisiting the code status, and (4) telling the patient story. The study findings also provide contextual information about participants' experiences of code status communication during the first wave (February 2020 to May 2020) of the COVID-19 pandemic. CONCLUSIONS The results of this study could inform standard communication frameworks or practices related to dissemination of code status decisions among members of the ICU team.
Collapse
Affiliation(s)
- Brianna Paddley
- Medical Surgical Intensive Care Unit, 10071St. Michael's Hospital, Toronto, Canada
| | - Sherry Espin
- Daphne Cockwell School of Nursing, 7984Ryerson University, Toronto, Canada
| | - Alyssa Indar
- Faculty of Health Sciences and Wellness, 10025Humber College, Toronto, Canada
| | - Don Rose
- Daphne Cockwell School of Nursing, 7984Ryerson University, Toronto, Canada
| | - Sue Bookey-Bassett
- Daphne Cockwell School of Nursing, 7984Ryerson University, Toronto, Canada
| |
Collapse
|
13
|
Tombazzi CR, Howe CF, Slaughter JC, Obstein KL. Rate of and Factors Associated with Palliative Care Referral among Patients Declined for Liver Transplantation. J Palliat Med 2022; 25:1404-1408. [PMID: 35333610 DOI: 10.1089/jpm.2021.0403] [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: End-stage liver disease (ESLD) is associated with high morbidity and mortality, with liver transplantation as the only existing cure. Despite reduced quality of life and limited life expectancy, referral to palliative care (PC) rarely occurs. Moreover, there is scarcity of data on the appropriate timing and type of PC intervention needed. Aim: To evaluate PC utilization and documentation in ESLD patients declined or delisted for transplant at a tertiary care medical center with a large liver transplantation program. Methods: We performed a retrospective cohort study of all patients discussed in Liver Transplant Committee (LTC) at our academic medical center between August 2018 and May 2020 in the United States. Patients declined or delisted for liver transplantation were included. Baseline demographics, model for end-stage liver disease (MELD) score, decompensation events, and reason for transplant ineligibility were recorded. The primary outcome was PC referral. Secondary outcomes included survival from LTC decision, time from LTC decision to PC referral, and code status in relation to PC referral. Results: Of 769 patients discussed at LTC, 135 were declined for transplantation. Thirty-seven (27%) received referral to PC. When adjusting for body mass index and age, MELD score of 21-30 had odds ratio (OR) of 4.5 (95% confidence interval [CI]: 1.7-12.3) and MELD score >30 had OR of 12.8 (95% CI: 3.9-47.7) for PC referral when compared with MELD score <20. When adjusting for MELD score, presence of ascites had OR of 4.6 (95% CI: 1.1-19.1) and presence of multiple complications had OR of 2.2 (95% CI: 2.2-3.8). Conclusions: Only 37 (27%) patients delisted or declined for liver transplantation were referred to PC. MELD score and degree of decompensation were important factors associated with referral. Continued exploration of these data could help guide future studies and help determine timing and criteria for PC referral.
Collapse
Affiliation(s)
- Claudio Roberto Tombazzi
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Catherine Filley Howe
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James Chris Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keith L Obstein
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
14
|
Topoll AB, Wagner JK, Salem KM, Levenson JE, Makaroun MS, Arnold RM. Improving Code Status Documentation Rates Using Communication Skills Training in Vascular Surgery: A Quality Improvement Initiative. J Palliat Med 2022; 25:628-635. [PMID: 34990280 DOI: 10.1089/jpm.2021.0364] [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
Introduction: Code status discussions are poorly understood by patients and variably performed by admitting providers, yet they are used as a quality metric. Surgical specialties, such as Vascular Surgery, admit patients with urgent and life-threatening illness. Surgical trainees are less likely to receive communication skills interventions when compared with nonsurgical specialties. Without a documented code status, nurses and physicians lack guidance on patient preference in the case of cardiopulmonary arrest and may deliver unwanted measures, which may also result in poor outcomes. Methods: We conducted a before-after Plan-Do-Study-Act quality improvement project between May 2018 and May 2019. A needs assessment included baseline code status documentation rates for the Vascular Surgery department admissions. A communication skills training (CST) and documentation intervention was provided to all Vascular Surgery trainees and advance practice providers (APPs). Departmental e-mails were sent over the 12-month intervention period, which demonstrated the code status documentation rates and served as reminders to document code status. Results: A total of 29 vascular surgery trainees and APPs received the intervention. At completion of the intervention, learners reported increased comfort initiating a code status discussion, making a recommendation for cardiopulmonary resuscitation (CPR) status, and having a strategy to discuss code status. A total of 2762 patient admissions were reviewed, with 1562 patient admissions occurring during the 12-month intervention period. The average code status documentation rate for the three months before the intervention was 7.8%. At the end of the 12-month intervention, documentation rates were 44.9% and 6 months after completion of the study period, average rates remained 45.2%. There was no change in admission rates during the study period. Discussion: CST and regular reminders increased vascular surgery residents' and APPs' comfort in engaging in code status discussions. After intervention, documentation of code status discussions increased with persistence up to six months after the intervention.
Collapse
Affiliation(s)
- Alicia B Topoll
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason K Wagner
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Karim M Salem
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joshua E Levenson
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michel S Makaroun
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
15
|
Stawiarski K, Priyadharshini Jeyashanmugaraja G, Edwards K, Bindelglass G, Lancaster G. Improved Physician Understanding of Patient End-of-Life Preferences: A Quality Improvement Project. J Pain Symptom Manage 2021; 62:1289-1294. [PMID: 34118369 DOI: 10.1016/j.jpainsymman.2021.05.023] [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: 03/23/2021] [Revised: 05/06/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Code status (CS) orders lack a universal definition. We aimed to improve provider understanding of order options. MEASURES Provider's knowledge of CS terminology, ease of understanding CS orders and ease of starting CS discussions. INTERVENTION A multifaceted intervention including 1) altered CS order language in the electronic medical record (EMR) from "Full Interventions," "Limited Interventions," and "Comfort Measures Only" to "Full advanced cardiovascular life support (ACLS)," "Partial ACLS," and "No ACLS" 2) clinical tools for CS identification 3) provider education. OUTCOMES Correct provider response rate for "Partial ACLS" and "No ACLS" terms increased from 43.5 to 60% and 20 to 71% (odds ratio 1.95; 95% confidence interval 0.99-3.83; P = 0.03, OR 9.8; CI 4.48-21.49; P < 0.001). The proportion of providers who felt understanding CS orders and starting conversations about CS was "very easy" (a score of 1-3 on a scale of 1 to 10) improved from 26.1 to 45.7% (P = 0.01) and 49.3 to 65.7% (P = 0.03). CONCLUSIONS/LESSONS LEARNED Provider understanding of CS options can be improved with a combined QI intervention.
Collapse
Affiliation(s)
- Kristin Stawiarski
- Section of Cardiovascular Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, CT.
| | | | - Kristin Edwards
- Section of Geriatrics and Palliative Care, Yale New Haven Health Bridgeport Hospital, Bridgeport, CT
| | - Gloria Bindelglass
- Section of Cardiovascular Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, CT
| | - Gilead Lancaster
- Section of Cardiovascular Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, CT
| |
Collapse
|
16
|
de Lasa C, Brown EE, Colman R, Rajji TK, Colman S. Invited letter: Integrated palliative care in a geriatric mental health setting during the COVID-19 pandemic. Int J Geriatr Psychiatry 2021; 37:10.1002/gps.5654. [PMID: 34792225 PMCID: PMC8646403 DOI: 10.1002/gps.5654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Cristina de Lasa
- Division of Medicine in PsychiatryCentre for Addiction and Mental HealthTorontoCanada
- Department of Family and Community MedicineUniversity of TorontoTorontoCanada
| | - Eric E. Brown
- Division of Adult Neurodevelopment and Geriatric PsychiatryCentre for Addiction and Mental HealthTorontoCanada
- Department of PsychiatryUniversity of TorontoTorontoCanada
| | - Rebecca Colman
- Divisions of Respirology and Division of Palliative MedicineDepartment of MedicineUniversity of TorontoTorontoCanada
- Temmy Latner Centre for Palliative CareSinai Health SystemTorontoCanada
| | - Tarek K. Rajji
- Division of Adult Neurodevelopment and Geriatric PsychiatryCentre for Addiction and Mental HealthTorontoCanada
- Department of PsychiatryUniversity of TorontoTorontoCanada
- Toronto Dementia Research AllianceUniversity of TorontoTorontoCanada
| | - Sarah Colman
- Division of Adult Neurodevelopment and Geriatric PsychiatryCentre for Addiction and Mental HealthTorontoCanada
- Department of PsychiatryUniversity of TorontoTorontoCanada
| |
Collapse
|
17
|
Katamreddy A, Wengrofsky AJ, Li W, Taub CC. DNR Code Status Is Not Associated with Under-Utilization of Inpatient Transthoracic Echocardiograms. J Cardiovasc Dev Dis 2021; 8:jcdd8090112. [PMID: 34564130 PMCID: PMC8471040 DOI: 10.3390/jcdd8090112] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/05/2021] [Accepted: 09/09/2021] [Indexed: 11/16/2022] Open
Abstract
In the strictest sense, do-not-resuscitate (DNR) status means that cardiopulmonary resuscitation should not be performed after death has occurred; all other medical interventions in line with a patient's goals of care should be implemented. The use of transthoracic echocardiography (TTE) in patients with DNR status is unknown. Therefore, we aim to evaluate the utilization of TTE among patients with DNR status using this retrospective data analysis. A total of 16,546 patient admissions were included in the final study. A total of 4370 (26.4%) of the patients had a TTE during hospitalization; among full code patients, 3976 (25.7%) underwent TTE, whereas TTEs were performed in 394 (37.4%) of DNR patients. On univariate logistic regression analysis, full code status had OR (95% confidence interval, CI) 0.57 (0.51-0.66), p < 0.01 compared with DNR status for the performance of inpatient TTE. In the final multivariate model adjusted for age, sex, race, and clinical comorbidities, the full code patients had OR (95% CI) 0.91 (0.79-1.05), p = 0.22 compared with DNR patients for the performance of inpatient TTE. DNR status is not associated with a decrease in inpatient transthoracic echocardiography performance.
Collapse
Affiliation(s)
- Adarsh Katamreddy
- Internal Medicine, Jacobi Medical Center, Bronx, NY 10461, USA; (A.K.); (W.L.)
| | | | - Weijia Li
- Internal Medicine, Jacobi Medical Center, Bronx, NY 10461, USA; (A.K.); (W.L.)
| | - Cynthia C. Taub
- Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA
- Correspondence: ; Tel.: +1-603-650-3540
| |
Collapse
|
18
|
Brecher DB, Morris SM. Back to the Basics-Is Comfort Care the Same as Do Not Resuscitate? How Misinterpreting Code Status May Lead to Potential Patient Harm. Am J Hosp Palliat Care 2021; 39:885-887. [PMID: 34519248 DOI: 10.1177/10499091211046235] [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: 11/17/2022] Open
Abstract
Several research studies have shown that code status documentation is misinterpreted or incorrectly defined by a significant number of medical professionals. This misinterpretation among the medical team (i.e. equating Do Not Resuscitate (DNR) with comfort care measures only) may lead to false reporting, poor symptom management, and potentially adverse clinical outcomes. Most Hospice and Palliative Care providers are aware of these distinctions, however a shortage (and continued foreseen shortage) of Hospice and Palliative Care providers may mean these conversations and distinctions will fall to non-subspecialists, or providers of other medical specialties or degrees. The literature has demonstrated that these shortfalls and misinterpretations are present and constitute potential harm to our patients.
Collapse
Affiliation(s)
- David B Brecher
- Palliative and Hospice Service, Geriatrics and Extended Care Service, Veterans Affairs Puget Sound Healthcare System, Tacoma, WA, USA
| | - Shane M Morris
- Internal Medicine Residency Program, Madigan Army Medical Center, Tacoma, WA, USA
| |
Collapse
|
19
|
Casas J, Jeppesen A, Peters L, Schuelke T, Magdoza NRK, Hesselgrave J, Loftis L. Using Quality Improvement Science to Create a Navigator in the Electronic Health Record for the Consolidation of Patient Information Surrounding Pediatric End-of-Life Care. J Pain Symptom Manage 2021; 62:e218-e224. [PMID: 33864845 DOI: 10.1016/j.jpainsymman.2021.04.006] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND It is important to document the domains surrounding end-of-life (EOL) care in the electronic health record (EHR). No pediatric navigator exists for these purposes. MEASURES Medical charts were reviewed for documentation surrounding code status and care at the time of death from January 2017 to June 2019. INTERVENTION Creation of a navigator in the EHR to consolidate advance care planning documents, code status orders and notes and EOL flowsheets. OUTCOMES After implementing the navigator, 96% code status changes had supporting documentation, an increase of 35%. The percentage of deaths supported by a psychosocial team (social worker, chaplain and certified child life specialist) increased by 25%. Post-mortem documentation became electronic. Patient level metrics began to be electronically collected. CONCLUSIONS/LESSONS LEARNED Little has been published regarding use of the EHR to consolidate EOL documentation in pediatrics. Development of a systematic approach to documentation is critical to providing EOL care and standardizing care delivered.
Collapse
Affiliation(s)
- Jessica Casas
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.
| | | | - Leah Peters
- Texas Children's Hospital, Houston, Texas, USA
| | | | | | | | - Laura Loftis
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
20
|
Mesfin N, Fischman A, Garcia MA, Johnson S, Parikh R, Wiener RS. Predictors to forgo resuscitative effort during Covid-19 critical illness at the height of the pandemic : A retrospective cohort study. Palliat Med 2021; 35:1519-1524. [PMID: 34479453 DOI: 10.1177/02692163211022622] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early in the Covid-19 pandemic, there was uncertainty regarding critical illness prognosis and challenges to traditional face-to-face family meetings. Ethnic minority populations have suffered disproportionately worse outcomes during the pandemic, which may in part relate to differences in end-of-life decision-making. AIM Characterize patterns of and factors associated with decisions to forgo resuscitative efforts, as measured by do-not-resuscitate orders, during critical illness with Covid-19. DESIGN Retrospective cohort with medical record abstraction. SETTING/PARTICIPANTS Adult patients diagnosed with SARS-Cov-2 virus via polymerase chain reaction and admitted to the intensive care unit at an academic hospital, which cares for the city's underserved communities, between March 1 and June 7, 2020 who underwent invasive mechanical ventilation for at least 48 hours. RESULTS In this cohort (n = 155), 45% were black people, and 51% spoke English as their primary language. Median time to first goals-of-care conversation was 3.9 days (IQR 1.9-7.6) after intensive care unit admission. Overall 61/155 patients (39%) transitioned to do-not-resuscitate status, and 50/62 (82%) patients who died had do-not-resuscitate orders. Multivariate analysis shows age and palliative care involvement as the strongest predictors of decision to instate do-not-resuscitate order. There was no association between race, ethnicity, or language and decisions to forego resuscitation. CONCLUSIONS During this time of crisis and uncertainty with limited resources and strained communication, time to first goals of care conversation was shorter than in pre-pandemic studies, but rates of foregoing resuscitation remained similar, with no differences observed by race, ethnicity, or language. This study suggests that early palliative care involvement and non-traditional communications, including videoconferencing, to facilitate goals of care conversations could have mitigated potential disparities in end-of-life decision making patterns during the pandemic.
Collapse
Affiliation(s)
- Nathan Mesfin
- Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Alexandra Fischman
- Graduate Medical Sciences, Boston University School of Medicine, Boston, MA, USA
| | - Michael A Garcia
- Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Shelsey Johnson
- Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Raj Parikh
- Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Renda Soylemez Wiener
- Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA.,Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| |
Collapse
|
21
|
Zhang K, Shi M, Powell T, Chuang E. Primary and Specialist-Level Palliative Care during the spring 2020 COVID-19 Surge: A Single-Center Experience in the Bronx. Am J Hosp Palliat Care 2021; 39:598-602. [PMID: 34313146 PMCID: PMC8922160 DOI: 10.1177/10499091211034416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: The COVID-19 pandemic surge necessitated a rapid increase in provision of
goals of care communication for patients with respiratory failure and high
risk of death. We aimed to describe the outcomes and incidence of code
status changes for mechanically ventilated patients in an acute care
hospital after deploying strategies to enhance primary palliative care,
including provision of goals of care communication scripts to front-line
physicians. Methods: This is a retrospective cohort study including all patients admitted with
COVID-19 disease and requiring mechanical ventilation during a 2-week period
in March and April of 2020. Results: Of the 440 total patients, 327 (74.3%) died. 162 patients received a
documented attempt at cardiopulmonary resuscitation (CPR) and only 4 (2.5%)
of them survived. No patient above the age of 64 survived a CPR attempt. On
admission, 404 patients (92.8%) were Full Code. 165 patients (37.5%) had a
code status change. Almost half of the patients (n = 219) had a palliative
care consult. Patients with a palliative care consult were more likely to
have a code status change (56.6% v. 18.6%, χ2 = 68.0, p <
0.01). Discussion: Mechanically ventilated patients had a high mortality, and CPR did not result
in survival to discharge in patients over 65. Palliative care specialists
are needed to guide goals of care discussions during the COVID-19 pandemic,
as there are numerous barriers to equipping primary care teams to lead such
discussions. The COVID-19 pandemic has underscored the vital role of
palliative care in disaster response.
Collapse
Affiliation(s)
| | - Marc Shi
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Tia Powell
- Montefiore-Einstein Center for Bioethics, Bronx, NY, USA
| | - Elizabeth Chuang
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
22
|
Kizawa Y, Yamaguchi T, Yagi Y, Miyashita M, Shima Y, Ogawa A. Conditions, possibility and priority for admission into inpatient hospice/palliative care units in Japan: a nationwide survey. Jpn J Clin Oncol 2021; 51:1437-1443. [PMID: 34184056 DOI: 10.1093/jjco/hyab098] [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: 03/29/2021] [Accepted: 06/12/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Known barriers to admission into inpatient hospice/palliative care units (PCUs) include poor accessibility and stringent conditions for admission. However, the exact criteria are unclear. The aim of this study was to clarify the actual conditions, possibilities and priorities for admission to PCU in Japan. METHODS We conducted a nationwide, anonymous, self-administered questionnaire survey to the responsible physicians of all 251 PCUs in 2014. RESULTS Responses were received from 190 institutions (response rate 76%). The most frequent condition for admission was 'either the patient or the family knows the diagnosis' [86%, 95% confidence interval (CI): 80-90]. For the conditions for admission to PCU, 10-40% fewer facilities answered that the patient's consent or understanding was required compared with those that answered the patient or family's consent was sufficient. Seventy-one percent (95% CI: 64-77) of PCUs answered that either the patient or a family member needed to agree to a do-not-resuscitate (DNR) policy. The factors most likely to result in refusal of admission to a PCU varied greatly. Ninety-four percent (95% CI: 90-97) of PCUs answered that patients who had undergone a long waiting time after applying for admission would be given higher priority, and approximately 50% of PCUs answered they gave priority to their outpatients and inpatients. CONCLUSIONS The findings of this study should be used to modify the system so that appropriate palliative care can be provided to patients who wish to be admitted to PCU.
Collapse
Affiliation(s)
- Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University School of Medicine, Kobe, Japan
| | - Takashi Yamaguchi
- Department of Palliative Medicine, Konan Medical Center, Kobe, Japan
| | - Yukako Yagi
- Department of Palliative Medicine, Konan Medical Center, Kobe, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Ibaraki, Japan
| | - Asao Ogawa
- Department of Psycho-Oncology Service, National Cancer Center Hospital East, Kashiwa, Japan
| |
Collapse
|
23
|
Huayanay I, Pantoja C, Chang C. End of Life Decision-Making Challenges in a Latino Patient with COVID-19: Facing Barriers. Gerontol Geriatr Med 2021; 7:23337214211021726. [PMID: 34104688 PMCID: PMC8170277 DOI: 10.1177/23337214211021726] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/13/2021] [Indexed: 11/16/2022] Open
Abstract
COVID-19 pandemic brought difficult scenarios that patients and families are
facing about end- of-life decisions. This exposed some weak areas in the
healthcare system where we can continue improve in reducing disparities and
emphasizing advance care planning from a primary level of care. We present a
case of challenges in end-of-life decision-making in a Latino patient.
Collapse
Affiliation(s)
- Irma Huayanay
- School of Medicine, The University of Texas Rio Grande Valley, Edinburg, Texas, USA.,Internal Medicine Residency Program, The University of Texas Rio Grande Valley, Edinburg, Texas, USA.,Doctors Hospital at Renaissance, Edinburg, Texas, USA
| | - Celia Pantoja
- Doctors Hospital at Renaissance, Edinburg, Texas, USA
| | - Chelsea Chang
- School of Medicine, The University of Texas Rio Grande Valley, Edinburg, Texas, USA.,Internal Medicine Residency Program, The University of Texas Rio Grande Valley, Edinburg, Texas, USA.,Doctors Hospital at Renaissance, Edinburg, Texas, USA
| |
Collapse
|
24
|
Goswami P, Mistric M, Diane Barber F. Advance Care Planning: Advanced Practice Provider-Initiated Discussions and Their Effects on Patient-Centered End-of-Life Care. Clin J Oncol Nurs 2021; 24:81-87. [PMID: 31961841 DOI: 10.1188/20.cjon.81-87] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 11/17/2022]
Abstract
BACKGROUND Advance care planning (ACP) is an ongoing process of communication involving patients, family members, and caregivers on one side and healthcare providers on the other to establish values, goals, and preferences for future care, along with discussions concerning end-of-life care options. Advance directives promote patient autonomy and provide written documentation of a patient's wishes for future care. OBJECTIVES This quality improvement project aimed to determine if ACP discussions initiated by an advanced practice provider (APP) would enhance patient-centered end-of-life care. METHODS This study involved retrospective data collection of 20 inpatients and 20 outpatients without a scanned advance directive in the electronic health record at the time of admission or clinic visit, as well as an ACP intervention by an APP. FINDINGS APPs can initiate ACP discussions with patients with cancer, which may assist in their understanding of ACP, resulting in completion of the advance directive documents and a change in their code (resuscitation) status.
Collapse
|
25
|
Sterie A, Jones L, Jox RJ, Truchard ER. 'It's not magic': A qualitative analysis of geriatric physicians' explanations of cardio-pulmonary resuscitation in hospital admissions. Health Expect 2021; 24:790-799. [PMID: 33682993 PMCID: PMC8235896 DOI: 10.1111/hex.13212] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/18/2021] [Accepted: 01/29/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Discussing patient preferences for cardio-pulmonary resuscitation (CPR) is routine in hospital admission for older people. The way the conversation is conducted plays an important role for patient comprehension and the ethics of decision making. OBJECTIVE The objective was to examine how CPR is explained in geriatric rehabilitation hospital admission interviews, focussing on circumstances in which physicians explain CPR and the content of these explanations. METHOD We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR was discussed. Data were analysed in French with thematic and conversation analysis, and the extracts used for publication were translated into English. RESULTS Mean patient age was 83.7 years; 53.5% were admitted for rehabilitation after surgery or traumatism. CPR was explained in 53.8% of the conversations. Most explanations were brief and concerned the technical procedures, mentioning only rarely potential outcome. With one exception, medical indication and prognosis of CPR did not feature in these explanations. Explanations occurred either before the patient's answer (as part of the question about CPR preferences) or after the patient's answer, generated by patients' indecision, misunderstanding and by the need to clarify answers. DISCUSSION AND CONCLUSIONS The scarcity and simplicity of CPR explanations highlight a reluctance to have in-depth discussions and reflect the assumption that CPR does not need explaining. Providing patients with accurate information about the outcomes and risks of CPR is incremental for reaching informed decisions and patient-centred care. PATIENT CONTRIBUTION Patients were involved in the data collection stage of the study.
Collapse
Affiliation(s)
- Anca‐Cristina Sterie
- Palliative and Supportive Care ServiceChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
- Service of Geriatrics and Geriatric RehabilitationChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Laura Jones
- Palliative and Supportive Care ServiceChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
- Service of Geriatrics and Geriatric RehabilitationChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Ralf J. Jox
- Palliative and Supportive Care ServiceChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
- Institute of Humanities in MedicineLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Eve Rubli Truchard
- Service of Geriatrics and Geriatric RehabilitationChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
| |
Collapse
|
26
|
Hickman SE, Steinberg K, Carney J, Lum HD. POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care. J Am Med Dir Assoc 2021; 22:1672-1677. [PMID: 34029523 DOI: 10.1016/j.jamda.2021.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/16/2021] [Accepted: 04/18/2021] [Indexed: 11/25/2022]
Abstract
POLST (Physician Orders for Life-Sustaining Treatment) is a medical order form used to document preferences about cardiopulmonary resuscitation (CPR), medical interventions such as hospitalization, care in the intensive care unit, and/or ventilation, as well as artificial nutrition. Programs based on the POLST paradigm are used in virtually every state under names that include POST (Physician Orders for Scope of Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and MOST (Medical Orders for Scope of Treatment), and these forms are used in the care of hundreds of thousands of geriatric patients every year. Although POLST is intended for persons who are at risk of a life-threatening clinical event due to a serious life-limiting medical condition, some nursing homes and residential care settings use POLST to document CPR preferences for all residents, resulting in potentially inappropriate use with patients who are ineligible because they are too healthy. This article focuses on reasons that POLST is used as a default code status order form, the risks associated with this practice, and recommendations for nursing homes to implement appropriate use of POLST.
Collapse
Affiliation(s)
- Susan E Hickman
- Indiana University School of Nursing, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA.
| | - Karl Steinberg
- California State University, Institute for Palliative Care, Oceanside, CA, USA
| | - John Carney
- Center for Practical Bioethics, Kansas City, MO, USA
| | - Hillary D Lum
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO, USA; Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
27
|
Huayanay I, Luu S. Tough Decisions During the COVID 19 Pandemic: A Frail Latino Patient. Gerontol Geriatr Med 2020; 6:2333721420970336. [PMID: 33225019 PMCID: PMC7649914 DOI: 10.1177/2333721420970336] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/11/2020] [Indexed: 11/16/2022] Open
Abstract
The pandemic of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had overwhelmed the healthcare system worldwide with multiple ethical dilemmas. Several tools have been used to assess risk factors in these patients. One of them, the Clinical Frailty scale, has shown good correlation between the patient functional status and hospital stay with overall mortality. We present a case were the Clinical Frailty Scale was used to assess patient management and goals of care.
Collapse
Affiliation(s)
- Irma Huayanay
- The University of Texas Rio Grande Valley, Edinburg, TX, USA.,University of Texas Rio Grande Valley, Edinburg, TX, USA.,Doctors Hospital at Renaissance, Edinburg, TX, USA
| | - Stephanie Luu
- The University of Texas Rio Grande Valley, Edinburg, TX, USA.,University of Texas Rio Grande Valley, Edinburg, TX, USA.,Doctors Hospital at Renaissance, Edinburg, TX, USA
| |
Collapse
|
28
|
Pham R, McQuade C, Somerfeld A, Blakowski S, Hickey GW. Palliative Care Consultation Affects How and Where Heart Failure Patients Die. Am J Hosp Palliat Care 2020; 38:807-811. [PMID: 33016083 DOI: 10.1177/1049909120963565] [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: 11/17/2022] Open
Abstract
OBJECTIVE Determine the role of palliative care on terminal code status and setting of death for those with heart failure. BACKGROUND Although palliative care consultation (PCC) has increased for many conditions, PCC has not increased in those with cardiovascular disease. While it has been shown that the majority of those with heart failure die in medical facilities, the impact of PCC on terminal code status and setting of death requires further analysis. METHODS Patients admitted with heart failure between 2014-2015 at an academic VA Healthcare System were reviewed. Primary outcome was terminal code status. Secondary outcomes included setting of death, hospice utilization, and mortality scores. Student t-testing and Chi-square testing were performed where appropriate. RESULTS 334 patients were admitted with heart failure and had a median follow up time of 4.3 years. 196 patients died, with 122 (62%) receiving PCC and 74 (38%) without PCC. Patients were more likely to have terminal code statuses of comfort measures with PCC (OR = 4.6, p = 0.002), and less likely to be full code (OR = 0.09, p < 0.001). 146 patients had documented settings of death and were more likely to receive hospice services with PCC (OR 6.76, p < 0.001). A patient's chance of dying at home was not increased with PCC (OR 0.49, p = 0.07), but they were more likely to die with inpatient hospice (OR = 17.03; p < 0.001). CONCLUSION Heart failure patients who received PCC are more likely to die with more defined care preferences and with hospice services. This does not translate to dying at home.
Collapse
Affiliation(s)
- Richard Pham
- Division of Cardiology, Department of Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Casey McQuade
- Division of Cardiology, Department of Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alex Somerfeld
- Division of Cardiology, Department of Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sandra Blakowski
- Department of Medicine, 6595Veterans Health Administration Pittsburgh Health System, Pittsburgh, PA, USA
| | - Gavin W Hickey
- Division of Cardiology, Department of Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
29
|
Lillemoe K, Lord A, Torres J, Ishida K, Czeisler B, Lewis A. Factors Associated With DNR Status After Nontraumatic Intracranial Hemorrhage. Neurohospitalist 2020; 10:168-175. [PMID: 32549939 DOI: 10.1177/1941874419873812] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage. Methods We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status. Results Of 88 patients who met inclusion criteria, 6 (7%) were do not resuscitate (DNR) on admission (aDNR). Do not resuscitate on admission patients were significantly older than those who were full code on admission (P = 0.04). There was no significant difference between admission code status and sex, marital status, active cancer, premorbid mRS, admission Glasgow Coma scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, or bleed severity. At discharge, 66 (75%) patients were full code (dFULL), 11 (13%) were DNR (dDNR), and 11 (13%) were comfort care. African American and Hispanic patients were significantly more likely to be dFULL than Asian or white patients (P = .01) and less likely to be seen by palliative care (P = .004). Patients with less aggressive code status had higher median APACHE II scores (P = .008) and were more likely to have active cancer (P = .06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity. Conclusions Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.
Collapse
Affiliation(s)
- Kaitlyn Lillemoe
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Aaron Lord
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Jose Torres
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Koto Ishida
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Barry Czeisler
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| |
Collapse
|
30
|
Ufere NN, Halford JL, Caldwell J, Jang MY, Bhatt S, Donlan J, Ho J, Jackson V, Chung RT, El-Jawahri A. Health Care Utilization and End-of-Life Care Outcomes for Patients With Decompensated Cirrhosis Based on Transplant Candidacy. J Pain Symptom Manage 2020; 59:590-598. [PMID: 31655192 PMCID: PMC7024665 DOI: 10.1016/j.jpainsymman.2019.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 08/20/2019] [Revised: 10/14/2019] [Accepted: 10/17/2019] [Indexed: 12/19/2022]
Abstract
CONTEXT Patients with decompensated cirrhosis have high rates of health care utilization at end of life (EOL). However, the impact of transplant candidacy on intensity of EOL care is currently unknown. OBJECTIVES To assess the relationship between transplant candidacy and intensity of EOL care in the last year of life in an ambulatory cohort of patients with decompensated cirrhosis. METHODS We performed a retrospective analysis of 230 patients with decompensated cirrhosis who were evaluated for liver transplantation in a large health care system between 1/1/2010 and 12/31/2017 and died by 6/20/2018. We compared health care utilization in the last year of life and EOL care outcomes between transplant-listed (n = 133) and nonlisted (n = 97) patients. We examined predictors of palliative and hospice care utilization using multivariate logistic regression. RESULTS During the last year of life, patients had a median of three hospitalizations (IQR 2-5) and spent a median of 31 days (IQR 16-49) in the hospital. In all, 80% of patients died in the hospital, with 70% dying in the intensive care unit. The majority (70.0%) received a life-sustaining procedure (mechanical ventilation, renal replacement therapy, or cardiopulmonary resuscitation) during their terminal hospitalization, which did not differ between transplant-listed and nonlisted patients (74.4% vs. 63.9%, P = 0.09). Transplant-listed patients had lower odds of receiving specialty palliative care (odds ratio 0.43, P = 0.005). Patients with hepatocellular carcinoma had higher odds of receiving hospice care (odds ratio 2.03, P = 0.049). CONCLUSION Patients with decompensated cirrhosis had intensive health care utilization during their last year of life regardless of transplant candidacy. Further work is needed to optimize their EOL care, particularly for patients who are ineligible for transplantation.
Collapse
Affiliation(s)
- Nneka N Ufere
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | | | | | | | - Sunil Bhatt
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Donlan
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Janet Ho
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond T Chung
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
31
|
Harari DY, Macauley RC. Betting on CPR: a modern version of Pascal's Wager. J Med Ethics 2020; 46:110-113. [PMID: 31527140 DOI: 10.1136/medethics-2019-105558] [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] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/28/2019] [Accepted: 09/01/2019] [Indexed: 06/10/2023]
Abstract
Many patients believe that cardiopulmonary resuscitation (CPR) is more likely to be successful than it really is in clinical practice. Even when working with accurate information, some nevertheless remain resolute in demanding maximal treatment. They maintain that even if survival after cardiac arrest with CPR is extremely low, the fact remains that it is still greater than the probability of survival after cardiac arrest without CPR (ie, zero). Without realising it, this line of reasoning is strikingly similar to Pascal's Wager, a Renaissance-era argument for accepting the proposition for God's existence. But while the original argument is quite logical-if not universally compelling-the modern variant makes several erroneous assumptions. The authors here present a case of a patient who unwittingly appeals to Pascal's Wager to explain his request for maximal treatment, in order to highlight the crucial divergences from the original Wager. In understanding the faulty assumptions inherent in the application of Pascal's Wager to code status decisions-and identifying the underlying motivations which the Wager serves to confirm-providers can better ensure that the true values and preferences of patients are upheld.
Collapse
Affiliation(s)
- David Y Harari
- Dept. of Psychiatry, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Robert C Macauley
- Dept. of Pediatrics, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| |
Collapse
|
32
|
Lake RE, Franks L, Meisenberg B. Reducing Discrepancy Between Code Status Orders and Physician Orders for Life-Sustaining Therapies: Results of a Quality Improvement Initiative. Am J Hosp Palliat Care 2020; 37:532-536. [PMID: 31916859 DOI: 10.1177/1049909119899079] [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: 11/15/2022] Open
Abstract
BACKGROUND Advanced care planning through Physician Order For Life-Sustaining Therapies (POLST) has been encouraged by professional societies. But these documents may be overlooked or ignored during hospitalization and "full-code" orders written as a default, putting patients at risk for unwanted resuscitation. After 2 instances of unwanted resuscitation in which limited support POLSTs were ignored, a series of improvements were implemented. This study measured the effectiveness of those steps in reducing POLST code status discrepancy. METHODS Pre-post implementation chart review of randomly chosen medical admissions to determine the rate of discordance between POLST orders (when present) and admission code status orders. Physician Order For Life-Sustaining Therapies were classified as either "full" or "limited" based on orders for life-sustaining therapies on the form. Chi-square tests or Fisher exact tests were performed on binary data to identify statistically significant differences at the 95% confidence level between pre- and postimplementation admissions. RESULTS In all, 444 preimplementation and 448 postimplementation admissions were evaluated. Discrepant code status orders for those with limited POLST fell from 10 (22.7%) of 44 preimplementation to 3 (4.6%) of 65 after implementation, P = .006. The number of documented code status discussions in admission notes increased from 19.6% to 63.6% (P < .001). The median age of all POLST in the chart was 1.2 years. CONCLUSIONS Among those patients with limited POLST orders, discrepant full-code orders increase the potential for unwanted resuscitation. Multistep improvements including documentation templates improved the process of verifying end-of-life wishes and increased meaningful code status discussions. The rate of discrepant orders fell in response to process improvements.
Collapse
Affiliation(s)
- Rachel Elisabeth Lake
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,Research Institute and Department of Medicine, Anne Arundel Medical Center Inc, Annapolis, MD, USA
| | - Lori Franks
- Department of Medicine, Anne Arundel Medical Center Inc, Annapolis, MD, USA
| | - Barry Meisenberg
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,Research Institute and Department of Medicine, Anne Arundel Medical Center Inc, Annapolis, MD, USA
| |
Collapse
|
33
|
Rubins JB, Kinzie SD, Rubins DM. Predicting Outcomes of In-Hospital Cardiac Arrest: Retrospective US Validation of the Good Outcome Following Attempted Resuscitation Score. J Gen Intern Med 2019; 34:2530-2535. [PMID: 31512185 PMCID: PMC6848295 DOI: 10.1007/s11606-019-05314-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 12/17/2018] [Revised: 05/15/2019] [Accepted: 08/07/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Providers should estimate a patient's chance of surviving an in-hospital cardiac arrest with good neurologic outcome when initially admitting a patient, in order to participate in shared decision making with patients about their code status. OBJECTIVE To examine the utility of the "Good Outcome Following Attempted Resuscitation (GO-FAR)" score in predicting prognosis after in-hospital cardiac arrest in a US trauma center. DESIGN Retrospective observational study SETTING: Level 1 trauma and academic hospital in Minneapolis, MN, USA PARTICIPANTS: All cases of pulseless in-hospital cardiac arrest occurring in adults (18 years or older) admitted to the hospital between Jan 2009 and Sept 2018 are included. For patients with more than one arrest, only the first was included in this analysis. MAIN MEASURES For each patient with verified in-hospital cardiac arrest, we calculated a GO-FAR score based on variables present in the electronic health record at time of admission. Pre-determined outcomes included survival to discharge and survival to discharge with good neurologic outcome. KEY RESULTS From 2009 to 2018, 403 adults suffered in-hospital cardiac arrest. A majority (65.5%) were male with a mean age of 60.3 years. Overall survival to discharge was 33.0%; survival to discharge with good neurologic outcome was 17.4%. GO-FAR score calculated at the time of admission correlated with survival to discharge with good neurologic outcome (AUC 0.68), which occurred in 5.3% of patients with below average survival likelihood by GO-FAR score, 22.5% with average survival likelihood, and 34.1% with above average survival likelihood. CONCLUSIONS The GO-FAR score can estimate, at time of admission to the hospital, the probability that a patient will survive to discharge with good neurologic outcome after an in-hospital cardiac arrest. This prognostic information can help providers frame discussions with patients on admission regarding whether to attempt cardiopulmonary resuscitation in the event of cardiac arrest.
Collapse
Affiliation(s)
- Jeffrey B Rubins
- Palliative Care Division, Hennepin Healthcare , University of Minnesota, Minneapolis, MN, USA.
| | - Spencer D Kinzie
- Division of General Internal Medicine, Hennepin Healthcare , University of Minnesota, Minneapolis, MN, USA
| | - David M Rubins
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
34
|
Ufere NN, Brahmania M, Sey M, Teriaky A, El-Jawahri A, Walley KR, Celi LA, Chung RT, Rush B. Outcomes of in-hospital cardiopulmonary resuscitation for patients with end-stage liver disease. Liver Int 2019; 39:1256-1262. [PMID: 30809903 DOI: 10.1111/liv.14079] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 09/12/2018] [Revised: 12/29/2018] [Accepted: 02/21/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS There have been improving survival trends after in-hospital cardiac arrest for the general population, but there is limited information on the outcomes of hospitalized patients with end-stage liver disease (ESLD) who undergo cardiopulmonary resuscitation (CPR). We aimed to examine survival to hospital discharge after receipt of in-hospital CPR in patients with ESLD using a nationally representative sample. METHODS We used the Nationwide Inpatient Sample database from 2006 to 2014 to identify adult patients who underwent in-hospital CPR. Using multivariate modelling, we compared survival to hospital discharge for patients with ESLD to those without ESLD. We also compared outcomes of patients with ESLD to patients with metastatic cancer. RESULTS A total of 177 533 patients underwent in-hospital CPR, of which 1474 (0.8%) had ESLD. Patients with ESLD had lower rates of survival to hospital discharge compared to patients without ESLD (10.7% vs 28.6%, P < 0.01). In multivariate modelling, ESLD was significantly associated with lower odds of survival to hospital discharge after in-hospital CPR (OR 0.35, 95% CI 0.28-0.44, P < 0.01). Among survivors of in-hospital CPR, ESLD patients had a significantly lower chance of discharge to home compared to patients without ESLD (3.2% vs 8.0%, P < 0.05). Patients with ESLD also had lower rates of survival to hospital discharge compared to those with metastatic cancer (10.7% vs 15.5%, P < 0.01). CONCLUSIONS Outcomes are poor after in-hospital CPR in patients with ESLD and are worse than for patients with metastatic cancer. The current analysis can be used to inform goals of care discussions for patients with ESLD.
Collapse
Affiliation(s)
- Nneka N Ufere
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Mayur Brahmania
- Division of Gastroenterology, Department of Medicine, London Health Sciences Center, University of Western Ontario, London, ON, Canada
| | - Michael Sey
- Division of Gastroenterology, Department of Medicine, London Health Sciences Center, University of Western Ontario, London, ON, Canada
| | - Anouar Teriaky
- Division of Gastroenterology, Department of Medicine, London Health Sciences Center, University of Western Ontario, London, ON, Canada
| | - Areej El-Jawahri
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Keith R Walley
- Division of Critical Care Medicine, Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Leo A Celi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Raymond T Chung
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Barret Rush
- Division of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
35
|
Tabibian BE, Salehani AA, Kuhn EN, Davis MC, Shank CD, Fisher Iii WS. Transitioning the Treatment Paradigm: How Early Palliative Care Service Involvement Affects the End-of-Life Course for Critically Ill Patients in the Neuro-Intensive Care Unit. J Palliat Med 2018; 22:489-492. [PMID: 30489190 DOI: 10.1089/jpm.2018.0428] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 11/12/2022] Open
Abstract
Background: Involvement of the palliative care service has potential for patient and family benefit in critically ill patients, regardless of etiology. Anecdotally, there is a lack of involvement of the palliative care (PC) service in the neuro-intensive care unit (neuro-ICU), and its impact has not been rigorously investigated in this setting. Objective: This study aims at assessing the effect of early involvement of the PC service on end-of-life care in the neuro-ICU. Design: Demographic variables and elements pertaining to the end-of-life care were obtained retrospectively via the electronic medical record from patients receiving their care at the University of Alabama at Birmingham Hospital neuro-ICU. The patient population was divided into two cohorts: patients who received PC services and patients who did not. Contingency analysis was performed to assess for associations with PC service involvement. Results: A total of 149 patients were included in the study. PC services were included in 56.4% of the cases. Involvement of the PC service led to more code status changes to comfort care-do-not-resuscitate p = 0.0021. This was more often a decremental change to less invasive measures rather than a direct change from full code to comfort care measures (p = 0.026). When PC specialists were involved, medications to treat anxiety/agitation, dyspnea/pain, and respiratory secretions were utilized more frequently (p < 0.001) and fewer procedures were performed on these critically ill patients within 48 hours of death (p < 0.001). Conclusion: Early involvement of the PC service has an impact on adjusting the treatment paradigm for patients suffering from devastating neurologic injuries. We recommend the creation of a standardized protocol to ensure early PC consultation in the neuro-ICU based on initial patient presentation parameters, imaging characteristics, and prognosis.
Collapse
Affiliation(s)
- Borna E Tabibian
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Arsalaan A Salehani
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth N Kuhn
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Matthew C Davis
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Christopher D Shank
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Winfield S Fisher Iii
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
36
|
Schoonover K, Herber A, Heusinkvelt S, Yadav H, Burton MC. Case-Based PowerPoint to Improve Knowledge and Comfort of Having Code Status Discussions by Physician Assistant and Nurse Practitioner Students. J Palliat Care 2018; 34:215-217. [PMID: 30381991 DOI: 10.1177/0825859718810725] [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: 11/16/2022]
Abstract
BACKGROUND Little is known about how certain educational interventions may improve informed code status discussions by physician assistant (PA) and nurse practitioner students. METHODS This is a prospective, prospective, single academic center pilot study utilizing a short case-based PowerPoint that reviewed the differences between code status choices and the likelihood of survival to hospital discharge of attempted resuscitation after a cardiac arrest. Training occurred between September 1, 2017, and May 31, 2018. The study population included PA and adult gerontology acute care nurse practitioner (AGACNP) students during their inpatient internal medicine rotation (n = 9) and preclinical PA students (n = 5). RESULTS After training, there was a significant increase in knowledge in the likelihood of survival to hospital discharge (P = .01) and comfort level in having an informed code status discussion (3.36 ± 0.81 vs 4.10 ± 0.80, P = .02). For questions related to identification of the correct code status, there were no significant differences before and after the intervention. CONCLUSION A short case-based PowerPoint viewed by PA and AGACNP students increased the knowledge about the likelihood of survival to hospital discharge of attempted resuscitation after a cardiac arrest and increased the comfort level of having code status discussions with patients by PA and AGACNP students.
Collapse
Affiliation(s)
| | - Andrew Herber
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sally Heusinkvelt
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hemang Yadav
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Caroline Burton
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
37
|
Escher M, Cullati S, Hudelson P, Nendaz M, Ricou B, Perneger T, Dayer P. Admission to intensive care: A qualitative study of triage and its determinants. Health Serv Res 2018; 54:474-483. [PMID: 30362106 DOI: 10.1111/1475-6773.13076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 11/30/2022] Open
Abstract
OBJECTIVE To examine physicians' decision making and its determinants about admission to intensive care. DATA SOURCES/STUDY SETTING ICU physicians (n = 12) and internists (n = 12) working in a Swiss tertiary care hospital. STUDY DESIGN We conducted in-depth interviews. DATA COLLECTION/EXTRACTION METHODS Interviews were analyzed using an inductive thematic approach. PRINCIPAL FINDINGS Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life-death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians' postponing the decision because of lack of beds, ICU physicians' dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician. CONCLUSIONS Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.
Collapse
Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.,Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stéphane Cullati
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Patricia Hudelson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Bara Ricou
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Perneger
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| |
Collapse
|
38
|
Barwise A, Jaramillo C, Novotny P, Wieland ML, Thongprayoon C, Gajic O, Wilson ME. Differences in Code Status and End-of-Life Decision Making in Patients With Limited English Proficiency in the Intensive Care Unit. Mayo Clin Proc 2018; 93:1271-1281. [PMID: 30100192 PMCID: PMC7643629 DOI: 10.1016/j.mayocp.2018.04.021] [Citation(s) in RCA: 34] [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: 01/11/2018] [Revised: 03/28/2018] [Accepted: 04/17/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine whether code status, advance directives, and decisions to limit life support were different for patients with limited English proficiency (LEP) in the intensive care unit (ICU) as compared with patients whose primary language was English. PATIENTS AND METHODS We conducted a retrospective cohort study in adult patients admitted to 7 ICUs in a single tertiary academic medical center from May 31, 2011, through June 1, 2014. RESULTS Of the 27,523 patients admitted to the ICU, 779 (2.8%) had LEP. When adjusted for severity of illness, sex, education level, and insurance status, patients with LEP were less likely to change their code status from full code to do not resuscitate during ICU admission (odds ratio [OR], 0.62; 95% CI, 0.46-0.82; P<.001) and took 3.8 days (95% CI, 1.9-5.6 days; P<.001) longer to change to do not resuscitate. Patients with LEP who died in the ICU were less likely to receive a comfort measures order set (OR, 0.38; 95% CI, 0.16-0.91; P=.03) and took 19.1 days (95% CI, 13.2-25.1 days; P<.001) longer to transition to comfort measures only. Patients with LEP were less likely to have an advance directive (OR, 0.23; 95% CI, 0.18-0.29; P<.001), more likely to receive mechanical ventilation (OR, 1.26; 95% CI, 1.07-1.48; P=.005), and more likely to have restraints used (OR, 1.36; 95% CI, 1.11-1.65; P=.003). The hospital length of stay was 2.7 days longer for patients with LEP. Additional adjustment for religion, race, and age yielded similar results. CONCLUSION There are important differences in end-of-life care and decision making for patients with LEP.
Collapse
Affiliation(s)
- Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Biomedical Ethics Program, Mayo Clinic, Rochester, MN.
| | | | - Paul Novotny
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Mark L Wieland
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Michael E Wilson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Biomedical Ethics Program, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| |
Collapse
|
39
|
El-Jawahri A, Lau-Min K, Nipp RD, Greer JA, Traeger LN, Moran SM, D'Arpino SM, Hochberg EP, Jackson VA, Cashavelly BJ, Martinson HS, Ryan DP, Temel JS. Processes of code status transitions in hospitalized patients with advanced cancer. Cancer 2017; 123:4895-4902. [PMID: 28881383 DOI: 10.1002/cncr.30969] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 06/15/2017] [Revised: 08/06/2017] [Accepted: 08/08/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown. METHODS We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes that led to code status order transitions from full code to DNR. RESULTS In total, 1047 hospitalizations were reviewed among 728 patients. Admitting clinicians did not address code status in 53% of hospitalizations, resulting in code status orders of "presumed full." In total, 275 patients (26.3%) transitioned from full code to DNR, and 48.7% (134 of 275 patients) of those had an order of "presumed full" at admission; however, upon further clarification, the patients expressed that they had wished to be DNR before the hospitalization. We identified 3 additional processes leading to order transition from full code to DNR acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared with discontinuing therapy and education, transitions because of acute clinical deterioration were associated with less patient involvement (P = .002), a shorter time to death (P < .001), and a greater likelihood of inpatient death (P = .005). CONCLUSIONS One-half of code status order changes among hospitalized patients with advanced cancer were because of full code orders in patients who had a preference for DNR before hospitalization. Transitions due of acute clinical deterioration were associated with less patient engagement and a higher likelihood of inpatient death. Cancer 2017;123:4895-902. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Areej El-Jawahri
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Kelsey Lau-Min
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ryan D Nipp
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Lara N Traeger
- Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Samantha M Moran
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sara M D'Arpino
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Vicki A Jackson
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Holly S Martinson
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David P Ryan
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
40
|
Abstract
BACKGROUND It is unknown how many hospice enrollees elect to be full code and if this is associated with higher hospice live discharge rates. OBJECTIVE To measure the rates of hospice enrollees electing full code, the characteristics predicting full code status, and the association of full code status with various hospice live discharge patterns. DESIGN Retrospective cohort study of electronic medical record data. SETTING/SUBJECTS A total of 25,636 decedents enrolled in two Michigan hospices between 2009 and 2014. MEASUREMENTS Code status was defined as full code versus do-not-resuscitate (DNR) orders. Covariates include demographics, location (home, hospice facility, nursing home, and hospital), primary diagnosis, and length of stay. Hospice live discharge was defined as short (0-14 days), medium (15-179 days), and long (>179 days). RESULTS A total of 12.9% of hospice enrollees elected full code status. This was significantly (p < 0.05) predicted by male sex, younger age, nonwhite race, home setting of care, and cancer diagnosis. Those with full code status had 1.76 times the adjusted odds of hospice live discharge compared with those with DNR orders (95% confidence interval [CI] 1.44-2.16) and 2.47 times the odds of short live discharge (95% CI 1.69-3.62) with no significant difference in long live discharge. The association of full code orders with hospice live discharge was stronger for nonwhite enrollees, with a live discharge rate of 23.8% versus 11.6% for African Americans with full code versus DNR orders. CONCLUSIONS Those electing full code status on admission to hospice are at high risk of live hospice discharge after short enrollments, particularly nonwhite enrollees.
Collapse
Affiliation(s)
- Claire K Ankuda
- 1 Robert Wood Johnson Clinical Scholars Program, University of Michigan , Ann Arbor, Michigan.,2 Department of Family Medicine, University of Michigan , Ann Arbor, Michigan
| | - Evan Fonger
- 3 Hospice of Michigan , Detroit, Michigan.,4 Arbor Hospice , Ann Arbor, Michigan
| | - Thomas O'Neil
- 4 Arbor Hospice , Ann Arbor, Michigan.,5 Department of Geriatric and Palliative Medicine, University of Michigan , Ann Arbor, Michigan
| |
Collapse
|
41
|
Abstract
IMPORTANCE Hip fracture in the elderly patients is associated with increased morbidity and mortality. There is great need for advance care planning should a patient fail to rehabilitate or experience an adverse event during or after recovery. This study was performed to evaluate for palliative care consultation and changes in code status and/or advance directives in elderly patients with hip fracture. METHODS We performed a retrospective review of 186 consecutive patients aged 65 years and older with a hip fracture due to a low-energy fall who underwent surgery at a large academic institution between August 1, 2013, and September 1, 2014. Risk factors assessed were patient demographics, home status, mobility, code status, comorbidities, medications, and hospitalizations prior to injury. Outcomes of interest included palliative care consultation, complications, mortality, and most recent code status, mobility, and home. RESULTS About 186 patients with hip fractures were included. Three patients died, and 12 (6.5%) sustained major complications during admission. Nearly one-third (51 patients) died upon final follow-up approximately 1.5 years after surgery. Of the patients who died, palliative care consulted on 6 (11.8%) during initial admission. Eleven (21.6%) were full code at death. Three patients underwent cardiopulmonary resuscitation (CPR) and 1 underwent massive transfusion and extracorporeal membrane oxygenation prior to changing their code status to do not attempt resuscitation. CONCLUSION Hip fracture in elderly patients is an important opportunity to reassess the patient's personal health-care priorities. Advance directives, goals of care, and code status documentation should be updated in all elderly patients with hip fracture, should the patient's health decompensate.
Collapse
|
42
|
Huber MT, Highland JD, Krishnamoorthi VR, Tang JWY. Utilizing the Electronic Health Record to Improve Advance Care Planning: A Systematic Review. Am J Hosp Palliat Care 2017. [PMID: 28627287 DOI: 10.1177/1049909117715217] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [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: 11/17/2022] Open
Abstract
PURPOSE Advance care planning may ensure care that is concordant with patient wishes. However, advance care plans are frequently absent when needed due to failure to engage patients in planning, inability to access prior documentation, or poor documentation quality. Interventions utilizing tools within the electronic health record (EHR) may address these barriers at the point of care. We aimed to identify EHR interventions previously utilized to improve advance care plans. METHODS We systematically searched 7 databases for observational and experimental studies of EHR interventions associated with advance care plans. We abstracted information on the study populations, EHR and non-EHR components of the interventions, and the efficacy for advance care plan-related outcomes. RESULTS We identified 16 articles that contained an EHR intervention to improve advance care plans. Study populations, study designs, and EHR components of the interventions were heterogeneous. Documentation templates were the most common EHR tool reported (n = 8), followed by automated prompts (n = 7) and electronic order sets (n = 5). The most common reported outcomes were documentation of an advance care planning conversation in the EHR (n = 7) and the placement of code status orders (n = 7). All studies reporting efficacy (n = 9) demonstrated an improvement in 1 or more advance care planning outcomes. CONCLUSIONS The use of EHR interventions may improve advance care plan completion and availability at the point of care. Further work should seek to develop and evaluate standardized EHR tools for advance care planning.
Collapse
Affiliation(s)
- Michael Todd Huber
- 1 Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | | | - Joyce Wing-Yi Tang
- 1 Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| |
Collapse
|
43
|
Galambos C, Starr J, Rantz MJ, Petroski GF. Analysis of Advance Directive Documentation to Support Palliative Care Activities in Nursing Homes. Health Soc Work 2016; 41:228-234. [PMID: 29206978 DOI: 10.1093/hsw/hlw042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/03/2015] [Indexed: 06/07/2023]
Abstract
As part of an intervention to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions, 1,877 resident records were reviewed for advance directive (AD) documentation. At the initial phases of the intervention, 50 percent of the records contained an AD. Of the ADs in the resident records, 55 percent designated a durable power of attorney for health care, most often a child (62 percent), other relative (14 percent), or spouse (13 percent). Financial power of attorney documents were sometimes found within the AD, even though these documents focused on financial decision making rather than health care decision making. Code status was the most prevalent health preference documented in the record at 97 percent of the records reviewed. The intervention used these initial findings and the philosophical framework of respect for autonomy to develop education programs and services on advance care planning. The role of the social worker within an interdisciplinary team is discussed.
Collapse
Affiliation(s)
- Colleen Galambos
- Graduate Certificate in Gerontological Social Work Program, School of Social Work, University of Missouri, Columbia, MO
| | - Julie Starr
- Urogynecology, University of Missouri Women's Health Center, Columbia
| | - Marilyn J Rantz
- Sinclair School of Nursing, University of Missouri, Columbia
| | | |
Collapse
|
44
|
Chavez LO, Einav S, Varon J. When Terminal Illness Is Worse Than Death: A Multicenter Study of Health-Care Providers' Resuscitation Desires. Am J Hosp Palliat Care 2016; 34:820-824. [PMID: 27488959 DOI: 10.1177/1049909116662195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/17/2022] Open
Abstract
PURPOSE To investigate how a terminal illness may affect the health-care providers' resuscitation preferences. METHODS We conducted a cross-sectional survey in 9 health-care institutions located in 4 geographical regions in North and Central America, investigating attitudes toward end-of-life practices in health-care providers. Statistical analysis included descriptive statistics and χ2 test for the presence of associations ( P < 0.05 being significant) and Cramer V for the strength of the association. The main outcome measured the correlation between the respondents' present code status and their preference for cardiopulmonary resuscitation (CPR) in case of terminal illness. RESULTS A total of 852 surveys were completed. Among the respondents, 21% (n = 180) were physicians, 36.9% (n = 317) were nurses, 10.5% (n = 90) were medical students, and 265 participants were other staff members of the institutions. Most respondents (58.3%; n = 500) desired "definitely full code" (physicians 73.2%; n = 131), only 13.8% of the respondents (physicians 8.33%; n = 15) desired "definitely no code" or "partial support," and 20.9% of the respondents (n = 179; among physicians 18.4%; n = 33) had never considered their code status. There was an association between current code status and resuscitation preference in case of terminal illness ( P < .001), but this association was overall quite weak (Cramer V = 0.180). Subgroup analysis revealed no association between current code status and terminal illness code preference among physicians ( P = .290) and nurses ( P = .316), whereupon other hospital workers were more consistent ( P < .01, Cramer V = .291). CONCLUSION Doctors and nurses have different end-of-life preferences than other hospital workers. Their desire to undergo CPR may change when facing a terminal illness.
Collapse
Affiliation(s)
- Luis O Chavez
- 1 Facultad de Medicina y Psicología, Universidad Autónoma de Baja California, Tijuana, México
| | - Sharon Einav
- 2 Faculty of Medicine, Shaare Zedek Medical Center, Hadassah-Hebrew University, Jerusalem, Israel
| | - Joseph Varon
- 3 Foundation Surgical Hospital of Houston, Houston, TX, USA
| |
Collapse
|
45
|
Shah K, Swinton M, You JJ. Barriers and facilitators for goals of care discussions between residents and hospitalised patients. Postgrad Med J 2016; 93:127-132. [PMID: 27450314 DOI: 10.1136/postgradmedj-2016-133951] [Citation(s) in RCA: 14] [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: 01/09/2016] [Revised: 05/05/2016] [Accepted: 07/03/2016] [Indexed: 11/04/2022]
Abstract
PURPOSE To observe how residents are engaging in goals of care discussions with patients and identify thematic patterns that inhibited (barriers) and promoted discussion (facilitators) about goals of care. DESIGN Admission encounters between residents and patients admitted to a tertiary care academic hospital were recorded and analysed using a qualitative descriptive method. Patients included in the study were individuals over the age of 65 being admitted to the internal medicine service. Residents were eligible if they were trainees in family medicine, emergency medicine, general surgery or internal medicine who were on call for the inpatient medicine rotation. RESULTS A total of 15 resident-patient encounters were recorded and analysed, of which 12 encounters included a goals of care discussion. Barriers to goals of care discussions were due to missed opportunities to clarify patient's preferences for life-sustaining treatment and missed opportunities to engage the patient in further discussion. Facilitators to goals of care discussions were use of simple language and exploration of patient's previous experiences with life-sustaining treatment. CONCLUSIONS Asking about patients' previous experiences with life support can be an effective strategy to gauge the patient's understanding and goals of care preferences. This knowledge can improve residents' skill in communicating with their patients about goals of care and inform future education initiatives.
Collapse
Affiliation(s)
- Kalpa Shah
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marilyn Swinton
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - John J You
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
46
|
Hiraoka E, Homma Y, Norisue Y, Naito T, Kataoka Y, Hamada O, Den Y, Takahashi O, Fujitani S. What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective. Int J Gen Med 2016; 9:213-20. [PMID: 27418851 PMCID: PMC4935165 DOI: 10.2147/ijgm.s105302] [Citation(s) in RCA: 12] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Japan has no official guidelines for do-not-resuscitate (DNR) orders. Therefore, we investigated the effect of DNR orders on physician decision making in relation to performing noncardiopulmonary resuscitation (CPR) and CPR procedures. Methods A case-scenario-based questionnaire that included a case of advanced cancer, a case of advanced dementia, and a case of nonadvanced heart failure was administered to physicians. The questions determined whether physicians would perform different non-CPR procedures and CPR procedures in the presence or absence of DNR orders. The number of non-CPR procedures each physician would perform and the number of physicians who would perform each non-CPR and CPR procedure in the absence and presence of DNR ocrders were compared. Physicians from three Japanese municipal acute care hospitals participated. Results We analyzed 111 of 161 (69%) questionnaires. Physicians would perform significantly fewer non-CPR procedures in the presence of DNR orders than in the absence of DNR orders for all three case scenarios (median [interquartile range] percentages: Case 1: 72% [45%–90%] vs 100% [90%–100%]; Case 2: 55% [36%–72%] vs 91% [63%–100%]; Case 3: 78% [55%–88%] vs 100% [88%–100%]). Fewer physicians would perform non-CPR and CPR procedures in the presence of DNR orders than in the absence of DNR orders. However, considerable numbers of physicians would perform electric shock treatment for ventricular fibrillation in the presence of DNR orders (Case 1: 26%; Case 2: 16%; Case 3: 20%). Conclusion DNR orders affect physician decision making about performing non-CPR procedures. Although some physicians would perform CPR for ventricular fibrillation in the presence of DNR orders, others would not. Therefore, a consensus definition for DNR orders should be developed in Japan, otherwise DNR orders may cause harm.
Collapse
Affiliation(s)
| | | | - Yasuhiro Norisue
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | | | | | | | - Yo Den
- Department of Internal Medicine
| | - Osamu Takahashi
- Department of Internal Medicine, St Luke's International Hospital, Tokyo, Japan
| | - Shigeki Fujitani
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| |
Collapse
|
47
|
Amro OW, Ramasamy M, Strom JA, Weiner DE, Jaber BL. Nephrologist-Facilitated Advance Care Planning for Hemodialysis Patients: A Quality Improvement Project. Am J Kidney Dis 2016; 68:103-9. [PMID: 26806003 DOI: 10.1053/j.ajkd.2015.11.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [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: 07/14/2015] [Accepted: 11/30/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The Renal Physicians Association's clinical practice guideline recommends that physicians address advance care planning with dialysis patients. However, data are lacking about how best to implement this recommendation. STUDY DESIGN Quality improvement project. SETTINGS & PARTICIPANTS Nephrologists caring for patients treated with maintenance hemodialysis at 2 dialysis facilities identified patients who might benefit most from advance care planning using the "surprise" question ("Would I be surprised if this patient died in the next year?"). QUALITY IMPROVEMENT PLAN Patients identified with a "no" response to the surprise question were invited to participate in nephrologist-facilitated advance care planning, including completion of a Medical Orders for Life-Sustaining Treatment (MOLST) form. OUTCOMES Change in MOLST completion rate and identification of preferences for limits on life-sustaining treatment. MEASUREMENTS Pre- and postintervention code status, MOLST completion rate, and vital status at 1 year. RESULTS Nephrologists answered "no" to the surprise question for 50 of 201 (25%) hemodialysis patients. Of these, 41 (82%) patients had a full-code status and 9 (18%) had a do-not-resuscitate (DNR) status. Encounters lasted 15 to 60 minutes. Following the encounter, 21 (42%) patients expressed preference for a DNR status and 29 (58%) maintained full-code status (P=0.001). The MOLST completion rate increased from 10% to 90%. One-year survival for patients whose nephrologists answered "no" to the surprise question was 58% compared to 92% for those with a "yes" answer (P<0.001). LIMITATIONS Sample size and possible nonrepresentative dialysis population. CONCLUSIONS Nephrologist-facilitated advance care planning targeting hemodialysis patients with limited life expectancy led to significant changes in documented patient preferences for cardiopulmonary resuscitation and limits on life-sustaining treatment. These changes demonstrate the benefit of advance care planning with dialysis patients and likely reflect better understanding of end-of-life treatment options.
Collapse
Affiliation(s)
- Osama W Amro
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Malar Ramasamy
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - James A Strom
- Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Nephrology, Department of Medicine, St Elizabeth Medical Center, Boston, MA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Bertrand L Jaber
- Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Nephrology, Department of Medicine, St Elizabeth Medical Center, Boston, MA.
| |
Collapse
|
48
|
Merja S, Lilien RH, Ryder HF. Clinical Prediction Rule for Patient Outcome after In-Hospital CPR: A New Model, Using Characteristics Present at Hospital Admission, to Identify Patients Unlikely to Benefit from CPR after In-Hospital Cardiac Arrest. Palliat Care 2015; 9:19-27. [PMID: 26448686 PMCID: PMC4578558 DOI: 10.4137/pcrt.s28338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 04/27/2015] [Revised: 07/20/2015] [Accepted: 08/05/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Physicians and patients frequently overestimate likelihood of survival after in-hospital cardiopulmonary resuscitation. Discussions and decisions around resuscitation after in-hospital cardiopulmonary arrest often take place without adequate or accurate information. METHODS We conducted a retrospective chart review of 470 instances of resuscitation after in-hospital cardiopulmonary arrest. Individuals were randomly assigned to a derivation cohort and a validation cohort. Logistic Regression and Linear Discriminant Analysis were used to perform multivariate analysis of the data. The resultant best performing rule was converted to a weighted integer tool, and thresholds of survival and nonsurvival were determined with an attempt to optimize sensitivity and specificity for survival. RESULTS A 10-feature rule, using thresholds for survival and nonsurvival, was created; the sensitivity of the rule on the validation cohort was 42.7% and specificity was 82.4%. In the Dartmouth Score (DS), the features of age (greater than 70 years of age), history of cancer, previous cardiovascular accident, and presence of coma, hypotension, abnormal PaO2, and abnormal bicarbonate were identified as the best predictors of nonsurvival. Angina, dementia, and chronic respiratory insufficiency were selected as protective features. CONCLUSIONS Utilizing information easily obtainable on admission, our clinical prediction tool, the DS, provides physicians individualized information about their patients' probability of survival after in-hospital cardiopulmonary arrest. The DS may become a useful addition to medical expertise and clinical judgment in evaluating and communicating an individual's probability of survival after in-hospital cardiopulmonary arrest after it is validated by other cohorts.
Collapse
Affiliation(s)
- Satyam Merja
- Department of Computer Science, University of Toronto, Toronto, Canada
| | - Ryan H Lilien
- Department of Computer Science, University of Toronto, Toronto, Canada
| | - Hilary F Ryder
- Department of Medicine and the Dartmouth Institute, Dartmouth Medical School, Hanover, NH, USA
- Section of Hospital Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| |
Collapse
|
49
|
Sharma RK, Jain N, Peswani N, Szmuilowicz E, Wayne DB, Cameron KA. Unpacking resident-led code status discussions: results from a mixed methods study. J Gen Intern Med 2014; 29:750-7. [PMID: 24526542 DOI: 10.1007/s11606-014-2791-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 12/03/2013] [Accepted: 01/06/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The quality of code status discussions (CSDs) is suboptimal as physicians often fail to discuss patients' goals of care and resuscitation outcomes. We previously demonstrated that internal medicine residents randomized to a communication skills intervention scored higher than controls on a CSD checklist using a standardized patient. However, the impact of this training on CSD content is unknown. OBJECTIVE Compare CSD content between intervention and control residents. DESIGN We conducted qualitative analysis of simulated CSDs. Augmenting a priori codes with constant comparative analysis, we identified key themes associated with resident determination of code status. We dichotomized each theme as present or absent. We used chi-square tests to evaluate the association between training and presence of each theme. PARTICIPANTS Fifty-six residents rotating on the internal medicine service in July 2010 were randomized to intervention (n = 25) or control (n = 31). INTERVENTION Intervention residents completed CSD skills training (lectures, deliberate practice, and self-study). Six months later, all 56 residents completed a simulated CSD. MAIN MEASURE Comparison of key themes identified in CSDs among intervention and controls. KEY RESULTS Fifty-one transcripts were recorded and reviewed. Themes identified included: exploration of patient values/goals, framing code status as a patient decision, discussion of resuscitation outcomes and quality of life, and making a recommendation regarding code status. Intervention residents were more likely than controls to explore patient values/goals (p = 0.002) and make a recommendation (p < 0.001); and less likely to frame the decision as one solely to be made by the patient (p = 0.01). Less than one-third of residents discussed resuscitation outcomes or quality of life. CONCLUSION Training positively influenced CSD content in key domains, including exploration of patient values/goals, making a recommendation regarding code status, and not framing code status as solely a patient decision. However, despite the intervention, residents infrequently discussed resuscitation outcomes and quality of life.
Collapse
|
50
|
Breault JL. DNR, DNAR, or AND? Is Language Important? Ochsner J 2011; 11:302-306. [PMID: 22190879 PMCID: PMC3241061] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
The American Heart Association in 2005 moved from the traditional do not resuscitate (DNR) terminology to do not attempt resuscitation (DNAR). DNAR reduces the implication that resuscitation is likely and creates a better emotional environment to explain what the order means. Allow natural death (AND) is the name recommended in some settings to make the meaning even clearer. Most hospitals still use the obsolete DNR term. Medical staffs should consider moving to DNAR and in some settings to AND. Language is important.
Collapse
Affiliation(s)
- Joseph L Breault
- Chair, Institutional Review Boards, Ochsner Clinic Foundation, New Orleans, LA
| |
Collapse
|