The Institute of Medicine's report on
called for honoring treatment preferences near the end of life for seriously ill patients. To achieve this objective, the report recommended that patients, their ...family members, other loved ones, and providers engage in shared decision making about current and future treatment decisions (that is, advance care planning). Yet decision science research suggests that preferences are objectively difficult to specify for complex contingencies and subjectively difficult to specify for unfamiliar choices. Because advance care planning involves both difficulties-the future may unfold in complex ways and pose unprecedented choices-it may not fully and faithfully specify patients' preferences. I discuss a powerful but overlooked influence on this planning: local providers' practice norms. Norms often begin as generally accepted procedures but evolve into rules enforced by both external and internal sanctions (such as shame and pride). Local practice norms regarding the timing, content, and interpretation of advance care planning conversations influence patient choice. While the influence of providers on patients' decisions cannot be entirely removed, I recommend increasing providers' awareness of this influence by using audit, feedback, and coaching and by systematizing processes for advance care planning.
Summary Background Although the extent of hospital and intensive-care use at the end of life is well known, patterns of surgical care during this period are poorly understood. We examined national ...patterns of surgical care in the USA among elderly fee-for-service Medicare beneficiaries in their last year of life. Methods We did a retrospective cohort study of elderly beneficiaries of fee-for-service Medicare in the USA, aged 65 years or older, who died in 2008. We identified claims for inpatient surgical procedures in the year before death and examined the relation between receipt of an inpatient procedure and both age and geographical region. We calculated an end-of-life surgical intensity (EOLSI) score for each hospital referral region defined as proportion of decedents who underwent a surgical procedure during the year before their death, adjusted for age, sex, race, and income. We compared patient characteristics with Rao-Scott χ2 tests, resource use with generalised estimating equations, regional differences with generalised estimating equations Wald tests, and end-of-life surgical intensity scores with Spearman's partial-rank-order correlation coefficients. Findings Of 1 802 029 elderly beneficiaries of fee-for-service Medicare who died in 2008, 31·9% (95% CI 31·9–32·0; 575 596 of 1 802 029) underwent an inpatient surgical procedure during the year before death, 18·3% (18·2–18·4; 329 771 of 1 802 029) underwent a procedure in their last month of life, and 8·0% (8·0–8·1; 144 162 of 1 802 029) underwent a procedure during their last week of life. Between the ages of 80 and 90 years, the percentage of decedents undergoing a surgical procedure in the last year of life decreased by 33% (35·3% 95% CI 34·7–35·9; 8858 of 25 094 to 23·6% 22·9–24·3; 3340 of 14 152). EOLSI score in the highest intensity region (Munster, IN) was 34·4 (95% CI 33·7–35·1) and in the lowest intensity region (Honolulu, HI) was 11·5 (11·3–11·7). Regions with a high number of hospital beds per head had high end-of-life surgical intensity (r=0·37, 95% CI 0·27–0·46; p<0·0001), as did regions with high total Medicare spending (r=0·50, 0·41–0·58; p<0·0001). Interpretation Many elderly people in the USA undergo surgery in the year before their death. The rate at which they undergo surgery varies substantially with age and region and might suggest discretion in health-care providers' decisions to intervene surgically at the end of life. Funding None.
Although the number of intensive care unit (ICU) beds in the United States is increasing, it is unknown whether this trend is consistent across all regions.
We sought to better characterize regional ...variation in ICU bed changes over time and identify regional characteristics associated with these changes.
We used data from the Centers for Medicare and Medicaid Services and the U.S. Census to summarize the numbers of hospitals, hospital beds, ICU beds, and ICU occupancy at the level of Dartmouth Atlas hospital referral region from 2000 to 2009. We categorized regions into quartiles of bed change over the study interval and examined the relationship between change categories, regional characteristics, and population characteristics over time.
From 2000 to 2009 the national number of ICU beds increased 15%, from 67,579 to 77,809, mirroring population. However, there was substantial regional variation in absolute changes (median, +16 ICU beds; interquartile range, -3 to +51) and population-adjusted changes (median, +0.9 ICU beds per 100,000; interquartile range, -3.8 to +5.9), with 25.0% of regions accounting for 74.8% of overall growth. At baseline, regions with increasing numbers of ICU beds had larger populations, lower ICU beds per 100,000 capita, higher average ICU occupancy, and greater market competition as measured by the Herfindahl-Hirschman Index (P < 0.001 for all comparisons).
National trends in ICU bed growth are not uniformly reflected at the regional level, with most growth occurring in a small number of highly populated regions.
Many ICUs are moving to models with intensivist staffing 24 hours a day. This study examined outcomes based on ICU staffing models, using data from ICU databases. A mortality benefit was associated ...with nighttime intensivist staffing only in ICUs with low-intensity daytime staffing.
Daytime intensivist physician staffing has been consistently associated with improved outcomes among patients admitted to an intensive care unit (ICU).
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This observation has led to policy initiatives calling for expansion of the intensivist staffing model to encompass all critically ill patients.
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More recently, some experts have proposed further extending the intensivist staffing model to provide care around the clock, with intensivist physicians remaining in the ICU overnight.
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Proponents of 24-hour intensivist staffing suggest that nighttime intensivist staffing may result in earlier establishment of treatment plans, more timely resuscitation of patients in unstable condition, uninterrupted provision of complex care, . . .
In septic shock, the first few hours of care are critical for survival. In this study, two protocols for the care of patients with septic shock were compared with usual care with respect to 60-day ...mortality and other outcomes. There were no significant differences in outcome.
There are more than 750,000 cases of severe sepsis and septic shock in the United States each year.
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Most patients who present with sepsis receive initial care in the emergency department, and the short-term mortality is 20% or more.
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In 2001, Rivers et al. reported that among patients with severe sepsis or septic shock in a single urban emergency department, mortality was significantly lower among those who were treated according to a 6-hour protocol of early goal-directed therapy (EGDT) than among those who were given standard therapy (30.5% vs. 46.5%).
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On the basis of the premise that usual care . . .
ABSTRACT
BACKGROUND
Studies using local samples suggest that racial minorities anticipate a greater preference for life-sustaining treatment when faced with a terminal illness. These studies are ...limited by size, representation, and insufficient exploration of sociocultural covariables.
OBJECTIVE
To explore racial and ethnic differences in concerns and preferences for medical treatment at the end of life in a national sample, adjusting for sociocultural covariables.
DESIGN
Dual-language (English/Spanish), mixed-mode (telephone/mail) survey.
PARTICIPANTS
A total of 2,847 of 4,610 eligible community-dwelling Medicare beneficiaries age 65 or older on July 1, 2003 (62% response).
MEASUREMENTS
Demographics, education, financial strain, health status, social networks, perceptions of health-care access, quality, and the effectiveness of mechanical ventilation (MV), and concerns and preferences for medical care in the event the respondent had a serious illness and less than 1 year to live.
RESULTS
Respondents included 85% non-Hispanic whites, 4.6% Hispanics, 6.3% blacks, and 4.2% “other” race/ethnicity. More blacks (18%) and Hispanics (15%) than whites (8%) want to die in the hospital; more blacks (28%) and Hispanics (21.2%) than whites (15%) want life-prolonging drugs that make them feel worse all the time; fewer blacks (49%) and Hispanics (57%) than whites (74%) want potentially life-shortening palliative drugs, and more blacks (24%, 36%) and Hispanics (22%, 29%) than whites (13%, 21%) want MV for life extension of 1 week or 1 month, respectively. In multivariable analyses, sociodemographic variables, preference for specialists, and an overly optimistic belief in the effectiveness of MV explained some of the greater preferences for life-sustaining drugs and mechanical ventilation among non-whites. Black race remained an independent predictor of concern about receiving too much treatment adjusted OR = 2.0 (1.5–2.7), preference for dying in a hospital AOR = 2.3 (1.6–3.2), receiving life-prolonging drugs 1.9 (1.4–2.6), MV for 1 week 2.3 (1.6–3.3) or 1 month’s 2.1 (1.6–2.9) life extension, and a preference not to take potentially life-shortening palliative drugs 0.4 (0.3–0.5). Hispanic ethnicity remained an independent predictor of preference for dying in the hospital 2.2 (1.3–4.0) and against potentially life-shortening palliative drugs 0.5 (0.3–0.7).
CONCLUSIONS
Greater preference for intensive treatment near the end of life among minority elders is not explained fully by confounding sociocultural variables. Still, most Medicare beneficiaries in all race/ethnic groups prefer not to die in the hospital, to receive life-prolonging drugs that make them feel worse all the time, or to receive MV.
The diffusion of palliative care has been rapid, yet uncertainty remains regarding palliative care's “active ingredients.” The National Consensus Project Guidelines for Quality Palliative Care ...identified eight domains of palliative care. Despite these identified domains, when pressed to describe the specific maneuvers used in clinical encounters, palliative care providers acknowledge that “it's complex.” The field of systems has been used to explain complexity across many different types of systems. Specifically, engineering systems develop a representation of a system that helps manage complexity to help humans better understand the system. Our goal was to develop a system model of what palliative care providers do such that the elements of the model can be described concretely and sequentially, aggregated to describe the high-level domains currently described by palliative care, and connected to the complexity described by providers and the literature. Our study design combined methodological elements from both qualitative research and systems engineering modeling. The model drew on participant observation and debriefing semi-structured interviews with interdisciplinary palliative care team members by a systems engineer. The setting was an interdisciplinary palliative care service in a US rural academic medical center. In the developed system model, we identified 59 functions provided to patients, families, non-palliative care provider(s), and palliative care provider(s). The high-level functions related to measurement, decision-making, and treatment address up to 8 states of an individual, including an overall holistic state, physical state, psychological state, spiritual state, cultural state, personal environment state, and clinical environment state. In contrast to previously described expert consensus domain-based descriptions of palliative care, this model more directly connects palliative care provider functions to emergent behaviors that may explain system-level mechanisms of action for palliative care. Thus, a systems modeling approach provides insights into the challenges surrounding the recurring question of what is in the palliative care “syringe.”
We described what palliative care providers do from a systems perspective.We identified 59 PC functions delivered to patients, families, and providers.Palliative care can now be described as concrete sequential processes.PC may be better described as a system, rather than behavior, level intervention.
Background Injured elderly patients experience high rates of undertriage to trauma centers (TCs) whereas debate continues regarding the age defining a geriatric trauma patient. We sought to identify ...when mortality risk increases in injured patients as the result of age alone to determine whether TC care was associated with improved outcomes for these patients and to estimate the added admissions burden to TCs using an age threshold for triage. Methods We performed a retrospective cohort study of injured patients treated at TCs and non-TCs in Pennsylvania from April 1, 2001, to March 31, 2005. Patients were included if they were between 19 and 100 years of age and had sustained minimal injury (Injury Severity Score < 9). The primary outcome was in-hospital mortality. We analyzed age as a predictor of mortality by using the fractional polynomial method. Results A total of 104,015 patients were included. Mortality risk significantly increased at 57 years (odds ratio 5.58; 95% confidence interval 1.07–29.0; P = .04) relative to 19-year-old patients. TC care was associated with a decreased mortality risk compared with non-TC care (odds ratio 0.83; 95% confidence interval 0.69–0.99; P = .04). Using an age of 70 as a threshold for mandatory triage, we estimated TCs could expect an annual increase of approximately one additional admission per day. Conclusion Age is a significant risk factor for mortality in trauma patients, and TC care improves outcomes even in older, minimally injured patients. An age threshold should be considered as a criterion for TC triage. Use of the clinically relevant age of 70 as this threshold would not impose a substantial increase on annual TC admissions.
Numerous healthcare decisions are faced by persons with advanced cancer from diagnosis to end-of-life. The family caregiver role in these decisions has focused on being a surrogate decision-maker, ...however, little is known about the caregiver's role in supporting upstream patient decision-making. We aimed to describe the roles of family caregivers in assisting community-dwelling advanced cancer patients with healthcare decision-making across settings and contexts.
Qualitative study using one-on-one, semi-structured interviews with community-dwelling persons with metastatic cancer (n = 18) and their family caregivers (n = 20) recruited from outpatient oncology clinics of a large tertiary care academic medical center, between October 2016 and October 2017. Transcribed interviews were analyzed using a thematic analysis approach.
Caregivers averaged 56 years and were mostly female (95%), white (85%), and the patient's partner/spouse (70%). Patients averaged 58 years and were mostly male (67%) in self-reported "fair" or "poor" health (50%) with genitourinary (33%), lung (17%), and hematologic (17%) cancers. Themes describing family member roles in supporting patients' upstream healthcare decision-making were: 1) seeking information about the cancer, its trajectory, and treatments options; 2) ensuring family and healthcare clinicians have a common understanding of the patient's treatment plan and condition; 3) facilitating discussions with patients about their values and the framing of their illness; 5) posing "what if" scenarios about current and potential future health states and treatments; 6) addressing collateral decisions (e.g., work arrangements) resulting from medical treatment choices; 6) originating healthcare-related decision points, including decisions about seeking emergency care; and 7) making healthcare decisions for patients who preferred to delegate healthcare decisions to their family caregivers.
These findings highlight a previously unreported and understudied set of critical decision partnering roles that cancer family caregivers play in patient healthcare decision-making. Optimizing these roles may represent novel targets for early decision support interventions for family caregivers.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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