Abstract Background Despite increasing interest in advance care planning (ACP) and prior ACP descriptions, a consensus definition does not yet exist to guide clinical, research, and policy ...initiatives. Objective To develop a consensus definition of ACP for adults. Design Delphi Panel Setting/Participants Participants included a multidisciplinary panel of international ACP experts consisting of 52 clinicians, researchers, and policy leaders from 4 countries, and a patient/surrogate advisory committee. Measurements We conducted 10 rounds of a modified Delphi method and qualitatively analyzed panelists’ input. Panelists identified several themes lacking consensus, and iteratively discussed and developed a final consensus definition. Results Panelists identified several tensions concerning ACP concepts such as whether the definition should focus on conversations vs. written advance directives; patients’ values vs. treatment preferences; current shared decision making vs. future medical decisions; and who should be included in the process. The panel achieved a final consensus one-sentence definition and accompanying goals statement: “Advance care planning is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness.” The panel also described strategies to best support adults in ACP. Conclusions A multidisciplinary Delphi panel developed a consensus definition for ACP for adults that can be used to inform implementation and measurement of ACP clinical, research, and policy initiatives.
Geriatric Cardiology: An Emerging Discipline Dodson, John A., MD MPH; Matlock, Daniel D., MD MPH; Forman, Daniel E., MD
Canadian journal of cardiology,
09/2016, Letnik:
32, Številka:
9
Journal Article
Recenzirano
Odprti dostop
Abstract Given changing demographics, patients with cardiovascular (CV) disease in developed countries are now older and more complex than even a decade ago. This trend is expected to continue into ...the foreseeable future; accordingly, cardiologists in practice are encountering patients with a greater number of comorbid illnesses as well as “geriatric conditions” such as cognitive impairment and frailty which complicate management and influence outcomes. Simultaneously, technological advances have widened the therapeutic options available for patients, including those with the most advanced CV disease. In the setting of these changes, geriatric cardiology has recently emerged as a discipline that aims to adapt principles from geriatric medicine into everyday cardiology practice. Accordingly, the tasks of a “geriatric cardiologist” may include both traditional evidence-based CV management plus comprehensive geriatric assessment, medication reduction, team-based coordination of care, and explicit incorporation of patient goals into management. Given that the field is still in its relative infancy, the training pathways and structure of clinical programs in geriatric cardiology are still being delineated. In this review we highlight the rationale behind geriatric cardiology as a discipline, several current approaches by geriatric cardiology programs, and future directions for the field.
Background Patients with end-stage renal disease have high mortality and symptom burden. Past studies demonstrated that nephrologists do not feel prepared to care for their patients at the end of ...life. We sought to characterize current palliative and end-of-life care education received during nephrology fellowship and compare this with data from 2003. Study Design Cross-sectional online survey of second-year nephrology trainees. Responses were compared to a similar survey in 2003. Setting & Participants 104 US nephrology fellowship programs in 2013. Measurements Quality of training in and attitudes toward end-of-life care and knowledge and preparedness to provide nephrology-specific end-of-life care. Results Of 204 fellows included for analysis (response rate, 65%), significantly more thought it was moderately to very important to learn to provide care at end of life in 2013 compared to 2003 (95% vs 54%; P < 0.001). Nearly all (99%) fellows in both surveys believed physicians have a responsibility to help patients at end of life. Ranking of teaching quality during fellowship in all areas (mean, 4.1 ± 0.8 on a scale of 0-5 0, poor; 5, excellent) and specific to end-of-life care (mean, 2.4 ± 1.1) was unchanged from 2003, but knowledge of the annual gross mortality rate for dialysis patients was nominally worse in 2013 because only 57% versus 67% in 2003 answered correctly ( P = 0.05). To an open-ended question asking what would most improve fellows’ end-of-life care education, the most common response was a required palliative medicine rotation during fellowship. Limitations Assessments were based on fellows’ subjective perceptions. Conclusions Nephrology fellows increasingly believe they should learn to provide end-of-life care during fellowship. However, perceptions about the quality of this teaching have not improved during the past decade. Palliative care training should be integrated into nephrology fellowship curricula.
Background Patients with heart failure have end-of-life care needs that may benefit from hospice care. The goal of this descriptive study was to understand hospice clinicians' perspectives on the ...unique aspects of caring for patients with heart failure to inform approaches to improving end-of-life care. Methods This qualitative study explored experiences, observations, and perspectives of hospice clinicians regarding hospice care for patients with heart failure. Thirteen hospice clinicians from a variety of professional disciplines and clinical roles, diverse geographic regions, and varying lengths of time working in hospice participated in semistructured interviews. Through team-based, iterative qualitative analysis, we identified 3 major themes. Results Hospice clinicians identified 3 themes regarding care for patients with heart failure. First, care for patients with heart failure involves clinical complexity and a tailored approach to cardiac medications and advanced cardiac technologies. Second, hospice clinicians describe the difficulty patients with heart failure have in trusting hospice care due to patient optimism, prognostic uncertainty, and reliance on prehospice health care providers. Third, hospice clinicians described opportunities to improve heart failure–specific hospice care, highlighting the desire for collaboration with referring cardiologists. Conclusions From a hospice clinician perspective, caring for patients with heart failure is unique compared with other hospice populations. This study suggests potential opportunities for hospice clinicians and referring providers who seek to collaborate to improve care for patients with heart failure during the transition to hospice care.
An abstract of a study by Sudore et al developing a consensus definition of advance care planning for adults is presented. Panelists identified several tensions such as whether the ACP definition ...should focus on conversations vs. written advance directives: patients' values vs. treatment preferences; current shared decision making vs. future medical decisions; and who should be included in the process.
Health status predicts adverse outcomes in heart failure and cardiac surgery patients, but its prognostic value in left ventricular assist device (LVAD) placement is unknown.
We examined the ...association of pre-operative health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), with survival and hospitalization after LVAD using the KCCQ score as a continuous variable and stratified by KCCQ score quartile plus missing KCCQ in 1,125 clinical trial participants who received the HeartMate II (Thoratec Corp, Pleasanton, CA) as destination therapy (n = 635) or bridge to transplantation (n = 490).
The mean pre-operative KCCQ score was 29.4 ± 18.7 among survivors (n = 719), and 27.1 ± 18.3 (n = 406) in those who died. In time-to-event analysis for all available follow-up using health status as a continuous variable, the pre-operative KCCQ score did not correlate with overall mortality after LVAD implantation (p = 0.178). Small absolute differences were seen between the pre-operative KCCQ quartile and 30-day survival (Q4 95% vs. Q1 89% vs. missing 87%; p = 0.0009 for trend), 180-day survival (Q4 83% vs. Q1 76% vs missing 79%; p = 0.060 for trend), and days hospitalized at 180 days (Q4 29.8 ± 25.6 vs. Q1 34.1 ± 27.1 vs. missing 36.5 ± 29.9 days; p = 0.009 for trend).
Our findings suggest that pre-operative health status has limited association with outcomes after LVAD implantation. Although these data require further study in a diverse population, mechanical circulatory support may represent a relatively unique clinical situation, distinct from heart failure and other cardiac surgeries, in which heart failure-specific health status measures may be largely reversed.
Abstract Background Beliefs around deactivation of a left ventricular assist device (LVAD) vary substantially between clinicians, institutions, and patients. Therefore, we sought to understand ...perspectives regarding LVAD deactivation among cardiology and hospice/palliative medicine (HPM) clinicians. Methods and Results We administered a 41-item survey via electronic mail to members of 3 cardiology and 1 HPM professional societies. A convergent parallel mixed methods design was used. From October–November 2011, 7,168 individuals were sent the survey and 440 responded. Three domains emerged: 1) LVAD as a life-sustaining therapy; 2) complexities of the process of LVAD deactivation and 3) legal and ethical considerations of LVAD deactivation. Most respondents (cardiology=92%; HPM=81%; p=0.15) believed that an LVAD is a life-sustaining treatment for patients with advanced heart failure; however, 60% of cardiology versus 2% of HPM clinicians believed a patient should be imminently dying in order to deactivate an LVAD (p=<0.001). Additionally, 87% of cardiology versus 100% of HPM clinicians believed the cause of death following LVAD deactivation was from underlying disease (p=<0.001), with 13% of cardiology clinicians considering it to be a form of euthanasia or physician-assisted suicide. Conclusion Cardiology and HPM clinicians have differing perspectives regarding LVAD deactivation. Bridging the gaps and engaging in dialogue among these two specialties is a critical first step in creating a more cohesive approach to care for LVAD patients.
Abstract Objective We explored the perceptions, experience, and meaning of fatigue as a distressing symptom of chronic heart failure (HF). Background Fatigue, a common symptom of HF, may indicate ...worsening condition. Patients interpret their symptoms to determine the need for assistance. The meaning of fatigue in everyday life for HF patients in the United States is not well understood. Methods We performed an interpretive study of in-depth interviews with HF patients (n = 26) who reported fatigue as a symptom, using a thematic analysis of transcripts within an iterative group framework. Results Fatigue is characterized by patient values related to their self-identity, their body, their experience of time, their environment, and their relationships with others, including the healthcare system. Conclusions Fatigue influences perceived proximity to death and how patients try to preserve what they can do. A patient's HF management plan should be tailored and responsive to that patient's experience of fatigue as communicated by the patient.
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