Browsing by Subject "Terminal Care"

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    Communication practices in physician decision-making for an unstable critically ill patient with end-stage cancer.
    (J Palliat Med, 2010-08) Mohan, Deepika; Alexander, Stewart C; Garrigues, Sarah K; Arnold, Robert M; Barnato, Amber E
    BACKGROUND: Shared decision-making has become the standard of care for most medical treatments. However, little is known about physician communication practices in the decision making for unstable critically ill patients with known end-stage disease. OBJECTIVE: To describe communication practices of physicians making treatment decisions for unstable critically ill patients with end-stage cancer, using the framework of shared decision-making. DESIGN: Analysis of audiotaped encounters between physicians and a standardized patient, in a high-fidelity simulation scenario, to identify best practice communication behaviors. The simulation depicted a 78-year-old man with metastatic gastric cancer, life-threatening hypoxia, and stable preferences to avoid intensive care unit (ICU) admission and intubation. Blinded coders assessed the encounters for verbal communication behaviors associated with handling emotions and discussion of end-of-life goals. We calculated a score for skill at handling emotions (0-6) and at discussing end of life goals (0-16). SUBJECTS: Twenty-seven hospital-based physicians. RESULTS: Independent variables included physician demographics and communication behaviors. We used treatment decisions (ICU admission and initiation of palliation) as a proxy for accurate identification of patient preferences. Eight physicians admitted the patient to the ICU, and 16 initiated palliation. Physicians varied, but on average demonstrated low skill at handling emotions (mean, 0.7) and moderate skill at discussing end-of-life goals (mean, 7.4). We found that skill at discussing end-of-life goals was associated with initiation of palliation (p = 0.04). CONCLUSIONS: It is possible to analyze the decision making of physicians managing unstable critically ill patients with end-stage cancer using the framework of shared decision-making.
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    Hip Fracture in the Elderly Patients: A Sentinel Event.
    (The American journal of hospice & palliative care, 2018-04) Koso, Riikka E; Sheets, Charles; Richardson, William J; Galanos, Anthony N

    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.
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    Medical Purgatory.
    (J Palliat Med, 2015-07) Brown, J Trig; Galanos, Antony N
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    Quality of Life and Recommendations for Further Care.
    (Crit Care Med, 2016-11) Putman, Michael S; Tak, Hyo Jung; Curlin, Farr A; Yoon, John D
    OBJECTIVES: Physician recommendations for further medical treatment or palliative treatment only at the end of life may influence patient decisions. Little is known about the patient characteristics that affect physician-assessed quality of life or how such assessments are related to subsequent recommendations. DESIGN, SETTING, AND SUBJECTS: A 2010 mailed survey of practicing U.S. physicians (1,156/1,878 or 62% of eligible physicians responded). MEASUREMENTS AND MAIN RESULTS: Measures included an end of life vignette with five experimentally varied patient characteristics: setting, alimentation, pain, cognition, and communication. Physicians rated vignette patient quality of life on a scale from 0 to 100 and indicated whether they would recommend continuing full medical treatment or palliative treatment only. Cognitive deficits and alimentation had the greatest impacts on recommendations for further care, but pain and communication were also significant (all p < 0.001). Physicians who recommended continuing full medical treatment rated quality of life three times higher than those recommending palliative treatment only (40.41 vs 12.19; p < 0.01). Religious physicians were more likely to assess quality of life higher and to recommend full medical treatment. CONCLUSIONS: Physician judgments about quality of life are highly correlated with recommendations for further care. Patients and family members might consider these biases when negotiating medical decisions.
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    The associations between prognostic awareness and health-related quality of life among patients with advanced cancer: A systematic review.
    (Palliative medicine, 2023-06) Ng, Sean; Ozdemir, Semra

    Background

    Prognostic awareness among patients with advanced cancer is important for better palliative and end-of-life care. However, the relationships between prognostic awareness and patient health-related quality of life outcomes remain inconsistent across studies. Critically synthesizing empirical literature will allow for a better understanding of these associations.

    Aim

    To investigate the associations between prognostic awareness and health-related quality of life outcomes among patients with advanced cancer.

    Design

    This study was a systematic review, prospectively registered on PROSPERO (CRD42020177228).

    Data sources

    Seven databases (PubMed/Medline, Embase, Scopus, Cochrane Central, PsycINFO, CINAHL, and Web of Science) were searched in March 2022. Cross-sectional and longitudinal empirical studies in English were included regardless of cancer type or publication date.

    Results

    We identified 1338 articles and included 36 for review. A substantial proportion of patients remained prognostically unaware (50%). Prognostic awareness was either not significantly associated (48%) or associated with worsened (40%) outcomes. These associations were found to vary (e.g., be differently associated with improved, worsened, or non-significant health-related quality of life outcomes) based on the definition of prognostic awareness used and the population sampled (Asian vs Western). Few structured, validated questionnaires were used and only three studies investigated how the associations evolved over time.

    Conclusions

    To facilitate better understanding of the relationships between prognostic awareness and health-related quality of life, future research must focus on developing a standardized, "gold standard" measurement of prognostic awareness. Research should also examine the influence of culture and the evolution of these relationships longitudinally.
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    Young caregivers in the end-of-life setting: a population-based profile of an emerging group.
    (J Palliat Med, 2010-10) Burns, CM; LeBlanc, TW; Abernethy, A; Currow, D
    PURPOSE: Little is known about young caregivers of people with advanced life-limiting illness. Better understanding of the needs and characteristics of these young caregivers can inform development of palliative care and other support services. METHODS: A population-based analysis of caregivers was performed from piloted questions included in the 2001-2007 face-to-face annual health surveys of 23,706 South Australians on the death of a loved one, caregiving provided, and characteristics of the deceased individual and caregiver. The survey was representative of the population by age, gender, and region of residence. FINDINGS: Most active care was provided by older, close family members, but large numbers of young people (ages 15-29) also provided assistance to individuals with advanced life-limiting illness. They comprised 14.4% of those undertaking "hands-on" care on a daily or intermittent basis, whom we grouped together as active caregivers. Almost as many young males as females participate in active caregiving (men represent 46%); most provide care while being employed, including 38% who work full-time. Over half of those engaged in hands-on care indicated the experience to be worse or much worse than expected, with young people more frequently reporting dissatisfaction thereof. Young caregivers also exhibited an increased perception of the need for assistance with grief. CONCLUSION: Young people can be integral to end-of-life care, and represent a significant cohort of active caregivers with unique needs and experiences. They may have a more negative experience as caregivers, and increased needs for grief counseling services compared to other age cohorts of caregivers.