Improving a mature palliative care program at a Level I trauma center.
Advance Directives; Confidence Intervals; Data Analysis Software; Depression; Descriptive Statistics; Documentation; Electronic Health Records; Fisher's Exact Test; Frailty Syndrome; Hospital Programs; Human; Palliative Care; Pearson's Correlation Coefficient; Quality Improvement; Questionnaires; Simulations; Trauma Centers
Background: Similar to the significant rise in the geriatric population in the United States, trauma centers have seen an increase in geriatric trauma patients. These patients present with additional challenges such as a higher likelihood of undertriage, mortality, and frailty. In addition, the varying presence of advanced directive documentation increases the importance of early palliative care consultations for geriatric trauma patients. Objective: In 2018, a Level I trauma center in the Midwest reviewed the American College of Surgeons Trauma Quality Improvement Program's Palliative Care Best Practice Guideline to identify opportunities for improvement to strengthen the collaboration between the palliative care consult service and trauma program. Methods: The guideline drove improvements, which included documentation changes (i.e., expansion of palliative care consultation triggers, frailty assessment, advanced directives questions, depression screening, and addition of palliative care consultation section on the performance improvement program form) and training (1-hr lecture on palliative care and 5-hr palliative care simulation training) opportunities. Results: A 3-month manual chart review (March 2019 through May 2019) revealed that by May 2019, 87.2% of admitted geriatric trauma patients received frailty assessments, which surpassed the benchmark (>85%). In addition, advanced care planning questions (i.e., health care power of attorney, do not resuscitate order, or living will) exceeded the benchmarks set forth by the guideline (>90%), with all of the questions being asked and documented in 95.7% of those same patient charts by May 2019. Conclusion: This quality improvement project has applicability for trauma centers that treat geriatric trauma patients; using the guidelines can drive changes to meet individual institution needs.
Moran ME; Soltis M; Politis T; Gothard MD; George RL
Journal Of Trauma Nursing
2021
2021-04-03
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
journalArticle
<a href="http://doi.org/10.1097/JTN.0000000000000569" target="_blank" rel="noreferrer noopener">10.1097/JTN.0000000000000569</a>
Advance Care Planning in Skilled Nursing Facilities: A Multisite Examination of Professional Judgments
Advance directives; African Americans; CONFIDENCE intervals; Gerontology And Geriatrics; Judgments; Nurses; Nursing; Quality of care; Quality of life; Race; Racism; Research design; Residential segregation; Rural areas; Rural education; Rural urban differences; Segregation; Social science research; Social workers; Urban education
Background and Objectives Lack of advance care planning (ACP) may increase hospitalizations and impact the quality of life for skilled nursing facility (SNF) residents, especially African American residents who may be less likely to receive ACP discussions. We examined the professional judgments of SNF providers to see if race of SNF residents and providers, and risk for hospitalization for residents influenced professional judgments as to when ACP was needed and feelings of responsibility for ensuring ACP discussions Research Design and Methods Nurses and social workers (n = 350) within 29 urban SNFs completed surveys and rated vignettes describing eight typical SNF residents. Linear mixed modeling was used to examine factors that impacted ratings of need for ACP and responsibility for ensuring ACP. Results Neither the race of the provider, resident, nor the interaction of the two were associated with either outcome variable. In contrast, providers rated (on a 9-point scale) residents at high risk for hospitalization as more in need of ACP (estimate = 0.86, confidence interval [CI] 0.65, 1.07) and felt more responsible for ensuring ACP (estimate = 0.60, CI 0.42, 0.78) Discussion and Implications Research on ACP is continuing to evolve and these results show the primacy of disease trajectory variables on providers' judgments about ACP. Differences between providers indicate a need for stronger policies and education. Further, research comparing rural, suburban, and urban SNFs is needed to explore possible forms of structural racism such as residential and SNF segregation.
Baughman Kristin R; Ludwick PhD R N-B C C N S F A A N Ruth; Jarjoura PhD David; Kropp BS Denise; Shenoy BS Vimal
The Gerontologist
2019
2019-04
<a href="http://doi.org/10.1093/geront/gnx129" target="_blank" rel="noreferrer noopener">10.1093/geront/gnx129</a>
Factors Associated With Advance Care Planning Discussions by Area Agency on Aging Care Managers.
Female; Male; Ohio; Aged; Advance Directives; Human; Chi Square Test; Cross Sectional Studies; Surveys; Middle Age; Correlation Coefficient; T-Tests; Case Managers; Secondary Analysis; Advance Care Planning – In Old Age
Hazelett Susan; Baughman Kristin R; Palmisano Barbara; Sanders Margaret; Ludwick Ruth E
American Journal of Hospice & Palliative Medicine
2013
2013-12
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1177/1049909112475153" target="_blank" rel="noreferrer noopener">10.1177/1049909112475153</a>
Nephrologists' subjective attitudes towards end-of-life issues and the conduct of terminal care.
Adult; Humans; Middle Aged; Pilot Projects; *Attitude of Health Personnel; Data Collection; *Attitude to Death; Empirical Approach; *Euthanasia; *Terminal Care; Advance Directive Adherence; Advance Directives; Death and Euthanasia; Nephrology; Withholding Treatment; Ethics; Medical; Active
Decisions which determine the duration and outcome of terminal care should be influenced by patient autonomy. Studies suggest, however, that end-of-life decision-making is more complex than a single principle and that physicians may be responsible for selected aspects of terminal care independent of patient choice. To study how nephrologists' perceptions toward end-of-life issues may affect decision-making, we anonymously surveyed 125 of them. The study employed the straightforward terminology of "hastening death" rather than adopting the ambiguous term "euthanasia" or the narrow term "assisted suicide." Subjective physician profiles demonstrated that nephrologists who are less comfortable with dying patients were significantly less likely to report that they omitted life-prolonging measures (p = 0.02) and more likely to report that they would not initiate measures in order to hasten death even were it legal (p = 0.04). Ninety-eight percent of nephrologists reported omissions in terminal care with patient knowledge and 80% without patient knowledge. In contrast, forty-three percent of the nephrologists said that were it to become legal to initiate measures in order to hasten death, they would "never" do so. The ethical framework utilized for discontinuation of dialysis decisions incorporated medical benefit (cancer as criterion, 48%; multisystem complications, 84%; dementia 79%) and quality of life criteria. Twenty-five percent of nephrologists admitted difficulty with advance directives if the directives clashed with heir beliefs. ESRD end-of-life decision-making in the USA may be altered by the subjective characteristics of nephrologists. In particular, nephrologists' level of discomfort with patient mortality is linked with their reported management of terminal patients.
Rutecki G W; Cugino A; Jarjoura D; Kilner J F; Whittier F C
Clinical nephrology
1997
1997-09
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Palliative care for acute kidney injury patients in the intensive care unit.
Acute kidney injury; Advance directives; Dialysis; Intensive care unit; Palliative care
Patients with acute kidney injury (AKI) in the intensive care unit (ICU) are often suitable for palliative care due to the high symptom burden. The role of palliative medicine in this patient population is not well defined and there is a lack of established guidelines to address this issue. Because of this, patients in the ICU with AKI deprived of the most comprehensive or appropriate care. The reasons for this are multifactorial including lack of palliative care training among nephrologists. However, palliative care in these patients can help alleviate symptoms, improve quality of life, and decrease suffering. Palliative care physicians can determine the appropriateness and model of palliative care. In addition to shared decision-making, advance directives should be established with patients early on, with specific instructions regarding dialysis, and those advance directives should be respected.
Krishnappa Vinod; Hein William; DelloStritto Daniel; Gupta Mona; Raina Rupesh
World journal of nephrology
2018
2018-12
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.5527/wjn.v7.i8.148" target="_blank" rel="noreferrer noopener">10.5527/wjn.v7.i8.148</a>
Transfer of DNR orders to the ED from extended care facilities.
*Advance Directives; *Critical Illness; *Health Services for the Aged; *Skilled Nursing Facilities; 80 and over; 80 and Over; Advance Directives; Aged; Coding – Administration; Coding – Standards; Critical Illness; Do-not-resuscitate; Emergency Medical Services – Administration; Emergency Medical Services/*organization & administration; Emergency Service; EMS; Extended care facilities; Female; Forms and Records Control/*organization & administration/standards; Health Services for the Aged; Hospital; Human; Humans; Length of Stay; Male; Medical Records – Statistics and Numerical Data; Medical Records/*statistics & numerical data; Middle Age; Middle Aged; Ohio; Outcome Assessment; Outcome Assessment (Health Care); Patient Advocacy; Physicians; Prospective Studies; Resuscitation Orders; Skilled Nursing Facilities
PURPOSE/OBJECTIVE: With an elderly and chronically ill patient population visiting the emergency department, it is important to know patients' wishes regarding care preferences and advanced directives. Ohio law states DNR orders must be transported with the patient when they leave an extended care facility (ECF). We reviewed the charts of ECF patients to evaluate which patients presenting to the ED had their DNR status recognized by the physician and DNR orders that were made during their hospital stay. METHODS: We prospectively enrolled patients presenting from ECFs to the ED, blinding the treating team to the purpose. We did a chart review for the presence of a DNR form, demographic data and acknowledgement of the DNR forms. RESULTS: Fifty patients were enrolled in this study. The mean age was 77.6years and 56% were female. Twenty-eight percent had a DNR order transported to the ED, but 68% had a DNR preference noted in their ECF notes. Registration only noted an advanced directive on 32% of patients (p=0.09). Eighteen percent had a DNR noted by the ED physician (p=0.42). Sixteen percent of patients had a DNR order written by an ED physician while 28% had a DNR order written by a non-ED physician during their inpatient evaluation. Thirty percent had a palliative care consult while in the hospital, but there was no significant association between DNR from the ECF and these consults. CONCLUSIONS: Hospital staff did a poor job of noting DNR preferences and ECFs were inconsistent with sending Ohio DNR forms.
McQuown Colleen M; Frey Jennifer A; Amireh Ahmad; Chaudhary Ali
The American journal of emergency medicine
2017
2017-07
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/j.ajem.2017.02.007" target="_blank" rel="noreferrer noopener">10.1016/j.ajem.2017.02.007</a>