BACKGROUND: A structured family meeting (FM) is recommended within 72 h of admission for trauma patients with high risk of mortality or disability. Multidisciplinary FMs (MDFMs) may further facilitate decision-making. We hypothesized that FM within three hospital days (HDs) or MDFM would be associated with increased use of comfort measures.
MATERIALS AND METHODS: We reviewed all adult trauma deaths at an academic level 1 trauma center from December 2014 to December 2017. Death in the first 24 h or on nonsurgical services were excluded. Demographics, injury characteristics, FM characteristics, and outcomes such as length of stay (LOS) were recorded. Early FM was defined as occurring within three HDs; MDFM required attendance by two or more specialty teams.
RESULTS: A total of 177 patients were included. Median LOS was 6 d (interquartile range 4-12). FMs were documented in 166 patients (94%), with 57% occurring early. MDFM occurred in 49 (28%), but usually occurred later (median HD 5 and interquartile range 2-8). Early FM was associated with reduced LOS (5 versus 11 d, P < 0.001), ventilator days (4 versus 9 d, P < 0.001), and deaths during a code (1.2% versus 13.2%, P < 0.001). MDFM was associated with higher use of comfort measures (88% versus 68%, P < 0.05). Of patients who transitioned to comfort care status (n = 130, 73.4%), code status change occurred earlier if an early FM occurred (5 versus 13 d, P < 0.001).
CONCLUSIONS: MDFM is associated with increased comfort care measures, whereas early FM is associated with reduced LOS, ventilator days, death during a code, and earlier comfort care transition.
BACKGROUND: Palliative simulation is a beneficial bridge between theory and practice; however, it can be emotionally laden. Often overlooked during a debrief session of a palliative simulation is ensuring that participants have the skills to process the feelings they may experience.
METHOD: The purpose of this mixed-methods concurrent triangulation study was to understand the perceived value and usefulness of debriefing in palliative simulation process feelings and emotions.
RESULTS: The simulation modality affects the intensity of feelings. A debriefer who is skilled in both debriefing simulation and coping with emotionally stressful situations allowed students to feel prepared to cope with their own feelings about palliative care. Having other students talk about their feelings in debriefing helped students to normalize their feelings.
CONCLUSION: The debriefing in palliative-based simulations requires additional considerations regarding modality and the skill set of the debriefer to adequately assist students to process feelings and emotions.
BACKGROUND: We sought to increase intensive care unit-family meeting (ICU-FM) documentation in the electronic health record in Veterans Affairs (VA) hospitals.
MEASURES: Primary outcomes were proportion of VA decedents with ICU-FM and Bereaved Family Survey-Performance Measure (BFS-PM) scores of "excellent".
INTERVENTION: Quality Improvement (QI) project, clinical champion and ICU-FM templates, were implemented in nine participating VA facilities. ICU-FMs and BFS-PM were determined in decedents between 2011-2018.
OUTCOMES: ICU-FM increased from 3% to 28% in participating vs. 5% to 6% in non-participating facilities over time. Participating facilities were 5-fold more likely to have ICU-FMs among ICU decedents (OR=5.69, [4.45-7.28]). Facility-wide excellent BFS-PM scores increased by 19% in participating vs. non-participating facilities at the end of the observation period (OR=1.19, [1.10-1.30] but no difference between groups was observed in patients who died in the ICU.
CONCLUSIONS: Increasing ICU-FMs is necessary but not sufficient to improve family-reported satisfaction following an ICU death.
PURPOSE: Family meetings in the medical intensive care unit can improve outcomes. Little is known about when meetings occur in practice. We aimed to determine the time from admission to family meetings in the medical intensive care unit and assess the relationship of meetings with mortality.
METHODS: We performed a prospective cohort study of critically ill adult patients admitted to the medical intensive care unit at an urban academic medical center. Using manual chart review, the primary outcome was any attempt at holding a family meeting within 72 hours of admission. Competing risk models estimated the time from admission to family meeting and to patient death or discharge.
RESULTS: Of the 131 patients who met inclusion criteria in the 12-month study period, the median time from admission to family meeting was 4 days. Fewer than half of patients had a documented family meeting within 72 hours of admission (n = 60/131, 46%), with substantial interphysician variability in meeting rates ranging from 28% to 63%. Patients with family meetings within 72 hours were 30 times more likely to die within 72 hours (32% vs 1%, P < .001). Of the 55 patients who died in the intensive care unit, 27 (49%) had their first family meeting within 1 day of death.
CONCLUSIONS: Family meetings occur considerably later than 72 hours and are often held in close proximity to a patient's death. This suggests for some physicians, family meetings may primarily be used to negotiate withdrawal of life support rather than to support the patient and family.
La tension entre les valeurs en conflit peut faire naître des désaccords au sein de l’équipe de soins. Face à un choix crucial, grave et irréversible, la déontologie n’est plus suffisante : elle doit être assortie d’une réunion d’éthique ad hoc. La délibération collégiale repose sur un “contrat moral” entre les membres de l’équipe qui s’engagent à respecter les principes de l’éthique et les règles de l’éthique de discussion, en tant que repères communément partagés.
BACKGROUND: Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent.
METHODS: We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days.
RESULTS: Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001).
CONCLUSIONS: Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.
This case study describes the involvement of a patient representative on a palliative care committee and outlines some of the issues that arose as her health deteriorated. A summary of the increasing involvement of patient representation within health care governance is provided, and some of the challenges raised by the case, many of which may be relatively unique to palliative care, are discussed. It is hoped that presentation of this fairly novel scenario provides other palliative care providers with the opportunity to consider their own processes and practices around managing a similar situation should it occur in their healthcare setting.
OBJECTIVE: Shared decision making is essential for patients and their families when facing serious and life-threatening diseases. This study aimed to evaluate the impact of patient-centred and family-centred care meetings (PFCCM) on intensive measures and resource utilisation during end-of-life (EOL) hospitalisation among terminally ill patients.
DESIGN AND SETTING: A retrospective cross-sectional study using electronic medical records was conducted in a tertiary referral medical centre in Taiwan.
PARTICIPANTS: We identified 6843 deceased patients with terminal illness who either received or did not receive PFCCM during EOL hospitalisation between January 2013 and December 2015.
PRIMARY AND SECONDARY OUTCOME MEASURES: Patients who were transferred to the intensive care unit (ICU). Those who underwent invasive or non-invasive mechanical ventilation, tracheostomy, haemodialysis and surgical intervention during the final hospitalisation were determined by the use of intensive care measures; secondary measures were individual total and daily medical expenditures. A generalised estimating equation (GEE) model was used to compare the differences between the two groups. OR and beta coefficients (ß) with 95% CI were estimated.
RESULTS: This study identified 459 patients (6.7%) who received PFCCM during EOL hospitalisation. Multivariate analyses showed that patients who received PFCCM were less likely to have ICU admissions (OR 0.44, 95% CI 0.34 to 0.57), undergo surgical interventions (OR 0.74, 95% CI 0.58 to 0.95) and invasive mechanical ventilation (OR 0.50, 95% CI 0.38 to 0.66) during the final hospitalisation, after adjusting for patient demographics, clinical conditions and year of admission. Additionally, a significant decrease in daily medical expenditures was observed in PFCCM patients (ß -0.18, 95% CI -0.25 to -0.12) than in non-PFCCM patients.
CONCLUSIONS: Patient-physician discussion through PFCCM is associated with less intensive care utilisation and daily medical expenditure during EOL hospitalisation in terminally ill patients.
Family meetings are important events in the care of hospitalized patients to ensure that patients and families understand what is happening medically, to support the patient and family emotionally, and to promote shared decision making.
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Qu'est-ce que l'interdisciplinarité ? Ce mode d'action vise un objectif commun, au bénéfice de la personne soignée et de ses proches, en faisant collaborer les différents professionnels du soin. Elle nécessite que ceux-ci, compétents dans leur champ disciplinaire, apprennent à se connaître, à s'écouter et à se faire confiance. La ritualisation des réunions, s'appuyant sur une méthodologie et une organisation formalisées, permettent de l'initier.
Ce livre s'adresse à tous les professionnels de santé, en formation ou en exercice, qui s'interrogent sur la dynamique du soin et sur leur rôle au sein d'une équipe soignante. Il a été pensé comme un guide qui permettra aux équipes de mettre en place des actions interdisciplinaires dans leur quotidien.
Objectif de l’étude : Par une étude qualitative, nous avons voulu analyser les conséquences sur l’information reçue de la présence de patients présentant un cancer des voies aérodigestives supérieures à une réunion de concertation pluridisciplinaire comparativement à une processus d’annonce conventionnel.
Patients et méthode : Six hommes ont été interrogés lors d’un entretien individuel, semi-directif et enregistré. Ils ont été répartis en deux groupes : trois n’ayant pas participé à la réunion de concertation pluridisciplinaire et trois y ayant pris part. Après avoir été exactement retranscrits sous forme numérique, les propos de chacun ont été analysés à l’aide d’un logiciel d’analyse sémantique et lexicométrique Tropes®.
Résultats : Les patients des deux groupes s’estimaient bien informés, parfois trop. L’utilisation fréquente du « je » dans chaque groupe montrait qu’ils se sentaient intégrés. Les patients participant à la réunion de concertation pluridisciplinaire en étaient satisfaits mais les informations y étaient davantage condensées, ce qui a pu les surprendre voire les angoisser et leur choix était également plus ouvertement demandé, ce qui a pu être pris pour un manque de certitude de la part des médecins.
Conclusion : Qu’ils aient ou non assisté à la réunion de concertation pluridisciplinaire, les patients des deux groupes s’estimaient bien informés. La présence à la réunion de concertation pluridisciplinaire présente l’avantage de pouvoir discuter de l’ensemble des possibilités thérapeutiques et l’inconvénient de trop condenser ces informations qui doivent être reprises dans un second temps avec un médecin. Ce mode particulier du processus d’annonce ne doit pas forcément être généralisé, mais peut être offert à certains patients.
Introduction: Patients with progressive idiopathic fibrotic interstitial lung disease (ILD), such as those with idiopathic pulmonary fibrosis (IPF), can have an aggressive disease course, with a median survival of only 3-5 years from diagnosis. The palliative care needs of these patients are often unmet. There are calls for new models of care, whereby the patient's usual respiratory clinician remains central to the integration of palliative care principles and practices into their patient's management, but the optimal model of service delivery has yet to be determined.
Methods: We developed a novel, collaborative, multidisciplinary team (MDT) meeting between our palliative care, psychology and ILD teams with the principal aim of integrating specialist care to ensure the needs of persons with ILD, and their caregivers were identified and met by referral to the appropriate service. The objective of this study was to assess the effectiveness of this novel MDT meeting on the assessment of a patient's palliative care needs.
Results: Significant increases in advance care planning discussions were observed, in conjunction with increased referrals to community courses and teams, following introduction of this novel MDT.
Conclusions: Our results suggest that our collaborative MDT is an effective platform to address patients' unmet palliative care needs. Further work is required to explore the effect of our model on achieving the preferred place of death and reductions in unplanned hospital admissions.
Research into self-care practices suggests the need for conscientious and systematic support of nurses and other health care providers. The purpose of this study was to explore the impact of an innovative self-care initiative. The goals were to explore the experience of nurses and other health care providers participating in a reflective, creative nonfiction storytelling event called “Dinner and Stories” and the potential benefits and limitations of using an informal, storytelling model for self-care. A qualitative narrative design was used. Twenty-seven participants including nurses, social workers, and hospice volunteers wrote creative nonfiction stories about a lingering experience of providing care. At predefined dates, groups of up to six met for dinner in a home setting. Participants read aloud, listened deeply, and discussed their narrated stories. Four sources of data were collected: creative nonfiction stories, online forum discussions, in-depth interviews, and host facilitator field notes. Researchers identified four themes: (1) needing a self-care culture, (2) storytelling and writing as healing, (3) co-creating layers of connection, and (4) preferring face-to-face contact. Results add to knowledge about the therapeutic benefits of writing and storytelling for nurses and other health care providers including enriched meaning-making, emotional conveyance, and therapeutic connections between storytellers and listeners.
Objectifs: la réunion de staff de soins palliatifs porte le symbole de l’interdisciplinarité. Mais qu’en est-il de la participation réelle des aides-soignants en son sein ? Si certains auteurs affirment l’intérêt de les intégrer aux discussions, plusieurs études suggèrent que leur participation dans d’autres services n’est pas optimale. L’objectif était d’étudier la participation des aides-soignants en réunion de staff de soins palliatifs et de mieux comprendre ses déterminants pour pouvoir proposer des pistes d’amélioration pratiques.
Méthodes: Une étude qualitative, par entretiens semi-directifs auprès d’aides-soignants et de médecins, a été menée dans trois services accueillant des patients en soins palliatifs (unité ou lits identifiés de soins palliatifs, service de médecine). L’analyse des verbatims a été faite par codage thématique. Trente des 32 points de la grille internationale COREQ ont été respectés.
Résultats: Neuf aides-soignants et trois médecins ont été interrogés. La majorité des aides-soignants déclarait ne jamais ou peu participer. Les déterminants étaient multiples : organisationnels, communicationnels, liés aux protagonistes. Une analyse distanciée a fait ressortir trois grandes « logiques » contraignant ces échanges : la hiérarchie, l’identité socioprofessionnelle des aides-soignants, l’organisation matérielle et institutionnelle.
Conclusion : La participation des aides-soignants aux réunions d’équipe ne semble pas optimale malgré le cadre a priori favorisant des soins palliatifs. L’analyse de ses déterminants fait ressortir trois grandes « logiques » dont aucune n’est facilement modifiable. Néanmoins, leur identification permet de proposer des pistes d’amélioration qui pourront être évaluées par des travaux ultérieurs.
Palliative care for end-stage heart failure should be provided by a multidisciplinary team. However, the influence of each occupational category on patients receiving palliative care for end-stage heart failure remains unclear. Thus, this study investigated the relationships between palliative care conferences and positive outcomes of palliative care for end-stage heart failure patients. We sent questionnaires to all cardiology training hospitals authorized by the Japanese Circulation Society (n = 1004); of these, responses from the directors at 554 institutions were analyzed. We divided the responding institutions into two groups according to their implementation of palliative care conferences for patients with end-stage heart failure. The institutions that had held such conferences (n = 223) had a larger number of hospital beds, beds in the cardiovascular department, and patients admitted to the cardiovascular department, compared with institutions that had not held these conferences (n = 321). The usage rates of opioids, non-steroidal anti-inflammatory drugs, and sedatives were significantly higher in institutions that held these conferences. Multivariate analysis revealed that nutritionists and medical social workers had greater involvement in the improvement of mental symptoms and ensuring that patients could stay where they wished, respectively. The presence of palliative care physicians, physical therapists, or pharmacists was associated with multiple positive outcomes. This study indicated that there are possible associations between palliative care conferences and positive outcomes when performing palliative care for patients with end-stage heart failure.
Context: Implementation of pediatric palliative care as a primary practice relevant for all pediatricians and pediatric subspecialists requires a grounding, shared knowledge. This study reports on the innovative application of a monthly Palliative Care E-Journal Club (Pal Care Club) to foster shared palliative care knowledge hospital wide.
Objectives: To explore the impact of a monthly electronic journal club to increase the number of palliative care-relevant articles read and discussed and to enhance provider comfort with the integration and introduction of palliative care.
Methods: A single cohort, predesign–post-design was utilized to explore the impact of a monthly palliative care electronic journal club.
Results: Preintervention barriers to reading pediatric palliative care literature were primarily access and time. The mean of paired differences (post–pre) for the number of full-text articles read per month was 2.56 (SD = 1.25). The journal club intervention increased participant personal comfort with integrating palliative care principles at the bedside (p < 0.0001) and introducing pediatric palliative care to patients and families (p < 0.0001).
Conclusion: An electronic journal club is a feasible and acceptable means of increasing number of palliative care articles read and discussed across an institution as well as enhancing pediatric palliative care knowledge across subspecialist and general pediatric services.
BACKGROUND: Engaging patients in advance care planning (ACP) is challenging but crucial to improving the quality of end-of-life care. Group visits and multiple patient-clinician interactions may promote advance directive (AD) completion.
OBJECTIVE: Facilitate ACP discussions with patients and caregivers and the creation of notarized AD's at a comprehensive cancer center.
DESIGN: Two-session, nurse-led ACP workshops for patients and their family caregivers.
SETTING/PARTICIPANTS: The workshop was offered to patients with cancer at a comprehensive cancer center and their family caregivers.
MEASUREMENTS: Validated 4-question ACP engagement survey, creation of a notarized AD by end of the workshop, and semistructured interviews.
RESULTS: Thirty-five patients participated in 10 workshops held March 2017 to February 2018. Median age was 52. Of 35, 24 (68.5%) patients completed pre- and postworkshop evaluation surveys. Mean preworkshop ACP readiness was 3.64 of 5; postworkshop readiness increased to 4.26 of 5 ( P = .001). Of 26, 17 (65.4%) of the patients who attended both workshop sessions had a new notarized AD scanned into the electronic medical record at the completion of the workshop series. Three family caregivers completed and had their own ADs notarized. Patient and family member response was overwhelmingly positive, with participants citing opportunities for group discussion and inclusion of family caregivers as important.
CONCLUSIONS: The ACP workshop was well received by participants and increased ACP readiness, discussion, and completion. Attendance at the workshop was low and barriers to attending workshops must be explored.
La loi Leonetti a introduit la nécessité d’une procédure collégiale en matière de décision de limitation ou d’arrêts de traitements. Or, la collégialité ne va pas de soi dans la pratique professionnelle quotidienne. Il existe des freins culturels, institutionnels et spécifiques aux soignants. Des réunions interdisciplinaires peuvent être mises en place afin d’accompagner le médecin responsable et de prendre une décision la mieux adaptée à la situation singulière du malade.