PURPOSE: Women who experience out-of-hospital cardiac arrest have similar rates of survival to hospital admission as men; however, women are less likely to survive to hospital discharge. We hypothesized that women would have higher rates of "do not attempt resuscitation" (DNAR) orders and that this order would be associated with lower use of aggressive interventions.
METHODS: We identified adult hospital admissions with a diagnosis of cardiac arrest (ICD-9 427.5) from the 2010 California State Inpatient Dataset. Multivariable logistic regression was used to test the association between patient sex and a DNAR order within the first 24 h of admission, adjusting for patient demographic characteristics and comorbid medical conditions. In secondary analysis, procedures performed after establishment of DNAR order and survival to hospital discharge were compared by sex.
FINDINGS: We analyzed 6562 patients (44% women, 56% men) who experienced out-of-hospital cardiac arrest and survived to hospital admission. In unadjusted analysis, more women than men had establishment of a DNAR order during the first 24 h of admission (23.4% versus 19.3%; P < 0.01). After adjusting for age, race, and comorbid conditions, women remained significantly more likely to have a DNAR order established during the first 24 h of their hospital admission after cardiac arrest compared with men (odds ratio = 1.23; 95% CI, 1.09-1.40). No sex difference was found in procedures used after DNAR order was established.
IMPLICATIONS: Female survivors of cardiac arrest are significantly more likely than men to have a DNAR order established within the first 24 h of in-hospital treatment. The establishment of a DNAR order is associated with patients undergoing fewer procedures than individuals who do not have a DNAR order established. Given that patients who have a DNAR order receive less-aggressive intervention after arrest, it is possible that an early DNAR order may contribute to sex differences in survival to hospital discharge.
OBJECTIVE: The aim of this study was to explore the status of aggressive end-of-life care and symptom relief treatments in terminally ill patients who had discussed the withdrawal of mechanical ventilation.
METHODS: This research is a retrospective observational study based on a chart review. Terminal patients aged = 20 years, who were intubated with mechanical ventilation support, who underwent hospice-shared care, and who personally, or whose close relatives, had discussed the withdrawal of mechanical ventilation with hospice-shared care team members in a tertiary hospital in Taiwan during 2012 to 2015 were included. Demographics, medical conditions, and aggressive end-of-life care, including hospitalization, use of vasopressors, artificial nutrition, tube feeding, antibiotics, and symptom relief treatments including the use of opioids, steroids, and sedatives, were identified. The modes of care and treatments of patients by the status of withdrawal of mechanical ventilation were compared.
RESULTS: A total of 141 patients had discussed the withdrawal of mechanical ventilation, and 111 (78.7%) had been withdrawn. Aggressive end-of-life care was noted in all patients regardless of mechanical ventilation status. There were no significant differences in the number and pattern of aggressive end-of-life care measures between patients who had or had not been withdrawn. There were significantly higher rates of symptom relief treatments used in patients who had been withdrawn.
CONCLUSIONS: Aggressive end-of-life care is common for patients who have discussed the withdrawal of mechanical ventilation. There are significantly higher rates of symptom relief medications administered in patients who have been withdrawn from mechanical ventilation.
Background: Aggressive care at the end of life (EOL) is a persistent issue for patients with stage IV nonsmall cell lung cancer (NSCLC). We evaluated the use of concurrent care (CC) with hospice care and cancer-directed treatment simultaneously within the Veteran's Health Administration (VHA) and aggressive care at the EOL.
Objective: To determine whether VHA facility-level CC is associated with changes in aggressive care at the EOL.
Design/Setting: Veterans with stage IV NSCLC who died between 2006 and 2012 and received lung cancer care within the VHA.
Measurements: The primary outcome was aggressive care at EOL (i.e., hospital admissions, chemotherapy, and intensive care unit) within the last month of life. To compare aggressive care across VHA facilities, we used a random intercept multilevel logistic regression model to examine the association between facility-level CC within each study year (<10%, 10% to 19%, and =20%) and aggressive care at the EOL among the decedents as a binary outcome.
Results: In total, 18,371 veterans with NSCLC at 154 VHA facilities were identified. Facilities delivering CC for =20% of veterans (high CC) increased from 20.0% in 2006 to 43.2% in 2012 (p < 0.001). Overall, hospice care significantly increased and aggressive care at EOL decreased over the study period. However, facility-level CC adoption was not associated with any difference in aggressive care at EOL (adjusted odds ratio high CC vs. low CC: 0.91 [95% CI, 0.79 to 1.05], p = 0.21).
Conclusions: Although the VHA adoption of CC increased hospice use among patients with NSCLC, additional measures may be needed to decrease aggressive care at the EOL.
Introduction: The ability of oncologists to understand patients’ goals of care is recognized as a key component of quality care. The purpose of this study is to examine the influence of patient–oncologist agreement regarding goals of care upon aggressive care at end of life (EOL) for patients with advanced cancer.
Methods: Patients with advanced cancer and their oncologists were interviewed at study enrollment and every 3 months thereafter until patient death or end of the study period (15 months). A 100-point visual analogue scale was used to represent goals of care, with quality of life (scored as 0) and survival (scored as 100) as anchors. Strong goal of care agreement for survival was defined as oncologist and patient dyadic goal of care scores that fell between 70 and 100 (100 = highest goal for survival) and for comfort, dyadic goal of care values that fell between 0 and 30 (0 = high goal for comfort).
Results: Two hundred and six patients and eleven oncologists provided data. At the last interview prior to death, 23.3% of dyads had strong goal of care agreement for either survival (8.3%) or comfort (15%) and 76.7% had no strong agreement. There was a significant association between aggressive care use and categories of dyadic agreement regarding goals of care (p = 0.024, Cramer’s V = 0.15).
Conclusions: A large percentage of oncologists did not understand their patients’ EOL goals of care. While aggressive care aligned with categories of dyadic agreement for goals of care, high rates of aggressive care were reported.
OBJECTIVES: In non-gynecologic cancers, clinical trial participation has been associated with aggressive care at the end of life. The objective of this investigation was to examine how trial participation affects end of life outcomes in patients with ovarian cancer.
METHODS: In a retrospective review of women diagnosed with ovarian cancer at our institution between January 2010 and December 2015, we collected variables identified by the National Quality Forum as measures of aggressive end of life care including chemotherapy in the last 14 days of life, intensive care unit (ICU) admission in the last 30 days of life, or death in the acute care setting. Trials investigating medications but not surgical interventions were included. The primary outcome of this study was the association between trial participation and the National Quality Forum measures of aggressive end of life care in ovarian cancer decedents. Data were analyzed with univariable and multivariable parametric and non-parametric testing, and time to event outcomes were analyzed using the Kaplan-Meier method and Cox's proportional hazard models.
RESULTS: Among 391 women treated for ovarian cancer, 62 patients (16%) participated in a clinical trial. Patients enrolled in clinical trials were more likely to have chemotherapy administered within 14 days of death; however, no association was found with other metrics of aggressive care at the end of life including the initiation of a new chemotherapy regimen in the last 30 days of life, ICU admissions, and death in an acute care setting. Among patients with recurrent ovarian cancer, median overall survival for trial participants was 57 months compared with only 31 months in non-trial participants (p<0.001).
CONCLUSIONS: In patients with ovarian cancer, clinical trial enrollment is associated with chemotherapy administration within 14 days of death, but not other measures of aggressive care at the end of life. Given the importance of clinical trial participation in improving care for women with ovarian cancer, this study suggests that concerns regarding aggressive care prior to death should not limit clinical trial participation.
Background: Although, efforts to encourage palliative care only for terminal patients, aggressive end-of-life care (EOL) care still common for those probably to die shortly.
Aim: Multicenter experiences to investigate where did we stand in this era?
Patients and Methods: A retrospective study included patients with advanced solid tumors. The presence of one or more of the following indicators in the last month of life (LM) referred to aggressive EOL care: emergency department (ED) visits = twice, admission to the hospital through ED, death in critical care units (CCUs), and palliative chemotherapy (PC) at the past 2 weeks before death.
Results: A total of 435 patients, 51.5% were men with a median age of 62 years (range: 17–108), were included in the study. Most of the patients (89.2%) belonged to Group II; they had attended ED at least twice (60%), approximately 53% admitted to the hospital through ED, 31% received PC-LM with 41% of them had at the past 2 weeks before death, 13% died in the CCUs, and more than half of them (53%) survived <2 weeks. Kaplan–Meier estimator revealed that median survival was 30 days in Group I versus 13 days in Group II (odds ratio: 1.63; 95% confidence interval: 1.20–2.21; P = 0.002). The median survival was statistically significantly associated with PC-LM =14 days and the admission mode. There was no statistically significant association with age, sex, and primary cancer sites.
Conclusion: The majority of our patients continue with anticancer treatments they possibly do not need and associated with poor survival.
Little is known about effective interventions to reduce aggressive end-of-life care in patients with cancer. We did a systematic review to assess what interventions are associated with reductions in aggressive end-of-life cancer care. We searched MEDLINE, CINAHL, Embase, Scopus, and PsychINFO for randomised control trials (RCTs), quasi-experimental, and observational studies published before Jan 19, 2018, which aimed to improve measures of aggressive end-of-life care for patients with cancer. We developed a taxonomy of interventions using the Systems Engineering Initiative for Patient Safety (SEIPS) model to summarise existing interventions that addressed aggressive care for patients with cancer. Of the 6451 studies identified by our search, five RCTs and 31 observational studies met the final inclusion criteria. Using the SEIPS framework, 16 subcategories of interventions were identified. With the exception of documentation of end-of-life discussions in the electronic medical record, no single intervention type or SEIPS domain led to consistent improvements in aggressive end-of-life care measures. The ability to discern the interventions' effectiveness was limited by inconsistent use of validated measures of aggressive care. Seven (23%) of 31 observational studies and no RCTs were at low risk of bias according to Cochrane's Risk of Bias tool. Evidence for improving aggressive end-of-life cancer care is limited by the absence of standardised measurements and poor study design. Policies and studies to address the gaps present in end-of-life care for cancer are necessary.
OBJECTIVES: Many older adult patients want to be treated aggressively for reversible conditions, even when their current quality of life is limited; however, most standard living wills focus on the very end of life and provide little guidance to acute care providers (ACPs) should their older adult patient be admitted with a potentially treatable acute condition and temporarily lose capacity. We developed what we believe is a more informational and directive living will for this population. We sought to determine whether ACPs would find our pilot living will more helpful when caring for their older adult patients.
METHODS: Convenience sample of members of the Society of Hospital Medicine (SHM). Respondents were asked to compare the pilot living will with their state form and then answer five attitudinal questions.
RESULTS: In total, 125 providers from 39 states completed the survey: 86% indicated that the pilot living will better helped them understand their patients' general end-of-life preferences, 87.5% indicated the pilot living will would be more helpful in making specific treatment decisions for their patients, and 85% indicated the pilot living will would better facilitate end-of-life discussions with surrogates.
CONCLUSIONS: Our results suggest that it is possible to design a functional advanced directive that better reflects the wishes of the older adult patient who wants to be treated aggressively in selected clinical situations. By more clearly defining these wishes, acute providers (eg, hospitalists, intensivists) can make more informed, patient-centered recommendations to surrogates.
It is not easy to characterize a problem patient or bereaved relatives because identifying a patient or his bereaved family as a problem; is not considered quite ethical. The approached emergency medical service employees and coroner service physicians were asked to complete a specific targeted anonymous survey. 100 % of survey questionnaires were returned. The questionnaire with a request for filling and returning was submitted to forty employees working full-time, twenty of whom were physicians, ten paramedics and ten lower-level healthcare professionals. The questionnaire comprised ten questions aimed at obtaining clear answers to questions about personal experience with problem patients, specifically aggressive patients, and more specifically whether the health care professionals (HCP) has ever felt immediately threatened by a patient in their work, whether they were exposed to verbal or even physical attack in the context of the patients basic diagnosis established during pre-hospital care. Seventy-five percent of respondents answered Yes to Question No. 5: Have you ever felt threatened by a patient or bereaved relative in your work? ; Eighty percent of respondents answered Yes to Question No. 6: Have you ever been exposed to a verbal attack by a patient or bereaved relative? Seventy-five percent of them answered Yes to Question No. 7: Have you ever been exposed to a physical attack by a patient? The rate of cases in which emergency medical service employees are exposed to verbal or physical attacks is high. The primary experience hypothesis that this happens has been proven as well as the fact that it is a highly topical and therefore unresolved issue that threatens the whole society with its social implications.
PURPOSE: For patients treated with palliative radiation, we examined the association between life expectancy predictions by radiation oncologists and aggressive end-of-life care.
MATERIALS AND METHODS: We included decedents from a study that assessed the ability of oncologists to predict survival of patients with metastatic cancer who received radiation. We identified patients who died within 12 months of study enrollment to assess accuracy of predictions. Aggressive end-of-life care was defined by the National Quality Forum, ASCO Quality Oncology Practice Initiative metrics, and advanced radiation modalities in the last month of life. Survival predictions were categorized as follows: correct (< 12 months), 12 to 18 months, 18 to 24 months, and more than 24 months. We assessed association between prediction and aggressive end-of-life care using a generalized estimation equation.
RESULTS: Of 489 decedents, we identified 467 encounters with survival estimates. Overall, 156 decedents (32%) met at least one metric of aggressive end-of-life care. Factors associated with aggressive end-of-life care included younger age, female sex, primary cancer diagnosis, no brain metastases, and private insurance. In each encounter when an oncologist predicted survival, 363 predictions (78%) were correct (< 12 months), 54 (11%) incorrectly predicted 12 to 18 months, 27 (6%) predicted 18 to 24 months, and 23 (5%) predicted more than 24 months. Compared with patients who had encounters that had correct survival predictions, patients predicted to live more than 24 months were more likely to meet at least one metric of aggressive end-of-life care (odds ratio, 2.55; 95% CI, 1.09 to 5.99; P = .03).
CONCLUSION: Inaccurate survival predictions by oncologists are associated with more aggressive end-of-life care for patients with advanced cancer.
Ce document aborde les points suivants : quel accueil pour initier l'accompagnement des proches ? le début de la relation... ; comment réagir face aux comportements envahissants/agressifs des proches ? ; Quel rôle pour l'entourage dans la décision médicale ? Ce que dit la loi ; Comment accueillir et accompagner les jeunes enfants ? ; le décès.
BACKGROUND: Early integration of palliative care for patients with metastatic lung cancer improves their quality of life and survival and reduces the aggressiveness of care near the end of life. This study examined the association between the timing of palliative care needs reporting and the aggressiveness of end-of-life care.
METHODS: This retrospective cohort study used the French National Hospital Registry to identify all hospitalized adults (=20 years old) who died of metastatic lung cancer in France between 2010 and 2013. It compared the use of care and treatments near the end of life as a function of the timing of the first reporting of palliative care needs. The use of chemotherapy and the use of invasive ventilation were defined as primary outcomes. Propensity score weighting was used to control for potential confounders.
RESULTS: Among a total of 64,950 deceased patients with metastatic lung cancer, the reporting of palliative care needs was characterized as timely (from 91 to 31 days before death) for 26.3%, late (from 30 to 8 days before death) for 31.5%, and very late (from 7 to 0 days before death) for 12.8%. Palliative care needs were not reported for 19,106 patients (29.4%). Patients with timely reporting of palliative care needs had the earliest and most progressive decrease in the use of anticancer therapy. The use of invasive ventilation also increased with a delay in palliative care needs reporting.
CONCLUSIONS: There is a clear association between the timing of palliative care needs reporting and the aggressiveness of care near the end of life.
The aim of this research was to determine the relation between death attitude and distress tolerance and aggression and anger. For this, 135 subjects among 7,535 professional and specialist members of the Iran National Library were selected using convenience sampling method. They replied to Death Attitudes Profile-Revised, distress tolerance questionnaire, and aggression questionnaire. The results showed that the attitudes of approach acceptance, neutral acceptance, and escape acceptance had positive relation to distress tolerance and negative relation to aggression and anger while the attitudes of fear of death and death avoidance had negative relation to distress tolerance and positive relation to aggression and anger. Furthermore, all death attitudes predicted distress tolerance. But only the attitudes of approach acceptance, escape acceptance, fear of death, and death avoidance predicted aggression, and only approach acceptance, neutral acceptance, fear of death, and death avoidance predicted anger.
BACKGROUND: Evidence suggests that the aggressiveness of care in cancer patients at the end of life is increasing. We sought to evaluate the use of invasive procedures at the end of life in patients with advanced non-small-cell lung cancer (NSCLC).
OBJECTIVE: To evaluate the utilization of invasive procedures at the end of life in Veterans with advanced NSCLC.
DESIGN: Retrospective cohort study of Veterans with newly diagnosed stage IV NSCLC who died between 2006 and 2012.
SETTING/SUBJECTS: Subjects were identified from the Veterans Affairs Central Cancer Registry.
MEASUREMENTS: All Veterans Administration (VA) and Medicare fee-for-service healthcare utilization and expenditure data were assembled for all subjects. The primary outcome was the number of invasive procedures performed in the last month of life. We classified procedures into three categories: minimally invasive, life-sustaining, and major-operative procedures. Logistic regression analysis was used to evaluate factors associated with the receipt of invasive procedures.
RESULTS: Nineteen thousand nine hundred thirty subjects were included. Three thousand (15.1%) subjects underwent 5523 invasive procedures during the last month of life. The majority of procedures (69.6%) were classified as minimally invasive. The receipt of procedures in the last month of life was associated with receipt of chemotherapy (odds ratio [OR] 3.68, 95% confidence interval [CI] 3.38-4.0) and ICU admission (OR 3.13, 95% CI 2.83-3.45) and was inversely associated with use of hospice services (OR 0.35, 95% CI 0.33-0.38).
CONCLUSIONS: Invasive procedures are commonly performed among Veterans with stage IV NSCLC during their last month of life and are associated with other measures of aggressive end-of-life care.
Studies have documented ethnic differences in advance directive (AD) completion, with lower rates in minority groups. Of those with ADs, blacks are more likely than whites to prefer aggressive care, but little is known about how these differences in preferences have changed over time in ethnic groups. This nationally representative study aimed to investigate whether these differences in AD development persisted after adjusting for important confounding variables. Year of death was analyzed to see how AD completion changed over time within ethnic groups, and for those with an AD, the association between these factors and opting for aggressive care was investigated. Data from the 2000 to 2012 Health and Retirement Study (HRS) exit interviews from 7,177 decedents were used. Analyses included logistic regression to determine the relationship between ethnicity and AD completion and preferences for aggressive care and how it changed over time in ethnic groups. Forty-six percent of decedents had completed an AD (whites 51.7%, Hispanics 18.0%, blacks 15.0%). Of blacks completing an AD, 23.8% elected prolonged care, compared with 13.3% of Hispanics and 3.3% of whites. Logistic regression revealed that blacks 75% lower odds of completing an AD and Hispanics had 70% lower odds. Model covariates had a small influence on ethnic differences, although in examining the change in AD completion over time, the odds of having an AD increased with each subsequent death year for blacks and whites but not Hispanics. Additional research is needed to investigate the effect of cultural differences in AD completion rates of ethnic minority groups to ensure that preferences are honored in the clinical setting.
Purpose: The aims of this study were to investigate trends of aggressive treatment of non-small cell lung cancer (NSCLC) patients at the end-of-life (EOL) during the recent 5 years and examine the relationship between hospice consultation (HC) and aggressive care.
Materials and Methods: The medical records of 789 patients with stage IIIB-IV NSCLC at Seoul National University Hospital (SNUH) who received palliative chemotherapy and died from 2010 to 2014 were retrospectively reviewed. Indicators of aggressive treatment were evaluated, and the association of HC with these indicators was analyzed.
Results: During the last 5 years, the frequency of HC increased from 26.7% to 43.6%. The time interval from last chemotherapy to death increased, and the proportion of patients who received palliative chemotherapy, visited an emergency room, were admitted to intensive care unit, during the last month of life, and died in SNUH significantly decreased over time. Referral to HC was significantly associated with lower intensive care unit admission rates, lower out-of-hospital death rates, and less use of the chemotherapy within 1 month prior to death. Overall survival did not differ by HC.
Conclusion: The pattern of cancer care nearthe EOL has become less aggressivewhen HCwas provided. The positive association of HCwith better EOL care suggests that providing HC at the optimal time might help to avoid futile aggressive treatment.
S'approprier son corps, faire sienne sa maladie, garder le lien avec sa vie : c'est tout l'enjeu lorsqu'en raison d'une maladie grave le corps perd de sa familiarité, lorsqu'il se manifeste dans son étrangeté, lorsque les médecins et les soignants finissent par mieux le connaître et le soigner que nous-mêmes ou nos proches. Comment, dans ces conditions, rester soi-même ? Comment regagner sa souveraineté subjective et narcissique ? La réponse à ces questions exige d'étudier les processus psychiques à l'oeuvre dans la maladie grave, et en particulier ceux qui relancent la subjectivité. Ce travail d'appropriation signifie, pour le patient, de subvertir les éprouvés provoqués par la maladie et les traitements, afin de reconstruire un corps sensoriel et libidinal auquel il pourra de nouveau s'identifier. C'est grâce à cette "subversion libidinale" qu'il parviendra à raconter ce corps, cette maladie, ces traitements, de sorte qu'ils prennent un sens dans sa vie et dans son histoire.
Origine : BDSP. Notice produite par EHESP CpErmR0x. Diffusion soumise à autorisation
Les auteurs abordent la fin de vie au domicile sous un angle philosophique et psychanalytique et notamment : l'irruption de la maladie dans la maison, l'intimité du domicile bouleversé, la fatigue et l'agressivité de la personne en fin de vie ; la mort à domicile.
Les auteures, assistante sociale et aide-soignante, évoquent une prise en charge palliative complexe. Il s'agit d'un homme atteint d'une pathologie cancéreuse avec atteinte cérébrale. Hospitalisé en centre de soins de suite, est évoqué ensuite le passage de relais (retour à domicile ? lit de répit ?) pour protéger le patient et les équipes.
L'auteure aborde le rôle du soignant face à un patient jeune, agressif, en phase palliative, qui négocie tous ses soins. Elle s'attache tout d'abord à définir la négociation, qu'elle relie aux soins et au rôle de soignant. Puis elle s'interroge sur le sens de la négociation chez ce patient.