Abstract
Curtis RJ, Treece PD, Nielsen EL, et al. Randomized trial of communication facilitators to reduce family distress and intensity of end-of-life care. Am J Respir Crit Care Med 2015;193:154–162.
Communication with family of critically ill patients is often poor and associated with family distress. The objective of this study was to determine if an intensive care unit (ICU) communication facilitator reduces family distress and intensity of end-of-life care. The authors conducted this randomized trial at two hospitals. Eligible patients had a predicted mortality greater than or equal to 30% and a surrogate decision maker. Facilitators supported communication between clinicians and families, adapted communication to family needs, and mediated conflict. Outcomes of the study included depression, anxiety, and posttraumatic stress disorder (PTSD) among family three and six months after ICU and resource use. The authors identified 488 eligible patients and randomized 168. Of 352 eligible family members, 268 participated (76%). Family follow-up at three and six months ranged from 42% to 47%.
Results demonstrated that the intervention was associated with decreased depressive symptoms at six months (p = 0.017), but there were no significant differences in psychological symptoms at three months or anxiety or PTSD at six months. The intervention was not associated with ICU mortality (25% control versus 21% intervention; p = 0.615) but decreased ICU costs among all patients (per patient: $75,850 control, $51,060 intervention; p = 0.042) and particularly among decedents ($98,220 control, $22,690 intervention; p = 0.028). Among decedents, the intervention reduced ICU and hospital length of stay (28.5 days versus 7.7 days and 31.8 days versus 8.0 days, respectively; p = 0.001). The authors conclude that communication facilitators may be associated with decreased family depressive symptoms at six months, but there was no significant difference at three months or in anxiety or PTSD. The intervention reduced costs and length of stay, especially among decedents. The authors note that this is the first study to find a reduction in intensity of end-of-life care with similar or improved family distress.
Ghesquiere AR, Aldridge MD, Johnson-Heurzeler R. Hospice services for complicated grief and depression: Results from a national survey. J Am Geriatr Soc 2015;63:2173–2180.
The objectives of this study were to describe the prevalence of screening for complicated grief (CG) and depression in hospice and access to bereavement therapy and to examine whether screening and access to therapy varied according to hospice organizational characteristics or staff training and involvement. The design of the study was a cross-sectional national survey of 591 hospices conducted from 2008 to 2009 in the United States. The measurements of the study were whether hospices screened for depression or CG at the time of death or provided access to bereavement therapy (individual or group). Organizational hospice characteristics included region, chain status, ownership, and patient volume. Staffing-related variables included training length and meeting attendance requirements. Results demonstrated that 51% of hospices provided screening for CG and depression and access to bereavement therapy, 13% provided screening but not access to bereavement therapy, 24% provided access to bereavement therapy but not screening, and 8% neither screened nor provided access to bereavement therapy. Hospices with 100 patients per day or more were significantly more likely to provide screening and access to bereavement therapy. The authors conclude that hospices appear to have high capacity to provide screening for CG and depression and to deliver group and individual therapy, but data are needed on whether screeners are evidence based and whether therapy addresses CG or depression specifically. Future work could build upon existing infrastructure to ensure use of well-validated screeners and evidence-based therapies.
Dose AM, Carey EC, Rhudy LM. Dying in the hospital: Perspectives of family members. J Palliat Care 2015;31:13–20.
Although most patients express a preference to die at home, many (over 30%) still die in hospital. The purpose of this study was to explore the experience of hospital death from the perspective of patients' family members. Interviews were conducted with family members of patients who had died at hospitals affiliated with a large tertiary referral center in the United States. Content analysis was used to analyze findings. The authors interviewed 30 family members by phone.
Themes were arranged by timeframe: before death, time of death, and after death. The authors conclude that families do not interpret clinical cues leading up to death in the same way health care providers do; families need clear and direct explanations from providers. Clinicians should assess patient and family understandings of prognosis and communicate clearly and directly. Family members value being with their loved one at the time of death, and they value spending time with the body after death; this should be facilitated in clinical practice.
Walkery AJ, Weinberg J, Weiner RS, et al. Association of do-not-resuscitate orders and hospital. JAMA Internal Med 2016;176:97–104.
Hospital quality measures that do not account for patient do-not-resuscitate (DNR) status may penalize hospitals admitting a greater proportion of patients with limits on life-sustaining treatments. The objective of this retrospective, population-based cohort study was to evaluate the effect of analytic approaches accounting for DNR status on risk-adjusted hospital mortality rates and performance rankings. The study was conducted among adults hospitalized with pneumonia in 303 California hospitals between January 1 and December 31, 2011. The authors used hierarchical logistic regression to determine associations between patient DNR status, hospital-level DNR rates, and mortality measures. Changes in hospital risk-adjusted mortality rates after accounting for patient DNR status and interhospital variation in the association between DNR status and mortality were examined.
The main outcomes and measures were in-hospital mortality, determined using hierarchical logistic regression. A total of 90,644 pneumonia cases (5.4% of admissions) were identified among the 303 California hospitals evaluated during 2011; mean age of the patients was 72.5 years, 51.5% were women, and 59.3% were white. Hospital DNR rates varied (median, 15.8%). Without accounting for patient DNR status, higher hospital-level DNR rates were associated with increased patient mortality corresponding to worse hospital mortality rankings. In contrast, after accounting for patient DNR status and between-hospital variation in the association between DNR status and mortality, hospitals with higher DNR rates had lower mortality, with reversal of associations between hospital mortality rankings and DNR rates. Only 14 of 27 hospitals (51.9%) characterized as low-performing outliers without accounting for DNR status remained outliers after DNR adjustment. Hospital DNR rates were not significantly associated with composite quality measures of processes of care for pneumonia; however, DNR rates were positively correlated with patient satisfaction scores (r = 0.35; p < 0.001). The authors conclude that failure to account for DNR status may confound the evaluation of hospital quality using mortality outcomes, penalizing hospitals that admit a greater proportion of patients with limits on life-sustaining treatments. The authors recommend that stakeholders should seek to improve methods to standardize and report DNR status in hospital discharge records to allow further assessment of implications of adjusting for DNR in quality measures.
Bloom MW, Hamo CE, Cardinale D, et al. Cancer therapy–related cardiac dysfunction and heart failure. Part 1: Definitions, pathophysiology, risk factors, and imaging. Circ Heart Fail 2016;9:e002661.
Advances in cancer therapy have resulted in significant improvement in long-term survival for many types of cancer but have also resulted in untoward side effects associated with treatment. One such complication that has become increasingly recognized is the development of cardiomyopathy and heart failure. Whether a previously healthy person from a cardiovascular perspective develops cancer therapy–related cardiac dysfunction or a high-risk cardiovascular patient requires cancer therapy, the team of oncologists and cardiologists must be better equipped with an evidence-based approach to care for these patients across the spectrum. Although the toxicities associated with various cancer therapies are well recognized, limitations to our understanding of the appropriate course of action remain. In this first of a two-part review, the authors discuss the epidemiologic, pathophysiologic risk factors and imaging aspects of cancer therapy–related cardiac dysfunction and heart failure. In a subsequent second part they discuss the prevention and treatment aspects, concluding with a section on evidence gap and future directions. The authors focus on adult patients in all stages of cancer therapy from pretreatment surveillance to ongoing therapy and long-term follow-up.