Abstract
Gray NA, Boucher NA, Kuchibhatia M, et al.: Hospice access for undocumented immigrants. JAMA Intern Med 2017; 177: 579–580.
The 11.2 million undocumented immigrants living in the United States are not covered by the Medicare Hospice Benefit, and most are uninsured. Aging of undocumented patients owing to increasing lengths of residence in the United States is likely to increase hospice demand, and undocumented immigrants are the largest demographic group explicitly excluded from Affordable Care Act provisions. Clinicians have reported challenges in obtaining hospice for undocumented immigrants; however, little is known about hospice access in this population. Therefore, this study examined hospice agency practices and access for undocumented immigrants. Results demonstrated that there is an existing demand for hospice for undocumented patients, and suggest hospice access may be disproportionately limited in areas with predominately smaller, for-profit agencies. As the proportion of for-profit hospice agencies continues to grow nationally, barriers to hospice access for undocumented patients may increase. Although some cities and states are expanding healthcare for undocumented immigrants, for many, healthcare access remains limited. Based on this study, such limitations persist through end-stage illness. The authors suggest that policies that reduce barriers to hospice for this population may improve end-of-life care and reduce costs.
Fritz Z, Slowther AM, Perkions GD: Resuscitation policy should focus on the patient, not the decision. BMJ 2017; 356: j813.
Do not attempt cardiopulmonary resuscitation (DNACPR) decisions are made commonly in healthcare but can be a source of ethical concern and legal challenge. They differ from other healthcare decisions because they are made in anticipation of a future event and concern withholding, rather than giving, a treatment. One of the reasons DNACPR decisions were introduced was to protect patients from invasive treatments that had little or no chance of success. However, inconsistencies in decision making, communication, and documentation have led to misunderstandings about what DNACPR means and to delivery of poorer care to some patients. In this article, the authors discuss the problems with current practice and outline newer approaches that place the patient, and their family, at the center of the discussions. They focus on overall treatment plans and supporting clinicians and patients to make shared decisions about emergency treatments.
Hopeck P, Harrison TR: Reframing, refocusing, referring, reconciling, and reflecting: Exploring conflict resolution strategies in end-of-life situations. Health Commun 2016; 32: 240–246.
A multitude of problems can occur between family members at the end of a patient's life, resulting in conflict that others—the nurses, patient advocates, clergy, and social workers involved in the case—must resolve. This article explores the strategies used by those individuals to resolve conflict. Using grounded practical theory as a theoretical and methodological framework, qualitative interviews (n = 71) revealed how they manage family conflict at the end of life. The management styles included reframing, refocusing, referring, reconciling, and reflecting (the “5 Rs”). These strategies can provide a conflict management typology for those who work with families during end-of-life situations.
Widger K, Seow H, Rapoport A, et al.: Children's end-of-life health care use and cost. Pediatrics 2017; 139: e20162956.
Healthcare use and cost for children at the end of life are not well documented across the multiple sectors wherein children receive care. The objective of this study was to examine demographics, location, cause of death, and healthcare use and costs over the last year of life for children aged 1 month to 19 years who died in Ontario, Canada. The authors conducted a population-based retrospective cohort study using administrative databases to determine the characteristics of and healthcare costs by age group and cause of death for a three-year period from 2010 to 2013. Results demonstrated that in this cohort of 1620 children, 41.6% died of a chronic disease with wide variation across age groups. The mean healthcare cost for the last year of life was $78,332 (Canadian) with a median of $18,450, reflecting the impact of high-cost decedents. The mean costs for children with chronic or perinatal/congenital illnesses nearly tripled for the last four months of life. The majority of costs (67.0%) were incurred in acute care settings, with 88.0% of children with a perinatal/congenital illness and 79.7% with a chronic illness dying in acute care. Only 33.4% of children received home care in the last year of life. The authors conclude that children in Ontario, Canada, receive the majority of their end-of-life care in acute care settings at a high cost to the healthcare system. Initiatives to optimize care should focus on early discussion of the goals of care and assessment of whether the care provided fits with these goals.
Gibbs AJO, Malyon AC: Themes and variations: An exploratory international investigation into resuscitation decision-making. Resuscitation 2016; 103: 75–81.
DNACPR decisions are made in hospitals throughout the world. International variation in clinicians' perception of DNACPR decision making and implementation and the factors influencing such variation have not previously been explored. In this study, the authors submitted a questionnaire asking how DNACPR decisions are made, communicated, and perceived in the country of the responder to the survey: it consisted of seven closed-answer and four open-answer questions. It was distributed to 143 medical professionals with prior published material relating to DNACPR decisions. Under-represented geographical areas were identified and an additional 34 physicians were contacted through medical colleagues and students at the university hospital from which this study was based. The respondents had four weeks to answer the questionnaire. Results demonstrated that 78 responses (44%) were received from 43 countries. All continents were represented. Eighty-eight percent of respondents reported a method for implementing DNACPR decisions, 90% of which discussed resuscitation wishes with the patient at least half of the time. Ninety-four percent of respondents thought that national guidance for DNACPR order implementation should exist; 53% of countries surveyed reported existence of such guidance. Cultural attitudes toward death, medical education and culture, health economics, and the societal role of family were commonly identified as factors influencing perception of DNACPR decisions. The authors conclude that most countries surveyed make some form of DNACPR decision but differing cultures and economic status contribute toward a heterogeneity of approaches to resuscitation decision making. Adequacy of relevant medical education and national policy are two areas that were regularly identified as impacting upon the processes of DNACPR decision making and implementation.
Atsalatsanis A, Hozo I, Djulbegovic B: Acceptable regret model in the end-of-life setting: Patients require high level of certainty before forgoing management recommendations. Eur J Cancer 2017; 75: 159–166.
The acceptable regret model postulates that under some circumstances decision makers may tolerate wrong decisions. The purpose of this work was to empirically evaluate the acceptable regret model of decision making in the end-of-life care setting, where terminally ill patients consider seeking curative treatment versus accepting hospice/palliative care. The authors conducted interviews with 48 terminally ill patients to assess their preferences about end-of-life treatment choices. They first elicited the patient's regret of potentially wrong choices with regard to the recommended management and provided information on life expectancy estimated by two prognostication models. They then elicited the patients' level of acceptable regret by assessing their tolerance for potentially wrongly accepting hospice care versus continuing unnecessary treatment. Using the levels of acceptable regret, the authors computed: (1) the probability of death above which a patient would tolerate wrongly accepting hospice care and (2) the probability of death below which the patient would tolerate unnecessary treatment. They also assessed patients' understanding of the interview questions using a seven-point Likert scale. Results demonstrated that the median probability of death above which a patient would tolerate wrongly accepting hospice care was 96%, whereas the median probability of death below which a patient would tolerate unnecessary treatment was 2.5%. They also found that the levels of acceptable regret measured for wrong hospice referral were similar to the levels of acceptable regret measured for unnecessary treatment, indicating that acceptable regret levels for either of the wrong decisions is felt similarly. The results were independent of the estimated probability of death communicated to patients before the acceptable regret interview. The authors conclude that they have elicited empirical data that corroborated the acceptable regret hypothesis, and suggest that the requirement for high level of certainty before accepting recommended management may explain the difficulties related to decision making in the end-of-life setting.
Clark J, Raijmakers NJH, Allan S, van Zuylen L, van der Heide A: Declining oral intake towards the end of life: How to talk about it? A qualitative study. Int J Palliat Nurs 2017; 23: 74–82.
Decreasing oral intake is common toward the end of life and a potential source of distress and concern for patients, family members, and clinicians. This article provides insight to inform practice regarding clinicians' perceptions, practices, responses, and communication with patients and their companions regarding declining oral intake toward the end of life. In this qualitative study, 10 specialist palliative care staff participated in semistructured interviews. Qualitative thematic analysis was used to analyze data. Results demonstrated that three themes were identified: declining oral intake was a natural part of the dying process, responding empathetically, and clinicians described specific aims and ways regarding communication. The authors conclude that insight into clinicians' endeavors to manage declining oral intake and support the well-being of patients and families can inform practice. However, the perspectives of family and health professionals continue to show significant variation regarding the communication given and received around declining oral intake toward the end of life.