Abstract
Lee RY, Brumback, Sathitratanacheewin S, et al.: Association of physician orders for life-sustaining treatment with ICU admission among patients hospitalized near the end of life. JAMA 2020. [E-pub ahead of print]; DOI: 10.1001/jama.2019.22523
Patients with chronic illness frequently use physician orders for life-sustaining treatment (POLST) to document treatment limitations. The aim of this study was to evaluate the association between POLST for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. A retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized six months or less before death in a two-hospital academic health care system was undertaken. POLST for medical interventions (“comfort measures only” vs. “limited additional interventions” vs. “full treatment”), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury were the exposures studied. Results demonstrated that among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLSTs for comfort measures only, 761 (42%) had POLSTs for limited additional interventions, and 656 (36%) had POLSTs for full treatment. ICU admissions occurred in 31% of patients with comfort-only orders, 46% with limited-interventions orders, and 62% with full-treatment orders. One or more life-sustaining treatments were delivered to 14% of patients with comfort-only orders and to 20% of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission. Across patients with comfort-only and limited-interventions POLSTs, 38% received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer. Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia. Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care. In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care. The authors conclude that among patients with POLSTs and with chronic life-limiting illness who were hospitalized within six months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission than full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.
Tate CE, Venechuk G, Brereton EJ: “It's Like a Death Sentence but It Really Isn't” What patients and families want to know about hospice care when making end-of-life decisions. Am J Hospice Palliat Med 2019. [E-pub ahead of print]; DOI: 10.1177/1049909119897259
Hospice is underutilized, due to both lack of initiation from patients and late referral from clinicians. Prior research has suggested that the reasons for underuse are multifactorial, including clinician and patient lack of understanding, misperceptions about the nature of hospice care, and poor communication during end-of-life discussions about hospice care. Little is known about the decisional needs of patients and families engaging in hospice decision making. The objective of this study was to understand the decisional needs of patients and families making decisions about hospice care. The authors conducted focus groups with family caregivers and hospice providers and one-on-one interviews with patients considering or enrolled in hospice care. They identified participants through purposeful and snowball sampling methods. All interviews were transcribed verbatim and analyzed using a grounded theory approach. Results demonstrated 4 patients, 32 family caregivers, and 27 hospice providers participated in the study. Four main themes around decisional needs emerged from the interviews and focus groups: (1) What is hospice care, (2) why might hospice care be helpful, (3) where is hospice care provided, and (4) how is hospice care paid for? From the interviews, the authors conclude that hospice may not be the right treatment choice for all with terminal illness. They further state that their study highlights where patients' and families' understanding could be enhanced to assure that they have the opportunity to benefit from hospice, if they so desire.
Huggins M, McGregor MJ, Cox MB, et al.: Advance care planning and decision-making in a home-based primary care service in a Canadian urban centre. Can Geriatr J 2019;22:182–189.
Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future, and has been shown to reduce hospital-based interventions at the end of life. The authors' goal in this study was to describe the current state of ACP in a home-based primary care program for frail homebound older people in Vancouver, Canada. The authors did this by identifying four key elements that should be essential to ACP in this program: frailty stage, documentation of substitute decision makers, and decision making with regard to both resuscitation (i.e., do not resuscitate [DNR]) and hospitalization (i.e., do not hospitalize [DNH]). Although these elements are an important part of the ACP process, they are often excluded from common practice. The study was a cross-sectional observational study of data abstracted from 200 randomly selected patient electronic medical records between July 1 and September 30, 2017. Results demonstrated that in 73% (n = 146) of the patient records, there was no explicit documentation of frailty stage. Sixty-four percent had documentation of a substitute decision maker. Of those who had their preferences documented, 90.6% (n = 144/159) indicated a preference for DNR and 23.6% (n = 29/123) indicated a preference for DNH. In multiple regression modeling, a diagnosis of dementia and older age were associated with documentation of a DNR preference. Older age, male gender, and English identified as the main language spoken were associated with a DNH preference. The authors conclude that clinician documentation of some elements of ACP, such as identification of a substitute decision maker and resuscitation status, has been widely adopted, whereas other elements that should be considered essential components of ACP, such as frailty staging and preferences around hospitalization, are infrequent and provide an opportunity for practice improvement initiatives. The significant association between language and ACP decisions suggests an important role for supporting cross-cultural fluency in the ACP process.
Etgen T: Case series of introducing palliative care consultation in psychiatry. Palliat Med 2020 [E-pub ahead of print]; DOI: 10.1177/0269216319901241
This article describes a series of cases in a new palliative care consultation service in a large psychiatric hospital. Palliative care consultation was established, and details including patient age, department, diagnosis, main problem, solution, and discharge were documented and analyzed during the first two years. There were 2 consultations in the first year and 18 consultations in the second year (18 geriatric, 2 addiction, 0 general, clinical social, and forensic psychiatry) involving 2 domains: delirium associated with dementia or another condition (75%) and mental illness (e.g., alcoholic psychosyndrome, psychosis, suicidal tendency, schizophrenia, and depression) and cancer (25%). Recommendations of consultations were realized in 95%. The author concludes that implementation of palliative care consultation in psychiatry is one possible method of how to introduce palliative care in a field of medicine with lack of palliative care. The author suggests that future research should focus on reasons for reservations about palliative care in psychiatry, include more patients with severe persistent mental illness, and assess the value of palliative care consultation in resolving this problem.
Orkin J, Beaune L, Moore C, et al.: Toward an understanding of advance care planning in children with medical complexity. Pediatrics 2020 [E-pub ahead of print]; DOI: 10.1542/peds.20192241
Children with medical complexity (CMC) often have multiple life-limiting conditions with no unifying diagnosis and an unclear prognosis and are at high risk for morbidity and mortality. ACP conversations need to be uniquely tailored to this population. The authors' primary objective for this study was to develop an in-depth understanding of the ACP experiences from the perspectives of both parents and health care providers (HCPs) of CMC.
The authors conducted 25 semistructured interviews with parents of CMC and HCPs of various disciplines from a tertiary pediatric hospital. Interview guide questions were focused on ACP, including understanding of the definition, positive and negative experiences, and suggestions for improvement. Interviews were conducted until thematic saturation was reached. Interviews were audio recorded, transcribed verbatim, coded, and analyzed using content analysis.
Results demonstrated that 14 mothers and 11 HCPs participated in individual interviews. Interviews revealed four major themes and several associated subthemes (in parentheses): (1) holistic mindset, (2) discussion content (beliefs and values, hopes and goals, and quality of life), (3) communication enhancers (partnerships in shared decision making, supportive setting, early and ongoing conversations, consistent language and practice, family readiness, provider expertise in ACP discussions, and provider comfort in ACP discussions), and (4) the ACP definition. The authors conclude that family and HCP perspectives revealed a need for family-centered ACP for CMC and their families. The authors state that their results aided the development of a family-centered framework to enhance the delivery of ACP through a holistic mindset, thoughtful discussion content, and promoting of conversation enhancers.