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Critical Care (London, England) Oct 2023Although the defining elements of "acute respiratory distress syndrome" (ARDS) have been known for over a century, the syndrome was first described in 1967. Since then,... (Review)
Review
Although the defining elements of "acute respiratory distress syndrome" (ARDS) have been known for over a century, the syndrome was first described in 1967. Since then, despite several revisions of its conceptual definition, it remains a matter of debate whether ARDS is a discrete nosological entity. After almost 60 years, it is appropriate to examine how critical care has modeled this fascinating syndrome and affected patient's outcome. Given that the diagnostic criteria of ARDS (e.g., increased pulmonary vascular permeability and diffuse alveolar damage) are difficult to ascertain in clinical practice, we believe that a step forward would be to standardize the assessment of pulmonary and extrapulmonary involvement in ARDS to ensure that each patient can receive the most appropriate and effective treatment. The selection of treatments based on arbitrary ranges of PaO/FiO lacks sufficient sensitivity to individualize patient care.
Topics: Humans; Respiratory Distress Syndrome; Lung; Treatment Outcome; Critical Care
PubMed: 37907946
DOI: 10.1186/s13054-023-04699-w -
CA: a Cancer Journal For Clinicians 2023Patient navigation is a strategy for overcoming barriers to reduce disparities and to improve access and outcomes. The aim of this umbrella review was to identify,... (Review)
Review
Patient navigation is a strategy for overcoming barriers to reduce disparities and to improve access and outcomes. The aim of this umbrella review was to identify, critically appraise, synthesize, and present the best available evidence to inform policy and planning regarding patient navigation across the cancer continuum. Systematic reviews examining navigation in cancer care were identified in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), Epistemonikos, and Prospective Register of Systematic Reviews (PROSPERO) databases and in the gray literature from January 1, 2012, to April 19, 2022. Data were screened, extracted, and appraised independently by two authors. The JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used for quality appraisal. Emerging literature up to May 25, 2022, was also explored to capture primary research published beyond the coverage of included systematic reviews. Of the 2062 unique records identified, 61 systematic reviews were included. Fifty-four reviews were quantitative or mixed-methods reviews, reporting on the effectiveness of cancer patient navigation, including 12 reviews reporting costs or cost-effectiveness outcomes. Seven qualitative reviews explored navigation needs, barriers, and experiences. In addition, 53 primary studies published since 2021 were included. Patient navigation is effective in improving participation in cancer screening and reducing the time from screening to diagnosis and from diagnosis to treatment initiation. Emerging evidence suggests that patient navigation improves quality of life and patient satisfaction with care in the survivorship phase and reduces hospital readmission in the active treatment and survivorship care phases. Palliative care data were extremely limited. Economic evaluations from the United States suggest the potential cost-effectiveness of navigation in screening programs.
Topics: Humans; Patient Navigation; Quality of Life; Systematic Reviews as Topic; Palliative Care; Neoplasms; Continuity of Patient Care
PubMed: 37358040
DOI: 10.3322/caac.21788 -
British Journal of Hospital Medicine... Mar 2024Enhanced supportive care is a care model providing earlier access to multiprofessional, coordinated care for patients from the point of cancer diagnosis. As a proactive... (Review)
Review
Enhanced supportive care is a care model providing earlier access to multiprofessional, coordinated care for patients from the point of cancer diagnosis. As a proactive model of care, it stands as a contrast to providing access to a multidisciplinary team once a patient has hit a crisis point, or when their prognosis has become sufficiently poor that they are able to access traditional end-of-life services. Its arrival in the UK through palliative care teams working in cancer care has led to enhanced supportive care being synonymous with early palliative care. While enhanced supportive care has enabled early palliative care, as it has become more embedded in the UK, it has taken on a wider remit for patients living longer with cancer and the management of side effects. Enhanced supportive care services have also begun to provide care for cancer survivors. Enhanced supportive care services have a key role in modern cancer care in maintaining and improving patients' quality of life alongside cancer treatment and ensuring that patients' priorities and preferences for treatment are considered. Furthermore, enhanced supportive care has been shown to support the wider healthcare system by creating capacity within the NHS, reducing demand on hospital services and saving money. As enhanced supportive care services continue to grow and venture into the care and support of cancer survivors and those receiving potentially curative treatments, ongoing work is needed to determine how these services can be made available throughout the NHS and how a shared vision of the way enhanced supportive care operates can be realised.
Topics: Humans; Quality of Life; Palliative Care; Terminal Care; Neoplasms; Delivery of Health Care
PubMed: 38557099
DOI: 10.12968/hmed.2023.0416 -
JAMA Jun 2023Discussions about goals of care are important for high-quality palliative care yet are often lacking for hospitalized older patients with serious illness.
IMPORTANCE
Discussions about goals of care are important for high-quality palliative care yet are often lacking for hospitalized older patients with serious illness.
OBJECTIVE
To evaluate a communication-priming intervention to promote goals-of-care discussions between clinicians and hospitalized older patients with serious illness.
DESIGN, SETTING, AND PARTICIPANTS
A pragmatic, randomized clinical trial of a clinician-facing communication-priming intervention vs usual care was conducted at 3 US hospitals within 1 health care system, including a university, county, and community hospital. Eligible hospitalized patients were aged 55 years or older with any of the chronic illnesses used by the Dartmouth Atlas project to study end-of-life care or were aged 80 years or older. Patients with documented goals-of-care discussions or a palliative care consultation between hospital admission and eligibility screening were excluded. Randomization occurred between April 2020 and March 2021 and was stratified by study site and history of dementia.
INTERVENTION
Physicians and advance practice clinicians who were treating the patients randomized to the intervention received a 1-page, patient-specific intervention (Jumpstart Guide) to prompt and guide goals-of-care discussions.
MAIN OUTCOMES AND MEASURES
The primary outcome was the proportion of patients with electronic health record-documented goals-of-care discussions within 30 days. There was also an evaluation of whether the effect of the intervention varied by age, sex, history of dementia, minoritized race or ethnicity, or study site.
RESULTS
Of 3918 patients screened, 2512 were enrolled (mean age, 71.7 [SD, 10.8] years and 42% were women) and randomized (1255 to the intervention group and 1257 to the usual care group). The patients were American Indian or Alaska Native (1.8%), Asian (12%), Black (13%), Hispanic (6%), Native Hawaiian or Pacific Islander (0.5%), non-Hispanic (93%), and White (70%). The proportion of patients with electronic health record-documented goals-of-care discussions within 30 days was 34.5% (433 of 1255 patients) in the intervention group vs 30.4% (382 of 1257 patients) in the usual care group (hospital- and dementia-adjusted difference, 4.1% [95% CI, 0.4% to 7.8%]). The analyses of the treatment effect modifiers suggested that the intervention had a larger effect size among patients with minoritized race or ethnicity. Among 803 patients with minoritized race or ethnicity, the hospital- and dementia-adjusted proportion with goals-of-care discussions was 10.2% (95% CI, 4.0% to 16.5%) higher in the intervention group than in the usual care group. Among 1641 non-Hispanic White patients, the adjusted proportion with goals-of-care discussions was 1.6% (95% CI, -3.0% to 6.2%) higher in the intervention group than in the usual care group. There was no evidence of differential treatment effects of the intervention on the primary outcome by age, sex, history of dementia, or study site.
CONCLUSIONS AND RELEVANCE
Among hospitalized older adults with serious illness, a pragmatic clinician-facing communication-priming intervention significantly improved documentation of goals-of-care discussions in the electronic health record, with a greater effect size in racially or ethnically minoritized patients.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT04281784.
Topics: Humans; Female; Aged; Male; Communication; Hospitalization; Terminal Care; Dementia; Patient Care Planning
PubMed: 37210665
DOI: 10.1001/jama.2023.8812 -
Palliative Medicine Feb 2024The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting...
BACKGROUND
The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability.
AIM
To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers.
DESIGN
Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure.
SETTING
European.
PARTICIPANTS
International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation.
RESULTS
A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms used to encompass distressing physical and psychological symptoms as well as existential suffering and to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided.
CONCLUSIONS
This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.
Topics: Humans; Palliative Care; Delphi Technique; Terminal Care; Consensus; Anesthesia; Deep Sedation
PubMed: 38297460
DOI: 10.1177/02692163231220225 -
Annals of Palliative Medicine Nov 2023Palliative care is a multidisciplinary field that aims to relieve physical pain and psychological suffering with the goal of improving quality of life rather than... (Review)
Review
Palliative care is a multidisciplinary field that aims to relieve physical pain and psychological suffering with the goal of improving quality of life rather than focusing on curing or prolonging life. Plastic surgeons may have a role in this near end-of-life care through palliative reconstruction. The use of palliative reconstruction has been frequently described in the setting of head and neck and thoracic malignancies However, there is a paucity in the literature about the role of palliative reconstruction in the lower extremity. In this review, we provide a summary of the current literature in support of the benefits of palliative reconstruction in the lower extremity as well as three case examples to demonstrate scenarios in which palliative lower extremity reconstruction may be used for select patients. In order to determine whether a patient may benefit from palliative reconstruction to merit its risks, the treatment goals and limitations must be assessed on a case-by-case basis in collaboration with the patient. Careful patient selection, focus on patient's ambulatory and personal goals, and minimizing donor site morbidity are important considerations in palliative reconstruction of the lower extremity. Together with a multidisciplinary approach, plastic surgeons can provide valuable contributions to improve the quality of life for certain palliative oncological patients by providing palliative reconstruction of the lower extremity.
Topics: Humans; Leg; Quality of Life; Palliative Care; Terminal Care; Hospice Care
PubMed: 37953221
DOI: 10.21037/apm-23-358 -
Deutsches Arzteblatt International Jul 2023Artificial intelligence (AI) is increasingly being used in patient care. In the future, physicians will need to understand not only the basic functioning of AI... (Review)
Review
BACKGROUND
Artificial intelligence (AI) is increasingly being used in patient care. In the future, physicians will need to understand not only the basic functioning of AI applications, but also their quality, utility, and risks.
METHODS
This article is based on a selective review of the literature on the principles, quality, limitations, and benefits AI applications in patient care, along with examples of individual applications.
RESULTS
The number of AI applications in patient care is rising, with more than 500 approvals in the United States to date. Their quality and utility are based on a number of interdependent factors, including the real-life setting, the type and amount of data collected, the choice of variables used by the application, the algorithms used, and the goal and implementation of each application. Bias (which may be hidden) and errors can arise at all these levels. Any evaluation of the quality and utility of an AI application must, therefore, be conducted according to the scientific principles of evidence-based medicine-a requirement that is often hampered by a lack of transparency.
CONCLUSION
AI has the potential to improve patient care while meeting the challenge of dealing with an ever-increasing surfeit of information and data in medicine with limited human resources. The limitations and risks of AI applications require critical and responsible consideration. This can best be achieved through a combination of scientific.
Topics: Humans; United States; Artificial Intelligence; Algorithms; Evidence-Based Medicine; Patient Care
PubMed: 37218054
DOI: 10.3238/arztebl.m2023.0124 -
CMAJ : Canadian Medical Association... Sep 2023
Topics: Humans; Central Nervous System Stimulants; Canada; Prescriptions; Continuity of Patient Care
PubMed: 37696557
DOI: 10.1503/cmaj.230266-f -
Air Medical Journal 2024The inclusion of nurse practitioners (NPs) in critical care transport teams has the potential to enhance patient care and improve team operations. NPs can manage complex... (Review)
Review
The inclusion of nurse practitioners (NPs) in critical care transport teams has the potential to enhance patient care and improve team operations. NPs can manage complex clinical situations during transport and excel in various roles such as leadership, education, mentoring, research, quality improvement, and clinical expertise. As we navigate the evolving landscape of critical care transport, it is crucial to explore the potential benefits offered by NPs. Their distinct skills and experiences effectively position them to improve patient outcomes, enhance team performance, and contribute to health care's financial sustainability. This article discusses the role of NPs in critical care transport, providing insight into their current uses, and recommendations for optimal use.
Topics: Humans; Nurse Practitioners; Critical Care; Leadership; Clinical Competence
PubMed: 38490781
DOI: 10.1016/j.amj.2024.01.005 -
Annals of Palliative Medicine Jul 2023Recognizing the need for palliative care (PC) and referral to PC teams improves patients' quality of life. However, in patients with moderate/severe clinical complexity,... (Review)
Review
BACKGROUND
Recognizing the need for palliative care (PC) and referral to PC teams improves patients' quality of life. However, in patients with moderate/severe clinical complexity, early recognition of the need for PC may not correspond to referral to specialized PC services. The definition for clinical complexity is still underexplored, as well as the instruments available to assess complexity. This scoping review aims to gather relevant information on the definition of clinical complexity in PC, as well as on the instruments used to objectively assess complexity.
METHODS
According to the methodology of a Scoping Review, the keywords: "palliative care", "hospitalization criteria", "complexity criteria", "complexity assessment" and "clinical complexity", were searched in PubMed, Scopus, Cochrane, and b-on databases, during April 2022, for relevant information on the definition and/or approach and/or protocols related to clinical complexity in patients followed in PC, or on the instruments used to assess it, regardless of study design, the language, or year of publication.
RESULTS
From the 626 references found, 15 studies were included in the review. According to these studies, complexity may be organized/defined into 3, 4, or 6 domains, generally including the patient, the family, the health system, and the socio-cultural context. Of the 13 instruments mentioned for the objective assessment of complexity, the HexCom, IDC-Pal, and the recent ID-PALL seem to offer the broadest determinations of complexity.
CONCLUSIONS
Complexity is a dynamic process, which reflects the reality of patients and families, and patients, families, and health professionals' perceptions, and so it must be systematically adjusted to the stage of the disease. The definition of complexity and the development and use of suitable instruments can help to identify, assess, and improve patients' quality of life, while supporting their family across the grieving process. Yet, this may not always be summarized in a quantitative value by easy-to-use instruments, highlighting the role of PC interdisciplinary teams.
Topics: Humans; Quality of Life; Palliative Care; Hospice and Palliative Care Nursing; Patient Care; Referral and Consultation
PubMed: 37038064
DOI: 10.21037/apm-22-894