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BMC Health Services Research Apr 2024Providing individualised healthcare in line with patient wishes is a particular challenge for emergency healthcare professionals. Documentation of patient wishes (DPW),...
BACKGROUND
Providing individualised healthcare in line with patient wishes is a particular challenge for emergency healthcare professionals. Documentation of patient wishes (DPW), e.g. as advance directives, can guide clinicians in making end-of-life decisions that respect the patient's wishes and autonomy. However, patient centered decisions are hindered by limited availability of DPWs in emergency settings.
OBJECTIVE
This systematic review aims to congregate present data on recorded rates for DPW existence and availability in the emergency department (ED) as well as contributing factors for these rates.
METHODS
We searched MEDLINE, Google Scholar, Embase and Web of Science databases in September 2023. Publications providing primary quantitative data on DPW in the ED were assessed. Publications referring only to a subset of ED patients (other than geriatric) and investigating DPW issued after admission were excluded.
RESULTS
A total of 22 studies from 1996 to 2021 were included in the analysis. Most were from the US (n = 12), followed by Australia (n = 4), Canada (n = 2), South Korea, Germany, the United Kingdom and Switzerland (n = 1 each). In the general adult population presenting to the ED, 19.9-27.8% of patients reported having some form of DPW, but only in 6.8% or less it was available on presentation. In the geriatric population, DPW rates (2.6-79%) as well as their availability (1.1-48.8%) varied widely. The following variables were identified as positive predictors of having DPW, among others: higher age, poorer overall health, as well as sociodemographic factors, such as female gender, having children, being in a relationship, higher level of education or a recent previous presentation to hospital.
CONCLUSIONS
Existence and availability of a recorded DPW among ED patients was low in general and even in geriatric populations mostly well below 50%. While we were able to gather data on prevalence and predictors, this was limited by heterogeneous data. We believe further research is needed to explore the quality of DPW and measures to increase both rates of existence and availability of DPW in the ED.
Topics: Aged; Adult; Child; Humans; Female; Advance Directives; Emergency Service, Hospital; Hospitalization; Health Personnel; Decision Making
PubMed: 38570808
DOI: 10.1186/s12913-024-10819-1 -
Journal of Gerontological Nursing Apr 2024To gather sufficient qualitative data to create an intervention that would prevent direct care workers (DCWs) from sending residents with do-not-hospitalize (DNH) orders...
PURPOSE
To gather sufficient qualitative data to create an intervention that would prevent direct care workers (DCWs) from sending residents with do-not-hospitalize (DNH) orders to the hospital.
METHOD
This was a qualitative study with eight participants that included a descriptive survey followed by semi-structured interviews.
RESULTS
DCWs were unfamiliar with DNH orders and their thinking on end-of-life care was binary (hospice or hospital) and protocol driven. However, supportive leaders were able to help DCWs problem-solve these complicated scenarios. Results were mixed on whether having a RN on site was helpful.
CONCLUSION
DCWs may benefit from having access to a nurse with palliative care experience when making decisions about residents with DNH orders. [(4), 11-15.].
Topics: Humans; Hospitalization; Advance Directives; Nursing Homes; Assisted Living Facilities; Hospices
PubMed: 38569104
DOI: 10.3928/00989134-20240311-02 -
Journal of Clinical Gastroenterology Apr 2024We examined the associations among advance directives (ADs) completion, coping, uncertainty in illness, and optimism and pessimism in patients with end-stage liver...
OBJECTIVE
We examined the associations among advance directives (ADs) completion, coping, uncertainty in illness, and optimism and pessimism in patients with end-stage liver disease (ESLD).
BACKGROUND
Although associations among ADs, coping, and uncertainty have been studied in patients with other life-limiting illnesses, these concepts have not been studied together in patients with ESLD.
PATIENTS AND METHODS
Patients were recruited at 2 health care institutions as part of a larger prospective study. They were enrolled if they had a diagnosis of nonhepatocellular carcinoma ESLD, Sodium Model for End-Stage Liver Disease ≥15, and no prior history of liver transplantation. Uncertainty, coping, optimism, and pessimism were assessed using the Uncertainty in Illness Scale for Adults, Revised Ways of Coping Checklist, and Life Orientation Test-revised. AD documentation at the time of study enrollment was retrospectively extracted from patient medical records.
RESULTS
In the sample [N = 181; median age = 57 y, 115 (64%) males], male sex [odds ratio (OR) = 4.66; 95% CI: 1.53, 14.17], being listed or under evaluation for liver transplantation (OR = 3.09; 95% CI: 1.10, 8.67), greater Sodium Model for End-Stage Liver Disease scores (OR = 1.10; 95% CI: 1.01, 1.20), and greater uncertainty (OR = 1.04; 95% CI: 1.01, 1.07) were positively associated with AD documentation. Higher coping avoidance was negatively associated with AD documentation (OR = 0.915; 95% CI: 0.840, 0.997).
CONCLUSIONS
Clinicians should consider the role of uncertainty and coping measures to improve patient-specific advance care planning conversations and expand opportunities for all patients with ESLD to file an AD, especially women and patients not listed or under evaluation for transplantation.
PubMed: 38567890
DOI: 10.1097/MCG.0000000000001981 -
Journal of Critical Care Aug 2024Limitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in... (Observational Study)
Observational Study
PURPOSE
Limitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in South Africa (SA).
MATERIALS AND METHODS
This study evaluated LLST in SA from the data of a prospective, international, multicentre, observational study (Ethicus-2) and compared practices with countries in the rest of the world.
RESULTS
LLST was relatively common in SA, and withholding was more frequent than withdrawing therapy. However, withdrawing and withholding therapy were less common, while failed CPR was more common, than in many other countries. No patients had an advance directive. Primary reasons for LLST in SA were poor quality of life, multisystem organ failure and patients' unresponsiveness to maximal therapy. Primary considerations for EOL decision-making were good medical practice and patients' best-interest, with the need for an ICU bed only rarely considered.
CONCLUSIONS
Withholding was more common than withdrawing treatment both in SA and worldwide, although both were significantly less frequent in SA compared with the world average.
Topics: Humans; South Africa; Prospective Studies; Withholding Treatment; Male; Life Support Care; Female; Intensive Care Units; Terminal Care; Middle Aged; Quality of Life; Aged; Decision Making; Adult
PubMed: 38554544
DOI: 10.1016/j.jcrc.2024.154797 -
Viruses Mar 2024Bacteriophage therapy is a promising approach to treating bacterial infections. Research and development of bacteriophage therapy is intensifying due to the increase in...
Bacteriophage therapy is a promising approach to treating bacterial infections. Research and development of bacteriophage therapy is intensifying due to the increase in antibiotic resistance and the faltering development of new antibiotics. Bacteriophage therapy uses bacteriophages (phages), i.e., prokaryotic viruses, to specifically target and kill pathogenic bacteria. The legal handling of this type of therapy raises several questions. These include whether phage therapeutics belong to a specially regulated class of medicinal products, and which legal framework should be followed with regard to the various technical ways in which phage therapeutics can be manufactured and administered. The article shows to which class of medicinal products phage therapeutics from wild type phages and from genetically modified (designer) phages do or do not belong. Furthermore, the article explains which legal framework is relevant for the manufacture and administration of phage therapeutics, which are manufactured in advance in a uniform, patient-independent manner, and for tailor-made patient-specific phage therapeutics. For the systematically coherent, successful translation of phage therapy, the article considers pharmaceutical law and related legal areas, such as genetic engineering law. Finally, the article shows how the planned legislative revisions of Directive 2001/83/EC and Regulation (EC) No 726/2004 may affect the legal future of phage therapy.
Topics: Humans; Phage Therapy; Bacteriophages; Bacteria; Bacterial Infections; Anti-Bacterial Agents; Pharmaceutical Preparations
PubMed: 38543808
DOI: 10.3390/v16030443 -
Medicina Intensiva May 2024The aim of this study is to describe the results of Spanish ICUs in ETHICUS II study.
OBJECTIVE
The aim of this study is to describe the results of Spanish ICUs in ETHICUS II study.
DESIGN
Planned substudy of patients from ETHICUS II study.
SETTING
12 Spanish ICU.
PATIENTS OR PARTICIPANTS
Patients admitted to Spanish ICU who died or in whom a limitation of life-sustaining treatment (LLST) was decided during a recruitment period of 6 months.
INTERVENTIONS
Follow-up of patients was performed until discharge from the ICU and 2 months after the decision of LLST or death.
MAIN VARIABLES OF INTEREST
Demographic characteristics, clinical profile, type of decision of LLST, time and form in which it was adopted. Patients were classified into 4 categories according to the ETHICUS II study protocol: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, failed cardiopulmonary resuscitation and patients with brain death.
RESULTS
A total of 795 patients were analyzed; 129 patients died after CPR, 129 developed brain death. LLST was decided in 537 patients, 485 died in the ICU, 90.3%. The mean age was 66.19 years ± 14.36, 63.8% of male patients. In 221 (41%) it was decided to withdraw life-sustaining treatments and in 316 (59%) withholding life-sustaining treatments. Nineteen patients (2.38%) had advance living directives.
CONCLUSIONS
The predominant clinical profile when LTSV was established was male patients over 65 years with mostly cardiovascular comorbidity. We observed that survival was higher in LLST decisions involving withholding of treatments compared to those in which withdrawal was decided. Spain has played a leading role in both patient and ICU recruitment participating in this worldwide multicenter study.
Topics: Humans; Male; Spain; Female; Intensive Care Units; Aged; Withholding Treatment; Life Support Care; Middle Aged; Cardiopulmonary Resuscitation; Follow-Up Studies
PubMed: 38538498
DOI: 10.1016/j.medine.2024.02.013 -
Sao Paulo Medical Journal = Revista... 2024Advance Directive documents allow citizens to choose the treatments they want for end-of-life care without considering therapeutic futility.
BACKGROUND
Advance Directive documents allow citizens to choose the treatments they want for end-of-life care without considering therapeutic futility.
OBJECTIVES
To analyze patients' and caregivers' answers to Advance Directives and understand their expectations regarding their decisions.
DESIGN AND SETTING
This study analyzed participants' answers to a previously published trial, conceived to test the document's efficacy as a communication tool.
METHODS
Sixty palliative patients and 60 caregivers (n = 120) registered their preferences in the Advance Directive document and expressed their expectations regarding whether to receive the chosen treatments.
RESULTS
In the patient and caregiver groups, 30% and 23.3% wanted to receive cardiorespiratory resuscitation; 23.3% and 25% wanted to receive artificial organ support; and 40% and 35% chose to receive artificial feeding and hydration, respectively. The participants ignored the concept of therapeutic futility and expected to receive invasive treatments. The concept of therapeutic futility should be addressed and discussed with both the patients and caregivers. Legal Advanced Directive documents should be made clear to reduce misinterpretations and potential legal conflicts.
CONCLUSION
The authors suggest that all citizens should be clarified regarding the futility concept before filling out the Advance Directives and propose a grammatical change in the document, replacing the phrase "Health Care to Receive / Not to Receive" with the sentence "Health Care to Accept / Refuse" so that patients cannot demand treatments, but instead accept or refuse the proposed therapeutic plans.
TRIAL REGISTRATION
ClinicalTrials.gov ID NCT05090072.
URL
https://clinicaltrials.gov/ct2/show/NCT05090072.
Topics: Humans; Cross-Sectional Studies; Medical Futility; Portugal; Advance Directives; Delivery of Health Care
PubMed: 38536997
DOI: 10.1590/1516-3180.2022.0537.R2.201023 -
Resuscitation May 2024In case of out-of-hospital cardiac arrest (OHCA) personnel of the emergency medical services (EMS) are regularly confronted with advanced directives (AD) and...
BACKGROUND AND OBJECTIVES
In case of out-of-hospital cardiac arrest (OHCA) personnel of the emergency medical services (EMS) are regularly confronted with advanced directives (AD) and do-not-attempt-resuscitation (DNACPR) orders. The authors conducted a retrospective analysis of EMS operation protocols to examine the prevalence of DNACPR in case of OHCA and the influence of a presented DNACPR on CPR-duration, performed Advanced-Life-Support (ALS) measures and decision making.
MATERIALS AND METHODS
Retrospective analysis of prehospital medical documentation of all resuscitation incidents in a German county with 250,000 inhabitants from 1 January 2016 to 31 December 2022. Combined with data from the structured CPR team-feedback database patients characteristics, measures and course of the CPR were analysed. Statistic testing with significance level p < 0.05.
RESULTS
In total n = 1,474 CPR events were analysed. Patients with DNACPR vs. no DNACPR: n = 263 (17.8%) vs. n = 1,211 (82.2%). Age: 80.0 ± 10.3 years vs. 68.0 ± 13.9 years; p < 0.001. Patients with ASA-status III/IV: n = 214 (81.3%) vs. n = 616 (50.9%); p < 0.001. Initial layperson-CPR: n = 148 (56.3%) vs. n = 647 (55.7%); p = 0.40. Airway management: n = 185 (70.3%) vs. n = 1,069 (88.3%); p < 0.001. With DNACPR CPR-duration initiated layperson-CPR vs. no layperson-CPR: 19:14 min (10:43-25:55 min) vs. 12:40 min (06:35-20:03 min); p < 0.001.
CONCLUSION
In case of CPR EMS-personnel are often confronted with DNACPR-orders. Patients are older and have more previous diseases than patients without DNACPR. Initiated layperson-CPR might lead to misinterpretation of patients will with impact on CPR-duration and unwanted measures. Awareness of this issue should be created through measures such as training programs in particular to train staff in the interpretation and legal admissibility of ADs.
Topics: Humans; Retrospective Studies; Out-of-Hospital Cardiac Arrest; Male; Female; Aged; Aged, 80 and over; Cardiopulmonary Resuscitation; Emergency Medical Services; Germany; Resuscitation Orders; Middle Aged; Advance Directives
PubMed: 38522733
DOI: 10.1016/j.resuscitation.2024.110189 -
The New Bioethics : a Multidisciplinary... Jun 2024To identify the frequency and nature of care conflict dilemmas that United States long-term care providers encounter, response strategies, and use of ethics resources to...
OBJECTIVE
To identify the frequency and nature of care conflict dilemmas that United States long-term care providers encounter, response strategies, and use of ethics resources to assist with dispute resolution.
DESIGN
An online cross-sectional survey was distributed to the Society for Post-Acute and Long-Term Care Medicine (AMDA).
RESULTS
Two-thirds of participants, primarily medical directors, have rejected surrogate instructions and 71% have managed family conflict. Conflict over treatment decisions and issues interpreting advance directives were frequently reported. Half of facilities lack a formal dispute mediation policy. Only five respondents have called an ethics consult for assistance.
CONCLUSION
Ethically tense care conflicts commonly arise in long-term and post-acute care facilities. Few facility procedures incorporate ethics resources into actual practice. Recommendations are made to create actionable policy, increase access to ethics services, and support staff skill development in order to improve the end-of-life care experiences for patients, families, and care facility staff.
Topics: Humans; Cross-Sectional Studies; Ethics Consultation; Long-Term Care; Negotiating; United States; Advance Directives; Dissent and Disputes; Terminal Care; Decision Making; Conflict, Psychological; Male; Female; Surveys and Questionnaires; Family
PubMed: 38509687
DOI: 10.1080/20502877.2024.2330275 -
BMC Palliative Care Mar 2024Advance Care Planning interventions should be evaluated as broadly as possible to gain a holistic understanding of the Advance Care Planning process. However, validated... (Randomized Controlled Trial)
Randomized Controlled Trial
Measuring patients' medical treatment preferences in advance care planning: development and validation of the Treat-Me-ACP instrument - a secondary analysis of a cluster-randomized controlled trial.
BACKGROUND
Advance Care Planning interventions should be evaluated as broadly as possible to gain a holistic understanding of the Advance Care Planning process. However, validated early stage outcome instruments are lacking. Therefore, the Treatment-Preference-Measure-Advance Care Planning (Treat-Me-ACP) instrument was developed and validated as part of the cluster-randomized controlled trial STADPLAN (Study on Advance Care Planning in care-dependent community-dwelling older persons) to assess the effects of Advance Care Planning interventions on patients' medical treatment preferences.
METHODS
The design of Treat-Me-ACP is based on the Emanuel Medical Directive and the Life Support Preferences Questionnaires. Using a multi-stage team approach a preliminary version of the Treat-Me-ACP was developed and pre-tested. The pre-tested instrument consists of one global medical care goal-item, five hypothetical scenarios with five hypothetical treatments, and one how would you feel-item within each scenario. A total of five scenario preference scores and five treatment preference scores can be formed. This version was subsequently applied to a subsample of the STADPLAN project (n = 80) to assess patient's preferences at baseline (T0) and at 12-month follow-up (T2). The further validation steps were based on this subsample and included: (1) acceptance by using completion rate and frequencies of missing data, (2) internal consistency by using Cronbach's α to test whether it was possible to create preference scores by scenario and treatment, (3) concurrent validation examining the association between the global medical care goal-item and the preference scores and the association between the how would you feel-items and the scenario preference scores, and (4) responsiveness of the instrument to changes in preferences for life-sustaining treatments by comparing preference scores from T0 to T2 between study groups.
RESULTS
Acceptance of the instrument was high. Results of concurrent validation indicate that the five scenarios represent the global medical care goal well. The preference scores showed an average tendency for decreasing preferences for life-sustaining treatments across all scales for the intervention group during study follow-up.
CONCLUSIONS
The Treat-Me-ACP can be used to evaluate the dynamics of patients' medical treatment preferences in Advance Care Planning. It has been validated for care-dependent community-dwelling older persons and can be used as an additional outcome measure in evaluating the effectiveness of ACP interventions.
TRIAL REGISTRATION
German Clinical Trials Register: DRKS00016886 on 04/06/2019.
Topics: Humans; Aged; Aged, 80 and over; Advance Directives; Advance Care Planning; Terminal Care; Patient Preference; Independent Living
PubMed: 38509501
DOI: 10.1186/s12904-024-01404-8