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PloS One 2023Advance directives (ADs) are integral to health care, allowing patients to specify surrogate decision-makers and treatment preferences in case of loss of capacity. The...
OBJECTIVE
Advance directives (ADs) are integral to health care, allowing patients to specify surrogate decision-makers and treatment preferences in case of loss of capacity. The present study sought to identify determinants of ADs among stroke survivors.
METHODS
In this cross-sectional study (Care Attitudes and Preferences in Stroke Survivors [CAPriSS]), community-dwelling stroke survivors were surveyed on ADs; validated scales were used to query palliative care knowledge and attitudes towards life-sustaining treatments. Logistic regression was used to determine variables associated with ADs.
RESULTS
Among 562 community-dwelling stroke survivors who entered the survey after screening questions confirmed eligibility, 421 (74.9%) completed survey components with relevant variables of interest. The median age was 69 years (IQR 58-75 years); 53.7% were male; and 15.0% were Black. Two hundred and fifty-one (59.6%) respondents had ADs. Compared to stroke survivors without ADs, those with ADs were more likely to be older (median age 72 vs. 61 years; p<0.001), White (91.2% vs. 75.9%, p<0.001), and male (58.6% vs. 46.5%, p = 0.015), and reported higher education (p<0.001) and income (p = 0.011). Ninety-eight (23.3%) participants had "never heard of palliative care". Compared to participants without ADs, participants with ADs had higher Palliative Care Knowledge Scale (PaCKS) scores (median 10 [IQR 5-12] vs. 7 [IQR 0-11], p<0.001), and lower scores on the Attitudes Towards Life-Sustaining Treatments Scale (indicating a more negative attitude towards life-sustaining treatments; median 23 [IQR 18-28] vs. 29 [IQR 24-35], p<0.001). Multivariable logistic regression identified age (OR 1.62 per 10 year increase, 95% CI 1.30-2.02; p<0.001), prior advance care planning discussion with a physician (OR 1.73, 95% CI 1.04-2.86; p = 0.034), PaCKS scores (OR 1.06 per 1 point increase, 95% CI 1.01-1.12; p = 0.018), and Attitudes Towards Life-Sustaining Treatments Scale scores (OR 0.91 per 1 point increase, 95% CI 0.88-0.95; p<0.001) as variables independently associated with ADs.
CONCLUSIONS
Age, prior advance care planning discussion with a physician, palliative care knowledge, and attitudes towards life-sustaining treatments were independently associated with ADs.
Topics: Humans; Male; Aged; Female; Cross-Sectional Studies; Independent Living; Advance Directives; Stroke; Survivors
PubMed: 37847705
DOI: 10.1371/journal.pone.0292484 -
Materials (Basel, Switzerland) Sep 2023Sewage sludge, also referred to as biosolids, consists of the by-products of wastewater treatment, which are a mixture of the water and organic and inorganic materials...
Sewage sludge, also referred to as biosolids, consists of the by-products of wastewater treatment, which are a mixture of the water and organic and inorganic materials eliminated from wastewater sourced from domestic sewage industries during physical, biological, and/or chemical treatments. Biosolids are nutrient-rich organic materials resulting from the treatment of domestic wastewater in treatment plants. Sewage sludge can be considered a significant biological resource for sustainable agriculture. A new composite has been made consisting of soil, sewage sludge collected from the Galati Wastewater Treatment Plant, and slag from the Galati Steel Plant. This study aimed to investigate the structural, morphological, and chemical parameters of this composite through FTIR, SEM-EDX analysis, and XRF analysis. The samples had values of potential toxic elements that were within normal limits according to Directive 86/278/CEE, and, in terms of the iron-to-calcium ratio (I/C), all samples were of a low grade. This is the first time that slag has been added in a sewage sludge-soil combination, which can be an effective fertilizer replacement. Sewage sludge contains substantial amounts of organic matter, and slag reduces the contents of potentially toxic elements. In addition to these attributes, they may provide an opportunity for the beneficial re-use of sewage sludge and slag as resources in agriculture.
PubMed: 37834576
DOI: 10.3390/ma16196440 -
BMC Medical Education Oct 2023Life expectancy in recent decades has increased the prevalence of chronic diseases in the population, requiring an approach to new health topics, such as discussions on... (Observational Study)
Observational Study
BACKGROUND
Life expectancy in recent decades has increased the prevalence of chronic diseases in the population, requiring an approach to new health topics, such as discussions on quality of life and expectations about death and dying. The concept of advance directives (ADs) gives individuals the opportunity to make known their decisions about the treatments they would like to receive at the end of life. Despite the recognition of relevance in clinical practice, the applicability of the concept presents challenges, including establishing the appropriate prognosis for each patient and the ideal time to approach the patient. Some prognostic tools were developed, such as the surprise question (SQ): "Would you be surprised if your patient died in 12 months?", which is used in some clinical settings to predict patient deaths and to make decisions regarding ADs. The main objective of the present study was to evaluate the behavior of second-year resident physicians (PGY-2) when the SQ was applied.
METHOD
In our observational study, from July 1, 2016, to February 28, 2017, (PGY-2) in the Internal Medicine Residency Program (IMRP) applied SQ to all patients with multiple and varied chronic no communicable comorbidities, who were followed up at the general medicine outpatient clinic (GMOC) of a tertiary university hospital in São Paulo- Brazil. The frequency of the outcome (death or non-death within 12 months) was analyzed by correlating it with the clinical data (impact of the studied variables).
RESULTS
Eight hundred forty patients entered the study. Fitfty-two of them (6.2%) died within one year. PGY-2 predicted that two hundred and fourteen patients (25.5% of total) would die within a year (answer No to SQ), of which, 32 (14.9%) did so. The correct residents' prognosis for the subgroup of 626 patients (answer "Yes" to SQ) was NPV = 96.8% (CI = 95.4%-98.2%) and PPV = 14.9% (CI 10.1%-19, 6%). Answering "Yes" to SQ correlated negatively to addressing AD while the outcomes death and the answer No to SQ were positively correlated, according to the number of comorbidities.
CONCLUSION
The SQ, in addition to care, contributed to health education, communication and care planning shared by the doctor and patient.
Topics: Humans; Palliative Care; Outpatients; Prognosis; Quality of Life; Prospective Studies; Brazil
PubMed: 37828485
DOI: 10.1186/s12909-023-04714-2 -
Journal of the Advanced Practitioner in... Sep 2023Oncology patients have tremendous symptom burden both physically and emotionally. Palliative care (PC) improves quality of life and prevents suffering. Advance care...
BACKGROUND
Oncology patients have tremendous symptom burden both physically and emotionally. Palliative care (PC) improves quality of life and prevents suffering. Advance care planning (ACP) empowers patients to articulate goals of their care. New guidelines call for palliative care to be provided and chemotherapy avoided the last 2 weeks of life. The American Society of Clinical Oncology (ASCO) recommends integrating palliative care within the oncology setting to achieve these outcomes. However, the best mode to provide this care remains unclear. A nurse practitioner/physician assistant (NP/PA)-based model from within the oncology clinic is a potential option.
METHODS
A program evaluation was done to determine the effectiveness of the "My Choices, My Wishes" NP/PA-led program.
RESULTS
From 2012 to 2018, the number of patients receiving PC/ACP visits increased from 2.6% to 19.4%. The percentage of patients receiving chemotherapy in the last 14 days of life decreased from 12.5% to 7.14%. The number of advance care directives completed increased from 17.5% to 37.5%.
CONCLUSION
This program was an effective way to provide PC/ACP for oncology patients. We still need to understand why patients pursue chemotherapy at the end of life. It is necessary to improve our communication techniques with patients and families in order to guarantee high-quality, high-value care.
PubMed: 37808072
DOI: 10.6004/jadpro.2023.14.6.3 -
BMJ Open Quality Oct 2023There is little evidence to suggest the best model of palliative and end-of-life care (PEOLC) in an acute care hospital. We introduced a bundle of care to drive...
OBJECTIVES
There is little evidence to suggest the best model of palliative and end-of-life care (PEOLC) in an acute care hospital. We introduced a bundle of care to drive improvements in PEOLC; this bundle included three full-time nursing positions providing a palliative care clinical consult service with physician backup, as well as educating staff, using the NSW Resuscitation Plan and the Last-Days-of-Life Toolkit.
METHODS
Two audits were performed at John Hunter Hospital, a tertiary hospital in Newcastle, Australia, each sampling from all deaths in a 12-month period, one prior to and one after the bundle of care was introduced. Sampling was stratified into deaths that occurred within 4-48 hours of admission and after 48 hours. Key outcomes/data points were recorded and compared across the two time periods.
RESULTS
Statistically significant improvements noted included: lower mortality on the wards after 48 hours of admission, better recognition of the dying patient, increased referral to palliative care nurses and physicians, reduction in the number of medical emergency team calls and increase in the use of comfort care and resuscitation plans. Currently, 73% of patients have their end-of-life wishes observed as per their advance care directive.
CONCLUSION
A bundle of care involving dedicated nurses with physician backup providing a consult service and education is an effective method for driving improvements in PEOLC.
Topics: Humans; Tertiary Care Centers; Terminal Care; Hospice Care; Palliative Care; Hospitalization
PubMed: 37802540
DOI: 10.1136/bmjoq-2023-002358 -
Nursing Ethics Oct 2023End-stage renal disease (ESRD) is the final stage of chronic kidney disease. Yet dialysis is not suitable for all ESRD patients. Moreover, while shared decision-making...
BACKGROUND
End-stage renal disease (ESRD) is the final stage of chronic kidney disease. Yet dialysis is not suitable for all ESRD patients. Moreover, while shared decision-making (SDM) is the preferred model for making medical decisions, little is known about SDM between nephrology nurses and ESRD patients in Israel.
RESEARCH OBJECTIVE
Assessing the views, attitudes, practices, and ethical dilemmas of nephrology nurses in Israel regarding SDM with ESRD patients.
METHODS
Using the descriptive quantitative approach, questionnaires were completed by 444 nephrology nurses in Israel. In addition to conducting descriptive statistics, t-tests for independent samples, f-tests for analysis of variance, and both tests for independence were also performed.
ETHICAL CONSIDERATIONS
The research aims, expected advantages and risks have been explained to respondents before completing the questionnaire to secure informed consent. Anonymity and confidentiality were ensured throughout the study. The study was approved by the Research Ethics Committee at the University of Haifa (Approval # 411/21).
RESULTS
About one-third (30%-36.5%) of nurses reported discussing quality of life issues with ESRD patients, asking about their advance directives/power of attorney, exploring cultural/religious beliefs in end-of-life care, and ask about their preferred place of death. Nurses who convey high levels of patient-centered care (68.9%, <0.0001), have high end-of-life training (76.2%, <0.0001), and report cooperating with interdisciplinary teams (63.8%, = 0.0415), also reported higher SDM practices than others. Nurses who refer less patients to palliative care (70%, <0.0001) reported higher involvement in SDM compared to other nurses.
CONCLUSIONS
Nephrology nurses in Israel do not tend to implement the SDM model, despite its potential for improving quality of life for ESRD patients and their families and increasing conservative care options. Policy makers and educators in Israel should develop and implement training programs and support in the workplace, to enhance SDM between nephrology nurses and ESRD patients.
PubMed: 37794561
DOI: 10.1177/09697330231200565 -
BMC Medical Ethics Oct 2023Each individual's unique health-related beliefs can greatly impact the patient-clinician relationship. When there is a conflict between the patient's preferences and...
BACKGROUND
Each individual's unique health-related beliefs can greatly impact the patient-clinician relationship. When there is a conflict between the patient's preferences and recommended medical care, it can create a serious ethical dilemma, especially in an emergency setting, and dramatically alter this important relationship.
CASE PRESENTATION
A 56-year-old man, who remained comatose after out-of-hospital cardiac arrest, was rushed to our hospital. The patient was scheduled for emergency coronary angiography when his adolescent daughter reported that she and her father held sincere beliefs against radiation exposure. We were concerned that she did not fully understand the potential consequences if her father did not receive the recommended treatment. A physician provided her with in depth information regarding the risks and benefits of the treatment. While we did not want to disregard her statement, we opted to save the patient's life due to concerns about the validity of her report.
CONCLUSIONS
Variations in beliefs regarding medical care force clinicians to incorporate patient beliefs into medical practice. However, an emergency may require a completely different approach. When faced with a patient in a life-threatening condition and unconscious, we should take action to prioritize saving their life, unless we are highly certain about the validity of their advance directives.
Topics: Humans; Middle Aged; Advance Directives; Male; Coronary Angiography; Radiation Exposure; Emergency Medicine
PubMed: 37794408
DOI: 10.1186/s12910-023-00962-5 -
Journal of Multidisciplinary Healthcare 2023Contrary to Western societies, more than 15% of patients with breast cancer in Jordan are diagnosed with stage IV disease. In this study, we evaluate the value of early...
BACKGROUND
Contrary to Western societies, more than 15% of patients with breast cancer in Jordan are diagnosed with stage IV disease. In this study, we evaluate the value of early palliative care integration in the end-of-life care of such patients.
METHODS
All consecutive adult patients who died between 2014 to 2018, while under the care of our institution, with a confirmed diagnosis of breast cancer at the time of death, irrespective of place of death, were retrospectively reviewed.
RESULTS
During the study period, a total of 433 patients, median age 51.6 years, were included in the analysis. Among the whole group, 102 (23.6%) were referred to palliative care service early (≥30 days prior to death), 182 (42.0%) had late referral (<30 days from death), while 149 (34.4%) were never referred and were followed up by their medical oncologists. During the last 30 days prior to death, patients who were never referred to palliative care were more likely to visit the Emergency Room (ER) more than once (OR 1.89, 95% CI 1.20-2.99, p = 0.006), more likely to be admitted to the hospital more than once (OR 2.27, 95% CI 1.38-3.73, p = 0.001), and more likely to be admitted to the intensive care unit (ICU) (OR 3.07, 95% CI 1.48-6.38, p = 0.0027). Fewer patients in the "no referral" group died with advance directives compared to those who had early or late referral; 60.8%, 75.0% and 82.5%, respectively, p = 0.0003. Survival of patients followed by medical oncologist was not better than those referred to palliative care, either late or early; median survival was 19.0, 19.1 and 23.8 months, respectively (p = 0.2338).
CONCLUSION
Findings suggest that earlier palliative care referral is associated with less aggressive end-of-life care, leading to less frequent ER visits, hospital and ICU admissions during the last month of life, and does not compromise survival.
PubMed: 37790988
DOI: 10.2147/JMDH.S422391 -
Innovation in Aging 2023The clinical progression of severe dementia frequently leads to situations where surrogate decision makers must quickly make choices about potentially burdensome...
BACKGROUND AND OBJECTIVES
The clinical progression of severe dementia frequently leads to situations where surrogate decision makers must quickly make choices about potentially burdensome treatments that offer limited clinical benefit. We examined whether the number of decision makers and their access to advance directives were related to treatment choice for patients with severe dementia in comparison to those with normal cognition.
RESEARCH DESIGN AND METHODS
We retrospectively linked survey responses about end-of-life treatment decisions to Medicare claims for Health and Retirement Study respondents dying between 2002 and 2015 whose next-of-kin reported a need for surrogate decision making. We estimated multivariable logistic regression models to study measures of aggressive care in the last 6 months of life; in-hospital death, burdensome transfers, and burdensome treatments.
RESULTS
Compared to patients who were cognitively normal near the end of life ( = 1 198), patients with severe dementia ( = 722) were less likely to experience burdensome treatments (18% [95% confidence interval {CI} 14-21] vs 32% [95% CI 29-35]), burdensome transfers (20% [95% CI 17-24] vs 30% [95% CI 27-33]), and in-hospital death (24% [95% CI 20-28] vs 30% [95% CI 26-33]) when surrogates were involved. Rates of burdensome treatments, transfers, or in-hospital death for decedents with severe dementia did not vary with single versus multiple decision makers or when decision makers were informed by advance directives. However, among decedents with normal cognition, a single decision maker informed by an advance directive was associated with the lowest rates of burdensome treatments and in-hospital death.
DISCUSSION AND IMPLICATIONS
Surrogate decision makers made similar choices around end-of-life care for patients with severe dementia regardless of the number of decision makers and availability of advance directives. However, both advance directives and single decision makers were associated with less aggressive care for cognitively normal decedents.
PubMed: 37771715
DOI: 10.1093/geroni/igad081 -
Journal of Hospice and Palliative Care Jun 2023This study aimed to identify attitudes toward advance directives (ADs) among female cancer patients and factors related to ADs.
PURPOSE
This study aimed to identify attitudes toward advance directives (ADs) among female cancer patients and factors related to ADs.
METHODS
The study was conducted at a university hospital in Seoul from September 19, 2020, to January 20, 2021. The participants were 153 patients diagnosed with gynecological cancer or breast cancer. Data were collected using questionnaires and included general characteristics, disease- and AD-related characteristics, knowledge and attitudes about ADs, and attitudes about dignified death. Data were analyzed using the t-test, analysis of variance, and multiple regression analysis.
RESULTS
Only 2% of the participants completed ADs. The mean score for attitudes toward ADs was 3.30, indicating a positive knowledge and attitude toward dignified death. The factors related to attitudes toward ADs were attitudes toward dignified death (β=0.25, P=0.001), experience discussing life-sustaining treatment (β=0.17, P=0.037), preferred time to have a consultation about ADs (β=0.19, P=0.046), intention to write ADs (β= 0.15, P=0.038), and Eastern Cooperative Oncology Group Performance Status (β=-0.37, P<0.001). The explanatory power of these variables for attitudes toward ADs was 38.5%.
CONCLUSION
Overall, patients preferred to have a consultation about ADs when they were still active, mentally healthy, and able to make decisions. Education about ADs should be provided to patients on the first day of hospitalization for chemotherapy or while awaiting treatment in an outpatient setting so patients can write ADs and discuss them with family and friends.
PubMed: 37753505
DOI: 10.14475/jhpc.2023.26.2.80