Did You Confirm Code Status?

Background: Timely identification of palliative care needs can reduce hospitalizations and improve quality of life. The Supportive & Palliative Care Indicators Tool (SPICT) identifies patients with advanced medical conditions who may need special care planning. The Rothman Index (RI) detects patients at high risk of acutely decompensating in the inpatient setting. SPICT and RI among cancer patients were utilized in this study to evaluate their potential roles in palliative care referrals. Methods: Advanced cancer patients admitted to an institution in Baltimore, Maryland in 2019 were retrospectively reviewed. Patient demographics, length of hospital stay (LOS), palliative care referrals, RI scores, and SPICT scores were obtained. Patients were divided into SPICT positive or negative and RI > 60 or RI < 60.Unpaired t-tests and chi-square tests were utilized to determine the associations between SPICT and RI and early palliative care needs and mortality. Results: 227 patients were included, with a mean age of 68 years, 63% Black, 59% female, with the majority having lung and GI malignancies. Sixty percent were SPICT +, 21% had RI < 60. SPICT + patients were more likely to have RI < 60 (p = 0.001). SPICT + and RI < 60 patients were more likely to have longer LOS, change in code status, more palliative/hospice referrals, and increased mortality (p <0.05). Conclusions: SPICT and RI are valuable tools in predicting mortality and palliative/hospice care referrals. These can also be utilized to initiate early palliative and goals of care discussions in patients with advanced cancer.

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Palliative Care in Patients With High-Grade Gliomas in the Neurological Intensive Care Unit

The Neurohospitalist ◽

10.1177/1941874419869714 ◽

2019 ◽

Vol 10 (3) ◽

pp. 163-167

Author(s):

Jon Rosenberg ◽

Allie Massaro ◽

James Siegler ◽

Stacey Sloate ◽

Matthew Mendlik ◽

...

Keyword(s):

Quality Of Life ◽

Intensive Care Unit ◽

Palliative Care ◽

High Grade ◽

Neurological Intensive Care Unit ◽

Code Status ◽

Neurological Intensive Care ◽

Palliative Care Consultation ◽

Care Consultation

Background: Palliative care improves quality of life in patients with malignancy; however, it may be underutilized in patients with high-grade gliomas (HGGs). We examined the practices regarding palliative care consultation (PCC) in treating patients with HGGs in the neurological intensive care unit (NICU) of an academic medical center. Methods: We conducted a retrospective cohort study of patients admitted to the NICU from 2011 to 2016 with a previously confirmed histopathological diagnosis of HGG. The primary outcome was the incidence of an inpatient PCC. We also evaluated the impact of PCC on patient care by examining its association with prespecified secondary outcomes of code status amendment to do not resuscitate (DNR), discharge disposition, 30-day mortality, and 30-day readmission rate, length of stay, and place of death. Results: Ninety (36% female) patients with HGGs were identified. Palliative care consultation was obtained in 16 (18%) patients. Palliative care consultation was associated with a greater odds of code status amendment to DNR (odds ratio [OR]: 18.15, 95% confidence interval [CI]: 5.01-65.73), which remained significant after adjustment for confounders (OR: 27.20, 95% CI: 5.49-134.84), a greater odds of discharge to hospice (OR: 24.93, 95% CI: 6.48-95.88), and 30-day mortality (OR: 6.40, 95% CI: 1.96-20.94). Conclusion: In this retrospective study of patients with HGGs admitted to a university-based NICU, PCC was seen in a minority of the sample. Palliative care consultation was associated with code status change to DNR and hospice utilization. Further study is required to determine whether these findings are generalizable and whether interventions that increase PCC utilization are associated with improved quality of life and resource allocation for patients with HGGs.

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Critical Care Documentation for the Dying Trauma Patient: Are We Recognizing Our Own Efforts?

The American Surgeon ◽

10.1177/0003134820972989 ◽

2020 ◽

pp. 000313482097298

Author(s):

Samuel J. Zolin ◽

Jasmin K. Bhangu ◽

Brian T. Young ◽

Sarah E. Posillico ◽

Husayn A. Ladhani ◽

...

Keyword(s):

Critical Care ◽

Trauma Patients ◽

Family Meeting ◽

Comfort Care ◽

Code Status ◽

Family Meetings ◽

Dying Patients ◽

Palliative Care Consultation ◽

Care Consultation ◽

Poor Outcomes

Background Missed documentation for critical care time (CCT) for dying patients may represent a missed opportunity for physicians to account for intensive care unit (ICU) services, including end-of-life care. We hypothesized that CCT would be poorly documented for dying trauma patients. Methods Adult trauma ICU patients who died between December 2014 and December 2017 were analyzed retrospectively. Critical care time was not calculated for patients with comfort care code status. Critical care time on the day prior to death and day of death was collected. Logistic regression was used to determine factors associated with documented CCT. Results Of 147 patients, 43% had no CCT on day prior to death and 55% had no CCT on day of death. 82% had a family meeting within 1 day of death. Family meetings were independently associated with documented CCT (OR 3.69, P = .008); palliative care consultation was associated with decreased documented CCT (OR .24, P < .001). Conclusions Critical care time is not documented in half of eligible trauma patients who are near death. Conscious (time spent in family meetings and injury acuity) and unconscious factors (anticipated poor outcomes) likely affect documentation.

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Identifying Palliative Care Needs in Assisted Living

Innovation in Aging ◽

10.1093/geroni/igaa057.2854 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 788-788

Author(s):

Daniel David ◽

Abraham Brody ◽

Tina Sadarangani ◽

Bei Wu ◽

Tara Cortez

Keyword(s):

Palliative Care ◽

Assisted Living ◽

Unmet Needs ◽

Care Needs ◽

Code Status ◽

Care Services ◽

Palliative Care Services ◽

Advance Care ◽

Palliative Care Needs

Abstract Many residents of Assisted Living (AL) confront serious illness and therefore might benefit from greater access to Palliative Care Services to improve quality of life. We surveyed resident records and AL nursing staff to identify patients in need of Palliative Care. Preliminary findings showed that nurses predicted 23% would not be alive and 49% would no longer live in AL. A majority of residents were over the age of 90, yet 30% did not have a reported code status. These findings suggest that a substantial portion of AL residents may have unmet needs with respect to palliative care. Future interventions are needed to support advance care planning conversations and make palliative care more accessible to this population.

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Abstract 68: Palliative Care Is Underutilized in Patients with Severe Intracerebral Hemorrhage

Stroke ◽

10.1161/str.46.suppl_1.68 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

April Sisson ◽

Karen C Albright ◽

Michelle Peck ◽

Linh M Nguyen ◽

Michael Lyerly ◽

...

Keyword(s):

Palliative Care ◽

Poor Prognosis ◽

Care Service ◽

Care Center ◽

Symptom Relief ◽

Tertiary Care ◽

Palliative Care Service ◽

Code Status ◽

Ich Score ◽

Expected Mortality

Background and Purpose: Palliative care is an essential part of ICH care, particularly in patients with high ICH scores given their poor prognosis. Palliative care involves consultation by the Palliative Care Service and includes de-escalation of care, changing code status, and making pain and symptom relief the central goal of management. Methods: We performed a retrospective review of consecutive patients presenting to our tertiary care center from 2008-2013 with primary ICH. Demographic and clinical data were collected. Our sample included only patients who died or were transferred to hospice. We examined the proportion of patients that received an inpatient palliative care consult and compared this group to patients who did not receive an inpatient palliative care consult. Patients were categorized by ICH score. Results: Of the 99 ICH patients who died or were discharged to hospice, only 23% received a palliative care consult. Figure 1 displays death, predicted death, and palliative care consult proportions by ICH score. Patients that received a Palliative Care consult were older (mean age 65 vs. 73, p=0.018) and more frequently had evidence of infection (32% vs. 13%, p=0.038); no other significant differences were found between groups. Conclusions: In our sample of ICH patients, 23% of patients received a palliative care consult. In those with high ICH scores utilization was only 28%, despite 30 day expected mortality of 97% or greater. This raises concern that palliative care may be underutilized in patients who may benefit from it the most.

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Association of medical futility with do-not-resuscitate (DNR) code status in hospitalised patients

Journal of Medical Ethics ◽

10.1136/medethics-2020-106977 ◽

2021 ◽

pp. medethics-2020-106977

Author(s):

Christoph Becker ◽

Alessandra Manzelli ◽

Alexander Marti ◽

Hasret Cam ◽

Katharina Beck ◽

...

Keyword(s):

Significant Proportion ◽

Medical Futility ◽

University Hospital ◽

Main Diagnosis ◽

Do Not Resuscitate ◽

Clinical Frailty Scale ◽

Code Status ◽

Probability Of Survival ◽

Hospitalised Patients ◽

Definition Of

Guidelines recommend a ‘do-not-resuscitate’ (DNR) code status for inpatients in which cardiopulmonary resuscitation (CPR) attempts are considered futile because of low probability of survival with good neurological outcome. We retrospectively assessed the prevalence of DNR code status and its association with presumed CPR futility defined by the Good Outcome Following Attempted Resuscitation score and the Clinical Frailty Scale in patients hospitalised in the Divisions of Internal Medicine and Traumatology/Orthopedics at the University Hospital of Basel between September 2018 and June 2019. The definition of presumed CPR futility was met in 467 (16.2%) of 2889 patients. 866 (30.0%) patients had a DNR code status. In a regression model adjusted for age, gender, main diagnosis, nationality, language and religion, presumed CPR futility was associated with a higher likelihood of a DNR code status (37.3% vs 7.1%, adjusted OR 2.99, 95% CI 2.31 to 3.88, p<0.001). In the subgroup of patients with presumed futile CPR, 144 of 467 (30.8%) had a full code status, which was independently associated with younger age, male gender, non-Christian religion and non-Swiss citizenship. We found a significant proportion of hospitalised patients to have a full code status despite the fact that CPR had to be considered futile according to an established definition. Whether these decisions were based on patient preferences or whether there was a lack of patient involvement in decision-making needs further investigation.

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Implementation of a Competency-Based, Interdisciplinary Pediatric Palliative Care Curriculum Using Content and Format Preferred by Pediatric Residents

Children ◽

10.3390/children5120156 ◽

2018 ◽

Vol 5 (12) ◽

pp. 156

Author(s):

Meaghann Weaver ◽

Christopher Wichman

Keyword(s):

Palliative Care ◽

Curriculum Design ◽

Cognitive Theory ◽

Curriculum Implementation ◽

Self Assessment ◽

Training Environment ◽

Pediatric Residents ◽

Code Status ◽

Personal Attitude ◽

Competency Based

Palliative care competencies at the pediatric resident training level expand learned knowledge into behavior. The objective of this study was to investigate mode of palliative care education delivery preferred by pediatric residents and to report on participatory approach to resident palliative care curriculum design. A one-hour monthly palliative care curriculum was designed and implemented in a participatory manner with 20 pediatric residents at a free-standing Midwestern children’s hospital. Outcome measures included pediatric residents’ personal attitude and perceived training environment receptivity before and after implementation of a palliative care competency-based curriculum. An 18-item survey utilizing Social Cognitive Theory Constructs was administered at baseline and after palliative care curriculum implementation (2017–2018 curricular year). Pediatric residents prioritized real case discussions in group format (16/20) over other learning formats. Topics of highest interest at baseline were: discussing prognosis and delivering bad news (weighted average 12.9), pain control (12.3), goals of care to include code status (11.1), and integrative therapies (10.7). Summary of ordinal responses revealed improvement in self-assessment of personal attitude toward palliative care and training environment receptivity to palliative care domains after year-long curriculum implementation. Curricular approach which is attentive to pediatric residents’ preferred learning format and self-assessment of their behaviors within their care setting environment may be beneficial in competency-based primary palliative training.

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EMR-based handoff tool improves completeness of internal medicine residents’ handoffs

BMJ Open Quality ◽

10.1136/bmjoq-2017-000188 ◽

2018 ◽

Vol 7 (3) ◽

pp. e000188 ◽

Cited By ~ 3

Author(s):

Rebecca L Tisdale ◽

Zac Eggers ◽

Lisa Shieh

Keyword(s):

Internal Medicine ◽

Medical Center ◽

Internal Medicine Resident ◽

Objective Data ◽

Code Status ◽

Medicine Resident ◽

Communication Breakdown ◽

Internal Medicine Residents ◽

Action List ◽

Identical Fashion

BackgroundThe majority of adverse events in healthcare involve communication breakdown. Physician-to-physician handoffs are particularly prone to communication errors, yet have been shown to be more complete when systematised according to a standardised bundle. Interventions that improve thoroughness of handoffs have not been widely studied.AimTo measure the effect of an electronic medical record (EMR)-based handoff tool on handoff completeness.InterventionThis EMR-based handoff tool included a radio button prompting users to classify patients as stable, a ‘watcher’ or unstable. It automatically pulled in EMR data on the patient’s 24-hour vitals, common lab tests and code status. Finally, it provided text boxes labelled ‘Active Issues’, ‘Action List (To-Dos)’ and ‘If/Then’ to fill in.Implementation and evaluationWritten handoffs from general and specialty (haematology, oncology, cardiology) Internal Medicine resident-run inpatient wards were evaluated on a randomly chosen representative sample of days in April and May 2015 at Stanford University Medical Center, focusing on a predefined set of content elements. The intervention was then implemented in June 2015 with postintervention data collected in an identical fashion in August to September 2016.ResultsHandoff completeness improved significantly (p<0.0001). Improvement in inclusion of illness severity was notable for its magnitude and its importance in establishing a consistent mental model of a patient. Elements that automatically pulled in data and those prompting users to actively fill in data both improved.ConclusionA simple EMR-based handoff tool providing a mix of frameworks for completion and automatic pull-in of objective data improved handoff completeness. This suggests that EMR-based interventions may be effective at improving handoffs, possibly leading to fewer medical errors and better patient care.

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