scholarly journals P29 Bringing into focus treatment limitation and DNACPR decisions: How COVID-19 has changed practice

BJS Open ◽  
2021 ◽  
Vol 5 (Supplement_1) ◽  
Author(s):  
Ella J Marson ◽  
Adam H Botkai ◽  
Jamie J Coleman ◽  
Felicity Evison ◽  
Jolene Atia ◽  
...  
Keyword(s):  
Decision Making ◽  
Success Rates ◽  
Comfort Care ◽  
The United Kingdom ◽  
Electronic Healthcare Record ◽  
Large Teaching Hospital ◽  
Treatment Limitation ◽  
Life Sustaining Treatment ◽  
Holistic Practice ◽  
Attitudinal Changes

Abstract Background The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR. Methods The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019. Results A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001). Conclusion During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.

Patient Involvement in Decisions to Limit Treatment: The Crucial Role of Agreement Between Physician and Patient

2009 ◽  
Vol 27 (13) ◽  
pp. 2225-2230 ◽  
Author(s):  
Eva C. Winkler ◽  
Stella Reiter-Theil ◽  
Dorothee Lange-Rieß ◽  
Nina Schmahl-Menges ◽  
Wolfgang Hiddemann
Keyword(s):  
Decision Making ◽  
Palliative Care ◽  
Patient Involvement ◽  
Medical Condition ◽  
Treatment Goals ◽  
Incurable Cancer ◽  
Comfort Care ◽  
Decision Making Capacity ◽  
Treatment Limitation ◽  
Diagnosis Therapy

Purpose The aim of this study was to describe, first, the decision-making process concerning the limitation of life-prolonging treatment (DLT); second, the extent to which patients are actually involved in these decisions; and third, to detect medical and ethical factors that affect patient involvement. Patients and Methods This prospective qualitative study enrolled 76 patients with incurable cancer with whom the limitation of life-prolonging treatment was discussed. Embedded researchers on the wards recorded the patient's history, medical condition, type of treatment limitation discussed, patient wishes, decision-making capacity, and patient involvement using an in-depth documentation procedure. Results While the majority of patients were informed about their diagnosis, therapy, and course of disease (99%, 97%, 90%, respectively), only 47% were involved in DLT. Two thirds of the patients preferred palliative care, and one third wished to extend their lifetime. If patients preferred palliative care, they were more often in line with physicians' treatment goals than patients who were striving for longer survival (91.4% v 46.7%; P = .001). They also were involved significantly more often in DLT. Multivariate analysis showed that age, Karnofsky performance index or decision-making capacity had no impact on patient involvement. Conclusion Only half of the patients were involved in DLT. Surprisingly, the main predictor of patient involvement was not their medical condition, but agreement with physicians' palliative treatment goals. These results show that if physicians switch to comfort care in terminally ill patients and patients are not yet prepared to follow this line, treatment limitations are often decided without involving the patient.

scholarly journals Patient–physician conversations about life-sustaining treatment: Treatment preferences and participant assessments

2021 ◽  
pp. 1-7
Author(s):  
Lone Doris Tuesen ◽  
Hans-Henrik Bülow ◽  
Anne Sophie Ågård ◽  
Sverre Maintz Strøm ◽  
Erik Fromme ◽  
...  
Keyword(s):  
Decision Making ◽  
Cardiopulmonary Resuscitation ◽  
Nursing Home Residents ◽  
Treatment Preferences ◽  
Comfort Care ◽  
Life Sustaining Treatment ◽  
Seriously Ill Patients ◽  
High Degree ◽  
Seriously Ill ◽  
Very High

Abstract Objective In 2019, the Danish parliament issued legislation requiring Danish physicians to clarify and honor seriously ill patients’ treatment preferences. The American POLST (Physician Orders for Life-Sustaining Treatment) document could be a valuable model for this process. The aim of the study was to examine patients' preferences for life-sustaining treatment and participant assessment of a Danish POLST form. Methods The study is a prospective intervention based on a pilot-tested Danish POLST form. Participant assessments were examined using questionnaire surveys. Patients with serious illness and/or frailty from seven hospital wards, two general practitioners, and four nursing homes were included. The patients and their physicians completed the POLST form based on a process of shared decision-making. Results A total of 95 patients (aged 41–95) participated. Hereof, 88% declined cardiopulmonary resuscitation, 83% preferred limited medical interventions or comfort care, and 74% did not require artificial nutrition. The preferences were similar within age groups, genders, and locations, but with a tendency toward younger patients being more in favor of full treatment and nursing home residents being more in favor of cardiopulmonary resuscitation. Questionnaire response rates were 69% (66/95) for patients, 79% (22/28) for physicians, and 31% (9/29) for nurses. Hereof, the majority of patients, physicians, and nurses found that the POLST form was usable for conversations and decision-making about life-sustaining treatment to either a high or very high degree. Significance of results The majority of seriously ill patients did not want a resuscitation attempt and opted for selected treatments. The majority of participants found that the Danish POLST was usable for conversations and decisions about life-sustaining treatment to either a high or a very high degree, and that the POLST form facilitated an opportunity to openly discuss life-sustaining treatment.

Entscheidungsprozesse beim Übersetzen: Routine und Reflexion bei Novizen und Berufsübersetzern

Fachsprache ◽  
2017 ◽  
Vol 32 (3-4) ◽  
pp. 100-121
Author(s):  
Friederike Prassl
Keyword(s):  
Decision Making ◽  
Success Rate ◽  
Knowledge Integration ◽  
Popular Science ◽  
Failure Rates ◽  
Science Text ◽  
Success Rates ◽  
Preliminary Results ◽  
Decision Making Processes ◽  
Cognitive Involvement

This article focuses on the decision-making processes involved in research and knowledge integration in translation processes. First, the relevance of decision taking intranslation is discussed. Second, the psychology of decision making as seen by Jungermann et al. (2005) is introduced, who propose a categorization of decision-making processes intofour types: “routinized”, “stereotype”, “reflected” and “constructed”. This classification is then applied to the translations by five professional translators and five novices of five segments occurring in a popular-science text. The analysis reveals that the decision-making types are distributed differently among students and professional translators, which also has to be seen against the background of whether the decisions made were successful or not. The preliminary results of this study show that students resort to reflected decisions in most cases, but with a low success rate. Professionals achieve a higher success rate when making reflected decisions. As expected, they also make more routinized decisions than students. The professionals’ success rates improve with increasing cognitive involvement, while their failure rates are relatively high when making routinized decisions, an aspect worthwhile considering in translation didactics.

Group Duties

2019 ◽  
Author(s):  
Stephanie Collins
Keyword(s):  
Decision Making ◽  
Human Rights ◽  
Systemic Reform ◽  
Moral Duty ◽  
Tripartite Model ◽  
Group Level ◽  
The United Kingdom ◽  
Moral Duties ◽  
Fundamental Categories ◽  
Group Pattern

Moral duties are regularly attributed to groups. We might think that the United Kingdom has a moral duty to defend human rights, that environmentalists have a moral duty to push for global systemic reform, or that the affluent have a moral duty to alleviate poverty. This book asks (i) whether such groups are apt to bear duties and (ii) what this implies for their members. It defends a ‘Tripartite Model’ of group duties, which divides groups into three fundamental categories. First, combinations are collections of agents that do not have any goals or decision-making procedures in common. Combinations cannot bear moral duties. Instead, we should re-cast their purported duties as a series of duties—one held by each agent in the combination. Each duty demands its bearer to ‘I-reason’: to do the best they can, given whatever they happen to believe the others will do. Second, coalitions are groups whose members share goals but lack decision-making procedures. Coalitions also cannot bear duties, but their alleged duties should be replaced with members’ several duties to ‘we-reason’: to do one’s part in a particular group pattern of actions, on the presumption that others will do likewise. Third, collectives have group-level procedures for making decisions. They can bear duties. Collectives’ duties imply duties for collectives’ members to use their role in the collective with a view to the collective doing its duty.

The Law & Politics of Brexit: Volume II

2020 ◽  
Keyword(s):  
Decision Making ◽  
European Union ◽  
Legal Framework ◽  
Comprehensive Analysis ◽  
The European Union ◽  
Trade Relations ◽  
The United Kingdom ◽  
The Uk ◽  
Financial Settlement ◽  
The Eu

This book provides the first comprehensive analysis of the withdrawal agreement concluded between the United Kingdom and the European Union to create the legal framework for Brexit. Building on a prior volume, it overviews the process of Brexit negotiations that took place between the UK and the EU from 2017 to 2019. It also examines the key provisions of the Brexit deal, including the protection of citizens’ rights, the Irish border, and the financial settlement. Moreover, the book assesses the governance provisions on transition, decision-making and adjudication, and the prospects for future EU–UK trade relations. Finally, it reflects on the longer-term challenges that the implementation of the 2016 Brexit referendum poses for the UK territorial system, for British–Irish relations, as well as for the future of the EU beyond Brexit.

scholarly journals Honoring Preferences—The Consistency Between End-of-Life Care and a Veteran’s Goal for Comfort Care

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 752-752
Author(s):  
Joan Carpenter ◽  
Winifred Scott ◽  
Mary Ersek ◽  
Cari Levy ◽  
Jennifer Cohen ◽  
...  
Keyword(s):  
Palliative Care ◽  
Logistic Regression ◽  
End Of Life ◽  
End Of Life Care ◽  
Life Care ◽  
Multivariate Logistic Regression ◽  
Comfort Care ◽  
Lower Odds ◽  
Medicare Data ◽  
Life Sustaining Treatment

Abstract This study examined the alignment between Veterans’ end-of-life care and a Life-Sustaining Treatment (LST) goal “to be comfortable.” It includes Veterans with VA inpatient or community living center stays overlapping July 2018--January 2019, with a LST template documented by January 31, 2019, and who died by April 30, 2019 (N = 18,163). Using VA and Medicare data, we found 80% of decedents with a comfort care goal received hospice and 57% a palliative care consult (compared to 57% and 46%, respectively, of decedents without a comfort care goal). Using multivariate logistic regression, a comfort care goal was associated with significantly lower odds of EOL hospital or ICU use. In the last 30 days of life, Veterans with a comfort care goal had 43% lower odds (AOR 0.57; 95% CI: 0.51, 0.64) of hospitalization and 46% lower odds of ICU use (AOR 0.54; 95% CI: 0.48, 0.61).

scholarly journals Chemical Exposure: European Citizens’ Perspectives, Trust, and Concerns on Human Biomonitoring Initiatives, Information Needs, and Scientific Results

2021 ◽  
Vol 18 (4) ◽  
pp. 1532
Author(s):  
Maria Uhl ◽  
Ricardo R. Santos ◽  
Joana Costa ◽  
Osvaldo Santos ◽  
Ana Virgolino ◽  
...  
Keyword(s):  
Decision Making ◽  
Policy Development ◽  
Information Needs ◽  
Policy Decision ◽  
Human Biomonitoring ◽  
Chemical Exposure ◽  
The European Union ◽  
Cross Sectional ◽  
The United Kingdom ◽  
Scientific Results

Over the last few decades, citizen awareness and perception of chemical products has been a topic of interest, particularly concerning national and international policy decision makers, expert/scientific platforms, and the European Union itself. To date, few qualitative studies on human biomonitoring have analysed communication materials, made recommendations in terms of biomonitoring surveillance, or asked for feedback in terms of specific biomonitoring methods. This paper provides in-depth insight on citizens’ perceptions of knowledge of biomonitoring, impact of chemical exposure on daily life, and claims on how results of research should be used. Four semi-structured focus groups were held in Austria, Portugal, Ireland, and the United Kingdom (UK). The cross-sectional observational qualitative design of this study allows for better understanding of public concern regarding chemicals, application, and use of human biomonitoring. The main findings of this study include citizens’ clear articulation on pathways of exposure, the demand on stakeholders for transparent decision-making, and sensitivity in communication of results to the public. Validated and trustful communication is perceived as key to empowering citizens to take action. The results can be used to facilitate decision-making and policy development, and feeds into the awareness needs of similar and future projects in human biomonitoring. Furthermore, it also brings to light ideas and concepts of citizens’ in shaping collaborative knowledge between citizens’, experts, scientists, and policy makers on equal terms.

scholarly journals A qualitative systematic review of factors influencing parents’ vaccination decision-making in the United Kingdom

2016 ◽  
Vol 2 ◽  
pp. 603-612 ◽  
Author(s):  
Alice S. Forster ◽  
Lauren Rockliffe ◽  
Amanda J. Chorley ◽  
Laura A.V. Marlow ◽  
Helen Bedford ◽  
...  
Keyword(s):  
Systematic Review ◽  
Decision Making ◽  
United Kingdom ◽  
The United Kingdom ◽  
Factors Influencing ◽  
Qualitative Systematic Review ◽  
Vaccination Decision

PP205 The Use Of Real-World Evidence To Support National Institute For Health And Care Excellence Medical Technology Submissions

2021 ◽  
Vol 37 (S1) ◽  
pp. 26-26
Author(s):  
Scott Gibson ◽  
Sita Saunders ◽  
Maximilian Blüher ◽  
Amanda Hansson Hedblom ◽  
Rafael Torrejon Torres ◽  
...  
Keyword(s):  
Decision Making ◽  
Real World ◽  
Trial Design ◽  
Clinical Evidence ◽  
Patient Characteristics ◽  
The United Kingdom ◽  
Real World Evidence ◽  
Guidance Documents ◽  
Meta Analyses ◽  
Positive Recommendation

IntroductionAlthough randomized controlled trials (RCTs) are recognized as providing the highest level of clinical evidence, few medical device RCTs are available due to underfunding or inherent challenges associated with trial design. This study examines the extent to which real-world evidence (RWE) supports the recommendations made by the National Institute for Health and Care Excellence Medical Technologies Evaluation Programme (MTEP).MethodsAll MTEP guidance documents published online prior to October 2020 were reviewed. The “case for adoption” recommendation, type of clinical data, and clinical critiques for each MTEP submission were extracted and categorized. RWE was defined as studies with neither blinding nor prospective selection or control of patient characteristics.ResultsOf the MTEP submissions reviewed, 34 of 45 (76%) received a positive recommendation. Independent of outcome, all submissions included RWE, but only 19 (42%) utilized RCT evidence (15 were recommended and four were not). Meta-analyses of RWE were used whenever possible. The most common clinical critiques in unsuccessful submissions were the following: (i) not generalizable to the United Kingdom National Health Service (NHS); (ii) low quality; (iii) likelihood of bias; (iv) trial design faults; (v) uncertain benefit; and (vi) evidence unrelated to scope.ConclusionsThis study suggests that while the use of RCTs has not always led to a positive recommendation, RWE can be valuable in decision-making. Evidence that is generalizable to the NHS, is related to the scope, and shows clear indication of benefit is more likely to positively influence MTEP decision-making.

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