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

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.

Letter to the Editor: Craniopharyngiomas in the elderly: the crucial influence of tumor topography on surgical risk assessment

2021 ◽  
Author(s):  
José M. Pascual ◽  
Ruth Prieto
Keyword(s):  
Risk Assessment ◽  
Elderly Patients ◽  
Tumor Tissue ◽  
Significant Proportion ◽  
Wide Band ◽  
The Elderly ◽  
Surgical Risk ◽  
Definition Of ◽  
Weighted Sequences ◽  
Tumor Topography

Classifying CPs within the overly vague, uninformative category “suprasellar” prevents gaining any true insight regarding the risks associated with the surgical procedure employed. Routine MRI obtained with conventional T1- and T2-weighted sequences along the midsagittal and coronal trans-infundibular planes allow an accurate and reliable preoperative definition of CP topography. CPs developing primarily within the infundibulum and/or tuberal region of the hypothalamus, as well as those wholly located within the 3V, should be distinguished preoperatively from those lesions originally expanding beneath the 3V floor (3VF), the true suprasellar tumors. Among adult patients, about 40% of CPs correspond to infundibulo-tuberal tumors expanding primarily within the 3VF, above an intact pituitary gland and stalk. This subgroup of CPs shows strong adherences to the surrounding hypothalamus, as they are embedded within a wide band of reactive gliotic tissue, usually infiltrated by microscopic finger-like solid cords of tumor tissue. In elderly patients, a significant proportion of CPs correspond to papillary tumors developing above an intact 3VF, usually showing small pedicle-like or sessile-like attachments to the infundibulum. With the current diagnostic MRI workup routinely employed for CPs, it is possible, for the majority of lesions, to preoperatively differentiate these topographical variants and predict the type of CP-hypothalamus relationship that will be found during surgery.

scholarly journals Why do frail patients with chronic heart failure die and become hospitalised?

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Sze ◽  
P Pellicori ◽  
J Zhang ◽  
J Weston ◽  
A.L Clark
Keyword(s):  
Heart Failure ◽  
Cause Of Death ◽  
Hospital Admissions ◽  
Average Length ◽  
Significant Proportion ◽  
Length Of Hospital Stay ◽  
Clinical Frailty Scale ◽  
Frail Patients ◽  
Increased Risk

Abstract Background Frailty is common in patients with heart failure (HF) and is associated with increased morbidity and mortality. A better understanding of the causes of hospitalisations and death in frail patients might help to tailor interventional strategies for these at-risk patients. Purpose We studied the cause of death and hospitalisations in ambulatory patients with HF and frailty. Methods We assessed frailty using the clinical frailty scale (CFS) in consecutive HF patients attending a routine follow-up visit. Those with CFS ≥5 were classified as frail. Mortality and hospitalisations were ascertained from medical records (updated systematically using an NHS electronic database), discharge letters, autopsy reports and death certificates. We studied the primary cause of death and hospitalisations within one year of enrolment. Results 467 patients (67% male, median (IQR) age 76 (69–82) years, median (IQR) NT-proBNP 1156 (469–2463) ng/L) were enrolled. 206 (44%) patients were frail. Frail patients were more likely to not receive or receive suboptimal doses of ACEi/ARB and Beta-blockers; while non-frail patients were more likely to be treated with optimal doses. At 1-year follow up, there were 56 deaths and 322 hospitalisations, of which 46 (82%) and 215 (67%) occurred in frail patients. Frailty was associated with an increased risk of all-cause mortality (HR (95% CI): 4.27 (2.60–7.01)) and combined mortality/ hospitalisation (HR (95% CI): 2.85 (2.14–3.80)), all p&lt;0.001. 57% (n=26) of frail patients died of cardiovascular causes (of which 58% were due to HF progression); although deaths due to non-cardiovascular causes (43%, n=20), especially severe infections, were also common (26%, n=12). (Figure 1) The proportion of frail patients who had non-elective hospital admissions within 1 year was more than double that of non-frail patients (46% (n=96) vs 21% (n=54); p&lt;0.001). Compared to non-frail patients, frail patients had more recurrent (≥2) hospitalisations (28% (n=59) vs 9% (n=24); p&lt;0.001) but median (IQR) average length of hospital stay was not significantly different (frail: 6 (4–11) vs non-frail: 6 (2–12) days, p=0.50). A large proportion of hospitalisations (64%, n=137) in frail patients were due to non-cardiovascular causes (of which 34%, 30% and 20% were due to infections, falls and comorbidities respectively). Of cardiovascular hospitalisations (36%, n=78), the majority were due to decompensated HF (67%, n=46). (Figure 1) Conclusion Frailty is common in patients with HF and is associated with an increased risk of mortality and recurrent hospitalisations. A significant proportion suffered non-cardiovascular deaths and hospitalisations. This implies that interventions targeted at HF alone can only have limited impact on outcomes in frail patients. Figure 1 Funding Acknowledgement Type of funding source: None

scholarly journals Validação da definição de termos identificados em registros eletrônicos de enfermagem de um hospital universitário/ Validation of the definition of terms identified in electronic records of nursing of a university hospital

2017 ◽  
Vol 16 (1) ◽  
Author(s):  
Rodrigo Guerra Leal ◽  
Cláudia Regina Biancato Bastos ◽  
Ana Luzia Rodrigues ◽  
Sandra Maria Bastos Pires ◽  
Deborah Ribeiro Carvalho ◽  
...  
Keyword(s):  
University Hospital ◽  
Electronic Records ◽  
Definition Of

Este estudo objetivou validar a definição de termos registrados por enfermeiros na evolução do paciente de um hospital universitário, com base na Classificação Internacional para as Práticas de Enfermagem (CIPE®). A base empírica foi composta por 15 termos não constantes na CIPE®, extraídos das evoluções registradas por enfermeiros em prontuário eletrônico do paciente, de um hospital da região Sul do país. As definições foram analisadas por 36 enfermeiros, por meio da proporção de concordância geral de utilização e do Índice de Validade de Conteúdo (IVC) geral e por princípios de definição terminológica. Os termos “anasarca”, “equimose” e “posição de Fowler” atingiram proporção de concordância geral de utilização acima de 80%, enquanto agonia obteve a menor proporção (25%). A variável ocupação não interferiu no resultado, porém enfermeiros com menor tempo de atuação na instituição reconheceram a utilização de mais seis termos. A definição dos termos “anasarca” e “equimose” foi validada com IVC de 0,98 e 0,90, respectivamente; por outro lado, a de posição de Fowler não foi validada (IVC = 0,67), tendo sido limitada por sua concisão. Concluiu-se que o reconhecimento ou não de termos por enfermeiros assistenciais é determinado pelas características da clientela assistida na instituição.

scholarly journals A prospective cohort study of older colorectal cancer surgical patients: an association of post-operative clinical outcome with sarcopenia, frailty, and nutritional status [Protocol] (Preprint)

2019 ◽  
Author(s):  
Nia Humphry
Keyword(s):  
Colorectal Cancer ◽  
Risk Factors ◽  
Nutritional Status ◽  
Significant Proportion ◽  
The Elderly ◽  
Operative Risk ◽  
Surgical Patients ◽  
Clinical Frailty Scale ◽  
Colorectal Cancer Surgery ◽  
Colorectal Cancer Resection

UNSTRUCTURED Older patients account for a significant proportion of patients undergoing colorectal cancer surgery, and are vulnerable to a number of pre-operative risk factors that are not often present in younger patients. Three pre-operative risk factors more prevalent in the elderly are frailty, sarcopenia, and malnutrition. Whilst each of these has been studied in isolation, there is little information on the interplay between them in older surgical patients. One particular area of increasing interest is the use of urine metabolomics for objective evaluation of dietary profiles and malnutrition. Herein we describe the design, cohort, and standard operating procedures of a planned prospective study of older surgical patients undergoing colorectal cancer resection across multiple institutions in the United Kingdom. These procedures include serial frailty evaluations (Clinical Frailty Scale and Groningen Frailty Indicator), functional assessments (with hand grip strength and 4-metre walk test), muscle mass evaluations using computerized tomography morphometric analysis and evaluation of nutritional status using analysis of urinary dietary biomarkers. As these are all areas of common derangement in the elderly surgical population, prospectively studying them in concert will allow for analysis of their interplay as well as the development of predictive models for those at risk for commonly tracked surgical complications and outcomes.

scholarly journals The Factors affecting the implementation of electronic training in health care organization in Saudi Arabia: The case of King Abdulaziz university hospital: العوامل المؤثرة في تطبيق التدريب الإلكتروني في المنظمات الصحية- دراسة تطبيقية على موظفي مستشفى جامعة الملك عبد العزيز الإداريين بالمملكة العربية السعودية

2019 ◽  
Vol 3 (10) ◽  
Author(s):  
Sabah Abdullah Alsomali  ,   Amira AbdulAziz Alghamdi
Keyword(s):  
Health Care Organization ◽  
General Information ◽  
University Hospital ◽  
Care Organization ◽  
Health Organizations ◽  
Factors Affecting ◽  
King Abdulaziz University ◽  
Definition Of ◽  
Study Hypothesis ◽  
Significant Factors

The current study focused on the definition of electronic training and the importance of electronic training in the health organizations. The study main objective was to study the most significant factors that are affecting the electronic training application in the health organizations. The researcher used both a descriptive and analytical methods in her study. A questionnaire was used as a tool for data collection; the questionnaire was divided into two sections. The first section contained questions about general information that included: sex – age- qualification – experience in years – computer skills. The second section dealt with questions related to the study hypothesis. This section consists of four parts as follows: The first part included 11 statements about the reality of the electronic training in the health organizations in the present, which is considered the dependent variable in this study. The second part consists of 15 statements; the third part consists of 13 statements. The fourth part consists of 8 statements. These parts addressed the most significant factors that affected the implementation of the electronic training in the health organizations. These were the independent variables of the study. The questionnaire was distributed to a study sample of (368) employee in the hospital. A (200) questionnaire were collected on a rate of 54%. The Results of the study showed that the infrastructure for the Information technology and the government's tends towards the digital society were the most important factors that primarily affect the possibility of applying the electronic training in the health organizations. The main recommendations of the study were: the need for a support from the high and senior management in the king Abdul Aziz University hospital to adopt the electronic application of the electronic training and manage the resistance of change that many organization faces. The necessity of the electronic training for all the staff on computers skills. Finally, the importance of having a unit for the technical support king Abdul Aziz University hospital.

scholarly journals 29 Predicting Unplanned Readmission and Death After Hospital Discharge: How Do Frailty Tools Compare to Electronic Health Record Frailty Markers?

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i7-i11
Author(s):  
A Anand ◽  
Y Yong Tew ◽  
J Hao Chan ◽  
P Keeling ◽  
S D Shenkin ◽  
...  
Keyword(s):  
Electronic Health Record ◽  
Hospital Discharge ◽  
Royal Infirmary ◽  
Unplanned Readmission ◽  
Health Record ◽  
Clinical Frailty Scale ◽  
Standard Deviation Increase ◽  
Face To Face ◽  
Hospitalised Patients ◽  
Electronic Health

Abstract Introduction Numerous frailty tools and definitions have been described. Amongst hospitalised patients, the validity of face-to-face instruments may be confounded by acute illness. However, patient assessment after recovery at the point of hospital discharge, or recognition of electronic health record (EHR) frailty markers, may overcome this issuep. Methods In a consented, prospective observational cohort study, we recruited patients ≥70 years old within 24 hours of expected discharge from the cardiology ward of the Royal Infirmary of Edinburgh. Three established frailty instruments were tested: the Fried phenotype, Short Physical Performance Battery and nurse-administered Clinical Frailty Scale (CFS). An unweighted 32-item EHR score was generated using frailty markers (e.g. falls risk, continence, cognition) recorded within mandated admission documentation. Comorbidity was assessed by count of chronic health conditions. Outcomes were a 90-day composite of unplanned readmission or death and 12-month mortality. Adjusted Cox modelling determined the hazard ratio (HR) per standard deviation increase in each frailty score. Results 186 patients (mean age 79 ± 6 years, 64% male) were included, of whom 55 (30%) had a 90-day composite outcome, and 21 (11%) died within 12 months. All four frailty tools were moderately correlated with age and comorbidity (Pearson’s r 0.21 to 0.43, all p &lt; 0.05). The Fried phenotype (HR 1.47, 95% CI 1.18–1.81), CFS (HR 1.24, 95% CI 1.01–1.51) and EHR score (HR 1.26, 95% CI 1.03–1.55) independently predicted 90-day readmission or death, after adjustment for age, sex and comorbidity. All frailty instruments were independent predictors of 12-month mortality, with age, sex and comorbidity losing predictive power (p &gt; 0.05) once frailty was included in modelling. Conclusions At hospital discharge, the Fried phenotype and CFS added to age and comorbidity in risk prediction for future unplanned readmission or death. EHR frailty markers appeared comparable to face-to-face assessment. An automated trigger for high-risk patients using routine EHR data merits prospective evaluation.

The secondary phloem of Austrobaileya scandens

1970 ◽  
Vol 48 (2) ◽  
pp. 341-359 ◽  
Author(s):  
Lalit M. Srivastava
Keyword(s):  
Tannic Acid ◽  
Cross Sections ◽  
Significant Proportion ◽  
Sieve Tube ◽  
Secondary Phloem ◽  
Sieve Elements ◽  
Sieve Cells ◽  
Companion Cells ◽  
Parenchyma Cells ◽  
Definition Of

The origin of sieve elements and parenchyma cells in the secondary phloem of Austrobaileya was studied by use of serial cross sections stained with tannic acid – ferric chloride and lacmoid. In three important respects, Austrobaileya phloem recalls gymnospermous features: it has sieve cells rather than sieve-tube members; a significant proportion of sieve elements and companion cells arise independently of each other; and sieve areas occur between sieve elements and companion cells ontogenetically unrelated to each other. The angiospermous feature includes origin of most sieve elements and parenchyma, including companion cells, after divisions in phloic initials. In these instances companion cells show a closer ontogenetic relationship to sieve elements than do other parenchyma cells. The combination of gymnospermous and angiospermous features makes phloem of Austrobaileya unique when compared to that of all those species that have been investigated in detail. It is further suggested that the term albuminous cells is inappropriate and should be replaced by companion cells but that the ontogenetic relationship implicit in the definition of companion cells is too restrictive and should be abandoned.

scholarly journals Workshops as a democratic proposal in order to change the supervision work in nursing

2018 ◽  
Vol 71 (4) ◽  
pp. 2050-2054 ◽  
Author(s):  
Maria Silvia Teixeira Giacomasso Vergílio ◽  
Vanessa Pellegrino Toledo ◽  
Eliete Maria Silva
Keyword(s):  
Action Research ◽  
Intervention Strategy ◽  
Public University ◽  
University Hospital ◽  
Work Context ◽  
Work Process ◽  
Communication Failure ◽  
Hospital Nursing ◽  
Definition Of

ABSTRACT Objective: to report the experience of developing workshops as an intervention strategy in an action research, aiming to review the work of supervision in hospital nursing. Method: to report of the experience of planning, developing and evaluating workshops with a psychosocial approach. Three workshops were held, in a reserved place, with the participation of 21 supervisors of a public university hospital. Each workshop was organized with heating, day work, closure with syntheses and consensus. Results: the work provided the exchange of experiences, reflections and proposals for difficulties identified in the work process that distract supervisors from the management of assistance such as communication failure, reworking and lack of definition of assignments in the team. Conclusion: the dynamics of the workshops favored supervisors to propose solutions to the difficulties of their practice in a more democratic and participative way, through dialogical interactions, sharing of the feelings pertinent to the work context and establishing consensus for the completion of the task.

scholarly journals Inflammatory phenotyping predicts clinical outcome in COVID-19

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
H. Burke ◽  
◽  
A. Freeman ◽  
D. C. Cellura ◽  
B. L. Stuart ◽  
...  
Keyword(s):  
Adverse Outcome ◽  
Outcome Data ◽  
University Hospital ◽  
Clinical Parameters ◽  
Gm Csf ◽  
Poor Outcome ◽  
Hospitalised Patients ◽  
Cytokine Levels ◽  
Patients At Risk ◽  
Multiplex Cytokine

Abstract Background The COVID-19 pandemic has led to more than 760,000 deaths worldwide (correct as of 16th August 2020). Studies suggest a hyperinflammatory response is a major cause of disease severity and death. Identitfying COVID-19 patients with hyperinflammation may identify subgroups who could benefit from targeted immunomodulatory treatments. Analysis of cytokine levels at the point of diagnosis of SARS-CoV-2 infection can identify patients at risk of deterioration. Methods We used a multiplex cytokine assay to measure serum IL-6, IL-8, TNF, IL-1β, GM-CSF, IL-10, IL-33 and IFN-γ in 100 hospitalised patients with confirmed COVID-19 at admission to University Hospital Southampton (UK). Demographic, clinical and outcome data were collected for analysis. Results Age > 70 years was the strongest predictor of death (OR 28, 95% CI 5.94, 139.45). IL-6, IL-8, TNF, IL-1β and IL-33 were significantly associated with adverse outcome. Clinical parameters were predictive of poor outcome (AUROC 0.71), addition of a combined cytokine panel significantly improved the predictability (AUROC 0.85). In those ≤70 years, IL-33 and TNF were predictive of poor outcome (AUROC 0.83 and 0.84), addition of a combined cytokine panel demonstrated greater predictability of poor outcome than clinical parameters alone (AUROC 0.92 vs 0.77). Conclusions A combined cytokine panel improves the accuracy of the predictive value for adverse outcome beyond standard clinical data alone. Identification of specific cytokines may help to stratify patients towards trials of specific immunomodulatory treatments to improve outcomes in COVID-19.

scholarly journals Late decisions about treatment limitation in patients with cancer: empirical analysis of end-of-life practices in a haematology and oncology unit at a German university hospital

ESMO Open ◽  
2020 ◽  
Vol 5 (5) ◽  
pp. e000950
Author(s):  
Katja Mehlis ◽  
Elena Bierwirth ◽  
Katsiaryna Laryionava ◽  
Friederike Mumm ◽  
Pia Heussner ◽  
...  
Keyword(s):  
Palliative Care ◽  
Advance Care Planning ◽  
Solid Tumours ◽  
University Hospital ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Treatment Limitation ◽  
Ethics Policy ◽  
Advance Care

BackgroundDecisions to limit treatment (DLTs) are important to protect patients from overtreatment but constitute one of the most ethically challenging situations in oncology practice. In the Ethics Policy for Advance Care Planning and Limiting Treatment study (EPAL), we examined how often DLT preceded a patient’s death and how early they were determined before (T1) and after (T2) the implementation of an intrainstitutional ethics policy on DLT.MethodsThis prospective quantitative study recruited 1.134 patients with haematological/oncological neoplasia in a period of 2×6 months at the University Hospital of Munich, Germany. Information on admissions, discharges, diagnosis, age, DLT, date and place of death, and time span between the initial determination of a DLT and the death of a patient was recorded using a standardised form.ResultsOverall, for 21% (n=236) of the 1.134 patients, a DLT was made. After implementation of the policy, the proportion decreased (26% T1/16% T2). However, the decisions were more comprehensive, including more often the combination of ‘Do not resuscitate’ and ‘no intense care unit’ (44% T1/64% T2). The median time between the determination of a DLT and the patient’s death was similarly short with 6 days at a regular ward (each T1/T2) and 10.5/9 (T1/T2) days at a palliative care unit. For patients with solid tumours, the DLTs were made earlier at both regular and palliative care units than for the deceased with haematological neoplasia.ConclusionOur results show that an ethics policy on DLT could sensitise for treatment limitations in terms of frequency and extension but had no significant impact on timing of DLT. Since patients with haematological malignancies tend to undergo intensive therapy more often during their last days than patients with solid tumours, special attention needs to be paid to this group. To support timely discussions, we recommend the concept of advance care planning.

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