Weekly Rounding With the MICU Team: Description of a Clinical Ethics Project

2018 ◽  
Vol 36 (4) ◽  
pp. 290-293 ◽  
Author(s):  
Elizabeth K. Vig
Keyword(s):  
Palliative Care ◽  
Moral Distress ◽  
Patient Goals ◽  
Project Description ◽  
Life Sustaining Treatment ◽  
Medical Intensive Care ◽  
Seriously Ill Patients ◽  
Attending Physicians ◽  
Seriously Ill

Context: Patients in medical intensive care units (MICUs) are medically complex. This complexity can lead to uncertainty about patient goals and prognosis. Ethical dilemmas arise when there is uncertainty about the clinically and ethically appropriate actions for managing seriously ill patients. Ethics and palliative care involvement may promote improved quality of care and reduced staff moral distress. Project Description: In this clinical project, a physician with ethics, palliative care, and geriatrics expertise attended morning rounds with the MICU team weekly. Data on the logistics and impact from the first 2 years of the project were collected. Project Logistics and Preliminary Impact: Rounds lasted approximately 1.75 hours per week. The rounder was present for discussion of approximately 200 patients per year and made comments on nearly half of the patients. The comments were categorized as 25% ethics, 40% palliative care, 10% geriatrics, and 25% a combination or other topic. Attending physicians rated the project as helpful. The number of ethics and palliative care consults from the MICU increased in the first 2 years. Downstream impact has included a dietician reviewing Physician Orders for Life Sustaining Treatment forms with teams throughout the hospital and routine review of advance directives of newly admitted patients. Discussion: Weekly MICU rounding provides an opportunity to briefly teach staff and trainees about relevant ethics, palliative care, and geriatrics issues. It also provides a forum for discussion of ethically challenging cases. Considerations when starting a similar program are discussed.

Final Thoughts (DRAFT)

2018 ◽  
Author(s):  
Robert C. Macauley
Keyword(s):  
Palliative Care ◽  
Moral Distress ◽  
Ethical Dilemmas ◽  
Economic Resources ◽  
Emotional Challenges ◽  
Seriously Ill Patients ◽  
External Forces ◽  
The Right ◽  
Developed World ◽  
Seriously Ill

It is not enough to know how to respond to ethical dilemmas in palliative care. Sufficient resources are required to implement the nuanced approach to ethical dilemmas presented in this textbook. In the developed world, there exists a profound shortage of palliative care clinicians, as well as regulatory barriers which may impede the provision of optimal palliative care. The situation is far more serious in the developing world, where access to symptomatic medications may be severely restricted due to lack of economic resources or bureaucratic barriers. Even when a qualified team is available and necessary tools are at hand, the emotional challenges inherent in caring for seriously ill patients may negatively impact team dynamics. This is particularly true in situations where members of the team believe they know what the “right” thing to do is, but external forces prevent them from doing it, thus causing moral distress.

Clinical interventions, economic impact, and palliative care

2015 ◽  
pp. 1048-1055
Author(s):  
Patrick J. Coyne ◽  
Thomas J. Smith ◽  
Laurel J. Lyckholm
Keyword(s):  
Palliative Care ◽  
Hospice Care ◽  
Management Strategies ◽  
Cost Savings ◽  
Palliative Care Teams ◽  
Futile Care ◽  
Seriously Ill Patients ◽  
Care Costs ◽  
Seriously Ill

Economic outcomes are increasingly important for all types of healthcare, including palliative care. There are substantial opportunities for improvement by using disease management strategies and care pathways. Directed, ethically motivated interventions about futile care appear to produce significant cost savings. The use of advance directives or hospice care may be good medical care, but have not been shown to produce major economic benefit. Integrated palliative care teams have been shown to reduce hospital and end-of-life care costs for seriously ill patients. For treatment to be justified, there must be some demonstrable improvement in disease-free or overall survival, toxicity, quality of life, or cost effectiveness.

scholarly journals Difficulties doctors experience during life-sustaining treatment discussion after enactment of the Life-Sustaining Treatment Decisions Act: A cross-sectional study

2020 ◽  
Author(s):  
Shin Hye Yoo ◽  
Wonho Choi ◽  
Yejin Kim ◽  
Min Sun Kim ◽  
Hye Yoon Park ◽  
...  
Keyword(s):  
Tertiary Hospital ◽  
Cross Sectional Study ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Life Sustaining Treatment ◽  
The Republic ◽  
Seriously Ill Patients ◽  
Attending Physicians ◽  
Seriously Ill ◽  
Structured Questionnaire

Abstract Background In the Republic of Korea, life-sustaining treatment (LST) for patients at the end of life should be legally discussed by a doctor according to the LST Decisions Act, which was enacted in February 2018. However, little is known about challenges doctors experience during LST discussion. This study aims to investigate the perceived difficulties of doctors during LST discussions after enactment of the new Act. Methods A cross-sectional survey was conducted in a tertiary hospital in August 2019 and included 686 doctors (432 attending physicians, 141 clinical fellows, and 295 residents) who care for seriously ill patients. The doctors were given a structured questionnaire, and difficulties during the discussion process were examined. Results A total of 132 doctors answered the questionnaire. Most (86.4%) experienced considerable difficulties during LST discussions (mean score, 7.4 ± 1.6/10). The two most common difficulties were communication with patients and family and determining when to discuss LST. Two-thirds of doctors found direct discussions with the patient difficult and said they would initiate LST discussions only with family. LST discussions were actually initiated later than considered appropriate. When medically assessing whether the patient is imminently dying, 56% of doctors experienced disagreements with other doctors, which could affect their decisions. Conclusion In the present study, most doctors experienced serious difficulties during LST discussions. To alleviate these difficulties, further institutional support is needed.

Fact file 9: Palliative care

2017 ◽  
Author(s):  
Daisy Fancourt
Keyword(s):  
Quality Of Life ◽  
Palliative Care ◽  
End Of Life ◽  
End Of Life Care ◽  
Improve Quality ◽  
Spiritual Support ◽  
Life Care ◽  
Seriously Ill Patients ◽  
Seriously Ill

Palliative care is support for seriously ill patients and their families. The aim of palliative care is to minimize pain and discomfort as much as possible and provide psychological, social, and spiritual support. An important part of palliative care is end-of-life care, which aims to improve quality of life as much as possible while patients are alive and then help them to die with dignity....

scholarly journals Aspects of Palliative Care Nursing in the Time of COVID-19

Aquichan ◽  
2021 ◽  
Vol 21 (1) ◽  
pp. 1-3
Author(s):  
Clare Butt
Keyword(s):  
Palliative Care ◽  
Interdisciplinary Team ◽  
Limited Time ◽  
Levels Of Care ◽  
Global Pandemic ◽  
The Family ◽  
Seriously Ill Patients ◽  
Seriously Ill ◽  
Care Nursing

During this COVID-19 global pandemic, seriously ill patients rely on nurses more than ever. Providing care in the altered environment of the pandemic can be stressful for nurses and the interdisciplinary team. Faced with limited time and resources, restricted visiting of family members and loved ones, and the changing science affecting treatments, nurses are extraordinarily challenged. Fortunately, nurses can benefit from integrating palliative care nursing skills into all levels of care. Because palliative care is holistic, improves the quality of life, and focuses on both the patient and the family, it can assist nurses—from acute care to home care settings—in managing symptoms, communicating with empathy, and discussing care decisions. Importantly, despite the enormous stress of these uncertain times, nurses can take the time to care for themselves and thereby find the strength to continue caring for patients.

Principles of care for seriously ill patients in palliative office

2020 ◽  
pp. 15-18
Author(s):  
Nina Tishchenko
Keyword(s):  
Palliative Care ◽  
The State ◽  
State Budget ◽  
Oncological Patients ◽  
Seriously Ill Patients ◽  
Seriously Ill

The article reflects the importance and importance of the work of nurses of the Department of Palliative Care for Oncological Patients of the State Budget Health Establishment «Samara Regional Clinical Oncological Clinic». Important stages and features of care when dealing with seriously ill patients.

The Surprise Question and Serious Illness Conversations: A pilot study

2021 ◽  
pp. 096973302098339
Author(s):  
Kathy Le ◽  
Jenny Lee ◽  
Sameer Desai ◽  
Anita Ho ◽  
Holly van Heukelom
Keyword(s):  
Pilot Study ◽  
Healthcare Professionals ◽  
Post Intervention ◽  
Acute Medicine ◽  
Serious Illness ◽  
Patient Goals ◽  
Ethical Approval ◽  
Seriously Ill Patients ◽  
Surprise Question ◽  
Seriously Ill

Background: Serious Illness Conversations aim to discuss patient goals. However, on acute medicine units, seriously ill patients may undergo distressing interventions until death. Objectives: To investigate the feasibility of using the Surprise Question, “Would you be surprised if this patient died within the next year?” to identify patients who would benefit from early Serious Illness Conversations and study any changes in the interdisciplinary team’s beliefs, confidence, and engagement as a result of asking the Surprise Question. Design: A prospective cohort pilot study with two Plan-Do-Study-Act cycles. Participants/context: Fifty-eight healthcare professionals working on Acute Medicine Units participated in pre- and post-intervention questionnaires. The intervention involved asking participants the Surprise Question for each patient. Patient charts were reviewed for Serious Illness Conversation documentation. Ethical considerations: Ethical approval was granted by the institutions involved. Findings: Equivocal overall changes in the beliefs, confidence, and engagement of healthcare professionals were observed. Six out of 23 patients were indicated as needing a Serious Illness Conversation; chart review provided some evidence that these patients had more Serious Illness Conversation documentation compared with the 17 patients not flagged for a Serious Illness Conversation. Issues were identified in equating the Surprise Question to a Serious Illness Conversation. Discussion: Appropriate support for seriously ill patients is both a nursing professional and ethical duty. Flagging patients for conversations may act as a filtering process, allowing healthcare professionals to focus on conversations with patients who need them most. There are ethical and practical issues as to what constitutes a “serious illness” and if answering “no” to the Surprise Question always equates to a conversation. Conclusion: The barriers of time constraints and lack of training call for institutional change in order to prioritise the moral obligation of Serious Illness Conversations.

scholarly journals Priming the System for Primary Palliative Care: More, Better, and Earlier Conversations with Seriously Ill Patients (P10)

2017 ◽  
Vol 53 (2) ◽  
pp. 308-309 ◽  
Author(s):  
Justin Sanders ◽  
Joshua Lakin ◽  
Rachelle Bernacki ◽  
Catherine Arnold ◽  
Joanna Paladino
Keyword(s):  
Palliative Care ◽  
Seriously Ill Patients ◽  
Seriously Ill

Fostering medical staff reflection on the technological alienation of parents in the NICU

2021 ◽  
pp. 147775092110618
Author(s):  
Abram Brummett ◽  
Annie B. Friedrich
Keyword(s):  
Medical Staff ◽  
Moral Distress ◽  
Ethical Issues ◽  
Treatment Refusal ◽  
Healthy Newborn ◽  
Incurable Condition ◽  
Life Sustaining Treatment ◽  
Terminal Diagnosis ◽  
The Relationship

We describe a case of parents refusing a tracheostomy for an otherwise healthy newborn. The refusal was not honored because permitting the refusal would have violated state law, which required a child to have a qualifying condition (e.g. a terminal diagnosis, permanent unconsciousness, incurable condition with severe suffering) to remove or withhold life-sustaining treatment. However, this case strained the relationship between the parents and medical staff, who worried about sending the newborn home with a tracheostomy where she was not wanted. While many ethical issues arise in treatment refusal cases like this, we focus on the opportunity for ethicists to help the medical staff reflect on the technological alienation of the parents, which may help foster empathy, reduce moral distress, and strengthen the quality of the doctor-parent-patient triad.

Earlier identification of seriously ill patients: an implementation case series

2019 ◽  
Vol 10 (4) ◽  
pp. e31-e31 ◽  
Author(s):  
Joshua R Lakin ◽  
Meghna Desai ◽  
Kyle Engelman ◽  
Nina O'Connor ◽  
Winifred G Teuteberg ◽  
...  
Keyword(s):  
Palliative Care ◽  
Patient Selection ◽  
Case Series ◽  
Healthcare Systems ◽  
Ongoing Research ◽  
Starting Point ◽  
Seriously Ill Patients ◽  
Analytical Approaches ◽  
Seriously Ill ◽  
Over Time

ObjectiveTo describe the strategies used by a collection of healthcare systems to apply different methods of identifying seriously ill patients for a targeted palliative care intervention to improve communication around goals and values.MethodsWe present an implementation case series describing the experiences, challenges and best practices in applying patient selection strategies across multiple healthcare systems implementing the Serious Illness Care Program (SICP).ResultsFive sites across the USA and England described their individual experiences implementing patient selection as part of the SICP. They employed a combination of clinician screens (such as the ‘Surprise Question’), disease-specific criteria, existing registries or algorithms as a starting point. Notably, each describes adaptation and evolution of their patient selection methodology over time, with several sites moving towards using more advanced machine learning–based analytical approaches.ConclusionsInvolving clinical and programme staff to choose a simple initial method for patient identification is the ideal starting place for selecting patients for palliative care interventions. However, improving and refining methods over time is important and we need ongoing research into better patient selection methodologies that move beyond mortality prediction and instead focus on identifying seriously ill patients—those with poor quality of life, worsening functional status and medical care that is negatively impacting their families.

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