Is there a shift in use of subacute rehabilitation (SAR) instead of hospice referral since immunotherapy became available?

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 11530-11530
Author(s):  
Jonathan Yeh ◽  
Louise Knight ◽  
Joyce M. Kane ◽  
Danielle Doberman ◽  
Arjun Gupta ◽  
...  
Keyword(s):  
Cancer Therapy ◽  
Discharge Planning ◽  
Drug Approval ◽  
Do Not Resuscitate ◽  
Post Discharge ◽  
Goals Of Care ◽  
Code Status ◽  
Hospice Referral ◽  
Electronic Chart ◽  
Time Of Admission

11530 Background: Immunotherapy has rapidly become mainstream treatment. Since the first drug approval in 2011, we have noted a decline in referrals from inpatient oncology to hospice, and an increase in referrals to sub-acute rehabilitation (SAR) facilities, possibly with the aim of “getting strong enough” for immunotherapy and other promising drugs. This study explores outcomes after discharge to SAR, including rates of cancer-directed therapy after SAR, overall survival, and hospice utilization. Methods: Electronic chart review of patients discharged from oncology units to SAR facilities from 2009-2017. Demographics, admission statistics, and post-discharge outcomes were gathered from discharge summaries and targeted chart searches. Results: SAR referrals increased from 28 in 2012 to 82 in 2016. Age 66, males 52%, solid tumors 58%. 358 patients were referred to SAR 413 times. 174 patients (49%) returned to the oncology clinic prior to re-admission or death, and only 117 (33%) ever received further cancer-directed treatment (chemotherapy, radiation, or immunotherapy). 219 of 358 (61%) died within 6 months. Only 3 individuals who were not on immunotherapy at time of admission went on to receive immunotherapy after discharge to SAR. Among all discharges, 28% led to readmissions within 30 days. 74 patients (21%) were deceased within 30 days, of whom only 31% were referred to hospice. Palliative care involvement resulted in more frequent do not resuscitate (DNR) code status (33 v 22%), documented goals of care (GOC) discussions (81 v 23%), and electronic advance directives (42 v 28%).(All p<0.05). Conclusions: A growing number of oncology inpatients are being discharged to SAR, but two-thirds do not receive further cancer therapy at any point, including a substantial fraction that are re-admitted or deceased within 1 month. Many patients lose the opportunity to use hospice for optimal end of life care, as few SAR facilities offer this. These data can help guide decision-making and discharge planning that aligns with patients’ goals of care. More clinical data are needed to predict who is most likely to benefit from SAR and proceed to further cancer therapy.

scholarly journals Has There Been a Shift in Use of Subacute Rehabilitation Instead of Hospice Referral Since Immunotherapy Has Become Available?

2019 ◽  
Vol 15 (10) ◽  
pp. e849-e855
Author(s):  
Jonathan C. Yeh ◽  
Louise S. Knight ◽  
Joyce Kane ◽  
Danielle J. Doberman ◽  
Arjun Gupta ◽  
...  
Keyword(s):  
Cancer Therapy ◽  
Discharge Planning ◽  
Drug Approval ◽  
Do Not Resuscitate ◽  
Multiple Cancer ◽  
Post Discharge ◽  
Goals Of Care ◽  
Code Status ◽  
Hospice Referral ◽  
Hospice Use

PURPOSE: Immunotherapy has rapidly become the mainstream treatment of multiple cancer types. Since the first drug approval in 2011, we have noted a decline in referrals from inpatient oncology to hospice and an increase in referrals to subacute rehabilitation (SAR) facilities, possibly with the aim of getting strong enough for immunotherapy and other promising drugs. This study explores outcomes after discharge to SAR, including rates of cancer-directed therapy after SAR, overall survival, and hospice use. METHODS: We performed an electronic chart review of patients discharged from our inpatient oncology units to SAR facilities from 2009 to 2017. Demographics, admission statistics, and post-discharge outcomes were gathered from discharge summaries and targeted chart searches. RESULTS: Three hundred fifty-eight patients were referred to SAR 413 times. One hundred seventy-four patients (49%) returned to the oncology clinic before readmission or death, and only 117 (33%) ever received additional cancer-directed treatment (chemotherapy, radiation, or immunotherapy). Among all discharges, 28% led to readmissions within 30 days. Seventy-four patients (21%) were deceased within 30 days, only 31% of whom were referred to hospice. Palliative care involvement resulted in more frequent do not resuscitate code status, documented goals of care discussions, and electronic advance directives. CONCLUSION: A growing number of oncology inpatients are being discharged to SAR, but two thirds do not receive additional cancer therapy at any point, including a substantial fraction who are readmitted or deceased within 1 month. These data can help guide decision making and hospital discharge planning that aligns with patients’ goals of care. More clinical data are needed to predict who is most likely to benefit from SAR and proceed to further cancer therapy.

scholarly journals Goals of Care or Goals of Life? A qualitative study of clinicians’ and patients’ experiences of hospital discharge using Patient-Oriented Discharge Summaries (PODS)

2020 ◽  
Author(s):  
Nayantara Hattangadi ◽  
Paul Kurdyak ◽  
Rachel Solomon ◽  
Sophie Soklaridis
Keyword(s):  
Hospital Discharge ◽  
Planning Process ◽  
Discharge Planning ◽  
Discrete Event ◽  
Discharge Summary ◽  
Qualitative Inquiry ◽  
Structured Interviews ◽  
Post Discharge ◽  
Goals Of Care ◽  
Asymmetrical Information

Abstract Background : Recognizing the need for improved communication with patients at the point of hospital discharge, a group of clinicians, patients, and designers in Toronto, Canada collaborated to develop a standardized tool known as the Patient-Oriented Discharge Summary (PODS). Although quantitative results suggest PODS helps mitigate gaps in knowledge, a qualitative inquiry from the clinician and patient perspective of hospital discharge using PODS has not been widely explored. Methods : We used a qualitative research design to explore clinicians’ and patients’ experiences with PODS. We used convenience sampling to identify and invite potential participants at the Center for Addiction and Mental Health in Toronto, Canada to participate in semi-structured interviews. Data was analyzed using a thematic analysis approach to develop descriptive themes. Results : The themes that emerged based on PODS experience was influenced by the asymmetrical information advantaged that clinicians had with the discharge planning process. Thus, the themes from the data between clinicians and patients were both different and complementary. Clinicians described PODS using the concept of “goals of care.” They relayed their experiences with PODS as a discrete event and emphasized its role in meeting their “goals of care” for discharge planning. Patients provided more of a “goals of life” perspective on recovery. They characterized PODS as only one facet of their recovery journey and not necessarily as a discrete or memorable event. Patients focused on their outcomes post-discharge and situated their experiences with PODS through its relation to their overall recovery. Conclusions : PODS was experienced differently by clinicians and patients. Clinicians experienced PODS as helpful in orienting them to the fulfillment of goals of care. Patients did not experience PODS as a particularly memorable intervention. Due to the asymmetrical information advantage that clinicians have about PODS, it is not surprising that clinicians and patients experienced the PODS differently. Despite that an asymmetrical relationship exists between clinician and patients, it did not detract from the potential benefits of PODS for the patient. This study expanded our understanding of hospital discharge from clinicians and patients perspectives, and suggests that there are additional areas that need improvement.

scholarly journals “Get the DNR”: residents’ perceptions of goals of care conversations before and after an e-learning module

2021 ◽  
Author(s):  
Leora Branfield Day ◽  
Stephanie Saunders ◽  
Leah Steinberg ◽  
Shiphra Ginsburg ◽  
Christine Soong
Keyword(s):  
Hidden Curriculum ◽  
Do Not Resuscitate ◽  
Patient Centered ◽  
Goals Of Care ◽  
Code Status ◽  
Care Plans ◽  
Learning Module ◽  
Before And After ◽  
E Learning ◽  
The Impact

Background: Residents frequently lead goals of care (GoC) conversations with patients and families to explore patient values and preferences and to establish patient-centered care plans. However, previous work has shown that the hidden curriculum may promote physician-driven agendas and poor communication in these discussions. We previously developed an online learning (e-learning) module that teaches a patient-centered approach to GoC conversations. We sought to explore residents’ experiences and how the module might counteract the impact of the hidden curriculum on residents’ perceptions and approaches to GoC conversations. Methods: Eleven first-year internal medicine residents from the University of Toronto underwent semi-structured interviews before and after completing the module. Themes were identified using principles of constructivist grounded theory.  Results: Prior to module completion, residents described institutional and hierarchical pressures to “get the DNR” (Do-Not-Resuscitate), leading to physician-centered GoC conversations focused on code status, documentation, and efficiency. Tensions between formal and hidden curricula led to emotional dissonance and distress. However, after module completion, residents described new patient-centered conceptualizations and approaches to GoC conversations, feeling empowered to challenge physician-driven agendas. This shift was driven by greater alignment of the new approach with their internalized ethical values, greater tolerance of uncertainty and complexity in GoC decisions, and improved clinical encounters in practice. Conclusion: An e-learning module focused on teaching an evidence-based, patient-centered approach to GoC conversations appeared to promote a shift in residents’ perspectives and approaches that may indirectly mitigate the influence of the hidden curriculum, with the potential to improve quality of communication and care.

scholarly journals Goals of Care or Goals of Life? A qualitative study of clinicians’ and patients’ experiences of hospital discharge using Patient-Oriented Discharge Summaries (PODS)

2020 ◽  
Author(s):  
Nayantara Hattangadi ◽  
Paul Kurdyak ◽  
Rachel Solomon ◽  
Sophie Soklaridis
Keyword(s):  
Hospital Discharge ◽  
Thematic Analysis ◽  
Discharge Planning ◽  
Discrete Event ◽  
Discharge Summary ◽  
Qualitative Inquiry ◽  
Structured Interviews ◽  
Post Discharge ◽  
Goals Of Care ◽  
Information Advantage

Abstract Background: Recognizing the need for improved communication with patients at the point of hospital discharge, a group of clinicians, patients, and designers in Toronto, Canada collaborated to develop a standardized tool known as the Patient-Oriented Discharge Summary (PODS). Although quantitative results suggest PODS helps mitigate gaps in knowledge, a qualitative inquiry from the clinician and patient perspective of psychiatric hospital discharge using PODS has not been widely explored. Our aim was to explore clinicians’ and patients’ experiences with PODS.Methods: We used a qualitative thematic analysis to explore clinicians’ (n=10) and patients’ (n=6) experiences with PODS. We used convenience sampling to identify and invite potential participants at the Center for Addiction and Mental Health in Toronto, Canada to participate in semi-structured interviews between February 2019 and September 2019. Data was analyzed using a thematic analysis approach to develop descriptive themes. Results: Emerging themes from the data between clinicians and patients were both different and complementary. Clinicians described PODS using the concept of “goals of care.” They relayed their experiences with PODS as a discrete event and emphasized its role in meeting their “goals of care” for discharge planning. Patients provided more of a “goals of life” perspective on recovery. They characterized PODS as only one facet of their recovery journey and not necessarily as a discrete or memorable event. Patients focused on their outcomes post-discharge and situated their experiences with PODS through its relation to their overall recovery.Conclusions: PODS was experienced differently by clinicians and patients. Clinicians experienced PODS as helpful in orienting them to the fulfillment of goals of care. Patients did not experience PODS as a particularly memorable intervention. Due to the information advantage that clinicians have about PODS, it is not surprising that clinicians and patients experienced the PODS differently. This study expanded our understanding of hospital discharge from clinicians and patients perspectives, and suggests that there are additional areas that need improvement.

Supportive care services and goals of care in early phase clinical trials (EP-CTs).

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 26-26
Author(s):  
Megan Healy ◽  
Debra Lundquist ◽  
Dejan Juric ◽  
Andrew Johnson ◽  
Sienna Durbin ◽  
...  
Keyword(s):  
Supportive Care ◽  
Symptom Management ◽  
Discharge Planning ◽  
Massachusetts General Hospital ◽  
Metastatic Cancer ◽  
Patient Characteristics ◽  
Goals Of Care ◽  
Code Status ◽  
Patients With Cancer ◽  
Care Services

26 Background: EP-CTs investigate novel therapeutic approaches for patients with cancer, but little is known about the use of supportive care services and timing of goals of care (GOC) discussions in EP-CTs. Methods: We conducted a retrospective review of consecutive patients with cancer enrolled on EP-CTs at Massachusetts General Hospital from 2017-2019. We collected information about patients’ demographic/clinical characteristics, use of supportive care services (palliative care [PC], social work [SW], physical therapy [PT], and nutrition), as well as documentation of GOC discussions and code status (before/during EP-CT vs after/never) via chart review. We examined patient characteristics associated with earlier receipt of supportive care services (before/during EP-CT vs after/never) and compared differences in the timing of GOC discussions and code status documented based on the receipt of supportive care services. Results: Among 425 patients enrolled on EP-CTs (median age 63.0; 56.0% female; 97.4% metastatic cancer; 22.1% gastrointestinal cancer), under half received supportive care services before/during trial (PC: 33.2% before/during, 66.8% post/never; SW: 41.9% before/during, 58.1% post/never; PT: 38.4% before/during, 61.6% post/never; and Nutrition: 33.2% before/during, 62.1% post/never). We identified the most common reasons for consulting each of the supportive care services (PC: 82.4% symptom management and 12.4% GOC; SW: 65.3% adjustment to illness and 23.8% referral for resources; PT: 44.8% safety/discharge planning and 24.6% mobility concerns; Nutrition: 73.2% for symptoms of anorexia/poor appetite and 21.5% nutrition assessment). Patients with GI cancer were more likely than those with other cancers to receive PC and SW before/during EP-CT (PC: 29.8% v 18.3%, p =.009; SW: 27.5% v 18.2%, p =.025). Earlier PC was associated with earlier hospice referral (HR = 1.95, p =.014) and shorter survival (HR = 1.54, p <.001). Patients receiving earlier supportive care services were more likely to have GOC discussions documented earlier (PC: 65.2% v 13.0%, p <.001; SW: 41.0% v 22.7%, p <.001; PT: 38.7% v 25.2%, p =.005; Nutrition: 39.1% v 25.0%, p =.002). Patients with earlier PC were more likely to have earlier documented code status (46.8% v 24.3%, p <.001), but not for any other service. Conclusions: In this cohort of patients with advanced cancer, under half received supportive care services before/during their participation in EP-CTs. We found that symptom management represented a common reason for referral to supportive care, highlighting the needs of this population. Patients who received earlier supportive care services were more likely to have earlier documentation of GOC discussions, with those receiving earlier PC having code status documented earlier and also experiencing earlier hospice use and shorter survival. These findings underscore the utility of supportive care services in EP-CTs.

Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting

2021 ◽  
pp. 104990912110178
Author(s):  
Kelly A. Rath ◽  
Kristi L. Tucker ◽  
Ariane Lewis
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Care Setting ◽  
Ethical Issues ◽  
Severe Illness ◽  
Healthcare Team ◽  
Do Not Resuscitate ◽  
Comfort Care ◽  
Goals Of Care ◽  
Code Status

Background: There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient’s wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions. Methods: Case report and discussion of the associated ethical issues. Results: We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team. Conclusion: It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.

Serum Magnesium Levels in Exacerbation of COPD: A Single Centre Prospective Study from Kashmir, India.

JMS SKIMS ◽  
2010 ◽  
Vol 13 (1) ◽  
pp. 15-19
Author(s):  
Bashir Ahmed Shah ◽  
Muzafar Ahmed Naik ◽  
Sajjad Rajab ◽  
Syed Muddasar ◽  
Ghulam Nabi Dhobi ◽  
...  
Keyword(s):  
Acute Exacerbation ◽  
Serum Magnesium ◽  
Stage Iii ◽  
Advanced Stage ◽  
Copd Exacerbation ◽  
Post Discharge ◽  
Duration Of Symptoms ◽  
Copd Patients ◽  
Exacerbation Of Copd ◽  
Time Of Admission

Objective: To study the significance of serum magnesium levels during COPD exacerbation and stability.Materials & Methods: The patient population consisted of all patients of COPD admitted as acute exacerbation as defined by the Anthonisens criteria, from June 2006 to may 2008. Same patients one month post discharge presenting to the OPD for routine check up as stable COPD served as controls. Results: A total number of 77 patients of COPD presenting as acute exacerbation were included in the study. The incidence of Hypomagnesaemia was 33.8% at admission; 5% at discharge and 4% at one month of post discharge in COPD patients. The mean serum magnesium levels were significantly lower in cases than controls (1.88±0.67mg/ dl V/S 2.3±0.36mg/dl; p<0.0001). Also, hypomagnesemia was present in higher number of cases (22/77, 33.8%) compared to controls, 3/75, 4.0%; (p<0.0001). Patients of COPD with acute exacerbation and hypomagnesemia, had longer duration of symptoms and had advanced stage III of COPD (p<0.001); and had raised mean corpuscle volume (p<0.045) and longer hospital stay (p<0.008).  Conclusion: We conclude COPD exacerbation is associated with hypomagnesemia. The duration of symptoms of more than 8 days, advanced stage of COPD (stage III) and raised MCV were associated with hypomagnesemia. We recommend to monitor serum magnesium levels in COPD patients with acute exacerbation at the time of admission and during their stay in the hospital.J Med Sci.2010;13(1);15-19

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.

scholarly journals Becoming a Carer for an Elderly Person after Discharge from an Acute Hospital Admission :

2004 ◽  
Author(s):  
Karen Grimmer ◽  
John Moss ◽  
Julie Falco
Keyword(s):  
Independent Living ◽  
Discharge Planning ◽  
Elderly Person ◽  
Community Setting ◽  
Community Services ◽  
Post Discharge ◽  
Acute Hospitals ◽  
Planning Processes ◽  
Discharge From Hospital ◽  
Patient Relationships

Objective: To describe the perceptions of people taking on a new or expanded caring role for an elderly patient recently hospitalised with a new or intensified health problem. Design: Observational study collecting qualitative data monthly for six months following patients’ discharge from hospital and attempted return to independent living in the community. Setting: Four South Australian acute hospitals (one metropolitan, three country). Subjects: 34 unpaid carers were nominated by 100 patients. 24 carers participated (17 elderly spouses, 3 younger family members, 4 neighbours and/ or friends). Results: The study highlighted carers’ perceptions of being unprepared for their new tasks, and their frustrations at the long-term and frequently significant changes to their lives brought about by assuming a caring role. Many carers felt their role had been imposed upon them without real choice, and that their own physical and emotional fitness for their new role had not been considered during discharge planning. Carers claimed to have been provided with little information about how to care for the patient, particularly when community services were seldom provided in the first week after discharge. Stresses developed in many of the carer-patient relationships, and patient and carer morale was often low for months post-discharge. Discussion: Carers indicated that their tasks could have been made easier by more timely, targeted education about their patient’s condition and their role in managing it. They would have liked greater inclusion in discharge planning processes whilst the patient was in hospital, and more timely and appropriate provision of post-discharge services that were patient- and carer-focused, and which addressed their ability to live independently in the community. Conclusion: Discharge planning systems should take greater account of the motivation and needs of carers, especially when this role is new or becoming expanded, and of the barriers they face in undertaking their role.

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