scholarly journals COVID-19 Palliative and End-of-Life Care Plan: Development and Audit of Outcomes

2021 ◽  
Vol 0 ◽  
pp. 1-9
Author(s):  
Seema Rajesh Rao ◽  
Krithika S. Rao ◽  
Pankaj Singhai ◽  
Mayank Gupta ◽  
Shwetapriya Rao ◽  
...  
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Symptom Management ◽  
End Of Life Care ◽  
Medical Advice ◽  
Care Plan ◽  
Resource Utilisation ◽  
Life Care ◽  
Health Resource ◽  
Life Sustaining Treatment

Objectives: Palliative care (PC) referral in serious and critical COVID-19 improves decision-making, health resource utilisation, end-of-life symptom management and family support. In this study, we explored developing a systematic decision-making matrix for PC referral in COVID-19 and audited its outcomes. Materials and Methods: A team of interdisciplinary experts developed a hospital COVID-19 PC plan. PC referral and outcomes of PC referral in hospitalised COVID-19 patients were audited. Results: Out of 1575 inpatients, 1066 (67.7%) had mild and 509 (32.3%) had serious and critical COVID-19 illness. Among 50 (3.1%) referred to PC, 5 (0.4%) had mild and 45 (8.8%) had serious and critical COVID-19 illness. Out of 45 serious and critical COVID-19 patients referred to PC, 38 (84%) received end-of-life care (EOLC), 4 (9%) self-discharged against medical advice and 3 (7%) recovered. Forty-seven (94%) were referred for goals-of-care discussion. About 78% received opioids, 70% benzodiazepines and 42% haloperidol for symptom management. Among 45 serious and critical COVID-19 patients referred to PC, foregoing life-sustaining treatment was documented in 43 (96%) but implemented only in 23 (53%). Out of 38 who received EOLC, ICU was the place of death in 31 (82%) and ward in 7 (18%). Conclusion: Despite interdisciplinary experts developing a hospital COVID-19 PC, low referral of serious and critical COVID-19 patients to PC was observed. PC referral enabled access to management of end-of-life symptoms and facilitated limitation of life-sustaining treatment in some COVID-19 patients with serious illness. Educating critical care physicians about the scope of PC in the COVID-19 setting might improve PC referral.

The pyramid of treatment levels: A tool to convey goal-based treatment options.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 147-147
Author(s):  
Heather Leeper ◽  
Andrew Kamell
Keyword(s):  
Decision Making ◽  
Medical Care ◽  
End Of Life ◽  
Symptom Management ◽  
End Of Life Care ◽  
Life Care ◽  
Care Providers ◽  
Goals Of Care ◽  
Code Status ◽  
Wide Range

147 Background: 60% of Americans die in acute care hospitals and under 40% of advanced cancer patients have end-of-life care discussions with their health care providers. Didactic methods and tools to teach about symptom management, navigation of treatment decisions, code status, and end-of-life care decisions within an inpatient setting are a necessity to meet this high demand. Methods: A model of medical care systematically dividing clinical management decisions into escalating levels of medical care relative to illness severity, treatment goals, and code status was created. The model is illustrated as a pyramid with a base of symptom management as the initial level of medical care. The second level represents disease-focused medical care including antibiotics, disease-modifying drugs, and chemotherapy administration. Hospitalization with increasingly complex and invasive interventions represents the third level followed by critical illness care including ICU admission and vasopressors as the fourth level. Intubation comprises the fifth level and CPR forms the top of the pyramid. Results: This model has been used extensively at our institution in educating medical students, residents, fellows, and faculty. All groups reported it was helpful in understanding POLST forms, code status, and collaboratively developing appropriate goal-based care plans with their patients. Symptom management remaining as a non-negotiable foundation of care emphasizes its importance. This depiction of medical care may facilitate goals of care and code status discussions and is particularly helpful for determining appropriate care goals or options when considering de-escalation of medical therapies. Used implicitly or explicitly in patient and family discussions, it has facilitated decision-making and discerning the appropriateness of the overall treatment plan relative to patient goals of care. Conclusions: This model of care with its companion pyramid accommodate a wide range of clinical scenarios, is an effective, high yield didactic device for patients, families, and healthcare providers alike, and has applications as supportive tool to optimize goal-based clinical decision making in the context of serious illness.

scholarly journals Complexity Analysis of Decision-Making in the Critically Ill

2016 ◽  
Vol 33 (10) ◽  
pp. 557-566 ◽  
Author(s):  
Barbara J. Daly ◽  
Sara L. Douglas ◽  
Elizabeth O’Toole ◽  
James Rowbottom ◽  
Alan Hoffer ◽  
...  
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Critically Ill ◽  
End Of Life Care ◽  
Treatment Effectiveness ◽  
Family Members ◽  
Cognitive Status ◽  
Care Plan ◽  
Life Care ◽  
Icu Discharge

Rationale: Despite multiple trials of interventions to improve end-of-life care of the critically ill, there is a persistent lack of understanding of factors associated with barriers to decision-making at the end of life. Objective: To apply the principles of complexity science in examining the extent to which transitions to end-of-life care can be predicted by physician, family, or patient characteristics; outcome expectations; and the evaluation of treatment effectiveness. Methods: A descriptive, longitudinal study was conducted in 3 adult intensive care units (ICUs). Two hundred sixty-four family surrogates of patients lacking decisional capacity and the physicians caring for the patients were interviewed every 5 days until ICU discharge or patient death. Measurements: Characteristics of patients, physicians, and family members; values and preferences of physicians and family; and evaluation of treatment effectiveness, expectations for patient outcomes, and relative priorities in treatment (comfort vs survival). The primary outcome, focus of care, was categorized as (1) maintaining a survival orientation (no treatment limitations), (2) transitioning to a stronger palliative focus (eg, some treatment limitations), or (3) transitioning to an explicit end-of-life, comfort-oriented care plan. Main Results: Physician expectations for survival and future cognitive status were the only variables consistently and significantly related to the focus of care. Neither physician or family evaluations of treatment effectiveness nor what was most important to physicians or family members was influential. Conclusion: Lack of influence of family and physician views, in comparison to the consistent effect of survival probabilities, suggests barriers to incorporation of individual values in treatment decisions.

Assessing Relationships Between Muslim Physicians’ Religiosity and End-of-Life Health-Care Attitudes and Treatment Recommendations: An Exploratory National Survey

2019 ◽  
Vol 36 (9) ◽  
pp. 780-788 ◽  
Author(s):  
Rosie Duivenbode ◽  
Stephen Hall ◽  
Aasim I. Padela
Keyword(s):  
Health Care ◽  
Decision Making ◽  
End Of Life ◽  
End Of Life Care ◽  
Religious Practice ◽  
Treatment Recommendations ◽  
Physician Attitudes ◽  
Life Care ◽  
Life Sustaining Treatment ◽  
Care Decision

Background: Research demonstrates that the attitudes of religious physicians toward end-of-life care treatment can differ substantially from their nonreligious colleagues. While there are various religious perspectives regarding treatment near the end of life, the attitudes of Muslim physicians in this area are largely unknown. Objective: This article attempts to fill in this gap by presenting American Muslim physician attitudes toward end-of-life care decision-making and by examining associations between physician religiosity and these attitudes. Methods: A randomized national sample of 626 Muslim physicians completed a mailed questionnaire assessing religiosity and end-of-life care attitudes. Religiosity, religious practice, and bioethics resource utilization were analyzed as predictors of quality-of-life considerations, attitudes regarding withholding and withdrawing life-sustaining treatment, and end-of-life treatment recommendations at the bivariate and multivariable level. Results: Two-hundred fifty-five (41% response rate) respondents completed surveys. Most physicians reported that religion was either very or the most important part of their life (89%). Physicians who reported consulting Islamic bioethics literature more often had higher odds of recommending active treatment over hospice care in an end-of-life case vignette. Physicians who were more religious had higher odds of viewing withdrawal of life-sustaining treatment more ethically and psychologically challenging than withholding it and had lower odds of agreeing that one should always comply with a competent patient’s request to withdraw life-sustaining treatment. Discussion: Religiosity appears to impact Muslim physician attitudes toward various aspects of end-of-life health-care decision-making. Greater research is needed to evaluate how this relationship manifests itself in patient care conversations and shared clinical decision-making in the hospital.

End-of-life care part 1: implications for paramedic practice

2020 ◽  
Vol 12 (9) ◽  
pp. 1-5 ◽  
Author(s):  
Helen Taylor ◽  
James Brogan
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
End Of Life Care ◽  
Mental Capacity ◽  
Life Care ◽  
Long Period ◽  
Life Sustaining Treatment ◽  
Advance Decisions ◽  
Unexpected Outcome ◽  
Dying Patient

Caring for patients who are approaching the end of life is an important part of the paramedic's role. Patients' circumstances are individual; for some, death is expected and may even a welcome (albeit sad) relief from a long period of pain and distress, while for others it is a tragic, unexpected outcome after every effort to prevent it has been exhausted. Regardless of circumstances, paramedics have to make wide-ranging clinical decisions, underpinned by a complex legal and regulatory framework. Paramedics generally have to obtain a patient's informed consent before proceeding with any intervention. They may be challenged if a dying patient refuses life-sustaining treatment or no longer has the mental capacity to consent and need to know the law on decision-making in these cases. This article discusses issues around capacity and consent at the end of life. The next article in this series considers issues such as advance decisions to refuse treatment and do not attempt CPR decisions.

scholarly journals Developing an applied model for making decisions towards the end of life about care for someone with dementia

PLoS ONE ◽  
2021 ◽  
Vol 16 (5) ◽  
pp. e0252464
Author(s):  
Nathan Davies ◽  
Tanisha De Souza ◽  
Greta Rait ◽  
Jessica Meehan ◽  
Elizabeth L. Sampson
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
End Of Life Care ◽  
Care Plan ◽  
Decision Making Process ◽  
Life Care ◽  
Family Carers ◽  
Modified Model ◽  
People With Dementia ◽  
Advance Care

Background Many people with dementia reach the end-of-life without an advance care plan. Many are not ready to have conversations about end-of-life, and decision-making is left to their families and professionals when they no longer have capacity. Carers may benefit from further support with decision-making. To develop this support, it is important to understand the decision-making process. Aim Explore with family carers and people living with dementia the decision-making process and factors that influence decision-making in dementia end of life care, to produce a model of decision-making in the context of dementia end-of-life care. Methods Semi-structured interviews with 21 family carers and 11 people with dementia in England (2018–2019) from memory clinics, general practice and carer organisations. Interviews were analysed using thematic analysis and findings were mapped onto the Interprofessional Shared Decision Making model, refined to produce a modified model of decision-making in dementia. Results Participants described five key decisions towards the end-of-life as examples of decision making. We used these experiences to produce a modified model of decision-making in dementia end-of-life-care. The model considers the contextual factors that influence the decision-making process, including: personal preferences; advance care planning and Lasting Power of Attorney; capacity and health and wellbeing of the person with dementia; support from others and clarity of roles. The decision-making process consists of seven inter-linked stages: 1) identifying the decision maker or team; 2) sharing and exchanging information; 3) clarifying values and preferences; 4) managing and considering emotions; 5) considering the feasibility of options; 6) balancing preferred choice and the actual choice; and 7) implementation and reflecting on outcomes. Conclusions The modified model breaks down the decision-making process and attempts to simplify the process while capturing the subtle nuances of decision making. It provides a framework for conversations and supporting decisions by carers.

scholarly journals Management of Heart Failure in Patients Nearing the End of Life–There is So Much More To Do

2015 ◽  
Vol 1 (1) ◽  
pp. 31
Author(s):  
Lisa LeMond ◽  
Sarah J Goodlin ◽  
◽  
Keyword(s):  
Heart Failure ◽  
Decision Making ◽  
End Of Life ◽  
Medical Therapy ◽  
Symptom Management ◽  
End Of Life Care ◽  
Life Care ◽  
Additive Process ◽  
Number Of Patients ◽  
Patients With Heart Failure

As the population of patients living with heart failure increases, the number of patients who will die with and from heart failure increases as well. End-of-life care in patients with heart failure is an additive process, whereby therapies to treat symptoms not alleviated by guideline-based medical therapy are integrated into the care of these individuals. This review focuses on providing clinicians with a basic framework for administration of end-of-life care in patients with heart failure, specifically focusing on decision-making, symptom management and functional management.

An Instrument to Assess Self-Perceived Competencies in End-of-Life Care for Health Care Professionals: The End-of-Life Care Questionnaire

2021 ◽  
pp. 104990912110057
Author(s):  
Marcos Montagnini ◽  
Heather M. Smith ◽  
Deborah M. Price ◽  
Linda Strodtman ◽  
Bidisha Ghosh
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Continuity Of Care ◽  
Emotional Support ◽  
Symptom Management ◽  
End Of Life Care ◽  
Spiritual Support ◽  
Life Care ◽  
Eol Care ◽  
Care Decision

Purpose: We describe the development and the psychometric properties of an instrument to assess self-perceived EOL care competencies for healthcare professionals: The End-of-Life Care Questionnaire (EOL-Q). Methods: The EOL-Q consists of 28 questions assessing knowledge, attitudes and behaviors with subscale items addressing seven domains of care: decision-making, communication, continuity of care, emotional support for patients/families, symptom management, spiritual support for patients/families, and support for clinicians. The EOL-Q was used to assess competencies of 1,197 healthcare professionals from multiple work units at a large medical center. Cronbach’s alpha coefficients were calculated for the survey and subscales. A factor analysis was also conducted. Results: Internal consistency reliability was for was high for the total scale (0.93) and for the subscales addressing knowledge, behaviors, decision-making, communication, emotional support and symptom management (0.84-0.92); and moderate (>0.68) for the attitudes and continuity of care subscales. The factor analysis demonstrated robust consolidation of the communication and continuity of care subscales (eigenvalue 9.47), decision-making subscale (eigenvalue 3.38), symptom management subscale (eigenvalue 1.51), and emotional and spiritual support subscales (eigenvalue 1.13). Conclusion: Analysis of the psychometric properties of the EOL-Q care across settings supports its reliability and validity as a measure of self-perceived EOL care competencies in the domains of communication and continuity of care, decision-making, symptom management, and emotional and spiritual support. The EOL-Q displays promise as a tool for use in a variety of educational, research, and program development initiatives in EOL care.

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