Documentation patterns on communicating prognosis to patients with terminal illness

Introduction@#Prognosis is an issue which most doctors and patients find difficult to discuss. Both patients and physicians find this process distressing as they can be unprepared to receive and give life-altering news. Although clinicians report that they are discussing prognosis, patients and caregivers frequently do not corroborate these reports, creating communication gaps especially in end-of-life situations.@*Objective@#This study determined how attending physicians documented the communication of prognosis on the patients’ records in terms of content, timing, and frequency during the course of hospitalization.@*Methods@#This is a retrospective chart review of 234 terminally-ill patients admitted from January 2020 to March 2020 in five (5) clinical departments of a public tertiary hospital. Discharge summaries and physicians’ daily chart notes were reviewed to identify the major events of each case.@*Results@#Two-thirds of the patients’ records had no documentation of any discussion with patient/family/significant others relating to patients’ worsening condition. The quantitative and qualitative forms of contextual information regarding patient prognosis were infrequently recorded. Notes on conversations of survival rate, probability of treatment response and failure were likewise lacking. However, for the occasional documentation observed, the timing of the communications was appropriate across the disease trajectory and was significantly correlated with all major points of illness deterioration (p<.001). Physician and patient characteristics had no association with the practice of documenting communication prognosis@*Conclusion@#Communication prognosis is not a common practice for most physicians. Prognosis was poorly documented on the patients’ charts, which could suggest that either such a communication process did not take place at all or physician education on documentation should be reinforced by an institutional protocol, especially in the care of terminally ill patients.

Diagnosis and management of acute Tonsillopharyngitis in family practice

Background@#Acute tonsillopharyngitis is a common reason for consult in the primary care setting. Although most cases are viral in etiology, more than half of patients with acute tonsillopharyngitis still receive antibiotic therapy for group A beta-hemolytic streptococcal infection. Streptococcal throat infection may lead uncommonly to suppurative complications like peritonsillar abscess and non-suppurative complications like acute rheumatic fever. It is with this consideration that streptococcal throat infection must be distinguished from viral infections. Clinical practice guidelines have focused their efforts on how it can be accurately diagnosed to prevent complications while reducing unnecessary antibiotic prescribing.@*Objective@#This clinical pathway was developed to serve as guidance for family and community medicine practitioners in making clinical decisions regarding the diagnosis and management of acute tonsillophrayngitis.@*Methods@#After defining the scope of the pathway, the PAFP Clinical Pathways Group first identified the key issues in managing patient with acute tonsillopharyngitis. These key issues were then translated to review question. The group then reviewed the published medical literature to identify, summarize, and operationalize the evidence in clinical publication. Databases were first searched for existing clinical practice guidelines from reputable medical organizations. Further search for evidence was also conducted using the terms “tonsillopharyngitis” or “tonsillitis”, “diagnosis” and “treatment”. Evidence was then summarized and its quality assessed using the modified GRADE approach. From the evidence-based summaries, the CPDG then developed general guideline and pathway recommendations which are stated as time-bound tasks of patient-care processes in the management of acute tonsillopharyngitis in family and community practice. The recommendations were then presented to a panel of family and community practitioners in both urban and rural settings, for a consensus agreement on the applicability of the recommendations to family and community practice. Lastly, the final clinical pathway was written and developed to include the recommendations, the clinical pathway tables, and an algorithm. The clinical pathway can be used as a checklist or standards of care. The algorithm can be used to explain the process of care to the patient.@*Recommendations@#This clinical pathway contains updates on recommendations in the 2010 clinical practice guidelines on acute tonsillopharyngitis. Recommendations on the utilization of clinical scoring and rapid antigen tests as basis for deciding on need for antibiotic therapy comprise the major changes from the previously published guidelines. Penicillin remains as the first-line antibiotic therapy for streptococcal throat infection.@*Implementation@#Implementation of the clinical pathway will be at the practice and the organizational levels. The pathway may be used as a checklist to guide family medicine specialists or general practitioners in individual clinic and community medicine practice. It may also be used as reference for exams by the training programs and the specialty board. In the commitment to achieve the goal of improving the effectiveness, efficiency and quality of patient care in family and community practice, the clinical pathway may also be implemented through quality improvement activities in the form of patient record reviews, audit and feedback. Audit standards will be the assessment and intervention recommendations in the clinical pathway. Organizational outcomes can be activities of the PAFP devoted to the promotion, development, dissemination and implementation of clinical pathways.

Clinical pathway for the management of uninvestigated Dyspepsia among adults in family and community practice: Updated 2021

Background@#Uninvestigated dyspepsia is a common complaint in family practice in the Philippines. Patients usually seek consult due to severity of symptoms which affect their quality of life. The goals of management are short- and long-term symptom control, with reversal of possible underlying mechanisms, achievable through a combination of pharmacologic and non-pharmacologic interventions.@*Objective@#The main objective of this pathway is to guide family physicians and primary care physicians in the assessment, diagnosis and management of adult patients with uninvestigated dyspepsia through a shared decision-making process.@*Method@#This clinical pathway is an update of the PAFP’s Clinical Pathways for the Management of Dyspepsia in Adults (2016). The current panel utilized the ADAPTE method and prioritized reviewing relevant clinical practice guidelines from 2017 to present. Grading of recommendation was achieved through a mixture of strength of available evidence and a consensus from a panel of experts.@*Summary of Recommendations@#The main changes in the recommendations in this update are as follows: symptom-based classification of dyspepsia, screening for anxiety and depression, family and SCREEM assessment; initiation of therapeutic trial for most patients to whom H. pylori testing is not available; extension of initial PPI treatment to 4-8 weeks, consideration of antacids/alginates for immediate symptom relief, consideration of tricyclic antidepressants for non-responders to initial treatment; symptom-based non-pharmacologic advice, consideration of counseling and other psychosocial interventions; empowerment for self-treatment and as-needed therapy for those who have completed the initial treatment regimen@*Dissemination and Implementation@#This guideline shall be disseminated and implemented at the clinic and organizational level. It will be published in the “The Filipino Family Physician” journal, social media platforms and will be disseminated through PAFP local chapters, training institutions and during the national convention. Non-FCM primary care physicians will also be reached through relevant agencies. It shall be included in the references required during training activities and national exams of accredited training institutions, in coordination with the PAFP committee on Residency Training. It shall be incorporated in checklists for compliance in audits and QA cycles, with support from the PAFP committee on Quality Assurance and that on Standards for Family Practice. Feedback on utility and applicability will be actively sought from the intended users and other stakeholders.

Effectiveness of non-pharmacologic strategies for parental smoking cessation to protect children: A meta-analytic review

@#<p style="text-align: justify;"><strong>Aims:</strong> This meta-analysis aims to synthesize available evidence from published studies on the effectiveness of parental non-pharmacologic smoking cessation programs which aim to reduce children's exposure to secondhand smoke.</p><p style="text-align: justify;"><strong>Methodology:</strong> A database search using The Cochrane Library, PubMed®, Medline, Embase, and Google Scholar, was done by the investigators. This study included 20 randomized controlled trials published up to 2020. Pooled estimates of risk ratio (RR) for quit rates were computed using the random effects model.</p><p style="text-align: justify;"><strong>Results:</strong> Overall, the quit rate among those who underwent parental smoking cessation was 13.4% while the quit rate for controls was 11.9%. The pooled RR demonstrated that the parental smoking cessation program was significantly associated with higher quit rates (RR = 1.22, 95%CI = 1.01 to 1.46, p-value = 0.04). The studies demonstrated moderate heterogeneity only (I2 = 54%). Among studies published prior to year 2000, no significant difference was observed between parental smoking cessation program and control (RR = 1.02, 95% CI = 0.62 to 1.70, p-value = 0.93). On the other hand, the pooled RR demonstrated that among studies published after 2020, parental smoking cessation program was significantly associated with higher quit rates (RR = 1.27, 95%CI = 1.03 to 1.56, p-value <0.0001). Among studies with self-help interventions, parental smoking cessation program has no additional benefit on quit rates (RR = 1.20, 95%CI = 0.94 to 1.58, p-value = 0.14). Among studies with biofeedback intervention also, no significant difference was observed (RR = 1.27, 95% CI = 0.86 to 1.89, p-value = 0.23).</p><p style="text-align: justify;"><strong>Conclusions:</strong> This meta-analysis demonstrated sufficient evidence that non-pharmacologic interventions for parental smoking cessation are effective.</p>

Can quality of life be better for older adults receiving home health care?

Background@#Home health care is a system of clinical care provided by skilled practitioners to patients in their homes. These visitations have positive effect on health, quality of life (QOL) and promote independence among elderly@*Objective@#This study aimed to evaluate the Quality of Life (QOL) of geriatric patients rendered home health care and ambulatory care in community-based clinic@*Subjects and Setting@#Older adults from an urban-based barangay in Metro Manila who received medical care from Family Medicine residents and post graduate interns at home and in the community-based clinic.@*Methods@#This cross-sectional study with ex post facto design used purposive sampling. The following tools were administered: WHOQOL-BREF FIL OP, validated for Filipino elderly to measure QOL; Katz’s Index Activities of Daily Living (ADLs) and Lawton’s Instrumental ADLs to determine the functional status. Descriptive statistics were used to summarize all data. Mann–Whitney U test and Pearson’s correlation coefficient were employed@*Results@#A total of 29 patients were recruited. A comparison of QOL between outpatient (n=16) and home health care (n=13) showed that all domains: physical, psychosocial, social and environmental of home-visited patients had higher mean scores compared to ambulatory care patients. However, the difference was not statistically different. QOL was higher in the home care patients (mean 3.3125) versus the ambulatory care patients (mean 3.0000). Same trend was seen in perceived general health.@*Conclusion@#Home health patients still had higher mean scores in all domains of QOL than those who seek in outpatient care. They had better scores in perceived overall QOL and general health. These findings though statistically not significant suggest possible benefits of home care and its potential to improve the quality of life of older adults. Inclusion of QOL measures could allow for comprehensive evaluation of outcomes of treatment and home care services provided.

Identifying cases of violence against women and children: An essential skill set in family medicine

@#<p style="text-align: justify;"><strong>INTRODUCTION:</strong> Child abuse, sexual and domestic violence are among the most destructive experiences afflicting women and children that result to physical, behavioral, psychological and economic consequences. Physicians in the front line need to be sensitive and vigilant in identifying both overt and subtle signs of these violations. As such, identification of victims is vital to prevent further abuse and injury, as well as to manage the patient holistically.<br /><strong>OBJECTIVE:</strong> To assess the skill of Family Medicine (FM) residents in detecting cases of violence against women and children (VAWC).<br /><strong>METHODS:</strong> Eight case scenarios were presented to 48 resident trainees from government and private hospitals in Metro Manila. They were tasked to identify cases pertaining to VAWC, and distinguish the case type.<br /><strong>RESULTS:</strong> Red flags that were easily detected by more than 80% of trainees were cases of physical abuse towards men, and neglect. Circumstances with moderate challenge were sexual harassment, rape, and abandonment, in that order. On the other hand, respondents had inadequacy in detecting cases of sexual abuse and physical abuse towards children; while the most difficult to recognize was emotional abuse.<br /><strong>CONCLUSION:</strong> Acquisition of this new skill set may prove beneficial in providing the ideal environment for proper management and support provision for the VAWC subjects. Lack of knowledge and training in this rising societal and health threat may cause underdiagnosis of common VAWC presentations. Consequently, this leads to failure of identification, assessment, documentation, and management of such patients.</p>