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Introduction: Orogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. Case Description/Methods: 71-year-old male presented with dyspnea, fever, chills, cough, and myalgia for 2 weeks. He had tachycardia, tachypnea, and was hypoxic to 66% in room air. He was found to have acute hypoxic respiratory failure secondary to COVID-19 Pneumonia and was admitted to ICU. But, he continued to be hypoxic and was started on BiPAP. He eventually became altered, and was intubated. Post intubation orogastric tube (OGT) placement was unsuccessful on the first attempt due to resistance. On the second attempt, the nurse was able to advance partially (Figure). But, a chest XR showed OGT in the mediastinum, and OGT was removed. CT of neck and chest revealed pneumomediastinum with possible mid-thoracic esophageal perforation. The patient was started on broad-spectrum antibiotics and thoracic surgery was consulted. Given his mechanical ventilation requirement, surgery deemed him unfit to tolerate thoracotomy and the endoscopic procedure was not available in the hospital. So, recommendation was to manage conservatively. His hospital course was complicated by hypotension requiring vasopressors and metabolic acidosis in setting of acute renal failure requiring CRRT. Code status was changed by the family to Do Not Resuscitate due to his deteriorating condition. Eventually, he had a PEA arrest and was expired. Discussion(s): OGT intubation is performed at hospitals for feeding, medication administration or gastric decompression. Although it is considered a safe procedure, complications can arise due to OGT misplacement or trauma caused by the OGT itself or the intubation process. OGT misplacement is typically endotracheal or intracranial. Misplacement within the upper GI lumen is usually detected by a kink in the oropharynx or esophagus. The subsequent complications are identified by the structure that is perforated (e.g., mediastinitis or pneumothorax). Regardless of whether counteraction is perceived, the physician must be careful not to apply excessive force. The location of the OGT tip should be determined by a chest radiograph;visualization of the tip below the diaphragm verifies appropriate placement. Complications of OGT insertion are uncommon;however, the consequences are potentially serious, and the anatomy of the upper GI tract should be understood by all who are involved in the care.
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Outcomes: 1. A better understanding of the benefits of embedded palliative care into a neuro surgery unit at a large academic hospital 2. An understanding of the financial impact related to embedding a palliative care APC into the neuro surgery unit at a large academic hospital Problem: Palliative care needs of patients admitted to neurology ICUs are often unmet. Patients with palliative care needs identified were more likely to die in an ICU setting or be transferred to the floor with comfort measures only. These patients were noted to have a longer length of stay. Because of the known benefits of palliative care, specifically, with this vulnerable population of patients, there was a desire to increase the palliative care presence on the neuro surgical service. Intervention(s): One APC palliative care position specific to the neuro ICU team was created. Responsibilities included symptom management, family support, medical decision making, managing conflicts over care goals, and disposition planning. Outcome(s): Outcomes included involvement in interdisciplinary rounds, increased donor opportunities, and increased billing by 28% in 2021. There was a 46% increase in palliative care consults from 2020 to 2021 and an increase in percentage of DNR/DNI orders obtained during admission from 2020 to 2021. An increase in deaths during hospitalization with active palliative care consults on comfort care was noted. Statistics were collected specific to mortality, ICU LOS, diagnosis, COVID status, social work involvement, as well as spiritual care involvement. Conclusion(s): Patients are seen earlier in their hospitalization and their medical wishes are now widely known and discussed by all interdisciplinary team members. The need for the involvement of the APC in these cases has only solidified with increased exposure to the palliative care team as consults increase. Patients are benefitting from the quality care being provided that now better aligns with their personal medical goals. Implications for nursing: There are many vulnerable patient populations for whom palliative care could be just as impactful;additional research should be completed to investigate further. Palliative care embedded on an ICU improves collaboration and increases exposure and understanding of the intent of palliative care.Copyright © 2023
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Outcomes: 1. Apply the knowledge about how the COVID-19 pandemic has impacted the care of patients with serious illness into daily practice. 2. Summarize current research findings in hospice and palliative care and describe its relevance to the care and treatment of patients with serious illness. Context: The urgency of the COVID-19 pandemic has brought forth an increased focus on palliative care involvement and advance care planning discussions around end-of-life preferences;however, few outcomes have been reported to date. The objective of this study was to compare characteristics of patients with advanced cancer during their terminal admission at a tertiary care comprehensive cancer center before and after the onset of the COVID-19 pandemic. Method(s): A random sample of 250 inpatient deaths from April 1, 2019 to July 31, 2019 was compared to a random sample of 250 inpatient deaths from April 1, 2020 to July 31. Sociodemographic and clinical characteristics, timing of palliative care referral, timing of DNR order, location of death, and pre-admission Out-of-Hospital DNR documentation were included. Result(s): Timing of DNR orders occurred earlier (2.9 days vs. 1.7 days prior to death, p=0.024), while the frequency of DNR orders before death did not change (94% vs. 90%, p=0.25). Palliative care referrals increased (68% vs. 60%, p=0.062) and occurred earlier (3.5 days vs. 2.5 days prior to death, p=0.037). Overall length of stay increased (9.4 days vs. 7 days, p=0.048). 36% of inpatient deaths occurred in ICU and 36% in the PCU, compared to 48% and 29% prior to the COVID-19 pandemic, respectively (p=0.01). Conclusion(s): DNR orders occurred significantly earlier after the onset of the COVID-19 pandemic, indicating a shift in early and intentional conversations with patients with advanced cancer at the time of their terminal admission. Earlier palliative care referrals and significantly fewer ICU deaths also suggest an improvement in quality end-of-life care. These findings highlight encouraging changes that have occurred as a response to the COVID-19 pandemic and may have future implications for timely integration of palliative care. Further research is needed to understand how to maintain and expand on such progress.Copyright © 2023
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Introduction The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form is widely adopted to document advanced care plans, including Do Not Attempt Resuscitation (DNACPR) decisions. Communication between clinicians and patients, or next of kin is required for completion. It is widely documented UK medical students have little exposure to these experiences, including being asked to leave whilst they are occurring. During the COVID19 pandemic, Foundation Year 1 (FY1) doctors led discussions with increased frequency and autonomy, with no documented concurrent training. We present a novel learning experience designed to aid these discussions. Students were timetabled to a 1.5 hour workshop, facilitated by a clinical teaching fellow. They were invited to complete ReSPECT form for a celebrity to familiarise themselves with the layout. They then considered a patient admission scenario in 3 different groups from the perspective of the patient, family and medical team, and used this to contemplate potential, future, emergency treatments. Subsequently a discussion surrounding CPR effectiveness, ways of communicating this, and legal advanced decision documents occurred. The session concludes with scrutinising example ReSPECT forms provided by the Resuscitation Council UK. Method Students' confidence levels were measured pre and post session using a Likhert scale questionnaire. Results 90 students attended workshops across 6 rotations. 80% students completed post - session questionnaires, of which 100% reported an increase in confidence with having a DNACPR/advanced care planning discussion compared to before the session. Conclusion DNACPR conversations can incite anxiety in any seniority of health care professionals. Medical educators need to adequately prepare medical students during their training in advanced care planning and DNACPR discussions. This can be done with simulated workshop experiences, reinforced with opportunistic or organised observational experience. Adequate preparation will lead to increased confidence in discussions, ultimately leading to better experiences for patients and their families.
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Use of patient/health proxy authorised do-not-resuscitate (DNR) or do-not-attempt-resuscitation (DNAR) orders is widespread in palliative, hospice and hospital-based chronic illness care. Such orders often reflect self-determination, avoidance of futile care and quality of dying principles. Reports during COVID-19 of physicians writing DNR/DNAR orders for people with intellectual disabilities at rates higher than the general population amplify past concerns about the value placed on their lives. Yet, absence of a DNR/DNAR or processes to permit one when someone cannot consent may result in painful and unnecessary prolongation of life. This chapter considers rationales for DNR/DNAR orders, use among people with intellectual disabilities, advance care planning, protocols when an individual is unable to consent and strategies for oversight of DNR/DNAR orders. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
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BACKGROUND: The impact of the COVID-19 pandemic on palliative care intervention (PCIs) in patients with do-not-resuscitate (DNR) status remains uncertain. METHODS: Case-control study of patients with DNR order with RT-PCR confirmed SARS-COV2 infection (cases), and those with DNR order but without SARS-COV2 infection (controls). The primary outcome measures included timing and delivery of PCIs, and secondary measures included pre-admission characteristics and in-hospital death. RESULTS: The ethnicity distribution was comparable between 69 cases and 138 controls, including Black/African Americans (61% vs. 44%), Latino/Hispanics (16% vs. 26%) and White (9% vs. 20%) (trend-p = .54). Cases were employed more (17% vs. 6%, adjusted-p = .012), less frail (fit 47% vs. 21%; mildly frail 22% vs. 36%; frail 31% vs. 43%, trend-p = .018) and had fewer comorbidities than controls. Cases had higher chances of intensive care unit admission (HR 1.76 [95% CI: 1.03-3.02]) and intubation (53% vs. 30%, p = .002), lower chances to be seen by palliative care team (HR .46 [.30-.70]) and a longer time to palliative care visit than controls (ß per ln-day .67 [.00-1.34]). In the setting of no-visiting hospitals policy, we did not find significant increase in utilisation of video conferencing (22% vs. 13%) and religious services (12% vs. 12%) both in case and in controls. CONCLUSION: Do-not-resuscitate patients with COVID-19 had better general health and higher employment status than 'typical' DNR patients, but lower chances to be seen by the palliative care team. This study raises a question of the applicability of the current palliative care model in addressing the needs of DNR patients with COVID-19 during the pandemic.
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INTRODUCTION: Advanced age is frequently cited as a prognostic indicator in critically ill patients. This study aimed to assess the association between outcomes in three age subgroups of older adults with COVID 19 patients. METHOD(S): Retrospective analysis of 994 adult patients admitted to our hospital between March 2020 and February 2022 with COVID-19. Patients with ages on admission >= 65 years were included and classified as young-old (65- 74 years), middle old (75-84 years), and oldest old (>= 85 years). Primary endpoints were survival, hospital length of stay (LOS), and need for mechanical ventilation. Secondary assessments included code status, ICHIKADO score, and the highest value of IL-6. Descriptive statistics, Pearson Chisquare, and Mann-Whitney-U methods were used. A p value <= 0.05 was considered statistically significant. RESULT(S): 293 patients with age on admission >= 65 years were included in this analysis. 183 (68.5%) were young old patients, 81(27.6%) middle old patients, and 29(9.9%) oldest old patients. The median age for non-survivors was 73[69- 78.2] years vs 72[68-78] years for survivors. 56(30.6%) patients from young old group died, 28 (34.6%) died in middle old group and 10(34.5%) in the oldest old (X2(2) =0.491, p=0.78). 22(12%) of the young old group were do not resuscitate (DNR), 11(13.6%) in the middle old group, and 7(24%) in the oldest old group(X2(2) =3.118, p=0.21). LOS for young old patients was 9[4-15] days, 10[5-16] days for middle old, and 8[5-13] days for oldest-old (H(2)=1.070 p=0.58). A total of 25(13.7%) young old patients required mechanical ventilation, 11(13.6%) middle old patients and 5(17.2%) oldest old patients (X2(2) =0.282, p= 0.86). ICHIKADO score was 160[121-200] in the young old group, 150 [110-230] in the middle old and 145[119.2-176.2] in the oldest old group (H(2) =1.426,p= 0.49). Regarding inflammatory markers, IL-6 wasn't different between the groups. In the young old IL-6 was 40.9[8.9-176.5]pg/ mL, 74.45[12-374.3]pg/mL in the middle old and 51.85 [14.25-812.2]pg/mL in the oldest old group (H(2) =3.336, p=0.189). CONCLUSION(S): Oldest old patients were not found to have increased IL6, worse computed tomography findings, increased risk of death, length of stay, or need for mechanical ventilation than their younger counterparts.
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Background. Adults aged >=65 years and those with underlying medical conditions, including residents of long-term care facilities (LTCF), are at increased risk for COVID-19-associated hospitalizations and other severe outcomes. Methods. Hospitalizations among LTCF residents aged >= 65 years from March 2020-January 2022 were described using data on a representative sample of hospitalizations from the CDC's COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), a population-based surveillance network of > 250 acute care hospitals in 99 counties across 14 states. A Poisson regression model adjusting for age, race/ethnicity, underlying medical conditions, vaccination status, month of admission, and do-not-resuscitate/intubate-or-provide comfort-measures-only (DNR/DNI/CMO) code status examined the relationship of LTCF residency to death during COVID-19-associated hospitalization. Results. Of 11,901 hospitalizations among adults aged >= 65 years reported during the study period, 2,965 (24.9%) were LTCF residents;most resided in nursing homes (53.8%) or assisted living facilities (26.8%). LTCF residents hospitalized with COVID-19 were older and more likely to have cardiovascular disease, congestive heart failure, a neurologic condition, dementia, or >= 3 underlying medical conditions than non-residents (Figure). The proportion of LTCF residents vs non-residents who required intensive care unit admission or invasive mechanical ventilation were not statistically different (23.2% vs 23.5% and 10.7 vs 13.5%, respectively). The proportion of in-hospital death was higher among LTCF residents than non-residents (22.8% vs 14.4%, p < 0.01). More LTCF residents have a DNR/DNI/CMO code status (48%) compared to non-residents (19%). The fully adjusted regression model found the risk ratio for death was 1.03 (95% CI, 1.01-1.05) among LTCF residents compared to non-residents. Conclusion. Compared to non-residents, LTCF residents were older, had more underly ingconditions, and had a higher risk of in-hospital death. After adjusting formultiple potential confounders, results suggest that LTCF residency is a weak but significant independent risk factor for death during COVID-19-associated hospitalization.
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Use of patient/health proxy authorised do-not-resuscitate (DNR) or do-not-attempt-resuscitation (DNAR) orders is widespread in palliative, hospice and hospital-based chronic illness care. Such orders often reflect self-determination, avoidance of futile care and quality of dying principles. Reports during COVID-19 of physicians writing DNR/DNAR orders for people with intellectual disabilities at rates higher than the general population amplify past concerns about the value placed on their lives. Yet, absence of a DNR/DNAR or processes to permit one when someone cannot consent may result in painful and unnecessary prolongation of life. This chapter considers rationales for DNR/DNAR orders, use among people with intellectual disabilities, advance care planning, protocols when an individual is unable to consent and strategies for oversight of DNR/DNAR orders. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
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Background: Multidisciplinary care has been shown to improve life expectancy and quality of life in patients with ALS (pALS) and is the cornerstone of pALS management. During the COVID 19 pandemic public safety precautions patients on noninvasive ventilation (NIV) and invasive ventilation were not seen in person due to hospital-wide infectious disease guidelines. Additionally, only one caregiver was permitted with each pALS during multidisciplinary clinic appointments. Objective(s): To facilitate the adoption of video-based telemedicine for discussion of goals of care in advanced ALS. Method(s): During the COVID 19 pandemic period ranging from 3/15/2020 to 5/10/2022, pALS enrolled in the VCU Health ALS clinic participated in in-person clinic visits as well as videobased telemedicine visits with the multi-disciplinary team. The pALS on NIV and invasive ventilation were seen, per VCU ALS clinic protocols, every 1-2 months by home care respiratory therapists (RT). The home care RT protocols alerted the team to a pALS vital capacity approaching 30% of normal. This triggered a goals of care discussion with the patient, family members, and caregivers. The neurologist, nurse navigator, respiratory therapist, and social worker discussed the two options for goals of care at this point in the disease process. One option involved discussion of all aspects of choosing a scheduled tracheostomy and long-term 24-hour care requirements for pALS by their caregivers. The second goals of care option presented to pALS was palliative care to manage symptoms and hospice at home. Telemedicine also enabled pALS to DocuSign Durable Do Not Resuscitate forms that were reviewed by the hospital attorney and placed in the electronic medical record. Out of the 53 patients who died during this time frame, 33 had the goals of care discussion via telemedicine. In-person discussions took place with 7 pALS. One pALS committed suicide 2 months after diagnosis and 2 pALS were lost to follow up. Ten pALS had no documented goals of care discussion prior to their death, per chart review. Two pALS, one via telemedicine and one in person, chose tracheostomy after the goals of care discussion. Conclusion(s): More patients had goals of care discussion via telemedicine (62%) than in person (13.2%) suggesting that video technology telemedicine with the multi-disciplinary team helped establish relationships with the team members and facilitated rapid access to the team for pALS. Telemedicine allowed the multi-disciplinary team to discuss at length with pALS and all their family members goals of care when pre-specified clinical end points of their disease were reached. Telemedicine was adopted by our clinic for discussion of withdrawal of invasive ventilator support on one patient who had been ventilated for several years. Further studies would be beneficial to gauge patient and caregiver satisfaction with goals of care discussion via telemedicine appointments.
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Background: Practices of Do-Not-Resuscitate (DNR) orders show discrepancies worldwide, but there are only few such studies from Saudi Arabia. Objective: To describe the practice of DNR orders in a Saudi Arabian tertiary care ICU. Methods: This retrospective study included all patients who died with a DNR order at the ICU of King Saud Medical City, Riyadh, Saudi Arabia, between January 1 to December 31, 2021. The percentage of early DNR (i.e., ≤48 hours of ICU admission) and late DNR (>48 hours) orders were determined and the variables between the two groups were compared. The determinants of late DNR were also investigated. Results: A total of 723 cases met the inclusion criteria, representing 14.9% of all ICU discharges and 63% of all ICU deaths during the study period. The late DNR group comprised the majority of the cases (78.3%), and included significantly more patients with acute respiratory distress syndrome (ARDS), community acquired pneumonia (CAP), acute kidney injury, and COVID-19, and significantly fewer cases of readmissions and malignancies. Septic shock lowered the odds of a late DNR (OR = 0.4, 95% CI: 0.2-0.9;P= 0.02), while ARDS (OR = 3.3, 95% CI: 2-5.4;P < 0.001), ischemic stroke (OR = 2.5, 95% CI: 1.1-5.4;P= 0.02), and CAP (OR = 2, 95% CI: 1.3-3.1;P= 0.003) increased the odds of a late DNR. Conclusion: There was a higher frequency of late DNR orders in our study compared to those reported in several studies worldwide. Cases with potential for a favorable outcome were more likely to have a late DNR order, while those with expected poorer outcomes were more likely to have an early DNR order. The discrepancies highlight the need for clearer guidelines to achieve consistency.
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SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Hypercoagulability is a well-known complication of COVID-19, with the most common vascular events being pulmonary embolism and deep vein thrombosis (1). Arterial thrombotic events, specifically aortic thrombosis, are rarely observed in COVID-19 infections. Literature review reveals less than 10 cases of aortic thrombosis have been reported in patients with COVID-19 infection. Here, we report a unique case of acute aortic thrombosis despite administration of therapeutic anticoagulation. CASE PRESENTATION: A 77 y.o. female with no known medical history presented to the hospital after a diagnosis of COVID-19 five days prior. Upon arrival, she was hypoxic requiring supplemental oxygen via non-rebreather (NRB) mask. CT chest with contrast revealed bilateral ground-glass opacities without evidence of pulmonary embolism or aortic thrombus. She was treated with remdesivir, dexamethasone, baricitinib and enoxaparin 40mg BID (essentially therapeutic dosing based on patient's body weight of 45kg). Adequate oxygenation was maintained with nasal cannula and NRB. However, on day eight of admission she was noted to desaturate to 80% requiring BiPAP. D-dimer and CRP drastically increased from 0.36ug/ml to 1.75ug/ml and 13.0 to 102.2, respectively. Repeat CT chest with contrast revealed multiple intraluminal thrombi in the distal thoracic aorta. Treatment with clopidogrel was initiated, however patient remained BiPAP dependent. Due to DNR/DNI status, intubation was not pursued. Ultimately, patient was transitioned to comfort care and expired. DISCUSSION: Thrombotic events are poorly understood but remain a well-documented sequela of COVID-19 infection. The pathophysiology of thrombosis in COVID-19 patients has not been fully elucidated, however, it likely involves amplification of the hypercoagulable state due to viral infection. Some of the proposed theories regarding this effect include endothelial dysfunction secondary to direct virus invasion and immuno-thrombosis due to viral mediated endothelial inflammation with resultant platelet activation (2,3). Regarding COVID-19 associated arterial thrombi, myocardial infarction and stroke are the most commonly encountered events. The few reported cases of aortic thrombi occurred almost exclusively in males with significant cardiovascular risk factors and not on anticoagulation (1,3). CONCLUSIONS: Due to the increased risk of venous thromboembolic events, prophylaxis is routinely used in patients with COVID-19. However, in our case, the patient developed multiple aortic thrombi without any typical risk factors for endothelial lesions despite being fully anticoagulated. This case highlights the need for continued research and trials related to appropriate anticoagulation therapies in hospitalized patients with COVID-19. Additionally, physicians should be aware of potential arterial thrombi in patients infected with COVID-19. Reference #1: de Carranza M, Salazar DE, Troya J, et al. Aortic thrombus in patients with severe COVID-19: review of three cases. J Thromb Thrombolysis. 2021;51(1):237-242. doi:10.1007/s11239-020-02219-z Reference #2: Loo J, Spittle DA, Newnham MCOVID-19, immunothrombosis and venous thromboembolism: biological mechanismsThorax 2021;76:412-420. doi:10.1136/ thoraxjnl-2020-216243 Reference #3: Woehl B, Lawson B, Jambert L, Tousch J, Ghassani A, Hamade A. 4 Cases of Aortic Thrombosis in Patients With COVID-19. JACC Case Rep. 2020;2(9):1397-1401. doi:10.1016/j.jaccas.2020.06.003 DISCLOSURES: No relevant relationships by Chelsey Bertrand- Hemmings No relevant relationships by Alyssa Foster No relevant relationships by Kyle Foster No relevant relationships by Yelena Galumyan No relevant relationships by Veronica Jacome No relevant relationships by Viet Nguyen
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Background Do not attempt cardiopulmonary resuscitation (DNACPR) discussions and decisions are an important part of person-centred care. Compassionate discussion with patients is a legal requirement when clinicians are introducing DNACPR forms. A recent Care Quality Commission report emphasised that all decisions should be individualised and part of broader advance care planning (Care Quality Commission, 2021). Aim The aims of this audit were to evaluate the timing of DNACPR discussions, to explore whether conversations regarding DNACPR were documented and whether DNACPR discussions were part of wider advance care planning. The standards for the audit were based on national Resuscitation Council guidance (2021), 'Deciding Right' regional document (Northern Cancer Alliance, 2015) alongside the Trust policy on resuscitation. Methods All patients with DNACPR forms initiated during an inpatient stay in November 2020 were identified from the Trust's database. A data collection tool was created to retrospectively collate information from the patient's electronic records. Results We identified 62 patients who had a DNACPR initiated in November 2020. The results were overall very positive;a discussion with the patient, or where necessary with a relative, took place in all patients where electronic notes were accessible. Six (10%) DNACPR forms were initiated at the time of deterioration and 39 (63%) were as part of a conversation incorporating elements of advance care planning, with more thorough advance care planning conversations occurring in six patients (10%). Almost 30% of patients audited were positive for COVID-19 infection. Where CPR was felt to be of no clinical benefit, COVID-19 infection was rarely (2% of patients) the named medical condition documented in the DNACPR. Conclusions Documentation regarding the timing of DNACPR decisions and DNACPR discussions was of a high standard, despite increased pressures during the COVID-19 pandemic. Advance care planning discussions occurred, however, further analysis would be necessary to fully evaluate the quality of these discussions.
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Background: Many hospitals have established goals-of-care (GOC) programs in response to the COVID- 19 pandemic;however, few have reported their outcomes. MD Anderson Cancer Center launched a multicomponent interdisciplinary GOC (myGOC) program in March 2020 that involved risk stratification, team huddles to discuss care planning, oncologist-initiated GOC discussions, communication training, palliative care involvement, rapid-response GOC team deployment, and daily monitoring with immediate feedback. We examined the impact of this myGOC program among medical inpatients. Methods: This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at MD Anderson Cancer Center, Texas during an 8-month pre-implementation (May 1, 2019 to December 31, 2019) and post-implementation period (May 1, 2020 to December 31, 2020). The primary outcome was intensive care unit (ICU) mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of patients with inhospital do-not-resuscitate (DNR) orders, medical power of attorney (MPOA), living will (LW) and outof- hospital DNR (OOHDNR). Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment (SOFA) Score. With a sample size of 600 ICU patients over each time period and a baseline ICU mortality of 28%, we had 80% power to detect a 5% reduction in mortality using a two-tailed test at 5% significance level. Results: This study involved 12,941 hospitalized patients with cancer (Pre n = 6,977;Post n = 5,964) including 1365 ICU admissions (Pre n = 727;Post n = 638). After myGOC initiation, we observed a significant reduction in ICU mortality (28.2% vs. 21.9%;change -6.3%, 95% CI -9.6, -3.1;P = 0.0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI -2.0, -0.7 days;P < 0.0001) and in-hospital mortality (7% vs. 6.1%, mean change -0.9%, 95% CI -1.5%, -0.3%;P = 0.004). The proportion of hospitalized patients with an inhospital DNR order increased significantly from 14.7% to 19.6% after implementation (odds ratio [OR] 1.4, 95% CI 1.3, 1.5;P < 0.0001) and DNR was established earlier (mean difference -3.0 d, 95% CI -3.9 d, -2.1 d;P < 0.0001). OOHDNR (OR 1.3, 95% CI 1.1, 1.6, P < 0.0007) also increased post-implementation but not MPOA and LW. MPOA, LW and OOHDNR were documented significantly earlier relative to the index hospitalization in the post-implementation period (P < 0.005 for all). Conclusions: This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent GOC intervention. Our findings may have implications for GOC programs during the pandemic and beyond.
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Background Anticipated severe illness at the start of the COVID-19 pandemic bought increased endorsement, awareness and provision of advance care planning in adults with serious illness. Place of death is often considered a surrogate quality indicator for end-of-life care. Aim To examine the impact of advance care planning on place of death for patients who died during the COVID-19 pandemic with a Coordinate My Care (CMC) record, the Electronic Palliative Care Coordination System currently commissioned in London. Methods Retrospective non-interventional cohort analysis of CMC records for patients aged over 18 who died between 20/03/20 and 05/03/21 with recorded place of death. Patient demographics, socio-economic position and advance care planning related factors associated with achieving preferred place of death were explored using logistic regression. Results 11,913 records were included. 76.9% patients died in their preference place of death (57.7% Home, 31.4% Care Home, 7.5% Hospice, 3.3% Hospital, 0.1% Other). A higher likelihood of dying in the preferred place was associated with a 'Not for resuscitation' (DNACPR) status (OR=1.55, 95% CI 1.23 to 1.95), a Ceiling of Treatment for 'Symptomatic Treatment' (when compared to 'Full active treatment', OR=3.55, 95% CI 2.78 to 4.53), discussions with family regarding resuscitation recommendations (OR=1.53, 95% CI 1.34 to 1.74) and at least 2 non-urgent care record views in the 30days before death (OR=1.27, 95% CI 1.23 to 1.43). Patients from areas of lower socio-economic position had a decreased likelihood of dying in their preferred place (OR= 0.65, 95% CI 0.54 to 0.79). Conclusion Components of Advance care planning carry potential to significantly influence place of death, even in times of crisis and when controlling for socio-economic and demographic determinants. Effective advance care planning is fundamental to achieving patient-centred, high-quality end-oflife care and factors relating to it must be considered in ongoing research on end-of-life outcomes.
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Background DNACPR decisions must be discussed with patients and, where patients lack capacity to be involved in DNACPR decision-making, with a legal proxy or next of kin. COVID-19 posed several challenges to DNACPR decisionmaking and communication including rapid, untimely clinical deteriorations and the prohibition of visitation in care homes. Simultaneously, there were concerning reports of blanket DNACPR orders being placed on care home residents. The Department of Health and Social Care (DHSC) issued guidance during the pandemic around remote capacity assessments. Aims This project reviewed practice around remote capacity assessments and communication around DNACPR decisions in care home residents in 2020. Methods Secondary analysis of data from a trust-wide audit was performed. 30 DNACPR forms from 2020 were randomly selected from Salford Care Homes Medical Practice. Results Capacity assessments were undertaken in line with DHSC guidance in all notes reviewed. Clinicians considered previous capacity assessments, remote assessments via iPad or telephone, and the views of care home staff, patients' relatives, legal proxy and IMCAs. 2 of 30 patients were deemed to have mental capacity. All DNACPR decisions were discussed with the patient, or where the patient lacked capacity, with the next of kin or legal proxy. Conclusion We identified good uptake of DHSC guidance around remote capacity assessments during 2020, however since undertaking this analysis, the MCA guidelines have been revoked. There is now no guidance to support clinicians should capacity assessments need to be undertaken remotely. There is an urgent need for policy makers to address this, due to the possibility of further outbreaks and the clinically vulnerable nature of the care home population.
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Introduction The urgency of the COVID-19 pandemic brought forth an increased emphasis on palliative care referrals and advance care planning discussions;however, few outcomes have been reported to date. The primary objective of this study was to compare the timing of DNR order for patients with advanced cancer during their terminal admission before and after the onset of the COVID-19 pandemic. Methods A random sample of 250 inpatient deaths from April 1, 2019 to July 31, 2019 was compared to another 250 inpatient deaths from April 1, 2020 to July 31, 2020. Clinical characteristics, timing and frequency of DNR orders, palliative care referral patterns, and location of death were included. Results Timing of DNR orders occurred earlier (2.9 days vs. 1.7 days prior to death, p=0.024), while the frequency of DNR orders before death did not change (94% vs 90%, p=0.25). Palliative care referrals increased (68% vs. 60%, p=0.062) and occurred earlier (3.5 days vs. 2.5 days prior to death, p=0.037). Overall length of stay increased (9.4 days vs. 7 days, p=0.048). Significantly fewer deaths occurred in the ICU (36% vs. 48%) and more deaths occurred in the Palliative Care Unit (36% vs. 29%). Conclusions During the COVID-19 pandemic, we observed a trend of earlier DNR orders, increased timely palliative care referrals, and fewer ICU deaths, indicating an improvement in quality end-of-life care. These findings may have implications for integration of palliative care. More research is needed to expand on such progress.
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Background and aims: We studied use of do not resuscitate (DNR) orders in the Brain Attack Surveillance in Corpus Christi (BASIC) study before and during the COVID-19 pandemic. Methods: All hospitalized stroke cases were ascertained in Nueces County, Texas, USA during an equal time period before the pandemic (January, 2019-Feb, 2020) and during the pandemic (March, 2020-April, 2021). We compared use of DNR orders before and during the pandemic using logistic regression adjusted for demographic and clinical variables including initial stroke severity (NIHSS score). Nueces County is geographically isolated making complete case capture likely. Cases were validated by stroke physicians using source documentation. Results: There were more cases during the pandemic (N=716) than pre-pandemic (N=681). Median NIHSS score was 5 (IQR 9) during the pandemic and 4 (IQR 9) pre-pandemic (p=0.03). During the pandemic 18.0% of stroke patients had DNR orders compared with 13.3% prepandemic (p=0.016). Other demographic and risk factors were similar in the two time periods. In models adjusted for age, sex, race-ethnicity, NIHSS score, diabetes, hypertension, current smoking and stroke history, DNR orders were not more common in the pandemic compared with pre-pandemic (p=0.2), but stroke severity (NIHSS score) remained significantly higher during the pandemic (p<0.01). Conclusions: In this population-based study, greater use of DNR orders were seen during the pandemic than before the pandemic. The greater use of DNR orders may be due, in part, to the worse stroke severity presenting to hospitals during the pandemic.
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Background/aims: At the beginning on the COVID-19 pandemic, advance care planning (ACP) was widely encouraged and endorsed for adults with serious illness to ensure their treatment and care preferences would be honoured, including location of death, often considered a surrogate quality indicator for end-of-life care. Coordinate My Care (CMC) represents the UK's largest Electronic Palliative Care Coordination System that comprises an ACP component. We aimed to examine the impact of ACP on place of death for people who died during the COVID-19 pandemic with a CMC record. Methods: Retrospective cohort analysis of CMC records for people aged over 18 who died between 20/03/20 and 05/03/21 with recorded place of death. Socio-demographic, clinical and ACP-related factors associated with achieving preferred place of death (PPD) were examined using logistic regression. Results: 11,913 records were included. 76.9% patients died in their preferred place location of death (57.7% Home, 31.4% Care Home, 7.5% Hospice, 3.3% Hospital, 0.1% Other). An increased likelihood of dying in PPD was associated with a 'Not for resuscitation' (DNACPR) status (OR=1.55, 95% CI 1.23 to 1.95), a Ceiling of Treatment for Symptomatic Treatment (when compared to Full active treatment, OR=3.55, 95% CI 2.78 to 4.53), documented family discussions regarding resuscitation recommendations (OR=1.53, 95% CI 1.34 to 1.74) and 2+ non-urgent care record views in the 30 days before death (OR=1.27, 95% CI 1.23 to 1.43). People from materially deprived areas had a decreased likelihood of dying in their PPD (OR= 0.65, 95% CI 0.54 to 0.79). Conclusions: Modifiable elements of ACP significantly influence place of death, even when controlling for socio-economic and demographic determinants. In times of crisis, effective ACP is central to delivering high quality end-of-life care;ACP related factors must be considered in ongoing research on end-of-life outcomes.
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Why you should read this article: • To understand the vulnerability of people with learning disabilities to coronavirus disease 2019 (COVID-19) • To find out about COVID-19-related deaths in patients with learning disabilities at one hospital • To enhance your awareness of the need to obtain more clinical awareness of the needs of the learning disability population There is evidence that people with learning disabilities are more vulnerable to coronavirus disease 2019 (COVID-19) than the general population, but there is a need to understand better how COVID-19 has affected that patient group. This article details a retrospective comparison study exploring the response of one acute hospital to COVID-19 in the learning disability population. A wide range of data were collected for the period between March 2020 and March 2021 about patients with learning disabilities, including admissions and deaths, do not attempt cardiopulmonary resuscitation (DNACPR) orders, ceilings of care and input from the learning disabilities acute liaison team. Data from the five years preceding the study were also collected. These data were compared with data about the general population, in the hospital and nationally. The data show that there had been no significant increase in the number of deaths of people with learning disabilities at the hospital during the first 13 months of the pandemic. However, this could be because fewer people attended hospital and more died in the community. Wider and more in-depth investigation is needed to understand the factors that may increase the risk of COVID-19-related death for people with learning disabilities. [ FROM AUTHOR] Copyright of Learning Disability Practice is the property of RNCi and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)