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1.
Int J Environ Res Public Health ; 19(22)2022 Nov 15.
Article in English | MEDLINE | ID: covidwho-2116144

ABSTRACT

Due to the global COVID-19 pandemic, a concomitant increase in awareness for end-of-life decisions (EOLDs) and advance care planning has been noted. Whether the dynamic pandemic situation impacted EOLD-processes on the intensive care unit (ICU) and patient-sided advance care planning in Germany is unknown. This is a retrospective analysis of all deceased patients of surgical ICUs of a university medical center from March 2020 to July 2021. All included ICUs had established standardized protocols and documentation for EOLD-related aspects of ICU therapy. The frequency of EOLDs and advance directives and the process of EOLDs were analyzed (No. of ethical approval EA2/308/20). A total number of 319 (85.5%) of all deceased patients received an EOLD. Advance directives were possessed by 83 (22.3%) of the patients and a precautionary power of attorney by 92 (24.7%) of the patients. There was no difference in the frequency of EOLDs and patient-sided advance care planning between patients with COVID-19 and non-COVID-19 patients. In addition, no differences in frequencies of do-not-resuscitate orders, withholding or withdrawing of intensive care medicine therapeutic approaches, timing of EOLDs, and participation of senior ICU attendings in EOLDs were noted between patients with COVID-19 and non-COVID-19 patients. Documentation of family conferences occurred more often in deceased patients with COVID-19 compared to non-COVID-19 patients (COVID-19: 80.0% vs. non-COVID-19: 56.8, p = 0.001). Frequency of EOLDs and completion rates of advance directives remained unchanged during the pandemic compared to pre-pandemic years. The EOLD process did not differ between patients with COVID-19 and non-COVID-19 patients. Institutional standard procedures might contribute to support the robustness of EOLD-making processes during unprecedented medical emergencies, such as new pandemic diseases.


Subject(s)
COVID-19 , Terminal Care , Humans , Pandemics , Retrospective Studies , Decision Making , COVID-19/epidemiology , Intensive Care Units
2.
Adv Anesth ; 40(1): 1-14, 2022 Dec.
Article in English | MEDLINE | ID: covidwho-2094920

ABSTRACT

Anesthesiologists receive extensive training in the area of perioperative care and the specialized skills required to maintain life during surgery and complex procedures. Integrated into almost every facet of contemporary medicine, they interact with patients at multiple stages of their health care journeys. While traditionally thought of as the doctors best equipped to save lives, they may also be some of the best doctors to help navigate the chapters at the end of life. Successfully navigating end-of-life care, particularly in the COVID-19 era, is a complicated task. Competing ethical principles of autonomy and nonmaleficence may often be encountered as sophisticated medical technologies offer the promise of extending life longer than ever before seen. From encouraging patients to actively engage in advance care planning, normalizing the conversations around the end of life, employing our skills to relieve pain and suffering associated with dying, and using our empathy and communication skills to also care for the families of dying patients, there are many ways for the anesthesiologist to elevate the care provided at the end of life. The aim of this article is to review the existing literature on the role of the anesthesiologist in end-of-life care, as well as to encourage future development of our specialty in this area.


Subject(s)
Advance Care Planning , COVID-19 , Terminal Care , Humans , Anesthesiologists , Terminal Care/methods , Death
3.
Int J Environ Res Public Health ; 19(19)2022 Oct 10.
Article in English | MEDLINE | ID: covidwho-2066091

ABSTRACT

In the midst of COVID-19, radical change in the work environment further exacerbated the detrimental effects of critical illness in the intensive care unit (ICU). This may be heightened if the patient experiences a lamentable end-of-life experience due to inadequate end-of-life care (EoLC). Anchoring on the theory of bureaucratic caring and the peaceful end-of-life theory, insights can be gained into the motivations and behaviors that support the delivery of palliative care during COVID-19. With this having been having said, the objective of this study was to use a narrative approach to examine the lived experience of 12 nurses who provided EoLC in the COVID-19 ward of several hospitals in the Western Philippines. Participants' narratives were transcribed, translated and analyzed. Among the themes that have emerged are: establishing a peaceful journey to death, holistic caring for the end of life, venturing into risky encounters in the call of duty, staying close amidst the reshaped work environment, and preparing the family life after a loved one's departure. The study identified the importance of assisting patients on their journey to a peaceful death, but this journey was also accompanied by a sense of self-preservation and safety for colleagues and families.


Subject(s)
COVID-19 , Terminal Care , Humans , Intensive Care Units , Palliative Care , Philippines , Qualitative Research
4.
Int J Environ Res Public Health ; 19(19)2022 Sep 28.
Article in English | MEDLINE | ID: covidwho-2065957

ABSTRACT

During the COVID-19 pandemic, the care of critically ill and dying patients in isolation wards, intensive care units (ICUs), and regular wards was severely impaired. In order to support physicians in communicative and palliative care skills, an e-learning tool was developed as part of the joint project "Palliative Care in Pandemic Times" (PallPan). This study investigates the feasibility of this e-learning tool. Secondly, we aim to analyze changes in knowledge and attitude upon completion of the e-learning tool. A 38-item questionnaire-based evaluation study with assessment of global and specific outcomes including ICU and non-ICU physicians was performed. In total, 24 questionnaires were included in the anonymous analysis. Feasibility was confirmed by a very high rate of overall satisfaction (94% approval), with relevance reaching 99% approval. Overall, we detected high gains in knowledge and noticeably lower gains on the attitude plane, with the highest gain in naming reasons for incorporating palliative care. The lowest learning gain on the attitude plane was observed when the participants were confronted with their own mortality. This study shows that e-learning is a feasible tool for gaining knowledge and even changing the attitudes of physicians caring for critically ill and dying patients in a self-assessment evaluation.


Subject(s)
COVID-19 , Computer-Assisted Instruction , Physicians , Terminal Care , Attitude of Health Personnel , COVID-19/epidemiology , Critical Illness , Humans , Palliative Care , Pandemics , Surveys and Questionnaires
5.
CMAJ ; 194(8): E313-E314, 2022 02 28.
Article in English | MEDLINE | ID: covidwho-2065174
7.
J Palliat Med ; 25(9): 1330-1331, 2022 09.
Article in English | MEDLINE | ID: covidwho-2017656
8.
J Crit Care ; 71: 154115, 2022 10.
Article in English | MEDLINE | ID: covidwho-2015608

ABSTRACT

PURPOSE: Death is common in intensive care units, and integrating palliative care enhances outcomes. Most research has been conducted in high-income countries. The aim is to understand what is known about the type and topics of research on the provision of palliative care within intensive care units in low- and middle-income countries MATERIALS AND METHODS: Scoping review with nine databases systematically searched for literature published in English on palliative care in intensive care units in low- and middle- income settings (01/01/1990 to 31/05/2021). Two reviewers independently checked search results and extracted textual data, which were analyzed and represented as themes. RESULTS: Thirty papers reported 19 empirical studies, two clinical case reports and six discussion papers. Papers originated from Asia and Africa, primarily using observational designs and qualitative approaches, with no trials or other robust evaluative or comparative studies. No studies directly sought data from patients or families. Five areas of research focus were identified: withholding and withdrawing treatment; professional knowledge and skills; patient and family views; culture and context; and costs of care. CONCLUSIONS: Palliative care in intensive care units in low-and middle-income countries is understudied. Research focused on the specific needs of intensive care in low- and middle-income countries is required to ensure optimal patient outcomes.


Subject(s)
Hospice and Palliative Care Nursing , Terminal Care , Developing Countries , Humans , Intensive Care Units , Palliative Care
9.
Int J Environ Res Public Health ; 19(18)2022 Sep 06.
Article in English | MEDLINE | ID: covidwho-2010073

ABSTRACT

The growing emphasis on evidence-based practice has led to a need for more research on healthcare disciplines, and for the synthesis and translation of that research into practice. This study explored the global research trend in regard to End-of-Life Care (EoLC), and assessed the impact and influence, on the scientific community, of relevant EoLC publications EoLC. Over 350,000 related publications on EoLC were retrieved from three databases (PubMed, Scopus, and Web of Science). Our analysis of the global research trend revealed an exponential rise in the number of related publications on EoLC since the year 1837. This study assessed the bibliometric information of 547 current journal publications on EoLC, sorted by relevance, from the three databases. The USA (47.3%) and the UK (16.1%) were the most productive countries, in terms of the number of relevant publications. The bibliometric analysis also revealed which EoLC research was most impactful and influential, from different parameters including documents, authors, sources, and organisations. The keyword analysis further suggested the growing importance of advance care planning and decision-making in regard to EoLC, as well as an episodic upsurge of EoLC publications related to the COVID-19 pandemic. There were few collaborations among the prolific research on EoLC. This study recommends increased research collaboration across the globe, for wider wisdom-sharing on EoLC issues.


Subject(s)
Advance Care Planning , COVID-19 , Terminal Care , Bibliometrics , Humans , Pandemics
10.
Crit Care Nurs Clin North Am ; 34(1): 67-78, 2022 Mar.
Article in English | MEDLINE | ID: covidwho-1628517

ABSTRACT

End of life (EOL) can be an extremely stressful experience for patients, their families, and health care staff. Critical care nurses are trained to help patients survive acute episodes and assist in restoring their health. Unfortunately, not all ICU patients are able to fully recover or obtain previous quality of life before hospitalization. In these situations, the focus moves to transitioning patients from restorative care to palliative care. This article will explain EOL care guidelines for critical care nurses using the Respiratory Distress Observation Scale to ensure patient comfort during compassionate extubation.


Subject(s)
Respiratory Distress Syndrome , Terminal Care , Airway Extubation , Humans , Intensive Care Units , Palliative Care , Quality of Life
11.
J Pain Symptom Manage ; 64(3): e133-e138, 2022 09.
Article in English | MEDLINE | ID: covidwho-1996385

ABSTRACT

CONTEXT: Opioid continuous infusions are commonly used for end-of-life (EOL) symptoms in hospital settings. However, prescribing practices vary, and even the recent literature contains conflicting protocols and guidelines for best practice. OBJECTIVES: To determine the prevalence of potentially inappropriate opioid infusion use for EOL comfort care at an academic medical center, and determine if inappropriate use is associated with distress. METHODS: Through literature review and iterative interdisciplinary discussion, we defined three criteria for "potentially inappropriate" infusion use. We conducted a retrospective, observational study of inpatients who died over six months, abstracting demographics, opioid use patterns, survival time, palliative care (PC) involvement, and evidence of patient/caregiver/staff distress from the electronic medical record. RESULTS: We identified 193 decedents who received opioid infusions for EOL comfort care. Forty-four percent received opioid infusions that were classified as "potentially inappropriate." Insufficient use of as-needed intravenous opioid boluses and use of opioid infusions in opioid-naïve patients were the most common problems observed. Potentially inappropriate infusions were associated with more frequent patient (24% vs. 2%; P < 0.001) and staff distress (10% vs. 2%; P = 0.02) and were less common when PC provided medication recommendations (20% vs. 50%; P < 0.001). CONCLUSION: Potentially inappropriate opioid infusions are prevalent at our hospital, an academic medical center with an active PC team and existing contracts for in-hospital hospice care. Furthermore, potentially inappropriate opioid infusions are associated with increased patient and staff distress. We are developing an interdisciplinary intervention to address this safety issue.


Subject(s)
Opioid-Related Disorders , Terminal Care , Analgesics, Opioid/therapeutic use , Death , Humans , Opioid-Related Disorders/drug therapy , Palliative Care/methods , Retrospective Studies
12.
J Pain Symptom Manage ; 64(3): 287-297.e1, 2022 09.
Article in English | MEDLINE | ID: covidwho-1996384

ABSTRACT

CONTEXT: Pediatric palliative care (PPC) improves quality of life and end-of-life outcomes for children with cancer, but often occurs late in the disease course. The Supportive Care Clinic (SCC) was launched in 2017 to expand outpatient PPC access. OBJECTIVES: To describe the inaugural four years (2017-2021) of an academic, consultative, embedded SCC within pediatric oncology. METHODS: Descriptive statistics (demographic, disease, treatment, visit, and end-of-life) and change over time were calculated. RESULTS: During the first four years, 248 patients (51.6% male; 58.1% White; 35.5% Black; 13.7% Hispanic/Latino) were seen in SCC, totaling 1,143 clinic visits (median 4, IQR 2,6), including 248 consultations and 895 follow-up visits. Clinic visits grew nearly 300% from year one to four. Primary diagnoses were central nervous system tumor (41.9%), solid tumor (37.5%), and leukemia/lymphoma (17.3%). The first point of PPC contact became SCC (70.6%) for most referred patients. Among the 136 deceased patients (54.8%), 77.9% had a do-not-resuscitate or Physician Orders for Life Sustaining Treatment in place, and 72.8% received hospice care. When known (n = 112), 89.3% died in their preferred location. The time from SCC consultation to death increased from 74 to 226 days over the four years (P < 0.0001). The proportion of SCC consultations that occurred greater than 90 days from death increased from 39.1% in year one to 85.0% in year four. CONCLUSION: Embedded SCC clinics can be successful, achieve steady growth, improve referrals and timing of PPC, and enhance end-of-life care for children with cancer. Large pediatric cancer centers should include SCC outpatient services.


Subject(s)
Neoplasms , Terminal Care , Child , Death , Female , Humans , Male , Neoplasms/therapy , Palliative Care , Quality of Life , Retrospective Studies
13.
Br J Community Nurs ; 27(8): 372-373, 2022 08 02.
Article in English | MEDLINE | ID: covidwho-1975393
14.
Palliat Support Care ; 20(4): 611-612, 2022 08.
Article in English | MEDLINE | ID: covidwho-1960199
15.
BMC Palliat Care ; 21(1): 91, 2022 Jun 01.
Article in English | MEDLINE | ID: covidwho-1951173

ABSTRACT

PURPOSE: To report the experiences of End of Life (EoL) care in UK care homes during the COVID-19 pandemic. METHODS: UK care home staff and family carers of residents in care home took part in remote, semi-structured interviews from October to November 2020, with 20 participants followed-up in March 2021. Interviews were conducted via telephone or online platforms and qualitatively analysed using inductive thematic analysis. RESULTS: Forty-two participants (26 family carers and 16 care home staff) were included in a wider qualitative study exploring the impact on dementia care homes during the pandemic. Of these, 11 family carers and 9 care home staff participated in a follow-up interview. Following descriptive thematic analysis, three central themes concerning EoL care during the pandemic specifically, were conceptualised and redefined through research team discussions: 1) Wasting or losing time; 2) Maintaining control, plans and routine; and 3) Coping with loss and lack of support. Lack of suitable, meaningful visits with people with dementia in care homes resulted in negative feelings of guilt and abandonment with both family carers and care home staff. Where families experienced positive EoL visits, these appeared to breach public health restrictions at that time. CONCLUSION: It is recommended that care homes receive clear guidance from the government offering equitable contact with relatives at EoL to all family members, to support their grieving and avoid subsequent negative impacts to emotional wellbeing.


Subject(s)
COVID-19 , Dementia , Terminal Care , Dementia/psychology , Dementia/therapy , Humans , Pandemics , United Kingdom
16.
Crit Care ; 26(1): 218, 2022 07 18.
Article in English | MEDLINE | ID: covidwho-1935548

ABSTRACT

The intensive care unit (ICU) is a complex environment where patients, family members and healthcare professionals have their own personal experiences. Improving ICU experiences necessitates the involvement of all stakeholders. This holistic approach will invariably improve the care of ICU survivors, increase family satisfaction and staff wellbeing, and contribute to dignified end-of-life care. Inclusive and transparent participation of the industry can be a significant addition to develop tools and strategies for delivering this holistic care. We present a report, which follows a round table on ICU experience at the annual congress of the European Society of Intensive Care Medicine. The aim is to discuss the current evidence on patient, family and healthcare professional experience in ICU is provided, together with the panel's suggestions on potential improvements. Combined with industry, the perspectives of all stakeholders suggest that ongoing improvement of ICU experience is warranted.


Subject(s)
Critical Care , Terminal Care , Family , Humans , Intensive Care Units , Survivors
17.
Int J Psychiatry Med ; 57(4): 256-258, 2022 07.
Article in English | MEDLINE | ID: covidwho-1927973
18.
Br Med Bull ; 142(1): 44-51, 2022 07 09.
Article in English | MEDLINE | ID: covidwho-1922201

ABSTRACT

INTRODUCTION: Covid-19 led to a sustained increase in deaths in all four United Kingdom nations, placing strain on the UK's palliative and end-of-life care sector and raising concerns about the long-term sustainability of the sector's funding and resourcing model in the face of rising demand for these services in the coming decades. SOURCES OF DATA: Published research, Marie Curie, King's College London Cicely Saunders Institute, Hull York Medical School, University of Hull, University of Cambridge, National Statistics, PubMed, DOI. AREAS OF AGREEMENT: Care for people at the end of their lives is a core part of the UK's health and care system with demand set to increase significantly as the UK's population ages. AREAS OF CONTROVERSY: The UK's funding model for palliative and end-of-life care, with most care delivered by charitable sector providers and reliant on charitable donations, may be unsustainable in the face of increasing demand. GROWING POINTS: The Covid-19 pandemic led to rapid service innovation in palliative and end-of-life care, and providers should assess which of and how these innovations can be retained after the pandemic. AREAS TIMELY FOR DEVELOPING RESEARCH: Although there has been a rapid growth in knowledge during Covid-19, gaps still remain including: the reasons underlying shifts to deaths at home and the implications for family carers; the education needs of the wider healthcare workforce in palliative care; the impact of specialist palliative care services on the wider health system, including hospital admissions and place of death; and inequalities in the experiences of dying, death and bereavement during Covid-19 among groups such as those from lower socioeconomic groups and BAME communities.


Subject(s)
COVID-19 , Terminal Care , COVID-19/epidemiology , Humans , Palliative Care , Pandemics , United Kingdom/epidemiology
19.
J Pain Symptom Manage ; 64(4): 359-369, 2022 10.
Article in English | MEDLINE | ID: covidwho-1907350

ABSTRACT

CONTEXT: The COVID-19 pandemic has highlighted variability in intensity of care. We aimed to characterize intensity of care among hospitalized patients with COVID-19. OBJECTIVES: Examine the prevalence and predictors of admission code status, palliative care consultation, comfort-measures-only orders, and cardiopulmonary resuscitation (CPR) among patients hospitalized with COVID-19. METHODS: This cross-sectional study examined data from an international registry of hospitalized patients with COVID-19. A proportional odds model evaluated predictors of more aggressive code status (i.e., Full Code) vs. less (i.e., Do Not Resuscitate, DNR). Among decedents, logistic regression was used to identify predictors of palliative care consultation, comfort measures only, and CPR at time of death. RESULTS: We included 29,923 patients across 179 sites. Among those with admission code status documented, Full Code was selected by 90% (n = 15,273). Adjusting for site, Full Code was more likely for patients who were of Black or Asian race (ORs 1.82, 95% CIs 1.5-2.19; 1.78, 1.15-3.09 respectively, relative to White race), Hispanic ethnicity (OR 1.89, CI 1.35-2.32), and male sex (OR 1.16, CI 1.0-1.33). Of the 4951 decedents, 29% received palliative care consultation, 59% transitioned to comfort measures only, and 29% received CPR, with non-White racial and ethnic groups less likely to receive comfort measures only and more likely to receive CPR. CONCLUSION: In this international cohort of patients with COVID-19, Full Code was the initial code status in the majority, and more likely among patients who were Black or Asian race, Hispanic ethnicity or male. These results provide direction for future studies to improve these disparities in care.


Subject(s)
COVID-19 , Terminal Care , COVID-19/therapy , Cross-Sectional Studies , Humans , Male , Pandemics , Resuscitation Orders , Retrospective Studies
20.
Palliat Med ; 36(8): 1252-1262, 2022 09.
Article in English | MEDLINE | ID: covidwho-1902229

ABSTRACT

BACKGROUND: The COVID-19 pandemic had a particularly severe impact on nursing homes, exposing numerous pre-existing deficiencies in end-of-life care. AIM: To describe how the COVID-19 pandemic affected nursing home and primary care professionals' attempts to achieve the objectives of a pre-existing end-of-life programme and to explore their personal experiences of end-of-life care in these facilities. DESIGN: A qualitative descriptive study using thematic analysis. SETTING/PARTICIPANTS: Twenty semi-structured interviews were conducted from March to November 2020 with professionals from nursing homes and primary care facilities who participated in the development of the NUHELP programme. RESULTS: Six main themes were identified: (1) Comprehensive assessments of residents at the homes were not conducted due to excessive workload and high staff turnover. (2) New technologies and changes to professional roles were used to meet relatives' needs for information. Residents only received information when they requested it. (3) Advance care planning was not carried out and was limited to potential hospital transfer. (4) Arrangements were made to allow relatives to spend time with residents during their final moments, but complicated grief among relatives and professionals is anticipated. (5) Management of complexity varied depending on the degree of coordination with primary care facilities. (6) Nursing home professionals felt abandoned, with a lack of human resources, equipment and training. CONCLUSIONS: The pandemic cast light on existing shortcomings in nursing homes in terms of comprehensive assessments, communication, decision making, grief management and palliative care complexity. Nursing homes need more human, material and training resources, as well as improved coordination with the public healthcare system.


Subject(s)
COVID-19 , Terminal Care , Aged , Homes for the Aged , Humans , Pandemics , Workforce
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