Prevalence and Contents of Advance Directives in Patients Receiving Home Parenteral Nutrition.

BACKGROUND: Ethical issues may arise with patients who receive home parenteral nutrition (HPN) and have a change in their overall health status. We sought to determine the extent of advance care planning and the use of advance directives (ADs) by patients receiving HPN. MATERIALS AND METHODS: Retrospective review of the medical records of adult patients newly started on HPN at the Mayo Clinic, Rochester, Minnesota, between January 1, 2003, and December 31, 2012, to determine the prevalence and contents of their ADs. RESULTS: A total of 537 patients met the inclusion criteria. Mean (SD) age at commencement of HPN was 52.8 (15.2) years, and 39% (n = 210) were men. Overall, 159 patients (30%) had ADs. Many mentioned specific life-prolonging treatments: cardiopulmonary resuscitation (44 [28%]), mechanical ventilation (43 [27%]), and hemodialysis (19 [12%]). Almost half mentioned pain control (78 [49%]), comfort measures (65 [41%]), and end-of-life management of HPN (76 [48%]). Many also contained general statements about end-of-life care (no "heroic measures"). The proportion specifically addressing end-of-life management of HPN (48%) was much higher than that previously reported in other populations with other life-supporting care such as cardiac devices. The primary diagnosis or the indication for HPN was not correlated with whether or not the patient had an AD (P = .07 and .46, respectively). CONCLUSION: Although almost one-third of the patients had an AD, less than half specifically mentioned HPN in it, which suggests that such patients should be encouraged to execute an AD that specifically addresses end-of-life management of HPN.

Choices for patients "without a choice": Interviews with patients who received a left ventricular assist device as destination therapy.

BACKGROUND: Patients undergo major physical and psychological changes after implantation of a left ventricular assist device as destination therapy (DT). We sought to qualitatively study outcomes and attitudes of patients after DT. METHODS AND RESULTS: Ambulatory outpatients with DT at our institution were invited to be interviewed between June and August 2011. In-person interviews were audio-recorded, transcribed, and analyzed qualitatively using thematic analysis. The study included 12 patients (11 men) from the Midwestern United States with a median age of 71.5 years (range, 33-78 years). Interviews were conducted at a median (range) time of 1.37 (0.43-5.04) years after DT implantation. Most patients were white (n=11), married (n=10), and Christian (n=10). We identified 6 themes commonly discussed by the interviewees: preparedness planning, new lease on life, optimizing support networks, systemic limitations, reflections on time, and communication matters. Analysis revealed that most patients saw DT as their only choice, despite other alternatives. CONCLUSIONS: Ambulatory patients reported varied experiences after DT but commonly reported gratitude for improved functional status and a perception of improved symptom burden. Recommendations for improving post-DT care include developing patient support systems, systematizing education for community providers, and expanding respite services.

Clinicians' attitudes regarding withdrawal of left ventricular assist devices in patients approaching the end of life.

AIMS: Left ventricular assist devices (LVADs) are implanted to support the circulation of patients with advanced heart failure. Patients approaching death, or their surrogates, may request withdrawal of LVAD support. We sought to study the attitudes and practices of heart failure clinicians regarding withdrawal of LVAD support in patients approaching death. METHODS AND RESULTS: Using internet-based and secure methods, we surveyed members of the European Society of Cardiology-Heart Failure Association (ESC-HFA), the International Society for Heart and Lung Transplantation (ISHLT), and the Heart Failure Society of America (HFSA) to assess their attitudes and practices regarding LVAD withdrawal for patients approaching death. The results indicated that clinicians have varied attitudes and practices regarding withdrawing LVAD support in these patients. Furthermore, ESC-HFA clinicians (primarily European) and ISHLT and HFSA clinicians (primarily North American) differed in their attitudes and practices regarding withdrawal of LVAD support, particularly its ethical and legal permissibility. For example, more European clinicians than North American clinicians regarded withdrawing LVAD support as a form of euthanasia. CONCLUSION: Opinions and level of comfort with LVAD withdrawal vary among clinicians. Clinicians should be aware of suggested approaches or guidelines for managing requests for withdrawal of LVAD therapy.

Improving efficiency and reducing administrative burden through electronic communication.

BACKGROUND: The InBox messaging system is an internal, electronic program used at Mayo Clinic, Rochester, MN, to facilitate the sending, receiving, and answering of patient-specific messages and alerts. A standardized InBox was implemented in the Division of General Internal Medicine to decrease the time physicians, physician assistants, and nurse practitioners (clinicians) spend on administrative tasks and to increase efficiency. METHODS: Clinicians completed surveys and a preintervention InBox pilot test to determine inefficiencies related to administrative burdens and defects (message entry errors). Results were analyzed using Pareto diagrams, value stream mapping, and root cause analysis to prioritize administrative-burden inefficiencies to develop a new, standardized InBox. Clinicians and allied health staff were the target of this intervention and received standardized InBox training followed by a postintervention pilot test for clinicians. RESULTS: Sixteen of 28 individuals (57%) completed the preintervention survey. Twenty-eight clinicians participated in 2 separate 8-day pilot tests (before and after intervention) for the standardized InBox. The number of InBox defects was substantially reduced from 37 (Pilot 1) to 7 (Pilot 2). Frequent InBox defects decreased from 25% to 10%. More than half of clinicians believed the standardized InBox positively affected their work, and 100% of clinicians reported no negative affect on their work. CONCLUSIONS: This project demonstrated the successful implementation of the standardized InBox messaging system. Initial assessments show substantial reduction of InBox entry defects and administrative tasks completed by clinicians. The findings of this project suggest increased clinician and allied health staff efficiency, satisfaction, improved clinician work-life balance, and decreased clinician burden caused by administrative tasks.

Teaching quality essentials: the effectiveness of a team-based quality improvement curriculum in a tertiary health care institution.

A unique quality improvement (QI) curriculum was implemented within the Division of General Internal Medicine to improve QI knowledge through multidisciplinary, team-based education, which also met the QI requirement for the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) and the Mayo Quality Fellows program. Participants completed up to 4 QI learning modules, including pretest and posttest assessments. A participant who successfully completed all 4 modules received certification as a Silver Quality Fellow and credit toward the quality requirement for ABIM MOC. Of 62 individuals invited to participate, 33 (53%) completed all 4 modules and corresponding pretests and posttests. Participants substantially improved knowledge in all 4 quality modules. Study group participants' pretest scores averaged 71.0%, and their posttest scores averaged 92.7%. Posttest scores of reference group participants compared favorably, averaging 89.2%. Initial assessments showed substantial knowledge improvements and successful implementation of staff-developed QI projects.