Opioid use in the acute setting: A survey of providers at an academic medical center.

OBJECTIVE: To examine attitudes, beliefs, and influencing factors of inpatient healthcare providers regarding prescription of opioid analgesics. DESIGN: Electronic cross-sectional survey. SETTING: Academic medical center. PARTICIPANTS: Physicians, advanced practice providers, and pharmacists from a single academic medical center in the southeast United States. MAIN OUTCOME MEASURES: Respondents completed survey items addressing: (1) their practice demographics, (2) their opinions regarding overall use, safety, and efficacy of opioids compared to other analgesics, (3) specific clinical scenarios, (4) main pressures to prescribe opioids, and (5) confidence/comfort prescribing opioids or nonopioids in select situations. RESULTS: The majority of the sample (n = 363) were physicians (60.4 percent), with 69.4 percent of physicians being attendings. Most respondents believed that opioids were overused at our institution (61.7 percent); nearly half thought opioids had similar efficacy to other analgesics (44.1 percent), and almost all believed opioids were more dangerous than other analgesics (88.1 percent). Many respondents indicated that they would modify a chronic regimen for a high-risk patient, and use of nonopioids in specific scenarios was high. However, this use was often in combination with opioids. Respondents identified patients (64 percent) and staff (43.1 percent) as the most significant sources of pressure to prescribe opioids during an admission; the most common sources of pressure to prescribe opioids on discharge were to facilitate discharge (44.8 percent) and to reduce follow-up requests, calls, or visits (36.3 percent). Resident physicians appear to experience more pressure to prescribe opioids than other providers. Managing pain in patients with substance use disorders and effectively using nonopioid analgesics were the most common educational needs identified by respondents. CONCLUSION: Most individuals believe opioid analgesics are overused in our specific setting, commonly to satisfy patient requests. In general, providers feel uncomfortable prescribing nonopioid analgesics to patients.

Pharmacy residents' preparedness for the emotional challenges of patient care.

PURPOSE: Results of a survey to determine levels of pharmacy resident exposure to and preparedness for emotionally unsettling clinical scenarios are presented. METHODS: A pretested electronic survey was distributed to 1501 U.S. pharmacy residency program directors (RPDs), who were asked to complete the survey and forward it to residents in their programs. Both respondent groups provided perspectives on pharmacy residents' frequency of exposure to and preparedness for nine scenarios that could potentially be emotionally unsettling to pharmacy residents (e.g., a patient's death, participation in a response to a cardiorespiratory arrest). RPDs and residents were queried regarding training methods used by their programs to prepare trainees to cope with emotionally unsettling events. RESULTS: A total of 940 responses were received. Overall, resident-reported ex posure to the nine scenarios listed in the survey was infrequent. Majorities of both RPDs and residents (85.2% and 67.1%, respectively) indicated that residents could be better prepared for the emotional challenges of patient care. The most common method of training was a one-on-one discussion between a preceptor and a resident on an as-needed basis. No training was reported by 30% and 40% of RPDs and residents, respectively. CONCLUSION: The majority of RPD and resident respondents indicated that residents could be better prepared for the emotional challenges of patient care. The most commonly reported method of training for coping with emotional challenges was a one-on-one discussion between a preceptor and a resident on an as-needed basis.

Assessing end-of-life preferences for advanced dementia in rural patients using an educational video: a randomized controlled trial.

OBJECTIVE: Few studies have evaluated the end-of-life preferences of elderly patients in rural communities and whether preferences are associated with level of health literacy. DESIGN: Randomized controlled trial of a goals-of-care video decision aid of advanced dementia. PARTICIPANTS: Elderly subjects (65 years or older) at a primary care clinic in rural Louisiana. METHODS: Half of subjects heard a verbal description of advanced dementia and the goals of care; the other half heard the same verbal description and then viewed the video decision aid. End points were the preferred goal of care in advanced dementia: life-prolonging care (cardiopulmonary resuscitation [CPR], etc.), limited care (hospitalization but not CPR), or comfort care (symptom relief). The principal category for analysis was the difference in proportions of subjects preferring comfort care for each characteristic including randomization group and health literacy level. RESULTS: Seventy-six subjects were randomized to the verbal (n = 43) or video (n = 33) arms of the study. Among subjects receiving the verbal description of advanced dementia and the goals of care, 31 (72%) preferred comfort; 5 (12%) chose limited; and 7 (16%) desired life-prolonging. In the video group, 30 (91%) preferred comfort; 3 (9%) chose limited; and none desired life-prolonging (χ(2) = 6.3, df = 2, p = 0.047). Factors associated with greater likelihood of opting for comfort included greater health literacy (unadjusted odds ratio [OR] 12.1; 95% confidence interval [CI], 2.4-62.6) and randomization to the video (unadjusted OR 3.9; 95% CI, 1.0-15.1). CONCLUSION: Rural subjects with higher health literacy were more likely to want comfort care compared to those with lower levels of health literacy. Furthermore, subjects who viewed a video decision aid were more likely to opt for comfort compared to those who solely listened to a verbal description. These findings suggest that video can help elicit preferences and that interventions to empower such patients need to be designed in a manner that is sensitive to health literacy.

"It helps me see with my heart": how video informs patients' rationale for decisions about future care in advanced dementia.

OBJECTIVE: To explore how a video of a patient with advanced dementia impacts the rationale for patients' decisions about future care. METHODS: Participants were read a verbal description of advanced dementia and asked their preferences for future care--either life-prolonging, limited, or comfort care--and the rationale for that choice. Participants then watched a video of a patient with advanced dementia and again stated their preferred level of care and the rationale. Thematic content analysis was utilized to develop common themes among the rationale of participants in each response category. RESULTS: We interviewed 120 participants. The rationale of those who initially chose life-prolonging or limited care (47/120) emphasized lengthening life and cited an inherent good of medical treatment. Those who initially chose comfort care (60/120) focused on avoiding suffering and quality of life. Post-video, 107/120 participants chose comfort care and the rationale focused on the experience of the patient and family rather than treatment-centered considerations. Participants found great value in the video images. CONCLUSIONS: While pre-video reasoning reflects general beliefs about extending life and the inherent good of treatment, the post-video reasoning reveals more focus on the experience of the actual patient and family. PRACTICE IMPLICATIONS: Video may serve an important role in advanced care planning by enriching the understanding of the condition and allowing one to imagine a future health state.

Changes in internal medicine residents' attitudes about resuscitation after cardiac arrest over a decade.

BACKGROUND: Resident physicians' beliefs about cardiopulmonary resuscitation (CPR) may impact their communication with patients about end-of-life care. We sought to understand how these perceptions and experiences have changed in the past decade because both medical education and American society have focused more on this domain. METHOD: We surveyed 2 internal medicine resident cohorts at a large academic medical center in 1995 and 2005. Residents were asked of their beliefs about survival after CPR, perceived patient understanding, and regret after attempted resuscitation. Residents in 2005 reported more numerical experience with CPR. Current internal medicine residents are more optimistic than the 1995 cohort about survival after an inpatient cardiac arrest. They believe that far fewer patients and families understand resuscitation but report less regret about attempting to resuscitate patients. CONCLUSIONS: These pilot data reveal potential changes in the attitudes of resident physicians toward CPR. The perceived poor understanding among decision makers calls into question the standard of informed consent. Despite this, residents report less regret leading one to ask what factors may underlie this response.

Communication and decision making about life-sustaining treatment: examining the experiences of resident physicians and seriously-ill hospitalized patients.

BACKGROUND: Despite evidence-based recommendations for communication and decision making about life-sustaining treatment, resident physicians' actual practice may vary. Few prior studies have examined these conversations qualitatively to uncover why ineffective communication styles may persist. OBJECTIVE: To explore how discussions about life-sustaining treatment occur and examine the factors that influence physicians' communicative practices in hopes of providing novel insight into how these processes can be improved. PARTICIPANTS AND APPROACH: We conducted and recorded 56 qualitative semi-structured interviews with participants from 28 matched dyads of a resident physician and a hospitalized patient or their surrogate decision maker with whom cardiopulmonary resuscitation was discussed. Transcripts were analyzed and coded using the constant comparative method to develop themes. MAIN RESULTS: Resident physicians introduced decisions about resuscitation in a scripted, depersonalized and procedure-focused manner. Decision makers exhibited a poor understanding of the decision they were being asked to make and resident physicians often disagreed with the decision. Residents did not advocate for a particular course of action; however, the discussions of resuscitation were framed in ways that may have implicitly influenced decision making. CONCLUSIONS: Residents' communication practices may stem from their attempt to balance an informed choice model of decision making with their interest in providing appropriate care for the patient. Physicians' beliefs about mandatory autonomy may be an impediment to improving communication about patients' choices for life-sustaining treatment. Redefining the role of the physician will be necessary if a shared decision making model is to be adopted.

Discussing preferences for cardiopulmonary resuscitation: what do resident physicians and their hospitalized patients think was decided?

OBJECTIVE: To explore the ways in which seriously ill hospitalized patients, their family members and physicians interpret the discussion of the patient's preferences for cardiopulmonary resuscitation (CPR). METHODS: Resident physicians, their patients, and family members were interviewed following a discussion regarding preferences for CPR. We sought the participants' perceptions of the resulting decision, examined how often these interpretations differed, and explored the communicative factors underlying discrepancies when they occurred. RESULTS: Fifty-six interviews with 28 matched dyads were completed. In six dyads (21%), the participants reported differing results of the discussion. Two patients had orders to limit their care based on the physician's interpretation of their discussion. Another two patients who did not want resuscitation lacked a DNR order. Two patients did not recall having the conversation. These discrepancies could be attributed to the physician misconstruing the patient's wishes, interference of a family member, and fluctuating preferences. CONCLUSIONS: Discrepant interpretations of a DNR discussion occur with a concerning frequency between resident physicians and their hospitalized patients. PRACTICE IMPLICATIONS: Educational efforts should focus on training physicians to clarify the language used in these discussions, remain vigilant about discerning the patient's preferences, and be aware that these preferences may be contextually fluid.

Medical residents' perspectives on discussions of advanced directives: can prior experience affect how they approach patients?

INTRODUCTION: Resident physicians are inadequately taught how to communicate with patients about end-of-life decision making. Their beliefs about resuscitation and prior experiences with end-of-life care may impact the manner in which they approach patients. OBJECTIVE: To explore residents' perceptions of end-of-life discussions, determine the features they find most important, and discern the challenges they face in this process. METHODS: Internal medicine residents were surveyed about their experiences discussing resuscitation with patients including perceptions of patient understanding, outcomes of resuscitation, and regret about attempting to resuscitate patients. They were asked what features of these discussions are most important and which are the most challenging. Qualitative content analysis was used to examine the responses to open-ended questions. RESULTS: Fifty-five residents completed the survey. Residents reported rarely feeling satisfied with the results of these discussions and disagreed with the decision for resuscitation numerous times. They perceive that few patients and families understand resuscitation. In their description of important features, they focus on the content of the discussion rather than the process, with the most common responses centering on a description of resuscitation. In contrast, the greatest challenge they identify is dealing with the emotional aspects of the discussion. CONCLUSIONS: Residents report internal conflict about their experiences discussing resuscitation with patients. Their approach to these discussions focuses on resuscitation itself with less attention paid to processes that might improve patient decision making. The challenges they describe may be overcome with improved education about end-of-life communication.