Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients.

CONTEXT: Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree. OBJECTIVES: Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families. METHODS: This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness. RESULTS: Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending. CONCLUSIONS: IA is a feasible and reasonable approach to CPR discussions in selected patient populations.

Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Critical Illness and Heart, Kidney, and Liver Diseases.

Specialty palliative care (PC) clinicians are frequently asked to discuss prognosis with patients and their families. When conveying information about prognosis, PC clinicians need also to discuss the likelihood of prolonged hospitalization, cognitive and functional disabilities, and death. As PC moves further and further upstream, it is crucial that PC providers have a broad understanding of curative and palliative treatments for serious diseases and can collaborate in prognostication with specialists. In this article, we present 10 tips for PC clinicians to consider when caring and discussing prognosis for the seriously ill patients along with their caregivers and care teams. This is the second in a three-part series around prognostication in adult and pediatric PC.

Palliative Care Specialist Access is Associated With Rankings of Hospital Quality.

CONTEXT: Increasing evidence has shown that access to specialty palliative care, particularly outpatient palliative care clinics, can yield improved health outcomes and be a marker of hospital quality. OBJECTIVE: To determine whether an association exists between access to specialty palliative care programs and hospital rankings found in the 2020-2021 U.S. News & World Report Best Hospitals. METHODS: This study used publicly available data from the Center to Advance Palliative Care (CAPC) Provider Directory to determine access to in-patient and out-patient palliative care in the 2020-2021 U.S. News & World Report Best Hospitals Rankings. Descriptive statistics and chi-squares were performed. Data were also analyzed across the four U.S. Census Bureau regions (Northeast, South, Midwest, West). RESULTS: Around 100% of the Top 20 hospitals include hospital-based palliative care consultation teams, and 95% offered outpatient palliative care. Of the second cohort of 83 hospitals, 99% offered inpatient palliative care, and 65% offered outpatient palliative care. Of the third cohort of 75 hospitals ranked, 96% had inpatient palliative care services, while only 41.3% offered outpatient palliative care. This represents a significant association between rank position and access to outpatient palliative care (P < 0.01). Ranked hospitals also have significantly higher access to hospital-based palliative care teams compared to the national prevalence rate (P < 0.01). CONCLUSION: These findings reflect the association of access to specialty palliative care with USNWR rankings for hospital quality. Further study is necessary to determine the specific influence of access to palliative care and USNWR rank position.

Impact of an Antibiotic-specific Sepsis Bundle on Appropriate and Timely Antibiotic Administration for Severe Sepsis in the Emergency Department.

BACKGROUND: Guidelines recommend initiation of appropriate antimicrobial therapy within 1 h of severe sepsis diagnosis. Few sepsis bundles exist in the literature emphasizing initiation of specific antibiotic therapy. OBJECTIVE: To determine the impact of an antibiotic-specific sepsis bundle on the timely initiation of appropriate antibiotics. METHODS: For this before-and-after interventional study, the sepsis bundle at this 803-bed academic tertiary-care facility was redesigned to include specific antibiotic selection and dosing, based on suspected source of infection and susceptibility patterns. Protocol education and advertising was completed and bundle-specific antibiotics were put in the automated medication cabinet. RESULTS: Stepwise analysis of timely initiation of appropriate antibiotics included: 1) Was the initial antibiotic appropriate? 2) If so, was it initiated within 1 h of diagnosis? 3) If so, were all necessary appropriate antibiotics started? and 4) If so, were they started within 3 h of diagnosis? In comparing the 3-month-before group and 3-month-after group (n = 124), the appropriate initial antibiotic was started in 33.9% vs. 54.8% of patients (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.19-0.93, p = 0.03) and within 1 h in 22.6% vs. 14.5% of patients (OR 1.71, 95% CI 0.62-4.92, p = 0.36), respectively. All necessary appropriate antibiotics were initiated in 16.1% vs. 12.9% of patients (OR 1.30, 95% CI 0.42-4.10, p = 0.80), and within 3 h in 14.5% vs. 9.7% of patients, respectively (OR 1.58, 95% CI 0.46-5.78, p = 0.58). CONCLUSIONS: An updated antibiotic-specific sepsis bundle, with antibiotics put in an automated medication cabinet, can result in improvements in the initiation of appropriate initial antibiotic therapy for severe sepsis in the emergency department.

Priorities for Evaluating Palliative Care Outcomes in Intensive Care Units.

Defining the quality of intensive care unit (ICU) care when patients are dying is challenging. Palliative care has been recommended to improve outcomes of dying ICU patients; however, traditional ICU quality indicators do not always align with palliative care. Evidence suggests that some aspects of ICU care improve when palliative care is integrated; however, consensus is lacking concerning the outcomes that should be measured. Overcoming challenges to measuring palliative care will require consensus development and rigorous research on the best way to evaluate ICU palliative care services.

Quality measures for palliative care in patients with cancer: a systematic review.

PURPOSE: Quality assessment is a critical component of determining the value of medical services, including palliative care. Characterization of the current portfolio of measures that assess the quality of palliative care delivered in oncology is necessary to identify gaps and inform future measure development. METHODS: We performed a systematic review of MEDLINE/PubMed and the gray literature for quality measures relevant to palliative care. Measures were categorized into National Quality Forum domains and reviewed for methodology of development and content. Measures were additionally analyzed to draw summative conclusions on scope and span. RESULTS: Two hundred eighty-four quality measures within 13 measure sets were identified. The most common domains for measure content were Physical Aspects of Care (35%) and Structure and Processes of Care (22%). Of symptom-related measures, pain (36%) and dyspnea (26%) were the most commonly addressed. Spiritual (4%) and Cultural (1%) Aspects of Care were least represented domains. Generally, measures addressed processes of care, did not delineate benchmarks for success, and often did not specify intended interventions to address unmet needs. This was most evident regarding issues of psychosocial and spiritual assessment and management. CONCLUSION: Within a large cohort of quality measures for palliative, care is often a focus on physical manifestations of disease and adverse effects of therapy; relatively little attention is given to the other aspects of suffering commonly observed among patients with advanced cancer, including psychological, social, and spiritual distress.

Strategies to combat chronic critical illness.

PURPOSE OF REVIEW: The population of chronically critically ill patients is growing as advances in intensive care management improve survival from the acute phase of critical illness. These patients are characterized by complex medical needs and heavy resource utilization. This article reviews evidence supporting a comprehensive approach to the prevention and management of chronic critical illness (CCI). RECENT FINDINGS: The most efficient approach to weaning patients with CCI at long-term acute care hospitals is daily unassisted breathing trials through a tracheostomy collar. However, a substantial number of patients transferred to long-term acute care hospitals pass their spontaneous weaning trials. Transfer to long-term acute care hospitals is associated with higher acute care costs and payments, but lower costs through the entire episode of illness. Universal decontamination is more effective than targeted decontamination or screening and isolation for preventing nosocomial bloodstream infections. SUMMARY: Combating CCI begins with prevention in the acute phase of illness. Management strategies include a spectrum of ventilatory, nutritional, and rehabilitation support. Further patient-centered outcome-based research in this specific population is needed to continue to help guide optimal care.

Dyspnea review for the palliative care professional: treatment goals and therapeutic options.

Although dyspnea is frequently encountered in the palliative care setting, its optimal management remains uncertain. Clinical approaches begin with accurate assessment, as delineated in part one of this two-part series. Comprehensive dyspnea assessment, which encompasses the physical, emotional, social, and spiritual aspects of this complex symptom, guide the clinician in choosing therapeutic approaches herein presented as part two. Global management of dyspnea is appropriate both as complementary to disease-targeted treatments that target the underlying etiology, and as the sole focus when the symptom has become intractable, disease is maximally treated, and goals of care shift to comfort and quality of life. In this setting, current evidence supports the use of oral or parenteral opioids as the mainstay of dyspnea management, and of inhaled furosemide and anxiolytics as adjuncts. Nonpharmacologic interventions such as acupuncture and pulmonary rehabilitation have potential effectiveness, although further research is needed, and use of a simple fan warrants consideration given its potential benefit and minimal burden and cost.

Dyspnea review for the palliative care professional: assessment, burdens, and etiologies.

BACKGROUND: Dyspnea is a common symptom experienced by many patients with chronic, life-threatening, and/or life-limiting illnesses. Although it can be defined and measured in several ways, dyspnea is best described directly by patients through regular assessment, as its burdens exert a strong influence on the patient's experience throughout the trajectory of serious illness. Its significance is amplified due to its impact on family and caregivers. DISCUSSION: Anatomic and physiologic changes associated with dyspnea, and cognitive perceptions related to patients and the underlying disease, provide insights into how to shape interventions targeting this oppressive symptom. Additionally, as described in the concept of "total dyspnea," the complex etiology and manifestation of this symptom require multidisciplinary treatment plans that focus on psychological, social, and spiritual distress as well as physical components. Several validated assessment tools are available for clinical and research use, and choice of method should be tailored to the individual patient, disease, and care setting in the context of patient-centered care. CONCLUSION: This article, the first in a two-part series, reviews the identification and assessment of dyspnea, the burden it entails, and the underlying respiratory and nonrespiratory etiologies that may cause or exacerbate it.

Early anticoagulation is associated with reduced mortality for acute pulmonary embolism.

BACKGROUND: Acute pulmonary embolism (PE) may be rapidly fatal if not diagnosed and treated. IV heparin reduces mortality and recurrence of PE, but the relationship between survival and timing of anticoagulation has not been extensively studied. METHODS: We studied 400 consecutive patients in the ED diagnosed with acute PE by CT scan angiography and treated in the hospital with IV unfractionated heparin from 2002 to 2005. Patients received heparin either in the ED or after admission. Time from ED arrival to therapeutic activated partial thromboplastin time (aPTT) was calculated. Outcomes included in-hospital and 30-day mortality, hospital and ICU lengths of stay, hemorrhagic events on heparin, and recurrent venous thromboembolism within 90 days. RESULTS: In-hospital and 30-day mortality rates were 3.0% and 7.7%, respectively. Patients who received heparin in the ED had lower in-hospital (1.4% vs 6.7%; P = .009) and 30-day (4.4% vs 15.3%; P < .001) mortality rates as compared with patients given heparin after admission. Patients who achieved a therapeutic aPTT within 24 h had lower in-hospital (1.5% vs 5.6%; P = .093) and 30-day (5.6% vs 14.8%; P = .037) mortality rates as compared with patients who achieved a therapeutic aPTT after 24 h. In multiple logistic regression models, receiving heparin in the ED remained predictive of reduced mortality, and ICU admission remained predictive of increased mortality. CONCLUSIONS: We report an association between early anticoagulation and reduced mortality for patients with acute PE. We advocate further study with regard to comorbidities to assess the usefulness of modifications to hospital protocols.