The effect of physician training and patient education on the discussion of care decisions at the internal medicine outpatient clinic.

BACKGROUND: Care decision discussions are intended to align treatment with the patient's wishes, goals and values. To overcome the numerous barriers to such discussions, physicians as well as patients need tailored support. We evaluate the effect of a physicians' training and a conversation aid for patients about care decisions on patient and physician outcomes. METHODS: At the internal medicine outpatient clinic of the University Medical Centre Utrecht, a 1:1 randomized, parallel-group study (patient conversation aid) was combined with a pre-post intervention (physicians' training) design. Primary outcome was patient satisfaction, secondary outcomes were patient-doctor relationship, shared-decision-making, doctor preparedness and patient appreciation of the conversation aid. RESULTS: Between October 2018 and February 2020 11 physicians (36% residents, 73% female) and 185 patients (median age 58 years (interquartile range (IQR) 50-68), 60% male) participated. Only 28% of the patients reported a care decision discussion during the consultation. We found no effect of the interventions on patient satisfaction (effect sizes -0.14 (95% confidence interval (CI) -0.56-0.27) for conversation aid; 0.04 (95% CI -0.40-0.48) for physician's training), nor on the patient-doctor relationship or shared-decision-making. However, physicians felt more prepared to discuss care decisions after training (median 3 (IQR 1-4) vs 1 (IQR 0-3), p = 0.015). Patients assessed the conversation aid informative and gave an overall mark of median 7 (IQR 7-8). CONCLUSIONS: First steps towards fruitful discussions about care decisions were made: patients considered the conversation aid informative and physicians felt better prepared to discuss care decisions after training. The low number of care decision conversations patients reported shows exactly how important it is to focus on interventions that facilitate these discussions, for both the patient and physician. Further work needs to be done to establish the best way to empower patients and physicians. TRIAL REGISTRATION: Dutch trial register, trial 6998 (NTR 7188), registered 04/05/2018, https://www.trialregister.nl/trial/6998 .

Discussing care decisions at the internal medicine outpatient clinic: A conversation analysis.

OBJECTIVE: Explore how often, when and how care decisions are discussed during consultations at an internal medicine outpatient clinic, and what we can learn from these observations. METHODS: Qualitative analysis of 150 video-taped consultations. Consultations involving a discussion of care decisions were analyzed using conversation analysis. RESULTS: 1) Only 21 of the 150 consultations involved a discussion of care decisions; 2) As there is no destined phase for the introduction of the topic of care decisions, the topic is most often introduced at the end of the phase 'treatment and course of the disease'; 3) A lot of interactional effort is needed to create common ground and make relevance clear with extensive justification. Hesitation markers, repairs and hypothetical talk show the precariousness of the topic. CONCLUSIONS: Three dilemma's need to be addressed: 1) a slot has to be created to introduce the topic of care decisions; 2) common ground has to be created, possibly over time; 3) the paradox of framing the topic as relevant 'in the future' but 'needs to be discussed now' needs to be attended to. PRACTICE IMPLICATIONS: We recommend that physician training should address the three dilemmas. Future research should focus on how to do so.

Code status documentation at admission in COVID-19 patients: a descriptive cohort study.

OBJECTIVES: The COVID-19 pandemic pressurised healthcare with increased shortage of care. This resulted in an increase of awareness for code status documentation (ie, whether limitations to specific life-sustaining treatments are in place), both in the medical field and in public media. However, it is unknown whether the increased awareness changed the prevalence and content of code status documentation for COVID-19 patients. We aim to describe differences in code status documentation between infectious patients before the pandemic and COVID-19 patients. SETTING: University Medical Centre of Utrecht, a tertiary care teaching academic hospital in the Netherlands. PARTICIPANTS: A total of 1715 patients were included, 129 in the COVID-19 cohort (a cohort of COVID-19 patients, admitted from March 2020 to June 2020) and 1586 in the pre-COVID-19 cohort (a cohort of patients with (suspected) infections admitted between September 2016 to September 2018). PRIMARY AND SECONDARY OUTCOME MEASURES: We described frequency of code status documentation, frequency of discussion of this code status with patient and/or family, and content of code status. RESULTS: Frequencies of code status documentation (69.8% vs 72.7%, respectively) and discussion (75.6% vs 73.3%, respectively) were similar in both cohorts. More patients in the COVID-19 cohort than in the before COVID-19 cohort had any treatment limitation as opposed to full code (40% vs 25%). Within the treatment limitations, 'no intensive care admission' (81% vs 51%) and 'no intubation' (69% vs 40%) were more frequently documented in the COVID-19 cohort. A smaller difference was seen in 'other limitation' (17% vs 9%), while 'no resuscitation' (96% vs 92%) was comparable between both periods. CONCLUSION: We observed no difference in the frequency of code status documentation or discussion in COVID-19 patients opposed to a pre-COVID-19 cohort. However, treatment limitations were more prevalent in patients with COVID-19, especially 'no intubation' and 'no intensive care admission'.

[Long term effects of Kawasaki disease]. / Langetermijneffecten van de ziekte van Kawasaki.

Kawasaki Disease (KD) is an acute, self-limiting, vasculitis typically occurring in children under the age of five. Less than 5% of children with KD develop coronary aneurysms and require follow-up by a (paediatric) cardiologist. The majority of patients do not receive follow-up care. However, recent data suggest that the inflammation associated with KD has the potential to affect the entire cardiovascular system. Patients with a history of KD may have an increased risk of long-term cardiovascular sequelae. Therefore KD should be considered a cardiovascular risk factor.