In Lumbar Fusion Patients, How Does Establishing a Comfort Function Goal Preoperatively Impact Postoperative Pain Scores?

The purpose of this feasibility study was to determine the impact of establishing a comfort function goal preoperatively on postoperative pain scores and opiate requirements in lumbar fusion patients. A comfort function goal is defined as the pain score identified by the patient describing the level of pain tolerance to participate in healing activities such as deep breathing, ambulation and participation in activities of daily living. The design was prospective, nonrandomized, intervention group (n = 30) compared with retrospective chart review as control group (n = 30). Sample included patients scheduled for routine lumbar fusion in an urban southeastern hospital. The study intervention established a comfort function goal during a routine preoperative patient education class. No significant difference in pain score or opiate requirement was found for these data. However, a fundamental clinical question arose surrounding opiate requirements and dosing management. In our hospital, the norm for postoperative pain management is to categorize pain scores as mild (1-3), moderate (4-6), and severe (7-10) pain. Physician orders commonly use this differential to order opiate dose ranges. In this sample, the mean pain score for the intervention group at home is 5.8 and the mean comfort function goal is 4.9. Based on normative categories of pain scores, if a patient's baseline of tolerable pain is 4.9, this has potential impact on clinician responses to managing pain, as 4.9-5.8 is, for this patient, perhaps a mild range of pain, not moderate. If a patient reports a pain score of 7, and their norm is 5.8, the delta is only 1.2. Does this imply that the patient is experiencing mild or severe pain? Does the nurse deliver a dose of pain medication that is in the mild or severe dose range?

Investigating critically ill patients' and families' perceptions of likelihood of survival.

OBJECTIVE: This study investigated the perception of chance for survival among critically ill patients and surrogates and compared those perceptions to actual survival and to clinical estimates of illness severity. Secondary aims explored whether select demographic, clinical, or personal measures were associated with different perceptions of chance for survival. DESIGN: Prospective, sequential, observational, survey-based study. Primary measures were perception of chance for survival as compared to actual survival and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. SETTING: Tertiary care, academic medical intensive care unit (MICU). PATIENTS: Subjects were English-speaking adult MICU patients with a MICU length-of-stay greater than three days or their surrogates (n = 100). RESULTS: Respondents tended to be more optimistic regarding chance for survival than supported by actual survival (p = 0.07) or APACHE II tertile (p = 0.34). Secondary analyses found African American race, faith, or religion impacting health decision-making, and higher health status reports were associated with more optimistic perceptions of chance for survival. CONCLUSION: Patient/surrogate perceptions of chance for survival were not associated with either actual MICU survival or illness severity (APACHE II) highlighting an opportunity to better inform critically ill patients and families regarding prognosis. Clinician recognition of patients' and families' backgrounds and values might set the stage for such discussions.

Lack of concordance between physician and patient: reports on end-of-life care discussions.

OBJECTIVE: To study the effectiveness of patient physician communications regarding health care choices at the end of life. We studied communications occurring between physicians and their patients who had either terminal cancer or congestive heart failure, with less than 6 months to live. METHODS: This pilot study used in-person interviews with 22 physicians and 71 of their (matched) patients. Subjects provided paired responses to questions regarding their conversations related to end-of-life care, including resources, attitudes, and preferences. We calculated the concordance of patient and physician reports about these discussions. We examined the physicians' and the patients' agreement on the patient's diagnosis, and on whether a variety of care options were discussed. We then measured whether physicians' were aware of their patients' preferences for pain management and for place of death. Finally, we measured physicians' knowledge of whether religious/spiritual concerns or financial concerns had affected their patients' decisions regarding end-of-life care. Both bivariate and multivariate models were used. RESULTS: As a whole, the concordance scores were poor; however, concordance varied across domains of issues discussed. Patients with less education had significantly lower concordance scores. DISCUSSION: We have identified domains in which the physicians and patients may be least effective in discussing end-of-life care options. Findings may help in designing interventions to improve communication, especially for patients with less education.

Care at the end of life: focus on communication and race.

OBJECTIVE: To profile communication and recommendations reported by adults with terminal illness and explore differences by patient and physician characteristics. METHOD: This pilot was a cross-sectional study sample of 90 patients (39 Caucasian, 51 African American) with advanced heart failure or cancer. Participants completed an in-person, race-matched interview. RESULTS: Participation was high (94%). DISCUSSION: For example, only 30% reported discussion of advance directives, and 22% reported their physician inquired about spiritual support. Participants with cancer were significantly more likely to be receiving pain and/or symptom management at home, aware of prognosis, and participating in hospice. African American participants who were under the care of African American physicians were less likely to report pain and/or symptom management than other racial matches.Discussion: Although additional research on factors related to communication is important, initiation of patient-centered counseling by all physicians with seriously ill patients is essential.

Physician perspectives on end-of-life care: factors of race, specialty, and geography.

OBJECTIVES: To describe physicians' end-of-life practices, perceptions regarding end-of-life care and characterize differences based upon physician specialty and demographic characteristics. To illuminate physicians' perceptions about differences among their African-American and Caucasian patients' preferences for end-of-life care. DESIGN AND METHODS: Twenty-four African-American and 16 Caucasian physicians (N=40) participated in an in-person interview including 23 primary care physicians, 7 cardiologists, and 10 oncologists. Twenty-four practices were in urban areas and 16 were in rural counties. RESULTS: Physicians perceived racial differences in preferences for end-of-life care between their Caucasian and African-American patients. Whereas oncologists and primary care physicians overwhelmingly reported having working relationships with hospice, only 57% of cardiologists reported having those contacts. African-American physicians were more likely than Caucasian physicians to perceive racial differences in their patients preferences for pain medication. SIGNIFICANCE OF RESULTS: Demographic factors such as race of physician and patient may impact the provider's perspective on end-of-life care including processes of care and communication with patients.

An interdisciplinary workshop to improve palliative care: advanced heart failure--clinical guidelines and healing words.

OBJECTIVE: Effective communication is recognized as an essential process to providing quality care, including palliative and end-of-life care. Discussion of prognosis and support needs of patients with heart failure is particularly challenging given the nature of the condition and care across several settings. The objective was to design, implement, and evaluate an interdisciplinary workshop aimed at improving attitudes and skills related to communication with patients and family, health team communication and documentation, and assessment of physical and emotional symptoms. METHODS: A pretest, delayed posttest evaluation design was used to evaluate two 4-h workshops offered to nurses, social workers, and other nonphysician clinicians. RESULTS: Although baseline reports of skills were high for the participants, significant improvement was noted for objectives emphasized in the workshop. SIGNIFICANCE OF RESULTS: This project demonstrated the feasibility of designing, marketing a brief workshop, and positively impacting communication and documentation skills.

End-of-life communication and hospital nurses: an educational pilot.

Heart failure is a high prevalence, high burden disease with an unpredictable trajectory. Given that approximately 50% of persons with the diagnosis die within 5 years, the implications for communication about advance planning and end of life, although simultaneously providing hope and treatment, are extremely challenging. This article reports on a feasibility trial of a modest continuing education seminar to increase awareness and communication skills of inpatient nurses. Curriculum design details, including objectives and methods, are described. Needs assessment and evaluation data are reported. At the 2-month posttest, a summary communications skill score showed significant improvement. Data also illustrated that the challenge of facing issues about dying are complicated by a work force of relatively young staff and low exposure to few actual deaths during relatively short lengths of stay.