Perspective of geriatric patients on advance care planning in Denmark: a qualitative study.

OBJECTIVE: Most previous studies on advance care planning (ACP) have focused on patients with specific diseases and only a few on frail ageing individuals. We therefore decided to examine the perspective of geriatric patients on ACP. Our research questions include if, when, with whom and with which content geriatric patients wish to have ACP conversations. DESIGN: Participants were interviewed either in the hospital or in their own home. The interviewer followed a semistructured interview guide. Interviews were transcribed and analysed using the systemic text condensation method. SETTING: Geriatric department in a regional hospital in a rural area in Region Zealand, Denmark. PARTICIPANTS: We included 11 geriatric patients aged above 65 who had been referred for geriatric inpatient or outpatient assessment. Participants were clinically judged by experienced geriatricians to have sufficient physical and mental capacity to take part in an interview. RESULTS: This study's main finding is that geriatric patients have varying preferences and feelings towards ACP. Some expressed concerns about ACP, especially regarding personal fear to talk about end-of-life (EOL) decisions, and whether a busy healthcare system has the resources to conduct ACP. Proper timing of ACP seemed unrelated to specific age but related to perception of health situation. The health professional involved should be well trained and a person the participant could trust. Most participants wanted family members to participate. Concerning content, participants mentioned quality of life, fear of losing their spouse, earlier experience with death, and practical concerns regarding funeral and will. CONCLUSION: Among geriatric patients, feelings towards ACP are mixed. Even participants who were generally positive towards the concept uttered concerns about the circumstances when talking about EOL topics. Health professionals therefore should approach ACP discussions with caution. Further studies aiming to develop guidelines describing the proper way to introduce and perform ACP in this patient group are needed.

Feasibility, quality and validity of narrative multisource feedback in postgraduate training: a mixed-method study.

OBJECTIVES: To examine a narrative multisource feedback (MSF) instrument concerning feasibility, quality of narrative comments, perceptions of users (face validity), consequential validity, discriminating capacity and number of assessors needed. DESIGN: Qualitative text analysis supplemented by quantitative descriptive analysis. SETTING: Internal Medicine Departments in Zealand, Denmark. PARTICIPANTS: 48 postgraduate trainees in internal medicine specialties, 1 clinical supervisor for each trainee and 376 feedback givers (respondents). INTERVENTION: This study examines the use of an electronic, purely narrative MSF instrument. After the MSF process, the trainee and the supervisor answered a postquestionnaire concerning their perception of the process. The authors coded the comments in the MSF reports for valence (positive or negative), specificity, relation to behaviour and whether the comment suggested a strategy for improvement. Four of the authors independently classified the MSF reports as either 'no reasons for concern' or 'possibly some concern', thereby examining discriminating capacity. Through iterative readings, the authors furthermore tried to identify how many respondents were needed in order to get a reliable impression of a trainee. RESULTS: Out of all comments coded for valence (n=1935), 89% were positive and 11% negative. Out of all coded comments (n=4684), 3.8% were suggesting ways to improve. 92% of trainees and supervisors preferred a narrative MSF to a numerical MSF, and 82% of the trainees discovered performance in need of development, but only 53% had made a specific plan for development. Kappa coefficients for inter-rater correlations between four authors were 0.7-1. There was a significant association (p<0.001) between the number of negative comments and the qualitative judgement by the four authors. It was not possible to define a specific number of respondents needed. CONCLUSIONS: A purely narrative MSF contributes with educational value and experienced supervisors can discriminate between trainees' performances based on the MSF reports.

Frequency and Impact of Hyponatremia on All-Cause Mortality in Patients With Aortic Stenosis.

Asymptomatic aortic stenosis (AS) is a frequent condition that may cause hyponatremia due to neurohumoral activation. We examined if hyponatremia heralds poor prognosis in patients with asymptomatic AS, and whether AS in itself is associated with increased risk of hyponatremia. The study question was investigated in 1,677 individuals that had and annual plasma sodium measurements in the SEAS (Simvastatin and Ezetimibe in AS) trial; 1,873 asymptomatic patients with mild-moderate AS (maximal transaortic velocity 2.5 to 4.0 m/s) randomized to simvastatin/ezetimibe combination versus placebo. All-cause mortality was the primary endpoint and incident hyponatremia (P-Na+ <137 mmol/L) a secondary outcome. At baseline, 4% (n = 67) had hyponatremia. After a median follow-up of 4.3 (interquartile range 4.1 to 4.6) years, 140 (9%) of those with initial normonatremia had developed hyponatremia, and 174 (10%) had died. In multiple regression Cox models, both baseline hyponatremia (hazard ratio [HR] 2.1, [95% confidence interval 1.1 to 3.8]) and incident hyponatremia (HR 1.9, [95% confidence interval 1.0 to 3.4], both p ≤ .03) was associated with higher all-cause mortality as compared with normonatremia. This association persisted after adjustment for diuretics as a time-varying covariate. Higher N-terminal pro b-type natriuretic peptide levels and lower sodium levels at baseline was associated with higher risk of incident hyponatremia. Conversely, assignment to simvastatin/ezetimibe protected against incident hyponatremia. In conclusion, both prevalent and incident hyponatremia associate with increased mortality in patients with AS. The prevalence of hyponatremia is around 4% and the incidence about 2% per year, which is comparable to that of older adults without AS.

Right atrial and ventricular function evaluated with speckle tracking in patients with acute pulmonary embolism.

AIMS: Assessment of right ventricular (RV) function in acute pulmonary embolism (PE) has prognostic significance. The aim of this study was to evaluate right atrium (RA) and RV myocardial damage with 2-dimensional speckle-tracking in patients with an acute central vs an acute peripheral PE. METHODS AND RESULTS: Twenty-six patients with acute PE and 10 controls were retrospectively enrolled. Right atrium and RV myocardial deformation was analyzed using speckle-tracking imaging echocardiography. Parameters were evaluated to illustrate myocardial damage in patients with a central or a peripherally located PE. Thirteen of the enrolled patients had a massive central PE, and thirteen subjects had a peripheral located PE. Baseline characteristics were not significantly different between the 3 groups besides a more elevated heart rate among patients with a central PE (P = .02) and a tendency of an increased D-dimer in this group. Right ventricular dimensions were more affected among patients with a PE. Compared with controls, segmental RV and RA strain/strain rate in the free wall was significantly reduced in patients with PE (P < .05). No difference was shown between the 2 groups of PE. CONCLUSION: This pilot study suggests that basal-/mid-segments of RA and RV free wall are more affected in patients with a PE compared with controls. Interestingly, we found no significant difference in myocardial RA and RV damage between patients with a central and a peripheral PE. We advocate that PE no matter central or peripheral is a serious condition and that a peripheral PE has to be intensively treated similar to a central PE.

[Assessment of the prognosis in patients who remain comatose after resuscitation from cardiac arrest]. / Vurdering af prognose hos patienter med manglende opvågning efter hjertestop

In Denmark there are around 3,500 unexpected cardiac arrests (CA) out of hospital each year. There is an unknown number of CA in hospitals. The survival rate after CA outside a hospital in Denmark is 10% after 30 days. There are varying data for the neurological outcome in this group of patients. The purpose of this work is to disseminate new knowledge and to help standardizing the treatment in the group of patients who remain comatose after being resuscitated from CA. Assessment of the prognosis for a patient in this group can be made after 72 hours and a multi-modal approach to the patient is required.

In-hospital cardiac arrest: characteristics and outcome after implementation of systematic practice-oriented training.

Survival after in-hospital cardiac arrest (CA) has been reported to be surprisingly low without any major improvement during the last decade. Cardiopulmonary resuscitation (CPR) quality affects survival after CA, and specific education is necessary for health care professionals participating in CPR. Decisions regarding CPR and do not attempt resuscitation (DNAR) orders remain demanding, as does including patients in the process. Addressed training regarding CPR/DNAR orders is necessary to improve the CPR/DNAR decision process used by physicians. The aim of this retrospective study is to evaluate the clinical impact (return of spontaneous circulation and 21-day survival after CA) of an intervention within one single hospital, including a systematic education of all health care professionals in CPR. In total, there were 33 in-hospital CAs before (12 months) and 176 after (36 months) the intervention. No significant difference was found between the 2 calendar periods.

[Life-saving prehospital interventions]. / Livreddende praehospital indsats.

INTRODUCTION: The Mobile Emergency Care Unit (MECU) in Copenhagen provides prehospital healthcare for the citizens in the Capital Region in case of acute illness or accidents. The aim of this study was to describe the patients whose treatment was categorized by the MECU as lifesaving and to compare these with all other patients. MATERIAL AND METHODS: We analysed the MECU database contents and ambulance records from 2005 with emphasis on treatment and diagnosis. Data related to admission to hospital and 30-day survival were retrieved via the Central Population Registry. RESULTS: A total of 296 treatments were classified as lifesaving in 2005, corresponding to 4.3% of all patient contacts in 2005. The most frequent diagnoses were "opioid-poisoning" and cardiac arrest. The treatment given in those cases was lifesaving in 34% and 16%, respectively. This is significantly higher than in the cases of convulsions/unconsciousness and trauma where only 0.6% and 6% of the treatments were lifesaving, respectively. After 30 days, 60.4% of the patients who received lifesaving treatment were alive. We found considerable differences among the individual diagnoses regarding both the 30-day survival and the hospitalization frequency. CONCLUSION: Approximately 4% of patient contacts in 2005 were classified as lifesaving, they were most frequently related to opioid-poisoning and cardiac arrest. A total of 60% of the patients were alive 30 days after the intervention.