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Schuler K, Jung IC, Zerlik M, Hahn W, Sedlmayr M, Sedlmayr B. Context factors in clinical decision-making: a scoping review. BMC Med Inform Decis Mak 2025; 25:133. [PMID: 40098142 PMCID: PMC11912758 DOI: 10.1186/s12911-025-02965-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Accepted: 03/10/2025] [Indexed: 03/19/2025] Open
Abstract
BACKGROUND Clinical decision support systems (CDSS) frequently exhibit insufficient contextual adaptation, diminishing user engagement. To enhance the sensitivity of CDSS to contextual conditions, it is crucial first to develop a comprehensive understanding of the context factors influencing the clinical decision-making process. Therefore, this study aims to systematically identify and provide an extensive overview of contextual factors affecting clinical decision-making from the literature, enabling their consideration in the future implementation of CDSS. METHODS A scoping review was conducted following the PRISMA-ScR guidelines to identify context factors in the clinical decision-making process. Searches were performed across nine databases: PubMed, APA PsycInfo, APA PsyArticles, PSYINDEX, CINAHL, Scopus, Embase, Web of Science, and LIVIVO. The search strategy focused on combined terms related to contextual factors and clinical decision-making. Included articles were original research articles written in English or German that involved empirical investigations related to clinical decision-making. The identified context factors were categorized using the card sorting method to ensure accurate classification. RESULTS The data synthesis included 84 publications, from which 946 context factors were extracted. These factors were assigned to six primary entities through card sorting: patient, physician, patient's family, institution, colleagues, and disease treatment. The majority of the identified context factors pertained to individual characteristics of the patient, such as health status and demographic attributes, as well as individual characteristics of the physician, including demographic data, skills, and knowledge. CONCLUSION This study provides a comprehensive overview of context factors in clinical decision-making previously investigated in the literature, highlighting the complexity and diversity of contextual influences on the decision-making process. By offering a detailed foundation of identified context factors, this study paves the way for future research to develop more effective, context-sensitive CDSS, enhancing personalized medicine and optimizing clinical outcomes with implications for practice and policy.
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Affiliation(s)
- Katharina Schuler
- Institute for Medical Informatics and Biometry, Faculty of Medicine, University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Fetscherstraße 74, 01307, Dresden, Germany.
| | - Ian-C Jung
- Institute for Medical Informatics and Biometry, Faculty of Medicine, University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Fetscherstraße 74, 01307, Dresden, Germany
| | - Maria Zerlik
- Institute for Medical Informatics and Biometry, Faculty of Medicine, University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Fetscherstraße 74, 01307, Dresden, Germany
| | - Waldemar Hahn
- Institute for Medical Informatics and Biometry, Faculty of Medicine, University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Fetscherstraße 74, 01307, Dresden, Germany
- Center for Scalable Data Analytics and Artificial Intelligence (ScaDS.AI), Dresden/Leipzig, Dresden, Germany
| | - Martin Sedlmayr
- Institute for Medical Informatics and Biometry, Faculty of Medicine, University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Fetscherstraße 74, 01307, Dresden, Germany
| | - Brita Sedlmayr
- Institute for Medical Informatics and Biometry, Faculty of Medicine, University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Fetscherstraße 74, 01307, Dresden, Germany
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Dotolo DG, Pytel CC, Nielsen EL, Uyeda AM, Im J, Engelberg RA, Khandelwal N. Time to Talk Money? Intensive Care Unit Clinicians' Perspectives on Addressing Patients' Financial Hardship. Am J Crit Care 2025; 34:137-144. [PMID: 40021345 DOI: 10.4037/ajcc2025476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2025]
Abstract
BACKGROUND Critically ill patients and their families commonly experience financial hardship, yet this experience is inadequately addressed by clinicians providing care in the intensive care unit. Understanding clinicians' perspectives on the barriers to addressing financial hardship provides an opportunity to identify and mitigate those barriers and improve patient outcomes. OBJECTIVE To characterize intensive care unit clinicians' experiences with and perceived barriers to addressing financial hardship with their patients. METHODS The study entailed a thematic analysis of semistructured interviews of 17 physicians, nurses, and social workers providing care to critically ill patients in a large academic health care system in the US Pacific Northwest. RESULTS Participants recognized the importance of addressing financial hardship as an integral part of patient-centered care but identified barriers influencing their comfort with and capacity to address financial hardship. Barriers fit into 2 themes: "(dis)comfort addressing financial hardship" and "values-based concerns." (Dis)comfort addressing financial hardship was influenced by systems- and practice-based barriers. Participants discussed concerns about real and perceived conflicts of interest when patient, family, clinician, and institutional priorities were not aligned. CONCLUSIONS Participants recognized financial hardship as an important consequence of critical illness that negatively affected patient and family outcomes, yet they described barriers to adequately addressing this topic. Normalizing discussions about the financial impacts of critical illness and systematically screening for financial hardship may be a first step in mitigating these barriers.
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Affiliation(s)
- Danae G Dotolo
- Danae G. Dotolo is a research assistant professor, Cambia Palliative Care Center of Excellence and Department of Medicine, Division of Pulmonary, Critical Care, & Sleep Medicine, University of Washington, Harborview Medical Center, Seattle
| | - C Clare Pytel
- C. Clare Pytel is a research coordinator, Cambia Palliative Care Center of Excellence and Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle
| | - Elizabeth L Nielsen
- Elizabeth L. Nielsen is a research coordinator, Cambia Palliative Care Center of Excellence and Department of Medicine, Division of Pulmonary, Critical Care, & Sleep Medicine, University of Washington, Harborview Medical Center, Seattle
| | - Alison M Uyeda
- Alison M. Uyeda is a clinical and research fellow, Cambia Palliative Care Center of Excellence and Department of Medicine, Division of Pulmonary, Critical Care, & Sleep Medicine, University of Washington, Harborview Medical Center, Seattle
| | - Jennifer Im
- Jennifer Im is a doctoral candidate, Department of Health Systems and Population Health, University of Washington, Seattle
| | - Ruth A Engelberg
- Ruth A. Engelberg is a research professor emeritus, Cambia Palliative Care Center of Excellence and Department of Medicine, Division of Pulmonary, Critical Care, & Sleep Medicine, University of Washington, Harborview Medical Center, Seattle
| | - Nita Khandelwal
- Nita Khandelwal is an associate professor, Cambia Palliative Care Center of Excellence and Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle
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Jensen HI, Bülow HH, Dierickx L, Vansteelandt S, Vaschetto R, Élö G, Piers R, Benoit DD. Perceptions of ethical decision-making climate among clinicians working in European and US ICUs: differences between religious and non-religious healthcare professionals. BMC Med Ethics 2025; 26:21. [PMID: 39910490 PMCID: PMC11796059 DOI: 10.1186/s12910-025-01178-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 01/28/2025] [Indexed: 02/07/2025] Open
Abstract
BACKGROUND Making appropriate end-of-life decisions in the intensive care unit (ICU) requires shared interprofessional decision-making. Thus, a decision-making climate that values the contributions of all team members, addresses diverse opinions and seeks consensus among team members is necessary. Little is known about religion's influence on ethical decision-making climates. Therefore, this study aimed to examine the association between religious belief and ethical decision-making climates. METHODS The study was a cross-sectional analytical observation study as a part of the prospective observational DISPROPRICUS study. A total of 2,275 nurses and 717 physicians from 68 ICUs representing 12 countries in Europe and the US participated. All participants were asked which religion (if any) they belonged to and how important their religion (if any) was for their professional attitude towards end-of-life care. Perceptions of ethical decision-making climates were evaluated using a validated, 35-item self-assessment questionnaire that evaluates seven factors. Using cluster analysis, ICUs were categorised into four ethical decision-making climates: good, average (with nurses' involvement at the end of life), average (without nurses' involvement at the end of life) and poor. RESULTS Of the 2,992 participants, 453 (15%) were religious (had religious convictions and found them important or very important for their attitude towards end-of-life care). The remaining 2,539 were non-religious (i.e. had religious convictions but assessed that they were not important for their attitude towards end-of-life care). When adjusting for country and ICU, the overall perception of the four ethical climates was associated with religious beliefs, with non-religious healthcare providers having more positive perceptions of the ethical climates compared to religious healthcare providers (p < 0.01). Within good climates, non-religious healthcare providers rated leadership by physicians (p < 0.01), interdisciplinary reflection (p = 0.049) and active decision-making by physicians (p = 0.02) as more positive compared to religious participants. In poor climates, religious healthcare providers had a more positive perception of the active involvement of nurses (p = 0.01). Within the other climates, no differences were found. CONCLUSIONS Overall perceptions of ethical decision-making climates were associated with religious beliefs, with non-religious healthcare providers generally having a more positive perception of the ethical climates than religious healthcare providers.
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Affiliation(s)
- Hanne Irene Jensen
- Departments of Anaesthesiology and Intensive Care, Vejle Hospital, University Hospital of Southern Denmark, Beriderbakken 4, Vejle, 7100, Denmark.
- Department of Anaesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Sygehusvej 24, Kolding, 6000, Denmark.
- Institute of Regional Health Research, University of Southern Denmark, J.B.Winsløwsvej 19, Odense, 5000, Denmark.
| | - Hans-Henrik Bülow
- Department of Anaesthesiology and Intensive Care, Holbaek Hospital, Smedelundsgade 60, Holbaek, 4300, Denmark
| | - Lucas Dierickx
- Department of Marketing, Innovation and Organisation, Ghent University, Tweekerkenstraat 2, Ghent, 9000, Belgium
| | - Stijn Vansteelandt
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Krijgslaan 281, S9, Ghent, 9000, Belgium
| | - Rosanna Vaschetto
- University of Eastern Piedmont, Via Solaroli 17, Novara, 28100, Italy
| | - Gábor Élö
- Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - Ruth Piers
- Department of Geriatrics, Ghent University Hospital and Ghent University, Corneel Heymanslaan 10, Ghent, 9000, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital and Ghent University, Corneel Heymanslaan 10, Ghent, 9000, Belgium
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Rodriguez-Ruiz E, Latour JM, van Mol MMC. Promoting an inclusive and humanised environment in the intensive care unit: Shift happens. Intensive Crit Care Nurs 2025; 86:103856. [PMID: 39418879 DOI: 10.1016/j.iccn.2024.103856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2024]
Affiliation(s)
- Emilio Rodriguez-Ruiz
- Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain; Simulation, Life Support & Intensive Care Research Unit of Santiago de Compostela (SICRUS), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain; CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Jos M Latour
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China; School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK; Curtin School of Nursing, Curtin University, Perth, Australia.
| | - Margo M C van Mol
- Department of Intensive Care Adults, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Janssen RME, Oerlemans AJM, Bos N, van der Hoeven JG, Oostdijk EAN, Derde LPG, Ten Oever J, Wertheim HFL, Schouten JA, Hulscher MEJL. Duration of antibiotic therapy in the intensive care unit: factors influencing decision-making during multidisciplinary meetings. BMJ Qual Saf 2025:bmjqs-2024-017796. [PMID: 39788727 DOI: 10.1136/bmjqs-2024-017796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 12/23/2024] [Indexed: 01/12/2025]
Abstract
OBJECTIVES In the intensive care unit (ICU), antibiotics are often given longer than recommended in guidelines. A better understanding of the factors influencing antibiotic therapy duration is needed to develop improvement strategies to effectively address these drivers of excessive duration. This study aimed to explore the determinants of adherence to recommended antibiotic therapy durations among healthcare professionals involved in antibiotic decision-making within the ICU, focusing on multidisciplinary meetings (MDMs). METHODS Semistructured interviews were held with healthcare professionals involved in antibiotic decision-making during MDMs in four Dutch ICUs. Participants included intensivists, clinical microbiologists and ICU residents. Transcripts were analysed using deductive and inductive content analysis methods. RESULTS A total of 20 participants were interviewed. The interviews revealed that decision-making regarding antibiotic therapy duration is a complex process, primarily centred around professional interactions during MDMs and involving a broad range of determinants. These determinants were categorised into the following four steps: (1) the introduction of duration as a topic for discussion in the MDM (eg, lack of priority to discuss antibiotic therapy duration); (2) the discussion of antibiotic therapy duration itself (eg, lack of core members during MDM); (3) the establishment of a concrete decision (eg, lack of documentation of the decisions made); (4) the execution of the decision (eg, forgetting to stop antibiotics). CONCLUSIONS Our study identified numerous factors that influence decisions about the duration of antibiotic therapy during MDMs in the ICU. By describing these factors throughout the decision-making process, we provided valuable insights into barriers that commonly arise in specific steps, highlighting critical areas for improvement. Daily MDMs were deemed essential for informed decision-making regarding antibiotic therapy duration by the interviewees. Strategies to improve appropriate duration in the ICU should prioritise strengthening interdisciplinary communication between healthcare professionals and adding structure to these meetings.
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Affiliation(s)
- Robin M E Janssen
- Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, Gelderland, Netherlands
- IQ Health Science Department, Radboud university medical center, Nijmegen, Gelderland, Netherlands
| | - Anke J M Oerlemans
- IQ Health Science Department, Radboud university medical center, Nijmegen, Gelderland, Netherlands
| | - Nynke Bos
- IQ Health Science Department, Radboud university medical center, Nijmegen, Gelderland, Netherlands
| | - Johannes G van der Hoeven
- Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, Gelderland, Netherlands
| | - Evelien A N Oostdijk
- Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, Gelderland, Netherlands
| | - Lennie P G Derde
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, Netherlands
| | - Jaap Ten Oever
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, Netherlands
| | - Heiman F L Wertheim
- Department of Medical Microbiology, Radboud university medical center, Nijmegen, Gelderland, Netherlands
| | - Jeroen A Schouten
- Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, Gelderland, Netherlands
| | - Marlies E J L Hulscher
- IQ Health Science Department, Radboud university medical center, Nijmegen, Gelderland, Netherlands
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Tingsvik C, Henricson M, Hammarskjöld F, Mårtensson J. Physicians' decision making when weaning patients from mechanical ventilation: A qualitative content analysis. Aust Crit Care 2025; 38:101096. [PMID: 39122604 DOI: 10.1016/j.aucc.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Weaning from mechanical ventilation is a complex and central intensive care process. This complexity indicates that the challenges of weaning must be explored from different perspectives. Furthermore, physicians' experiences and the factors influencing their decision-making regarding weaning are unclear. OBJECTIVES This study aimed to explore and describe the factors influencing physicians' decision-making when weaning patients from invasive mechanical ventilation in Swedish intensive care units (ICUs). METHODS This qualitative study used an exploratory and descriptive design with qualitative content analysis. Sixteen physicians from five ICUs across Sweden were purposively included and interviewed regarding their weaning experiences. FINDINGS The physicians expressed that prioritising the patient's well-being was evident, and there was agreement that both the physical and mental condition of the patient had a substantial impact on decision-making. Furthermore, there was a lack of agreement on whether patients should be involved in the weaning process and how their resources, needs, and wishes should be included in decision-making. In addition, there were factors not directly linked to the patient but which still influenced decision-making, such as the available resources and teamwork. Sometimes, it was difficult to point out the basis for decisions; in that decisions were made by gut feeling, intuition, or clinical experience. CONCLUSION Physicians' decision-making regarding weaning was a dynamic process influenced by several factors. These factors were related to the patient's condition and the structure for weaning. Increased understanding of weaning from the physicians' and ICU teams' perspectives may improve the weaning process by broadening the knowledge about the aspects influencing the decision-making.
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Affiliation(s)
- Catarina Tingsvik
- Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping SE-551 11, Sweden; Department of Anaesthesia and Intensive Care Medicine, Ryhov County Hospital, Jönköping SE-55185, Sweden.
| | - Maria Henricson
- Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping SE-551 11, Sweden; Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås SE-501 90, Sweden.
| | - Fredrik Hammarskjöld
- Department of Anaesthesia and Intensive Care Medicine, Ryhov County Hospital, Jönköping SE-55185, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping SE-581 83, Sweden.
| | - Jan Mårtensson
- Department of Nursing Science, School of Health and Welfare, Jönköping University, Jönköping SE-551 11, Sweden.
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Savitsky B, Shvartsur R, Kagan I. Predictors of intention to stay in the profession among novice nurses: a cross-sectional study. Isr J Health Policy Res 2024; 13:75. [PMID: 39716248 DOI: 10.1186/s13584-024-00662-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2024] [Accepted: 12/08/2024] [Indexed: 12/25/2024] Open
Abstract
BACKGROUND Preserving new graduate nurses in the profession is an essential step for addressing the nursing shortage and sustaining the future of the profession. This study aimed to examine the relationship between employment characteristics and job satisfaction of novice nurses and their willingness to stay in the nursing profession in the next 5 years. METHODS Novice nurses' intention to stay in the profession was assessed, considering demographics, employment characteristics, and components of job satisfaction. Among the sample of 216 novice nurses (93% response rate), four components of job satisfaction were extracted and included in the multivariable logistic regression model with the intention to stay in the profession as a dependent variable. RESULTS Professional self-accomplishment was significantly and positively associated with the intention to stay in the profession, with an elevation of one standard deviation in this component associated with more than a two-fold increase in the odds of staying (OR = 2.3, 95% CI 1.3-3.9). This component contributed 10% to the variance in intention to stay. Independently, managerial support also contributed 10% to the variance and was significantly associated with willingness to stay (OR = 1.9, 95% CI 1.2-3.0). Overall, self-accomplishment, managerial support, and healthier organizational culture were significantly associated with novice nurses' intention to stay, whereas work conditions and rewards were not. The multivariable analysis model explained 38.0% of the variance in the intention to stay in the profession. CONCLUSIONS This study found that novice nurses' intention to stay in the profession is highly associated with their self-accomplishment and better managerial support. Thus, to enhance the retention of novice nurses, managers must establish an environment that fosters professional development and support. This involves providing engaging work assignments, facilitating the seamless integration of novice nurses into the team, and offering managerial support and guidance.
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Affiliation(s)
- Bella Savitsky
- Department of Nursing, School of Health Sciences, Ashkelon Academic College, Yitshak Ben Zvi 12, Ashkelon, Israel
| | - Rachel Shvartsur
- Department of Nursing, School of Health Sciences, Ashkelon Academic College, Yitshak Ben Zvi 12, Ashkelon, Israel.
| | - Ilya Kagan
- Department of Nursing, School of Health Sciences, Ashkelon Academic College, Yitshak Ben Zvi 12, Ashkelon, Israel
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Carvajal-Valcárcel A, Benitez E, Lizarbe-Chocarro M, Galán-Espinilla MJ, Vázquez-Calatayud M, Errasti-Ibarrondo B, Choperena A, McCormack B, Tyagi V, La Rosa-Salas V. Translation, Cultural Adaptation, and Validation of the Spanish Version of the Person-Centred Practice Inventory-Staff (PCPI-S). Healthcare (Basel) 2024; 12:2485. [PMID: 39685107 DOI: 10.3390/healthcare12232485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Revised: 11/23/2024] [Accepted: 12/02/2024] [Indexed: 12/18/2024] Open
Abstract
Background: Person-centredness, a global movement in healthcare, is consistent with international developments in healthcare policy. It is important to have instruments to measure person-centred care. The Person-Centred Practice Inventory-Staff (PCPI-S) is an internationally recognized instrument that aims to measure how healthcare staff experience person-centred practice. Aim: To perform the cultural adaptation and psychometric testing of a Spanish version of the PCPI-S (PCPI-S (Sp)). Method: A two-stage research design was implemented as follows: (1) the translation and cultural adaptation of the PCPI-S from English to Spanish using the "Translation and Cultural Adaptation of Patient Reported Outcomes Measures-Principles of Good Practice"; (2) a quantitative cross-sectional survey for the psychometric evaluation of the PCPI-S. Test-retest reliability was evaluated using the Kendall tau concordance coefficient, internal reliability was assessed through the ordinal theta (OT) coefficient, and confirmatory factor analysis was performed to examine the theoretical measurement model. Results: A Spanish version of the PCPI-S was obtained. There were no significant difficulties in the translation process or the consulting sessions. A sample of 287 healthcare professionals participated in the study at least once. All the items showed at least a fair level of test-retest reliability. The OT scores were adequate (>0.69). The model showed good to adequate levels of fit: CFI = 0.89, SRMR = 0.068; RMSEA = 0.060 with CI90% (0.056-0.063). Conclusions: The Spanish translation of the PCPI-S was psychometrically valid when tested with Spanish healthcare professionals. This instrument will help identify professionals' perceptions of person-centred practice, track the evolution of this practice over time, and assess interventions aimed at improving person-centred practice.
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Affiliation(s)
- Ana Carvajal-Valcárcel
- Facultad de Enfermería, Universidad de Navarra, 31008 Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Edgar Benitez
- Instituto de Ciencia de los Datos e Inteligencia Artificial (DATAI), Universidad de Navarra, 31009 Pamplona, Spain
- Tecnun Escuela de Ingeniería, Universidad de Navarra, 20018 San Sebastián, Spain
| | - Marta Lizarbe-Chocarro
- Facultad de Enfermería, Universidad de Navarra, 31008 Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - María José Galán-Espinilla
- Centro de Salud de Ultzama, Servicio Navarro de Salud-Osasunbidea, 31003 Pamplona, Spain
- Gerencia de Atención Primaria de Navarra, Servicio Navarro de Salud-Osasunbidea, 31003 Pamplona, Spain
| | - Mónica Vázquez-Calatayud
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
- Área de Desarrollo Profesional e Investigación en Enfermería, Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - Begoña Errasti-Ibarrondo
- Facultad de Enfermería, Universidad de Navarra, 31008 Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Ana Choperena
- Facultad de Enfermería, Universidad de Navarra, 31008 Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Brendan McCormack
- Susan Wakil School of Nursing and Midwifery, University of Sydney, Sydney 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney 2050, Australia
| | - Vaibhav Tyagi
- Susan Wakil School of Nursing and Midwifery, University of Sydney, Sydney 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney 2050, Australia
| | - Virginia La Rosa-Salas
- Facultad de Enfermería, Universidad de Navarra, 31008 Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
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Mehta AB, Lockhart S, Lange AV, Matlock DD, Douglas IS, Morris MA. Identifying Decisional Needs for Adult Tracheostomy and Prolonged Mechanical Ventilation Decision Making to Inform Shared Decision-Making Interventions. Med Decis Making 2024; 44:867-879. [PMID: 39082480 PMCID: PMC11543511 DOI: 10.1177/0272989x241266246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
BACKGROUND Decision making for adult tracheostomy and prolonged mechanical ventilation is emotionally complex. Expectations of surrogate decision makers and physicians rarely align. Little is known about what surrogates need to make goal-concordant decisions. Currently, little is known about the decisional needs of surrogates and providers, impeding efforts to improve the decision-making process. METHODS Using a thematic analysis approach, we performed a qualitative study with semistructured interviews with surrogates of adult patients receiving mechanical ventilation (MV) being considered for tracheostomy and physicians routinely caring for patients receiving MV. Recruitment was stopped when thematic saturation was reached. We describe the decision-making process, identify core decisional needs, and map the process and needs for possible elements of a future shared decision-making tool. RESULTS Forty-three participants (23 surrogates and 20 physicians) completed interviews. Hope, Lack of Knowledge Data, and Uncertainty emerged as the 3 main themes that described the decision-making process and were interconnected with one another and, at times, opposed each other. Core decisional needs included information about patient wishes, past activity/medical history, short- and long-term outcomes, and meaningful recovery. The themes were the lens through which the decisional needs were weighed. Decision making existed as a balance between surrogate emotions and understanding and physician recommendations. CONCLUSIONS Tracheostomy and prolonged MV decision making is complex. Hope and Uncertainty were conceptual themes that often battled with one another. Lack of Knowledge & Data plagued both surrogates and physicians. Multiple tangible factors were identified that affected surrogate decision making and physician recommendations. IMPLICATIONS Understanding this complex decision-making process has the potential to improve the information provided to surrogates and, potentially, increase the goal-concordant care and alignment of surrogate and physician expectations. HIGHLIGHTS Decision making for tracheostomy and prolonged mechanical ventilation is a complex interactive process between surrogate decision makers and providers.Qualitative themes of Hope, Uncertainty, and Lack of Knowledge & Data shared by both providers and surrogates were identified and described the decision-making process.Concrete decisional needs of patient wishes, past activity/medical history, short- and long-term outcomes, and meaningful recovery affected each of the larger themes and represented key information from which surrogates and providers based decisions and recommendations.The qualitative themes and decisional needs identified provide a roadmap to design a shared decision-making intervention to improve adult tracheostomy and prolonged mechanical ventilation decision making.
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Affiliation(s)
- Anuj B Mehta
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health & Hospital Association, Denver, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. National Jewish Health, Denver, CO
| | - Steven Lockhart
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Daniel D Matlock
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
- Division of Geriatric Medicine. Department of Medicine. University of Colorado School of Medicine. Aurora, CO
- Veteran’s Affairs Eastern Colorado Geriatric Research Education and Clinical Center. Aurora, CO
| | - Ivor S Douglas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health & Hospital Association, Denver, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Megan A Morris
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
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10
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Kesecioglu J, Rusinova K, Alampi D, Arabi YM, Benbenishty J, Benoit D, Boulanger C, Cecconi M, Cox C, van Dam M, van Dijk D, Downar J, Efstathiou N, Endacott R, Galazzi A, van Gelder F, Gerritsen RT, Girbes A, Hawyrluck L, Herridge M, Hudec J, Kentish-Barnes N, Kerckhoffs M, Latour JM, Malaska J, Marra A, Meddick-Dyson S, Mentzelopoulos S, Mer M, Metaxa V, Michalsen A, Mishra R, Mistraletti G, van Mol M, Moreno R, Nelson J, Suñer AO, Pattison N, Prokopova T, Puntillo K, Puxty K, Qahtani SA, Radbruch L, Rodriguez-Ruiz E, Sabar R, Schaller SJ, Siddiqui S, Sprung CL, Umbrello M, Vergano M, Zambon M, Zegers M, Darmon M, Azoulay E. European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit. Intensive Care Med 2024; 50:1740-1766. [PMID: 39361081 PMCID: PMC11541285 DOI: 10.1007/s00134-024-07579-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/28/2024] [Indexed: 11/07/2024]
Abstract
The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research.
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Affiliation(s)
- Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Katerina Rusinova
- Department of Palliative Medicine, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Daniela Alampi
- Sapienza University of Rome, A.O.U. Sant'Andrea, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Julie Benbenishty
- Faculty of Medicine, School of Nursing, Hebrew University, Jerusalem, Israel
| | - Dominique Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| | | | - Maurizio Cecconi
- Biomedical Sciences Department, Humanitas University, Milan, Italy
- Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Christopher Cox
- Division of Pulmonary and Critical Care Medicine, Duke University, Durham, NC, USA
| | - Marjel van Dam
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Diederik van Dijk
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - James Downar
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Bruyere Research Institute, Ottawa, Canada
| | - Nikolas Efstathiou
- School of Nursing and Midwifery, University of Birmingham, Birmingham, UK
| | - Ruth Endacott
- National Institute for Health and Care Research, London, UK
| | | | | | - Rik T Gerritsen
- Centrum Voor Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Armand Girbes
- Department of Critical Care, AmsterdamUMC Location VUmc, Amsterdam, The Netherlands
| | - Laura Hawyrluck
- Interdepartmental Division Critical Care Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Margaret Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Toronto, Canada
- Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jan Hudec
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Nancy Kentish-Barnes
- Famiréa Research Group, APHP Nord, Saint Louis Hospital, Intensive Care Unit, Paris, France
| | - Monika Kerckhoffs
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jos M Latour
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
- Curtin School of Nursing, Curtin University, Perth, Australia
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jan Malaska
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czechia
- Second Department of Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czechia
| | - Annachiara Marra
- Department of Neuroscience, Reproductive Science and Dentistry, University of Naples, Naples, Italy
| | - Stephanie Meddick-Dyson
- Wolfson Palliative Care Research Centre, Hull York, Medical School, University of Hull, Hull, UK
| | - Spyridon Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Mervyn Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine and Pain Therapy, Konstanz Hospital, Constance, Germany
| | - Rajesh Mishra
- Ahmedabad Shaibya Comprehensive Care Clinic, Ahmedabad, India
| | - Giovanni Mistraletti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- S.C. Anesthesia and Intensive Care, Legnano Hospital, ASST Ovest Milanese, Milan, Italy
| | - Margo van Mol
- Department of Intensive Care Adults, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Rui Moreno
- Hospital de São José, Unidade Local de Saúde São José, Lisbon, Portugal
- Faculdade de Ciências Médicas de Lisboa, Nova Medical School, Centro Clínico Académico de Lisboa, Lisbon, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - Judith Nelson
- Memorial Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Andrea Ortiz Suñer
- Hospital Arnau de Vilanova-Lliria, Valencia, Spain
- Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
| | - Natalie Pattison
- University of Hertfordshire, East and North Hertfordshire NHS Trust, Hatfield, UK
- Imperial Healthcare NHS Trust, Imperial College, London, UK
| | - Tereza Prokopova
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Kathleen Puntillo
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Kathryn Puxty
- Intensive Care, Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Samah Al Qahtani
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Emilio Rodriguez-Ruiz
- Department of Intensive Care Medicine, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
- Simulation, Life Support and Intensive Care Research Unit of Santiago de Compostela (SICRUS), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Stefan J Schaller
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Shahla Siddiqui
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care Medicine and Pain, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michele Umbrello
- S.C. Anesthesia and Intensive Care, Legnano Hospital, ASST Ovest Milanese, Milan, Italy
| | - Marco Vergano
- Department of Anesthesia, Intensive Care and Emergency, San Giovanni Bosco Hospital, Turin, Italy
| | - Massimo Zambon
- Anesthesia and Intensive Care Ospedale "Uboldo", Cernusco sul Naviglio, Milan, Italy
| | - Marieke Zegers
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michael Darmon
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital, Paris, France
- Université Paris Cité, Paris, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital, Paris, France
- Université Paris Cité, Paris, France
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11
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Benoit DD, De Pauw A, Jacobs C, Moors I, Offner F, Velghe A, Van Den Noortgate N, Depuydt P, Druwé P, Hemelsoet D, Meurs A, Malotaux J, Van Biesen W, Verbeke F, Derom E, Stevens D, De Pauw M, Tromp F, Van Vlierberghe H, Callebout E, Goethals K, Lievrouw A, Liu L, Manesse F, Vanheule S, Piers R. Coaching doctors to improve ethical decision-making in adult hospitalized patients potentially receiving excessive treatment. The CODE stepped-wedge cluster randomized controlled trial. Intensive Care Med 2024; 50:1635-1646. [PMID: 39230678 PMCID: PMC11457692 DOI: 10.1007/s00134-024-07588-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 08/01/2024] [Indexed: 09/05/2024]
Abstract
PURPOSE The aim of this study was to assess whether coaching doctors to enhance ethical decision-making in teams improves (1) goal-oriented care operationalized via written do-not-intubate and do-not attempt cardiopulmonary resuscitation (DNI-DNACPR) orders in adult patients potentially receiving excessive treatment (PET) during their first hospital stay and (2) the quality of the ethical climate. METHODS We carried out a stepped-wedge cluster randomized controlled trial in the medical intensive care unit (ICU) and 9 referring internal medicine departments of Ghent University Hospital between February 2022 and February 2023. Doctors and nurses in charge of hospitalized patients filled out the ethical decision-making climate questionnaire (ethical decision-making climate questionnaire, EDMCQ) before and after the study, and anonymously identified PET via an electronic alert during the entire study period. All departments were randomly assigned to a 4-month coaching. At least one month of coaching was compared to less than one month coaching and usual care. The first primary endpoint was the incidence of written DNI-DNACPR decisions. The second primary endpoint was the EDMCQ before and after the study period. Because clinicians identified less PET than required to detect a difference in written DNI-DNACPR decisions, a post-hoc analysis on the overall population was performed. To reduce type I errors, we further restricted the analysis to one of our predefined secondary endpoints (mortality up to 1 year). RESULTS Of the 442 and 423 clinicians working before and after the study period, respectively 270 (61%) and 261 (61.7%) filled out the EDMCQ. Fifty of the 93 (53.7%) doctors participated in the coaching for a mean (standard deviation [SD]) of 4.36 (2.55) sessions. Of the 7254 patients, 125 (1.7%) were identified as PET, with 16 missing outcome data. Twenty-six of the PET and 624 of the overall population already had a written DNI-DNACPR decision at study entry, resulting in 83 and 6614 patients who were included in the main and post hoc analysis, respectively. The estimated incidence of written DNI-DNACPR decisions in the intervention vs. control arm was, respectively, 29.7% vs. 19.6% (odds ratio 4.24, 95% confidence interval 4.21-4.27; P < 0.001) in PET and 3.4% vs. 1.9% (1.65, 1.12-2.43; P = 0.011) in the overall study population. The estimated mortality at one year was respectively 85% vs. 83.7% (hazard ratio 2.76, 1.26-6.04; P = 0.011) and 14.5% vs. 15.1% (0.89, 0.72-1.09; P = 0.251). The mean difference in EDMCQ before and after the study period was 0.02 points (- 0.18 to 0.23; P = 0.815). CONCLUSION This study suggests that coaching doctors regarding ethical decision-making in teams safely improves goal-oriented care operationalized via written DNI-DNACPR decisions in hospitalized patients, however without concomitantly improving the quality of the ethical climate.
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Affiliation(s)
- Dominique D Benoit
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium.
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
| | - Aglaja De Pauw
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Celine Jacobs
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Ine Moors
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Fritz Offner
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Anja Velghe
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium
| | - Nele Van Den Noortgate
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium
| | - Pieter Depuydt
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Intensive Care Medicine, Medical Unit, Ghent University Hospital, Ghent, Belgium
| | - Patrick Druwé
- Department of Intensive Care Medicine, Medical Unit, Ghent University Hospital, Ghent, Belgium
| | | | - Alfred Meurs
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Jiska Malotaux
- Department of General Internal Medicine and Infectious Diseases, Ghent University Hospital, Ghent, Belgium
| | - Wim Van Biesen
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Francis Verbeke
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Eric Derom
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dieter Stevens
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Fiona Tromp
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Hans Van Vlierberghe
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Gastro-Enterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Eduard Callebout
- Department of Gastro-Enterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | | | - An Lievrouw
- Cancer Center, Ghent University Hospital, Ghent, Belgium
| | - Limin Liu
- Department of Applied Mathematics, Computer Sciences and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium
| | - Frank Manesse
- Independent, Conversio, Ghent, Belgium
- Kets de Vries Institute, London, UK
| | - Stijn Vanheule
- Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| | - Ruth Piers
- Faculty of Medicine and Health Care Sciences, Ghent University, Ghent, Belgium
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium
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12
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Accogli A, Vergano M. Managing the Labyrinth of Complex Ethical Issues in Anesthesia Practice: The Anesthesiologist's Ariadne's Thread. Anesthesiol Clin 2024; 42:357-366. [PMID: 39054012 DOI: 10.1016/j.anclin.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Facing ethical dilemmas is challenging and sometimes becomes a real burden for anesthesiologists, particularly because they rarely have previous or long-standing patient relationships that help inform clinical decision-making. Although there is no ideal algorithm that can fit all clinical situations, some basic moral and ethical principles, which should be part of every clinician's armamentarium, can guide the decision-making process. Dealing with conflicting views among providers and/or patients can be distressing but can lead to meaningful professional and personal growth for each clinician.
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Affiliation(s)
- Agnese Accogli
- Department of Surgical Sciences, University of Turin, Corso Dogliotti 14, Turin, Italy
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy.
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13
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Papadimitriou C, Clayman ML, Mallinson T, Weaver JA, Guernon A, Meehan AJ, Kot T, Ford P, Ideishi R, Prather C, van der Wees P. A New Process Model for Relationship-Centred Shared Decision-Making in Physical Medicine and Rehabilitation Settings. Health Expect 2024; 27:e14162. [PMID: 39140244 PMCID: PMC11322820 DOI: 10.1111/hex.14162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 06/07/2024] [Accepted: 07/16/2024] [Indexed: 08/15/2024] Open
Abstract
INTRODUCTION We present a relationship-centred shared-decision-making (RCSDM) process model to explicate factors that shape decision-making processes during physical medicine and rehabilitation (PMR) encounters among patients, their care partners and practitioners. Existing shared decision-making (SDM) models fall short in addressing the everyday decisions routinely made regarding persons with chronic disabilities who require high levels of support, their care partners and rehabilitation practitioners. In PMR, these everyday decisions are small scale, immediate and in service to a larger therapeutic goal. They can be thought of as micro-decisions and involve multiple practitioners, care partners and patients. How micro-decisions are made in this context is contingent on multiple roles and relationships among these relevant parties. Our model centres on micro-decisions among patients, their care partners and practitioners based on our disorders of consciousness (DoC) research. METHODS To develop our model, we examined peer-reviewed literature in SDM in PMR, chronic disability and person-centeredness; formed collaborations and co-created our constructs with rehabilitation practitioners and with care partners who have lived experience of caring for persons with DoC; analysed emerging empirical data and vetted early versions with expert scientific and clinical audiences. Our model builds from the core tenets of relational autonomy, and scholarship and activism of disability advocates. FINDINGS Our model conceptualizes four non-hierarchical levels of analysis to understand the process of micro-decision-making in chronic disability and medical rehabilitation: social forces (historical and sociological); roles and relationships (multiple and intersecting); relational dimensions (interactional and contextual) and micro-decision moments (initiation, response and closure). DISCUSSION Relationships among patients, their care partners and practitioners are the intersubjective milieu within which decisions are made. Our conceptual model explicates the process of micro-decision-making in PMR. PATIENT OR PUBLIC CONTRIBUTION Care partners (or caregivers) and rehabilitation practitioners are active members of our team. We work together to develop research projects, collect, analyse and disseminate data. The conceptual model we present in this manuscript was co-created-input from care partners and practitioners on previously collected data became the impetus to develop the RCSDM process model and share co-authorship in this manuscript.
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Affiliation(s)
| | - Marla L. Clayman
- Department of Population and Quantitative Health SciencesEdith Nourse Rogers Memorial Veterans Hospital, UMass Chan Medical SchoolBedfordMassachusettsUSA
| | - Trudy Mallinson
- Department of Clinical Research and LeadershipGeorge Washington UniversityWashingtonDCUSA
| | - Jennifer A. Weaver
- Department of Occupational TherapyColorado State UniversityFort CollinsColoradoUSA
| | - Ann Guernon
- Department of Speech‐Language PathologyLewis UniversityRomeovilleIllinoisUSA
| | - Albert J. Meehan
- Department of Sociology, Anthropology, Criminal Justice, and Social Work, College of Arts & SciencesOakland UniversityRochesterMichiganUSA
| | | | | | - Roger Ideishi
- Department of Occupational TherapyGeorge Washington UniversityWashingtonDCUSA
| | - Christina Prather
- Division of Geriatrics and Palliative MedicineGeorge Washington UniversityWashingtonDCUSA
| | - Philip van der Wees
- Department of Clinical Research and LeadershipGeorge Washington UniversityWashingtonDCUSA
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14
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Andersen SK, Yang Y, Kross EK, Haas B, Geagea A, May TL, Hart J, Bagshaw SM, Dzeng E, Fischhoff B, White DB. Achieving Goals of Care Decisions in Chronic Critical Illness: A Multi-Institutional Qualitative Study. Chest 2024; 166:107-117. [PMID: 38365177 PMCID: PMC11251076 DOI: 10.1016/j.chest.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/29/2024] [Accepted: 02/11/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Physicians, patients, and families alike perceive a need to improve how goals of care (GOC) decisions occur in chronic critical illness (CCI), but little is currently known about this decision-making process. RESEARCH QUESTION How do intensivists from various health systems facilitate decision-making about GOC for patients with CCI? What are barriers to, and facilitators of, this decision-making process? STUDY DESIGN AND METHODS We conducted semistructured interviews with a purposeful sample of intensivists from the United States and Canada using a mental models approach adapted from decision science. We analyzed transcripts inductively using qualitative description. RESULTS We interviewed 29 intensivists from six institutions. Participants across all sites described GOC decision-making in CCI as a complex, longitudinal, and iterative process that involved substantial preparatory work, numerous stakeholders, and multiple family meetings. Intensivists required considerable time to collect information on prior events and conversations, and to arrive at a prognostic consensus with other involved physicians prior to meeting with families. Many intensivists stressed the importance of scheduling multiple family meetings to build trust and relationships prior to explicitly discussing GOC. Physician-identified barriers to GOC decision-making included 1-week staffing models, limited time and cognitive bandwidth, difficulty eliciting patient values, and interpersonal challenges with care team members or families. Potential facilitators included scheduled family meetings at regular intervals, greater interprofessional involvement in decisions, and consistent messaging from care team members. INTERPRETATION Intensivists described a complex time- and labor-intensive group process to achieve GOC decision-making in CCI. System-level interventions that improve how information is shared between physicians and decrease logistical and relational barriers to timely and consistent communication are key to improving GOC decision-making in CCI.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada.
| | - Yanran Yang
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA; Global Health Research Center, Duke Kunshan University, Jiangsu, China
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
| | - Barbara Haas
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anna Geagea
- Division of Critical Care Medicine, Department of Medicine, North York General Hospital, Toronto, ON, Canada
| | - Teresa L May
- Department of Pulmonary and Critical Care, Maine Medical Center, Portland, ME
| | - Joanna Hart
- Palliative and Advanced Illness Research Center, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Elizabeth Dzeng
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA
| | - Douglas B White
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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15
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Benbenishty J, Ganz FD, Lautrette A, Jaschinski U, Aggarwal A, Søreide E, Weiss M, Dybwik K, Çizmeci EA, Ackerman RCM, Estebanez-Montiel B, Ricou B, Robertsen A, Sprung CL, Avidan A. Variations in reporting of nurse involvement in end-of-life practices in intensive care units worldwide (ETHICUS-2): A prospective observational study. Int J Nurs Stud 2024; 155:104764. [PMID: 38657432 DOI: 10.1016/j.ijnurstu.2024.104764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND ICU nurses are most frequently at the patient's bedside, providing care for both patients and family members. They perform an essential role and are involved in decision-making. Despite this, research suggests that nurses have a limited role in the end-of-life decision-making process and are occasionally not involved. OBJECTIVE Explore global ICU nurse involvement in end of life decisions based on the physician's perceptions and sub-analyses from the ETHICUS-2 study. DESIGN This is a secondary analysis of a prospective multinational, observational study of the ETHICUS-2 study. SETTING End of life decision-making processes in ICU patients were studied during a 6-month period between Sept 1, 2015, and Sept 30, 2016, in 199 ICUs in 36 countries. INTERVENTION None. METHODS The ETHICUS II study instrument contained 20 questions. This sub-analysis addressed the four questions related to nurse involvement in end-of-life decision-making: Who initiated the end-of-life discussion? Was withholding or withdrawing treatment discussed with nurses? Was a nurse involved in making the end-of-life decision? Was there agreement between physicians and nurses? These 4 questions are the basis for our analysis. Global regions were compared. RESULTS Physicians completed 91.8 % of the data entry. A statistically significant difference was found between regions (p < 0.001) with Northern Europe and Australia/New Zealand having the most discussion with nurses and Latin America, Africa, Asia and North America the least. The percentages of end-of-life decisions in which nurses were involved ranged between 3 and 44 %. These differences were statistically significant. Agreement between physicians and nurses related to decisions resulted in a wide range of responses (27-86 %) (p < 0.001). There was a wide range of those who replied "not applicable" to the question of agreement between physicians and nurses on EOL decisions (0-41 %). CONCLUSION There is large variability in nurse involvement in end-of-life decision-making in the ICU. The most concerning findings were that in some regions, according to physicians, nurses were not involved in EOL decisions and did not initiate the decision-making process. There is a need to develop the collaboration between nurses and physicians. Nurses have valuable contributions for best possible patient-centered decisions and should be respected as important parts of the interdisciplinary team. TWEETABLE ABSTRACT Wide global differences were found in nurse end of life decision involvement, with low involvement in North and South America and Africa and higher involvement in Europe and Australia/New Zealand.
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Affiliation(s)
- Julie Benbenishty
- Hadassah Hebrew University Medical Center and School of Nursing Jerusalem Israel, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel.
| | - Freda DeKeyser Ganz
- Hadassah Hebrew University Medical Center and School of Nursing Jerusalem Israel, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel; Faculty of Life and Health Sciences, Jerusalem College of Technology, Jerusalem, Israel
| | - Alexandre Lautrette
- Department of Intensive Care Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ulrich Jaschinski
- Department of Anaesthesiology and Critical Care, University Hospital Augsburg, Germany
| | - Avneep Aggarwal
- Department of General Anesthesiology, Department of Intensive Care and Resuscitation Cleveland Clinic, OH, USA
| | - Eldar Søreide
- Section for Quality and Patient Safety, Stavanger University Hospital and Faculty of Health Sciences University of Stavanger, Stavanger, Norway
| | - Manfred Weiss
- Clinic for Anaesthesiology and Intensive Care Medicine, University of Ulm, Germany
| | - Knut Dybwik
- Intensive Care Unit, Nordland Hospital, Bodø, Norway
| | - Elif Ayşe Çizmeci
- University of Toronto, Faculty of Medicine, Interdepartmental Division of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | | | - Bara Ricou
- Intensive Care of Geneva, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva Hospital and University of Geneva, Switzerland
| | - Annette Robertsen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway; Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Ein Kerem Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Ramaswamy T, Sparling JL, Chang MG, Bittner EA. Ten misconceptions regarding decision-making in critical care. World J Crit Care Med 2024; 13:89644. [PMID: 38855268 PMCID: PMC11155500 DOI: 10.5492/wjccm.v13.i2.89644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/25/2024] [Accepted: 03/01/2024] [Indexed: 06/03/2024] Open
Abstract
Diagnostic errors are prevalent in critical care practice and are associated with patient harm and costs for providers and the healthcare system. Patient complexity, illness severity, and the urgency in initiating proper treatment all contribute to decision-making errors. Clinician-related factors such as fatigue, cognitive overload, and inexperience further interfere with effective decision-making. Cognitive science has provided insight into the clinical decision-making process that can be used to reduce error. This evidence-based review discusses ten common misconceptions regarding critical care decision-making. By understanding how practitioners make clinical decisions and examining how errors occur, strategies may be developed and implemented to decrease errors in Decision-making and improve patient outcomes.
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Affiliation(s)
- Tara Ramaswamy
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Jamie L Sparling
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
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17
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Haidinger E, Krutter S. [Nurses' common experiences of old age and intensive care: A qualitative study]. Pflege 2024; 37:139-147. [PMID: 36866776 DOI: 10.1024/1012-5302/a000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Nurses' common experiences of old age and intensive care: A qualitative study Abstract. Background: Increasingly more people in the 80+ age group are receiving treatment in the ICU-setting. The related critical care nurses' experience has been the subject of very few studies. Aim: To better understand the everyday nursing practice in the care of old patients in the ICU setting, the knowledge of critical care nurses that guides their actions will be examined and presented in terms of their orientations and typologies. Method: Within the interpretative paradigm, three guideline-based group discussions were conducted with a total of 14 critical care nurses from an Austrian clinic. Data was analyzed using the documentary method according to Bohnsack. Results: Five orientations characterize the knowledge and the actions of critical care nurses relating to old patients: the respect for the patients' will, the search for ethical justification, the beauty of the job, the own reflection of professional actions as well as the perception of a partly misguided health care system. The superior action-guiding typology is advocacy in the representation of the very old patients' interests. Conclusions: The multi-faceted experiences of critical care nurses are characterized by personal, interpersonal, and structural challenges, but also by positive experiences. The findings offer approaches to improve the care situation for nurses as well as for old people in intensive care units.
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Affiliation(s)
- Eduard Haidinger
- Masterstudium Pflegewissenschaft, Institut für Pflegewissenschaft und -praxis, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Simon Krutter
- Institut für Pflegewissenschaft und -praxis, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
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18
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Hewitt J, Alsaba N, May K, Kang E, Cartwright C, Willmott L, White B, Marshall AP. End-of-life decision-making in the emergency department and intensive care unit: Health professionals' perspectives on and knowledge of the law in Queensland. Emerg Med Australas 2024; 36:429-435. [PMID: 38361400 DOI: 10.1111/1742-6723.14377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/20/2023] [Accepted: 01/13/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To investigate ED and intensive care unit healthcare professionals' perspectives and knowledge of the law that underpins end-of-life decision-making in Queensland, Australia. METHODS An online survey with questions about perspectives, perceived, and actual, knowledge of the law was distributed by the professional organisations of medical practitioners, nurses and social workers who work in Queensland EDs and intensive care units. RESULTS The survey responses of 126 healthcare professionals were included in the final analysis. Most respondents agreed that the law was relevant to end-of-life decision-making, but that clinician and family consensus mattered more than following the law. Generally, doctors' legal knowledge was higher than nurses'; however, there were significant gaps in the knowledge of all respondents about the operation of advance health directives in Queensland. CONCLUSIONS The legal framework that supports end-of-life decision-making for adults who lack decision-making capacity has been in place for more than two decades. Despite frequently being involved in making or enacting these decisions, gaps in the legal knowledge of healthcare professionals who work in EDs and intensive care units in Queensland are evident. Further research to better understand how to improve knowledge and application of the law is warranted.
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Affiliation(s)
- Jayne Hewitt
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Law Futures Centre, Griffith University, Southport, Queensland, Australia
| | - Nemat Alsaba
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Science and Medicine, Bond University, Robina, Queensland, Australia
| | - Katya May
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Evelyn Kang
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
| | - Colleen Cartwright
- Office of the Deputy Vice Chancellor (Research), Southern Cross University, Lismore, New South Wales, Australia
| | - Lindy Willmott
- Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben White
- Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
- ARC Future Fellow, Brisbane, Queensland, Australia
| | - Andrea P Marshall
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Nursing Education and Research Unit, Gold Coast University Hospital, Southport, Queensland, Australia
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19
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Said CM, Ramage E, McDonald CE, Bicknell E, Hitch D, Fini NA, Bower KJ, Lynch E, Vogel AP, English K, McKay G, English C. Co-designing resources for rehabilitation via telehealth for people with moderate to severe disability post stroke. Physiotherapy 2024; 123:109-117. [PMID: 38458033 DOI: 10.1016/j.physio.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/15/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVES The COVID-19 pandemic necessitated rapid transition to telehealth. Telehealth presents challenges for rehabilitation of stroke survivors with moderate-to-severe physical disability, which traditionally relies on physical interactions. The objective was to co-design resources to support delivery of rehabilitation via telehealth for this cohort. DESIGN Four-stage integrated knowledge translation co-design approach. Stage 1: Research team comprising researchers, clinicians and stroke survivors defined the research question and approach. Stage 2: Workshops and interviews were conducted with knowledge users (participants) to identify essential elements of the program. Stage 3: Resources developed by the research team. Stage 4: Resources reviewed by knowledge users and adapted. PARTICIPANTS Twenty-one knowledge users (clinicians n = 11, stroke survivors n = 7, caregivers n = 3) RESULTS: All stakeholders emphasised the complexities of telehealth rehabilitation for stroke and the need for individualised programs. Shared decision-making was identified as critical. Potential risks and benefits of telehealth were acknowledged and strategies to ameliorate risks and deliver effective rehabilitation were identified. Four freely available online resources were co-designed; three resources to support clinicians with shared decision-making and risk management and a decision-aid to support stroke survivors and caregivers throughout the process. Over six months, 1129 users have viewed the webpage; clinician resources were downloaded 374 times and the decision-aid was downloaded 570 times. CONCLUSIONS The co-design process identified key elements for delivery of telehealth rehabilitation to stroke survivors with moderate-to-severe physical disability and led to development of resources to support development of an individualised telehealth rehabilitation plan. Future research should evaluate the effectiveness of these resources. CONTRIBUTION OF PAPER.
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Affiliation(s)
- Catherine M Said
- Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia; Physiotherapy, Western Health, St Albans, Australia; Australian Institute of Musculoskeletal Sciences, St Albans, Australia.
| | - Emily Ramage
- Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia; Physiotherapy, Western Health, St Albans, Australia; School of Health Sciences and Priority Research Centre for Stroke and Brain Injury, University of Newcastle, Australia; Allied Health Strategy, Planning, Innovation, Research and Education Unit, Western Health, St Albans, Australia.
| | - Cassie E McDonald
- Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia; Physiotherapy, The Royal Melbourne Hospital, Parkville, Australia; Allied Health, Alfred Health, Melbourne, Australia.
| | - Erin Bicknell
- Physiotherapy, Western Health, St Albans, Australia; Physiotherapy, The Royal Melbourne Hospital, Parkville, Australia.
| | - Danielle Hitch
- Allied Health Strategy, Planning, Innovation, Research and Education Unit, Western Health, St Albans, Australia; School of Health and Social Development, Deakin University, Geelong, Australia.
| | - Natalie A Fini
- Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia.
| | - Kelly J Bower
- Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia.
| | - Elizabeth Lynch
- College of Nursing and Health Sciences, Flinders University, Bedford Park, Australia.
| | - Adam P Vogel
- Audiology and Speech Pathology, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia; Redenlab Inc, Melbourne, Australia.
| | | | - Gary McKay
- Consumer Representative, Melbourne, Australia.
| | - Coralie English
- School of Health Sciences and Priority Research Centre for Stroke and Brain Injury, University of Newcastle, Australia.
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20
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Blakeney EAR, Chu F, White AA, Randy Smith G, Woodward K, Lavallee DC, Salas RME, Beaird G, Willgerodt MA, Dang D, Dent JM, Tanner E“I, Summerside N, Zierler BK, O’Brien KD, Weiner BJ. A scoping review of new implementations of interprofessional bedside rounding models to improve teamwork, care, and outcomes in hospitals. J Interprof Care 2024; 38:411-426. [PMID: 34632913 PMCID: PMC8994791 DOI: 10.1080/13561820.2021.1980379] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/13/2021] [Accepted: 08/29/2021] [Indexed: 01/22/2023]
Abstract
Poor communication within healthcare teams occurs commonly, contributing to inefficiency, medical errors, conflict, and other adverse outcomes. Interprofessional bedside rounds (IBR) are a promising model that brings two or more health professions together with patients and families as part of a consistent, team-based routine to share information and collaboratively arrive at a daily plan of care. The purpose of this systematic scoping review was to investigate the breadth and quality of IBR literature to identify and describe gaps and opportunities for future research. We followed an adapted Arksey and O'Malley Framework and PRISMA scoping review guidelines. PubMed, CINAHL, PsycINFO, and Embase were systematically searched for key IBR words and concepts through June 2020. Seventy-nine articles met inclusion criteria and underwent data abstraction. Study quality was assessed using the Mixed Methods Assessment Tool. Publications in this field have increased since 2014, and the majority of studies reported positive impacts of IBR implementation across an array of team, patient, and care quality/delivery outcomes. Despite the preponderance of positive findings, great heterogeneity, and a reliance on quantitative non-randomized study designs remain in the extant research. A growing number of interventions to improve safety, quality, and care experiences in hospital settings focus on redesigning daily inpatient rounds. Limited information on IBR characteristics and implementation strategies coupled with widespread variation in terminology, study quality, and design create challenges in assessing the effectiveness of models of rounds and optimal implementation strategies. This scoping review highlights the need for additional studies of rounding models, implementation strategies, and outcomes that facilitate comparative research.
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Affiliation(s)
- Erin Abu-Rish Blakeney
- Department of Biobehavioral Nursing and Health Informatics,
School of Nursing, University of Washington
| | | | - Andrew A. White
- Department of Medicine, University of Washington School of
Medicine
| | | | | | | | | | | | - Mayumi A. Willgerodt
- Department of Family and Child Nursing, School of Nursing,
University of Washington
| | | | | | | | | | - Brenda K. Zierler
- Department of Biobehavioral Nursing and Health
Informatics, School of Nursing, University of Washington
| | | | - Bryan J. Weiner
- Departments of Global Health and Health Services, School
of Public Health, University of Washington
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21
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Tong HH, Creutzfeldt CJ, Hicks KG, Kross EK, Sharma RK, Jennerich AL. Questions From Family Members During the Dying Process And Moral Distress Experienced by ICU Nurses. J Pain Symptom Manage 2024; 67:402-410.e1. [PMID: 38342474 DOI: 10.1016/j.jpainsymman.2024.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND For a hospitalized patient, transitioning to comfort measures only (CMO) involves discontinuation of life-prolonging interventions with a goal of allowing natural death. Nurses play a pivotal role during the provision of CMO, caring for both the dying patient and their family. OBJECTIVE To examine the experiences of ICU nurses caring for patients receiving CMO. METHODS Between October 2020 and June 2021, nurses in the neuro- and medical-cardiac intensive care units at Harborview Medical Center in Seattle, WA, completed surveys about their experiences providing CMO. Surveys addressed involvement in discussions about CMO and questions asked by family members of dying patients. We also assessed nurses' moral distress related to CMO and used ordinal logistic regression to examine predictors of moral distress. RESULTS Surveys were completed by 82 nurses (response rate 44%), with 79 (96%) reporting experience providing CMO in the previous year. Most preferred to be present for discussions between physicians or advanced practice providers and family members about transitioning to CMO (89% most of the time or always); however, only 31% were present most of the time or always. Questions from family about time to death, changes in breathing, and medications to relieve symptoms were common. Most nurses reported moral distress at least some of the time when providing CMO (62%). Feeling well-prepared to answer specific questions from family was associated with less moral distress. CONCLUSION There is discordance between nurses' preferences for inclusion in discussions about the transition to CMO and their actual presence. Moral distress is common for nurses when providing CMO and feeling prepared to answer questions from family members may attenuate distress.
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Affiliation(s)
- Hao H Tong
- University of Pennsylvania, Division of Pulmonary, Allergy and Critical Care (H.H.T.), Philadelphia, Pennsylvania, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Department of Neurology (C.J.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA
| | - Katherine G Hicks
- Baylor College of Medicine, Section of Geriatrics and Palliative Medicine (K.G.H.), Houston, Texas, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA; Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington (E.K.K., A.L.J.), Seattle, Washington, USA
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA; University of Washington, Division of General Internal Medicine (R.K.S.), Seattle, Washington, USA
| | - Ann L Jennerich
- Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA; Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington (E.K.K., A.L.J.), Seattle, Washington, USA.
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22
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Yang S, Barwise A, Perrucci A, Bartz D. Equitable abortion care for patients with non-English language preference. Contraception 2024; 133:110389. [PMID: 38354764 DOI: 10.1016/j.contraception.2024.110389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Sherry Yang
- Harvard Medical School, Boston, MA, United States; Harvard Kennedy School of Government, Cambridge, MA, United States
| | - Amelia Barwise
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, United States
| | - Alissa Perrucci
- Women's Options Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, United States
| | - Deborah Bartz
- Harvard Medical School, Boston, MA, United States; Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, United States.
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23
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Abstract
During the last decades, shared decision making (SDM) has become a very popular model for the physician-patient relationship. SDM can refer to a process (making a decision in a shared way) and a product (making a shared decision). In the literature, by far most attention is devoted to the process. In this paper, I investigate the product, wondering what is involved by a medical decision being shared. I argue that the degree to which a decision to implement a medical alternative is shared should be determined by taking into account six considerations: (i) how the physician and the patient rank that alternative, (ii) the individual preference scores the physician and the patient (would) assign to that alternative, (iii) the similarity of the preference scores, (iv) the similarity of the rankings, (v) the total concession size, and (vi) the similarity of the concession sizes. I explain why shared medical decisions are valuable, and sketch implications of the analysis for the physician-patient relationship.
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Affiliation(s)
- Coos Engelsma
- Department of Ethics, Centre for Dentistry and Oral Hygiene, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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24
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Guidet B, Vallet H, Flaatten H, Joynt G, Bagshaw SM, Leaver SK, Beil M, Du B, Forte DN, Angus DC, Sviri S, de Lange D, Herridge MS, Jung C. The trajectory of very old critically ill patients. Intensive Care Med 2024; 50:181-194. [PMID: 38236292 DOI: 10.1007/s00134-023-07298-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/27/2023] [Indexed: 01/19/2024]
Abstract
The demographic shift, together with financial constraint, justify a re-evaluation of the trajectory of care of very old critically ill patients (VIP), defined as older than 80 years. We must avoid over- as well as under-utilisation of critical care interventions in this patient group and ensure the inclusion of health care professionals, the patient and their caregivers in the decision process. This new integrative approach mobilises expertise at each step of the process beginning prior to intensive care unit (ICU) admission and extending to long-term follow-up. In this review, several international experts have contributed to provide recommendations that can be universally applied. Our aim is to define a minimum core dataset of information to be shared and discussed prior to ICU admission and to facilitate the shared-decision-making process with the patient and their caregivers, throughout the patient journey. Documentation of uncertainty may contribute to a tailored level of care and ultimately to discussions around possible limitations of life sustaining treatments. The goal of ICU care is not only to avoid death, but more importantly to maintain an acceptable quality of life and functional autonomy after hospital discharge. Societal consideration is important to highlight, together with alternatives to ICU admission. We discuss challenges for the future and potential areas of research. In summary, this review provides a state-of-the-art current overview and aims to outline future directions to address the challenges in the treatment of VIP.
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Affiliation(s)
- Bertrand Guidet
- Medical ICU, Assistance Publique, Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, 75012, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, 75013, Paris, France.
| | - Helene Vallet
- Department of Geriatrics, Sorbonne Université, Institut National de la Santé Et de la Recherche Médicale (INSERM), UMRS 1135, Centre d'immunologie et de Maladies Infectieuses (CIMI), Saint Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), 75012, Paris, France
| | - Hans Flaatten
- Department of Clinical Medicine, Haukeland University Hospital, University of Bergen, Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Gavin Joynt
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Daniel N Forte
- Departament of Emergency Medicine, Faculdade de Medicina, Universidade de São Paulo, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Derek C Angus
- Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, USA
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Christian Jung
- Department of Cardiology, Pulmonology and Angiology, University Hospital, Düsseldorf, Germany
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25
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Mehta AB, Lockhart S, Lange AV, Matlock DD, Douglas IS, Morris MA. Drivers of Decision-Making for Adult Tracheostomy for Prolonged Mechanical Ventilation: A Qualitative Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.20.24301492. [PMID: 38293156 PMCID: PMC10827243 DOI: 10.1101/2024.01.20.24301492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Background Decision-making about tracheostomy and prolonged mechanical ventilation (PMV) is emotionally complex. Expectations of surrogate decision-makers and physicians rarely align. Little is known about what surrogates need to make goal-concordant decisions. We sought to identify drivers of tracheostomy and PMV decision-making. Methods Using Grounded Theory, we performed a qualitative study with semi-structured interviews with surrogates of patients receiving mechanical ventilation (MV) being considered for tracheostomy and physicians routinely caring for patients receiving MV. Recruitment was stopped when thematic saturation was reached. Separate codebooks were created for surrogate and physician interviews. Themes and factors affecting decision-making were identified and a theoretical model tracheostomy decision-making was developed. Results 43 participants (23 surrogates and 20 physicians) completed interviews. A theoretical model of themes and factors driving decision-making emerged for the data. Hope, Lack of Knowledge & Data, and Uncertainty emerged as the three main themes all which were interconnected with one another and, at times, opposed each other. Patient Wishes, Past Activity/Medical History, Short and Long-Term Outcomes, and Meaningful Recovery were key factors upon which surrogates and physicians based decision-making. The themes were the lens through which the factors were viewed and decision-making existed as a balance between surrogate emotions and understanding and physician recommendations. Conclusions Tracheostomy and prolonged MV decision-making is complex. Hope and Uncertainty were conceptual themes that often battled with one another. Lack of Knowledge & Data plagued both surrogates and physicians. Multiple tangible factors were identified that affected surrogate decision-making and physician recommendations. Implications Understanding this complex decision-making process has the potential to improve the information provided to surrogates and, potentially, increase the goal concordant care and alignment of surrogate and physician expectations. Highlights Decision-making for tracheostomy and prolonged mechanical ventilation is a complex interactive process between surrogate decision-makers and providers.Using a Grounded Theory framework, a theoretical model emerged from the data with core themes of Hope, Uncertainty, and Lack of Knowledge & Data that was shared by both providers and surrogates.The core themes were the lenses through which the key decision-making factors of Patient Wishes, Past Activity/Medical History, Short and Long-Term Outcomes, and Meaningful Recovery were viewed.The theoretical model provides a roadmap to design a shared decision-making intervention to improve tracheostomy and prolonged mechanical ventilation decision-making.
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Jöbges S, Dutzmann J, Barndt I, Burchardi H, Duttge G, Grautoff S, Gretenkort P, Hartog C, Knochel K, Nauck F, Neitzke G, Meier S, Michalsen A, Rogge A, Salomon F, Seidlein AH, Schumacher R, Riegel R, Stopfkuchen H, Janssens U. Ethisch begründet entscheiden in der Intensivmedizin. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:52-57. [PMID: 38190826 DOI: 10.1055/a-2211-9608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
The process recommendations of the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) for ethically based decision-making in intensive care medicine are intended to create the framework for a structured procedure for seriously ill patients in intensive care. The processes require appropriate structures, e.g., for effective communication within the treatment team, with patients and relatives, legal representatives, as well as the availability of palliative medical expertise, ethical advisory committees and integrated psychosocial and spiritual care services. If the necessary competences and structures are not available in a facility, they can be consulted externally or by telemedicine if necessary. The present recommendations are based on an expert consensus and are not the result of a systematic review or a meta-analysis.
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Villavaso CD, Williams S, Parker TM. Polypharmacy in the Cardiovascular Geriatric Critical Care Population: Improving Outcomes. Crit Care Nurs Clin North Am 2023; 35:505-512. [PMID: 37838422 DOI: 10.1016/j.cnc.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
The cardiovascular geriatric population requiring intensive or critical care is a group vulnerable to adverse outcomes because of age, the critical care environment, geriatric syndromes, and multiple chronic conditions. Polypharmacy increases the risk of adverse events in this group. Several tools and aids are available to guide the clinical practice of appropriate prescribing and deprescribing. To optimize the care of the cardiovascular geriatric population, evidence-based prescribing, and deprescribing tools can be implemented by the interprofessional team consisting of the patient, their support system, critical care nurses, advanced practice clinicians, physicians, and allied health professionals.
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Affiliation(s)
- Chloé Davidson Villavaso
- Clinical Faculty, Tulane University School of Medicine, Heart and Vascular Institute, 1430 Tulane Avenue #8548, New Orleans, LA 70112, USA.
| | | | - Tracy M Parker
- Touro Heart and Vascular Care, LCMC Health, 3715 Prytania Street, Suite 400, New Orleans, LA 70115, USA
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Michels G, John S, Janssens U, Raake P, Schütt KA, Bauersachs J, Barchfeld T, Schucher B, Delis S, Karpf-Wissel R, Kochanek M, von Bonin S, Erley CM, Kuhlmann SD, Müllges W, Gahn G, Heppner HJ, Wiese CHR, Kluge S, Busch HJ, Bausewein C, Schallenburger M, Pin M, Neukirchen M. [Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DG Palliativmedizin]. Med Klin Intensivmed Notfmed 2023; 118:14-38. [PMID: 37285027 PMCID: PMC10244869 DOI: 10.1007/s00063-023-01016-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 06/08/2023]
Abstract
The integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3 guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
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Affiliation(s)
- Guido Michels
- Zentrum für Notaufnahme, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus der Universitätsmedizin Mainz, Nordallee 1, 54292, Trier, Deutschland.
| | - Stefan John
- Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität und Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, 90471, Nürnberg, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Philip Raake
- I. Medizinischen Klinik, Universitätsklinikum Augsburg, Herzzentrum Augsburg-Schwaben, Augsburg, Deutschland
| | - Katharina Andrea Schütt
- Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin (Medizinische Klinik I), Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Johann Bauersachs
- Klinik für Kardiologie und Angiologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Thomas Barchfeld
- Medizinische Klinik II, Klinik für Pneumologie, Intensivmedizin und Schlafmedizin, Knappschaftskrankenhaus Dortmund, Klinikum Westfalen, Dortmund, Deutschland
| | - Bernd Schucher
- Abteilung Pneumologie, LungenClinic Großhansdorf, Großhansdorf, Deutschland
| | - Sandra Delis
- Helios Klinikum Emil von Behring GmbH, Berlin, Deutschland
| | - Rüdiger Karpf-Wissel
- Westdeutsches Lungenzentrum am Universitätsklinikum Essen gGmbH, Klinik für Pneumologie, Universitätsmedizin Essen Ruhrlandklinik, Essen, Deutschland
| | - Matthias Kochanek
- Medizinische Klinik I, Medizinische Fakultät und Uniklinik Köln, Center for Integrated Oncology (CIO) Cologne-Bonn, Universität zu Köln, Köln, Deutschland
| | - Simone von Bonin
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | | | | | - Wolfgang Müllges
- Neurologische Klinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Georg Gahn
- Neurologische Klinik, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Deutschland
| | - Hans Jürgen Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik, Klinikum Bayreuth - Medizincampus Oberfranken, Bayreuth, Deutschland
| | - Christoph H R Wiese
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
- Klinik für Anästhesiologie und Intensivmedizin, HEH Kliniken Braunschweig, Braunschweig, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg, Deutschland
| | - Hans-Jörg Busch
- Universitätsklinikum, Universitäts-Notfallzentrum, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Claudia Bausewein
- Klinik und Poliklinik für Palliativmedizin, LMU Klinikum München, München, Deutschland
| | - Manuela Schallenburger
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Martin Pin
- Zentrale Interdisziplinäre Notaufnahme, Florence-Nightingale-Krankenhaus Düsseldorf, Düsseldorf, Deutschland
| | - Martin Neukirchen
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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Janssen RME, Oerlemans AJM, van der Hoeven JG, Oostdijk EAN, Derde LPG, Ten Oever J, Wertheim HFL, Hulscher MEJL, Schouten JA. Decision-making regarding antibiotic therapy duration: An observational study of multidisciplinary meetings in the intensive care unit. J Crit Care 2023; 78:154363. [PMID: 37393864 DOI: 10.1016/j.jcrc.2023.154363] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/05/2023] [Accepted: 06/17/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE Antibiotic therapy is commonly prescribed longer than recommended in intensive care patients (ICU). We aimed to provide insight into the decision-making process on antibiotic therapy duration in the ICU. METHODS A qualitative study was conducted, involving direct observations of antibiotic decision-making during multidisciplinary meetings in four Dutch ICUs. The study used an observation guide, audio recordings, and detailed field notes to gather information about the discussions on antibiotic therapy duration. We described the participants' roles in the decision-making process and focused on arguments contributing to decision-making. RESULTS We observed 121 discussions on antibiotic therapy duration in sixty multidisciplinary meetings. 24.8% of discussions led to a decision to stop antibiotics immediately. In 37.2%, a prospective stop date was determined. Arguments for decisions were most often brought forward by intensivists (35.5%) and clinical microbiologists (22.3%). In 28.9% of discussions, multiple healthcare professionals participated equally in the decision. We identified 13 main argument categories. While intensivists mostly used arguments based on clinical status, clinical microbiologists used diagnostic results in the discussion. CONCLUSIONS Multidisciplinary decision-making regarding the duration of antibiotic therapy is a complex but valuable process, involving different healthcare professionals, using a variety of argument-types to determine the duration of antibiotic therapy. To optimize the decision-making process, structured discussions, involvement of relevant specialties, and clear communication and documentation of the antibiotic plan are recommended.
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Affiliation(s)
- Robin M E Janssen
- Radboud university medical center, Department of Intensive Care Medicine, Nijmegen, the Netherlands; Radboud university medical center, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, the Netherlands; Radboud university medical center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands.
| | - Anke J M Oerlemans
- Radboud university medical center, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, the Netherlands
| | | | | | - Lennie P G Derde
- University Medical Center Utrecht, Department of Intensive Care Medicine, Utrecht, the Netherlands
| | - Jaap Ten Oever
- Radboud university medical center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands; Radboud university medical center, Department of Internal Medicine, Nijmegen, the Netherlands
| | - Heiman F L Wertheim
- Radboud university medical center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands; Radboud university medical center, Department of Medical Microbiology, Nijmegen, the Netherlands
| | - Marlies E J L Hulscher
- Radboud university medical center, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, the Netherlands; Radboud university medical center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands
| | - Jeroen A Schouten
- Radboud university medical center, Department of Intensive Care Medicine, Nijmegen, the Netherlands; Radboud university medical center, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, the Netherlands; Radboud university medical center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands
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Poku CA, Attafuah PYA, Anaba EA, Abor PA, Nketiah-Amponsah E, Abuosi AA. Response to patient safety incidents in healthcare settings in Ghana: the role of teamwork, communication openness, and handoffs. BMC Health Serv Res 2023; 23:1072. [PMID: 37803364 PMCID: PMC10559624 DOI: 10.1186/s12913-023-10000-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/04/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Patient safety incidents (PSIs) in healthcare settings are a critical concern globally, and Ghana is no exception. Addressing PSIs to improve health outcomes requires various initiatives to be implemented including improving patient safety culture, teamwork and communication between healthcare providers during handoffs. It is essential to acknowledge the significance of teamwork, communication openness, and effective handoffs in preventing and managing such incidents. These factors play a pivotal role in ensuring the well-being of patients and the overall quality of healthcare services. AIM This study assessed the occurrence and types of PSIs in health facilities in Ghana. It also examined the role of teamwork, handoffs and information exchange, and communication openness in response to PSIs by health professionals. METHODS A cross-sectional study was conducted among 1651 health workers in three regions of Ghana. Using a multi-staged sampling technique, the Survey on Patient Safety Culture Hospital Survey questionnaire and the nurse-reported scale were used to collect the data and it was analysed by descriptive statistics, Pearson correlation, and linear multiple regression model at a significance of 0.05. RESULTS There was a reported prevalence of PSIs including medication errors (30.4%), wound infections (23.3%), infusion reactions (24.7%), pressure sores (21.3%), and falls (18.7%) at least once a month. There was a satisfactory mean score for responses to adverse events (3.40), teamwork (4.18), handoffs and information exchange (3.88), and communication openness (3.84) among healthcare professionals. Teamwork, handoffs and information exchange and communication openness were significant predictors of response to PSIs, accounting for 28.3% of the variance. CONCLUSIONS Effective teamwork, handoffs and information exchange, and communication openness in the healthcare environment are critical strategies to enhance PSI response. Creating a culture that encourages error response through teamwork, communication and handoffs provides healthcare professionals with opportunities for learning and improving patient outcomes. Training programs should therefore target health professionals to improve patient safety and competency. Through the implementation of evidence-based practices and learning from past incidents, the healthcare system will be able to deliver safe and high-quality care to patients nationwide. Patient safety must be recognized as an ongoing process. Therefore, a meaningful improvement in patient outcomes requires all stakeholders' commitment.
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Affiliation(s)
- Collins Atta Poku
- Department of Nursing, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Emmanuel Anongeba Anaba
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
| | - Patience Aseweh Abor
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Accra, Ghana
| | | | - Aaron Asibi Abuosi
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Accra, Ghana
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Steinberg A, Fischhoff B. Cognitive Biases and Shared Decision Making in Acute Brain Injury. Semin Neurol 2023; 43:735-743. [PMID: 37793424 DOI: 10.1055/s-0043-1775596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, Neurology, and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
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Michels G, Schallenburger M, Neukirchen M. Recommendations on palliative care aspects in intensive care medicine. Crit Care 2023; 27:355. [PMID: 37723595 PMCID: PMC10506254 DOI: 10.1186/s13054-023-04622-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND The timely integration of palliative care is important for patients suffering from various advanced diseases with limited prognosis. While a German S-3-guideline on palliative care exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for integration of palliative care into intensive care medicine is missing to date. METHOD Ten German medical societies worked on recommendations on palliative care aspects in intensive care in a consensus process from 2018 to 2023. RESULTS Based on the german consensus paper, the palliative care aspects of the respective medical disciplines concerning intensive care are addressed. The recommendations partly refer to general situations, but also to specific aspects or diseases, such as geriatric issues, heart or lung diseases, encephalopathies and delirium, terminal renal diseases, oncological diseases and palliative emergencies in intensive care medicine. Measures such as non-invasive ventilation for symptom control and compassionate weaning are also included. CONCLUSION The timely integration of palliative care into intensive care medicine aims to improve quality of life and symptom control and also takes into acccount the often urgently needed support for patients' highly stressed relatives.
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Affiliation(s)
- Guido Michels
- Department of Emergency Medicine, Hospital of the Barmherzige Brüder, Trier, Germany
| | - Manuela Schallenburger
- Interdisciplinary Centre for Palliative Medicine, Heinrich-Heine-University Duesseldorf, University Hospital Duesseldorf, Düsseldorf, Germany.
| | - Martin Neukirchen
- Interdisciplinary Centre for Palliative Medicine, Heinrich-Heine-University Duesseldorf, University Hospital Duesseldorf, Düsseldorf, Germany
- Department of Anaesthesiology, Heinrich-Heine-University Duesseldof, Düsseldorf, Germany
- Center of integrated oncology Aachen, Bonn, Cologne (CIO ABCD) Heinrich-Heine-University, Düsseldorf, Germany
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Dennison Himmelfarb CR, Beckie TM, Allen LA, Commodore-Mensah Y, Davidson PM, Lin G, Lutz B, Spatz ES. Shared Decision-Making and Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation 2023; 148:912-931. [PMID: 37577791 DOI: 10.1161/cir.0000000000001162] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Shared decision-making is increasingly embraced in health care and recommended in cardiovascular guidelines. Patient involvement in health care decisions, patient-clinician communication, and models of patient-centered care are critical to improve health outcomes and to promote equity, but formal models and evaluation in cardiovascular care are nascent. Shared decision-making promotes equity by involving clinicians and patients, sharing the best available evidence, and recognizing the needs, values, and experiences of individuals and their families when faced with the task of making decisions. Broad endorsement of shared decision-making as a critical component of high-quality, value-based care has raised our awareness, although uptake in clinical practice remains suboptimal for a range of patient, clinician, and system issues. Strategies effective in promoting shared decision-making include educating clinicians on communication techniques, engaging multidisciplinary medical teams, incorporating trained decision coaches, and using tools (ie, patient decision aids) at appropriate literacy and numeracy levels to support patients in their cardiovascular decisions. This scientific statement shines a light on the limited but growing body of evidence of the impact of shared decision-making on cardiovascular outcomes and the potential of shared decision-making as a driver of health equity so that everyone has just opportunities. Multilevel solutions must align to address challenges in policies and reimbursement, system-level leadership and infrastructure, clinician training, access to decision aids, and patient engagement to fully support patients and clinicians to engage in the shared decision-making process and to drive equity and improvement in cardiovascular outcomes.
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Piers RD, Banner-Goodspeed V, Åkerman E, Kieslichova E, Meyfroidt G, Gerritsen RT, Uyttersprot E, Benoit DD. Outcomes in Patients Perceived as Receiving Excessive Care by ICU Physicians and Nurses: Differences Between Patients < 75 and ≥ 75 Years of Age? Chest 2023; 164:656-666. [PMID: 37062350 DOI: 10.1016/j.chest.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/24/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND The benefit of the ICU for older patients is often debated. There is little knowledge on subjective impressions of excessive care in ICU nurses and physicians combined with objective patient data in real-life cases. RESEARCH QUESTION Is there a difference in treatment limitation decisions and 1-year outcomes in patients < 75 and ≥ 75 years of age, with and without concordant perceptions of excessive care by two or more ICU nurses and physicians? STUDY DESIGN AND METHODS This was a reanalysis of the prospective observational DISPROPRICUS study, performed in 56 ICUs. Nurses and physicians completed a daily questionnaire about the appropriateness of care for each of their patients during a 28-day period in 2014. We compared the cumulative incidence of patients with concordant perceptions of excessive care, treatment limitation decisions, and the proportion of patients attaining the combined end point (death, poor quality of life, or not being at home) at 1 year across age groups via Cox regression with propensity score weighting and Fisher exact tests. RESULTS Of 1,641 patients, 405 (25%) were ≥ 75 years of age. The cumulative incidence of concordant perceptions of excessive care was higher in older patients (13.6% vs 8.5%; P < .001). In patients with concordant perceptions of excessive care, we found no difference between age groups in risk of death (1-year mortality, 83% in both groups; P > .99; hazard ratio [HR] after weighting, 1.11; 95% CI, 0.74-1.65), treatment limitation decisions (33% vs 31%; HR after weighting, 1.11; 95% CI, 0.69-2.17), and reaching the combined end point at 1 year (90% vs 93%; P = .546). In patients without concordant perceptions of excessive care, we found a difference in risk of death (1-year mortality, 41% vs 30%; P < .001; HR after weighting, 1.38; 95% CI, 1.11-1.73) and treatment limitation decisions (11% vs 5%; P < .001; HR, 2.11; 95% CI, 1.37-3.27); however, treatment limitation decisions were mostly documented prior to ICU admission. The risk of reaching the combined end point was higher in the older adults (61.6% vs 52.8%; P < .001). INTERPRETATION Although the incidence of perceptions of excessive care is slightly higher in older patients, there is no difference in treatment limitation decisions and 1-year outcomes between older and younger patients once patients are identified by concordant perceptions of excessive care. Additionally, in patients without concordant perceptions, the outcomes are worse in the older adults, pleading against ageism in ICU nurses and physicians.
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Affiliation(s)
- Ruth D Piers
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium.
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eva Åkerman
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden; General Intensive Care Unit, Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Kieslichova
- Department of Anesthesiology, Resuscitation and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Emma Uyttersprot
- Department of Applied Mathematics and Computer Sciences, Ghent University, Ghent, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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Dzeng E, Batten JN, Dohan D, Blythe J, Ritchie CS, Curtis JR. Hospital Culture and Intensity of End-of-Life Care at 3 Academic Medical Centers. JAMA Intern Med 2023; 183:839-848. [PMID: 37399038 PMCID: PMC10318547 DOI: 10.1001/jamainternmed.2023.2450] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/22/2023] [Indexed: 07/04/2023]
Abstract
Importance There is substantial institutional variability in the intensity of end-of-life care that is not explained by patient preferences. Hospital culture and institutional structures (eg, policies, practices, protocols, resources) might contribute to potentially nonbeneficial high-intensity life-sustaining treatments near the end of life. Objective To understand the role of hospital culture in the everyday dynamics of high-intensity end-of-life care. Design, Setting, and Participants This comparative ethnographic study was conducted at 3 academic hospitals in California and Washington that differed in end-of-life care intensity based on measures in the Dartmouth Atlas and included hospital-based clinicians, administrators, and leaders. Data were deductively and inductively analyzed using thematic analysis through an iterative coding process. Main Outcome and Measure Institution-specific policies, practices, protocols, and resources and their role in the everyday dynamics of potentially nonbeneficial, high-intensity life-sustaining treatments. Results A total of 113 semistructured, in-depth interviews (66 women [58.4%]; 23 [20.4%] Asian, 1 [0.9%] Black, 5 [4.4%] Hispanic, 7 [6.2%] multiracial, and 70 [61.9%] White individuals) were conducted with inpatient-based clinicians and administrators between December 2018 and June 2022. Respondents at all hospitals described default tendencies to provide high-intensity treatments that they believed were universal in US hospitals. They also reported that proactive, concerted efforts among multiple care teams were required to deescalate high-intensity treatments. Efforts to deescalate were vulnerable to being undermined at multiple points during a patient's care trajectory by any individual or entity. Respondents described institution-specific policies, practices, protocols, and resources that engendered broadly held understandings of the importance of deescalating nonbeneficial life-sustaining treatments. Respondents at different hospitals reported different policies and practices that encouraged or discouraged deescalation. They described how these institutional structures contributed to the culture and everyday dynamics of end-of-life care at their institution. Conclusions and Relevance In this qualitative study, clinicians, administrators, and leaders at the hospitals studied reported that they work in a hospital culture in which high-intensity end-of-life care constitutes a default trajectory. Institutional structures and hospital cultures shape the everyday dynamics by which clinicians may deescalate end-of-life patients from this trajectory. Individual behaviors or interactions may fail to mitigate potentially nonbeneficial high-intensity life-sustaining treatments if extant hospital culture or a lack of supportive policies and practices undermine individual efforts. Hospital cultures need to be considered when developing policies and interventions to decrease potentially nonbeneficial, high-intensity life-sustaining treatments.
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Affiliation(s)
- Elizabeth Dzeng
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Cicely Saunders institute, King’s College London, London, England
| | - Jason N. Batten
- Department of Anesthesia, Perioperative, and Pain Medicine, Stanford University, Stanford, California
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, California
| | - Daniel Dohan
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Jacob Blythe
- Department of Radiology, Massachusetts General Hospital, Boston
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute Center for Aging and Serious Illness, Department of Medicine, Massachusetts General Hospital, Boston
| | - J. Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
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Inagaki N, Seto N, Lee K, Takahashi Y, Nakayama T, Hayashi Y. The role of critical care nurses in shared decision-making for patients with severe heart failure: A qualitative study. PLoS One 2023; 18:e0288978. [PMID: 37471342 PMCID: PMC10358911 DOI: 10.1371/journal.pone.0288978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
AIM Patients with severe heart failure undergo highly invasive and advanced therapies with uncertain treatment outcomes. For these patients, shared decision-making is necessary. To date, the nursing perspective of the decision-making process for patients facing difficulties and how nurses can support patients in this process have not been fully elucidated. This study aimed to clarify the perceptions of critical care nurses regarding situations with patients with severe heart failure that require difficult decision-making, and their role in supporting these patients. METHODS Individual semi-structured interviews were conducted with 10 certified nurse specialists in critical care nursing at nine hospitals in Japan. A qualitative inductive method was used and the derived relationships among the themes were visually structured and represented. RESULTS The nurses' perceptions on patients' difficult situations in decision-making were identified as follows: painful decisions under uncertainties; tense relationships; wavering emotions during decision-making; difficulties in coping with worsening medical conditions; patients' wishes that are difficult to realize or estimate; and difficulties in transitioning from advanced medical care. Critical care nurses' roles were summarized into six themes and performed collaboratively within the nursing team. Of these, the search for meaning and value was fundamental. Two positions underpin the role of critical care nurses. The first aims to provide direct support and includes partnerships and rights advocacy. The second aims to provide a holistic perspective to enable necessary adjustments, as indicated by situation assessments and mediation. By crossing various boundaries, co-creating, and forming a good circular relationship in the search for meaning and values, the possibility of expanding treatment and recuperation options may be considered. CONCLUSIONS Patients with severe heart failure have difficulty participating in shared decision-making. Critical care nurses should collaborate within the nursing team to improve interprofessional shared decision-making by providing decisional support to patients that focuses on values and meaning.
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Affiliation(s)
- Noriko Inagaki
- Graduate School of Nursing, Kansai Medical University, Hirakata, Osaka, Japan
| | - Natsuko Seto
- Graduate School of Nursing, Kansai Medical University, Hirakata, Osaka, Japan
| | - Kumsun Lee
- Graduate School of Nursing, Kansai Medical University, Hirakata, Osaka, Japan
| | - Yoshimitsu Takahashi
- Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan
| | - Takeo Nakayama
- Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan
| | - Yuko Hayashi
- Graduate School of Nursing, Kansai Medical University, Hirakata, Osaka, Japan
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Kumpf O, Assenheimer M, Bloos F, Brauchle M, Braun JP, Brinkmann A, Czorlich P, Dame C, Dubb R, Gahn G, Greim CA, Gruber B, Habermehl H, Herting E, Kaltwasser A, Krotsetis S, Kruger B, Markewitz A, Marx G, Muhl E, Nydahl P, Pelz S, Sasse M, Schaller SJ, Schäfer A, Schürholz T, Ufelmann M, Waydhas C, Weimann J, Wildenauer R, Wöbker G, Wrigge H, Riessen R. Quality indicators in intensive care medicine for Germany - fourth edition 2022. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2023; 21:Doc10. [PMID: 37426886 PMCID: PMC10326525 DOI: 10.3205/000324] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 07/11/2023]
Abstract
The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.
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Affiliation(s)
- Oliver Kumpf
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | | | - Frank Bloos
- Jena University Hospital, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany
| | - Maria Brauchle
- Landeskrankenhaus Feldkirch, Department of Anesthesiology and Intensive Care Medicine, Feldkirch, Austria
| | - Jan-Peter Braun
- Martin-Luther-Krankenhaus, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Alexander Brinkmann
- Klinikum Heidenheim, Department of Anesthesia, Surgical Intensive Care Medicine and Special Pain Therapy, Heidenheim, Germany
| | - Patrick Czorlich
- University Medical Center Hamburg-Eppendorf, Department of Neurosurgery, Hamburg, Germany
| | - Christof Dame
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neonatology, Berlin, Germany
| | - Rolf Dubb
- Kreiskliniken Reutlingen, Academy of the District Hospitals Reutlingen, Germany
| | - Georg Gahn
- Städt. Klinikum Karlsruhe gGmbH, Department of Neurology, Karlsruhe, Germany
| | - Clemens-A. Greim
- Klinikum Fulda, Department of Anesthesia and Surgical Intensive Care Medicine, Fulda, Germany
| | - Bernd Gruber
- Niels Stensen Clinics, Marienhospital Osnabrueck, Department Hospital Hygiene, Osnabrueck, Germany
| | - Hilmar Habermehl
- Kreiskliniken Reutlingen, Klinikum am Steinenberg, Center for Intensive Care Medicine, Reutlingen, Germany
| | - Egbert Herting
- Universitätsklinikum Schleswig-Holstein, Department of Pediatrics and Adolescent Medicine, Campus Lübeck, Germany
| | - Arnold Kaltwasser
- Kreiskliniken Reutlingen, Academy of the District Hospitals Reutlingen, Germany
| | - Sabine Krotsetis
- Universitätsklinikum Schleswig-Holstein, Nursing Development and Nursing Science, affiliated with the Nursing Directorate Campus Lübeck, Germany
| | - Bastian Kruger
- Klinikum Heidenheim, Department of Anesthesia, Surgical Intensive Care Medicine and Special Pain Therapy, Heidenheim, Germany
| | | | - Gernot Marx
- University Hospital RWTH Aachen, Department of Intensive Care Medicine and Intermediate Care, Aachen, Germany
| | | | - Peter Nydahl
- Universitätsklinikum Schleswig-Holstein, Nursing Development and Nursing Science, affiliated with the Nursing Directorate Campus Kiel, Germany
| | - Sabrina Pelz
- Universitäts- und Rehabilitationskliniken Ulm, Intensive Care Unit, Ulm, Germany
| | - Michael Sasse
- Medizinische Hochschule Hannover, Department of Pediatric Cardiology and Pediatric Intensive Care Medicine, Hanover, Germany
| | - Stefan J. Schaller
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Anesthesiology and Intensive Care Medicine, Munich, Germany
| | | | - Tobias Schürholz
- University Hospital RWTH Aachen, Department of Intensive Care Medicine and Intermediate Care, Aachen, Germany
| | - Marina Ufelmann
- Technical University of Munich, Klinikum rechts der Isar, Department of Nursing, Munich, Germany
| | - Christian Waydhas
- Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Surgical University Hospital and Polyclinic, Bochum, Germany
- Medical Department of the University of Duisburg-Essen, Essen, Germany
| | - Jörg Weimann
- Sankt-Gertrauden Krankenhaus, Department of Anesthesia and Interdisciplinary Intensive Care Medicine, Berlin, Germany
| | | | - Gabriele Wöbker
- Helios Universitätsklinikum Wuppertal, Universität Witten-Herdecke, Department of Intensive Care Medicine, Wuppertal, Germany
| | - Hermann Wrigge
- Bergmannstrost Hospital Halle, Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Halle, Germany
- Martin-Luther University Halle-Wittenberg, Medical Faculty, Halle, Germany
| | - Reimer Riessen
- Universitätsklinikum Tübingen, Department of Internal Medicine, Medical Intensive Care Unit, Tübingen, Germany
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Bushuven S, Bentele M, Gerber B, Michalsen A, Ilkilic I, Inthorn J. Single-rater reliability of a three-dimensional instrument for decision-making in tertiary triage and ICU- prioritization-a case vignette simulation study. BMC Anesthesiol 2023; 23:215. [PMID: 37340343 DOI: 10.1186/s12871-023-02173-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 06/09/2023] [Indexed: 06/22/2023] Open
Abstract
Disconcerting reports from different EU countries during the first wave of the COVID-19 pandemic demonstrated the demand for supporting decision instruments and recommendations in case tertiary triage is needed. COVID-19 patients mainly present sequentially, not parallelly, and therefore ex-post triage scenarios were expected to be more likely than ex-ante ones. Decision-makers in these scenarios may be highly susceptible to second victim and moral injury effects, so that reliable and ethically justifiable algorithms would have been needed in case of overwhelming critical cases.To gather basic information about a potential tertiary triage instrument, we designed a three-dimensional instrument developed by an expert group using the Delphi technique. The instrument focused on three parameters: 1) estimated chance of survival, 2) estimated prognosis of regaining autonomy after treatment, and 3) estimated length of stay in the ICU. To validate and test the instrument, we conducted an anonymous online survey in 5 German hospitals addressing physicians that would have been in charge of decision-making in the case of a mass infection incident. Of about 80 physicians addressed, 47 responded. They were presented with 16 fictional ICU case vignettes (including 3 doublets) which they had to score using the three parameters of the instrument.We detected a good construct validity (Cronbach's Alpha 0.735) and intra-reliability (p < 0.001, Cohens Kappa 0.497 to 0.574), but a low inter-reliability (p < 0.001, Cohen's Kappa 0.252 to 0.327) for the three parameters. The best inter-reliability was detected for the estimated length of stay in the ICU. Further analysis revealed concerns in assessing the prognosis of the potentially remaining autonomy, especially in patients with only physical impairment.In accordance with German recommendations, we concluded that single-rater triage (which might happen in stressful and highly resource-limited situations) should be avoided to ensure patient and health care provider safety. Future work should concentrate on reliable and valid group decision instruments and algorithms and question whether the chance of survival as a single triage parameter should be complemented with other parameters, such as the estimated length of stay in the ICU.
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Affiliation(s)
- Stefan Bushuven
- Institute for Hospital Hygiene and Infection Prevention, Hegau-Jugendwerk Hospital Gailingen, Health Care Association District of Constance, Hausherrenstrasse 12, 78315, Radolfzell, Germany.
- Institute for Medical Education, University Hospital, LMU Munich, Munich, Germany.
- Institute for Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Hegau Bodensee Hospital, Singen, Germany.
| | - Michael Bentele
- Institute for Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Hegau Bodensee Hospital, Singen, Germany
| | - Bianka Gerber
- Institute for Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Hegau Bodensee Hospital, Singen, Germany
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine and Pain Therapy, Konstanz Hospital, Constance, Germany
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Abstract
BACKGROUND Italy was the first European country to be involved with the COVID-19 pandemic. As a result, many healthcare professionals were deployed and suddenly faced end-of-life care management and its challenges. AIMS To understand the experiences of palliative care professionals deployed in supporting emergency and critical care staff during the COVID-19 first and second pandemic waves. RESEARCH DESIGN A qualitative descriptive design was adopted, and in-depth interviews were used to investigate and analyse participants' perceptions and points of view. PARTICIPANTS AND RESEARCH CONTEXT Twenty-four healthcare professionals (physicians, nurses, psychologists, physiotherapists, and spiritual support) from the most affected areas of Italy were recruited via the Italian society of palliative care and researchers' network. ETHICAL CONSIDERATIONS The University Institutional Board granted ethical approval. Participants gave written informed consent and agreed to be video-recorded. FINDINGS The overarching theme highlighted participants' experience supporting health professionals to negotiate ethical complexity in end-of-life care. Crucial topics that emerged within themes were: training emergency department professionals on ethical dimensions of palliative and end-of-life care, preserving dying patients' dignity and developing ethical competence in managing end-of-life care. CONCLUSIONS Our study showed palliative care teams' challenges in supporting health professionals' ethical awareness in emergencies. However, while they highlighted their concerns in dealing with the emergency staff's lack of ethical perspectives, they also reported the positive impact of an ethically-informed palliative care approach. Lastly, this study illuminates how palliative care professionals' clinical and ethical competence might have assisted a cultural change in caring for dying patients during COVID-19 and future emergencies.
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Affiliation(s)
- Enrico De Luca
- Faculty of Health and Life Science, Academy of
Nursing, Exeter, Exeter University, Exeter, UK
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40
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Kruser JM, Viglianti EM, Mylvaganam R, Krolikowski KA, Khorzad R, Detsky ME, Wiegmann DA, Wunderink RG, Holl JL. Mapping the process of ICU care delivery to improve treatment decisions in acute respiratory failure. IISE TRANSACTIONS ON HEALTHCARE SYSTEMS ENGINEERING 2023; 14:32-41. [PMID: 38646086 PMCID: PMC11025699 DOI: 10.1080/24725579.2023.2188319] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Evidence suggests system-level norms and care processes influence individual patients' medical decisions, including end-of-life decisions for patients with critical illnesses like acute respiratory failure. Yet, little is known about how these processes unfold over the course of a patient's critical illness in the intensive care unit (ICU). Our objective was to map current-state ICU care delivery processes for patients with acute respiratory failure and to identify opportunities to improve the process. We conducted a process mapping study at two academic medical centers, using focus groups and semi-structured interviews. The 70 participants represented 17 distinct roles in ICU care, including interprofessional medical ICU and palliative care clinicians, surrogate decision makers, and patient survivors. Participants refined and endorsed a process map of current-state care delivery for all patients admitted to the ICU with acute respiratory failure requiring mechanical ventilation. The process contains four critical periods for active deliberation about the use of life-sustaining treatments. However, active deliberation steps are inconsistently performed and frequently disrupted, leading to prolongation of life-sustaining treatment by default, without consideration of patients' individual goals and priorities. Interventions to standardize active deliberation in the ICU may improve treatment decisions for ICU patients with acute respiratory failure.
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Affiliation(s)
- Jacqueline M Kruser
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Elizabeth M Viglianti
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Ruben Mylvaganam
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Kristyn A Krolikowski
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Chicago, IL, United States
| | - Rebeca Khorzad
- Arvin LLC Healthcare Quality Improvement, Lake Forest, Illinois, United States of America
| | - Michael E Detsky
- Department of Medicine, Sinai Health System, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Douglas A Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Richard G Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Jane L Holl
- Biological Sciences Division, University of Chicago, Chicago, Illinois, United States of America
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Oyekan AA, Lee JY, Hodges JC, Chen SR, Wilson AE, Fourman MS, Clayton EO, Njoku-Austin C, Crasto JA, Wisniewski MK, Bilderback A, Gunn SR, Levin WI, Arnold RM, Hinrichsen KL, Mensah C, Hogan MV, Hall DE. Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates: One-Year Results of the Surgical Pause Program. JB JS Open Access 2023; 8:JBJSOA-D-22-00107. [PMID: 37101601 PMCID: PMC10125643 DOI: 10.2106/jbjs.oa.22.00107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a "surgical pause" (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Anthony A. Oyekan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Email for corresponding author:
| | - Joon Y. Lee
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob C. Hodges
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen R. Chen
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan E. Wilson
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mitchell S. Fourman
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Elizabeth O. Clayton
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Jared A. Crasto
- Department of Orthopaedic Surgery, The Spine Institute of Arizona, Scottsdale, Arizona
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Bilderback
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Scott R. Gunn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William I. Levin
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie L. Hinrichsen
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Mensah
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - MaCalus V. Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Dahmer M, Jennings A, Parker M, Sanchez-Pinto LN, Thompson A, Traube C, Zimmerman JJ. Pediatric Critical Care in the Twenty-first Century and Beyond. Crit Care Clin 2023; 39:407-425. [PMID: 36898782 DOI: 10.1016/j.ccc.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pediatric critical care addresses prevention, diagnosis, and treatment of organ dysfunction in the setting of increasingly complex patients, therapies, and environments. Soon burgeoning data science will enable all aspects of intensive care: driving facilitated diagnostics, empowering a learning health-care environment, promoting continuous advancement of care, and informing the continuum of critical care outside the intensive care unit preceding and following critical illness/injury. Although novel technology will progressively objectify personalized critical care, humanism, practiced at the bedside, defines the essence of pediatric critical care now and in the future.
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Affiliation(s)
- Mary Dahmer
- Division of Critical Care, Department of Pediatrics, University of Michigan, 1500 East Medical Center Drive, F6790/5243, Ann Arbor, MI, USA
| | - Aimee Jennings
- Division of Critical Care Medicine, Advanced Practice, FA.2.112, Seattle Children's Hospital, 4800 Sandpoint Way Northeast, Seattle, WA 98105, USA
| | - Margaret Parker
- Department of Pediatrics, Stony Brook University, 7762 Bloomfield Road, Easton, MD 21601, USA
| | - Lazaro N Sanchez-Pinto
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 73, Chicago, IL 60611-2605, USA
| | - Ann Thompson
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medicine, 525 East 68th Street, Box 225, New York, NY 10065, USA
| | - Jerry J Zimmerman
- Department of Pediatrics, FA.2.300B Seattle Children's Hospital, 4800 Sandpoint Way Northeast, Seattle, WA 98105, USA; Pediatric Critical Care Medicine, Seattle Children's Hospital, Harborview Medical Center, University of Washington, School of Medicine, FA.2.300B, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA.
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43
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Benoit DD, Vanheule S, Manesse F, Anseel F, De Soete G, Goethals K, Lievrouw A, Vansteelandt S, De Haan E, Piers R, on behalf of the CODE study group. Coaching doctors to improve ethical decision-making in adult hospitalised patients potentially receiving excessive treatment: Study protocol for a stepped wedge cluster randomised controlled trial. PLoS One 2023; 18:e0281447. [PMID: 36943825 PMCID: PMC10030010 DOI: 10.1371/journal.pone.0281447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/18/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Fast medical progress poses a significant challenge to doctors, who are asked to find the right balance between life-prolonging and palliative care. Literature indicates room for enhancing openness to discuss ethical sensitive issues within and between teams, and improving decision-making for benefit of the patient at end-of-life. METHODS Stepped wedge cluster randomized trial design, run across 10 different departments of the Ghent University Hospital between January 2022 and January 2023. Dutch speaking adult patients and one of their relatives will be included for data collection. All 10 departments were randomly assigned to start a 4-month coaching period. Junior and senior doctors will be coached through observation and debrief by a first coach of the interdisciplinary meetings and individual coaching by the second coach to enhance self-reflection and empowering leadership and managing group dynamics with regard to ethical decision-making. Nurses, junior doctors and senior doctors anonymously report perceptions of excessive treatment via the electronic patient file. Once a patient is identified by two or more different clinicians, an email is sent to the second coach and the doctor in charge of the patient. All nurses, junior and senior doctors will be invited to fill out the ethical decision making climate questionnaire at the start and end of the 12-months study period. Primary endpoints are (1) incidence of written do-not-intubate and resuscitate orders in patients potentially receiving excessive treatment and (2) quality of ethical decision-making climate. Secondary endpoints are patient and family well-being and reports on quality of care and communication; and clinician well-being. Tertiairy endpoints are quantitative and qualitative data of doctor leadership quality. DISCUSSION This is the first randomized control trial exploring the effects of coaching doctors in self-reflection and empowering leadership, and in the management of team dynamics, with regard to ethical decision-making about patients potentially receiving excessive treatment.
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Affiliation(s)
- Dominique D. Benoit
- Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
- Intensive Care Medicine, University Hospital Ghent, Gent, Belgium
| | - Stijn Vanheule
- Ghent University Faculty of Psychology and Educational Sciences, Gent, Belgium
| | - Frank Manesse
- Independent, Conversio, Gent, Belgium
- Kets de Vries Institute, London, United Kingdom
| | - Frederik Anseel
- Ghent University Faculty of Psychology and Educational Sciences, Gent, Belgium
| | - Geert De Soete
- Ghent University Faculty of Psychology and Educational Sciences, Gent, Belgium
| | | | - An Lievrouw
- Intensive Care Medicine, University Hospital Ghent, Gent, Belgium
- Ghent University Hospital Cancer Centre, Gent, Belgium
| | - Stijn Vansteelandt
- Faculty of Applied Mathematics, Computer Sciences and Statistics, Ghent University Faculty of Sciences, Gent, Belgium
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Erik De Haan
- Hult International Business School Ashridge Centre for Coaching, Berkhamsted, United Kingdom
- VU Amsterdam School of Business and Economics, Amsterdam, The Netherlands
| | - Ruth Piers
- Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
- Ghent University Hospital Geriatrics, Gent, Belgium
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The Perspectives of Surrogates and Healthcare Providers Regarding SDM (Shared Decision-Making). DISEASE MARKERS 2023; 2023:6251492. [PMID: 36820102 PMCID: PMC9938785 DOI: 10.1155/2023/6251492] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/02/2022] [Accepted: 01/27/2023] [Indexed: 02/13/2023]
Abstract
The purpose of this paper is to explore the attitudes of surrogacy and medical service providers toward SDM and to identify the barriers and promoters of SDM in this population. To this end, we conducted a qualitative study of surrogacy and medical service providers in the First Affiliated Hospital of Soochow University using semistructured interviews. Thirty participants (11 agents, 12 ICU physicians, and 7 ICU nurses) were interviewed. The three stakeholders showed different attitudes toward SDM. They reported barriers to SDM, including insufficient cognition of decision-makers, high expectations, negative psychological experiences, previous decision-making experiences, excessive workload, heavy financial burden, and lack of decision AIDS. They reported facilitators of SDM, including trust, effective communication, decision support, value clarification, outcome commitment, and continuous service. This study explored the different attitudes of the three stakeholders and identified various barriers and facilitators of SDM. It highlights the need to develop localised decision AIDS and to involve agents and nurses more in the decision-making process. Therefore, this paper identifies barriers and facilitators of SDM in this population. In addition, the study identified various barriers and facilitators to SDM and highlighted the need to develop localised decision AIDS and involve agents and nurses more in the decision-making process. Finally, the barriers and facilitators of SDM are established. The paper also shows that the development of localized decision AIDS and greater involvement of agents and nurses in the decision-making process are integral to good treatment outcomes.
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Reifarth E, Garcia Borrega J, Kochanek M. How to communicate with family members of the critically ill in the intensive care unit: A scoping review. Intensive Crit Care Nurs 2023; 74:103328. [PMID: 36180318 DOI: 10.1016/j.iccn.2022.103328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To map the existing approaches to communication with family members of the critically ill in the intensive care unit and the corresponding implementation requirements and benefits. METHODS We conducted a scoping review in February 2022 by searching PubMed, CINAHL, APA PsycINFO, and Cochrane Library for articles published between 2000 and 2022. We included records of all designs that met our inclusion criteria and applied frequency counts and qualitative coding. RESULTS The search yielded 3749 records, 63 met inclusion criteria. The included records were of an interventional (43 %) or observational (14 %) study design or review articles (43 %), and provided information in three categories: communication platforms, strategies, and tools. For implementation in the intensive care unit, the approaches required investing time and resources. Their reported benefits were an increased quality of communication and satisfaction among all parties involved, improved psychological outcome among family members, and reduced intensive care unit length of stay and costs. CONCLUSION The current approaches to communication with patients' family members offer insights for the development and implementation of communication pathways in the intensive care unit of which the benefits seem to outweigh the efforts. Structured interprofessional frameworks with standardised tools based on empathic communication strategies are encouraged.
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Affiliation(s)
- Eyleen Reifarth
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO), Faculty of Medicine, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Jorge Garcia Borrega
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO), Faculty of Medicine, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Matthias Kochanek
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO), Faculty of Medicine, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
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Abstract
ABSTRACT Now more than ever, we know that there is uncertainty in medicine. Over the past 2 years, we have witnessed the evolution of knowledge that occurs in medicine and how this informs medical recommendations. Similarly, we have learned that patients have varying levels of risk tolerance, goals, and values. Although this is not a new reality, the COVID-19 pandemic has put it on display. Shared decision making is a tool for clinicians to use that recognizes this reality, honors the individuality of each patient, and guides us to the best decision for each patient.
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Gregory ME, MacEwan SR, Sova LN, Gaughan AA, McAlearney AS. A Qualitative Examination of Interprofessional Teamwork for Infection Prevention: Development of a Model and Solutions. Med Care Res Rev 2023; 80:30-42. [PMID: 35758303 PMCID: PMC10278586 DOI: 10.1177/10775587221103973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Health care-associated infections (HAIs), such as central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), are associated with patient mortality and high costs to the health care system. These are largely preventable by practices such as prompt removal of central lines and Foley catheters. While seemingly straightforward, these practices require effective teamwork between physicians and nurses to be enacted successfully. Understanding the dynamics of interprofessional teamwork in the HAI prevention context requires further examination. We interviewed 420 participants (physicians, nursing, others) across 18 hospitals about interprofessional collaboration in this context. We propose an Input-Mediator-Output-Input (IMOI) model of interprofessional teamwork in the context of HAI prevention, suggesting that various organizational processes and structures facilitate specific teamwork attitudes, behaviors, and cognitions, which subsequently lead to HAI prevention outcomes including timeliness of line and Foley removal, ensuring sterile technique, and hand hygiene. We then propose strategies to improve interprofessional teamwork around HAI prevention.
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Affiliation(s)
- Megan E. Gregory
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, OH
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH
| | - Sarah R. MacEwan
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, OH
| | - Lindsey N. Sova
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, OH
| | - Alice A. Gaughan
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, OH
| | - Ann Scheck McAlearney
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, OH
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH
- Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH
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Huang J, Qi H, Zhu Y, Zhang M. Factors Influencing the Initiative Behavior of Intensive Care Unit Nurses toward End-of-Life Decision Making: A Cross-Sectional Study. J Palliat Med 2022; 25:1802-1809. [PMID: 35749724 DOI: 10.1089/jpm.2021.0640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: Although the importance of intensive care unit (ICU) nurse initiative in end-of-life (EOL) decision making has been confirmed, there are few studies on the nurses' initiative in EOL situations. Objectives: To explore the role and mechanism of facilitators/barriers and perceived stress on the behavior of ICU nurses that initiate EOL decision making (i.e., initiative behavior). Design: This research adopted a cross-sectional descriptive design. Setting/Participants: A questionnaire composed of demographics, facilitators/barriers scale, perceived stress scale, and initiative behavior for EOL decision-making scale was used for registered ICU nurses in five tertiary general hospitals in Zhejiang Province, China. Results: The average score of the EOL decision initiative behavior was 5.54 on a range of 2-10. The results of correlation analysis indicated that the facilitators promote the initiative behavior, whereas the barriers interfere with initiative behavior. Facilitators/barriers in the EOL decision-making process significantly predicted the initiative behavior of ICU nurses in decision making (β = 0.698, p < 0.001). Facilitators/barriers had a significant indirect effect on the initiative behavior of ICU nurses through perceived stress. The 95% confidence interval was (-0.327 to -0.031), and the mediating effect of perceived stress accounted for 6.31% of the total effect. Conclusion: In the EOL context, the decision initiative of ICU nurses was at a medium level. Medical managers should implement intervention strategies based on the path that affects the initiative behavior of ICU nurses to reduce barriers and stress level in the decision-making process. That is, they should improve inter-team collaboration, nurse-patient communication, clarity of role responsibilities, and emotional support in dying situations to increase initiative and participation of ICU nurses in decision making.
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Affiliation(s)
- Jingying Huang
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Haiou Qi
- Nursing Department, and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Yiting Zhu
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Minyan Zhang
- Intensive Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
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49
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Forte DN. Shared decision-making: why, for whom, and how? CAD SAUDE PUBLICA 2022; 38:e00134122. [PMID: 36169518 DOI: 10.1590/0102-311xpt134122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Daniel Neves Forte
- Hospital Sírio-Libanês, São Paulo, Brasil.,Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
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Yu SF, Hsu CM, Wang HT, Cheng TT, Chen JF, Lin CL, Yu HT. Establishing the Competency Development and Talent Cultivation Strategies for Physician-Patient Shared Decision-Making Competency Based on the IAA-NRM Approach. Healthcare (Basel) 2022; 10:healthcare10101844. [PMID: 36292290 PMCID: PMC9601707 DOI: 10.3390/healthcare10101844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/13/2022] [Accepted: 09/17/2022] [Indexed: 11/21/2022] Open
Abstract
Shared decision making (SDM) is a collaborative process involving patients and their healthcare workers negotiating to reach a shared decision about medical care. However, various physician stakeholders (attending physicians, medical residents, and doctors in post-graduate years) may have different viewpoints on SDM processes. The purpose of this study is to explore the core competence of physicians in performing SDM tasks and to investigate the significant competency development aspects/criteria by applying the literature research and expert interviews. We adopt the IAA (importance awareness analysis) technique for different stakeholders to evaluate the status of competency development aspects/criteria and to determine the NRM (network relation map) based on the DEMATEL (decision-making trial and evaluation laboratory) technique. The study combines the IAA and NRM methods and suggests using the IAA-NRM approach to evaluate the adoption strategies and common suitable paths for different levels of physicians. Our findings reveal that SDM perception and practice is the primary influencer of SDM competence development for all stakeholders. The current model can help hospital administrators and directors of medical education understand the diverse stakeholders’ perspectives on the core competence of SDM tasks and determine common development plans. It provides strategic directions for SDM competency development and talent cultivation programs.
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Affiliation(s)
- Shan-Fu Yu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Puzi City 613, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Tayouan City 333, Taiwan
- Graduate Institute of Adult Education, National Kaohsiung Normal University, Kaohsiung City 802, Taiwan
| | - Chih-Ming Hsu
- Medical Education Department, Chiayi Chang Gung Memorial Hospital, Puzi City 613, Taiwan
- Department of Business Administration, National Chung Cheng University, Minxiong Township, Chiayi 621, Taiwan
| | - Hui-Ting Wang
- Graduate Institute of Adult Education, National Kaohsiung Normal University, Kaohsiung City 802, Taiwan
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Tayouan City 333, Taiwan
| | - Jia-Feng Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
| | - Chia-Li Lin
- Department of International Business, Ming Chuan University, Taipei City 111, Taiwan
- Correspondence: (C.-L.L.); (H.-T.Y.)
| | - Hsing-Tse Yu
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei City 105, Taiwan
- Correspondence: (C.-L.L.); (H.-T.Y.)
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