The Ambulatory Patient and Comprehensive Care

Comprehensive health care is a complex but important aspect of the future of medicine. It is based on a series of medical realities: the care of the whole patient, not merely the disease; the implicit contract between patient and physician; and the importance of continuity of care, preventive medicine and medical teamwork.     

Advance Care Planning in Serious Illness: A Narrative Review

ContextAdvance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility.ObjectiveTo delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness.MethodsWe conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000–2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care.ResultsEarly ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients’ wishes will be honored and revisited at end-of-life. An iterative, ‘building block’ framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations.ConclusionsWe advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.     

Operationalizing Depression Screening in Ambulatory Palliative Care: A Quality Improvement Project

BackgroundDepression is common in the palliative care setting and impacts outcomes. Operationalized screening is unusual in palliative care.Local ProblemLack of operationalized depression screening at two ambulatory palliative care sites.MethodsA fellow-driven quality improvement initiative to implement operationalized depression screening using the patient health questionnaire-2 (PHQ-2). The primary measure was rate of EMR-documented depression screening. Secondary measures were clinician perspectives on the feasibility and acceptability of implementing the PHQ-2.InterventionThe intervention is a clinic-wide implementation of PHQ-2 screening supported by note templates, brief clinician training, referral resources for clinicians, and opportunities for indirect psychiatric consultation.ResultsOperationalized depression screening rates increased from 2% to 38%. All clinicians felt incorporation of depression screening was useful and feasible.ConclusionsOperationalized depression screening is feasible in ambulatory palliative care workflow, though optimization through having screening be completed prior to clinician visit might improve uptake.     

基于自我效能的集中群组保健模式对产妇母乳喂养的效果观察

目的 探讨对孕产妇基于增强自我效能的集中群组保健模式的应用效果.方法 选择2017年1—4月在我院分娩并符合要求的初产妇为研究对象,按入院时间先后顺序分成观察组和对照组,2017年1—2月入院的143名孕产妇为对照组, 2017年3—4月入院的142孕产妇为观察组.对照组按照常规母乳喂养宣教模式,观察组在对照组的基础上实施基于增强自我效能的集中群组保健模式.比较2组孕产妇在妊娠32周、产后1周、6周、6个月的母乳喂养自我效能得分及产后1周、6周及6个月的纯母乳喂养率.结果 在妊娠32周时,2组孕妇的母乳喂养自我效能各维度及总分比较差异无统计学意义(P>0.05);观察组产后1周、6周、6个月的母乳喂养自我效能总分及各维度得分均高于对照组(P<0.01),纯母乳喂养率均高于对照组(P<0.05).结论基于增强自我效能的集中群组保健模式可以提高孕产妇母乳喂养自我效能及纯母乳喂养率,值得临床借鉴使用.     

A Clinical Update on Delirium: Focus on the Intensive Care Unit Patient

Acute care nurse practitioners manage a wide range of patient diagnoses and problems encountered in critical care, including management of delirium. As such, they are positioned to be leaders in the prevention, recognition, and management of delirium in the intensive care unit setting. Delirium in the hospitalized patient is linked with a prolonged length of stay, higher risk of death, and cognitive decline. Delirium will occur in up to 87% of intensive care unit patients with severe illness or recovering from major surgery. This overview of current evidence-based practice guidelines and an accompanying case study will assist interdisciplinary teams of health care providers to diagnose, treat, and manage hospitalized patients with delirium, with a focus on the complex care of the critically ill patient population.     

Palliative Care as a Primary Therapeutic Approach in Advanced Dementia: A Narrative Review

PurposeThe goal of this narrative review was to identify and summarize the ways in which palliative care could benefit patients who have advanced dementia.MethodsThis case-based discussion article examines current literature on palliative care for dementia.FindingsDementia is an incurable, progressive disease that affects millions of subjects. The prevalence has grown in the last decade and is projected to continue on this trajectory. In the later stages of dementia, subjects require increasing levels of care due to severe cognitive and functional impairment. Although the field of palliative medicine focuses on improving the quality of life of patients with life-limiting illnesses, many patients with advanced dementia do not receive palliative care services.ImplicationsPalliative care has been shown to improve patient and caregiver satisfaction, quality of life, and symptom burden at the end of life. Patients with advanced dementia would benefit from increased access to palliative care.