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1.
Yen-Ni Hung Fur-Hsing Wen Tsang-Wu Liu Jen-Shi Chen Siew Tzuh Tang 《Journal of pain and symptom management》2018,55(3):755-765.e5
Context
Evidence for the association of hospice exposure with lower health care expenditures at end of life (EOL) remains inconclusive and neglects EOL care being concentrated in patients' last few months.Objective
The association between hospice exposure and health care expenditures in cancer patients' last one, three, six, and 12 months was evaluated.Methods
In this population-based, retrospective cohort study, Taiwanese cancer decedents in 2001–2010 (N = 195,228) were matched 1:1, with proportions of matched hospice users reaching 87.8%, by a hospice-utilization propensity score. For each matched pair, exposure to hospice (time from hospice enrollment to death) was matched to equivalent periods for hospice nonusers before death. Hospice-care associations with health care expenditures were evaluated by hospice use/exposure interactions with multilevel linear regression modeling using generalized estimating equations.Results
The unadjusted main effect showed lower total mean health care expenditures for hospice users than for hospice nonusers only in the last one and three months (rate ratio [95% CI]: 0.86 [0.81, 0.90] and 0.93 [0.89, 0.96], respectively). However, after accounting for exposure time, hospice care was significantly associated with lower health care expenditures at exposures of ≤30, ≤60, and ≤180 days for health care expenditures measured in the last one and three months, six months, and 12 months, respectively. Savings for patients with lengthy hospice stays were neutralized or even disappeared.Conclusion
Hospice care was associated with lower health care expenditures when it could actively intervene in EOL care. Hospice philosophy should be applied not only shortly before death but also throughout the dying trajectory to achieve maximum cost savings. 相似文献2.
Renea L. Beckstrand Rebecca F. Isaacson Janelle L.B. Macintosh Karlen E. Luthy Lacey Eden 《Journal of neonatal nursing : JNN》2019,25(1):32-36
Background
Neonatal deaths (infants less than 28 days old) account for two thirds (66.7%) of all infant deaths with most occurring in an ICU setting. NICU nurses are frequently involved in end-of-life (EOL) care and face unique obstacles.Objective
The objective of this study was to obtain NICU nurses’ suggestions for improving obstacles in EOL care in NICUs.Methods
Suggestions were obtained through mailed survey research in qualitative study design. Returned surveys yielded 121 nurse respondents who gave a total of 138 suggestions.Results
A total of 10 cohesive themes were identified: (1) environmental design issues, (2) improved communication between healthcare teams, (3) ending futile care earlier, (4) realistic and honest physician communications to families, (5) providing a “good death,” (6) improved nurse staffing, (7) need for EOL education, (8) earlier entry into hospice/palliative care, (9) availability of ancillary staff, and (10) allowing parents more time to prepare for death.Conclusions
Despite the variety of obstacles encountered in providing EOL care to dying infants and their families, NICU nurses can influence environmental factors, help improve communication, and use self-assessment tools to identify current EOL care practices. 相似文献3.
Hsin-Yun Tsai Kuo-Piao Chung Raymond Nien-Chen Kuo 《Journal of pain and symptom management》2018,55(3):798-807.e4
Context
Targeted therapies with epidermal growth factor receptor tyrosine kinase inhibitors have been widely used in the treatment of advanced non–small-cell lung cancer (NSCLC). However, little research has focused on the use of targeted therapies at the end of life (EOL).Objectives
This study investigated the determinants of receiving targeted therapy during the last month of life and how targeted therapies affect the quality of EOL care.Methods
We conducted a retrospective population-based study using a cancer registry and National Health Insurance claims data among 42,678 Taiwanese NSCLC decedents in 2005–2012. Propensity score matching and generalized linear mixed models were used to estimate associations.Results
We identified 3439 (21.3%) NSCLC patients who received targeted therapy within 30 days of death. Younger age, adenocarcinoma histology, postdiagnosis survival exceeding six months, and later year of death were associated with receiving targeted agents at EOL. The odds increased when patients were treated by pulmonologists or oncologists or in district hospitals or facilities with a higher case volume. Patients who were prescribed targeted therapy near death were significantly more likely to undergo aggressive EOL care (odds ratio = 2.35, 95% CI = 1.83–3.02) including multiple emergency department visits, hospitalization exceeding 14 days, admission to intensive care units, use of intubation and mechanical ventilation, cardiopulmonary resuscitation, and late hospice referrals.Conclusions
Targeted therapy at EOL should be considered a quality-of-care indicator. Guidance in the cessation of targeted therapy and the ongoing monitoring of practice initiatives are warranted. The decision-making processes associated with EOL care also require further investigation. 相似文献4.
Erica C. Kaye Melanie Gattas Ashley Kiefer Jason Reynolds Kristina Zalud Chen Li Zhaohua Lu Justin N. Baker 《Journal of pain and symptom management》2019,57(2):241-250
Context
Approximately 500,000 children in the United States suffer from life-limiting illnesses each year, many of whom are hospice eligible each year. Few hospice agencies, however, offer formal pediatric programs.Objective
To determine the levels of experience and comfort of hospice nurses who provide care to children and families in the community.Methods
A cross-sectional survey was developed to assess hospice nurse experience/comfort across the domains of symptom management, end-of-life care, goals of care, family-centered care, and bereavement. The survey was pilot tested and distributed to hospice nurses across a tristate region.Results
A total of 551 respondents across 71 hospices completed surveys. The majority of nurses reported no training in pediatric palliative or hospice care (89.8%), with approximately half reporting <5 years of hospice experience (53.7%) and no pediatric hospice experience (49.4%). Those with pediatric hospice experience reported limited opportunities to maintain or build their skills, with the majority providing care to children several times a year or less (85.7%). Nurses reported feeling somewhat or very uncomfortable providing services to children during the illness trajectory and at the end of life across all domains.Conclusion
Children with serious illness who receive care from local hospices often interface with nurses who lack training, experience, and comfort in the provision of palliative and hospice care to pediatric patients. These findings should inform future development and investigation of educational resources, training programs, and child- and family-centered policies to improve the delivery of palliative and hospice care to children in the community. 相似文献5.
Bernard L. Prado Ali Haider Syed Naqvi Roberto C. Pestana Janet L. Williams Seyedeh Dibaj Diane Liu Julio Allo Vera De La Cruz Eduardo Bruera 《Journal of pain and symptom management》2019,57(1):86-92
Context
Optimal benefits from palliative care (PC) are achieved when first consults (PC1) occur early, in the outpatient setting. Late PC1, like those in the intensive care unit (ICU), limit these benefits.Objectives
The objective of this study was to determine the proportion of PC1 over time in the outpatient, ICU, and inpatient non-ICU settings. We also examined patients' baseline characteristics and the timing of PC access (from PC1 to death) by the setting of PC1.Methods
We retrospectively evaluated consecutive cancer patients' records at our cancer center to ascertain the annual number of PC1 and its distribution across settings (2011–2017). ICU PC1 (n = 309) and a random sample of an equal number of outpatient and inpatient non-ICU PC1 were reviewed to retrieve patients' characteristics and death date.Results
PC1 total annual number increased by 58% from 2011 (n = 2286) to 2017 (n = 3615). We found a significant decrease in the proportion of ICU PC1 (from 2.3% in 2011 to 1% in 2017, P < 0.001). There were no significant changes in the proportion of PC1 at outpatient versus inpatient settings (P = 0.2). Hematologic cancer patients were more likely to have an ICU PC1 (P < 0.001). Median survival (months) was 7.7 (6.3–9.7), 3.4 (2.4–4.5), and 0.1 (0.1–0.1) for outpatient, inpatient, and ICU, respectively (P < 0.01).Conclusion
PC1 total annual number has increased, and the proportion of PC1 at ICU, a very late clinical setting, is decreasing. Further efforts are needed to integrate PC in hematologic cancer care. 相似文献6.
Laura C. Hanson Christine E. Kistler Kyle Lavin Stacey L. Gabriel Natalie C. Ernecoff Feng-Chang Lin Greg A. Sachs Susan L. Mitchell 《Journal of pain and symptom management》2019,57(1):10-19
Context
Persons with late-stage dementia have limited access to palliative care.Objective
The objective of this study was to test dementia-specific specialty palliative care triggered by hospitalization.Methods
This pilot randomized controlled trial enrolled 62 dyads of persons with late-stage dementia and family decision-makers on admission to hospital. Intervention dyads received dementia-specific specialty palliative care consultation plus postacute transitional care. Control dyads received usual care and educational information. The primary outcome was 60-day hospital or emergency department visits. Secondary patient- and family-centered outcomes were patient comfort, family distress, palliative care domains addressed in the treatment plan, and access to hospice or community-based palliative care. Secondary decision-making outcomes were discussion of prognosis, goals of care, completion of Medical Orders for Scope of Treatment (MOST), and treatment decisions.Results
Of 137 eligible dyads, 62 (45%) were enrolled. The intervention proved feasible, with protocol completion ranging from 77% (family two-week call) to 93% (initial consultation). Hospital and emergency department visits did not differ (intervention vs. control, 0.68 vs. 0.53 transfers per 60 days, P = 0.415). Intervention patients had more palliative care domains addressed and were more likely to receive hospice (25% vs. 3%, P < 0.019). Intervention families were more likely to discuss prognosis (90% vs. 3%, P < 0.001) and goals of care (90% vs. 25%, P < 0.001) and to have a MOST at 60-day follow-up (79% vs. 30%, P < 0.001). More intervention families made decisions to avoid rehospitalization (13% vs. 0%, P = 0.033).Conclusion
Specialty palliative care consultation for hospitalized patients with late-stage dementia is feasible and promising to improve decision-making and some treatment outcomes. 相似文献7.
Jennifer L. Woodburn Linda L. Staley Sara E. Wordingham Jenifer Spadafore Eva Boldea Samantha Williamson Sharene Hollenbach Heather M. Ross D. Eric Steidley Octavio E. Pajaro 《Journal of pain and symptom management》2019,57(2):330-340.e4
Context
Destination therapy (DT) patients face significant challenges as they transition from chronic left ventricular assist device (LVAD) support to comfort-oriented care. Integration of palliative medicine (PM) into the multidisciplinary team is important to facilitate advanced care planning (ACP) and improve quality of life (QoL).Objectives
We evaluated the impact of a structured programmatic approach to the end-of-life (EOL) process in DT patients as measured by QoL surveys and the utilization of ACP.Methods
We instituted a four prong intervention approach: 1) delineated the path from implant to EOL by defining specific stages, including a transitional phase where care limits were agreed upon, 2) standardized the role of PM, 3) held transitional care meetings to support shared decision-making, and 4) held multidisciplinary team debriefings to facilitate communication. Preintervention and postintervention outcomes were measured for patients/caregivers by using the QUAL-E/QUAL-E (family) QoL instrument. Wilcoxon signed-ranks test compared nonparametric variables.Results
All patients (n = 41)/caregivers (n = 28) reported improved QoL measures (patient P = 0.035/caregiver P = 0.046). Preparedness plans increased from 52% to 73% after implementation and advance directives increased from 71% to 83%. Fifty-nine percent of the patients completed an outpatient PM clinic visit; 51% completed/scheduled a second visit. Clinician outcomes improved including satisfaction with multidisciplinary team communication/expectations, ACP processes, and EOL management.Conclusion
A programmatic approach that standardizes the role of PM and delineates the patient's path from implant to EOL improved quality outcomes and increased implementation of ACP. A defined communication process allowed the multidisciplinary team to have a clear patient management approach. 相似文献8.
Fur-Hsing Wen Jen-Shi Chen Wen-Chi Chou Wen-Cheng Chang Chia-Hsun Hsieh Siew Tzuh Tang 《Journal of pain and symptom management》2019,57(2):190-198.e2
Context
High-quality end-of-life (EOL) care depends on thoroughly assessing terminally ill patients' preferences for EOL care and tailoring care to individual needs. Studies on predictors of EOL-care preferences were primarily cross-sectional and assessed preferences for multiple life-sustaining treatments (LSTs), making clinical applications difficult.Objective/Methods
We examined factors predisposing cancer patients (N = 303) to specific LST-preference states (life-sustaining preferring, comfort preferring, uncertain, and nutrition preferring) derived from six LSTs (cardiopulmonary resuscitation, intensive care unit care, chest compression, intubation with mechanical ventilation, intravenous nutrition, and tube feeding) in patients' last six months by multilevel multinomial logistic regression.Results
Participants with accurate prognostic awareness and physician-patient EOL-care discussions were less likely to be in life-sustaining-preferring, uncertain, and nutrition-preferring states than in the comfort-preferring state. Better quality of life (QOL) and more depressive symptoms predisposed participants to be less likely to be in the uncertain than in the comfort-preferring state. Membership in the nutrition-preferring rather than the comfort-preferring state was significantly higher for participants in the state of moderate symptom distress with severe functional impairment than in the state of mild symptom distress with high functioning.Conclusion
Accurate prognostic awareness, physician-patient EOL-care discussions, QOL, depressive symptoms, and symptom-functional states predisposed terminally ill cancer patients to distinct LST-preference states. Clinicians should cultivate patients' accurate prognostic awareness and facilitate EOL-care discussions to foster realistic expectations of LST efficacy at EOL. Clinicians should enhance patients' QOL to reduce uncertainty in EOL-care decision making and provide adequate psychological support to those with more depressive symptoms who prefer comfort care only. 相似文献9.
Paola Di Giulio Silvia Finetti Fabrizio Giunco Ines Basso Debora Rosa Francesca Pettenati Alessandro Bussotti Daniele Villani Simona Gentile Lorenzo Boncinelli Massimo Monti Sandro Spinsanti Massimo Piazza Lorena Charrier Franco Toscani 《Journal of pain and symptom management》2019,57(1):93-99
Context
End-of-life care in nursing homes (NHs) needs improvement. We carried out a study in 29 NHs in the Lombardy Region (Italy).Objectives
The objective of this study was to compare end-of-life care in NH residents with advanced dementia before and after an educational intervention aimed to improving palliative care.Methods
The intervention consisted of a seven-hour lecture, followed by two 3-hour meetings consisting of case discussions. The intervention was held in each NH and well attended by NH staff. This multicenter, comparative, observational study included up to 20 residents with advanced dementia from each NH: the last 10 who died before the intervention (preintervention group, 245 residents) and the first 10 who died at least three months after the intervention (postintervention group, 237 residents). Data for these residents were collected from records for 60 days and seven days before death.Results
The use of “comfort hydration” (<1000 mL/day subcutaneously) tended to increase from 16.9% to 26.8% in the postintervention group. The number of residents receiving a palliative approach for nutrition and hydration increased, though not significantly, from 24% preintervention to 31.5% postintervention. On the other hand, the proportion of tube-fed residents and residents receiving intravenous hydration decreased from 15.5% to 10.5%, and from 52% to 42%, respectively. Cardiopulmonary resuscitations decreased also from 52/245 (21%) to 18/237 (7.6%) cases (P = 0.002).Conclusion
The short educational intervention modified some practices relevant to the quality of end-of-life care of advanced dementia patients in NHs, possibly raising and reinforcing beliefs and attitudes already largely present. 相似文献10.
Erica C. Kaye Jonathan Jerkins Courtney A. Gushue Samantha DeMarsh April Sykes Zhaohua Lu Jennifer M. Snaman Lindsay Blazin Liza-Marie Johnson Deena R. Levine R. Ray Morrison Justin N. Baker 《Journal of pain and symptom management》2018,55(6):1550-1556
Context
Early integration of palliative care (PC) in the management of children with high-risk cancer is widely endorsed by patients, families, clinicians, and national organizations. However, optimal timing for PC consultation is not standardized, and variables that influence timing of PC integration for children with cancer remain unknown.Objectives
To investigate associations between demographic, disease, treatment, and end-of-life attributes and timing of PC consultation for children with high-risk cancer enrolled on a PC service.Methods
A comprehensive standardized tool was used to abstract data from the medical records of 321 patients treated at a large academic pediatric cancer center, who died between 2011 and 2015.Results
Gender, race, ethnicity, enrollment on a Phase I protocol, number of high-acuity hospitalizations, and receipt of cardiopulmonary resuscitation were not associated with timing of PC involvement. Patients with hematologic malignancy, those who received cancer-directed therapy during the last month of life, and those with advance directives documented one week or less before death had higher odds of late PC referral (malignancy: odds ratio [OR] 3.24, P = 0.001; therapy: OR 4.65, P < 0.001; directive: OR 4.81, P < 0.0001). Patients who received hospice services had lower odds of late PC referral <30 days before death (OR 0.31, P < 0.001).Conclusion
Hematologic malignancy, cancer-directed therapy at the end of life, and delayed documentation of advance directives are associated with late PC involvement in children who died of cancer. Identification of these variables affords opportunities to study targeted interventions to enhance access to earlier PC resources and services for children with high-risk cancer and their families. 相似文献11.
Context
Methadone is a long-acting opioid known for its unique pharmacokinetic and pharmacodynamic properties. Most research on methadone in children is limited to its effect on the prolongation of the corrected QT (QTc) interval.Objectives
To better understand the attitudes, beliefs, and practices of pediatric palliative care physicians regarding the use of methadone in children with advanced cancer.Methods
A survey was sent to the American Academy of Pediatrics Section of Hospice and Palliative Medicine LISTSERV. Information on demographics, dosing of methadone, and the use of electrocardiograms (ECGs) was collected.Results
One-hundred and five respondents (91%) provide palliative care to children ≥ 50% of the time, and a majority (81, 77%) prescribe methadone. Most (62, 77%) physicians were board certified in Hospice and Palliative Medicine, and most (39, 63%) certified via the direct pathway (“grandfathering”). Most physicians (57, 70%) do not use loading doses of methadone. Board-certified physicians trended toward decreasing methadone dose more (40% ± 19%) than non–board-certified physicians (28%, ±20%) when changing from the oral to intravenous route (P = 0.07). Respondents defined a QTc interval as “prolonged” (mean ± SD) at 444 milliseconds (±68 milliseconds). The percentage of patients receiving a baseline ECG was 65% (±33%). The most common reason for not performing a baseline ECG was that the patient was on hospice (13, 36%).Conclusions
There are consistent practices, attitudes, and beliefs of pediatric palliative care providers with regard to methadone. More education is needed on the accurate value of a prolonged QTc interval. 相似文献12.
Hillary D. Lum Adreanne Brungardt Sarah R. Jordan Phoutdavone Phimphasone-Brady Lisa M. Schilling Chen-Tan Lin Jean S. Kutner 《Journal of pain and symptom management》2019,57(1):112-117.e2
Background
Electronic health record–based portal tools may help patients engage in advance care planning (ACP). We designed and implemented portal-based ACP tools to enable patients to create a medical durable power of attorney (MDPOA).Measures
MDPOA documentation and System Usability Scale were assessed.Intervention
Stakeholder-informed portal-based ACP tools include an electronic MDPOA form, patient educational webpage, online messaging, and patient access to completed advance directives.Outcomes
A total of 2814 patients used the tools over 15 months. Patients had a mean age 45 years (17–98 years) and 69% were women. Eighty-nine percent completed an MDPOA form, 2% called or sent online messages, and 8% viewed the MDPOA form but did not complete it. The tools were rated highly usable.Conclusions/Lessons Learned
Patients demonstrated willingness to use the portal to complete an MDPOA and rated the new ACP tools as highly usable. Future work will optimize population-based outreach strategies to engage patients in ACP through the portal. 相似文献13.
Marcia A. Clevesy Tricia K. Gatlin Callie Cheese Kord Strebel 《Nursing for Women's Health》2019,23(1):21-30
Objective
The purpose of this project was to improve health care providers’ postpartum depression (PPD) knowledge and screening practices with the implementation of a standardized screening tool.Design
The plan–do–study–act model was used as a framework to measure and implement a practice change aimed at universal screening for PPD.Setting/Local Problem
Health care providers’ screening practices for PPD were inconsistent and lacked use of a standardized screening tool at a southwestern U.S. community women’s health care clinic serving minority women of lower socioeconomic status.Participants
Health care providers at a community women’s health care clinic.Intervention/Measurements
A single educational in-service was presented to health care providers regarding preventive PPD screening practices and documentation recommendations. Measurements included pre- and post-education questionnaire results and electronic health record chart reviews.Results
PPD screening documentation rates increased from 56% to 92.7% (p < .5).Conclusion
PPD screening education for health care providers and the addition of EPDS criteria to the electronic health record were associated with increased screening rates for PPD at a community women’s health care clinic. 相似文献14.
Ashley S. Mogul David M. Cline Jennifer Gabbard Casey Bryant 《The Journal of emergency medicine》2019,56(2):145-152
Background
Early integration of palliative care from the emergency department (ED) is an underutilized care modality with potential benefits, but few studies have identified who is appropriate for such care.Objective
Our hypothesis is that patients aged 65 years or older who present to the ED as level I Emergency Severity Index from a long-term care (LTC) facility have high resource utilization and mortality and may benefit from early palliative care involvement.Methods
We performed a retrospective chart review of patients aged 65 years or older who arrived in the ED of an academic suburban southeastern level I trauma center from an LTC facility and triaged as level I priority. The ED course, hospital course, and final outcomes were analyzed.Results
Of the 198 patients studied, 54% were deceased 30 days after discharge, with only 29.8% alive at 12 months. Admitted patients had a median hospital length of stay of 5 days and 73% required intensive care. Formal palliative care intervention was provided in 40.4%, occuring a median of 4 days into hospitalization and leading to 85% downgrading their advanced directive wishes, and discharge occuring a median of 1 day later. Few formal palliative care interventions occurred in the ED (9.1%).Conclusions
Elderly patients from LTC facilities presenting with severe acute illness have high mortality and seldom receive early palliative care. Introduction of palliative care has the ability to change the course of treatment in this vulnerable population and should be considered early in the hospitalization and, where available, be initiated in the ED. 相似文献15.
Laura C. Prater Thomas Wickizer Seuli Bose-Brill 《Journal of pain and symptom management》2019,57(4):731-737
Context
Opportunities for patients to receive unnecessary, costly, and potentially harmful care near the end of life abound. Advance care planning (ACP) can help to make this vulnerable period better for patients, caregivers, and providers.Objective
The objective of this study was to determine whether older age predicted the presence of certain forms of retrievable ACP documentation in the electronic health record (EHR) in a large sample of hospice-referred patients.Methods
This was a retrospective analysis of medical-record data on 3595 patients referred to hospice between January 1, 2013 and December 31, 2015. EHR documentation of an ACP note in the problem list, presence of a scanned advance directive, and the presence of a verified do-not-resuscitate order were the outcome measures. Logistic regression was used to assess the effect of age, education, race, gender, cancer diagnosis, dementia diagnosis, palliative encounter, and death on the outcome variables.Results
Our results suggest that when we control for prognosis, patients over age 70 years may experience gaps in ACP communication. We found that as patients age, the odds of having documentation of a conversation (odds ratio [OR] = 0.56; P < 0.001) or scanned advance directive decreased (OR = 0.63; P < 0.001), while the odds of having a verified do-not-resuscitate order increased (OR = 1.42; P < 0.001).Conclusion
The results of this study may imply some degree of unilateral and physician-driven decision making for end-of-life care among older adults. Collaborative efforts between an interdisciplinary medical team should focus on developing policies to address this potential disparity between younger and older adults at the end of life. 相似文献16.
Victoria L. Zhou Frances S. Shofer Nikita G. Desai Ilona S. Lorincz Nikhil K. Mull David H. Adler John C. Greenwood 《The Journal of emergency medicine》2019,56(2):127-134
Background
The resuscitation and critical care unit is a novel emergency department–intensive care unit designed to provide early critical care to emergency department patients for ≤24 h.Objectives
This study sought to identify clinical variables associated with short intensive care unit (ICU) stays in patients with diabetic ketoacidosis (DKA), who commonly require ICU-level care.Methods
We conducted a retrospective, single-center, cross-sectional study of DKA patients ≥18 years of age who presented to an academic, urban hospital emergency department over 16 months. Patient demographics and clinical variables extracted from medical records were compared between prolonged ICU stay patients of ≥24 h versus short ICU stay patients (SSPs) of <24 h. ICU care was defined as treatment in the resuscitation and critical care unit or inpatient ICU.Results
One hundred sixty-eight emergency department visits with a primary diagnosis of DKA were analyzed. There were 53 prolonged ICU stay patients, 58 SSPs, and 57 patients required no ICU time. SSPs had significantly higher initial serum bicarbonate (13.0 vs. 9.0 mEq/L, p = 0.01) and shorter anion gap closure time (9.8 vs. 14.4 hours, p = 0.003). Medication nonadherence was a significantly more frequent precipitant in SSPs (67.2% vs. 47.2%, p = 0.03). Initial anion gap, glucose, beta-hydroxybutyrate, and severity of illness scores were not significantly different between groups. After multivariate logistic regression adjusting for variables significant from univariate analysis, higher initial bicarbonate (p = 0.04) and medication nonadherence (p = 0.03) remained significantly associated with SSPs.Conclusions
Patients with DKA with short ICU stays have higher initial bicarbonate levels and are more likely to have medication nonadherence than patients requiring prolonged critical care. These variables may identify patients with DKA who are best treated in an emergency department–intensive care unit to potentially reduce inpatient ICU use. 相似文献17.
Ilona Fridman Paul A. Glare Stacy M. Stabler Andrew S. Epstein Alison Wiesenthal Thomas W. Leblanc E. Tory Higgins 《Journal of pain and symptom management》2018,55(6):1540-1545
Background
Negative attitudes toward hospice care might prevent patients with cancer from discussing and choosing hospice as they approach end of life. When making a decision, people often naturally focus on either expected benefits or the avoidance of harm. Behavioral research has demonstrated that framing information in an incongruent manner with patients' underlying motivational focus reduces their negative attitudes toward a disliked option.Objective
Our study tests this communication technique with cancer patients, aiming to reduce negative attitudes toward a potentially beneficial but often-disliked option, that is, hospice care.Methods
Patients (n = 42) with active cancer of different types and/or stages completed a paper survey. Participants read a vignette about a patient with advanced cancer and a limited prognosis. In the vignette, the physician's advice to enroll in a hospice program was randomized, creating a congruent message or an incongruent message with patients' underlying motivational focus (e.g., a congruent message for someone most interested in benefits focuses on the benefits of hospice, whereas an incongruent message for this patient focuses on avoiding harm). Patients' attitudes toward hospice were measured before and after receiving the physician's advice.Results
Regression analyses indicated that information framing significantly influenced patients with strong initial negative attitudes. Patients were more likely to reduce intensity of their initial negative attitude about hospice when receiving an incongruent message (b = ?0.23; P < 0.01) than a congruent one (b = ?0.13; P = 0.08).Conclusion
This finding suggests a new theory-driven approach to conversations with cancer patients who may harbor negative reactions toward hospice care. 相似文献18.
David Wang Caleb Ing Craig D. Blinderman May Hua 《Journal of pain and symptom management》2019,57(1):73-78
Context
In the intensive care unit (ICU), 14% of patients meet criteria for specialized palliative care, but whether subgroups of patients differ in their palliative care needs is unknown.Objectives
The objective of this study was to use latent class analysis to separate ICU patients into different classes of palliative care needs and determine if such classes differ in their palliative care resource requirements.Methods
We conducted a retrospective cohort study of ICU patients who received specialized palliative care, August 2013 to August 2015. Reason(s) for consultation were extracted from the initial note and entered into a latent class analysis model to generate mutually exclusive patient classes. Differences in “high use” of palliative care (defined as having five or more palliative care visits) between classes were assessed using logistic regression, adjusting for age, race, Charlson Comorbidity Index, and length of stay.Results
In a sample of 689 patients, a four-class model provided the most meaningful groupings: 1) Pain and Symptom Management (n = 218, 31.6%), 2) Goals of Care and Advance Directives (GCAD) (n = 131, 19.0%), 3) All Needs (n = 112, 16.3%), and 4) Supportive Care (n = 228, 33.1%). In comparison to GCAD patients, all other classes were more likely to require “high use” of palliative care (adjusted odds ratio [aOR] 2.61 [1.41–4.83] for “All Needs,” aOR 2.01 [1.16–3.50] for “Pain and Symptom Management,” aOR 1.94 [1.12–3.34] for “Supportive Care”).Conclusion
Based on the initial reason for consultation, we identified four classes of palliative care needs among critically ill patients, and GCAD patients were least likely to be high utilizers. These findings may help inform allocation of palliative care resources for this population. 相似文献19.
Margaret H. Sandham Oleg N. Medvedev Emma Hedgecock Irene J. Higginson Richard J. Siegert 《Journal of pain and symptom management》2019,57(2):290-296
Context
Accurate assessment of a patient's palliative care needs is essential for the timely provision of treatment and support. The Integrated Palliative Care Outcome Scale (IPOS) is an ordinal measure possessing acceptable psychometric properties, but its ability to discriminate precisely between individual symptom levels has not been rigorously investigated.Objectives
The study aimed to conduct Rasch analysis of the IPOS to evaluate and enhance precision of the instrument.Methods
Responses of 300 community-dwelling palliative care patients were subjected to Rasch analysis using the partial credit model.Results
Initial analysis supported the use of the Rasch model and acceptable reliability (person separation index = 0.77) was observed; however, unsatisfactory model fit was found. Local dependency between items was resolved through the creation of super-items, which increased model fit, reliability (person separation index = 0.80), and unidimensionality. There were no misfitting super-items or differential item functioning by age, rater, sex, or ethnicity. The IPOS showed satisfactory coverage of symptoms within the present clinical sample, with the ability to assess higher severity patients.Conclusion
The modified IPOS showed excellent reliability for a clinical measure in assessing the overall palliative care needs of a patient. The provided ordinal-to-interval conversion table accounts for unique contribution of each symptom to the overall symptom burden and easy to use without the need to modify the original IPOS format. 相似文献20.