Content of advance care planning among Japanese elderly people living at home: A qualitative study

Purpose of studyElderly peoples’ values and preferences for end-of-life care have not yet known in details. The aim of the present study was to investigate the end-of-life wishes and decision making among Japanese elderly people who required home care services. The study was designed to qualitative research strategies, using face to face interview data recorded in nursing care records, with a focus on advance care planning.Design and methodsA total of 102 elderly people (47 males, 55 females) of 6 home care support offices in Hyogo prefecture participated.Results and implicationsWe finally extracted the following 5 themes: anxiety about the future, abandonment of control, clinging to current daily life, precarious mutual support, delegating decision-making. While elderly people living at home generally feel anxious and fearful about the future, they seemed to try to avoid thinking too seriously about possible complications in their life.They also tend to leave end-of-life decision to someone else, and their decisions tend to change as they advance in age and as their condition deteriorates. Our findings suggest that medical professionals and care managers always support their patients’ decisions, allowing for the views of the informal caregivers on whom elderly people rely for decision-making.     

Shared decision making in primary care: Process evaluation of the intervention in the OPTIMAL study,a cluster randomised trial

AimsTo analyse the performance of a Shared Decision Making (SDM) intervention, we assessed perceived and experienced SDM in General Practitioners (GPs) and patients with type 2 diabetes (T2DM).MethodsCluster-Randomised Controlled Trial (cRCT) testing the effect of a decision aid. Opinions and experienced role regarding SDM were assessed in 72 patients and 18 GPs with the SDM-Q-9 (range 0–45) and Control Preferences Scale (CPS, 0–5), and observed SDM with the OPTION5 (0–20). SDM at baseline was compared to 24 months’ follow-up using paired t-tests.ResultsAt baseline, perceived levels of SDM did not significantly differ between GPs and patients with T2DM (difference of 2.3, p = 0.24). At follow-up, mean patients’ perceived level of SDM was 7.9 lower compared to baseline (p < 0.01), whereas GPs’ opinions had not changed significantly. After both visits, mean CPS scores differed significantly between patients and GPs. OPTION5 scores ranged between 6 and 20.ConclusionPatients and GPs perceived similar baseline levels of SDM. Two years later, patients perceived less SDM, while GPs did not change their opinion. SDM was appropriate immediately after training, but perhaps GPs fell back in old habits over time. We recommend repeated SDM training.     

Home discharge following critical illness: A qualitative analysis of family caregiver experience

Background

Few studies have longitudinally explored the experience and needs of family caregivers of ICU survivors after patients' home discharge.

End-of-life care of elderly patients with dementia: A cross-sectional study of family carer decision-making

BackgroundDementia syndromes pose a major worldwide challenge to public health. In terminal stage of dementia, carers are responsible for decision making in end-of-life treatment and there may be multiple factors that contribute to the choice of a palliative or invasive treatment.AimTo identify possible factors that influence the decision-making of family caregivers on implementing invasive or palliative interventions for people with end stage dementia.DesignA structured interview with family caregivers of elderly patients addressing aspects of the following categories: elderly with dementia, caregiver, medical treatment history. Statistical analysis was performed to test whether there was a significant association between the carer's decision (invasive or palliative treatment) and the collected variables.Settingand participantsThe study was conducted in three hospitals in Brazil. Participants were family caregivers of inpatients with end stage dementiaResultsMost of caregivers chose not to perform invasive procedures. The factors with the greatest association with the decision for invasive care were: elderly with tracheostomy, dementia diagnosis for less than 2 years, caregiver's age less than 50 years, history of hospital admission in the last year, affirmation that interviewee would be surprised with the death of the elderly within 1 year and the denial that health care team has already explained about treatment options.ConclusionThere were identified several factors related to the carer, the elderly person and their medical treatment that may influence the choice between palliative and invasive care for the elderly person with dementia.     

Frailty indexes in perioperative and critical care: A systematic review

Background/objectivesFrail patients are increasingly presenting for both perioperative and intensive care, highlighting the need for simple, valid and scaleable frailty measurement. Frailty indexes comprehensively assess a range of deficits in health, and can incorporate routinely collected data. The purpose of this systematic review was to evaluate the effect of frailty indexes on surgical and intensive care risk stratification and patient outcomes (mortality, complications, length of stay, and discharge location).MethodsA prospectively registered systematic review was performed. MEDLINE, EMBASE, and CINAHL were searched to identify studies enrolling adult surgical or intensive care patients which used a frailty index. Included studies were those published subsequent to 1990, of any study design, which utilised a frailty index consisting of ≥30 health deficits. Primary outcome was mortality; secondary outcomes were complications, length of stay (LOS) and discharge location. Study and frailty index quality were critically appraised by three independent reviewers, with findings narratively described.Results2026 articles were screened, from which nine prospective and four retrospective cohort studies (enrolling 2539 patients) were included. Frailty prevalence ranged between 19–62%; frailty indexes identified patients at risk of increased death [mortality rates ranging between 1.9–73.1%; reported odds ratios (ORs) for death ranging between 1.76–3.09 for frail vs. non-frail patients], surgical complications (ORs = 1.67–4.4), increased LOS, and discharge to residential care (ORs = 1.9–3.64). The term “frailty index” was found to be applied to a number of alternative measurement scales.ConclusionFrail patients are at significantly increased risk in critical illness and the perioperative period. Better standardisation of frailty indexes is recommended.     

Primary care nurses using guidelines in Thailand: a randomized controlled trial

BACKGROUND: Nurses run primary health centres in Thailand. We examined whether clinical guidelines improved the quality of the care they provide. METHODS: Eighteen nurse-led health centres randomized to (a) guidelines, receiving a training workshop plus educational outreach visit, with guidelines for children (acute respiratory tract infection and diarrhoea) and adults (diazepam prescribing and diabetes management) or (b) usual care. Outcomes were changes at 6 months in antibiotic use, diazepam prescribing, drug costs per patient, and a composite process index for diabetes care. RESULTS: Baseline prescribing was high for antibiotics (37% of all attendees), and no difference between intervention and control sites was detected at follow-up for this variable. In children (0-5 years old), antibiotics were widely used for acute respiratory tract infection (34%), and fell with guidelines (intervention: 42% at baseline to 27% at follow-up; control: 27-30%, P=0.022), with an associated fall in drug costs per patient. Antibiotics were widely prescribed for diarrhoea in children (91%), but no change was detected with guidelines. In adults, diazepam prescribing at baseline was high (17%), and fell in the guidelines group (intervention: 17-10%; control 21-18%; P=0.029). Diabetes care was generally good, and changed little with guidelines. CONCLUSION: Staff at primary health centres over-prescribe antibiotics in children and tranquilizer in adults. Clinical guidelines implemented with workshops and educational outreach visits improved some but not all aspects of prescribing in the short-term.     

重症监护病房耐碳青霉烯肺炎克雷伯菌感染情况的临床分析

目的了解我院重症医监护病房耐碳青霉烯类肺炎克雷伯(carbapenem-resistant Klebsiella pneumonia,CRKP)感染患者的临床特点及抗生素耐药情况,为CRKP防控提供依据,指导临床用药。方法收集我院2015年10月至2015年12月期间重症监护病房患者临床资料,回顾性分析其临床基本情况、临床表现、治疗方案及预后情况。结果我科CRKP发生率为27.42%,CRKP患者多为高龄男性(平均年龄64.14±14.45岁,男性占78.57%),发热(肺克组85.71%vs.非肺克组51.35%、非感染组9.09%,χ~2=14.484,P=0.001)、白细胞总数(肺克组15.70±6.92 vs.非肺克组10.09±4.33、非感染组9.41±4.48×109/L,χ~2=9.980,P=0.007)、C反应蛋白(肺克组142.00(50.50,240.00)vs.非肺克组71.10(27.00,107.50)、非感染组14.10(5.00,53.30)mg/L,χ~2=9.387,P=0.009)及降钙素原(肺克组3.50(1.07,27.05)vs.非肺克组0.71(0.20,3.14)、非感染组0.20(0.20,0.30)μg/L,χ~2=16.236,P0.001)升高为主要表现,经替加环素联合碳青霉烯治疗后病死率(肺克组35.71%vs.非肺克组45.95%、非感染组36.36%,χ~2=0.607,P=0.738)无明显增高,但会延长住院时间(肺克组33.00(18.75,44.50)vs.非肺克组7.00(4.00,11.50)、非感染组9.00(4.00,13.00)天,χ~2=15.398,P0.001)、增加住院费用(肺克组23.92(10.14,36.08)vs.非肺克组4.41(2.64,11.22)、非感染组2.80(1.94,3.19)万元,χ~2=21.370,P0.001)。结论重症监护病房易出现CRKP流行,减少广谱抗生素的不规范使用和不必要的侵入性操作,及时调整抗感染方案,是控制CRPK流行、减轻临床负担的重要措施。     

Patients' and providers' perceptions of asthma and asthma care: a qualitative study

Background: Differences in patients' and providers' perceptions of asthma and asthma care can create barriers to successful treatment. The primary goal of this qualitative study was to further explore patient and provider perceptions of asthma and asthma care as part of a larger Asthma Comparative Effectiveness Study. Methods: Focus groups held every 6 months for 3 years were designed to have a mix of both patients and providers allowing for unique understanding around asthma care. Results: The discussion centered on goal setting, asthma action plans and prevention strategies for asthma exacerbations. Three overarching themes, with a variety of subthemes, emerged as the main findings of this study. The three main themes were Cost/Economic Barriers/Process, Self-Governance/Adherence and Education. Conclusions: These themes indicated a strong need for patient educational interventions around asthma as well as education for providers around cost, insurance coverage and patient-centered communication. Specifically, education on learning to use inhalers properly, avoiding triggers and understanding the importance of a controller medication will benefit patients in the long-term management of asthma.     

A vignette-based survey to assess clinical decision making regarding antibiotic use and hospitalization of patients with probable aseptic meningitis

BACKGROUND:

The many etiologies of meningitis influence disease severity – most viral causes are self-limiting, while bacterial etiologies require antibiotics and hospitalization. Aided by laboratory findings, the physician judges whether to admit and empirically treat the patient (presuming a bacterial cause), or to treat supportively as if it were viral.

OBJECTIVE:

To determine factors that lead infectious disease specialists to admit and treat in cases of suspected meningitis.

METHODS:

A clinical vignette describing a typical case of viral meningitis in the emergency department was presented to clinicians. They were asked to indicate on a Likert scale the likelihood of administering empirical antibiotics and admitting the patient from the vignette and for eight subsequent scenarios (with varied case features). The process was repeated in the context of an inpatient following initial observation and/or treatment.

RESULTS:

Participants were unlikely to admit or to administer antibiotics in the baseline scenario, but a low Glasgow Coma Score or a high cerebrospinal fluid (CSF) white blood cell count with a high neutrophil percentage led to empirical treatment and admission. These factors were less influential after a negative bacterial CSF culture. These same clinical variables led to maintaining treatment and hospitalization of the inpatient.

CONCLUSIONS:

Most participants chose not to admit or treat the patient in the baseline vignette. Confusion and CSF white blood cell count (and neutrophil predominance) were the main influences in determining treatment and hospitalization. A large range of response scores was likely due to differing regional practices or to different levels of experience.     

Toward optimal end-of-life care for patients with advanced chronic obstructive pulmonary disease: Insights from a multicentre study

BACKGROUND:

Understanding patients’ needs and perspectives is fundamental to improving end-of-life (EOL) care. However, little is known of what quality care means to patients who have advanced lung disease.

OBJECTIVES:

To describe ratings of importance and satisfaction with elements of EOL care, informational needs, decision-making preferences, obstacles to a preferred location of death, clinical outcomes, and health care use before and during an index hospital admission for patients who have advanced chronic obstructive pulmonary disease (COPD).

METHODS:

A questionnaire with regard to quality EOL care was administered to patients older than 55 years of age who had advanced medical disease in five Canadian teaching hospitals.

RESULTS:

For 118 hospitalized patients who had advanced COPD, the following items were rated as extremely important for EOL care: not being kept alive on life support when there is little hope for meaningful recovery (54.9% of respondents), symptom relief (46.6%), provision of care and health services after discharge (40.0%), trust and confidence in physicians (39.7%), and not being a burden on caregivers (39.6%). Compared with patients who had metastatic cancer, patients with COPD had lower (P<0.05) satisfaction with care, interest in information about prognosis, cardiopulmonary resuscitation or mechanical ventilation, and referral rates to palliative care, whereas use of acute care services was higher (P<0.05) for patients who had advanced COPD.

CONCLUSION:

Canadian patients who have advanced COPD identify several priorities for improving care. Avoidance of prolonged or unwanted life support requires more effective communication, decision making and goal setting. Patients also deserve better symptom control and postdischarge strategies to minimize perceived burdens on caregivers, emergency room visits and hospital admissions.     

Influences that drive clinical decision-making among rheumatology nurses. Part 1: literature review

Decisions nurses make while providing patient care to their client group will impact on the patient's immediate and long-term outcomes and will also impact on service provision. Although many studies have focused on the clinical decision-making process itself within general nursing areas, little has been published as to what factors influence decisions in rheumatology nursing at the clinical level. Initial review of the literature suggested the following themes could influence decision-making: clinical decision-making, intuition, evidence-based practice, experiential learning, knowing the patient, skilled knowledge and rheumatology nursing. This article examines the literature surrounding clinical decision-making which may influence decision-making within rheumatology nursing practice.