Barriers to quality end-of-life care in West Virginia ICU units: physicians' and nurses' prospectives

Most deaths in West Virginia occur in hospitals and a high proportion take place in intensive care units (ICU). This study was undertaken to determine what West Virginia physicians and nurses treating patients in ICUs perceive to be the barriers to quality end-of-life care. A total of 626 physicians and nurses practicing in 28 hospitals completed surveys and the results showed that physicians and nurses agree the top three barriers are patient/family demands for all possible treatment; inadequate insurance coverage; and lack of health care professional education. The study indicated that the majority of physicians were satisfied with their end-of-life care skills. In addition, it showed that physicians referred an average of 10 patients to hospice in the preceding year and that they did not refer more patients because the patient or family did not accept that the patient was dying. Futher education of physicians, nurses and especially the public is needed to improve end-of-life care in West Virginia.     

终止治疗的讨论和伦理问题

ICU的医护人员必须就许多危重患者生命支持治疗的维持或终止等问题与家属讨论。作者就这种医患交流的重要性、方式、步骤和医学伦理问题进行讨论。     

Medical decisions concerning the end of life: a discussion with Japanese physicians.

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed.     

The legal status of consent obtained from families of adult patients to withhold or withdraw treatment

A review is provided of (1) state legislation on living wills and advance directives and (2) state court decisions and legislation authorizing family members to make the decision to withhold or withdraw life-sustaining treatment from adult patients. Five aspects of the emerging legal standards are summarized: the type of patient eligible; the type of treatment that may be withdrawn or withheld; designation of which family members are empowered to exercise authority; measures intended to prevent abuse of the new power by family members; and provisions empowering physicians to decide. The author suggests that the most prudent course would be to direct health care providers to accept family decisions unless it appears that the family is acting out of ignorance or in bad faith, in which case the decision would be referred to a hospital ethicist or ethics committee and then--only if there were good grounds to suspect ignorance or bad faith--to judicial review.     

Involvement of nurses in euthanasia: a review of the literature

In ethical debates about euthanasia, the focus is often exclusively on the involvement of physicians and the involvement of nurses is seldom given much attention. Yet nurses occupy a central position in the care of terminal patients, where being confronted with a euthanasia request is an ever present possibility. To assess the involvement of nurses in euthanasia, this article provides an overview of relevant findings from the scientific literature. From this it becomes apparent that nurses are involved in various phases of the euthanasia process: observing the request for euthanasia, decision making, carrying out of euthanasia, and the aftercare for the patient's family members.     

Autonomy, informed consent and advance directives: a study of physician attitudes

The rights of patients to make decisions concerning their care have been promoted by ethical guidelines under the banner of respect for autonomy, and by legal statutes that address informed consent requirements and advance directives. Given these trends, this study investigated the opinions of 90 physicians specializing in family practice and internal medicine at the Joan C. Edwards Marshall University School of Medicine and the West Virginia University School of Medicine in relation to physician-patient communication. Beliefs and attitudes of these physicians with respect to the participation of patients and family members in medical decisions were explored, using a survey instrument with closed questions. Although physicians surveyed showed respect for the primary elements of informed consent and supported stronger patients' rights, many respondents reported a willingness to override the explicit directives of patients, based on the requests of surrogates. These results reveal a conflict between current ethical and legal standards and the moral intuitions of many practicing physicians. More research focusing explicitly on the role and authority of surrogate decision-makers is warranted.     

Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions.

The first part of this paper examines the practice of informed treatment decisions in the protective medical system in China today. The second part examines how health care professionals in China perceive and carry out their responsibilities when relaying information to vulnerable patients, based on the findings of an empirical study that I had undertaken to examine the moral experience of nurses in practice situations. In the Chinese medical ethics tradition, refinement [jing] in skills and sincerity [cheng] in relating to patients are two cardinal virtues that health care professionals are required to possess. This notion of absolute sincerity carries a strong sense of parental protectiveness. The empirical findings reveal that most nurses are ambivalent about telling the truth to patients. Truth-telling would become an insincere act if a patient were to lose hope and confidence in life after learning of his or her disease. In this system of protective medical care, it is arguable as to whose interests are being protected: the patient, the family or the hospital. I would suggest that the interests of the hospital and the family members who legitimately represent the patient's interests are being honoured, but at the expense of the patient's right to know.     

End of life decisions: attitudes of Finnish physicians

OBJECTIVES: This study investigated Finnish physicians' experiences of decisions concerning living wills and do not resuscitate (DNR) orders and also their views on the role of patients and family members in these decisions. DESIGN: A questionnaire was sent to 800 physicians representing the following specialties: general practice (n = 400); internal medicine (n = 207); neurology (n = 100), and oncology (n = 93). RESULTS: The response rate was 56%. Most of the respondents had a positive attitude toward (92%), and respect for (86%) living wills, and 72% reported situations in which such a will would have been helpful, although experience with their use was limited. The physicians reported both benefits and problems with living wills. Thirteen per cent had completed a living will of their own. Half did not consider living wills to be reliable if they were several years old. Do not resuscitate orders were interpreted in two ways: resuscitation forbidden (70%) or only palliative (symptom oriented) care required (30%). The respondents also documented DNR orders differently. Seventy two per cent discussed DNR decisions always or often with patients able to communicate, and even 76% discussed DNR orders with the family members of patients unable to communicate. Most respondents were able to approach a dying patient without difficulty. They also felt that education in general was needed. CONCLUSIONS: In general Finnish physicians accept living wills, but find they are accompanied by several problems. Many problems could be avoided if physicians and patients conducted progressive discussions about living wills. The differing interpretations of DNR orders are a matter of concern in that they may affect patient treatment. The promotion of patient autonomy with respect to treatment seems rather good, but the limitations of the study need to be kept in mind.     

护士对急诊重危患者家属需求认知的分析

目的：调查分析急诊重危患者家属需求和护理人员对患者家属需求的认知状况,并针对认知差异采取有效对策。方法：采用重危患者家属需求量表对100例急诊抢救间/EICU患者家属和100名急诊护理人员进行调查,分析其差异。结果：5个因子中4个因子急诊重危患者家属的需求与急诊护理人员对家属需求的认知存有差异（P〈0.05）。45条需求中有24条家属与护士之间差异显著（P〈0.05）。不同患者家属的需求在病情保证需求方面存有差异（P〈0.05）。不同护理人员对家属需求的认知存有差异（P〈0.05）：护师和护士在“医护人员的支持”方面有差异,不同年龄和职称的护理人员在“获取信息”方面存在差异。结论：急诊护理人员对重危患者家属的需求大部分均能满足。     

武汉市某医院呼吸内科重症监护病房患者与家属关怀需求及护理对策

目的：了解武汉市某医院呼吸内科重症监护病房（RICU）患者及家属的满意度及关怀需求,制定相关护理对策及干预措施。方法：采取单纯随机抽样的方法,对62例重症监护病房住院患者,126名患者家属对护理工作的总体满意度、探视需求、入住RICU后担心的问题等进行问卷调查。结果：患者对护理工作的满意度明显高于患者家属（P〈0.05）;患者及家属均有探视的要求,并建议实行放宽条件的限制式探视制度;患者希望护理人员更多的陪伴,及时了解患者的情况。结论：护理人员应采取多种形式加强与患者及家属的沟通,注重细节管理;医院要实施人性化的探视管理制度,从多方面关注患者及家属的需求。     

居家老年患者家庭支持问题探讨

目的探讨居家老年患者家庭支持的常见问题,创造良好的养病治病家庭环境。方法用访谈法对在建家庭病床的老年患者及家庭成员、照顾者进行非结构性访谈。结果老年患者家庭支持问题主要存在三个方面：①家庭关怀不足,未能满足老年患者的情感需要;②健康照顾功能有限,家庭护理困难,需求专业指导;③家庭经济支持乏力。结论社区护士要善于鉴别有问题的家庭及其患病成员,采取必要的护理干预措施,帮助家庭发挥最大功能。     

Physicians' Perception of Palliative Care Consultation Service in a Major General Hospital in China

Objective s The in-hosptial palliative care consultation (PCC) is emerging as a routine service in some medical center in China. The current study evaluated how physicians in primary care team and consultation team perceive the PCC service for the purpose of investigating the effectiveness of this consultation model in a general hospital. Methods In-hosptial palliative care consultations have been carried out at Peking Union Medical College Hosptial by a dedicated consultation team, and 37 consultations were completed in 2016. A questionnaire was designed for physicians in terms of its benefits to patients,their family as well as the primary care team. Physicians who applied for consultation in 2016 formally (requested from the department other than the Geriatrics) and informally (by rotating residents and unemployed visiting doctors in geriatric department) were invited to participate in the survey by scanning a two dimentional code on social networking platform. Results There were 103 physicians participated in the survey, including primary care physicians from the department of Internal Medicine (n=8), Gynaecology (n=16) and Surgery (n=13), rotating residents (n=30), visiting doctors (n=16) in Geriatric department, and PCC team members (n=20). 94.0% of the non-PCC physicians agreed that PCC relieved the suffering of patients; 89.2% thought PCC improved the quality of patients’ life; there were 91.6%, 95.2%, 90.4% physicians who felt it relieved the anxiety of patients, of family members and of care providers, respectively. There were 96.4% physicians who felt it could ease the tension in physician-patient relationship; 97.6% felt it lower the risk for medical negligence, and 96.4% of doctors who applied for PPC felt satisfied with PCC service in terms of process and achieving objectives of consultation. More primary-team physician agree “PCC service helps the physicians better understand palliative care” than PCC members (97.6% vs. 80%, P<0.05), while both were interested in learning more on palliative medicine (100% vs. 96.4%, P>0.05). Conclusion Palliative care consultation service in a general hospital is efficacious and acclaimed.The primary care physicians and the PCC members hold positive attitudes to the benefits that the PCC services bring to patients, family members, and physicians themselves. PCC for terminal patients in a general hospital may serve as a good modle for promotion of palliative care in China.     

美国新毕业家庭医生寻找产科相关工作的体验

背景　足够的产科家庭医生对于确保患者获取必需的产科服务至关重要。然而,既往研究表明执业范围包含产科的家庭医生数量正在逐年减少,如今从事新生儿接生工作的家庭医生不到10%。目的　旨在探究希望将产科纳入其执业范围的新毕业家庭医生如何发现和选择工作,并进一步了解当前就业形势对家庭医生的执业范围,特别是产科、新生儿接生方面的影响。方法　于2017年进行问卷调查和定性访谈的混合方法研究。对美国家庭医生进行电子问卷调查并在目的性子抽样后对这些医生进行深度半结构化电话访谈。问卷调查总结了家庭医生未从事产科工作的原因,为进一步明确选择从事产科工作的家庭医生的具体情况,采用基于群体的沉浸式方法来转译定性访谈的结果。本研究向2 098例毕业于2014-2016年并希望从事新生儿接生工作的美国家庭医学专业实习医生发送调查问卷,回复1 016份,回复率48.43%,其中56例接受了电话访谈。结果　问卷调查结果显示,未能找到工作范围包含产科的工作是希望从事产科工作的家庭医学毕业生未从事该工作的主要原因。定性访谈结果显示,家庭医生通常通过人脉关系或人才招聘的途径找到产科相关工作,并根据地理位置偏好、家庭义务及生活方式要求等个人考虑因素做出选择。同时,求职过程和择业决策也受到工作结构、执业特点及缺乏产科相工作经验等因素的限制。结论　虽然个人意向决定大部分医学生的工作选择,但其选择仍受到多种不可控因素限制,特别是家庭医学工作提供产科相关工作的能力。美国毕业医学生从医院实习生到执业医师的转变同时影响着毕业生的求职选择和医疗机构患者寻求医疗服务的质量。因此,了解就业情况对家庭医生就业范围的影响方式,有助于进一步明确如何协助家庭医生在其希望从事的范围内工作并对其进行相应协助,从而确保每一个家庭可以获得更好的医疗服务。     

Family physicians' perceptions of health manpower needs in West Virginia.

West Virginia family physicians feel that they are able to assess the health care needs of their communities. There is a need for more physicians in all of the major specialties in West Virginia, but the largest numbers of physicians are needed in family practice and obstetrics. More registered nurses and licensed practical nurses are needed than any other health care professionals. Twenty-five percent of the respondents are actively recruiting associates, and 48 percent have seriously considered leaving, or are leaving West Virginia. The most commonly cited reasons for leaving are inadequate reimbursement, the state's economy, SB-576, lack of tort reform, and state government in general. The greatest advantage given to practicing in the state are its people, the quality of life, and home and family. In addition, the greatest problems are reimbursement, state government, the malpractice climate and the state economy. The survey shows that state government needs to show a good faith effort to enact tort reform to improve relations with physicians. The threat of losing more physicians is real and must be addressed. Improving the climate for the practice of medicine is a viable solution to West Virginia's manpower problems. There is also a need to continue all present health care professional training programs. More emphasis should be placed on recruitment and retention of nursing students. There is expressed support for nurse midwives, nurse practitioners, and physicians' assistants all working under the supervision of physicians. The finding that home and family are frequently listed as advantages to practicing here indicates recruitment and nurturing of students from underserved areas should be increased.(ABSTRACT TRUNCATED AT 250 WORDS)     

Costs Associated with Developing and Implementing a Computerized Clinical Decision Support System for Medication Dosing for Patients with Renal Insufficiency in the Long-term Care Setting

A team of physicians, pharmacists, and informatics professionals developed a CDSS added to a commercial electronic medical record system to provide prescribers with patient-specific maximum dosing recommendations based on renal function. We tracked the time spent by team members and used US national averages of relevant hourly wages to estimate costs. The team required 924.5 hours and $48,668.57 in estimated costs to develop 94 alerts for 62 drugs. The most time intensive phase of the project was preparing the contents of the CDSS (482.25 hours, $27,455.61). Physicians were the team members with the highest time commitment (414.25 hours, $25,902.04). Estimates under alternative scenarios found lower total cost estimates with the existence of a valid renal dosing database ($34,200.71) or an existing decision support add-on for renal dosing ($23,694.51). Development of a CDSS for a commercial computerized prescriber order entry system requires extensive commitment of personnel, particularly among clinical staff.     

内科急危重患者护患沟通障碍原因分析及对策

目的对我院存在的护理沟通障碍原因进行分析及探讨。方法从患者和医护两个方面存在的沟通障碍原因进行剖析。结果患者角色的转换、家属的过分关注、护士的技术不精及缺乏沟通知识和意识是引起护患沟通障碍原因的关键。结论良好的护患沟通不仅可以增进护患双方理解,减少医疗纠纷,更能促进患者康复,提高护理服务质量。     

Assessing the Sensibility of Two Clinical Decision Support Systems

Clinicians in Emergency Medicine (EM) are increasingly exposed to guidelines and treatment recommendations. To help access and recall these recommendations, electronic Clinical Decision Support Systems (CDSS) have been developed. This study examined the use and sensibility of two CDSS designed for emergency physicians. CDDS for community acquired pneumonia (CAP) and neutropenic fever (NF) were developed by multidisciplinary teams and have been accessed via an intranet-based homepage (eCPG) for several years. Sensibility is a term coined by Feinstein that describes common sense aspects of a survey instrument. It was modified by emergency researchers to include four main headings: (1) Appropriateness; (2) Objectivity; (3) Content; and (4) Discriminative Power. Sensibility surveys were developed using an iterative approach for both the CAP and NF CDSS and distributed to all 25 emergency physicians at one Canadian site. The overall response rate was 88%. Respondents were 88% male and 83% were less than 40; all were attending EM physicians with specialty designations. A number reported never having used the CAP (21%) or NF (33%) CDSS; 54% (CAP) and 21% (NF) of respondents had used the respective CDSS less than 10 times. Overall, both CDSS were rated highly by users with a mean response of 4.95 (SD 0.56) for CAP and 5.62 (SD 0.62) for NF on a seven-point Likert scale. The majority or respondents (CAP 59%, NF 80%) felt that the NF CDSS was more likely than the CAP CDSS to decrease the chances of making a medical error in medication dose, antibiotic choice or patient disposition (4.61 vs. 5.81, p=0.008). Despite being in place for several years, CDSS for CAP and NF are not used by all EM clinicians. Users were generally satisfied with the CDSS and felt that the NF was more likely than the CAP CDSS to decrease medical errors. Additional research is required to determine the barriers to CDSS use.     

Quality of care in family practice: does residency training make a difference?

As the proportion of physicians who enter residency training in family practice steadily increases, so does the need to evaluate the impact of their training and postgraduate education on the quality of care in their practices. We audited the practices of 120 randomly selected family physicians in Ontario, who were separated into four groups: nonmembers of the College of Family Physicians of Canada (CFPC), members of the CFPC with no certification in family medicine, certificated members without residency training in family medicine and certificated members with residency training in family medicine. The practices were assessed according to predetermined criteria for charting, procedures in periodic health examination, quality of medical care and use of indicator drugs. Generally the scores were significantly higher for CFPC members with residency training in family medicine than for those in the other groups, nonmembers having the lowest scores. Patient questionnaires indicated no difference in satisfaction with specific aspects of care between the four groups. Self-selection into residency training and CFPC membership may account for some of the results; nevertheless, the findings support the contention that residency training in family medicine should be mandatory for family physicians.