Implementing 'Goals of Care' discussion and palliative care referral for patients with advanced lung cancer: an outpatient-based pilot project.

BACKGROUND: Early involvement of palliative care and advance care planning improves quality-of-life outcomes and survival for patients with advanced lung cancer; however, there are barriers to implementation. AIMS: A single-centre prospective audit reviewing 'Goals of Care' (GOC) form completion and palliative care referrals in an oncology clinic was undertaken with the aim of increasing GOC completion and palliative care referrals for patients with advanced lung cancer. METHODS: Involved physicians attended a communication skills course and then received a communication-priming intervention. Clinicopathological factors associated with GOC completion and palliative care referral were explored. RESULTS: A total of 84 patients receiving palliative treatment for advanced lung cancer was enrolled. Clinicopathological factors, such as poorer performance status, were associated with higher likelihood of GOC completion (P = 0.018) prior to the intervention. Male sex (P = 0.023), absence of sensitising epidermal growth factor receptor mutation or anaplastic lymphoma kinase rearrangement (P = 0.017), type of systemic therapy (P = 0.031) and poorer performance status (P < 0.001) were associated with higher likelihood of palliative care referral. The intervention improved GOC completion (relative risk (RR) 1.29, P = 0.004); however, this was not sustained in a follow-up audit (RR 0.98, P = 0.92) and there was no change in palliative care referral rate (RR 2.5, P = 0.16). Predictors of palliative referral following clinical review included age (RR 1.16, P = 0.001), male sex (RR 14.2, P = 0.02) and poorer performance status (RR 1.76, P < 0.001). CONCLUSIONS: Communication-priming interventions can improve GOC completion for patients with advanced lung cancer. Further investigation is needed to pursue sustainable options for managing this complex patient group and improve guideline-adherence and patient care.

Goals of care: a clinical framework for limitation of medical treatment.

A novel clinical framework called "goals of care" (GOC) has been designed as a replacement for not-for-resuscitation orders. The aim is to improve decision making and documentation relating to limitations of medical treatment. Clinicians assign a patient's situation to one of three phases of care - curative or restorative, palliative, or terminal -according to an assessment of likely treatment outcomes. This applies to all admitted patients, and the default position is the curative or restorative phase. GOC helps identify patients who wish to decline treatments that might otherwise be given, such as treatment with blood products. This includes patients for whom specific limitations apply because of their beliefs. GOC has been introduced at Royal Hobart Hospital, Tasmania, and at Northern Health, Melbourne. So far, audit data and staff feedback have been favourable. There have been no reported major incidents or complaints in which GOC has been causally implicated in an adverse outcome.

How clinicians can support posttraumatic growth following psychosis: a perspective piece.

Psychosis is often a traumatic experience that can lead to significant suffering. However, people may also experience posttraumatic growth following psychosis. Posttraumatic growth refers to the positive changes that people experience following a struggle with an adversarial event and has been shown to occur in at least five domains, including a greater appreciation for life; improved relationships with others; greater personal strengths; new life possibilities and spiritual/existential growth. Studies have shown that mental health services can play a key role in facilitating posttraumatic growth. However, there are no recommendations that clinicians can follow to best support posttraumatic growth following psychosis specifically. Without guidance, clinicians risk invalidating people's experiences of, or providing improper support for, posttraumatic growth. To address this knowledge gap, we reflect on current research and clinical guidelines to recommend ways that clinicians can support posttraumatic growth following psychosis.

Medical Assistance in Dying: A Review of Canadian Health Authority Policy Documents.

The purpose of this study was to describe policies developed by English-speaking Canadian health authorities to guide multi-disciplinary healthcare practice in the context of MAID. Seventeen policies from 9 provinces and 3 territories were identified and analyzed thematically. Themes developed from these documents related to ensuring a team approach to care, supporting informed patient choice, creating region-specific guidance on eligibility criteria and safeguards, accommodating conscientious objection, and making explicit organizational responsibilities. Ethical language concerned vulnerability, non-judgmental care, dignity, non-abandonment, confidentiality, moral conscience, and diverse cultural values. Overall, these policies addressed important risk mitigation strategies, acknowledged important social contracts, and supported ethical practice. Collectively, these policies outline important considerations in the evolving Canadian context for other jurisdictions seeking to create policy around assisted death.

Developing competencies for volunteer navigators to support caregivers of children living with medical complexity: a mixed-method e-Delphi study.

Background: Providing specially trained volunteer navigators is one promising strategy for supporting the increasing number of family caregivers who are caring for children living with medical complexity. Objective: The objective of this study was to develop consensus on the role and competencies required for volunteer navigators who support caregivers of children living with medical complexity. Design: This was a mixed-method study using modified e-Delphi and focus group methods. In phase 1, a modified e-Delphi survey with 20 family caregivers and a focus group with 4 family caregivers were conducted to develop consensus on their unmet needs and the potential roles of a volunteer to meet those needs. In phase 2, a modified e-Delphi survey was conducted with experts to develop consensus on the volunteer competencies required to meet the roles identified by family caregivers in phase 1. Results: Findings from phase 1 resulted in 36 need-related items over 8 domains: communication, daily life and chores, emotional support, information and knowledge, respite, support with decision-making, and sharing the caregiving experience. Concerns about the volunteer role included the potential lack of commitment in the absence of remuneration, the complexity of the child's condition that was beyond the role of a volunteer, and a preference for support from individuals they knew. Findings from the phase 2 Delphi survey with professionals resulted in 22 competencies, derived from the roles identified in phase 1, that would be required of volunteers who wished to support these family caregivers. Conclusion: This study provides insight into a role for volunteers in meeting the needs of family caregivers of children living with medical complexity. A volunteer with lived experience and adequate preparation can assist with meeting some of these important needs. Further research is required to better understand the feasibility and acceptability of such a role.

Robotic lower extremity exoskeleton use in a non-ambulatory child with cerebral palsy: a case study.

PURPOSE: With few treatment options available for non-ambulatory children with cerebral palsy (CP), a robotic lower extremity gait trainer may provide a non-invasive addition to conventional treatment options. This case study investigates the usage and impact of robotic lower extremity gait trainer use in a participant with CP over the initial 3 months of use. MATERIALS AND METHODS: This prospective case study involves a 7-year old female (GMFCS V) with CP (registered clinical trial: NCT04251390). The participant used a Trexo Home robotic gait trainer (Trexo) in the community with assessments occurring in the home and school. Trexo usage and bowel movements (BMs) were tracked daily. Postural control and lower extremity range of motion (ROM) and spasticity were evaluated prior to Trexo use and weekly to biweekly thereafter. RESULTS: The participant used the device an average of 46 min/week, over 3.3 d/week. BM frequency increased from 0.4/d at baseline, to 1.2 (±0.5)/d during Trexo use. There were no diffuse systematic changes in postural stability, ROM or muscle spasticity, but specifically head control and spasticity in the knee flexors had improvements. CONCLUSIONS: Data and anecdotal reports suggest that regular use of the Trexo Home robotic gait trainer has positive outcomes on frequency and quality of BMs, and may improve head control, and knee flexor spasticity. Larger controlled studies are needed to evaluate the impacts of Trexo use in children with CP.Implications for RehabilitationNon-ambulatory children with CP can use and may experience benefits from using a robot-assisted gait trainer (RAGT).Constipation, aspects of balance and focal spasticity may improve.

Impact of Personal Cooling on Performance, Comfort and Heat Strain of Healthcare Workers in PPE, a Study From West Africa.

Background: Personal protective equipment (PPE) is an essential component of safely treating suspected or confirmed SARS-CoV-2 patients. PPE acts as a barrier to heat loss, therefore increasing the risk of thermal strain which may impact on cognitive function. Healthcare workers (HCWs) need to be able to prioritize and execute complex tasks effectively to ensure patient safety. This study evaluated pre-cooling and per-cooling methods on thermal strain, thermal comfort and cognitive function during simulated emergency management of an acutely unwell patient. Methods: This randomized controlled crossover trial was run at the Clinical Services Department of the Medical Research Unit The Gambia. Each participant attended two sessions (Cool and Control) in standard PPE. Cool involved pre-cooling with an ice slurry ingestion and per-cooling by wearing an ice-vest external to PPE. Results: Twelve participants completed both sessions. There was a significant increase in tympanic temperature in Control sessions at both 1 and 2 h in PPE (p = 0.01). No significant increase was seen during Cool. Effect estimate of Cool was -0.2°C (95% CI -0.43; 0.01, p = 0.06) post 1 h and -0.28°C (95% CI -0.57; 0.02, p = 0.06) post 2 h on tympanic temperature. Cool improved thermal comfort (p < 0.001), thermal sensation (p < 0.001), and thirst (p = 0.04). No difference on cognitive function was demonstrated using multilevel modeling. Discussion: Thermal strain in HCWs wearing PPE can be safely reduced using pre- and per-cooling methods external to PPE.

Xanthogranulomatous pyelonephritis caused by fusobacterium nucleatum. Case report and review of literature.

Xanthogranulomatous pyelonephritisis (XGP) is a rare and aggressive form of chronic urinary tract infection. The most common microorganism is Proteus but other microorganisms have been described in the literature. In this article, we describe a sixty-year-old male who presented with urosepsis and sever thrombocytopenia secondary to Fusobacterium nucleatum urinary tract infection which led to poorly functioning XGP. The rarity of the microorganism and the devastating clinical course encourages us to report it as anaerobes don't usually cause UTI but unusual microorganism should be suspected if the clinical course is atypical or if urinary tract abnormalities are present.