Patients, Nurses, and Physicians Working Together to Develop a Discharge Entrustable Professional Activity Assessment Tool.

PROBLEM: The Accreditation Council for Graduate Medical Education milestones were written by physicians and thus may not reflect all the behaviors necessary for physicians to optimize their performance as a key member of an interprofessional team. APPROACH: From April to May 2013, the authors, Educational Research Outcomes Collaborative leaders, assembled interprofessional team discussion groups, including patients or family members, nurses, physician trainees, physician educators, and other staff (optional), at 11 internal medicine (IM) programs. Led by the site's principal investigator, the groups generated a list of physician behaviors related to the entrustable professional activity (EPA) of a safe and effective discharge of a patient from the hospital, and prioritized those behaviors. OUTCOMES: A total of 182 behaviors were listed, with lists consisting of between 10 and 29 behaviors. Overall, the site principal investigators described all participants as emerging from the activity with a new understanding of the complexity of training physicians for the discharge EPA. The authors batched behaviors into six components of a safe and effective discharge: medication reconciliation, discharge summary, patient/caregiver communication, team communication, active collaboration, and anticipation of posthospital needs. Specific, high-priority behavior examples for each component were identified, and an assessment tool for direct observation was developed for the discharge EPA. NEXT STEPS: The authors are currently evaluating trainee and educator perceptions of the assessment tool after implementation in 15 IM programs. Additional next steps include developing tools for other EPAs, as well as a broader evaluation of patient outcomes in the era of milestone-based assessment.

In-hospital mortality in patients older than 60 years with very low albumin levels.

CONTEXT: Low albumin levels have been associated with increased mortality, but few studies have looked at the mortality rates of patients with very low albumin levels. OBJECTIVES: The objective of this study was to determine the in-hospital mortality rates for patients older than 60 years with albumin levels <2.0 g/dL. METHODS: This was a retrospective study of 543 consecutive patients older than the age of 60 who had an albumin level <2.0 g/dL while admitted to Summa Akron City Hospital between July and November 2008. Data were obtained from hospital databases. Mortality rates were calculated for each albumin level and compared with the overall inpatient mortality for patients older than 60 years. Rates of discharge to home were calculated by albumin level. Cross-tabulations and correlations were conducted to determine the association between albumin level and mortality, and to assess the independent effects of total parenteral nutrition, dialysis, cancer, and end-stage renal disease. RESULTS: Patients with albumin levels between 1.0 and 1.4 had a 41% in-hospital mortality rate, with only 16% of the patients being discharged to home. Patients with albumin levels between 1.5 and 1.9 had a 21% mortality rate, with 33% of patients discharged to home. Overall hospital mortality for patients older than 60 years was 6% during the study period. Total parenteral nutrition, cancer, dialysis, and end-stage renal disease were not independent risk factors for mortality in this study. CONCLUSION: An albumin level is readily obtained across all areas of the hospital and provides a simple and useful aid in identifying patients at high risk of a poor hospital outcome.

End-of-life decision making and emotional burden: placing family meetings in context.

BACKGROUND: Helping families make end-of-life care decisions can be challenging for health care providers in an intensive care unit (ICU). Family meetings facilitated by palliative care consult services (PCCS) have been recommended and found effective for improving support for families in these difficult situations. These services can be improved with a deeper understanding of factors associated with emotional burden in the aftermath of end-of-life decision making. OBJECTIVE: This qualitative study seeks to provide a better understanding of family experiences and emotional burden surrounding end-of-life decision making. PARTICIPANTS AND METHODS: We conducted in-depth, semistructured interviews with 23 family members following the death of a loved one in the ICU. All participants had been involved in a PCCS-led family meeting concerning end-of-life decisions about their loved one. Methodology from grounded theory was used to analyze the content of transcripts and to build a theoretical model. RESULTS: From the perspective of the family, decision making at the end of life is described within a theoretical model of salient experiences that are relevant to families' emotional burdens. Three temporal stages were evident: (1) the illness experience, (2) decision making in the family meeting, and (3) the dying process. However, emotional burden in the form of lingering questions and resentment was more common when families reported having negative experiences during the final hospital stay. CONCLUSIONS: Supportive responsiveness from the PCCS for families who have experienced critical incidents or who have unanswered questions or resentment about treatment may be an important consideration to alleviate later emotional burden.

Hungarians' perspectives on end-of-life care.

INTRODUCTION: Death and dying are taboo topics in Hungary. The care of the dying, the adequate relief of their symptoms, and the psychosocial and spiritual support of both patients and their relatives are not yet well addressed. As a preliminary study, we obtained information about the feelings and thoughts of Hungarian patients on death and dying, and about their expectations for end-of-life care. METHODS: A questionnaire was mailed to a convenience sample of 29 adult primary care offices where a total of 845 unselected patients completed the questionnaire. RESULTS: Only 19% of respondents would prefer to die in a hospital; while 69% of respondents would like to receive end of life care in their home. Respondents' greatest fear was to lose their autonomy and be dependent on their caregivers (55%). The second most noted concern was fear of pain and suffering (38%). DISCUSSION: The majority of Hungarian patients visiting their primary care physician's office prefer to receive end-of-life care in their own home. This mirrors findings in other European countries. It would appear that hospice and palliative care approaches would be acceptable to the Hungarian public if they were to be broadly developed.