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1.
J Pain Symptom Manage ; 68(1): 53-60, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38574875

RESUMO

CONTEXT: Despite being one of the fastest growing ethnic groups in the U.S., there exists a gap in how treatment preferences among Chinese Americans are expressed and enacted upon in inpatient settings. OBJECTIVES: To compare the rates of advance care documentation and life-sustaining treatment between Chinese American and White American ICU decedents. METHODS: In this matched retrospective decedent cohort study, we included four ICUs within a tertiary medical center located in a Chinatown neighborhood. The Chinese American cohort included adult patients during the terminal admission in the ICU with primary language identified as Chinese (Mandarin, Cantonese, Taishanese). The White American cohort was matched according to age, sex, year of death, and admitting diagnosis. RESULTS: We identified 154 decedents in each cohort. Despite similar odds on admission, Chinese American decedents had higher odds of DNR completion (OR 1.82; 95%CI 0.99-3.40) and DNI completion (OR 1.81; 95%CI, 1.07-1.57) during the terminal ICU admission. Although Chinese American decedents had similar odds of intubation (aOR 0.90; 95%CI, 0.55-1.48), a higher proportion signed a DNI after intubation (41% vs 25%). Chinese American decedents also had higher odds of CPR (aOR 2.03; 95%CI, 1.03-41.6) with three Chinese American decedents receiving CPR despite a signed DNR order (12% vs 0%). CONCLUSIONS: During terminal ICU admissions, Chinese American decedents were more likely to complete advance care documentation and to receive CPR than White American decedents. Changes in code status were more common for Chinese Americans after intubation. Further research is needed to understand these differences and identify opportunities for goal-concordant care.


Assuntos
Asiático , Unidades de Terapia Intensiva , Cuidados para Prolongar a Vida , Humanos , Masculino , Feminino , Idoso , Estudos Retrospectivos , Pessoa de Meia-Idade , Cuidados para Prolongar a Vida/estatística & dados numéricos , Documentação , População Branca , Assistência Terminal , Idoso de 80 Anos ou mais , Estados Unidos , Ordens quanto à Conduta (Ética Médica) , Diretivas Antecipadas , Planejamento Antecipado de Cuidados
2.
J Palliat Med ; 22(5): 500-507, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30484728

RESUMO

Background: The Physician Orders for Life-Sustaining Treatment (POLST) began in Oregon in 1993 and has since spread nationally and internationally. Objectives: Describe and compare demographics and POLST orders in two decedent cohorts: deaths in 2010-2011 (Cohort 1) and in 2015-2016 (Cohort 2). Design: Descriptive retrospective study. Setting/Subjects: Oregon decedents with an active form in the Oregon POLST Registry. Measurements: Oregon death records were matched with POLST orders. Descriptive analysis and logistic regression models assess differences between the cohorts. Results: The proportion of Oregon decedents with a registered POLST increased by 46.6% from 30.9% (17,902/58,000) in Cohort 1 to 45.3% (29,694/65,458) in Cohort 2. The largest increase (83.3%) was seen in decedents 95 years or older with a corresponding 78.7% increase in those with Alzheimer's disease and dementia, while the interval between POLST form completion and death in these decedents increased from a median of 9-52 weeks. Although orders for do not resuscitate and other orders to limit treatment remained the most prevalent in both cohorts, logistic regression models confirm a nearly twofold increase in odds for cardiopulmonary resuscitation and full treatment orders in Cohort 2 when controlling for age, sex, race, education, and cause of death. Conclusion: Compared with Cohort 1, Cohort 2 reflected several trends: a 46.6% increase in POLST Registry utilization most marked in the oldest old, substantial increases in time from POLST completion to death, and disproportionate increases in orders for more aggressive life-sustaining treatment. Based on these findings, we recommend testing new criteria for POLST completion in frail elders.


Assuntos
Planejamento Antecipado de Cuidados/tendências , Cuidados para Prolongar a Vida/tendências , Mortalidade , Cuidados Paliativos/tendências , Padrões de Prática Médica/estatística & dados numéricos , Padrões de Prática Médica/tendências , Sistema de Registros/estatística & dados numéricos , Adulto , Planejamento Antecipado de Cuidados/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Previsões , Idoso Fragilizado/estatística & dados numéricos , Humanos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Oregon , Cuidados Paliativos/estatística & dados numéricos , Estudos Retrospectivos , Fatores Socioeconômicos
3.
Pediatr Neurol ; 91: 20-26, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30559002

RESUMO

PURPOSE: We describe the frequency and timing of withdrawal of life-support (WLS) in moderate or severe hypoxic-ischemic encephalopathy (HIE) and examine its associations with medical and sociodemographic factors. PROCEDURES: We undertook a secondary data analysis of a prospective multicenter data registry of regional level IV Neonatal Intensive Care Units participating in the Children's Hospitals Neonatal Database. Infants ≥36 weeks gestational age with HIE admitted to a Children's Hospitals Neonatal Database Neonatal Intensive Care Unit between 2010 and 2016, who underwent therapeutic hypothermia were categorized as (1) infants who died following WLST and (2) survivors with severe HIE (requiring tube feedings at discharge). RESULTS: Death occurred in 267/1,925 (14%) infants with HIE, 87.6% following WLS. Compared to infants with WLS (n = 234), the survived severe group (n = 74) had more public insurance (73% vs 39.3%, P = 0.00001), lower household income ($37,020 vs $41,733, P = 0.006) and fewer [20.3% vs 35.0%, P = 0.0212] were from the South. Among infants with WLS, electroencephalogram was performed within 24 hours in 75% and was severely abnormal in 64% cases; corresponding rates for MRI were 43% and 17%, respectively. Private insurance was independently associated with WLS, after adjustment for HIE severity and center. CONCLUSIONS: In a multicenter cohort of infants with HIE, WLS occurred frequently and was associated with sociodemographic factors. The rationale for decision-making for WLS in HIE require further exploration.


Assuntos
Hipotermia Induzida/estatística & dados numéricos , Hipóxia-Isquemia Encefálica/terapia , Doenças do Recém-Nascido/terapia , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Estudos de Coortes , Feminino , Humanos , Hipotermia Induzida/economia , Hipóxia-Isquemia Encefálica/economia , Hipóxia-Isquemia Encefálica/epidemiologia , Recém-Nascido , Doenças do Recém-Nascido/economia , Doenças do Recém-Nascido/epidemiologia , Unidades de Terapia Intensiva Neonatal/economia , Cuidados para Prolongar a Vida/economia , Masculino , Estudos Prospectivos , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Suspensão de Tratamento/economia
4.
Health Serv Res ; 53(3): 1644-1661, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-28097649

RESUMO

OBJECTIVE: To determine between-hospital variation in interventions provided to patients with do not resuscitate (DNR) orders. DATA SOURCES/SETTING: United States Agency of Healthcare Research and Quality, Healthcare Cost and Utilization Project, California State Inpatient Database. STUDY DESIGN: Retrospective cohort study including hospitalized patients aged 40 and older with potential indications for invasive treatments: in-hospital cardiac arrest (indication for CPR), acute respiratory failure (mechanical ventilation), acute renal failure (hemodialysis), septic shock (central venous catheterization), and palliative care. Hierarchical logistic regression to determine associations of hospital "early" DNR rates (DNR order placed within 24 hours of admission) with utilization of invasive interventions. DATA COLLECTION/EXTRACTION METHODS: California State Inpatient Database, year 2011. PRINCIPAL FINDINGS: Patients with DNR orders at high-DNR-rate hospitals were less likely to receive invasive mechanical ventilation for acute respiratory failure or hemodialysis for acute renal failure, but more likely to receive palliative care than DNR patients at low-DNR-rate hospitals. Patients without DNR orders experienced similar rates of invasive interventions regardless of hospital DNR rates. CONCLUSIONS: Hospitals vary widely in the scope of invasive or organ-supporting treatments provided to patients with DNR orders.


Assuntos
Estado Terminal/epidemiologia , Hospitais/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Ordens quanto à Conduta (Ética Médica) , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/estatística & dados numéricos , Preferência do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
5.
J Am Geriatr Soc ; 64(9): 1798-805, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27549337

RESUMO

OBJECTIVES: To examine whether racial differences in end-of-life (EOL) hospitalizations vary according to the presence of advance directives, specifically do-not-hospitalize (DNH) orders, and individual cognitive status in nursing home (NH) residents. DESIGN: National data, including Medicare data and Minimum Data Set (MDS) 2.0, between January 1, 2007, and September 30, 2010, were linked. EOL hospitalizations were hospitalizations in the last 30 days of life. Linear probability models with an interaction term (between race and DNH) and NH fixed-effects were estimated. The analyses were stratified according to cognitive status. SETTING: Nursing homes in the United States. PARTICIPANTS: Dually eligible Medicare-Medicaid decedents enrolled in Medicare fee-for-service plans and long-stay NH residents (in NHs ≥ 90 days before death) (N = 394,948). MEASUREMENTS: Racial difference in EOL hospitalizations from a NH. RESULTS: End-of-life hospitalization rate was 31.7% for whites and 42.8% for blacks. For participants without DNH orders, adjusted probability of EOL hospitalization was higher for blacks than for whites: 2.7 percentage points in those with moderate cognitive impairment (P < .001) and 4.7 percentage points in those with severe cognitive impairment (P < .001). For those with DNH orders, adjusted racial differences in EOL hospitalization were not statistically significant in those with moderate (P = .25) or severe (P = .93) cognitive impairment, but blacks had a higher probability of EOL hospitalization than whites if they had relatively intact cognitive status. CONCLUSION: Racial differences in EOL hospitalization varied with DNH orders and cognitive status in dying residents. Future research is necessary to understand the reasons behind these variations.


Assuntos
Diretivas Antecipadas/etnologia , População Negra/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Ordens quanto à Conduta (Ética Médica) , Assistência Terminal/estatística & dados numéricos , População Branca/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etnologia , Estudos Transversais , Feminino , Instituição de Longa Permanência para Idosos/estatística & dados numéricos , Humanos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Casas de Saúde/estatística & dados numéricos , Probabilidade , Estados Unidos , Revisão da Utilização de Recursos de Saúde
6.
Injury ; 46(9): 1706-11, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25799473

RESUMO

Outcome after traumatic brain injury (TBI) in the elderly has not been fully elucidated. The present retrospective observational study investigates the age-dependent outcome of patients suffering from severe isolated TBI with regard to operative and non-operative treatment. Data were prospectively collected in the TraumaRegister DGU. Anonymous datasets of 8629 patients with isolated severe blunt TBI (AISHead≥3, AISBody≤1) documented from 2002 to 2011 were analysed. Patients were grouped according to age: 1-17, 18-59, 60-69, 70-79 and ≥80 years. Cranial fractures (44.8%) and subdural haematomas (42.6%) were the most common TBIs. Independent from the type of TBI the group of patients with operative treatment declined with rising age. Subgroup analysis of patients with critical TBI (AISHead=5) revealed standardised mortality ratios (SMRs) of 0.81 (95% CI 0.75-0.87) in case of operative treatment (n=1201) and 1.13 (95% CI 1.09-1.18) in case of non-operative treatment (n=1096). All age groups ≥60 years showed significantly reduced SMRs in case of operative treatment. Across all age groups the group of patients with low/moderate disability according to the GOS (4 or 5 points) was higher in case of operative treatment. Results of this retrospective observational study have to be interpreted cautiously. However, good outcome after TBI with severe space-occupying haemorrhage is more frequent in patients with operative treatment across all age groups. Age alone should not be the reason for limited care or denial of operative intervention.


Assuntos
Lesões Encefálicas/cirurgia , Hematoma Subdural/cirurgia , Cuidados para Prolongar a Vida/estatística & dados numéricos , Ferimentos não Penetrantes/cirurgia , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas/complicações , Lesões Encefálicas/mortalidade , Análise Custo-Benefício , Feminino , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Hematoma Subdural/etiologia , Hematoma Subdural/mortalidade , Mortalidade Hospitalar , Humanos , Cuidados para Prolongar a Vida/economia , Masculino , Seleção de Pacientes , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/mortalidade
7.
Med Intensiva ; 39(7): 395-404, 2015 Oct.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-25241266

RESUMO

OBJECTIVE: Limitation of life-sustaining treatment (LLST) is a recommended practice in certain circumstances. Limitation practices are varied, and their application differs from one center to another. The present study evaluates the current situation of LLST practices in patients with prolonged admission to the ICU who suffer worsening of their condition. DESIGN: A prospective, observational cohort study was carried out. SETTING: Seventy-five Spanish ICUs. PATIENTS: A total of 589 patients suffering 777 complications or adverse events with organ function impairment after day 7 of admission, during a three-month recruitment period. MAIN VARIABLES OF INTEREST: The timing of limitation, the subject proposing LLST, the degree of agreement within the team, the influence of LLST upon the doctor-patient-family relationship, and the way in which LLST is implemented. RESULTS: LLST was proposed in 34.3% of the patients presenting prolonged admission to the ICU with severe complications. The incidence was higher in patients with moderate to severe lung disease, cancer, immunosuppressive treatment or dependence for basic activities of daily living. LLST was finally implemented in 97% of the cases in which it was proposed. The decision within the medical team was unanimous in 87.9% of the cases. The doctor-patient-family relationship usually does not change or even improves in this situation. CONCLUSION: LLST in ICUs is usually carried out under unanimous decision of the medical team, is performed more frequently in patients with severe comorbidity, and usually does not have a negative impact upon the relationship with the patients and their families.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Cuidados Críticos/ética , Cuidados Críticos/tendências , Tomada de Decisões , Grupos Diagnósticos Relacionados , Progressão da Doença , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Relações Interprofissionais , Cuidados para Prolongar a Vida/ética , Cuidados para Prolongar a Vida/tendências , Masculino , Futilidade Médica , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Relações Profissional-Família , Estudos Prospectivos , Espanha , Suspensão de Tratamento/ética , Suspensão de Tratamento/tendências
8.
Am J Respir Crit Care Med ; 190(7): 818-26, 2014 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-25271745

RESUMO

RATIONALE: The high costs of health care in the United States and other developed nations are attributable, in part, to overuse of tests, treatments, and procedures that provide little to no benefit for patients. To improve the quality of care while also combating this problem of cost, the American Board of Internal Medicine Foundation developed the Choosing Wisely Campaign, tasking professional societies to develop lists of the top five medical services that patients and physicians should question. OBJECTIVES: To present the Critical Care Societies Collaborative's Top 5 list in Critical Care Medicine and describe its development. METHODS: Each professional society in the Collaborative nominated members to the Choosing Wisely task force, which established explicit criteria for evaluating candidate items, generated lists of items, performed literature reviews on each, and sought external input from content experts. Task force members narrowed the list to the Top 5 items using a standardized scoring system based on each item's likely overall impact and merits on the five explicit criteria. MEASUREMENTS AND MAIN RESULTS: From an initial list of 58 unique recommendations, the task force proposed a Top 5 list that was ultimately endorsed by each Society within the Collaborative. The five recommendations are: (1) do not order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions; (2) do not transfuse red blood cells in hemodynamically stable, nonbleeding ICU patients with an Hb concentration greater than 7 g/dl; (3) do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay; (4) do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation; and (5) do not continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort. CONCLUSIONS: These five recommendations provide a starting point for clinicians and patients to make decisions leading to higher-quality, lower-cost care. Future work is needed to promote adherence to these recommendations and to develop additional ways for intensive care clinicians to take leadership in reining in health-care costs.


Assuntos
Transfusão de Sangue/estatística & dados numéricos , Cuidados Críticos/métodos , Cuidados Críticos/normas , Sedação Profunda/estatística & dados numéricos , Testes Diagnósticos de Rotina/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Nutrição Parenteral/estatística & dados numéricos , Transfusão de Sangue/economia , Cuidados Críticos/economia , Estado Terminal/economia , Sedação Profunda/economia , Testes Diagnósticos de Rotina/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Cuidados para Prolongar a Vida/economia , Nutrição Parenteral/economia , Médicos , Sociedades Médicas , Estados Unidos
9.
Crit Care Med ; 42(4): 824-30, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24201177

RESUMO

OBJECTIVE: To investigate whether the proactive intervention of a clinical ethicist in cases of prolonged lengths of stay in a critical care setting reduces nonbeneficial treatment while increasing perceived patient/surrogate and provider satisfaction and reducing associated costs. Nonbeneficial treatment is defined here as the use of life-sustaining treatments delivered to patients who had been in the ICU for 5 days and did not survive to discharge. DESIGN: Prospective randomized exploratory trial from October 2007 to February 2010 in the adult ICU of a large, urban, not-for-profit community hospital. SETTING: Medical/surgical ICU of California Pacific Medical Center, a large tertiary not-for-profit hospital in San Francisco, CA. PATIENTS: Three hundred eighty-four patients with ICU lengths of stay of five days or greater. Patients were randomized to either an intervention arm (Proactive Ethics Intervention) (n = 174) or control arm (n = 210). There were 56 patients in the intervention arm and 52 patients in the control arm who did not survive to discharge. INTERVENTIONS: Proactive ethics intervention involves a trained bioethicist in the care of all ICU patients with a length of stay greater than or equal to 5 days. The intervention used a nine step process model designed to look for manifest or latent ethics conflicts and address them. MEASUREMENTS AND MAIN RESULTS: The primary outcome measures were days in the ICU; overall length of hospital stay; mortality; nonbeneficial treatments, for example, provision of nutritional support; surrogate and survivor satisfaction, and cost. The intervention and control arms showed no significant difference in mortality. Proactive Ethics Intervention, at the 95% CI, was not associated with reductions of overall length of stay (23 d for intervention and 21 d for control, p = 0.74), ICU days (11 in each arm, p = 0.91), life-sustaining treatments (days on ventilator: intervention, 14.6; control, 13.7; p = 0.74; days receiving artificial nutrition and hydration: intervention, 16.5; control, 15.9; p = 0.85), or cost ($167,350.00 for intervention and $164,670.00 for control, p =0.92) in patients who did not survive to discharge. Perceptions of quality of care by patients and providers showed no difference between intervention and control arms. CONCLUSION: Our study finds that Proactive Ethics Intervention, provided to all patients in a critical care setting for 5 days, and before an ethical conflict has been recognized, is ineffective in reducing overall length of hospital stay, ICU days, nonbeneficial treatments, or hospital costs. It is also not effective in increasing perceptions of quality of care by patients or providers.


Assuntos
Eticistas , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , APACHE , Idoso , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Apoio Nutricional/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , Estudos Prospectivos , Qualidade da Assistência à Saúde/organização & administração , Qualidade da Assistência à Saúde/estatística & dados numéricos , Fatores Socioeconômicos
10.
J Palliat Med ; 16(7): 780-5, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23790184

RESUMO

BACKGROUND: Hospice care is important for patients with terminal hepatocellular carcinoma (HCC), especially in endemic areas of viral hepatitis. Differences between hospice care and usual care for geriatric HCC inpatients have not yet been explored in a nationwide survey. OBJECTIVE: The study's purpose was to analyze differences between hospice care and usual care for geriatric HCC inpatients in a nationwide survey. METHODS: This nationwide, population-based study used data obtained from the Taiwan National Health Insurance Database. Patients with terminal HCC who were ≥65 years old and received their end-of-life care in the hospital between January 2001 and December 2004 were recruited. The comparison group was selected by propensity score matching from patients receiving usual care in acute wards. RESULTS: We enrolled 729 terminal HCC patients receiving inpatient hospice care and 729 matched controls selected from 2482 HCC patients receiving usual care. Hospice care patients were treated mainly by family medicine doctors (36%) and oncologists (26%), while usual care patients were treated mainly by gastroenterologists (60.2%). The natural opium alkaloids were used more in the hospice care group than in the usual care group (72.7% versus 25.5%, P<0.001), whereas the length of stay (8±7.7 days versus 14.1±14.3 days, P<0.001), aggressive procedures (all P<0.005), and medical expenses (all P<0.001) were significantly less in the hospice care group. CONCLUSION: HCC patients in hospice wards received more narcotic palliative care, underwent fewer aggressive procedures, and incurred lower costs than those in acute wards. Hospice care should be promoted as a viable option for terminally ill, elderly HCC patients.


Assuntos
Analgésicos Opioides/uso terapêutico , Carcinoma Hepatocelular/economia , Cuidados Paliativos na Terminalidade da Vida/economia , Cuidados para Prolongar a Vida/economia , Neoplasias Hepáticas/economia , Cuidados Paliativos/economia , Idoso , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/normas , Carcinoma Hepatocelular/fisiopatologia , Carcinoma Hepatocelular/terapia , Custos e Análise de Custo , Feminino , Pesquisas sobre Atenção à Saúde , Cuidados Paliativos na Terminalidade da Vida/métodos , Cuidados Paliativos na Terminalidade da Vida/normas , Mortalidade Hospitalar , Humanos , Pacientes Internados/estatística & dados numéricos , Revisão da Utilização de Seguros/estatística & dados numéricos , Cuidados para Prolongar a Vida/normas , Cuidados para Prolongar a Vida/estatística & dados numéricos , Neoplasias Hepáticas/fisiopatologia , Neoplasias Hepáticas/terapia , Masculino , Cuidados Paliativos/métodos , Cuidados Paliativos/normas , Pontuação de Propensão , Padrão de Cuidado , Taiwan/epidemiologia , Doente Terminal/estatística & dados numéricos
11.
Am J Respir Crit Care Med ; 186(12): 1264-71, 2012 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-23087028

RESUMO

RATIONALE: Severe sepsis is common and highly morbid, yet the epidemiology of severe sepsis at the frontier of the health care system-pre-hospital emergency care-is unknown. OBJECTIVES: We examined the epidemiology of pre-hospital severe sepsis among emergency medical services (EMS) encounters, relative to acute myocardial infarction and stroke. METHODS: Retrospective study using a community-based cohort of all nonarrest, nontrauma King County EMS encounters from 2000 to 2009 who were transported to a hospital. MEASUREMENTS AND MAIN RESULTS: Overall incidence rate of hospitalization with severe sepsis among EMS encounters, as well as pre-hospital characteristics, admission diagnosis, and outcomes. Among 407,176 EMS encounters, we identified 13,249 hospitalizations for severe sepsis, of whom 2,596 died in the hospital (19.6%). The crude incidence rate of severe sepsis was 3.3 per 100 EMS encounters, greater than for acute myocardial infarction or stroke (2.3 per 100 and 2.2 per 100 EMS encounters, respectively). More than 40% of all severe sepsis hospitalizations arrived at the emergency department after EMS transport, and 80% of cases were diagnosed on admission. Pre-hospital care intervals, on average, exceeded 45 minutes for those hospitalized with severe sepsis. One-half or fewer of patients with severe sepsis were transported by paramedics (n = 7,114; 54%) or received pre-hospital intravenous access (n = 4,842; 37%). CONCLUSIONS: EMS personnel care for a substantial and increasing number of patients with severe sepsis, and spend considerable time on scene and during transport. Given the emphasis on rapid diagnosis and intervention for sepsis, the pre-hospital interval may represent an important opportunity for recognition and care of sepsis.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Sepse/diagnóstico , Sepse/epidemiologia , Idoso , Diagnóstico Diferencial , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/organização & administração , Feminino , Humanos , Incidência , Cuidados para Prolongar a Vida/métodos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Avaliação de Resultados em Cuidados de Saúde , Admissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Sepse/terapia , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Washington/epidemiologia
13.
Med Law Rev ; 18(4): 471-96, 2010.
Artigo em Inglês | MEDLINE | ID: mdl-21098046

RESUMO

This contribution describes the regulation of end-of-life decisions in neonatology in the Netherlands. An account is given of the process of formulating rules, which includes a report by the Dutch Association for Paediatrics, two Court rulings, a report by a Consultation Group appointed by the Ministry of Health and a professional Protocol regulating deliberate ending of life in neonatology that was subsequently adopted as the regulation of this type of decision-making at the national level. The paper presents Dutch and comparative data on the attitude of the medical profession towards end-of-life decisions in neonatology and the frequency of such decisions in medical practice.


Assuntos
Tomada de Decisões , Eutanásia Ativa/legislação & jurisprudência , Eutanásia Passiva/legislação & jurisprudência , Cuidados para Prolongar a Vida/legislação & jurisprudência , Futilidade Médica/legislação & jurisprudência , Neonatologia/legislação & jurisprudência , Analgésicos Opioides/administração & dosagem , Atitude do Pessoal de Saúde , Atitude Frente a Morte , Comparação Transcultural , Dissidências e Disputas/legislação & jurisprudência , Eutanásia Ativa/normas , Eutanásia Ativa/estatística & dados numéricos , Eutanásia Passiva/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Mortalidade Infantil , Recém-Nascido , Cuidados para Prolongar a Vida/normas , Cuidados para Prolongar a Vida/estatística & dados numéricos , Neonatologia/normas , Neonatologia/estatística & dados numéricos , Países Baixos , Dor/tratamento farmacológico , Formulação de Políticas
14.
Am J Emerg Med ; 28(8): 922-7, 2010 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-20825925

RESUMO

AIM: The aim of this study was to evaluate (a) the differences between men and women in symptom profile, allocated life support level (LSL), and presence of acute myocardial infarction (AMI), life-threatening condition (LTC), or death and (b) whether a computer-based decision support system could improve the allocation of LSL. PATIENTS: All patients in Göteborg, Sweden, who called the dispatch center because of chest pain during 3 months (n = 503) were included in this study. METHODS: Age, sex, and symptom profile were background variables. Based on these, we studied allocation of LSL by the dispatchers and its relationship to AMI, LTC, and death. All evaluations were made from a sex perspective. Finally, we studied the potential benefit of using a statistical model for allocating LSL. RESULTS: The advanced life support level (ALSL) was used equally frequently for men and women. There was no difference in age or symptom profile between men and women in relation to allocation. However, the allocation of ALSL was predictive of AMI and LTC only in men. The sensitivity was far lower for women than for men. When a statistical model was used for allocation, the ALSL was predictive for both men and women. Using a separate model for men and women respectively, sensitivity increased, especially for women, and specificity was kept at the same level. CONCLUSION: This exploratory study indicates that women would benefit most from the allocation of LSL using a statistical model and computer-based decision support among patients who call for an ambulance because of acute chest pain. This needs further evaluation.


Assuntos
Dor no Peito/terapia , Serviços Médicos de Emergência/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Fatores Sexuais , Doença Aguda , Fatores Etários , Idoso , Ambulâncias/estatística & dados numéricos , Distribuição de Qui-Quadrado , Tomada de Decisões Assistida por Computador , Feminino , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Alocação de Recursos , Suécia
15.
Omega (Westport) ; 56(3): 273-88, 2007.
Artigo em Inglês | MEDLINE | ID: mdl-18300651

RESUMO

Research on end-of-life treatment preferences has documented robust racial differences, with African-Americans preferring more life-prolonging treatment than Whites. Although little research has attempted to explain these racial differences systematically, speculation has centered on religiosity. We examined a dimension of religiosity frequently invoked in end-of-life research-guidance by God's will-as a potential mediator of racial differences in such treatment preferences. Three hundred African-American and White men and women aged 60 or older participated in a 35-minute telephone interview that elicited preferences for four common life-prolonging treatments in each of nine health scenarios. The questionnaire included the five-item God's will (GW) scale, a health conditions checklist, a depression measure, and sociodemographic questions. GW mediated racial differences at least partially for most treatments and in most health scenarios. Implications are discussed for understanding end-of-life treatment preferences and why races tend to differ.


Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Satisfação do Paciente/etnologia , Espiritualidade , População Branca/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Atitude Frente a Morte/etnologia , Características Culturais , Diversidade Cultural , Depressão/etnologia , Feminino , Comportamentos Relacionados com a Saúde/etnologia , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Philadelphia/epidemiologia , Apoio Social
16.
J Pain Symptom Manage ; 31(2): 111-21, 2006 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-16488344

RESUMO

We investigated the drugs used in the alleviation of pain and symptoms (APS) with a possible life-shortening side effect in six European countries' end-of-life care. We sent mail questionnaires to physicians who signed a representative sample of death certificates in each country. APS with a possible life-shortening effect occurred from 19% of all deaths in Italy to 26% in Denmark. Physicians usually administered opioids (from 76% of APS cases in Italy to 96% in The Netherlands), but the type of opioids and administration practice differed markedly between countries. The doses of opioids given in the last 24 hours also varied significantly and were usually lower than 300 mg oral morphine equivalent (from 83% of cases in Belgium to 93% in Sweden). The highly variable results bring into question whether existing guidelines for pain relief were applied appropriately and to what extent unfounded concerns about the possible life-shortening effect of opioids resulted in less than optimal symptom management in end-of-life care.


Assuntos
Eutanásia Ativa/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Entorpecentes/uso terapêutico , Dor/tratamento farmacológico , Dor/mortalidade , Padrões de Prática Médica/estatística & dados numéricos , Assistência Terminal/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos/uso terapêutico , Atestado de Óbito , Tomada de Decisões , Relação Dose-Resposta a Droga , Prescrições de Medicamentos/estatística & dados numéricos , Europa (Continente)/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/estatística & dados numéricos , Suicídio Assistido/estatística & dados numéricos , Inquéritos e Questionários
17.
Health Aff (Millwood) ; 24(4): 961-71, 2005.
Artigo em Inglês | MEDLINE | ID: mdl-16136635

RESUMO

Ethics consultations have been shown to reduce the use of "nonbeneficial treatments," defined as life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, when treatment conflicts occurred in the adult intensive care unit (ICU). In this paper we estimated the costs of nonbeneficial treatment using the results from a randomized trial of ethics consultations. We found that ethics consultations were associated with reductions in hospital days and treatment costs among patients who did not survive to hospital discharge. We conclude that consultations resolved conflicts that would have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU instead of focusing on more appropriate comfort care.


Assuntos
Cuidados Críticos/economia , Consultoria Ética/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Unidades de Terapia Intensiva/economia , Cuidados para Prolongar a Vida/economia , Futilidade Médica , Adulto , Cuidados Críticos/ética , Cuidados Críticos/estatística & dados numéricos , Tomada de Decisões , Dissidências e Disputas , Feminino , Humanos , Unidades de Terapia Intensiva/ética , Tempo de Internação , Cuidados para Prolongar a Vida/ética , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Análise de Sobrevida , Estados Unidos
18.
Med Decis Making ; 24(5): 518-24, 2004.
Artigo em Inglês | MEDLINE | ID: mdl-15359001

RESUMO

Patient characteristics may influence medical decision making in various ways. The contribution of several patient characteristics to medical decision making was studied. Thirty oncologists, 29 nursing home physicians, and 22 cardiologists were interviewed (overall response = 60%). Respondents were asked whether they would apply a specified intervention for a number of hypothetical seriously ill patients, who varied with respect to factors that were not relevant to the outcome of treatment. The condition that made patients clearly eligible for treatment was kept constant. In a multivariate regression model, patients with a better physical condition, a more obvious social role, and a lower age were more likely to be treated than were other patients. Medical decision making is not exclusively based on empirical evidence but also related to morally complex issues such as patient age and social status.


Assuntos
Atitude do Pessoal de Saúde , Estado Terminal/terapia , Tomada de Decisões , Indicadores Básicos de Saúde , Cuidados para Prolongar a Vida/estatística & dados numéricos , Adulto , Fatores Etários , Cardiologia , Feminino , Humanos , Entrevistas como Assunto , Masculino , Oncologia , Pessoa de Meia-Idade , Países Baixos , Casas de Saúde , Análise de Regressão
20.
Crit Care Med ; 31(7): 1901-7, 2003 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-12847381

RESUMO

OBJECTIVE: To determine whether gender-related differences exist in the provided level of care and outcome in a large cohort of critically ill patients. DESIGN: Prospective, observational cohort study with data collection from January 1, 1998, to December 31, 2000. SETTING: Thirty-one intensive care units in Austria. PATIENTS: A total of 25,998 adult patients, consecutively admitted to 31 intensive care units in Austria. INTERVENTIONS: We assessed severity of illness, level of provided care, and vital status at hospital discharge. MEASUREMENTS AND MAIN RESULTS: Of 25,998 patients, 58.3% were male and 41.7% were female. Hospital mortality rate was slightly higher in women (18.1%) than in men (17.2%), but severity of illness-adjusted mortality rate was not different. Men received an overall increased level of care and had a significantly higher probability of receiving invasive procedures, such as mechanical ventilation (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.16-1.28), single vasoactive medication (OR, 1.18; 95% CI, 1.12-1.24), multiple vasoactive medication (OR, 1.21; 95% CI, 1.15-1.28), intravenous replacement of large fluid losses (OR, 1.14; 95% CI, 1.08-1.20), central venous catheter (OR, 1.06; 95% CI, 1.01-1.12), peripheral arterial catheter (OR, 1.15; 95% CI, 1.10-1.22), pulmonary artery catheter (OR, 1.48; 95% CI, 1.34-1.62), renal replacement therapy (OR, 1.28; 95% CI, 1.16-1.42), and intracranial pressure measurement (OR, 1.34; 95% CI, 1.18-1.53). CONCLUSIONS: In a large cohort of critically ill patients, no differences in severity of illness-adjusted mortality rate between men and women were found. Despite a higher severity of illness in women, men received an increased level of care and underwent more invasive procedures. This different therapeutic approach in men did not translate into a better outcome.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Estado Terminal/mortalidade , Mortalidade Hospitalar , Preconceito , Garantia da Qualidade dos Cuidados de Saúde/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Áustria , Estudos de Coortes , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Feminino , Humanos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do Tratamento
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