Effect of a person-centred goals-of-care form and clinical communication training on shared decision-making and outcomes in an acute hospital: a prospective longitudinal interventional study.

BACKGROUND: Patients with a life-limiting illness (LLI) requiring hospitalisation have a high likelihood of deterioration and 12-month mortality. To avoid non-aligned care, we need to understand our patients' goals and values. AIM: To describe the association between the implementation of a shared decision-making (SDM) programme and documentation of goals of care (GoC) for hospitalised patients with LLI. METHODS: A prospective longitudinal interventional study of patients admitted to acute general medicine wards in an Australian tertiary hospital over 5 years was conducted. A SDM programme with a new GoC form, communication training and clinical support was implemented. The primary outcome was the proportion of patients with a documented person-centred GoC discussion (PCD). Clinical outcomes included hospital utilisation and 90-day mortality. RESULTS: 1343 patients were included. The proportion of patients with PCDs increased from 0% to 35.4% (adjusted odds ratio (aOR), 2.38; 95% confidence interval (CI), 2.01-2.82; P < 0.001). During this time, median hospital length of stay decreased from 8 days (interquartile range (IQR), 4-14) to 6 days (IQR, 3-11) (adjusted estimate effect, -0.38; 95% CI, -0.64 to -0.11; P = 0.005) and rapid response team activation from 28% to 13% (aOR, 0.87; 95% CI, 0.78-0.97; P value = 0.01). Documented treatment preference of high-dependency unit care decreased from 39.7% to 24.4% (aOR, 0.81; 95% CI, 0.73-0.89; P value < 0.001), and ward-based care increased from 31.9% to 55.1% (aOR, 1.24; 95% CI, 1.14-1.36; P value < 0.001). CONCLUSION: The implementation of a SDM programme was associated with increased documentation of person-centred GoC, changed patient treatment preference to lower intensity care and reduced hospital utilisation.

Intensive care doctors and nurses personal preferences for Intensive Care, as compared to the general population: a discrete choice experiment.

BACKGROUND: To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient. METHODS: Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care. RESULTS: A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves. CONCLUSION: The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival.

Locating advance care planning facilitators in general practice increases consumer participation.

BACKGROUND: Advance care planning (ACP) can positively affect end-of-life care experiences. However, uptake of ACP completion is low. The aim of this study was to investigate whether co-locating ACP facilitators in general practice increased participation METHODS: Barwon Health commenced promoting its ACP program in 2008. Trained ACP facilitators assisted consumers, which usually occurred in the program's community-based consulting rooms. From 2012 onwards, ACP facilitators were co-located with 18 general practices, where they assisted consumers at the point of care. RESULTS: Referrals to the program increased from 2008-11 (n = 2520) to 2012-15 (n = 6847). Between 2012 and 2015, 48% of referrals to the program were from the 18 general practices with co-located ACP facilitators, and 93% of these referrals resulted in ACPs completed, compared with 74% from practices without co-located facilitators and 55% from all other sources (P DISCUSSION: Co-locating ACP facilitators in general practice increased the number of referrals to the program and produced higher plan completion rates.

Effect of communication skills training on documentation of shared decision-making for patients with life-limiting illness: An observational study in an intensive care unit.

Objectives: This article aims to examine the association between a shared decision-making (SDM) clinical communication training program and documentation of SDM for patients with life-limiting illness (LLI) admitted to intensive care. Methods: This article used a prospective, longitudinal observational study in a tertiary intensive care unit (ICU). Outcomes included the proportion of patients with SDM documented on an institutional Goals of Care Form during hospital admission, as well as characteristics, outcomes, and factors associated with an SDM admission. Intervention: Clinical communication skills training (iValidate) and clinical support program are the intervention for this study. Results: A total of 325 patients with LLI were admitted to the ICU and included in the study. Overall, 184 (57%) had an SDM admission, with 79% of Goals of Care Form completed by an iValidate-trained doctor. Exposure to an iValidate-trained doctor was the strongest predictor of an ICU patient with LLI having an SDM admission (odds ratio: 22.72, 95% confidence interval: 11.91-43.54, p < 0.0001). A higher proportion of patients with an SDM admission selected high-dependency unit-level care (29% vs. 12%, p < 0.001) and ward-based care (36% vs. 5%, p < 0.0001), with no difference in the proportion of patients choosing intensive care or palliative care. The proportion of patients with no deterioration plan was higher in the non-SDM admission cohort (59% vs. 0%, p < 0.0001). Conclusions: Clinical communication training that explicitly teaches identification of patient values is associated with improved documentation of SDM for critically ill patients with LLI. Understanding the relationship between improved SDM and patient, family, and clinical outcomes requires appropriately designed high-quality trials randomised at the patient or cluster level.

Values, preferences and goals identified during shared decision making between critically ill patients and their doctors.

Objective: Examine values, preferences and goals elicited by doctors following goals-of-care (GOC) discussions with critically ill patients who had life-limiting illnesses. Design: Descriptive qualitative study using four-stage latent content analysis. Setting: Tertiary intensive care unit (ICU) in South Western Victoria. Participants: Adults who had life-limiting illnesses and were admitted to the ICU with documented GOC, between October 2016 and July 2018. Intervention: The iValidate program, a shared decision-making clinical communication education and clinical support program, for all ICU registrars in August 2015. Main outcome measures: Matrix of themes and subthemes categorised into values, preferences and goals. Results: A total of 354 GOC forms were analysed from 218 patients who had life-limiting illnesses and were admitted to the ICU. In the categories of values, preferences and goals, four themes were identified: connectedness and relational autonomy, autonomy of decision maker, balancing quality and quantity of life, and physical comfort. The subthemes - relationships, sense of place, enjoyment of activities, independence, dignity, cognitive function, quality of life, longevity and physical comfort - provided a matrix of issues identified as important to patients. Relationship, place, independence and physical comfort statements were most frequently identified; longevity was least frequently identified. Conclusion: Our analysis of GOC discussions between medical staff and patients who had life-limiting illnesses and were admitted to the ICU, using a shared decision-making training and support program, revealed a framework of values, preferences and goals that could provide a structure to assist clinicians to engage in shared decision making.

Population Preferences for Treatments When Critically Ill: A Discrete Choice Experiment.

BACKGROUND: Many patients in the intensive care unit are too unwell to participate in shared decision making or have not previously documented their wishes. In these situations, understanding the values of the general population could help doctors provide appropriate guidance to surrogate decision makers. METHODS: Using a discrete choice experiment design, we conducted an online survey using an Australian panel. Participants were asked about their willingness to accept treatments, faced with a variety of possible outcomes and probabilities (low, moderate or high). The outcomes were across four domains: loss of functional autonomy, pain, cognitive disability and degree of burden on others. Demographic details, prior experience of intensive care unit and current health conditions were also collected. Data were analysed using logistic regression, predicting whether respondents choose to continue active treatment or not. RESULTS: Nine hundred and eighty-four respondents, representative of age and sex completed the web-based survey. With the increasing likelihood of negative post-intensive care unit sequelae, there was a higher probability of the respondent preferring to stop ongoing active treatment, with the largest coefficients being on caring assistance and the need for full-time residential care. Those who identified as very religious, were younger or who had children under 5 years of age were more likely to choose to continue active treatment. CONCLUSIONS: Respondents valued their independence as the most important factor in deciding whether to receive ongoing medical treatments in the intensive care unit. When clinicians are unable to obtain specific patient information, they should consider framing their decision making around the likelihood of the patient achieving functional independence rather than survival.

A prospective observational study of prevalence and outcomes of patients with Gold Standard Framework criteria in a tertiary regional Australian Hospital.

OBJECTIVES: Report the use of an objective tool, UK Gold Standards Framework (GSF) criteria, to describe the prevalence, recognition and outcomes of patients with palliative care needs in an Australian acute health setting. The rationale for this is to enable hospital doctors to identify patients who should have a patient-centred discussion about goals of care in hospital. DESIGN: Prospective, observational, cohort study. PARTICIPANTS: Adult in-patients during two separate 24 h periods. MAIN OUTCOME MEASURES: Prevalence of in-patients with GSF criteria, documentation of treatment limitations, hospital and 1 year survival, admission and discharge destination and multivariate regression analysis of factors associated with the presence of hospital treatment limitations and 1 year survival. RESULTS: Of 626 in-patients reviewed, 171 (27.3%) had at least one GSF criterion, with documentation of a treatment limitation discussion in 60 (30.5%) of those patients who had GSF criteria. Hospital mortality was 9.9%, 1 year mortality 50.3% and 3-year mortality 70.2% in patients with GSF criteria. One-year mortality was highest in patients with GSF cancer (73%), renal failure (67%) and heart failure (60%) criteria. Multivariate analysis revealed age, hospital length of stay and presence of the GSF chronic obstructive pulmonary disease criteria were independently associated with the likelihood of an in-hospital treatment limitation. Non-survivors at 3 years were more likely to have a GSF cancer (25% vs 6%, p=0.004), neurological (10% vs 3%, p=0.04), or frailty (45% vs 3%, p=0.04) criteria. After multivariate logistic regression GSF cancer criteria, renal failure criteria and the presence of two or more GSF clinical criteria were independently associated with increased risk of death at 3 years. Patients returning home to live reduced from 69% (preadmission) to 27% after discharge. CONCLUSIONS: The use of an objective clinical tool identifies a high prevalence of patients with palliative care needs in the acute tertiary Australian hospital setting, with a high 1 year mortality and poor return to independence in this population. The low rate of documentation of discussions about treatment limitations in this population suggests palliative care needs are not recognised and discussed in the majority of patients. TRIAL REGISTRATION NUMBER: 11/121.

Effect of communication skills training on outcomes in critically ill patients with life-limiting illness referred for intensive care management: a before-and-after study.

OBJECTIVES: To describe the effect of a communication skills training programme on patient-centred goals of care documentation and clinical outcomes in critically ill patients with life-limiting illnesses (LLI) referred for intensive care management. METHODS: Prospective before-and-after cohort study in a tertiary teaching hospital in Australia. The population was 222 adult patients with LLI referred to the intensive care unit (ICU). The study was divided into two periods, before (1 May to 31 July 2015) and after (15 September to 15December 2015) the intervention. The intervention was a 2-day, small group, simulated-patient, communication skills course, and process of care for patients with LLI. The primary outcome was documentation of patient-centred goals of care discussion (PCD) within 48 hours of referral to the ICU. Secondary outcomes included clinical outcomes and 90-day mortality. RESULTS: The intervention was associated with increased documentation of a PCD from 50% to 69% (p=0.004) and 43% to 94% (p<0.0001) in patients deceased by day 90. A significant decrease in critical care as the choice of resuscitation goal (61% vs 42%, p=0.02) was observed. Although there was no decrease in admission to ICU, there was a significant decrease in medical emergency team call prevalence (87% vs 73%, p=0.009). The cancer and organ failure groups had a significant decrease in 90-day mortality (75% vs 44%, p=0.02; 42% vs 16%, p=0.01), and the frailty group had a significant decrease in 90-day readmissions (48% vs 19%, p=0.003). CONCLUSIONS: The intervention was associated with increased PCD documentation and decrease in the choice of critical care as the resuscitation goal. Admissions to ICU did not decrease, and although limited by study design, condition-specific trajectory changes, clinical interventions and outcomes warrant further study.

Prevalence, goals of care and long-term outcomes of patients with life-limiting illness referred to a tertiary ICU.

OBJECTIVE: To describe the prevalence, characteristics, long-term outcomes and goals-of-care discussions of patients with objective indicators of life-limiting illnesses (LLIs) referred to the intensive care unit. DESIGN, SETTING AND PATIENTS: A prospective, observational, cohort study of all adult inpatients referred to the ICU by the medical emergency team or by direct referral, during the period 30 August 2012 to 1 February 2013, at a tertiary teaching hospital in Australia. MAIN OUTCOME MEASURES: Mortality, LLIs, discharge destination and documentation on goals of care in medical record. RESULTS: A total of 649 of 1024 patients referred to the ICU had an LLI, and only 34.4% of these patients had goals of care documented. Overall, 49.2% were admitted to the ICU, 48.4% were discharged home, and the 1-year mortality was 35.1%. The most common LLI criteria were heart disease (52.2%), chronic obstructive pulmonary disease (24.8%) and frailty (23.7%). The highest 1-year mortality was associated with pre-hospital residence in a nursing home (64.9%), dementia (63.3%), cancer (60.8%) and frailty (50.6%). Analysis of patients by clinical trajectory showed that 1-year mortality was significantly higher for patients with cancer (59.6%), combined organ failure and frailty (47.3%), frailty (43.8%) and organ failure (23.6%), compared with patients with no LLI (P < 0.0001). CONCLUSIONS: A high proportion of patients referred to the ICU have an LLI, and this is associated with prolonged hospital length of stay and a high 1-year mortality, and only one-quarter have documented discussions on goals of care. Patients with cancer-related and frailty-related LLIs have the worst survival trajectories.

Prevalence of bullying, discrimination and sexual harassment among trainees and Fellows of the College of Intensive Care Medicine of Australia and New Zealand.

BACKGROUND: Anecdotal reports about bullying behaviour in intensive care emerged during College of Intensive Care Medicine (CICM) hospital accreditation visits. Bullying, discrimination and sexual harassment (BDSH) in the medical profession, particularly in surgery, were widely reported in the media recently. This prompted the College to formally survey its Fellows and trainees to identify the prevalence of these behaviours in the intensive care workplace. METHODS: An online survey of all trainees (n = 951) and Fellows (n = 970) of the CICM. RESULTS: The survey response rate was 51% (Fellows, 60%; trainees, 41%). The overall prevalences of bullying, discrimination and sexual harassment were 32%, 12% and 3%, respectively. The proportions of Fellows and trainees who reported being bullied and discriminated against were similar across all age groups. Women reported a greater prevalence of sexual harassment (odds ratio [OR], 2.97 [95% CI, 1.35-6.51]; P = 0.006) and discrimination (OR, 2.10 [95% CI, 1.39-3.17]; P = 0.0004) than men. Respondents who obtained their primary medical qualification in Asia or Africa appeared to have been at increased risk of discrimination (OR, 1.88 [95% CI, 1.15-3.05]; P = 0.03). Respondents who obtained their degree in Australia, New Zealand or Hong Kong may have been at increased risk of being bullied. In all three domains of unprofessional behaviour, the perpetrators were predominantly consultants (70% overall), and the highest proportion of these was ICU consultants. CONCLUSIONS: The occurrence of BDSH appears to be common in the intensive care environment in Australia and New Zealand.

Infarcted intestine: a diagnostic void.

The diagnostic approaches to infarction of the small intestine are reviewed in the present paper. The inadequacy of current methods, especially biochemical methods, are highlighted. Additionally, the benefits of a sensitive and specific test of intestinal infarction are discussed.

High-stakes assessment of the non-technical skills of critical care trainees using simulation: feasibility, acceptability and reliability.

OBJECTIVE: To evaluate the use of high-fidelity simulation for summative high-stakes assessment of intensive care trainees, focusing on non-technical skills (NTS), testing feasibility and acceptability of simulation assessment, and the reliability of two NTS rating scales. DESIGN, SETTING AND PARTICIPANTS: Prospective observational study of senior intensive care trainees in a simulated specialist examination. METHODS: Participants undertook a simulated patient management scenario and were assessed using two rating scales: the Anaesthesia Non-technical Skills (ANTS) scale and the Ottawa Global Rating Scale (GRS). Assessors were trained, currently active, high-stakes examiners. Participants also completed a survey on simulation-based summative assessment. OUTCOME MEASURES: The inter-rater reliability of two rating scales for NTS assessment. We evaluated the feasibility of simulation-based assessment, and used survey results to assess acceptability to participants. RESULTS: Simulation assessment was feasible. Participants considered simulation-based high-stakes assessment to be acceptable and felt their scenario performance was reflective of real-world performance. Participants identified a need for debriefing following scenario-based assessment. Inter-rater reliability was fair for the ANTS and Ottawa GRS scores (intra-class correlation coefficient, 0.39 and 0.42, respectively). There was only fair agreement between raters for an NTS pass or fail (weighted kappa, 0.32) and for a technical skills pass or fail (weighted kappa, 0.36). CONCLUSIONS: Summative high-stakes assessment using a single simulated scenario was feasible and acceptable to senior intensive care trainees. The low inter-rater reliability for the ANTS and Ottawa GRS rating scales and for pass or fail discrimination may limit its incorporation into an existing examination format.

Teaching general practitioners and doctors-in-training to discuss advance care planning: evaluation of a brief multimodality education programme.

OBJECTIVE: To develop and evaluate an interactive advance care planning (ACP) educational programme for general practitioners and doctors-in-training. DESIGN: Development of training materials was overseen by a committee; informed by literature and previous teaching experience. The evaluation assessed participant confidence, knowledge and attitude toward ACP before and after training. SETTING: Training provided to metropolitan and rural settings in Victoria, Australia. PARTICIPANTS: 148 doctors participated in training. The majority were aged at least 40 years with more than 10 years work experience; 63% had not trained in Australia. INTERVENTION: The programme included prereading, a DVD, interactive patient e-simulation workshop and a training manual. All educational materials followed an evidence-based stepwise approach to ACP: Introducing the topic, exploring concepts, introducing solutions and summarising the conversation. MAIN OUTCOME MEASURES: The primary outcome was the change in doctors' self-reported confidence to undertake ACP conversations. Secondary measures included pretest/post-test scores in patient ACP e-simulation, change in ACP knowledge and attitude, and satisfaction with programme materials. RESULTS: 69 participants completed the preworkshop and postworkshop evaluation. Following education, there was a significant change in self-reported confidence in six of eight items (p=0.008 -0.08). There was a significant improvement (p<0.001) in median scores on the e-simulation (pre 7/80, post 60/80). There were no significant differences observed in ACP knowledge following training, and most participants were supportive of patient autonomy and ACP pretraining. Educational materials were rated highly. CONCLUSIONS: A short multimodal interactive education programme improves doctors' confidence with ACP and performance on an ACP patient e-simulation.

Effect of a supplement clarifying patients' intentions on doctors' willingness to follow the wishes of an agent with medical enduring power of attorney.

OBJECTIVE: Doctors have concerns about withholding medical treatment at the request of a legally appointed surrogate. We examined whether the addition of statements to a medical enduring power of attorney to clarify the intent of the person appointing the surrogate helped doctors accept the surrogate's treatment choice. DESIGN: Survey of all doctors employed in acute clinical medicine at Barwon Heath, Geelong, VIC. RESULTS: 94 of 436 doctors (22%) returned the survey. Of the 41 respondents who initially indicated they would decline the surrogate's request to reject life-sustaining treatment for a hypothetical patient, 22 (53%) accepted the surrogate's decision after reading the additional statements. CONCLUSIONS: These results suggest that additional statements clarifying the intent of the person appointing a surrogate would encourage doctors to comply with the surrogate's choice to decline life-prolonging treatment for that person.

Predicting future intensive care demand in Australia.

BACKGROUND: Predicting future demand for intensive care is vital to planning the allocation of resources. METHOD: Mathematical modelling using the autoregressive integrated moving average (ARIMA) was applied to intensive care data from the Australian and New Zealand Intensive Care Society (ANZICS) Core Database and population projections from the Australian Bureau of Statistics to forecast future demand in Australian intensive care. RESULTS: The model forecasts an increase in ICU demand of over 50% by 2020, with current total ICU bed-days (in 2007) of 471 358, predicted to increase to 643 160 by 2020. An increased rate of ICU use by patients older than 80 years was also noted, with the average bed-days per 10 000 population for this group increasing from 396 in 2006 to 741 in 2007. CONCLUSION: An increase in demand of the forecast magnitude could not be accommodated within current ICU capacity. Significant action will be required.

The influence of medical enduring power of attorney and advance directives on decision-making by Australian intensive care doctors.

OBJECTIVE: Despite government encouragement for patients to make advance plans for medical treatment, and the increasing numbers of patients who have done this, there is little research that examines how doctors regard these plans. DESIGN: We surveyed Australian intensive care doctors, using a hypothetical clinical scenario, to evaluate how potential end-of-life treatment decisions might be influenced by advance planning - the appointment of a medical enduring power of attorney (MEPA) or an advance care plan (ACP). Using open-ended questions we sought to explore the reasoning behind the doctors' decisions. RESULTS: 275 surveys were returned (18.3% response rate). We found that opinions expressed by an MEPA and ACP have some influence on treatment decisions, but that intensive care doctors had major reservations. Most did not follow the request for palliation made by the MEPA in the hypothetical scenario. CONCLUSIONS: Many intensive care doctors believe end-oflife decisions remain medical decisions, and MEPAs and ACPs need only be respected when they accord with the doctor's treatment decision. This study suggests a need for further education of doctors, particularly those working in intensive care, who are responsible for initiating and maintaining life support treatment.

Implementation and outcomes of a severe sepsis protocol in an Australian tertiary hospital.

OBJECTIVE: To evaluate the effect of implementation of a sepsis protocol. DESIGN: Before and after cohort study. SETTING: Level III ICU in a tertiary regional hospital, February - July, 2006 (before intervention) and 2007 (after). PARTICIPANTS: Adult patients who fulfilled criteria for severe sepsis or septic shock within 48 hours of ICU admission. INTERVENTION: Implementation of a locally modified sepsis protocol. MAIN OUTCOME MEASURES: Delivery of process of care components, and ICU and hospital mortality. RESULTS: A total of 110 patients were included in the study: 44 in the pre-protocol group, and 66 in the post-protocol group. Demographic variables and severity of illness variables were similar in the two groups except for a lower incidence of respiratory sepsis in the post-protocol group. Post-protocol, there was a shorter time to initiation of appropriate antibiotics, and an increase in the use of vasopressors, deep vein thrombosis prophylaxis, and nutritional support, with no difference in ICU or hospital mortality. There was no difference in resuscitation endpoints at 6, 24, and 72 hours. CONCLUSIONS: Implementation of a sepsis protocol led to a change in the delivery of care with no reduction in mortality in patients with severe sepsis and septic shock admitted to a Level III ICU in a tertiary hospital.

A retrospective audit of the use of Prothrombinex-HT for refractory bleeding following adult cardiac surgery.

OBJECTIVE: To review the frequency of use, possible efficacy and safety profile of Prothrombinex-HT (CSL Bioplasma, Melbourne, VIC) in treatment of patients with microvascular bleeding refractory to standard measures after cardiothoracic surgery. METHODS: A retrospective chart review was performed of 60 consecutive cardiothoracic surgical patients who received Prothrombinex-HT between February and August 2003. Data collected included baseline demographic information, nature and complexity of surgery, preoperative medications, baseline haematological parameters and evidence of clinically significant prothrombotic complications. Consumption of blood products, haematological parameters and mediastinal bleeding rates before and after administration of Prothrombinex-HT were documented in 22 patients who received Prothrombinex-HT in the ICU. RESULTS: No major prothrombotic complications were noted in the series of 60 patients. Two patients had superficial thrombophlebitis. Blood product consumption and haematological parameters were markedly reduced after administering Prothrombinex-HT. CONCLUSIONS: Use of Prothrombinex-HT was not associated with significant prothrombotic complications. Limited evidence of its efficacy suggests that it should be further evaluated in the setting of cardiothoracic surgery.