Clinical documentation of patient identities in the electronic health record: Ethical principles to consider.

The American Psychological Association's multicultural guidelines encourage psychologists to use language sensitive to the lived experiences of the individuals they serve. In organized care settings, psychologists have important decisions to make about the language they use in the electronic health record (EHR), which may be accessible to both the patient and other health care providers. Language about patient identities (including but not limited to race, ethnicity, gender, and sexual orientation) is especially important, but little guidance exists for psychologists on how and when to document these identities in the EHR. Moreover, organizational mandates, patient preferences, fluid identities, and shifting language may suggest different documentation approaches, posing ethical dilemmas for psychologists to navigate. In this article, we review the purposes of documentation in organized care settings, review how each of the five American Psychological Association Code of Ethics' General Principles relates to identity language in EHR documentation, and propose a set of questions for psychologists to ask themselves and their patients when making choices about documenting identity variables in the EHR. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effect of Computer-Tailored Print Feedback, Motivational Interviewing, and Motivational Enhancement Therapy on Engagement in Advance Care Planning: A Randomized Clinical Trial.

Importance: There is a tension between clinician-led approaches to engagement in advance care planning (ACP), which are effective but resource-intensive, and self-administered tools, which are more easily disseminated but rely on ability and willingness to complete. Objective: To examine the efficacy of computer-tailored print feedback (CTPF), motivational interviewing (MI), and motivational enhancement therapy (MET) on completion of a set of ACP activities, each as compared with usual care. Design, Setting, and Participants: This randomized clinical trial was conducted from October 2017 to December 2020 via telephone contact with primary care patients at a single VA facility; 483 veterans aged 55 years or older were randomly selected from a list of patients with a primary care visit in the prior 12 months, with oversampling of women and people from minoritized racial and ethnic groups. Statistical analysis was performed from January to June 2022. Interventions: Mailed CTPF generated in response to a brief telephone assessment of readiness to engage in and attitudes toward ACP; MI, an interview exploring ambivalence to change and developing a change plan; and MET, MI plus print feedback, delivered by telephone at baseline, 2, and 4 months. Main Outcome and Measures: Self-reported completion of 4 ACP activities: communicating about views on quality vs quantity of life, assignment of a health care agent, completion of a living will, and submitting documents for inclusion in the electronic health record at 6 months. Results: The study included 483 persons, mean (SD) age 68.3 (8.0) years, 18.2% women and 31.1% who were people from minoritized racial and ethnic groups. Adjusting for age, education, race, gender, and baseline stage of change for each ACP, predicted probabilities for completing the ACP activities were: usual care 5.7% (95% CI, 2.8%-11.1%) for usual care, 17.7% (95% CI, 11.8%-25.9%; P = .003) for MET, 15.8% (95% CI, 10.2%-23.6%; P = .01) for MI, P = .01, and 10.0% (95% CI, 5.9%-16.7%; P = .18) for CTPF. Conclusions and Relevance: This randomized clinical trial found that a series of 3 MI and MET counseling sessions significantly increased the proportion of middle-aged and older veterans completing a set of ACP activities, while print feedback did not. These findings suggest the importance of clinical interaction for ACP engagement. Trial Registration: ClinicalTrials.gov Identifier: NCT03103828.

Mental healthcare and palliative care: barriers.

CONTEXT: Psychological symptoms are common among palliative care patients with advanced illness, and their effect on quality of life can be as significant as physical illness. The demand to address these issues in palliative care is evident, yet barriers exist to adequately meet patients' psychological needs. OBJECTIVES: This article provides an overview of mental health issues encountered in palliative care, highlights the ways psychologists and psychiatrists care for these issues, describes current approaches to mental health services in palliative care, and reviews barriers and facilitators to psychology and psychiatry services in palliative care, along with recommendations to overcome barriers. RESULTS: Patients in palliative care can present with specific mental health concerns that may exceed palliative care teams' available resources. Palliative care teams in the USA typically do not include psychologists or psychiatrists, but in palliative care teams where psychologists and psychiatrists are core members of the treatment team, patient well-being is improved. CONCLUSION: Psychologists and psychiatrists can help meet the complex mental health needs of palliative care patients, reduce demands on treatment teams to meet these needs and are interested in doing so; however, barriers to providing this care exist. The focus on integrated care teams, changing attitudes about mental health, and increasing interest and training opportunities for psychologists and psychiatrists to be involved in palliative care, may help facilitate the integration of psychology and psychiatry into palliative care teams.

Increasing engagement in advance care planning using a behaviour change model: study protocol for the STAMP randomised controlled trials.

INTRODUCTION: Advance care planning (ACP) is a key component of high-quality end-of-life care but is underused. Interventions based on models of behaviour change may fill an important gap in available programmes to increase ACP engagement. Such interventions are designed for broad outreach and flexibility in delivery. The purpose of the Sharing and Talking about My Preferences study is to examine the efficacy of three behaviour change approaches to increasing ACP engagement through two related randomised controlled trials being conducted in different settings (Veterans Affairs (VA) medical centre and community). METHODS AND ANALYSIS: Eligible participants are 55 years or older. Participants in the community are being recruited in person in primary care and specialty outpatient practices and senior living sites, and participants in the VA are recruited by telephone. In the community, randomisation is at the level of the practice or site, with all persons at a given practice/site receiving either computer-tailored feedback with a behaviour stage-matched brochure (computer-tailored intervention (CTI)) or usual care. At the VA, randomisation is at the level of the participant and is stratified by the number of ACP behaviours completed at baseline. Participants are randomised to one of four groups: CTI, motivational interviewing, motivational enhancement therapy or usual care. The primary outcome is completion of four key ACP behaviours: identification of a surrogate decision maker, communication about goals, completing advance directives and ensuring documents are in the medical record. Analysis will be conducted using mixed effects models, taking into account the clustered randomisation for the community study. ETHICS AND RANDOMISATION: The studies have been approved by the appropriate Institutional Review Boards and are being overseen by a Safety Monitoring Committee. The results of these studies will be disseminated to academic audiences and leadership in in the community and VA sites. TRIAL REGISTRATION NUMBERS: NCT03137459 and NCT03103828.

Ototoxic effects of single-dose versus 19-day daily-dose gentamicin.

INTRODUCTION: Gentamicin is one of the most extensively studied aminoglycoside antibiotics. The dogma of gentamicin ototoxicity theorizes that (1) the toxic effects of the drug are cumulative and dose dependent, despite clinical observations of ototoxicity after a single dose, and (2) gentamicin's ototoxic effects are irreversible, although clinicians have observed improvement in hearing over time. The objective of this study was to evaluate this basic dogma by examining the ototoxic differences between single-dose and 19-day daily dosing of gentamicin over a 60-day period. METHODS: Thirty-six C57 mice were randomly assigned to one of three treatment groups: (1) 19-day daily normal saline intraperitoneal injections (control; n = 10), (2) single-dose intraperitoneal 120 mg/kg gentamicin (n = 12), and (3) 19-day daily intraperitoneal 120 mg/kg gentamicin (n = 14). Pure-tone testing using auditory brainstem response was performed at frequencies of 6, 8, 12, 20, and 30 kHz. Hearing threshold was determined at each frequency by presenting stimuli from 90 dB to 5 dB using 10 dB decrements. Pure-tone testing was performed at days 1, 35, and 60 +/- 2 days. RESULTS: The results showed that hearing (1) improved between days 35 and 60 (p = .023) and (2) was not significantly different between a single dose versus 19 daily doses of gentamicin (p = .285). CONCLUSION: This study concurs with clinical observations that a single large dose of gentamicin may have ototoxic effects similar to those of multiple doses of gentamicin and that, over time, there is the potential for hearing recovery from gentamicin ototoxicity.

Prevention of aminoglycoside-induced sensorineural hearing loss.

BACKGROUND: Aminoglycoside antibiotics are some of the most commonly used agents for treating gram-negative bacterial infections. They are extremely efficacious but can result in ototoxicity. It has been postulated that the mechanism inducing damage is the formation of oxygen free radicals. Many compounds have been employed in an attempt to reduce aminoglycoside-induced hearing loss. We endeavour to do likewise using sodium thiosulphate. This free radical scavenging agent has a proven ability to minimize cochlear damage owing to the chemotherapeutic agent cisplatin. OBJECTIVES: This study had two distinct objectives. The first was to determine if sodium thiosulphate can reduce hearing loss in C57 mice concurrently subjected to gentamicin. The second goal was to assess the value of this animal model. METHODS: This study was accomplished by creating four treatment arms. The animals were provided with daily intraperitoneal injections of gentamicin (120 mg/kg), sodium thiosulphate (1600 mg/kg), gentamicin plus sodium thiosulphate, or normal saline. Auditory brainstem response threshold changes were calculated comparing differences between baseline values and those observed at day 35. RESULTS: The results indicate a trend suggesting that sodium thiosulphate may afford some degree of otologic protection when provided in conjunction with gentamicin. However, a statistical significance could not be established. Our mice appear to be more resistant to gentamicin-induced ototoxicity than found in previously reported animal models. CONCLUSION: We were unable to demonstrate that sodium thiosulphate can attenuate gentamicin-induced ototoxicity. Furthermore, we observe that the susceptibility to hearing loss varies considerably between individual C57 mice. Consequently, we hold some degree of reservation with the use of this model to assess the benefit of prospective rescue agents.