My Life, My Way: A Quality Improvement Program to Increase Advance Care Planning in a Racially and Ethnically Diverse Patient Population.

BACKGROUND: A multilevel quality improvement program was implemented at an urban community hospital, serving a racially and ethnically pluralistic patient population, to increase participation in advance care planning (ACP). MEASURES: Number of eligible patients who completed an ACP form. INTERVENTION: Projects were implemented over the course of two years that targeted patients, health care providers, the organization, and the community. OUTCOMES: The intervention resulted in increased completion of four unique ACP forms. Completion of the Living Will increased by 60%, Health Care Proxy increased by 9%, Medical Orders for Life-Sustaining Treatment increased by 5%, and Do-Not-Resuscitate/Do-Not-Intubate orders increased by 3%. CONCLUSION: Multilevel interventions can increase ACP participation in a racially and ethnically pluralistic patient population.

Introduction to Hospice and Palliative Care.

Palliative care is a field of medicine that delivers patient-centered care for individuals and their families suffering from serious illness at all stages of the disease trajectory. It addresses the major priorities of relieving suffering, establishing goals of care, and managing physical symptoms while integrating the psychosocial, cultural, spiritual, and existential complexities of coping with chronic illness. This article discusses the role of palliative care in the health care system. It reviews the importance of prognostication, disease trajectory, and communication. The role of the primary care physician as part of a multidisciplinary team member delivering primary palliative care is emphasized.

An analysis of assessment instruments for the minimally responsive patient (MRP): clinical observations.

The purpose for presenting these cases is to report on clinical observations that may have relevance for improvement in individuals responding minimally to their environment as a result of a severe traumatic brain injury. Specifically, the authors observe that there is a sub-group of minimally responsive patients who, when given sensory stimulation, show an increase in responding that is being under-reported with current assessment instruments. Further, subtle changes in responding can occur over a wide temporal gradient and under-reporting of said changes may result in the premature cessation of a beneficial therapeutic intervention. Advantages and disadvantages of the instruments that have been developed to specifically assess responses to sensory stimulation are discussed. The authors' observations suggest that clinical findings do not correlate with assessment scores. These provisory observations indicate that there is a need to develop methodologically sound tools that will accurately monitor individuals throughout the rehabilitative process.