Adaptive Care Planning: A paradigm shift.

A key challenge of implementing advance care planning lies in the fact that decisions made in advance require patients and their family members to imagine what their clinical picture will look like rather than knowing or experiencing the clinical circumstances as they unfold. Even more important is the acknowledgment of the unpredictability of a given clinical course. This type of situation requires adaptiveness and flexibility in decision-making that frequently occurs in the moment(s) triggered by changes in health state(s). We describe an alternative frameshifting approach called "Adaptive Care Planning (AdaptCP)," which features an evolving communication between physicians and patients/families with ongoing incorporation of the patient's/family's perspective. This process continues iteratively until each decision can be reached in a way that is both harmonious with the patient's/family's perspective and is consistent with medical treatment options that are actionable for the healthcare team. We include a table of tools drawn from the literature that can help clinicians when implementing AdaptCP.

Preferred Place of End-of-Life Care Based on Clinical Scenario: A Cross-Sectional Study of a General Japanese Population.

In Japan, which has an aging society with many deaths, it is important that people discuss preferred place for end-of-life care in advance. This study aims to investigate whether the preferred place of end-of-life care differs by the assumed clinical scenario. This clinical scenario-based survey used data from a nationwide survey conducted in Japan in December 2017. Participants aged 20 years and older were randomly selected from the general population. The survey contained questions based on three scenarios: cancer, end-stage heart disease, and dementia. For each scenario, respondents were asked to choose the preferred place of end-of-life care among three options: home, nursing home, and medical facility. Eight hundred eighty-nine individuals participated in this study (effective response rate: 14.8%). The proportions of respondents choosing home, nursing home, and medical facility for the cancer scenario were 49.6%, 10.9%, and 39.5%, respectively; for the end-stage heart disease scenario, 30.5%, 18.9%, and 50.6%; and for the dementia scenario, 15.2%, 54.5%, and 30.3% (p < 0.0001, chi-square test). The preferred place of end-of-life care differed by the assumed clinical scenario. In clinical practice, concrete information about diseases and their status should be provided during discussions about preferred place for end-of-life care to reveal people's preferences more accurately.

The effect of comorbidity on the prognosis of acute lung injury and acute respiratory distress syndrome.

OBJECTIVE: We conducted a retrospective study assessing the relationship between comorbidity, using the Charlson Comorbidity Index (CCI), and the prognoses of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) patients. METHODS: We analyzed the data of 47 patients with ALI and ARDS who were admitted to our center between April 2004 and July 2009. The patients were classified into 2 groups (survival and non-survival) 3 months after diagnosis, and demographic and clinical characteristics were analyzed. We also evaluated the ROC curve and Akaike's information criterion (AIC) to determine the most appropriate cut-off level for the CCI at 3 months survival. The survival rate was estimated based on the AIC results. RESULTS: The mean age was 71.0 years; 25 (53%) of the patients died within 3 months of the diagnosis. Although age, etiology of ALI and ARDS, and APACHE II score did not differ between the two groups, smoking history, CCI, SOFA score, and steroid use were higher in the non-survival group than in the survival group. Age was not significantly correlated with CCI; however, CCI had weak, but statistically significant correlations with the APACHE II and SOFA scores (r=0.387, p<0.01 and r=0.288, p<0.05, respectively). AIC analysis revealed that a score of 4 on the CCI was the most appropriate cut off level for 3 months survival. The 3-month survival rate was lower in patients with a CCI≥4 than in those with a CCI<4 (9.5% vs. 55.5%, p<0.05). DISCUSSION: This study showed that the prognosis of ALI and ARDS was affected more by comorbidity than by age, and that the CCI was useful for assessing patient comorbidities in ALI and ARDS. We have to consider that patients with a CCI score of 4 or more are at risk of developing multi-organ failure and have a poor prognosis.