AARC Clinical Practice Guideline: Patient-Ventilator Assessment.

Given the important role of patient-ventilator assessments in ensuring the safety and efficacy of mechanical ventilation, a team of respiratory therapists and a librarian used Grading of Recommendations, Assessment, Development, and Evaluation methodology to make the following recommendations: (1) We recommend assessment of plateau pressure to ensure lung-protective ventilator settings (strong recommendation, high certainty); (2) We recommend an assessment of tidal volume (VT) to ensure lung-protective ventilation (4-8 mL/kg/predicted body weight) (strong recommendation, high certainty); (3) We recommend documenting VT as mL/kg predicted body weight (strong recommendation, high certainty); (4) We recommend an assessment of PEEP and auto-PEEP (strong recommendation, high certainty); (5) We suggest assessing driving pressure to prevent ventilator-induced injury (conditional recommendation, low certainty); (6) We suggest assessing FIO2 to ensure normoxemia (conditional recommendation, very low certainty); (7) We suggest telemonitoring to supplement direct bedside assessment in settings with limited resources (conditional recommendation, low certainty); (8) We suggest direct bedside assessment rather than telemonitoring when resources are adequate (conditional recommendation, low certainty); (9) We suggest assessing adequate humidification for patients receiving noninvasive ventilation (NIV) and invasive mechanical ventilation (conditional recommendation, very low certainty); (10) We suggest assessing the appropriateness of the humidification device during NIV and invasive mechanical ventilation (conditional recommendation, low certainty); (11) We recommend that the skin surrounding artificial airways and NIV interfaces be assessed (strong recommendation, high certainty); (12) We suggest assessing the dressing used for tracheostomy tubes and NIV interfaces (conditional recommendation, low certainty); (13) We recommend assessing the pressure inside the cuff of artificial airways using a manometer (strong recommendation, high certainty); (14) We recommend that continuous cuff pressure assessment should not be implemented to decrease the risk of ventilator-associated pneumonia (strong recommendation, high certainty); and (15) We suggest assessing the proper placement and securement of artificial airways (conditional recommendation, very low certainty).

Brain cancer patients' levels of distress and supportive care needs over time.

PURPOSE: This study aimed to describe patient self-reported distress over time and how this was associated with wellbeing, and supportive care needs over a 6-month period from commencing chemoradiotherapy for high grade glioma (HGG). METHODS: In this prospective cohort study, participants completed surveys at three time points: before chemoradiotherapy, at 3 and 6 months. These included Distress Thermometer, Functional Assessment of Cancer/Brain Cancer Treatment-general (Fact-G/FACT-BR), Supportive Care Needs Scale (SF-34) and Brain Tumour Specific subscale. Patient survival time was also collected. Group-based trajectory modelling was performed. Multinominal logistic regression assessed variables associated with different distress trajectory groups. RESULTS: One hundred and sixteen participants completed assessments at baseline, 89 participants at 3 and 64 at 6 months. Four distress trajectory groups were identified; consistent low distress (18%), low to high distress (38%), high-to low distress (24%) and consistent high distress (19%). Younger participants tended to report decreased distress over time, whereas older participants reported consistently high distress. High distress trajectory participants had less education, lower physical wellbeing, more unmet needs, but higher functional wellbeing compared to the low to high distress trajectory. The number of unmet needs paralleled the patterns of distress over time. The highest unmet needs in people with HGG and high distress were disease specific changes in mental ability and physical side effects. CONCLUSION: This study demonstrates people with HGG experience ongoing distress and highlights a need for continuous distress and unmet needs screening and referrals.

Moral Distress Entangled: Patients and Providers in the COVID-19 Era.

Moral distress is defined as the inability to act according to one's own core values. During the COVID-19 pandemic, moral distress in medical personnel has gained attention, related to the impact of pandemic-associated factors, such as the uncertainty of treatment options for the virus and the accelerated pace of deaths. Measures to provide aid and mitigate the long-term pandemic effect on providers are starting to be designed. Yet, little has been said about the moral distress experienced by patients and the relational and additive effect on provider moral distress. Pandemic-associated factors affecting moral distress in patients include the constraining effects of isolation on spiritual and religious traditions as well as the intentional separation of patients from their families. This paper will explore the idea that patients are suffering their own moral distress and further how this impacts the intensity of moral distress experienced by the providers-nurses and physicians. The paucity of research in this area with the implications on patient's distress, decision making, and distress experienced by providers compels further investigation and analysis.

Assessing patient risk from cancer and COVID-19: Managing patient distress.

The rapid spread of coronavirus disease 2019 (COVID-19) beginning in Spring 2020 necessitated significant changes to day-to-day interactions in society, as well as to the practice of medicine. Particularly in patients with cancer, these changes can exacerbate the pre-existing psychological stress associated with cancer diagnosis and treatment. We performed a narrative review, encompassing changes to cancer care as a result of COVID-19, the psychological effects of treatment delays, and strategies to mitigate these effects. A number of review articles and guideline bodies have provided guidance on patients for whom treatment may be safely delayed, including low-risk bladder, prostate and kidney tumors, as well as intermediate and high-risk prostate cancer. Mental health diagnoses are prevalent in patients with genitourinary malignancies. Evidence regarding psychologic effects of deferred treatment is limited to those with low risk of disease related morbidity. In this population, psychologic distress attenuated with time. However, in the COVID-19 context, patients with advanced disease are particularly prone to psychologic distress, as are women and younger patients. Strategies to mitigate this distress are emerging and center on recognition from the treating oncologist with appropriate referral as necessary to psycho-oncology providers and engagement of peer-supports. The COVID-19 pandemic has reshaped social structures and health care delivery. For patients with genitourinary malignancies, this may be associated with significant distress, particularly among those with advanced disease and those undergoing active treatment. Physicians treating these patients need to be aware of the psychologic stress the combined effects of the COVID-19 pandemic, cancer diagnosis, and cancer treatment can have and make appropriate referrals to support the holistic care of their patients.

Both trusting and understanding medical advice: Assessing patient alliance and confusion after medical consultations.

OBJECTIVE: The current objective is to validate the Medical Consultation Experience Questionnaire (MCEQ) and to examine distinctions between constructs of patient perceived alliance and experienced confusion in relation to key health outcomes. METHODS: A total of 857 participants were recruited online across two samples (adults with various medical conditions and with diabetes and/or hypertension specifically). RESULTS: A confirmatory factor analysis demonstrated good fit and high item loadings for the theoretical bifactor model. Item response theory analyses showed very high individual item discrimination and good test information across a wide range of values. Confusion was uniquely and significantly more strongly related to psychological distress than was alliance; the same was true for alliance with positive affect. Both alliance and confusion significantly contributed to treatment motivation. Only confusion explained unique variance in control of HbA1C levels and blood pressure after controlling for alliance and other variables. CONCLUSIONS: The MCEQ is a valid instrument for assessing distinct constructs of alliance and confusion. Future research should focus on the unique role of confusion for patient outcomes. PRACTICE IMPLICATIONS: By using the MCEQ to assess patient alliance and confusion, it may be possible to detect and prioritize individual patient needs and improve patient outcomes.

Classism in Pain Care: The Role of Patient Socioeconomic Status on Nurses' Pain Assessment and Management Practices.

OBJECTIVE: Research on social disparities in pain care has been mainly focused on the role of race/racism and sex/sexism. Classism in pain assessment and management practices has been much less investigated. We aimed to test the effect of patient socioeconomic status (SES; a proxy of social class) on nurses' pain assessment and management practices and whether patient SES modulated the effects of patient distress and evidence of pathology on such practices. DESIGN: Two experimental studies with a two (patient SES: low/high) by two (patient distress or evidence of pathology: absent/present) between-subject design. SUBJECTS: Female nurses participated in two experimental studies (N = 150/N = 158). METHODS: Nurses were presented with a vignette/picture depicting the clinical case of a female with chronic low back pain, followed by a video of the patient performing a pain-inducing movement. Afterwards, nurses reported their pain assessment and management practices. RESULTS: The low-SES patient's pain was assessed as less intense, more attributed to psychological factors, and considered less credible (in the presence of distress cues) than the higher-SES patient's pain. Higher SES buffered the detrimental impact of the presence of distress cues on pain assessment. No effects were found on management practices. CONCLUSIONS: Our findings point to the potential buffering role of SES against the detrimental effect of certain clinical cues on pain assessments. This study contributes to highlighting the need for further investigation of the role of SES/social class on pain care and its underlying meanings and processes.

How can we explain physician accuracy in assessing patient distress? A multilevel analysis in patients with advanced cancer.

OBJECTIVE: To examine the determinants of the accuracy with which physicians assess metastatic cancer patient distress, also referred to as their empathic accuracy (EA). Hypothesized determinants were physician empathic attitude, self-efficacy in empathic skills, physician-perceived rapport with the patient, patient distress and patient expressive suppression. METHODS: Twenty-eight physicians assessed their patients' distress level on the distress thermometer, while patients (N=201) independently rated their distress level on the same tool. EA was the difference between both scores in absolute value. Hypothesized determinants were assessed using self-reported questionnaires. Multilevel analyses were carried out. RESULTS: Little of the variance in EA was explained by physician variables. EA was higher with higher levels of patient distress. Physician-perceived quality of rapport was positively associated with EA. However, for highly distressed patients, good rapport was associated with lower EA. Patient expressive suppression was also related to lower EA. CONCLUSION: This study adds to the understanding of EA in oncological settings, particularly in challenging the common assumption that EA depends largely on physician characteristics or that better rapport would always favor higher EA. PRACTICE IMPLICATIONS: Physicians should ask patients for feedback regarding their emotions. In parallel, patients should be prompted to express their concerns.