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1.
Public Health Res Pract ; 30(1)2020 Mar 10.
Artículo en Inglés | MEDLINE | ID: mdl-32152613

RESUMEN

Recent reports highlight an inconsistent provision of palliative and end-of-life (palliative) care across Australia, particularly in regional, rural and remote areas. Palliative care improves quality of life and the experience of dying, and all people should have equitable access to quality needs-based care as they approach and reach the end of their lives. A palliative approach to care is crucial in rural and remote Australia where there is a reliance for such care on generalist providers amid the challenges of a limited workforce, poorer access, and vast geography. This article describes the development and implementation of the Far West NSW Palliative and End-of-Life Model of Care, a systematic solution that could drive improvement in the provision of a quality palliative approach to care and support from any clinician in a timely manner, for patients, their families and carers anywhere.


Asunto(s)
Cuidados Paliativos/normas , Servicios de Salud Rural/estadística & datos numéricos , Cuidado Terminal/normas , Australia , Necesidades y Demandas de Servicios de Salud , Humanos , Calidad de la Atención de Salud , Calidad de Vida , Población Rural
2.
Am J Occup Ther ; 74(1): 7401205020p1-7401205020p14, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32078513

RESUMEN

IMPORTANCE: Underutilization of hospice occupational therapy may be attributable to a lack of evidence on efficacy. OBJECTIVE: To conduct a scoping review of occupational therapy outcome studies to ascertain how efficacy is captured in the literature. DATA SOURCES: PubMed, CINAHL, MEDLINE, Scopus, Directory of Open Access Journals, Web of Science, OT Search, and Google Scholar. STUDY SELECTION AND DATA COLLECTION: Search terms: hospice, palliative care, occupational therapy, rehabilitation, outcome measure, and assessment. Inclusion criteria: research studies in English, centered on adult hospice care, published between January 1997 and September 2017, and investigated occupational therapy efficacy with an outcome measure. Exclusion criteria: systematic reviews, participants not at terminal disease end stages, or intervention program reviews lacking differentiated occupational therapy outcomes. FINDINGS: Seven articles met the inclusion criteria. Findings include frequent use of noncontrolled, quasi-experimental, prospective research designs; a focus on occupational performance; and no generally accepted hospice occupational therapy outcome measure. CONCLUSION AND RELEVANCE: Outcome measures of participation in end-of-life occupations and environmental influences on occupational engagement are needed to effectively support occupational therapy practice and research with people who are terminally ill. WHAT THIS ARTICLE ADDS: Occupational therapy in end-of-life care is growing in complexity yet remains low in utilization. This review adds insights into current practice and future research foci for the profession.


Asunto(s)
Cuidados Paliativos al Final de la Vida , Terapia Ocupacional , Cuidado Terminal , Adulto , Humanos , Cuidados Paliativos , Estudios Prospectivos , Cuidado Terminal/normas
3.
J Nurs Adm ; 50(2): 72-77, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31929345

RESUMEN

OBJECTIVE: To examine whether end-of-life care quality is superior in Magnet hospitals, a recognition designating nursing excellence. BACKGROUND: Considerable research shows better patient outcomes in hospitals with excellent nurse work environments, but end-of-life care quality has not been studied in Magnet hospitals. METHODS: An analysis of cross-sectional data was completed using surveys of nurses and hospitals. Multivariate logistic regression models were used to determine the association between Magnet hospitals and measures of end-of-life care quality. RESULTS: Overall, nurses report poor quality of end-of-life care in US hospitals. In Magnet hospitals, nurses were significantly less likely to give their hospital an unfavorable rating on end-of-life care. CONCLUSIONS: Hospital Magnet status may signal better quality in end-of-life care. Administrators looking to improve the quality of end-of-life care may consider improving aspects of nursing that distinguish Magnet hospitals.


Asunto(s)
Hospitales/estadística & datos numéricos , Personal de Enfermería en Hospital/psicología , Personal de Enfermería en Hospital/normas , Calidad de la Atención de Salud/estadística & datos numéricos , Calidad de la Atención de Salud/normas , Cuidado Terminal/psicología , Cuidado Terminal/normas , Adulto , Actitud del Personal de Salud , Estudios Transversales , Femenino , Encuestas de Atención de la Salud , Humanos , Satisfacción en el Trabajo , Masculino , Persona de Mediana Edad , Cultura Organizacional , Cuidado Terminal/estadística & datos numéricos , Estados Unidos
4.
Nurs Educ Perspect ; 41(1): 52-53, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31860490

RESUMEN

This article summarizes a pilot simulation using standardized patients that was designed to develop skills necessary to care for the critically ill mental health patient nearing the end of life. Although the simulation was found to be a valuable teaching strategy, additional research, with a rigorous design, is recommended to further develop this teaching method. The authors suggest adopting a theoretical framework for debriefing that would elicit emotions, address the emotional needs of students, and assist them to develop coping strategies and skills necessary to care for patients at the end of life.


Asunto(s)
Enfermedad Crítica , Trastornos Mentales , Cuidado Terminal , Competencia Clínica , Emociones , Humanos , Salud Mental , Simulación de Paciente , Cuidado Terminal/normas
5.
Medicina (B Aires) ; 79(6): 468-476, 2019.
Artículo en Español | MEDLINE | ID: mdl-31829949

RESUMEN

The integrated care pathways for the last days of life propose quality standards optimizing the care of patients and families. The Pallium Multidisciplinary Assistance Program (PAMPA ©) was implemented based on standards of the International Collaborative for Best Care for the Dying Person in 4 phases: induction, implementation, dissemination and sustainability, in five health centres in Argentina, between 2008 and 2018. A total of 1237 adult patients in the last days of life were included and cared for by palliative care teams trained in PAMPA©. An audit was conducted before and after the implementation of the Program, which is still going on. The median range of follow up into five centres from the beginning of the pathway until death varied from 16 to 178 hours. Care goals were compared: symptom control, communication, multidimensional needs, hydration and nutrition, documentation of interventions and post-mortem care. The overall analysis showed an improvement in the number of records (p = 0.001). The goal of communication on care plan to the patient showed no difference (p = 0.173). Continuous training, support and permanent teams supervision were carried out and perceptions and impact of the implementation were registered. The main emerging items of the qualitative analysis were: attitudes towards the program, fundamental contributions, strengths, weaknesses and subjective definition of the program, recognition of institutional cultural singularities and its influence on care. PAMPA© demonstrated its feasibility as a model of end of life care for patients and families, based on international quality standards.


Asunto(s)
Cuidados Paliativos/normas , Evaluación de Programas y Proyectos de Salud , Garantía de la Calidad de Atención de Salud/normas , Cuidado Terminal/normas , Adulto , Anciano , Anciano de 80 o más Años , Argentina , Vías Clínicas/normas , Femenino , Implementación de Plan de Salud/métodos , Implementación de Plan de Salud/normas , Humanos , Masculino , Persona de Mediana Edad , Cuidados Paliativos/métodos , Reproducibilidad de los Resultados , Cuidado Terminal/métodos , Factores de Tiempo
7.
BMC Health Serv Res ; 19(1): 745, 2019 Oct 24.
Artículo en Inglés | MEDLINE | ID: mdl-31651314

RESUMEN

BACKGROUND: The PACE Steps to Success programme is a complex educational and development intervention to improve palliative care in nursing homes. Little research has investigated processes in the cross-cultural adaptation and implementation of interventions in palliative care across countries, taking account of differences in health and social care systems, legal and regulatory policies, and cultural norms. This paper describes a framework for the cross-cultural development and support necessary to implement such an intervention, taking the PACE Steps to Success programme as an exemplar. METHODS: The PACE Steps to Success programme was implemented as part of the PACE cluster randomised control trial in seven European countries. A three stage approach was used, a) preparation of resources; b) training in the intervention using a train-the-trainers model; and c) cascading support throughout the implementation. All stages were underpinned by cross-cultural adaptation, including recognising legal and cultural norms, sensitivities and languages. This paper draws upon collated evidence from minutes of international meetings, evaluations of training delivered, interviews with those delivering the intervention in nursing homes and providing and/or receiving support. RESULTS: Seventy eight nursing homes participated in the trial, with half randomized to receive the intervention, 3638 nurses/care assistants were identified at baseline. In each country, 1-3 trainers were selected (total n = 16) to deliver the intervention. A framework was used to guide the cross-cultural adaptation and implementation. Adaptation of three English training resources for different groups of staff consisted of simplification of content, identification of validated implementation tools, a review in 2 nursing homes in each country, and translation into local languages. The same training was provided to all country trainers who cascaded it into intervention nursing homes in local languages, and facilitated it via in-house PACE coordinators. Support was cascaded from country trainers to staff implementing the intervention. CONCLUSIONS: There is little guidance on how to adapt complex interventions developed in one country and language to international contexts. This framework for cross-cultural adaptation and implementation of a complex educational and development intervention may be useful to others seeking to transfer quality improvement initiatives in other contexts.


Asunto(s)
Casas de Salud/normas , Cuidados Paliativos/normas , Mejoramiento de la Calidad/normas , Comparación Transcultural , Europa (Continente) , Humanos , Cuidados a Largo Plazo/normas , Cuidado Terminal/normas
8.
Home Healthc Now ; 37(4): 208-212, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31274583

RESUMEN

In 2010, the Institute of Medicine published the vision for how to transform healthcare to achieve a more seamless patient-centered, high-quality system of care. Among the recommendations were four specifically focused on leveraging nursing which is the largest group of healthcare workers: (1) Ensure that nurses can practice to the full extent of their education and training, (2) Improve nursing education, (3) Provide opportunities for nurses to assume leadership positions and to serve as full partners in healthcare redesign and improvement efforts, and (4) Improve data collection for workforce planning and policy making. At the Care New England Health Care System's Visiting Nurse Association, located in the state of Rhode Island, we redesigned access to end-of-life care by leveraging these recommendations. An experienced palliative care nurse practitioner (NP) leads the program development to improve care delivered by home healthcare nurses and NP specialists. This program was designed to allow patients to remain in their preferred setting of care-their home-until the end of their life. In the 5 years of this program's existence, it has achieved a yearly impact on community-based palliative care and hospice services. The number of documented advance directives increased by 75%, referrals to palliative care and hospice increased by 300% and the length of time on hospice doubled. In addition, NP home visits became an accepted referral source and improvements in both the quality and satisfaction scores for the home healthcare agency were realized.


Asunto(s)
Accesibilidad a los Servicios de Salud , Enfermería de Cuidados Paliativos al Final de la Vida , Guías de Práctica Clínica como Asunto , Cuidado Terminal , Accesibilidad a los Servicios de Salud/organización & administración , Cuidados Paliativos al Final de la Vida/métodos , Cuidados Paliativos al Final de la Vida/organización & administración , Enfermería de Cuidados Paliativos al Final de la Vida/métodos , Enfermería de Cuidados Paliativos al Final de la Vida/organización & administración , Enfermería de Cuidados Paliativos al Final de la Vida/normas , Humanos , Cuidados Paliativos/métodos , Cuidados Paliativos/organización & administración , Rhode Island , Cuidado Terminal/métodos , Cuidado Terminal/organización & administración , Cuidado Terminal/normas , Cuidado Terminal/estadística & datos numéricos
9.
BMC Health Serv Res ; 19(1): 486, 2019 Jul 15.
Artículo en Inglés | MEDLINE | ID: mdl-31307457

RESUMEN

BACKGROUND: At the end of life, about 85-90% of patients can be treated within primary palliative care (PC) provided by general practitioners (GPs). In Germany, there is no structured approach for the provision of PC by GPs including a systematic as well as timely identification of patients who might benefit from PC, yet. The project "Optimal care at the end of life" (OPAL) focusses on an improvement of primary PC for patients with both oncological and non-oncological chronic progressive diseases in their last phase of life provided by GPs and health care services. METHODS: OPAL will take place in Hameln-Pyrmont, a rural region in Lower Saxony, Germany. Target groups are (a) GPs, (b) relatives of deceased patients and (c) health care providers. The study follows a three-phase approach in a mixed-methods and pre-post design. In phase I (baseline, t0) we explore the usual practice of providing PC for patients with chronic progressive diseases by GPs and the collaboration with other health care providers. In phase II (intervention) the Supportive and Palliative Care Indicators Tool (SPICT) for the timely identification of patients who might benefit from PC will be implemented and tested in general practices. Furthermore, a public campaign will be started to inform stakeholders, to connect health care providers and to train change agents. In phase III (follow-up, t1) we investigate the potential effect of the intervention to evaluate differences in the provision of PC by GPs and to convey factors for the implementation of SPICT in general practices. DISCUSSION: The project OPAL is the first study to implement the SPICT-DE regionwide in general practices in Germany. The project OPAL may contribute to an overall optimisation of primary PC for patients in Germany by reducing GPs' uncertainty in initiating PC, by consolidating their skills and competencies in identifying patients who might benefit from PC, and by improving the cooperation between GPs and different health care stakeholders. TRIAL REGISTRATION: The study was retrospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien; trial registration number: DRKS00015108 ; date of registration: 22th of January 2019).


Asunto(s)
Familia/psicología , Médicos Generales/psicología , Atención Primaria de Salud , Participación de los Interesados/psicología , Cuidado Terminal/normas , Prestación de Atención de Salud , Femenino , Medicina General , Alemania , Humanos , Cuidados Paliativos/métodos , Atención Primaria de Salud/métodos , Estudios Prospectivos , Encuestas y Cuestionarios
10.
Int J Palliat Nurs ; 25(7): 334-343, 2019 Jul 02.
Artículo en Inglés | MEDLINE | ID: mdl-31339819

RESUMEN

BACKGROUND: The Patient Dignity Inventory (PDI) is based on an empirically-driven dignity model that has been developed and used for clinically assessing the various sources of dignity-related distress. In a recent review, it received the highest score as a useful instrument in both practice and research in palliative care. The PDI has been adapted to and validated for use in various countries, but not yet Sweden. AIMS: To translate the PDI into Swedish, including cultural adaptation for clinical use. METHODS: A multi-step process of translation, negotiated consensus, expert group discussion (n=7: four invited experts and three researchers) and cognitive interviewing (n=7: persons with palliative care needs). FINDINGS: Discussion, by the expert reviewers, of both linguistic and cultural issues regarding the content and readability of the translated Swedish version resulted in revisions of items and response alternatives, focusing mainly on semantic, conceptual, and experiential equivalence. A pilot version for cognitive interviews was produced. The analysis of data showed that most of the items were judged to be relevant by the persons with palliative care needs. CONCLUSION: The process of translation and adaptation added clarity and consistency. The Swedish version of the PDI can be used in assessing dignity-related distress. The next step will be to test this Swedish version for psychometric properties in a larger group of patients with palliative care needs before use in research.


Asunto(s)
Cuidados Paliativos/normas , Personeidad , Psicometría/normas , Derecho a Morir , Encuestas y Cuestionarios/normas , Cuidado Terminal/normas , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Paliativos/psicología , Reproducibilidad de los Resultados , Suecia , Cuidado Terminal/psicología , Traducciones
11.
Artículo en Inglés | MEDLINE | ID: mdl-31151321

RESUMEN

Opioid errors are a leading cause of patient harm. Active failures in opioid dose conversion can contribute to error. Conversion is complex and is currently performed manually using tables of approximate equivalence. Apps that offer opioid dose double-checking are available but there are concerns about their accuracy and clinical validation. This study evaluated a novel opioid dose conversion app, The Safer Prescription of Opioids Tool (SPOT), a CE-marked Class I medical device, as a clinician decision support (CDS) platform. This single-centre prospective clinical utility pilot study followed a mixed methods design. Prescribers completed an initial survey exploring their current opioid prescribing practice. Thereafter prescribers used SPOT for opioid dosage conversions in parallel to their usual clinical practice, then evaluated SPOT through a survey and focus group. SPOT matched the Gold Standard result in 258 of 268 (96.3%) calculations. The 10 instances (3.7%) when SPOT did not match were due to a rounding error. Users had a statistically significant increase in confidence in prescribing opioids after using SPOT. Focus group feedback highlighted benefits in Quality Improvement and Safety when using SPOT. SPOT is a safe, reliable and validated CDS that has potential to reduce harms from opioid dosing errors.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Sistemas de Apoyo a Decisiones Clínicas/organización & administración , Cuidados Paliativos/organización & administración , Cuidado Terminal/organización & administración , Analgésicos Opioides/administración & dosificación , Sistemas de Apoyo a Decisiones Clínicas/normas , Relación Dosis-Respuesta a Droga , Humanos , Aplicaciones Móviles , Cuidados Paliativos/normas , Proyectos Piloto , Pautas de la Práctica en Medicina , Estudios Prospectivos , Cuidado Terminal/normas
12.
Pediatr Int ; 61(9): 859-864, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31247125

RESUMEN

BACKGROUND: End-of-life (EOL) care is an important topic in critical care medicine, but EOL discussions with families can be difficult and stressful for intensivists. The aim of this study was to clarify the current practices and barriers facing pediatric intensive care unit (PICU) EOL care and to identify the requisites for excellent PICU EOL care in Japan. METHODS: A survey was conducted in 29 facilities across Japan in 2016. The questionnaire consisted of 19 multiple-choice questions and one open-ended question. RESULTS: Twenty-seven facilities responded to the survey. Only 19% had educational programs on EOL care for fellows or residents. Although 21 hospitals (78%) had a multidisciplinary palliative care team, only eight of these teams were involved in EOL care in PICUs. Mental health care for health-care providers provided by a psychiatrist was rare (4%). The free comments were categorized as individual, team, environment, legal/ethics, or culture. Commonly raised individual issues included "lack of experience and knowledge about EOL care", "fear of making the decision to end care", and "reluctance to be involved in EOL care because of its complex process". Team issues included "insufficient frequency of conferences" and "non-multidisciplinary approach". Legal and ethics issues were "lack of legal support" and "fear of lawsuits". CONCLUSIONS: This study is the first to investigate the current conditions and barriers in PICU EOL care in Japan. Most of the facilities involved were not satisfied with current practices. A need was identified for relevant educational programs, as well as the importance of multidisciplinary and legal support.


Asunto(s)
Actitud del Personal de Salud , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Cuidado Terminal/estadística & datos numéricos , Adolescente , Niño , Preescolar , Toma de Decisiones Clínicas/métodos , Encuestas de Atención de la Salud , Humanos , Lactante , Unidades de Cuidado Intensivo Pediátrico/normas , Japón , Cuidados Paliativos/métodos , Cuidados Paliativos/normas , Cuidados Paliativos/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Cuidado Terminal/métodos , Cuidado Terminal/normas
14.
PLoS One ; 14(5): e0217134, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31136601

RESUMEN

BACKGROUND: End-of-life (EOL) decisions are a serious ethical dilemma and are frequently carried out in intensive care units (ICUs). The aim of this systematic review was to investigated the different approaches used in ICUs and reported in randomized controlled trials (RCTs) to address EOL decisions and compare the impact of these different strategies regarding potential bias and mortality estimates. METHODS: We identified relevant RCTs published in the past 15 years via PubMed, EMBASE, and CINAHL. In addition, we searched The Cochrane Library and checked registries, including ClinicalTrials.gov to assess concordance between declared and published outcomes. Among the journals we screened were the 3 ICU specialty journals and the four general medicine journals with the highest impact factor. Only RCTs were selected in which in-ICU mortality was the primary or secondary outcome. The primary outcome was information regarding EOL decisions, and the secondary outcome was how EOL decisions were treated in the study analysis. RESULTS: A total of 178 relevant trials were identified. The details regarding the methodological aspects resulting from EOL decisions were reported in only 62 articles (35%). The manner in which EOL decisions were considered in the study analysis was very heterogeneous, often leading to a high risk of bias. CONCLUSION: There is a heterogeneity regarding the management of data on EOL decisions in randomized control trials with mortality endpoints. Recommendations or rules are required regarding the inclusion of patients with potential EOL decisions in RCT analyses and how to manage such decisions from a methodological point of view. TRIAL REGISTRATION: PROSPERO website (CRD42013005724).


Asunto(s)
Técnicas de Apoyo para la Decisión , Unidades de Cuidados Intensivos/normas , Publicaciones Periódicas como Asunto , Sistema de Registros/estadística & datos numéricos , Cuidado Terminal/métodos , Cuidado Terminal/normas , Humanos , Metaanálisis como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto
15.
Intensive Crit Care Nurs ; 53: 8-14, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31023516

RESUMEN

OBJECTIVE: To determine perceptions of Jordanian critical care staff about obstacles and facilitators to end-of-life care. RESEARCH METHODOLOGY: The "National Survey of Critical Care Nurses' Perceptions of End-of-Life Care" was adapted and distributed to 143 critical care nurses (n = 110) and physicians (n = 33) in two Jordanian hospitals. Nurses and physicians completed items about perceived obstacles to end-of-life care. Nurses only completed items about facilitators to end-of-life care. RESULTS: The overall response rate was 72.7% (n = 104/143). Seventy-six nurses (69.1%) and 28 physicians (84.5%) responded. Nurses and physicians agreed that the highest scoring obstacles were: 'family members who do not understand what life-saving measures mean' and the 'poor design of critical care units'. Other highly scoring obstacles related to clinicians' behaviours, characteristics and attitudes. Nurses perceived the highest scoring facilitator was 'family members who accepted that the patient was dying'. CONCLUSION: There is a need to further explore the issues underlying perceptions about clinicians' behaviours, which were perceived to be key barriers to quality end-of-life care and to find acceptable solutions that fit with Islamic culture. It is the first time that the survey has been used to gather perceptions of doctors and nurses in a non-western culture.


Asunto(s)
Personal de Salud/psicología , Cuidado Terminal/métodos , Centros Médicos Académicos/organización & administración , Centros Médicos Académicos/estadística & datos numéricos , Adulto , Actitud del Personal de Salud , Femenino , Personal de Salud/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos/organización & administración , Unidades de Cuidados Intensivos/estadística & datos numéricos , Relaciones Interprofesionales , Jordania , Masculino , Persona de Mediana Edad , Percepción , Encuestas y Cuestionarios , Cuidado Terminal/normas , Cuidado Terminal/estadística & datos numéricos
16.
In Vivo ; 33(3): 903-909, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31028215

RESUMEN

BACKGROUND/AIM: Appropriate decision-making in end-of-life (EOL) care is essential for both junior and senior physicians. The aim of this study was to compare the decision-making and attitudes of medical students with those of experienced general practitioners (GP) regarding EOL-care. MATERIALS AND METHODS: A questionnaire presenting three cancer patient scenarios concerning decisions and ethical aspects of EOL-care was offered to 500 Finnish GPs and 639 graduating medical students in 2015-2016. RESULTS: Responses were received from 222 (47%) GPs and 402 (63%) students. The GPs withdrew antibiotics (p<0.001) and nasogastric tubes (p=0.007) and withheld resuscitation (p<0.001), blood transfusions (p=0.002) and pleural drainage (p<0.001) more often than did the students. The students considered euthanasia and assisted suicide less reprehensible (p<0.001 in both) than did the GPs. CONCLUSION: Medical students were more unwilling to withhold and withdraw therapies in EOL-care than were the GPs, but the students considered euthanasia less reprehensible. Medical education should include aspects of decision-making in EOL-care.


Asunto(s)
Toma de Decisiones Clínicas , Neoplasias/epidemiología , Médicos , Pautas de la Práctica en Medicina , Estudiantes de Medicina , Cuidado Terminal , Adulto , Anciano , Anciano de 80 o más Años , Actitud del Personal de Salud , Manejo de la Enfermedad , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/terapia , Encuestas y Cuestionarios , Cuidado Terminal/métodos , Cuidado Terminal/normas
17.
BMC Palliat Care ; 18(1): 35, 2019 Apr 05.
Artículo en Inglés | MEDLINE | ID: mdl-30953487

RESUMEN

BACKGROUND: Accessible indicators of aggressiveness of care at the end-of-life are useful to monitor implementation of early integrated palliative care practice. To determine the intensity of end-of-life care from exhaustive data combining administrative databases and hospital clinical records, to evaluate its variability across hospital facilities and associations with timely introduction of palliative care (PC). METHODS: For this study designed as a decedent series nested in multicentre cohort of advanced cancer patients, we selected 997 decedents from a cohort of patients hospitalised in 2009-2010, with a diagnosis of metastatic cancer in 3 academic medical centres and 2 comprehensive cancer centres in the Paris area. Hospital data was combined with nationwide mortality databases. Complete data were collected and checked from clinical records, including first referral to PC, chemotherapy within 14 days of death, ≥1 intensive care unit (ICU) admission, ≥2 emergency department visits (ED), and ≥ 2 hospitalizations, all within 30 days of death. RESULTS: Overall (min-max) indicator values as reported by facility providing care rather than the place of death, were: 16% (8-25%) patients received chemotherapy within 14 days of death, 16% (6-32%) had ≥2 admissions to acute care, 6% (0-15%) had ≥2 emergency visits and 18% (4-35%) had ≥1 intensive care unit admission(s). Only 53% of these patients met the PC team, and the median (min-max) time between the first intervention of the PC team and death was 41 (17-112) days. The introduction of PC > 30 days before death was independently associated with lower intensity of care. CONCLUSIONS: Aggressiveness of end-of-life cancer care is highly variable across centres. This validates the use of indicators to monitor integrated PC in oncology. Disseminating a quality audit-feedback cycle should contribute to a shared view of appropriate end-of-life care objectives, and foster action for improvement among care providers.


Asunto(s)
Neoplasias/terapia , Cuidado Terminal/normas , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Neoplasias/psicología , Paris , Investigación Cualitativa , Calidad de la Atención de Salud/normas , Estudios Retrospectivos , Cuidado Terminal/métodos
20.
JAMA Netw Open ; 2(4): e192036, 2019 04 05.
Artículo en Inglés | MEDLINE | ID: mdl-30977852

RESUMEN

Importance: Despite its spread in much of the United States and increased international interest, the Physician Orders for Life-Sustaining Treatment (POLST) paradigm still lacks supporting evidence. The interrater reliability of the POLST form to translate patients' values and preferences into medical orders for care at the end of life remains to be studied. Objective: To assess the interrater reliability of the medical orders documented in POLST forms. Design, Setting, and Participants: This cross-sectional study was conducted in a public university hospital in southeastern Brazil. Two independent researchers interviewed the same patients or decision-making surrogates (n = 64) during a single episode of hospitalization within a time frame of 1 to 7 days. Eligible participants were hospitalized adults aged 21 years or older who were expected to remain hospitalized for at least 4 days and whose attending physician responded no to the question, Would I be surprised if this patient died in the next year? Data collection occurred between November 1, 2015, and September 20, 2016, and first data analyses were performed on October 3, 2016. Main Outcomes and Measures: Interrater reliability as measured by κ statistics. Results: Of the 64 participants interviewed in the study, 53 (83%) were patients and 11 (17%) were surrogates. Patients' mean (SD) age was 64 (14) years, and 35 patients (55%) and 8 surrogates (73%) were women. Overall, in 5 cases (8%), disagreement in at least 1 medical order for life-sustaining treatment was found in the POLST form, changing from the first interview to the second interview. The κ statistic for cardiopulmonary resuscitation was 0.92 (95% CI, 0.80-1.00); for level of medical intervention, 0.89 (95% CI, 0.76-1.00); and for artificially administered nutrition, 0.92 (95% CI, 0.83-1.00). Conclusions and Relevance: The high interrater reliability of the medical orders in POLST forms appears to offer further support for this advance care planning paradigm; in addition, the finding that this interrater reliability was not 100% underscores the need to ensure that patients or their surrogates have decision-making capacity and to confirm that the content of POLST forms accurately reflects patients' current treatment preferences.


Asunto(s)
Planificación Anticipada de Atención/normas , Actitud Frente a la Muerte , Cuidados para Prolongación de la Vida/psicología , Prioridad del Paciente/psicología , Cuidado Terminal/normas , Adulto , Anciano , Anciano de 80 o más Años , Brasil , Estudios Transversales , Toma de Decisiones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Médicos/psicología , Reproducibilidad de los Resultados , Cuidado Terminal/psicología , Traducciones
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