Goals of Care Discussions Over the Course of a Patient's End of Life Admission: A Retrospective Study.

BACKGROUND: As deaths in hospitals increase, clear discussions regarding resuscitation status and treatment limitations, referred to as goals of care (GOC), are vital. GOC may need revision as disease and patient priorities change over time. There is limited data about who is involved in GOC discussions, and how this changes as patients deteriorate in hospital. AIMS: To review the timing and clinicians involved in GOC discussions for a cohort of patients who died in hospital. METHODS: Retrospective observational audit of 80 consecutive end of life admissions between March 11th and April 9th, 2019. RESULTS: Of 80 patients, 75 (93.6%) had GOC recorded during their admission, about half for ward-based non-burdensome symptom management or end-of-life care. GOC were revised in 68.0% of cases. Medical staff involved in initial versus final GOC discussions included home team junior doctor (54.7% versus 72.5%), home team consultant (37.3% versus 56.9%) and ICU doctor (16.0% versus 21.6%). For initial versus final GOC decisions, patients were involved in 34.7% versus 31.4%, and family in 53.3% versus 86.3%. Dying was documented for 92.0% of patients and this was documented to have been communicated to the family and patient in 98.6% and 19.5% of cases respectively. CONCLUSIONS: As patients deteriorated, family and senior clinician involvement in GOC discussions increased, but patient involvement did not. Junior doctors were most heavily involved in discussions. We advocate for further GOC training and modeling to enhance junior doctors' confidence and competence in conducting and involving patients and families in GOC conversations.

Introducing Voluntary Assisted Dying: Staff Perspectives in an Acute Hospital.

BACKGROUND: Voluntary assisted dying (VAD) was legalised in Victoria, Australia in June 2019. Physicians can now assist patients to end their lives by providing drugs for self-administration at their voluntary and competent request (or for physician administration in limited circumstances). This study investigates the opinions of clinicians on the implementation of the legislation in one Victorian hospital. METHODS: This exploratory survey study was conducted at a 600-bed acute hospital in Melbourne, Australia in Jan 2019. 382 clinicians completed one or more qualitative questions. Participants commented on VAD, potential workplace challenges and staff support required. Free-text responses were analysed using inductive content analysis. RESULTS: Six themes: (1) Polarised views; (2) Fear of conflict; (3) Emotional burden; (4) Vulnerable patients; (5) Organisational challenges; (6) Decision-making. There were diverse views including objections to VAD for religious or ethical reasons, and whole-hearted support based on a compassionate response to suffering and the right of patients to self-determination. Participants feared conflict between colleagues, families and patients, and aggression towards staff. Clinicians called for educational and psychological support. There was concern that vulnerable patients may be coerced to opt for VAD to lessen the burden on families or the health system. Clinicians feared workloads would increase with the introduction of VAD. Patient decision-making capacity in this context must be firmly established before proceeding, and thorough assessments for depression, and optimal symptom management must be implemented before VAD is approved. A dedicated VAD team was suggested to support staff and manage VAD patients. CONCLUSION: Participants expressed polarised opinions about VAD and showed considerable anxiety about its introduction. Additional education and support are required to ensure that clinicians understand details of the legislation and their professional and personal options. Tolerance and respect for alternative viewpoints must be advocated within the organisation and more broadly.

Support for and willingness to be involved in voluntary assisted dying: a multisite, cross-sectional survey study of clinicians in Victoria, Australia.

BACKGROUND: In the Australian state of Victoria, specialist doctors are central to the operation of voluntary assisted dying (VAD). However, a broad range of clinicians may be involved in the care of patients requesting or using VAD. AIMS: To describe levels of support for and willingness to be involved in VAD and consider factors associated with clinician support for the VAD legislation and physicians' willingness to provide VAD in practice. METHODS: A multisite, cross-sectional survey of clinicians in seven Victorian hospitals. All clinicians were invited to complete an online survey measuring demographic characteristics, awareness of and support for the VAD legislation, willingness to participate in VAD related activities and reasons for willingness or unwillingness to participate in VAD. RESULTS: Of 5690 who opened the survey, 5159 (90.1%) were included in the final sample and 73% (n = 3768) supported the VAD legislation. The strongest predictor of support for the VAD legislation was clinical role. Forty percent (n = 238) of medical specialists indicated they would be willing to participate in either the VAD consulting or coordinating role. Doctors did not differ in willingness between high impact (44%) and low impact specialty (41%); however, doctors specialising in palliative care or geriatric medicine were significantly less willing to participate (27%). CONCLUSION: Approximately 73% of surveyed staff supported Victoria's VAD legislation. However, only a minority of medical specialists reported willingness to participate in VAD, suggesting potential access issues for patients requesting VAD in accordance with the legal requirements in Victoria.

Identification and Management of Ischemic Stroke in the Postanesthesia Care Unit.

A thromboembolic stroke is a debilitating event that can occur with little or no warning. This report details the case of a 63-year-old male experiencing a stroke in the immediate postoperative period after total knee arthroplasty. Risk for perioperative stroke is influenced by age, sex, ethnicity, comorbidities, and some medications. The depressed neurocognitive state of patients recovering from anesthesia warrants special consideration for the identification and management of perioperative stroke.

Performance-Improvement Project: Increasing Nursing Knowledge of the Impact of Sugammadex in Female Patients Taking Steroidal Contraceptives.

PURPOSE: This process-improvement project improved postoperative education for female patients by facilitating the development of a topic-specific education program to improve knowledge and confidence among perianesthesia nurses in a military treatment facility. DESIGN: An educational program was developed and presented which reviewed the impact sugammadex has on steroidal contraceptive efficacy, evidence-based postoperative teaching strategies, and specific patient education recommendations for female sugammadex-exposed patients taking steroidal contraceptives. METHODS: Effectiveness was measured by comparing nurses' baseline knowledge and confidence scores before and immediately after presentation of the educational program. These results were then compared with 2-week reassessments to determine if lasting improvements were achieved. FINDINGS: Statistically significant increases in knowledge and confidence were achieved upon both postintervention assessments. CONCLUSIONS: Interactive evidence-based educational interventions can effectively create sustained increases in knowledge and confidence among health care professionals which translates into improved postoperative patient education.

Implementation of an Education Program for an Ultrasound-Guided Liposomal Bupivacaine Transversus Abdominis Plane (TAP) Block Protocol for Open Abdominal Procedures.

Anesthesia practitioners at the authors' facility had varying education and training with placing transversus abdominis plane (TAP) blocks and with the use of liposomal bupivacaine limiting the utilization of this regional anesthetic technique for patients undergoing abdominal surgical procedures. An expansive literature review suggested that ultrasound-guided liposomal bupivacaine TAP blocks were safe and effective for reducing postoperative pain scores, opioid use, and no reported adverse effects. Current literature findings were used to craft an educational intervention to update current practices among anesthesia practitioners. The purpose of the project was to develop and implement an educational intervention to improve the knowledge and confidence of all anesthesia providers at our facility when placing and managing liposomal bupivacaine TAP blocks in patients undergoing abdominal surgery. We used the Ajzen Theory of Planned Behavior to create an effective practice change, combined with skill acquisition through simulation, among anesthesia providers at our facility in performing ultrasound-guided liposomal bupivacaine TAP blocks. The implementation of a multistrategy education program using simulation resulted in a significant increase in knowledge and confidence among anesthesia practitioners.