Effect of communication skills training on documentation of shared decision-making for patients with life-limiting illness: An observational study in an intensive care unit.

Objectives: This article aims to examine the association between a shared decision-making (SDM) clinical communication training program and documentation of SDM for patients with life-limiting illness (LLI) admitted to intensive care. Methods: This article used a prospective, longitudinal observational study in a tertiary intensive care unit (ICU). Outcomes included the proportion of patients with SDM documented on an institutional Goals of Care Form during hospital admission, as well as characteristics, outcomes, and factors associated with an SDM admission. Intervention: Clinical communication skills training (iValidate) and clinical support program are the intervention for this study. Results: A total of 325 patients with LLI were admitted to the ICU and included in the study. Overall, 184 (57%) had an SDM admission, with 79% of Goals of Care Form completed by an iValidate-trained doctor. Exposure to an iValidate-trained doctor was the strongest predictor of an ICU patient with LLI having an SDM admission (odds ratio: 22.72, 95% confidence interval: 11.91-43.54, p < 0.0001). A higher proportion of patients with an SDM admission selected high-dependency unit-level care (29% vs. 12%, p < 0.001) and ward-based care (36% vs. 5%, p < 0.0001), with no difference in the proportion of patients choosing intensive care or palliative care. The proportion of patients with no deterioration plan was higher in the non-SDM admission cohort (59% vs. 0%, p < 0.0001). Conclusions: Clinical communication training that explicitly teaches identification of patient values is associated with improved documentation of SDM for critically ill patients with LLI. Understanding the relationship between improved SDM and patient, family, and clinical outcomes requires appropriately designed high-quality trials randomised at the patient or cluster level.

Values, preferences and goals identified during shared decision making between critically ill patients and their doctors.

Objective: Examine values, preferences and goals elicited by doctors following goals-of-care (GOC) discussions with critically ill patients who had life-limiting illnesses. Design: Descriptive qualitative study using four-stage latent content analysis. Setting: Tertiary intensive care unit (ICU) in South Western Victoria. Participants: Adults who had life-limiting illnesses and were admitted to the ICU with documented GOC, between October 2016 and July 2018. Intervention: The iValidate program, a shared decision-making clinical communication education and clinical support program, for all ICU registrars in August 2015. Main outcome measures: Matrix of themes and subthemes categorised into values, preferences and goals. Results: A total of 354 GOC forms were analysed from 218 patients who had life-limiting illnesses and were admitted to the ICU. In the categories of values, preferences and goals, four themes were identified: connectedness and relational autonomy, autonomy of decision maker, balancing quality and quantity of life, and physical comfort. The subthemes - relationships, sense of place, enjoyment of activities, independence, dignity, cognitive function, quality of life, longevity and physical comfort - provided a matrix of issues identified as important to patients. Relationship, place, independence and physical comfort statements were most frequently identified; longevity was least frequently identified. Conclusion: Our analysis of GOC discussions between medical staff and patients who had life-limiting illnesses and were admitted to the ICU, using a shared decision-making training and support program, revealed a framework of values, preferences and goals that could provide a structure to assist clinicians to engage in shared decision making.

Maternal Risk Modeling in Critical Care-Development of a Multivariable Risk Prediction Model for Death and Prolonged Intensive Care.

OBJECTIVES: We aimed to develop and validate an accurate risk prediction model for both mortality and a combined outcome of mortality and morbidity for maternal admissions to critical care. DESIGN: We used data from a high-quality prospectively collected national database, supported with literature review and expert opinion. We tested univariable associations between each risk factor and outcome. We then developed two separate multivariable logistic regression models for the outcomes of acute hospital mortality and death or prolonged ICU length of stay. We validated two parsimonious risk prediction models specific for a maternal population. SETTING: The Intensive Care National Audit and Research Centre Case Mix Programme is the national clinical audit for adult critical care in England, Wales, and Northern Ireland. PATIENTS: All female admissions to adult general critical care units, for the period January 1, 2007-December 31, 2016, 16-50 years old, and admitted either while pregnant or within 42 days of delivery-a cohort of 15,480 women. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We aimed to develop and validate an accurate risk prediction model for both mortality and a combined outcome of mortality and morbidity for maternal admissions to critical care. For the primary outcome of acute hospital mortality, our parsimonious risk model consisting of eight variables had an area under the receiver operating characteristic of 0.96 (95% CI, 0.91-1.00); these variables are commonly available for all maternal admissions. For the secondary composite outcome of death or ICU length of stay greater than 48 hours, the risk model consisting of 17 variables had an area under the receiver operating characteristic of 0.80 (95% CI, 0.78-0.83). CONCLUSIONS: We developed risk prediction models specific to the maternal critical care population. The models compare favorably against general adult ICU risk prediction models in current use within this population.

Diverse Helotiales associated with the roots of three species of Arctic Ericaceae provide no evidence for host specificity.

Ericoid mycorrhizal fungi differ in their abilities to use nitrogen sources and may be integral to maintaining fungal and plant diversity in ecosystems in which Ericaceae occur. In this study, we tested whether the fungal communities differ among three species of co-occurring Ericaceae. Fungi colonizing Cassiope tetragona, Empetrum nigrum and Vaccinium vitis-idaea roots in the Arctic tundra were characterized via culture-dependent and culture-independent techniques. The cultured fungi were tested for their ability to colonize Vaccinium uliginosum in laboratory-based assays. The pure-cultured Helotiales were grouped into eight clades and dominated by the Phialocephala-Acephala complex. Representatives of these clades, plus an unknown basidiomycete with affinity to the genus Irpex (Polyporales), colonized V. uliginosum intracellularly. The Helotiales detected by direct PCR, cloning and sequencing were assigned to 14 clades and dominated by members of the Rhizoscyphus ericae complex. Ordination analyses indicated that culture-dependent and culture-independent assays provided distinct views of root fungal communities, but no evidence for host specificity. These data suggest that ericaceous roots host diverse fungal communities dominated by the Helotiales. However, these fungal communities are unlikely to be controlled by fungal host preferences. The mechanisms maintaining high diversity in root-symbiotic communities remain to be elucidated.

Application of fungistatics in soil reduces N uptake by an arctic ericoid shrub (Vaccinium vitis-idaea).

In arctic tundra soil N is highly limiting, N mineralization is slow and organic N greatly exceeds inorganic N. We studied the effects of fungistatics (azoxystrobin [Quadris] or propiconazole [Tilt]) on the fungi isolated from ericaceous plant roots in vitro. In addition to testing the phytotoxicity of the two fungistatics we also tested their effects on growth and nitrogen uptake of an ericaceous plant (Vaccinium uliginosum) in a closed Petri plate system without root-associated fungi. Finally, to evaluate the fungistatic effects in an in vivo experiment we applied fungistatics and nitrogen isotopes to intact tundra soil cores from Toolik Lake, Alaska, and examined the ammonium-N and glycine-N use by Vaccinium vitis-idaea with and without fungistatics. The experiments on fungal pure cultures showed that Tilt was more effective in reducing fungal colony growth in vitro than Quadris, which was highly variable among the fungal strains. Laboratory experiments aiming to test the fungistatic effects on plant performance in vitro showed that neither Quadris nor Tilt affected V. uliginosum growth or N uptake. In this experiment V. uliginosum assimilated more than an order of magnitude more ammonium-N than glycine-N. The intact tundra core experiment provided contrasting results. After 10 wk of fungistatic application in the growth chamber V. vitis-idaea leaf %N was 10% lower and the amount of leaf 15N acquired was reduced from labeled ammonium (33%) and glycine (40%) during the 4 d isotope treatment. In contrast to the in vitro experiment leaf 15N assimilation from glycine was three times higher than from 15NH4 in the treatments that received no-fungistatics. We conclude that the function of the fungal communities is essential to the acquisition of N from organic sources and speculate that N acquisition from inorganic sources is mainly inhibited by competition with complex soil microbial communities.

Molecular phylogenetics of the gomphoid-phalloid fungi with an establishment of the new subclass Phallomycetidae and two new orders.

Molecular phylogenetic analyses for the gomphoid-phalloid fungi were conducted based on the five gene dataset with extensive taxon sampling. The monophyly of the gomphoid-phalloid clade was strongly supported, and four well supported major subclades were recognized. Three of the four subclades were represented entirely by gastroid taxa, and only Gomphales contained both gastroid and non-gastroid taxa. While the gastroid morphology is derived from epigeous, nongastroid taxa in Gomphales, the topology of Phallales indicated that truffle-like form is an ancestral morphology of the stinkhorn fruiting bodies. Although basidiospore maturation occurs within the enclosed fruiting bodies of the stinkhorn, the elevation of the mature spore-producing tissue represents an independent origin of the stipe among Basidiomycota. Comparisons are made between previous and new classification schemes, which are based on the results of phylogenetic analyses. Based on the results of these analyses, a new subclass Phallomycetidae, and two new orders, Hysterangiales and Geastrales, are proposed.