Finding the balance between person-centred and treatment-centred discussions in advance care planning-a qualitative analysis of conversations within the MUTUAL (Multidisciplinary Timely Undertaken Advance Care Planning conversations) intervention using a narrative analysis.

INTRODUCTION: Advance care planning (ACP) aims to create conditions for more person-centred care. We aimed to explore variations in person-centred care discussions and treatment-centred care discussions within ACP conversations in the Multidisciplinary Timely Undertaken Advance Care Planning (MUTUAL) intervention and how person-centred care discussions could be encouraged. The MUTUAL intervention consists of the following: (i) timely patient selection, (ii) the patient and healthcare professionals preparing for the conversation, (iii) a scripted ACP conversation in a multidisciplinary setting and (iv) documentation. METHODS: We conducted a narrative analysis of ACP conversations. A narrative summary template was created and used to analyse 18 audio-recordings. RESULTS: We noticed variations in person-centred and treatment-centred focus within the ACP conversations. We identified three important strategies that facilitated person-centred care discussions within ACP conversations. First, healthcare professionals' acceptance that ACP is an individual process. We believe it is important that healthcare professionals recognise and accept where the patient is in his or her individual ACP process; not making decisions right away can also be part of a decisional process. Secondly, exploring the underlying motivation for treatment wishes can give insights into patient's wishes, values and needs. Lastly, healthcare professionals who demonstrated an adaptive, curious and engaged attitude throughout the ACP process achieved more person-centred ACP conversations. This coincided with elaborating on the patient's emotions, fears and worries. CONCLUSION: Person-centred and treatment-centred focus varied within the ACP conversations in the MUTUAL intervention. Certain strategies by healthcare professionals facilitated a more person-centred focus.

Barriers and facilitators for healthcare professionals to the implementation of Multidisciplinary Timely Undertaken Advance Care Planning conversations at the outpatient clinic (the MUTUAL intervention): a sequential exploratory mixed-methods study.

BACKGROUND: Advance Care Planning (ACP) enables patients to define and discuss their goals and preferences for future medical treatment and care. However, the structural implementation of ACP interventions remains challenging. The Multidisciplinary Timely Undertaken Advance Care Planning (MUTUAL) intervention has recently been developed which takes into account existing barriers and facilitators. We aimed to evaluate the MUTUAL intervention and identify the barriers and facilitators healthcare professionals experience in the implementation of the MUTUAL intervention and also to identify suggestions for improvement. METHODS: We performed a sequential exploratory mixed-methods study at five outpatient clinics of one, 300-bed, non-academic hospital. Firstly, semi-structured interviews were performed with a purposive sample of healthcare professionals. The content of these interviews was used to specify the Measurement Instrument for Determinants of Innovations (MIDI). The MIDI was sent to all healthcare professionals. The interviews and questionnaires were used to clarify the results. RESULTS: Eleven healthcare professionals participated in the interviews and 37 responded to the questionnaire. Eight barriers and 20 facilitators were identified. Healthcare professionals agreed that the elements of the MUTUAL intervention are clear, correct, complete, and simple - and the intervention is relevant for patients and their proxies. The main barriers are found within the user and the organisational domain. Barriers related to the organisation include: inadequate replacement of staff, insufficient staff, and insufficient time to introduce and invite patients. Several suggestions for improvement were made. CONCLUSION: Our results show that healthcare professionals positively evaluate the MUTUAL intervention and are very receptive to implementing the MUTUAL intervention. Taking into account the suggestions for improvement may enhance further implementation.

The development and feasibility study of Multidisciplinary Timely Undertaken Advance Care Planning conversations at the outpatient clinic: the MUTUAL intervention.

BACKGROUND: Patients still receive non-beneficial treatments when nearing the end of life. Advance care planning (ACP) interventions have shown to positively influence compliance with end of life wishes. Hospital physicians seem to miss opportunities to engage in ACP, whereas patients visiting the outpatient clinic usually have one or more chronic conditions and are at risk for medical emergencies. So far, implemented ACP interventions have had limited impact. Structural implementation of ACP may be beneficial. We hypothesize that having ACP conversations more towards the end of life and involving the treating physician in the ACP conversation may help patient wishes and goals to become more concrete and more often documented, thus facilitating goal-concordant care. AIM: To facilitate timely shared decision making and increase patient autonomy we aim to develop an ACP intervention at the outpatient clinic for frail patients and determine the feasibility of the intervention. METHODS: The United Kingdom's Medical Research Council framework was used to structure the development of the ACP intervention. Key elements of the ACP intervention were determined by reviewing existing literature and an iterative process with stakeholders. The feasibility of the developed intervention was evaluated by a feasibility study of 20 ACP conversations at the geriatrics and pulmonology department of a non-academic hospital. Feasibility was assessed by analysing evaluation forms by patients, nurses and physicians and by evaluating with stakeholders. A general inductive approach was used for analysing comments. The developed intervention was described using the template for intervention description and replication (TIDieR). RESULTS: We developed a multidisciplinary timely undertaken ACP intervention at the outpatient clinic. Key components of the developed intervention consist of 1) timely patient selection 2) preparation of patient and healthcare professional 3) a scripted ACP conversation in a multidisciplinary setting and 4) documentation. 94.7% of the patients, 60.0% of the nurses and 68.8% of the physicians agreed that the benefits of the ACP conversation outweighed the potential burdens. CONCLUSION: This study showed that the developed ACP intervention is feasible and considered valuable by patients and healthcare professionals.

[Dealing with treatment limitations during anaesthesia]. / Omgaan met behandelgrenzen tijdens anesthesie.

Treatment limitations may create a clinical dilemma during anaesthesia. Because mostly, pre-existing treatment limitations have been decided upon without considering the occurrence of a future medical intervention with its unique circumstances. In case treatment limitations are not reassessed prior to an intervention and a life threatening situation occurs during the intervention, a dilemma may arise between the patient's wishes and physician's actions. For example, overtreatment may occur when treatment limitations are ignored during an intervention without the patient's consent. Or undertreatment may occur if a physician strictly adheres to the treatment limitations without taking the situation of an intervention into account. So, how do we respect a patient's autonomy while striving to provide acute care in the patient's best interests? We suggest (re)considering treatment limitations under anaesthesia with every patient with pre-existing limitations, and ideally, with every fragile patient, prior to an intervention.

[Euglycemic diabetic ketoacidosis during pregnancy]. / Euglykemische diabetische ketoacidose tijdens de zwangerschap.

BACKGROUND: Diabetic ketoacidosis (DKA) can have an atypical presentation during pregnancy. In the case of euglycemic DKA, relatively normal blood glucose levels can hinder a quick diagnosis. CASE DESCRIPTION: A 34-year-old DM1 patient, 31 weeks pregnant, was admitted because of reduced fetal movements and nausea. She had reduced the amount of insulin that her insulin pump administered and had a severe euglycemic DKA. The CTG was abnormal and there was a threat of preterm birth. She was treated with insulin, glucose and bicarbonate. A month later the patient underwent an emergency cesarean section because of an abnormal CTG. A daughter was born that weighed 4820 grams, the Apgar score was 5/8/8, and the pH was 7.14. The girl required intravenous glucose for a week. CONCLUSION: Euglycemic DKA during pregnancy requires swift recognition and treatment but this remains challenging.

[Acute fatty liver of pregnancy]. / Acute leververvetting tijdens de zwangerschap.

BACKGROUND: Acute fatty liver of pregnancy (AFLP) is a rare complication of pregnancy which is potentially fatal to mother and child. CASE DESCRIPTION: A primigravida at term with gestational diabetes presented at hospital complaining mainly of nausea and vomiting. Test results were consistent with acute fatty liver of pregnancy (AFLP). Due to the seriousness and rapid progression of the disease, we strove for a rapid delivery. The patient was admitted to the intensive care unit, but was eventually able to leave hospital in a good condition with a healthy child. CONCLUSION: AFLP is a rare and potentially dangerous condition of pregnancy and requires multidisciplinary collaboration. Knowledge of clinical symptoms, early diagnosis, treatment and anticipation of expected complications is essential to prevent the death of mother and child. Diabetes gravidarum can complicate the making of the diagnosis. More research into potential early diagnostics or screening instruments and the long-term outcomes for mother and child is necessary.

[A woman with fever and a painful hip]. / Een vrouw met koorts en een pijnlijke heup.

An immunocompromised 78-year-old woman had a painful hip and subacute fever. An abdominal CT scan revealed a diverticular sigmoid stenosis fistulating to the presacral space, with free gas in the paravertebral musculature and spinal canal. Because a deep necrotising infection was suspected, she underwent surgery and was treated with antibiotics. She recovered completely.

Noninvasive and invasive positive pressure ventilation for acute respiratory failure in critically ill patients: a comparative cohort study.

BACKGROUND: Noninvasive positive pressure ventilation (NPPV) for acute respiratory failure in the intensive care unit (ICU) is associated with a marked reduction in intubation rate, complications, hospital length of stay and mortality. Multiple studies have indicated that patients failing NPPV have worse outcomes compared with patients with successful NPPV treatment; however limited data is available on risks associated with NPPV failure resulting in (delayed) intubation and outcomes compared with initial intubation. The purpose of this study is to assess rates and predictors of NPPV failure and to compare hospital outcomes of patients with NPPV failure with those patients primarily intubated without a prior NPPV trial. METHODS: A retrospective observational study using data from patients with acute respiratory failure admitted to the ICU in the period 2013-2014. All patients treated with NPPV were evaluated. A sample of patients who were primarily intubated was randomly selected to serve as controls for the group of patients who failed NPPV. RESULTS: NPPV failure was recorded in 30.8% of noninvasively ventilated patients and was associated with longer ICU stay [OR, 1.16, 95% confidence interval (95% CI): 1.04-1.30] and lower survival rates (OR, 0.10, 95% CI: 0.02-0.59) compared with NPPV success. Multivariate analysis showed presence of severe sepsis at study entry, higher Simplified Acute Physiology II Score (SAPS-II) score, lower ratio of arterial oxygen tension to fraction of inspired oxygen (PF-ratio) and lower plasma glucose were predictors for NPPV failure. After controlling for potential confounders, patients with NPPV failure did not show any difference in hospital outcomes compared with patients who were primarily intubated. CONCLUSIONS: Patients with acute respiratory failure and NPPV failure have worse outcomes compared with NPPV success patients, however not worse than initially intubated patients. An initial trial of NPPV therefore may be suitable in selected cases of patients with acute respiratory failure, since NPPV could be potentially beneficial and does not seem to result in worse outcome in case of NPPV failure compared to primary intubation. A prospective trial is warranted to confirm findings.

[Treatment in the Intensive Care Unit: continue or withdraw?]. / Behandeling op de IC: stoppen of doorgaan?

End-of-life decision-making in the Intensive Care Unit is a common and complex process. The step-by-step process of decision-making leading to withdrawal of life-sustaining treatment is illustrated in this paper by a clinical case. A variety of factors influences the decision to adjust the initial curative treatment policy towards withdrawal of life-sustaining therapy and the pursuit of comfort care. For a smooth decision-making process, it is necessary to make a prognosis and obtain consensus amongst the healthcare team. Withdrawal of life-sustaining treatment is ultimately a medical decision and a consensual decision should be reached by all medical staff and nurses, and preferably also by the patient and family. Timely involvement of a legal representative of the patient is essential for an uncomplicated decision-making process. Advance care planning and advance directives provide opportunities for patients to express their preferences beforehand. It is important to realise that end-of-life decisions are significantly influenced by personal and cultural values.

[Thrombus in a patent foramen ovale]. / Een trombus in een persisterend foramen ovale.

BACKGROUND: A "thrombus in transit" is a relatively rare diagnosis involving a thrombus in a patent foramen ovale. Patent foramen ovale occurs in about 25% of the population. A thrombus in transit may lead to paradoxical arterial emboli in the cerebral circulatory system and the extremities, as well as other locations. CASE DESCRIPTION: A 60-year-old male patient with severe pneumonia sepsis appeared to have a thrombus in the right atrium, extending into the left atrium through a patent foramen ovale. The patient was treated with therapeutic anticoagulants. Cerebral embolization occurred despite this, with extensive cerebral ischaemia. The patient ultimately died from multiple organ failure. CONCLUSION: A thrombus in transit may be treated with heparins, thrombolysis or by surgical removal of the thrombus. The optimum treatment must be decided for each individual patient. The mortality rate of this condition is high (16-36%).

Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients.

Laryngeal edema is a frequent complication of intubation. It often presents shortly after extubation as post-extubation stridor and results from damage to the mucosa of the larynx. Mucosal damage is caused by pressure and ischemia resulting in an inflammatory response. Laryngeal edema may compromise the airway necessitating reintubation. Several studies show that a positive cuff leak test combined with the presence of risk factors can identify patients with increased risk for laryngeal edema. Meta-analyses show that pre-emptive administration of a multiple-dose regimen of glucocorticosteroids can reduce the incidence of laryngeal edema and subsequent reintubation. If post-extubation edema occurs this may necessitate medical intervention. Parenteral administration of corticosteroids, epinephrine nebulization and inhalation of a helium/oxygen mixture are potentially effective, although this has not been confirmed by randomized controlled trials. The use of non-invasive positive pressure ventilation is not indicated since this will delay reintubation. Reintubation should be considered early after onset of laryngeal edema to adequately secure an airway. Reintubation leads to increased cost, morbidity and mortality.