How Engaged in Legal Planning for Incapacity and Death Are Canadians? A Mixed-Methods Survey.

Background: This study aimed to measure the level of involvement of Canadians in preparing for incapacity and death and to explore facilitators and barriers. Method: The authors used an online survey based on the social cognitive theory and the Stages of Change model. Result: One-hundred and forty-eight participants took part. The main facilitators were avoiding burdening others and reducing conflicts. Some respondents thought legal planning did not apply to young and healthy people. Some did not trust lawyers. Conclusion: The authors suggest that more people would trust lawyers if they knew the limits of legal documents and if they worked with medical experts.

The influence of POLST on treatment intensity at the end of life: A systematic review.

BACKGROUND: Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. METHODS: We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life). RESULTS: Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes. CONCLUSION: We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.

Advance Directives State Requirements, Center Practices, and Participant Prevalence in Adult Day Services Centers: Findings From the 2016 National Study of Long-Term Care Providers.

OBJECTIVES: Adult day services centers (ADSCs) may serve as an entrée to advance care planning. This study examined state requirements for ADSCs to provide advance directives (ADs) information to ADSC participants, ADSCs' awareness of requirements, ADSCs' practice of providing AD information, and their associations with the percentage of participants with ADs. METHODS: Using the 2016 National Study of Long-Term Care Providers, analyses included 3,305 ADSCs that documented ADs in participants' files. Bivariate and linear regression analyses were conducted. RESULTS: Nine states had a requirement to provide AD information. About 80.8% of ADSCs provided AD information and 41.3% of participants had documented ADs. There were significant associations between state requirements, awareness, and providing information with AD prevalence. State requirement was mediated by awareness. DISCUSSION: This study found many ADSCs provided AD information, and ADSCs that thought their state had a requirement and provided information was associated with AD prevalence, regardless of state requirements.

Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review.

BACKGROUND/OBJECTIVES: Advance care planning (ACP) has shown benefit in some, but not all, studies. It is important to understand the utility of ACP. We conducted a scoping review to identify promising interventions and outcomes. DESIGN: Scoping review. MEASUREMENTS: We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for ACP randomized controlled trials from January 1, 2010, to March 3, 2020. We used standardized Preferred Reporting Items for Systematic Review and Meta-Analyses methods to chart study characteristics, including a standardized ACP Outcome Framework: Process (e.g., readiness), Action (e.g., communication), Quality of Care (e.g., satisfaction), Health Status (e.g., anxiety), and Healthcare Utilization. Differences between arms of P < .05 were deemed positive. RESULTS: Of 1,464 articles, 69 met eligibility; 94% were rated high quality. There were variable definitions, age criteria (≥18 to ≥80 years), diseases (e.g., dementia and cancer), and settings (e.g., outpatient and inpatient). Interventions included facilitated discussions (42%), video only (20%), interactive, multimedia (17%), written only (12%), and clinician training (9%). For written only, 75% of primary outcomes were positive, as were 69% for multimedia programs; 67% for facilitated discussions, 59% for video only, and 57% for clinician training. Overall, 72% of Process and 86% of Action outcomes were positive. For Quality of Care, 88% of outcomes were positive for patient-surrogate/clinician congruence, 100% for patients/surrogate/clinician satisfaction with communication, and 75% for surrogate satisfaction with patients' care, but not for goal concordance. For Health Status outcomes, 100% were positive for reducing surrogate/clinician distress, but not for patient quality of life. Healthcare Utilization data were mixed. CONCLUSION: ACP is complex, and trial characteristics were heterogeneous. Outcomes for all ACP interventions were predominantly positive, as were Process and Action outcomes. Although some Quality of Care and Health Status outcomes were mixed, increased patient/surrogate satisfaction with communication and care and decreased surrogate/clinician distress were positive. Further research is needed to appropriately tailor interventions and outcomes for local contexts, set appropriate expectations of ACP outcomes, and standardize across studies.

Public Perceptions of Advance Care Planning, Palliative Care, and Hospice: A Scoping Review.

Background: Although access to advance care planning (ACP), palliative care, and hospice has increased, public attitudes may still be barriers to their optimal use. Purpose: To synthesize empirical research from disparate sources that describes public perceptions of ACP, palliative care, and hospice in ways that could inform public messaging. Data Sources: Searches of PubMed and other databases were made from January 2011 to January 2020. Study Selection: Studies reporting survey or interview data with the public that asked specifically about awareness and attitudes toward ACP, palliative care, or hospice were included. Data Extraction and Synthesis: Two reviewers independently screened citations, read full texts, and performed data abstraction. Twelve studies met inclusion criteria and included >9800 participants. For ACP, 80% to 90% of participants reported awareness, and a similar proportion considered it important, but only 10% to 41% reported having named a proxy or completed a written document. For palliative care, 66% to 71% of participants reported no awareness of palliative care, and those who reported awareness often conflated it with end-of-life care. However, after being prompted with a tested definition, 95% rated palliative care favorably. For hospice, 86% of participants reported awareness and 70% to 91% rated it favorably, although 37% held significant misconceptions. Limitations: A limited number of studies met inclusion criteria, and some were published in nonpeer reviewed sources. The studies reflect public perceptions pre-COVID-19. Conclusion: Consumer perceptions of ACP, palliative care, and hospice each have a distinct profile of awareness, perceptions of importance, and reports of action taking, and these profiles represent three different challenges for public messaging.

Older Adults without Desired Surrogates in a Nationally Representative Sample.

BACKGROUND/OBJECTIVES: Little is known about older adults who have intact capacity but do not have a desired surrogate to make decisions if their capacity becomes impaired. DESIGN: Cross-sectional study of a nationally representative sample. SETTING: National Social Life, Health, and Aging Project (NSHAP), 2005-2006. PARTICIPANTS: Community-dwelling older adults without known cognitive impairment, aged 57 to 85, interviewed as part of NSHAP (n = 2,767). MEASUREMENTS: We examined demographic, medical, and social connectedness characteristics associated with answering "no" to this question: "Do you have someone who you would like to make medical decisions for you if you were unable, as for example if you were seriously injured or very sick?" Because many states permit nuclear family to make decisions for persons with no legally appointed health care agent, we used logistic regression to identify factors associated with individuals who were ill suited to this paradigm in the sense that they had nuclear family but did not have a desired surrogate. RESULTS: Among NSHAP respondents, 7.5% (95% confidence interval = 6.4-8.7) did not have a desired surrogate. Nearly 90% of respondents without desired surrogates had nuclear family. Compared with respondents with desired surrogates, those without desired surrogates had lower indicators of social connectedness. On average, however, they had four confidants, approximately 70% socialized at least monthly, and more than 90% could discuss their health with a confidant. Among respondents who had nuclear family, few characteristics distinguished those with and without desired surrogates. CONCLUSION: Nearly 8% of older adults did not have a desired surrogate. Most had nuclear family and were not socially disconnected. Older adults should be asked explicitly about a desired surrogate, and strategies are needed to identify surrogates for those who do not have family or would not choose family to make decisions for them.

Changes in Advance Care Planning for Nursing Home Residents During the COVID-19 Pandemic.

OBJECTIVE: Describe the care preference changes among nursing home residents receiving proactive Advance Care Planning (ACP) conversations from health care practitioners during the COVID-19 pandemic. DESIGN: Retrospective chart review. SETTING AND PARTICIPANTS: Nursing home residents (n = 963) or their surrogate decision makers had at least 1 ACP conversation with a primary health care practitioner between April 1, 2020, and May 30, 2020, and made decisions of any changes in code status and hospitalization preferences. METHODS: Health care practitioners conducted ACP conversations proactively with residents or their surrogate decision makers at 15 nursing homes in a metropolitan area of the southwestern United States between April 1, 2020, and May 30, 2020. ACP conversations reviewed code status and goals of care including Do Not Hospitalize (DNH) care preference. Resident age, gender, code status, and DNH choice before and after the ACP conversations were documented. Descriptive data analyses identified significant changes in resident care preferences before and after ACP conversations. RESULTS: Before the most recent ACP discussion, 361 residents were full code status and the rest were Out of Hospital Do Not Resuscitate (DNR). Of the individuals with Out of Hospital DNR, 188 residents also chose DNH. After the ACP conversation, 88 residents opted to change from full code status to Out of Hospital DNR, thereby increasing the percentage of residents with Out of Hospital DNR from 63% to 72%. Almost half of the residents decided to keep or change to the DNH care option after the ACP conversation. CONCLUSION AND IMPLICATIONS: Proactive ACP conversations during COVID-19 increased DNH from less than a quarter to almost half among the nursing home residents. Out of Hospital DNR increased by 9%. It is important for all health care practitioners to proactively review ACP with nursing home residents and their surrogate decision makers during a pandemic, thereby ensuring care consistent with personal goals of care and avoiding unnecessary hospitalizations.

The Association of Spanish Language Preference with Advance Directive Completion.

BACKGROUND/OBJECTIVES: Hispanics have lower advance directive (AD) completion than non-Hispanic Whites. Few studies have assessed the role of language preference in end-of-life planning. We investigated whether language preference and needing an interpreter affected AD completion among older adults in an integrated health system. DESIGN: Retrospective cohort investigation of electronic medical records. SETTING: Northern California integrated health system. PARTICIPANTS: A total of 620,948 Hispanic and non-Hispanic White patients, aged 55 years and older, between January 1, 2013, and December 31, 2017. MEASUREMENTS: Descriptive statistics and bivariate analysis were performed to compare AD completion among non-Hispanic Whites, Hispanics, and Hispanic subgroups by language preference (English speaking, Spanish speaking, and needed interpreter). We conducted multivariable logistic regression to determine the relationship between language preference and having an AD while controlling for demographic, clinical, and utilization factors. RESULTS: We found 20.3% of non-Hispanic Whites (n = 512,577) and 10.9% of Hispanics (n = 108,371) had completed an AD. Among Hispanics, after controlling for demographic, clinical, and utilization factors, compared with Spanish speakers requiring an interpreter, English speakers had nearly two-fold increased odds of completing an AD (adjusted odds ratio (aOR) = 2.6; 95% confidence interval (CI) = 2.4-2.9), whereas Spanish speakers not requiring an interpreter had 20% increased odds (aOR = 1.2; 95% CI = 1.1-1.3). Additional predictors of successful AD completion were being female, being older, having more comorbidities, having more hospital and emergency department visits, and having higher socioeconomic status. There were no differences associated with primary care provider characteristics. CONCLUSION: These findings indicate the need for a tailored outreach to Hispanics, particularly among those subgroups who require the need of an interpreter, to reduce AD completion disparities.

Improving Patient Preparedness and Confidence in Discussing Advance Directives for End-of-Life Care with Health Care Providers in the United States and Japan.

BACKGROUND: The low completion rate of advance directives (ADs) has received attention in Japan and the United States, as policy makers and health care professionals face aging populations with multiple comorbidities. Among the barriers to AD planning, cultural values and attitudes appear to be particularly influential. A comparison of culturally distinct societies provides a deeper understanding of these barriers. Through such an approach, this study identifies strategies for increasing AD planning among late-middle-age Japanese and US individuals. METHODS: After giving informed consent for the Institutional Review Board-approved study, Japanese and US respondents (45-65 y; 50% female) without ADs completed a language-appropriate online survey. Participants were asked to review a decision aid as part of a scenario-based physician consultation regarding artificial nutrition and hydration (ANH). Hypotheses were analyzed using multigroup structural equation modeling. RESULTS: Important similarities were identified across the 2 groups. After reviewing the decision aid, both samples strongly preferred "no ANH." Respondents who strongly valued either self-reliance or interpersonal relationships experienced greater preparedness for AD planning. In both countries, greater decision preparedness and positive death attitude predicted greater confidence to discuss care options with a provider. Finally, cultural values predicted preference for family participation: respondents with a strong interdependent self-concept desired more family involvement, whereas high independents preferred less. CONCLUSIONS: Findings indicate the importance of documenting care preferences and accounting for individual differences. To increase AD adoption, providers should identify patient segments likely to benefit most from the interventions. Targeting individuals in both countries who value self-reliance and interpersonal relationships appears to be a good place to begin. Such individuals can be identified clinically through administration of validated measures used in this study.

Prevalence and factors associated with advanced care directives in a motor neuron disease multidisciplinary clinic in Australia.

OBJECTIVES: Motor neuron disease (MND) is a neurodegenerative disorder leading to functional decline and death. Multidisciplinary MND clinics provide an integrated approach to management and facilitate discussion on advanced care directives (ACDs). The study objectives are to analyse (1) the prevalence of ACD in our MND clinic, (2) the relationship between ACD and patient demographics and (3) the relationship between ACD decision-making and variables such as NIV, PEG, hospital admissions and location of death. METHODS: Using clinic records, all patients who attended the MND clinic in Liverpool Hospital between November 2014 and November 2019 were analysed. Data include MND subtypes, symptom onset to time of diagnosis, time of diagnosis to death, location and reason of death. ACD prevalence, non-invasive ventilation (NIV) and percutaneous endoscopic gastrostomy (PEG) requirements were analysed. RESULTS: There were 78 patients; M:F=1:1. 44 (56%) patients were limb onset, 28 (36%) bulbar onset, 4 primary lateral sclerosis and 2 flail limb syndrome presentations. 27% patients completed ACDs, while 32% patients declined ACDs. Patients born in Australia or in a majority English-speaking country were more likely to complete ACDs compared to those born in a non-English-speaking country. There was no significant correlation between ACD completion and age, gender, MND subtype, symptom duration, NIV, PEG feeding, location of death. CONCLUSION: One-quarter of patients completed ACDs. ACDs did not correlate with patient age, gender, MND subtype and symptom duration or decision-making regarding NIV, PEG feeding or location of death. Further studies are needed to address factors influencing patients' decisions regarding ACDs.

Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment.

BACKGROUND: There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists. METHODS: We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients' characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD). RESULTS: A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p < 0.001). High inter-intensivist variability did not change with ADs (RSD: 0.56 (round 1) vs 0.46 (round 2), p = 0.84). Inter-intensivist agreement on DFLSTs was weak with ADs (intra-class correlation coefficient: 0.28). No factor associated with DFLSTs was identified. A qualitative analysis of ADs showed focus on end-of-life wills, unwanted things and fear of pain. CONCLUSIONS: ADs increased the DFLST rate but did not reduce variability between the intensivists. In the decision-making process using ADs, the intensivist's decision took priority. Further research is needed to improve the matching of the physicians' decision with the patient's wishes. Trial registration ClinicalTrials.gov Identifier: NCT03013530. Registered 6 January 2017; https://clinicaltrials.gov/ct2/show/NCT03013530 .

Lugar de la muerte de las personas tributarias de recibir cuidados paliativos en las Illes Balears / Place of death of people candidate to recive palliative care in the Balearic Islands

OBJETIVO: Describir dónde fallecen las personas tributarias de recibir atención por servicios específicos de cuidados paliativos en la Comunidad Autónoma de les Illes Balears (CAIB) en los años 2015 y 2016. MÉTODO: Estudio descriptivo. Sujetos: personas fallecidas en la CAIB por causas susceptibles de requerir atención paliativa prestada por los servicios específi cos de CP. VARIABLES: lugar de fallecimiento, sector sanitario, causa, sexo y edad. Fuentes: registro de mortalidad de la CAIB y memorias de actividad de los Equipos de Soporte de Atención Domiciliaria y de la Unidad de Cuidados Paliativos Pediátricos del Hospital Son Espases. RESULTADOS: En 2015 fallecieron en el domicilio 852 personas, mientras que en el año 2016 fueron 837. Representan el 31,2 y el 28,9 %, respectivamente, del total de fallecidos tributarios de recibir cuidados paliativos específicos. El número de personas que fallecen en el domicilio es distinto entre los sectores sanitarios de las islas con porcentajes que oscilan entre el 20,6 y el 48 %. También se han hallado diferencias en función del sexo de las personas fallecidas en domicilio, siendo menor en los hombres que en las mujeres. CONCLUSIONES: Los porcentajes de fallecidos en domicilio en CAIB se encuentran alejados de las preferencias manifestadas en los estudios revisados. Existe variabilidad entre los sectores sanitarios de la Comunidad. Se han reducido los porcentajes de muerte en domicilio entre los años 2015 y 2016. Se identifi can diferencias en función del sexo y de las patologías analizadas. Necesitamos avanzar en la disponibilidad de estándares

OBJECTIVE: To describe where people candidate to receive specific palliative care (PC) services died in the autonomous community of the Balearic Islands (CAIB) from 2015 through 2016. METHOD: This was a descriptive study. Subjects: people who died in the CAIB from causes susceptible to requiring palliative care by specific PC services. VARIABLES: place of death, health care sector, cause, sex, and age. Sources: CAIB death registry and activity reports by home care suport teams (ESAD) and the pediatric palliative care unit (PPCUN) at Hospital Son Espases. RESULTS: In 2015 a total of 852 patients died in their homes, whereas in 2016 the number of home deaths was 837. These represent 31.2 % and 28.9 % of all deaths in patients candidate to receive specific palliative care, respectively. The number of patients who die in their homes varies among health care sectors in the Islands, with percentages oscillating between 20.6 % and 48 %. Differences were also found according to the gender of those who died in their homes, with numbers being lower for men as compared to women. CONCLUSIONS: The percentages of home deaths in the CAIB are far removed from the preferences reported in the studies reviewed. There is variability among health care sectors in our autonomous community. Home death percentages decreased from 2015 to 2016. Differences may be identified according to gender and health condition. We need to move forward to having some standards available

¿Conocen los profesionales de cuidados intensivos el documento de voluntades anticipadas? Revisión crítica / Are palliative care proffesionals aware of the advanced care planning document? Critical review

JUSTIFICACIÓN: Las instrucciones previas o documento de voluntades anticipadas (IP/DVA) constituyen un conjunto de documentos en los que el paciente puede dejar constancia de cómo desea morir o ser tratado al final de su vida, con el fin de que su voluntad sea respetada. En 1998 surgió una nueva corriente, Advance Care Planning (Planificación Anticipada de las Decisiones). En ella, el DVA aparece como una herramienta, resultado final de un amplio proceso de comunicación que exige a los profesionales sanitarios una formación acorde para proporcionar una mejor atención sanitaria al final de la vida. A este respecto, son varios los estudios que muestran que una inadecuada formación en los cuidados al final de la vida, especialmente en las unidades de cuidados intensivos (UCI), dificulta las habilidades y actitudes en la comunicación, los cuidados y el respeto del DVA con todas las medidas que contempla y, en definitiva, dificulta mantener la dignidad en el proceso de la muerte del paciente. OBJETIVO: Analizar la competencia (conocimientos, habilidades y actitudes) de médicos y enfermeras de las UCI de la Comunidad de Madrid sobre las IP o DVA. DISEÑO: Estudio observacional, descriptivo y transversal. LUGAR Y PERÍODO: Nueve hospitales de la Comunidad de Madrid, entre octubre y diciembre de 2010. PARTICIPANTES: Se encuestó a una muestra de conveniencia cuyos criterios de inclusión fueron todos los médicos y enfermeras de las UCI de adultos de los nueve hospitales. INTERVENCIÓN: Cuestionario ad hoc estructurado, anónimo, autocumplimentado, con variables dicotómicas y escala de tipo Likert. RECOGIDA DE DATOS Y ANÁLISIS: Las variables estudiadas fueron: sociodemográficas, de conocimientos, habilidades y actitudes. Para la entrega de los cuestionarios se contactó con las supervisoras de las unidades y jefes de servicio, se hizo una charla informativa, se colgaron carteles informativos y se repartieron los cuestionarios a través de los investigadores y personas de enlace. Para la recogida de las encuestas se dispuso de urnas ubicadas en las unidades. La entrega de formularios se realizó mediante consentimiento informado previo y el estudio fue aprobado por el Comité de Ética e Investigación Clínica del Hospital Clínico San Carlos de Madrid. as variables cualitativas se describieron mediante frecuencias absolutas y relativas porcentuales de sus categorías, y se buscaron asociaciones con la prueba de ji cuadrado o el test exacto de Fisher. En las variables objeto de análisis se calculó su intervalo de confianza para un error a del 5 %, a través del programa estadístico SPSS V. 18.0. RESULTADOS: Se entregaron 649 encuestas en total y se recogieron 331 al terminar el periodo de recepción (3 meses). La tasa de respuesta fue del 51 %. De las características sociodemográficas destaca que el 73,4 % (243) de los profesionales eran mujeres y el 67,2 % (222) con más de 31 años; del total, el 20,5 % (68) eran médicos y el 79,5 % (263) profesionales de enfermería. Los resultados obtenidos con relación a los conocimientos muestran que el 64,4 % de los encuestados afirma no conocer los diferentes documentos que existen para expresar últimas voluntades. Con relación a las medidas concretas que contemplan las IP, como son la limitación del esfuerzo terapéutico, los cuidados paliativos, la donación de órganos, el rechazo a la obstinación terapéutica y la asignación de un representante legal, tan solo el 9,7 % de los profesionales las conocían todas. El 82,8 % opinaba que el DVA es un instrumento útil para los profesionales en la toma de decisiones. El 50,2 % opinaba que los DVA no se respetan. El 85,3 % de los médicos respetaría el DVA de un paciente en caso de urgencia vital, frente al 66,2 % de las enfermeras (p = 0,007). Solo el 19,1 % de los médicos y el 2,3 % de las enfermeras conocían si los pacientes que llevaban a su cargo poseían un DVA (p < 0,001). CONCLUSIONES: Aunque los profesionales sanitarios muestran conocimientos escasos sobre las IP, presentan una actitud favorable hacia su utilidad. Sin embargo, la mayoría no conocen si los pacientes que están a su cargo poseen un DVA e incluso algunos profesionales, a pesar de conocerlo, en caso de urgencia vital no lo respetarían. Se hace necesaria una mayor formación sobre las IP

Conflicting Orders in Physician Orders for Life-Sustaining Treatment Forms.

BACKGROUND/OBJECTIVES: Many older persons with chronic illness use Physician Orders for Life-Sustaining Treatment (POLST) to document portable medical orders for emergency care. However, some POLSTs contain combinations of orders that do not translate into a cohesive care plan (eg, cardiopulmonary resuscitation [CPR] without intensive care, or intensive care without antibiotics). This study characterizes the prevalence and predictors of POLSTs with conflicting orders. DESIGN: Retrospective cohort study. SETTING: Large academic health system. PARTICIPANTS: A total of 3,123 POLST users with chronic life-limiting illness who died between 2010 and 2015 (mean age = 69.7 years). MEASUREMENTS: In a retrospective review of all POLSTs in participants' electronic health records, we describe the prevalence of POLSTs with conflicting orders for cardiac arrest and medical interventions, and use clustered logistic regression to evaluate potential predictors of conflicting orders. We also examine the prevalence of conflicts between POLST orders for antibiotics and artificial nutrition with orders for cardiac arrest or medical interventions. RESULTS: Among 3,924 complete POLSTs belonging to 3,123 decedents, 209 (5.3%) POLSTs contained orders to "attempt CPR" paired with orders for "limited interventions" or "comfort measures only"; 745/3169 (23.5%) POLSTs paired orders to restrict antibiotics with orders to deliver non-comfort-only care; and, 170/3098 (5.5%) POLSTs paired orders to withhold artificial nutrition with orders to deliver CPR or intensive care. Among POLSTs with orders to avoid intensive care, orders to attempt CPR were more likely to be present in POLSTs completed earlier in the patient's illness course (adjusted odds ratio = 1.27 per twofold increase in days from POLST to death; 95% confidence interval = 1.18-1.36; P < .001). CONCLUSION: Although most POLSTs are actionable by clinicians, 5% had conflicting orders for cardiac arrest and medical interventions, and 24% had one or more conflicts between orders for cardiac arrest, medical interventions, antibiotics, and artificial nutrition. These conflicting orders make implementation of POLST challenging for clinicians in acute care settings.

Early Comfort Care Following Operative Intervention for Traumatic Injury.

BACKGROUND: Several studies have described the population of adult trauma patients who undergo withdrawal of life-sustaining treatments (WLST); however, no study has looked specifically at trauma patients who undergo WLST following surgery. METHODS: This was a retrospective chart review of all trauma patients who underwent surgery at our trauma center between January 1 and December 31, 2017. Demographics were collected along with injury patterns and advance directives. Charts of all patients who died or who were discharged to hospice were analyzed to determine whether WLST occurred. Statistics included Fisher's exact test and Mann-Whitney U test. RESULTS: Three thousand and twenty-five adult trauma patients received care and 1495 (49.4%) had operations. Thirty (2.0%) patients underwent WLST, 15 (50.0%) of whom died in the hospital and 15 (50.0%) of whom were discharged to hospice. Twenty-six (86.7%) patients had a palliative care consult and 12 (40.0%) had prior advance directives. The most common injuries were femur fractures and subdural hematomas. Adjusting for age, white race, and age-adjusted CCI, femur fracture patients had, on average, 8.8 more hours between presentation and surgery (95% CI 2.1-15.4, P = .01) and 39 fewer hours between surgery and WLST (95% CI -107-29, P = .26) than traumatic brain injury patients. DISCUSSION: The short time between surgery and WLST in this cohort of patients may demonstrate that surgery was not aligned with patients' goals of care. A patient-centered approach that includes surgeon-driven palliative care discussions may help avoid nonbeneficial surgery in the last few days of life.

[Pulmonologist perceptions and practices of palliative care for people with chronic obstructive pulmonary disease]. / Perceptions et pratiques pneumologiques des soins palliatifs chez les patients atteints de bronchopneumopathie chronique obstructive.

INTRODUCTION: Numerous studies about poor communication and altered quality of life of patients with chronic obstuctive pulmonary disease (COPD) lead to the conclusion that overall palliative management of COPD remains to be improved. The aim of this study was to describe pulmonologists' practice of palliative care for COPD patients in order to identify obstacles to it. MATERIAL AND METHOD: A survey was sent to all pulmonologists whose email appeared in the 2017 French-language Respiratory Medicine Society's directory. RESULTS: A total of 294 responses were obtained, among which 287 were analysed. Overall, 81.6% of the pulmonologists said that they identify a distinct palliative phase from "sometimes to often" in the care of COPD patients. When not identified, the most common reason given (68.8%) was the difficulty of defining when to start palliative care. Aspects of the palliative approach, which were considered the most problematic for pulmonologists, were the discussion of end of life care, and the impression that COPD patients have a low demand for information. 31% of pulmonologists reported that they gathered information about patients' wishes to undergo resuscitation and endotracheal intubation in 61 % to 100% of patients who they judged to have the most severe disease. CONCLUSION: Uncertainty as to when to begin a palliative approach for COPD patients and perceptions around communication in chronic diseases appear to be the main obstacles to a palliative approach.

Cardiopulmonary resuscitation and endotracheal intubation decisions for adults with advance care directive and resuscitation plans in the emergency department.

BACKGROUND: Emergency departments routinely offer cardiopulmonary resuscitation and endotracheal intubation to patients in resuscitative states. With increasing longevity and prevalence of chronic conditions in Australia, there has been growing need to uptake and implement advance care directives and resuscitation plans. This study investigates the frequency of the presence of advance care directives and resuscitation plans and its utilisation in cardiopulmonary and endotracheal intubation decision making. METHODS: Retrospective audit of electronic patients' medical records aged ≥65 years presenting over a 3-month period. Data collected included demographics, triage categories, advance care directive and/or resuscitation plans/orders status. RESULTS: A total of 6439 patients were included representing 29% of the total patient population during the study period. Participants were randomly selected (N = 300); mean age was 78.7 (±8.1) years. An advance care directive was present in only 8% and one in three patients (37%) had a previous resuscitation plan/order. Senior consultant was present at the department for consultation by junior doctors for most of the patients (82%). Acknowledgment of either advance care directive or resuscitation plans/orders in clinical notes was only 9.5% (n = 116). CONCLUSION: Advance care directive prevalence was low with resuscitation plans/orders being more common. However, clinician acknowledgement was infrequent for both.