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1.
Intern Med J ; 50(8): 918-923, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32881275

RESUMO

The novel Coronavirus disease 2019 (COVID-19) outbreak has led to rapid and profound changes in healthcare system delivery and society more broadly. Older adults, and those living with chronic or life-limiting conditions, are at increased risk of experiencing severe or critical symptoms associated with COVID-19 infection and are more likely to die. They may also experience non-COVID-19 related deterioration in their health status during this period. Advance care planning (ACP) is critical for this cohort, yet there is no coordinated strategy for increasing the low rates of ACP uptake in these groups, or more broadly. This paper outlines a number of key reasons why ACP is an urgent priority, and should form a part of the health system's COVID-19 response strategy. These include reducing the need for rationing, planning for surges in healthcare demand, respecting human rights, enabling proactive care coordination and leveraging societal change. We conclude with key recommendations for policy and practice in the system-wide implementation of ACP, to enable a more ethical, coordinated and person-centred response in the COVID-19 context.


Assuntos
Planejamento Antecipado de Cuidados , Infecções por Coronavirus , Assistência à Saúde , Pandemias , Pneumonia Viral , Planejamento Antecipado de Cuidados/ética , Planejamento Antecipado de Cuidados/organização & administração , Fatores Etários , Austrália/epidemiologia , Betacoronavirus , Deterioração Clínica , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Estado Terminal/terapia , Assistência à Saúde/organização & administração , Assistência à Saúde/tendências , Necessidades e Demandas de Serviços de Saúde/tendências , Direitos Humanos , Humanos , Inovação Organizacional , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia
2.
Einstein (Sao Paulo) ; 18: eAO5395, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32935826

RESUMO

OBJECTIVE: To investigate the prevalence of palliative sedation use and related factors. METHODS: An observational study based on data collected via electronic questionnaire comprising 23 close-ended questions and sent to physicians living and working in the state of São Paulo. Demographic data, prevalence and frequency of palliative sedation use, participant's familiarity with the practice and related motivating factors were analyzed. In order to minimize memory bias, questions addressing use frequency and motivating factors were limited to the last year prior to survey completion date. Descriptive statistics were used to summarize data. RESULTS: In total, 20,168 e-mails were sent and 324 valid answers obtained, resulting in 2% adherence. The overall prevalence of palliative sedation use over the course of professional practice was 68%. However, only 48% of respondents reported having used palliative sedation during the last year, primarily to relieve pain (35%). The frequency of use ranged from one to six times (66%) during the study period and the main reason for not using was the lack of eligible patients (64%). Approximately 83% of physicians felt comfortable using palliative sedation but only 26% reported having specific academic training in this field. CONCLUSION: The prevalence of palliative sedation use is high, the primary indication being pain relief. However, frequency of use is low due to lack of eligible patients.


Assuntos
Hipnóticos e Sedativos/uso terapêutico , Cuidados Paliativos/estatística & dados numéricos , Assistência Terminal , Planejamento Antecipado de Cuidados/ética , Humanos , Dor , Cuidados Paliativos/ética , Cuidados Paliativos/métodos , Prevalência
3.
Circ Heart Fail ; 13(9): e007516, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32894988

RESUMO

The coronavirus disease 2019 (COVID-19) pandemic imposed severe restrictions on traditional methods of patient care. During the pandemic, the heart failure program at New York-Presbyterian Hospital in New York, NY rapidly and comprehensively transitioned its care delivery model and administrative organization to conform to a new healthcare environment while still providing high-quality care to a large cohort of patients with heart failure, heart transplantation, and left ventricular assist device. In addition to the widespread adoption of telehealth, our program restructured outpatient care, initiating a shared clinic model and introducing a comprehensive remote monitoring program to manage patients with heart failure and heart transplant. All conferences, including administrative meetings, support groups, and educational seminars were converted to teleconferencing platforms. Following the peak of COVID-19, many of the new changes have been maintained, and the program structure will be permanently altered as a lasting effect of this pandemic. In this article, we review the details of our program's transition in the face of COVID-19 and highlight the programmatic changes that will endure.


Assuntos
Cardiologia/organização & administração , Infecções por Coronavirus/epidemiologia , Assistência à Saúde/organização & administração , Insuficiência Cardíaca/terapia , Pneumonia Viral/epidemiologia , Telemedicina/organização & administração , Planejamento Antecipado de Cuidados , Assistência Ambulatorial/organização & administração , Betacoronavirus , Transplante de Coração , Coração Auxiliar , Humanos , Cidade de Nova Iorque/epidemiologia , Profissionais de Enfermagem , Pandemias , Médicos , Papel Profissional , Grupos de Autoajuda , Telecomunicações , Centros de Atenção Terciária/organização & administração , Comunicação por Videoconferência
4.
Dtsch Med Wochenschr ; 145(16): 1152-1156, 2020 08.
Artigo em Alemão | MEDLINE | ID: mdl-32791551

RESUMO

In view of dramatically increasing patient numbers worldwide in the face of the corona pandemic and scarce resources in intensive care medicine in many countries, some of which are dramatically undersupplied, concerns and fears have spread among the population in Germany. Healthcare workers didn't know how to deal with an overload of the healthcare system. Numerous inquiries from concerned physicians as well as ethics committees prompted the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) together with seven other medical associations to work out a clinical-ethical recommendation on "Decisions on resource allocation in emergency and intensive care in the context of the COVID-19 pandemic".


Assuntos
Infecções por Coronavirus/terapia , Cuidados Críticos/ética , Pandemias/ética , Pneumonia Viral/terapia , Planejamento Antecipado de Cuidados/ética , Cuidados Críticos/estatística & dados numéricos , Medicina de Emergência/ética , Medicina de Emergência/estatística & dados numéricos , Alemanha/epidemiologia , Prioridades em Saúde/ética , Humanos
5.
Jpn J Clin Oncol ; 50(9): 976-989, 2020 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-32761078

RESUMO

Ageing has been recognized as one of the most critically important health-care issues worldwide. It is relevant to Asia, where the increasing number of older populations has drawn attention to the paramount need for health-care investment, particularly in end-of-life care. The advocacy of advance care planning is a mean to honor patient autonomy. Since most East Asian countries are influenced by Confucianism and the concept of 'filial piety,' patient autonomy is consequently subordinate to family values and physician authority. The dominance from family members and physicians during a patient's end-of-life decision-making is recognized as a cultural feature in Asia. Physicians often disclose the patient's poor prognosis and corresponding treatment options to the male, family member rather to the patient him/herself. In order to address this ethical and practical dilemma, the concept of 'relational autonomy' and the collectivism paradigm might be ideally used to assist Asian people, especially older adults, to share their preferences on future care and decision-making on certain clinical situations with their families and important others. In this review article, we invited experts in end-of-life care from Hong Kong, Indonesia, Japan, South Korea, Singapore and Taiwan to briefly report the current status of advance care planning in each country from policy, legal and clinical perspectives. According to the Asian experiences, we have seen different models of advance care planning implementation. The Asian Delphi Taskforce for advance care planning is currently undertaken by six Asian countries and a more detailed, culturally sensitive whitepaper will be published in the near future.


Assuntos
Planejamento Antecipado de Cuidados/normas , Assistência Terminal/normas , Idoso , Envelhecimento , Grupo com Ancestrais do Continente Asiático , Feminino , Humanos , Masculino
8.
Am J Hosp Palliat Care ; 37(11): 985-987, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32720520

RESUMO

CONTEXT: The coronavirus disease 2019 (COVID-19) pandemic laid bare the immediate need for primary palliative care education for many clinicians. Primary care clinicians in our health system reported an urgent need for support in advance care planning and end-of-life symptom management for their vulnerable patients. This article describes the design and dissemination of palliative care education for primary care clinicians using an established curriculum development method. OBJECTIVES: To develop a succinct and practical palliative care toolkit for use by primary care clinicians during the COVID-19 pandemic, focused on 2 key elements: (i) advance care planning communication skills based on the narrative 3-Act Model and (ii) comfort care symptom management at the end of life. RESULTS: The toolkit was finalized through an iterative process involving a team of end-users and experts in palliative care and primary care, including social work, pharmacy, nursing, and medicine. The modules were formatted into an easily navigable, smartphone-friendly document to be used at point of care. The toolkit was disseminated to our institution's primary care network with practices spanning our state. Early feedback has been positive. CONCLUSION: While we had been focused primarily on the inpatient setting, our palliative care team at Johns Hopkins Bayview Medical Center pivoted existing infrastructure and curriculum development expertise to meet the expressed needs of our primary care colleagues during the COVID-19 pandemic. Through collaboration with an interprofessional team including end-users, we designed and disseminated a concise palliative care toolkit within 6 weeks.


Assuntos
Assistência Ambulatorial/métodos , Betacoronavirus , Infecções por Coronavirus/terapia , Cuidados Paliativos/métodos , Pandemias , Pneumonia Viral/terapia , Planejamento Antecipado de Cuidados , Comunicação , Humanos
9.
J Med Internet Res ; 22(8): e21385, 2020 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-32716900

RESUMO

BACKGROUND: Advance care planning is the process of discussing health care treatment preferences based on patients' personal values, and it often involves the completion of advance directives. In the first months of 2020, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began circulating widely in the American state of Colorado, leading to widespread diagnosis of coronavirus disease (COVID-19), hospitalizations, and deaths. In this context, the importance of technology-based, non-face-to-face methods to conduct advance care planning via patient portals has increased. OBJECTIVE: The aim of this study was to determine the rates of use of a web-based advance care planning tool through a health system-based electronic patient portal both before and in the early months of the COVID-19 pandemic. METHODS: In 2017, we implemented web-based tools through the patient portal of UCHealth's electronic health record (EHR) for patients to learn about advance care planning and complete an electronically signed medical durable power of attorney (MDPOA) to legally appoint a medical decision maker. Patients accessing the portal can complete and submit a legally valid MDPOA, which becomes part of their medical record. We collected data on the patients' date of MDPOA completion, use of advance care planning messaging, age, sex, and geographic location during the early phase of the COVID-19 pandemic (December 29, 2019, to May 30, 2020). RESULTS: Over a 5-month period that includes the early phase of the COVID-19 pandemic in Colorado, total monthly use of the advance care planning portal tool increased from 418 users in January to 1037 users in April and then decreased slightly to 815 users in May. The number of MDPOA forms submitted per week increased 2.4-fold after the stay-at-home order was issued in Colorado on March 26, 2020 (P<.001). The mean age of the advance care planning portal users was 47.7 years (SD 16.1), and 2206/3292 (67.0%) were female. Women were more likely than men to complete an MDPOA, particularly in younger age groups (P<.001). The primary use of the advance care planning portal tools was the completion of an MDPOA (3138/3292, 95.3%), compared to sending an electronic message (148/3292, 4.5%). Over 50% of patients who completed an MDPOA did not have a prior agent in the EHR. CONCLUSIONS: Use of a web-based patient portal to complete an MDPOA increased substantially during the first months of the COVID-19 pandemic in Colorado. There was an increase in advance care planning that corresponded with state government shelter-in-place orders as well as public health reports of increased numbers of COVID-19 cases and deaths. Patient portals are an important tool for providing advance care planning resources and documenting medical decision makers during the pandemic to ensure that medical treatment aligns with patient goals and values.


Assuntos
Betacoronavirus , Infecções por Coronavirus , Pandemias , Pneumonia Viral , Adulto , Planejamento Antecipado de Cuidados , Registros Eletrônicos de Saúde , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Portais do Paciente , Estudos Retrospectivos
10.
J Nurs Adm ; 50(7-8): 426-432, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32694441

RESUMO

OBJECTIVE: This quality improvement initiative sought to develop a proactive integrated system approach to advance care planning (ACP) through leadership and colleague engagement. BACKGROUND: Nurse leaders have the capacity to influence the professional competencies of care teams in ACP. Nurse leaders were educated on the importance of ACP, national quality metrics, resources for staff education, and ways to integrate ACP into workflows based on a population management model. METHODS: The project design is a prospective, mixed method design. RESULTS: Nurse leader participants demonstrated a significant increase in knowledge of the importance of ACP and evidence-based models to increase staff engagement and competency. CONCLUSIONS: Study supports nurse leader interventions, promoted engagement of proactive ACP to honor patient choice, and aligns with the mission and vision of one of the largest national Catholic healthcare organizations of being a trusted partner for life.


Assuntos
Planejamento Antecipado de Cuidados , Prestação Integrada de Cuidados de Saúde , Liderança , Enfermeiras Administradoras/educação , Melhoria de Qualidade , Planejamento Antecipado de Cuidados/organização & administração , Planejamento Antecipado de Cuidados/estatística & dados numéricos , Enfermagem Baseada em Evidências , Humanos , Competência Profissional , Estudos Prospectivos
11.
J Am Med Dir Assoc ; 21(7): 943-947, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32674824

RESUMO

Residents in long-term care settings are particularly vulnerable to COVID-19 infections and, compared to younger adults, are at higher risk of poor outcomes and death. Given the poor prognosis of resuscitation outcomes for COVID-19 in general, the specter of COVID-19 in long-term care residents should prompt revisiting goals of care. Visitor restriction policies enacted to reduce the risk of transmission of COVID-19 to long-term care residents requires advance care planning discussions to be conducted remotely. A structured approach can help guide discussions regarding the diagnosis, expected course, and care of individuals with COVID-19 in long-term care settings. Information should be shared in a transparent and comprehensive manner to allay the increased anxiety that families may feel during this time. To achieve this, we propose an evidence-based COVID-19 Communication and Care Planning Tool that allows for an informed consent process and shared decision making between the clinician, resident, and their family.


Assuntos
Infecções por Coronavirus/prevenção & controle , Tomada de Decisão Compartilhada , Planejamento em Saúde/organização & administração , Assistência de Longa Duração/organização & administração , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Instituições de Cuidados Especializados de Enfermagem/organização & administração , Adulto , Planejamento Antecipado de Cuidados/organização & administração , Infecções por Coronavirus/epidemiologia , Feminino , Humanos , Controle de Infecções/organização & administração , Comunicação Interdisciplinar , Masculino , Pessoa de Meia-Idade , Pandemias/estatística & dados numéricos , Equipe de Assistência ao Paciente/organização & administração , Pneumonia Viral/epidemiologia , Desenvolvimento de Programas , Análise de Sobrevida , Estados Unidos
13.
N C Med J ; 81(4): 242-248, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32641457

RESUMO

Advance care planning (ACP) is associated with benefits for seriously ill patients, caregivers, and clinicians. As ACP usage expands, there should be greater emphasis on supporting an ongoing communication process among patients, families, and clinicians, as well as removing barriers for advance directive document completion and retrieval.


Assuntos
Planejamento Antecipado de Cuidados/organização & administração , Objetivos , Diretivas Antecipadas , Cuidadores/psicologia , Comunicação , Humanos , North Carolina , Relações Profissional-Família , Relações Profissional-Paciente
14.
BMJ Open ; 10(7): e040999, 2020 07 14.
Artigo em Inglês | MEDLINE | ID: mdl-32665394

RESUMO

INTRODUCTION: Advance care planning (ACP) is associated with improved health outcomes for patients with cancer, and its absence is associated with unfavourable outcomes for patients and their caregivers. However, older adults do not complete ACP at expected rates due to patient and clinician barriers. We present the original design, methods and rationale for a trial aimed at improving ACP for older patients with advanced cancer and the modified protocol in response to changes brought by the COVID-19 pandemic. METHODS AND ANALYSIS: The Advance Care Planning: Promoting Effective and Aligned Communication in the Elderly study is a pragmatic, stepped-wedge cluster randomised trial examining a Comprehensive ACP Program. The programme combines two complementary evidence-based interventions: clinician communication skills training (VitalTalk) and patient video decision aids (ACP Decisions). We will implement the programme at 36 oncology clinics across three unique US health systems. Our primary outcome is the proportion of eligible patients with ACP documentation completed in the electronic health record. Our secondary outcomes include resuscitation preferences, palliative care consultations, death, hospice use and final cancer-directed therapy. From a subset of our patient population, we will collect surveys and video-based declarations of goals and preferences. We estimate 11 000 patients from the three sites will be enrolled in the study. ETHICS AND DISSEMINATION: Regulatory and ethical aspects of this trial include Institutional Review Board (IRB) approval via single IRB of record mechanism at Dana-Farber Cancer Institute, Data Use Agreements among partners and a Data Safety and Monitoring Board. We plan to present findings at national meetings and publish the results. TRIAL REGISTRATION NUMBER: NCT03609177; Pre-results.


Assuntos
Planejamento Antecipado de Cuidados , Betacoronavirus , Tomada de Decisão Clínica/métodos , Infecções por Coronavirus/prevenção & controle , Comunicação em Saúde/métodos , Neoplasias/terapia , Pandemias/prevenção & controle , Participação do Paciente/métodos , Pneumonia Viral/prevenção & controle , Idoso , Análise por Conglomerados , Humanos , Avaliação de Programas e Projetos de Saúde/métodos , Projetos de Pesquisa , Estados Unidos
15.
Eur Respir J ; 56(3)2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32675211

RESUMO

BACKGROUND: Many people are dying from coronavirus disease 2019 (COVID-19), but consensus guidance on palliative care in COVID-19 is lacking. This new life-threatening disease has put healthcare systems under pressure, with the increased need of palliative care provided to many patients by clinicians who have limited prior experience in this field. Therefore, we aimed to make consensus recommendations for palliative care for patients with COVID-19 using the Convergence of Opinion on Recommendations and Evidence (CORE) process. METHODS: We invited 90 international experts to complete an online survey including stating their agreement, or not, with 14 potential recommendations. At least 70% agreement on directionality was needed to provide consensus recommendations. If consensus was not achieved on the first round, a second round was conducted. RESULTS: 68 (75.6%) experts responded in the first round. Most participants were experts in palliative care, respiratory medicine or critical care medicine. In the first round, consensus was achieved on 13 recommendations based upon indirect evidence and clinical experience. In the second round, 58 (85.3%) out of 68 of the first-round experts responded, resulting in consensus for the 14th recommendation. CONCLUSION: This multi-national task force provides consensus recommendations for palliative care for patients with COVID-19 concerning: advance care planning; (pharmacological) palliative treatment of breathlessness; clinician-patient communication; remote clinician-family communication; palliative care involvement in patients with serious COVID-19; spiritual care; psychosocial care; and bereavement care. Future studies are needed to generate empirical evidence for these recommendations.


Assuntos
Planejamento Antecipado de Cuidados/organização & administração , Infecções por Coronavirus , Cuidados Paliativos , Pandemias , Pneumonia Viral , Sistemas de Apoio Psicossocial , Terapia Respiratória/métodos , Comitês Consultivos , Betacoronavirus/isolamento & purificação , Consenso , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/psicologia , Infecções por Coronavirus/terapia , Europa (Continente) , Humanos , Cuidados Paliativos/métodos , Cuidados Paliativos/organização & administração , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/psicologia , Pneumonia Viral/terapia , Índice de Gravidade de Doença
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