In dubio pro CPR? The Controversial Status of 'Do Not Resuscitate' Imprints on the Human Body - a Swiss Innovation.

'Do not resuscitate' (DNR) imprints on the human body have recently appeared in medical practice. These non-standard DNR orders (e.g., tattoos, stamps, patches) convey the patient's refusal of resuscitation efforts should he be incapable of doing so. The article focuses on such innovative tools to express one's end-of-life wishes. Switzerland provides a unique example, as 'No Cardio-Pulmonary Resuscitation' stamps and patches have been commercialised. The article discusses the challenging legal questions as to the validity of non-standard DNR orders imprinted on the human body. It analyses the obligation of healthcare providers to honour such orders, either as an advance directive or an expression of an individual's presumed wishes, and withhold treatment. Finally, the article addresses the balancing of interests between the presumed wishes of an unconscious patient and his best interests of being resuscitated and potentially staying alive, a dilemma facing healthcare providers in a medical emergency.

Does implementation matter if comprehension is lacking? A qualitative investigation into perceptions of advance care planning in people with cancer.

PURPOSE: While advance care planning holds promise, uptake is variable and it is unclear how well people engage with or comprehend advance care planning. The objective of this study was to explore how people with cancer comprehended advance care plans and examine how accurately advance care planning documentation represented patient wishes. METHODS: This study used a qualitative descriptive design. Data collection comprised interviews and an examination of participants' existing advance care planning documentation. Participants included those who had any diagnosis of cancer with an advance care plan recorded: Refusal of Treatment Certificate, Statement of Choices, and/or Enduring Power of Attorney (Medical Treatment) at one cancer treatment centre. RESULTS: Fourteen participants were involved in the study. Twelve participants were female (86%). The mean age was 77 (range: 61-91), and participants had completed their advance care planning documentation between 8 and 72 weeks prior to the interview (mean 33 weeks). Three themes were evident from the data: incomplete advance care planning understanding and confidence, limited congruence for attitude and documentation, advance care planning can enable peace of mind. Complete advance care planning understanding was unusual; most participants demonstrated partial comprehension of their own advance care plan, and some indicated very limited understanding. Participants' attitudes and their written document congruence were limited, but advance care planning was seen as helpful. CONCLUSIONS: This study highlighted advance care planning was not a completely accurate representation of patient wishes. There is opportunity to improve how patients comprehend their own advance care planning documentation.

Formal procedure to facilitate the decision to withhold or withdraw life-sustaining interventions in a neonatal intensive care unit: a seven-year retrospective study.

BACKGROUND: Neonatal deaths are often associated with the complex decision to limit or withdraw life-sustaining interventions (LSIs) rather than therapeutic impasses. Despite the existence of a law, significant disparities in clinical procedures remain. This study aimed to assess deaths occurring in a Neonatal Intensive Care Unit (NICU) and measure the impact of a traceable Limitation or Withdrawal of Active Treatment (LWAT) file on the treatment of these newborns. METHODS: In this monocentric retrospective study, we reviewed all consecutive neonatal deaths occurring during two three-year periods among patients in the NICU at the North Hospital of Marseille: cohort 1 (from 2009 to 2011 without the LWAT file) and cohort 2 (from 2013 to 2015 after introduction of the LWAT file). Newborns included were: gestational age over 22 weeks, birth weight over 500 g, and admission and death in the same NICU. Deaths were categorized according to the classification described by Verhagen et al.: 1) children who died despite cardiopulmonary resuscitation (CPR) (no withholding nor withdrawing of LSIs), (2) children who died while the ventilator, without CPR (no withdrawing of LSIs, but CPR withheld), (3) children who died after LSIs were withdrawn, or (4) LSIs were withheld. RESULTS: 193 deaths were analyzed: 77 in cohort 1 and 116 in cohort 2. 50% of deaths followed the decision to limit or stop life-sustaining interventions. The mean age at death did not differ between the two cohorts (p = 0.525). An increase in the mortality rate after life-sustaining interventions were withdrawn was observed. The number of multidisciplinary decision meetings was statistically higher in cohort 2 (32.5% versus 55.2% p = 0.002), which were most often prompted due to neurological pathologies, with an increase in parental advice concerning the management of their child (p = 0.026). Even if the introduction of this file did not have an effect on patient age at death, it was significantly associated with a better understanding of end-of-life conditions (p = 0.019), including medication used to sedate and comfort the patient. CONCLUSIONS: Introduction of the LWAT file seems imperative to develop a personalized healthcare strategy for each child and situation.

Documentation of limitation of medical therapy at the time of a rapid response team call.

OBJECTIVES: The aims of the present study were to: (1) describe the documentation process of limitation of medical therapy (LMT) orders at the time of a rapid response team (RRT) call; and (2) compare documented LMT orders not associated with an RRT call (control, Group 1) with LMT orders documented at the time of an RRT call (Group 2). METHODS: A descriptive study, over a 6-month period (February-August 2011), involving the review of the medical records of patients prospectively identified as either Group 1 or Group 2. RESULTS: There were 994 RRT calls; of these, 50 patients (5%) had an LMT order documented by the RRT. A cardiac arrest was the trigger for the RRT for six patients (12%). Patients in Group 1 (n=50) and Group 2 were of similar median age (80.5 vs 78.5 years; P=0.30), LMTs were recorded at a similar time of day (15:30 vs 15:55 hours; P=0.52) and day of the week (weekend: 32% vs 35%; P=0.72). Comparing group 2 with Group 1, the RRT was less likely to document a not-for-resuscitation (NFR; 31 (62%) vs 49 (98%); P<0.01) or a not-for-ICU (NFICU; 18 (36%) vs 41 (82%); P<0.01) order, but more likely to document a not-for-RRT call (NFRRT; 31 (62%) vs 22 (44%); P=0.04) and modified RRT calling criteria (MRRT; 4 (8%) vs 0 (0%); P=0.04) orders. For Group 2 compared with Group 1 orders, involvement of the patient in the decision making process (9 (18%) vs 25 (50%); P<0.01) or the next of kin (29 (58%) vs 45 (90%); P<0.01) was documented less often. CONCLUSIONS: Documentation of LMT orders at the time of an RRT call is less likely to include documented involvement of patients or their next of kin, and is more likely to be an NFRRT or MRRT order. These findings have implications for overall clinical governance. What is known about the topic? RRT are not infrequently involved in documenting LMT orders. What does this paper add? This is the first study in Australasia to look into the timing and circumstances surrounding the issuing of a NFR order during an RRT call. The study findings clarify the type of LMT orders documented by RRT and to what extent patients, their carers and senior medical staff are involved. What are the implications for practitioners? Our findings indicate that, in the setting of a rapid response system, there is a need to consider beyond the narrow interpretation of the NFR order, when a NFRRT may also be appropriate. This will require standardisation of such nomenclature, and training and education of those involved in documenting and interpreting such orders. Equally, it will require a different approach to the discussion with patients and their carers as to what the implications of an NFRRT order are. The findings also have significant implications as to the senior medical oversight of LMT, in particular for RRT, for whom it is their first encounter with such patients. Finally, the findings suggest that consideration be given to better delineating the documentation of the role of nursing staff when setting LMT orders.

Are Canadians providing advance directives about health care and research participation in the event of decisional incapacity?

OBJECTIVE: Advance planning for health care and research participation has been promoted as a mechanism to retain some control over one's life, and ease substitute decision making, in the event of decisional incapacity. Limited data are available on Canadians' current advance planning activities. We conducted a postal survey to estimate the frequency with which Canadians communicate their preferences about health care and research should they become incapacitated. METHOD: We surveyed 5 populations (older adults, informal caregivers, physicians, researchers in aging, and research ethics board members) from Nova Scotia, Ontario, Alberta, and British Columbia. We asked respondents whether they had expressed their preferences regarding a substitute decision maker, health care, and research participation in the event of incapacity. RESULTS: Two out of 3 respondents (62.0%; 95% CI 59.1% to 64.8%) had been advised to communicate their health care preferences in advance. Oral expression of wishes was reported by 69.1% of respondents (95% CI 66.8% to 71.3%), and written expression by 46.7% (95% CI 44.3% to 49.2%). Among respondents who had expressed wishes in advance (orally or in writing), 91.2% had chosen a substitute decision maker, 80.9% had voiced health care preferences, and 19.5% had voiced preferences regarding research participation. Having been advised to communicate wishes was a strong predictor of the likelihood of having done so. CONCLUSIONS: Advance planning has increased over the last 2 decades in Canada. Nonetheless, further efforts are needed to encourage Canadians to voice their health care and research preferences in the event of incapacity. Physicians are well situated to promote advance planning to Canadians.

A call to improve practice concerning cultural sensitivity in advance directives: a review of the literature.

BACKGROUND: The Patient Self Determination Act of 1990 mandates healthcare providers (HCP) to speak with patients about end-of-life preferences and advance directives (AD). HCP work with patients of varying cultures, and standard ADs do not address cultural differences. In order to understand various cultural beliefs, cultural sensitivity is important especially when discussing advance care planning (ACP). AIMS: Individuals from differing ethnic backgrounds are likely to turn to their traditional norms of practice when ill or treatment choices must be made. An AD that addresses varying cultural values and beliefs was sought. METHODS: A comprehensive review of the literature was conducted. Articles selected for review included qualitative and quantitative studies. The evidence was evaluated and synthesized for information related to cultural sensitivity and ADs. FINDINGS: Three common themes emerged related to ACP discussions and culture. Healthcare provider awareness, communication, and education concerning cultural differences and ACP assisted in meeting the needs for end-of-life planning in the current era of increased globalization. Education for HCP on cultural differences and how to lead discussions promoted ACP. IMPLICATION FOR PRACTICE: ADs are an essential part of health care and promote patient-centered care. (HCP) should be able to recognize differing cultural values and beliefs in order to initiate conversations about end of life. Initiating conversations about ACP can be facilitated by using open-ended questions that respect the values and beliefs of various cultures.

National Standards and State Variation in Physician Orders for Life-Sustaining Treatment Forms.

BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is used across the country to document the treatment preferences of seriously ill or frail patients as medical orders. The National POLST Paradigm Task Force maintains consensus-based standards for POLST programs and uses these to determine whether a state POLST program is developing, endorsed, or mature. OBJECTIVES: To evaluate state program form adherence to national standards. DESIGN: Document review. MEASUREMENTS: Forms from endorsed/mature (n = 21) and developing (n = 23) states were compared with national standards to assess adherence to required and optional form elements. RESULTS: Required elements were present on 84% of endorsed/mature state POLST forms and 73% of the developing state POLST forms. Compliance with required elements in endorsed states ranged from 50% to 100%. Three endorsed/mature states (14%) had forms that met all of the required elements fully and 14 (67%) had forms that met the all of the elements fully or partially. CONCLUSIONS: There is variability in adherence to required and optional standards as well as challenges in interpreting and applying existing standards. Although there may be legal and logistical barriers to the existence of a national POLST form, standardization remains an important goal to support patient-centered care.

Compliance with and understanding of advance directives among trainee doctors in the United Kingdom.

AIM: To investigate doctors' response to and understanding of the legal status of advance directives. METHODS: A vignette-based study administered at palliative medicine, oncology, general practice, and geriatric medicine specialist registrar meetings (United Kingdom). Respondents determined the treatment to provide for a patient presenting with a myocardial infarction with or without an advance directive requesting maximum therapy. RESULTS: Response rate 77% (43/56). Twenty-five percent (10/40) of respondents increased the care that they would provide in response to the advance directive (p = 0.004); 77% (33/43) support/strongly support use of advance directives; 51% (22/43) did not know the legal status of advance directives; 44% found that their medical school education was not an important influence on their decision making. CONCLUSIONS: Advance directives requesting treatment can increase the level of care provided by the physician, however, most trainees chose a level of care different from that in the advance directive. Confusion exists among doctors about the legal status of advance directives, which limits their usefulness. Medical education needs to be improved to train doctors to deal with advance directives.

Factores de no adherencia al Programa de atención integral de salud para adolescentes, Santa Ana, El Salvador / Factors of non-adherence to the Comprehensive Health Care Program for Adolescents, Santa Ana, El Salvador

Introducción: La adolescencia se considera una etapa fundamental para el desarrollo del sujeto. Desde el 2015 en El Salvador se instauró un programa de atención integral para el adolescente. Objetivo: Caracterizar los principales factores asociados a la no adherencia al Programa de atención integral de salud para adolescente de 11 a 15 años, del municipio Santa Ana del El Salvador. Métodos: Estudio descriptivo transversal en el primer nivel de atención del municipio de Santa Ana, entre enero y marzo de 2018. Se aplicó un instrumento confeccionado por los autores. La muestra fue de 247 adolescentes que recibieron control e inscripción. Resultados: La mayoría de los adolescentes eran del sexo femenino, el 65,2 por ciento residían en el área rural, el 96 por ciento estudiaba, solo el 32,8 por ciento conocía el programa y de estos lo utilizaban el 48,1 por ciento (15,8 por ciento del total de entrevistados), la vía por la que lo conoció fue el promotor de salud (63 por ciento). Los principales factores relacionados con el no conocimiento del programa fueron; residir en el área urbana, nivel de estudios secundarios, ser estudiante, vivir cerca del centro de salud y no tener promotor de salud. Solo el trabajar resultó significativo (razón de prevalencia 1,71 IC 95 por ciento 1,17-2,51) para no ser adherente. Conclusiones: A pesar de los esfuerzos del Estado, los servicios de salud para adolescente deben ser reorientados de acuerdo con los principios y lineamientos de los documentos regulatorios y el marco legal del país, enfatizando en acciones de promoción de la demanda temprana y prestación de servicios de atención integral(AU)

Introduction: Adolescence is considered a fundamental stage for the development of the individual. Since 2015, a comprehensive health care program for adolescents has been established in El Salvador. Objective: Characterize the main factors associated with non-adherence to the Comprehensive Health Care Program for adolescents aging 11 to 15 years, from Santa Ana municipality, El Salvador. Methods: Cross-sectional descriptive study at the first level of care of Santa Ana municipality, from January to March 2018. An instrument made by the authors was applied. The sample was of 247 adolescents who were controlled and registered. Results: Most adolescents were females, 65.2 percent lived in rural areas, 96 percent were studying, only 32.8 percent knew about the programme and it was being used by 48.1 percent (15.8 percent of all interviewees), and the way they knew about it was by the health promoter (63 percent). The main factors related to not knowing on the program were: living in the urban area, junior high school level, being a student, living near the health center and not having health promoter. Only work was significant (prevalence rate 1.71 CI 95 percent 1.17-2.51) for not being adherent. Conclusions: Despite the efforts of the State, health services for adolescents should be redirected in accordance with the principles and guidelines of the country's regulatory documents and legal framework, emphasizing in actions to promote early demand and provide comprehensive care services(AU)

Investigating Compliance with Standard Precautions During Residency Physicians in Gynecology and Obstetrics.

OBJECTIVES: Physician compliance with standard precautions is important in the specialty of gynecology and obstetrics because of the high frequency of invasive procedures. The current study investigated compliance with standard precautions among resident physicians working in gynecology and obstetrics. METHOD: A cross-sectional study was conducted among resident physicians in gynecology and obstetrics in their first (R1), second (R2) and third (R3) years of residency at a teaching hospital in a city in São Paulo. A structured questionnaire that included demographic and professional aspects and the Standard Precautions Adherence Scale were used to collect data. Statistical analysis was performed using IBM® SPSS version 20. Ethical aspects were considered. RESULTS: Fifty-eight resident physicians participated in the study. Of the enrolled participants, 27 (46.6%) were in R1, 12 (20.7%) were in R2 and 19 (32.8%) were in R3. The standard precautions compliance score was 4.1, which was classified as intermediate. There were no significant differences in the compliance scores of the resident physicians across the three years of residency (H=2.34, p=0.310). CONCLUSION: Compliance with standard precautions among resident physicians was intermediate. Preventive measures in clinical practice are not fully adopted in the specialty of gynecology and obstetrics. More important, many professionals claimed lack of sufficient training in standard precautions in the workplace. Such circumstances should draw the attention of hospital management with regard to occupational health risks.

Code status and resuscitation options in the electronic health record.

AIM: The advance discussion and documentation of code-status is important in preventing undesired cardiopulmonary resuscitation and related end of life interventions. Code-status documentation remains infrequent and paper-based, which limits its usefulness. This study evaluates a tool to document code-status in the electronic health records at a large teaching hospital, and analyzes the corresponding data. METHODS: Encounter data for patients admitted to the Medical Center were collected over a period of 12 months (01-APR-2012-31-MAR-2013) and the code-status attribute was tracked for individual patients. The code-status data were analyzed separately for adult and pediatric patient populations. We considered 131,399 encounters for 83,248 adult patients and 80,778 encounters for 55,656 pediatric patients in this study. RESULTS: 71% of the adult patients and 30% of the pediatric patients studied had a documented code-status. Age and severity of illness influenced the decision to document code-status. Demographics such as gender, race, ethnicity, and proximity of primary residence were also associated with the documentation of code-status. CONCLUSION: Absence of a recorded code-status may result in unnecessary interventions. Code-status in paper charts may be difficult to access in cardiopulmonary arrest situations and may result in unnecessary and unwanted interventions and procedures. Documentation of code-status in electronic records creates a readily available reference for care providers.

National directives on managing 'violent' patients: a critique.

The incidence and nature of patient aggression and violence in health care has been a neglected area of investigation. However, since the 1980s there has been an increase in the amount of research examining the problem of patients who are aggressive and violent in a multitude of health care settings. A critique of three initiatives highlights the problems associated with aggression and violence in healthcare. They fail, however, to make the distinction between aggression and violence, and as aggression is more common, inappropriate, restrictive care for patients will continue at the expense of developing therapeutic relationships.

Family involvement in decision making for people with dementia in residential aged care: a systematic review of quantitative literature.

AIM: Ensuring older adults' involvement in their care is accepted as good practice and is vital, particularly for people with dementia, whose care and treatment needs change considerably over the course of the illness. However, involving family members in decision making on people's behalf is still practically difficult for staff and family. The aim of this review was to identify and appraise the existing quantitative evidence about family involvement in decision making for people with dementia living in residential aged care. METHODS: The present Joanna Briggs Institute (JBI) metasynthesis assessed studies that investigated involvement of family members in decision making for people with dementia in residential aged care settings. While quantitative and qualitative studies were included in the review, this paper presents the quantitative findings. A comprehensive search of 15 electronic databases was performed. The search was limited to papers published in English, from 1990 to 2013. Twenty-six studies were identified as being relevant; 10 were quantitative, with 1 mixed method study. Two independent reviewers assessed the studies for methodological validity and extracted the data using the JBI Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). The findings were synthesized and presented in narrative form. RESULTS: The findings related to decisions encountered and made by family surrogates, variables associated with decisions, surrogates' perceptions of, and preferences for, their roles, as well as outcomes for people with dementia and their families. CONCLUSIONS: The results identified patterns within, and variables associated with, surrogate decision making, all of which highlight the complexity and variation regarding family involvement. Attention needs to be paid to supporting family members in decision making in collaboration with staff.

A qualitative metasynthesis: family involvement in decision making for people with dementia in residential aged care.

AIM: Involving people in decisions about their care is good practice and ensures optimal outcomes. Despite considerable research, in practice family involvement in decision making can be challenging for both care staff and families. The aim of this review was to identify and appraise existing knowledge about family involvement in decision making for people with dementia living in residential aged care. METHODS: The present Joanna Briggs Institute meta-synthesis considered studies that investigate involvement of family members in decision making for people with dementia in residential aged care settings. While quantitative and qualitative studies were included in the review, this article presents the qualitative findings. A comprehensive search of studies was conducted in 15 electronic databases. The search was limited to papers published in English, from 1990 to 2013. Twenty-six studies were identified as relevant for this review; 16 were qualitative papers reporting on 15 studies. Two independent reviewers assessed the studies for methodological validity and extracted the data using the standardized Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). The findings were synthesized using JBI-QARI. RESULTS: The findings related to the decisions encountered and made by family surrogates, family perceptions of, and preferences for, their role/s, factors regarding treatment decisions and the collaborative decision-making process, and outcomes for family decision makers. CONCLUSION: Results indicate varied and complex experiences and multiple factors influencing decision making. Communication and contacts between staff and families and the support available for families should be addressed, as well as the role of different stakeholders in decisions.

Documentation quality of inpatient code status discussions.

CONTEXT: Accurate documentation of inpatient code status discussions (CSDs) is important because of frequent patient care handoffs. OBJECTIVES: To examine the quality of inpatient CSD documentation and compare documentation quality across physician services. METHODS: This was a retrospective study of patients hospitalized between January 1 and June 30, 2011 with a new or canceled do-not-resuscitate (DNR) order at least 24 hours after hospital admission. We developed a chart abstraction tool to assess the documentation of five quality elements: 1) who the DNR discussion was held with, 2) patient goals/values, 3) prognosis, 4) treatment options and resuscitation outcomes, and 5) health care power of attorney (HCPOA). RESULTS: We identified 379 patients, of whom 235 (62%) had a note documenting a CSD. After excluding patients lacking a note from their primary service, 227 remained for analysis. Sixty-three percent of notes contained documentation of who the discussion was held with. Patient goals/values were documented in 43%, discussion of prognosis in 14%, treatment options and resuscitation outcomes in 40%, and HCPOA in 29%. Hospitalists were more likely than residents to document who the discussion was held with (P < 0.001) and patient goals/values (P < 0.001), whereas internal medicine residents were more likely to document HCPOA (P = 0.04). The mean number of elements documented for hospitalists was 2.40, followed by internal medicine residents at 2.07, and non-internal medicine trainees at 1.30 (P < 0.001). CONCLUSION: Documentation quality of inpatient CSDs was poor. Our findings highlight the need to improve the quality of resident and attending CSD documentation.

Factors considered in end-of-life care decision making by health care professionals.

AIM: To explore the importance of factors influencing the end-of-life care decision making of health care professionals (HCPs) in Singapore. METHODS: This cross-sectional survey encompassed facets of patient, family, and HCP-related care considerations. In total, 187 questionnaires were distributed to physicians and nurses and had a response rate of 78.6%. RESULTS: The respondents rated patients' wishes (96.6%), their clinical symptoms (93.9%), and patients' beliefs (91.1%) very high. In all, 94.6% of the HCPs would respect a competent patient's wishes over the family's wishes when goals conflict. However, 59.9% of HCPs would abide by the family's wishes when the patient loses capacity even if the patient's previously expressed wishes are known. CONCLUSION: End-of-life care decision making by HCPs appears largely patient centered, although familial determination still wields significant influence with implications for advance care planning.

End-of-life issues in caring for patients with dementia: the case for palliative care in management of terminal dementia.

The number of people suffering with dementia is increasing in the general population and the trend is projected to continue as people live longer, especially in countries with developed economies. The most common cause of dementia (among the many other causes) is Alzheimer's dementia, which is considered a terminal illness. The disease could eventually lead to death, or death could occur as a consequence of co-morbid physical complications. The problem of end of life (EOL) care for patients suffering from dementia though spoken of and written about, does not get the attention and system support as for example patients suffering from cancer receive. Many reasons have been advanced for the current state of affairs where EOL issues for patients suffering from dementia are concerned. This article attempts to revisit the issues, and the reasons, that may contribute to this. Some guidelines on palliative management in cases of patients suffering from severe dementia exist; the evidence base for these guidelines though is relatively weak. The ethical and legal issues that may influence or impact on the decision to initiate the palliative care pathway in the management of EOL issues for dementia patients in the terminal or end stage of the illness is highlighted. Initiatives by the department of health in England and Wales, and other bodies with interest in dementia issues and palliative care in the United Kingdom to ensure good and acceptable EOL pathways for patients with dementia are mentioned.

Más allá de la orden de no resucitar / Beyond the do-not-resuscitate (DNR) order

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