RESUMEN
BACKGROUND: Many patients live with serious chronic or terminal illnesses. Multicomponent palliative care interventions have been increasingly utilized in patient care; however, it is unclear what is being implemented and who is delivering these interventions. OBJECTIVES: To (1) describe the delivery of multicomponent palliative care interventions, (2) characterize the disciplines delivering care, (3) identify the components being implemented, and (4) analyze whether the number of disciplines or components being implemented are associated with positive outcomes. DESIGN: Systematic review. STUDY SELECTION: English-language articles analyzing multicomponent palliative care interventions. OUTCOMES MEASURED: Delivery of palliative interventions by discipline, components of palliative care implemented, and number of positive outcomes (eg, pain, quality of life). RESULTS: Our search strategy yielded 71 articles, which detailed 64 unique multicomponent palliative care interventions. Nurses (n = 64, 88%) were most often involved in delivering care, followed by physicians (n = 43, 67%), social workers (n = 33, 52%), and chaplains (n = 19, 30%). The most common palliative care components patients received were symptom management (n = 56, 88%), psychological support/counseling (n = 52, 81%), and disease education (n = 48, 75%). Statistical analysis did not uncover an association between number of disciplines or components and positive outcomes. CONCLUSIONS: While there has been growth in multicomponent palliative care interventions over the past 3 decades, important aspects require additional study such as better inclusion of key groups (eg, chronic obstructive pulmonary disease, end-stage renal disease, minorities, older adults); incorporating core components of palliative care (eg, interdisciplinary team, integrating caregivers, providing spiritual support); and developing ways to evaluate the effectiveness of interventions that can be readily replicated and disseminated.
Asunto(s)
Enfermedad Crónica/terapia , Cuidados Paliativos/organización & administración , Enfermo Terminal , Clero , Personal de Salud/organización & administración , Cuidados Paliativos al Final de la Vida/organización & administración , Humanos , Planificación de Atención al Paciente/organización & administración , Grupo de Atención al Paciente/organización & administración , Educación del Paciente como Asunto/organización & administración , Calidad de Vida , Religión , Trabajadores SocialesRESUMEN
OBJECTIVES: Although postdischarge outpatient follow-up appointments after a hospitalization for heart failure represent a potentially effective strategy to prevent heart failure readmissions, patterns of scheduled follow-up appointments upon discharge are poorly described. We aimed to characterize real-world patterns of scheduled follow-up appointments among adult patients with heart failure upon hospital discharge. PATIENTS AND METHODS: This was a retrospective cohort study performed at a large urban academic center in the United States among adults hospitalized with a principal diagnosis of congestive heart failure between January 1, 2013, and December 31, 2014. Patient demographics, administrative data, clinical parameters, echocardiographic indices, and scheduled postdischarge outpatient follow-up appointments were collected. RESULTS: Of the 796 patients hospitalized for heart failure, just over half of the cohort had a scheduled follow-up appointment upon discharge. Follow-up appointments were less likely among patients who were white and had heart failure with preserved ejection fraction and more likely among patients with Medicaid and chronic obstructive pulmonary disease. In an adjusted multivariable regression model, age ≥65 years was inversely associated with a scheduled follow-up appointment upon hospital discharge, despite higher rates of several cardiovascular and noncardiovascular comorbidities. CONCLUSION: Just half of the patients discharged home following a hospitalization for heart failure had a follow-up appointment scheduled, representing a missed opportunity to provide a recommended care transition intervention. Despite a greater burden of both cardiovascular and noncardiovascular comorbidities, older adults (age ≥65 years) were less likely to have a follow-up appointment scheduled upon discharge compared with younger adults, revealing a disparity that warrants further investigation.
Asunto(s)
Citas y Horarios , Insuficiencia Cardíaca/epidemiología , Cooperación del Paciente/estadística & datos numéricos , Alta del Paciente , Readmisión del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Comorbilidad , Femenino , Hospitalización , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pacientes Ambulatorios , Estudios Retrospectivos , Estados UnidosRESUMEN
BACKGROUND: Substantial agreement has been achieved on research priorities in palliative care over the past 15 years, as evidenced by consensus conferences and systematic reviews. Despite the presence of a widely endorsed research agenda, however, addressing the gaps in scientific knowledge has progressed slowly, suggesting that researchers face significant obstacles to conducting high-quality research on the most pressing topics in the field. OBJECTIVE: To systematically identify barriers to improved and expanded palliative care research as reported by researchers. DESIGN: Semistructured telephone interviews to solicit barriers to research in palliative care. SETTING/SUBJECTS: A purposive, interdisciplinary sample of 61 leading researchers in palliative care. MEASUREMENTS: Interviews were transcribed and analyzed using standard qualitative methods. RESULTS: Respondents named five barriers impeding progress: (1) funding, (2) institutional capacity, (3) researcher workforce, (4) challenges related to the topic and population (e.g., attrition, heightened human subjects protections), and (5) public and professional misunderstanding of palliative care and aversion to topics related to serious illness and end-of-life. CONCLUSIONS: Research in palliative care is being held back by significant barriers that require the attention of institutions and funders. The consensus within the interdisciplinary sample indicates that concentrated effort to address barriers related to funding and researcher workforce could facilitate progress on established research priorities. More research is needed on viable strategies for overcoming the identified barriers.
Asunto(s)
Investigación sobre Servicios de Salud/normas , Cuidados Paliativos , Investigadores , Investigación sobre Servicios de Salud/economía , Humanos , Entrevistas como Asunto , Investigación Cualitativa , Investigadores/psicología , Apoyo a la Investigación como Asunto , Estados UnidosRESUMEN
BACKGROUND: Effective communication is essential for shared decision making with families of critically ill patients in the intensive care unit (ICU), yet there is limited evidence on effective strategies to teach these skills. OBJECTIVE: The study's objective was to pilot test an educational intervention to teach internal medicine interns skills in discussing goals of care and treatment decisions with families of critically ill patients using the shared decision making framework. DESIGN: The intervention consisted of a PowerPoint online module followed by a four-hour workshop implemented at a retreat for medicine interns training at an urban, academic medical center. MEASUREMENTS: Participants (N=33) completed post-intervention questionnaires that included self-assessed skills learned, an open-ended question on the most important learning points from the workshop, and retrospective pre- and post-workshop comfort level with ICU communication skills. Participants rated their satisfaction with the workshop. RESULTS: Twenty-nine interns (88%) completed the questionnaires. Important self-assessed communication skills learned reflect key components of shared decision making, which include assessing the family's understanding of the patient's condition (endorsed by 100%) and obtaining an understanding of the patient/family's perspectives, values, and goals (100%). Interns reported significant improvement in their comfort level with ICU communication skills (pre 3.26, post 3.73 on a five-point scale, p=0.004). Overall satisfaction with the intervention was high (mean 4.45 on a five-point scale). CONCLUSIONS: The findings suggest that a brief intervention designed to teach residents communication skills in conducting goals of care and treatment discussions in the ICU is feasible and can improve their comfort level with these conversations.
Asunto(s)
Comunicación , Enfermedad Crítica/terapia , Toma de Decisiones , Capacitación en Servicio , Medicina Interna/educación , Internado y Residencia , Adulto , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Proyectos Piloto , Encuestas y CuestionariosRESUMEN
Dyspnea is one of the most common symptoms in advanced cancer patients at the end of their life. It is often multifactorial with diverse malignant, nonmalignant, and cancer treatment related etiologies. Oxygen, opiates, and anxiolytics are commonly administered. Here a complex case of progressive dyspnea and its treatments in a patient with advanced pancreatic cancer is described, and its multiple potential contributing causes are identified and clinical responses evaluated. Literature review is conducted on pulmonary drug toxicity and tumor lymphangitic spread, and the role of corticosteroids in relieving dyspnea in the palliative care setting.
Asunto(s)
Corticoesteroides/uso terapéutico , Disnea/tratamiento farmacológico , Cuidados Paliativos , Neoplasias Pancreáticas/complicaciones , Anciano de 80 o más Años , Progresión de la Enfermedad , Femenino , HumanosRESUMEN
BACKGROUND: Despite new guidelines and nationally mandated regular assessments, managing pain in cognitively impaired patients remains a complex and challenging task. Numerous studies have focused on assessing pain in this population; however, studies of treatment are limited. PURPOSE: The purpose of this article was to characterize assessment and pain management strategies used by providers caring for hospitalized cognitively impaired patients with acute pain, and to assess for associations between amount of opioid received and specific adverse outcomes in this patient population. METHODS: Medical records of patients admitted to the Geriatrics Service or Orthopedic Service or evaluated by the Geriatrics Consult Service at an urban tertiary care hospital between September 01, 2006 and September 30, 2007 with cognitive impairment and an acute pain problem on admission were reviewed. RESULTS: Participants (N=100) had a mean age of 86 years (range=68-99), and were mostly female (83%) with fracture-related pain (62%). A numeric pain score was recorded in 67% of nursing assessments vs <5% of physician assessments. Opioids were prescribed for 100% of the surgical patients vs 43% of the medical patients. Only 15% of patients were placed on a standing analgesic regimen. Nonpharmacological management was employed for 75% of surgical patients vs 43% of medical patients. Delirium occurred in 27% of patients, and 33% experienced an interruption of physical therapy. Neither, however, was associated with level of opioid use. CONCLUSIONS: Current assessment and treatment practices in acute pain management for cognitively impaired patients vary widely (to include service and provider type). Implementation of evidence-based guidelines is needed to improve patient care.
Asunto(s)
Trastornos del Conocimiento/complicaciones , Manejo del Dolor , Anciano , Anciano de 80 o más Años , Analgésicos/administración & dosificación , Analgésicos/efectos adversos , Analgésicos/uso terapéutico , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Analgésicos Opioides/uso terapéutico , Interpretación Estadística de Datos , Delirio/inducido químicamente , Delirio/psicología , Relación Dosis-Respuesta a Droga , Femenino , Fracturas Óseas/complicaciones , Personal de Salud , Hospitalización , Humanos , Masculino , Dolor/complicaciones , Dolor/psicología , Dimensión del Dolor/métodos , Médicos , Estudios Retrospectivos , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
PURPOSE: Implantable cardioverter defibrillator shocks at the end of life are distressing and warrant consideration of implantable cardioverter defibrillator deactivation discussions. A nationwide survey collected physicians' comments regarding such discussions. METHODS: Vignettes ascertained respondents' practices regarding implantable cardioverter defibrillator deactivation discussions. Respondents' comments were analyzed to identify themes. RESULTS: About 177 respondents (32%) provided 310 comments. One third reported that initiating the discussion would depend on specific circumstances, such as do not resuscitate status (35%); 21% advocated life-prolonging therapies; 17% said the patient/family or another physician should initiate the discussion; and 9% expressed inadequate education/awareness about implantable cardioverter defibrillator functions. Geriatricians and general internists expressed inadequate knowledge most frequently (12 writers, 75% in this theme), while electrophysiologists most frequently suggested further treatments/procedures (22 writers, 58%), and another doctor (13 writers, 76%) or the patient (8 writers, 62%) should begin the discussion. CONCLUSIONS: Improving the end of life care for patients with implantable cardioverter defibrillators will require additional physician education and increased commitment by subspecialists to deactivation discussions.