Inappropriate Prolongation Research Articles

Choosing Hospice is Not Giving Up

Choosing Hospice is Not Giving Up

Reducing Inappropriate Urinary Catheter Use by Involving Patients Through the Participatient App: Before-and-After Study

BackgroundThe risk of urinary tract infections is increased by the inappropriate placement and unnecessary prolongation of the use of indwelling urinary catheters. Sustained behavior change in infection prevention could be promoted by empowering patients through a smartphone app.ObjectiveThe aim of this study is to assess the feasibility and efficacy of implementation actions on patients’ use of the Participatient app on a clinical ward and to compare 3 survey methods for urinary catheter use.MethodsParticipatient was introduced for all admitted patients at the surgical nursing ward in a university hospital in the Netherlands. Over a period of 3 months, the number of new app users, days of use, and sessions were recorded. In a comparison of urinary catheter use before and after the implementation of the app, 3 methods for point prevalence surveys of catheter use were tested. Surveys were conducted through manual parsing of the text in patients’ electronic medical records, parsing a survey of checkbox items, and parsing nursing notes.ResultsIn all, 475 patients were admitted to the ward, 42 (8.8%) installed the app, with 1 to 5 new users per week. The actions with the most ensuing app use were the kick-off with the clinical lesson and recruiting of the intake nurse. Between the survey methods, there was considerable variation in catheter use prevalence. Therefore, we used the standard method of manual parsing in further analyses. Catheter use prevalence decreased from 38% (36/96) to 27% (23/86) after app introduction (OR 0.61, 95% CI 0.32-1.14).ConclusionsThe clinical application of Participatient, the infection prevention app for patients, could be feasible when implementation actions are also used. For surveying indwelling urinary catheter use prevalence, manual parsing is the best approach.

Chest X-ray Does Not Predict the Risk of Endotracheal Intubation and Escalation of Treatment in COVID-19 Patients Requiring Noninvasive Respiratory Support.

Forms of noninvasive respiratory support (NIRS) have been widely used to avoid endotracheal intubation in patients with coronavirus disease-19 (COVID-19). However, inappropriate prolongation of NIRS may delay endotracheal intubation and worsen patient outcomes. The aim of this retrospective study was to assess whether the CARE score, a chest X-ray score previously validated in COVID-19 patients, may predict the need for endotracheal intubation and escalation of respiratory support in COVID-19 patients requiring NIRS. From December 2020 to May 2021, we included 142 patients receiving NIRS who had a first chest X-ray available at NIRS initiation and a second one after 48–72 h. In 94 (66%) patients, the level of respiratory support was increased, while endotracheal intubation was required in 83 (58%) patients. The CARE score at NIRS initiation was not predictive of the need for endotracheal intubation (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.96–1.06) or escalation of treatment (OR 1.01, 95% CI 0.96–1.07). In conclusion, chest X-ray severity, as assessed by the CARE score, did not allow predicting endotracheal intubation or escalation of respiratory support in COVID-19 patients undergoing NIRS.

Abstract TP92: Inappropriately Prolonged Dual Antiplatelet Therapy In The Treatment Of Stroke And Transient Ischemic Attack At An Urban Safety Net Hospital

Introduction: Time-limited dual antiplatelet therapy (DAPT) with aspirin and clopidogrel has emerged as an important treatment modality for secondary stroke prevention in patients with symptomatic intracranial atherosclerotic disease, minor stroke, or high-risk transient ischemic attack. However, continuation beyond the indicated treatment period may expose patients to bleeding risk without additional benefit. Methods: We conducted a retrospective study of a prospectively maintained registry (the Get-With-The-Guidelines database at our hospital) evaluating patients discharged on time-limited DAPT for secondary stroke prevention between January 1st, 2019 and July 31st, 2020. Intended and actual duration of therapy were extracted from clinical notes and prescription records. We assessed the frequency of inappropriate continuation within the entire cohort and performed univariate analyses to assess for differences in outcome with respect to clinical and demographic characteristics, including social determinants of health (such as race and primary spoken language). Results: Of the 127 patients included, 17 (13%) had inappropriately prolonged treatment with DAPT. Black patients had a significantly higher incidence of inappropriate continuation than non-Black patients and individuals speaking languages other than English or Spanish exhibited a trend toward more frequent occurrence. Patients intended to transition to monotherapy with clopidogrel and those initially presenting with stroke (rather than transient ischemic attack) had similar trends toward more frequent occurrence. Conclusions: Our study represents the first attempt to approximate the incidence of inappropriate prolongation of time-limited DAPT for secondary stroke prevention at a hospital caring for a large underserved population. Our results suggest that social determinants of health may contribute to this phenomenon, but further studies are required to replicate our observations in larger multicenter cohorts. Systems-based interventions should be aimed at ensuring proper duration of therapy to minimize bleeding risk and other side effects.

Barriers to High Quality End of Life Care in the Surgical Intensive Care Unit.

End of life discussions frequently take place in surgical intensive care units, as a significant number of patients die while admitted to the hospital, and surgery is common during the last month of life. Multiple barriers exist to the initiation of these conversations, including: miscommunication between clinicians and surrogates, a paternalistic approach to surgical patients, and perhaps, conflicts of interest as an unwanted consequence of surgical quality reporting. Goal discordant care refers to the care that is provided to a patient that is incapacitated and that is not concordant to his/her wishes. This is a largely unrecognized medical error with devastating consequences, including inappropriate prolongation of life and non-beneficial therapy utilization. Importantly, hospice and palliative care needs to be recognized as quality care in order to deter the incentives that might persuade clinicians from offering these services.

Nephrologist Calls for ‘Age-Attuned Approach’ to Chronic Kidney Disease

Nephrologist Calls for ‘Age-Attuned Approach’ to Chronic Kidney Disease

Preferences regarding disclosure of prognosis and end-of-life care: A survey of cancer patients with advanced disease in a lower-middle-income country

Background: Cancer patients’ preferences regarding disclosure of prognosis and end-of-life care remain under-reported from low- and middle-income countries where cancer poses an increasing demand on scarce healthcare resources. A better knowledge of these preferences can help in achievement of shared treatment goals. Aim: To survey preferences of adult cancer patients regarding disclosure of prognosis and end-of-life care Design: A multidimensional questionnaire was developed to survey consecutively sampled patients. A fifth of the participants completed a repeat survey 3 months later. Setting/participants: Adult patients at a specialist cancer center in Pakistan. Results: In total, 520 patients were surveyed initially (participation rate 98.6%) and 100 completed the repeat survey. Three in five respondents wanted a healthcare provider to give them detailed information about their prognosis and life expectancy. Those who wanted information withheld were significantly more likely to be female, to have a lower socioeconomic status, or to have lung cancer. Only two in five patients agreed that they wanted to die at home and more than 90% wanted all possible care till end-of-life. Yet, a little over half also agreed that they did not wish to be placed on a ventilator. In rank ordering preferences about end-of-life, respondents ranked “religious wellbeing” as the highest and “avoiding inappropriate prolongation of dying” as the lowest of six options. Conclusion: A majority of adult cancer patients surveyed in this study wanted a truthful disclosure about their disease prognosis and expressed a preference for hospital-based care at end-of-life. Healthcare providers should find ways to tailor prognostic information to patients’ expressed information needs.

Chapter 19 - Palliative care at the end-of-life in glioma patients

The end-of-life (EOL) phase of patients with a glioma starts when symptom prevalence increases and antitumor treatment is no longer effective. During the EOL phase, care is primarily aimed at reducing symptom burden while maintaining quality of life as long as possible without inappropriate prolongation of life. Palliative care during the EOL phase also involves complex medical decisions for the prevention and relief of suffering. We discuss the prevalence and treatment of the most common EOL symptoms, decision making in the EOL phase, the organization of EOL care, and the role of the patient's caregiver. Treating disease-specific symptoms, such as impaired consciousness, seizures, focal neurologic deficits and cognitive disturbances, is a major concern during the EOL phase, as these symptoms may interfere with EOL decision making. Advance care planning is aimed at reaching consensus about possible EOL decisions between all participants, respecting the values of patients and their informal caregivers. In order to prevent the possibility that the patient becomes incompetent to make informed decisions, we recommend initiating EOL conversations at a relatively early stage in the disease course.

Lean Six Sigma: a new approach to the management of patients undergoing prosthetic hip replacement surgery

In 2012, health care spending in Italy reached €114.5 billion, accounting for 7.2% of the Gross Domestic Product (GDP) and 14.2% of total public spending. Therefore, reducing waste in health facilities could generate substantial cost savings. The objective of this study is to show that Lean Six Sigma represents an appropriate methodology for the development of a clinical pathway which allows to improve quality and to reduce costs in prosthetic hip replacement surgery. The methodology used for the development of a new clinical pathway was Lean Six Sigma. Problem solving in Lean Six Sigma is the DMAIC (Define, Measure, Analyse, Improve, Control) roadmap, characterized by five operational phases which make possible to reach fixed goals through a rigorous process of defining, measuring, analysing, improving and controlling business problems. The following project indicated several variables influencing the inappropriate prolongation of the length of stay for inpatient treatment and corrective actions were performed to improve the effectiveness and efficiency of the process of care. The average length of stay was reduced from 18.9 to 10.6 days (-44%). This article shows there is no trade-off between quality and costs: Lean Six Sigma improves quality and, at the same time, reduces costs.

Good End-of-Life Care: Perspectives of Middle-Aged and Older Singaporeans

ContextUnderstanding preferences for end-of-life care is important for planning and improving services that provide such care. However, little is known about the perspective of Singaporeans regarding good end-of-life care. ObjectivesTo identify the key components of good end-of-life care as perceived by middle-aged and older Singaporeans (≥50 years). MethodsNine focus groups were conducted with a total of 63 participants. Preferences regarding end-of-life care were discussed. Thematic analysis was conducted on the transcribed results of the focus groups. ResultsEight components of good end-of-life care were identified: 1) have physical comfort at the end of life, 2) avoid inappropriate prolongation of the dying process, 3) maintain sensitivity toward religious and spiritual beliefs, 4) avoid burden on the family, 5) avoid expensive care, 6) be cared for by a trustworthy doctor, 7) maintain control over care decisions, and 8) achieve a sense of completion. ConclusionEight components of good end-of-life care involving the person, family, and health services were identified among middle-aged and older Singaporeans. A focus on better management of pain, training of caregivers and doctors, shared decision making, and availability of affordable care may improve care at the end of life.

Aligning Patient Preferences and Patient Care at the End of Life

Aligning Patient Preferences and Patient Care at the End of Life

Antidepressants utilization among elderly in Lombardy from 2000 to 2007: dispensing trends and appropriateness

To investigate the prevalence and incidence of antidepressant (AD) use in the elderly during an 8-year period and to evaluate AD treatment appropriateness. A population-based dispensation study on community-dwelling elderly of a large area in Lombardy was performed. Data were drawn from the regional administrative database and from a general practice registry. For each year, prevalence of AD use (i.e., at least one recorded dispensation) and AD treatment (i.e., at least four recorded dispensations) was compared. The prevalence of AD use and treatment doubled and tripled, respectively. The greatest shift occurred between 2000 and 2002 and was entirely due to SSRIs. The most pronounced increase was seen in females who accounted for 72% of all dispensations. The increase in prevalence was not mirrored by incident use, which slightly decreased (OR: 0.98; 95% CI: 0.98-0.98). The proportion of those who received a minimally adequate AD treatment grew over the years (OR: 1.63; 95% CI: 1.59-1.68). The increase in prevalence of AD treatment was most pronounced among older age groups (ORs between 1.02 and 1.06 for age classes ≥75years relative to the 65-69 age class; P < 0.001) and was proportional to that of depressive disorders. A dramatic rise in dispensations was observed. The increasing prevalence of minimally adequately treated subjects and a possible decrease in untreated depression may reflect an improvement in the pharmacological treatment of depression. The increase in prevalence and not in the incidence of dispensations could be related to an inappropriate prolongation of treatment duration.

Bleeding Complications in Patients Undergoing Pulmonary Vein Isolation without Discontinuance of Warfarin

Background: Periprocedural anticoagulation with warfarin was reported to reduce the risk of stroke without increasing the risk of bleeding complications for radiofrequency catheter ablation of atrial fibrillation in US population. Methods and Results: The outcome of thromboembolic and hemorrhagic complication was surveyed in 20 consecutive patients who underwent pulmonary vein isolation in our hospital without discontinuance of warfarin. In these patients, the INR was aimed to keep >2.0. After the transseptal puncture, a heparin bolus (2000–5000 U) was administered, followed by additional heparin bolus and infusion to keep the activated clotting time (ACT) >350. As a result, no periprocedural stroke/transient ischemic attack was reported. Bleeding complications that need transfusion and/or prolongation of hospitarization occurred in 3 (15%) patients (1 cardiac tamponade, 1 massive hematoma, and 1 outside bleeding from venous puncture site). In 2 (10%) patients, ACT was inappropriately prolonged (>800) by initial 5000 U of heparin bolus. Conclusion: It is suggested that above mentioned control of periprocedural INR and ACT during procedure may increase hemorrhagic events in Japanese patients who undergo pulmonary vein isolation. In the case whose INR is >2.0, initial heparin bolus may be ristricted <5000 U to avoid inappropriate prolongation of ACT.

Characteristics of patients with brain metastases from lung cancer in a palliative care center

Patients with brain metastases present severe symptoms owing to the tumor growth or treatment side effects, and supportive measures are often critical for the patients and their families. However, there is currently a lack of palliative care and end-of-life (EoL) provision for patients affected by advanced brain tumors. We performed a retrospective analysis of the characteristics of patients with brain metastases from lung cancer between August 1998 and December 2008 in our palliative care center. During this period, 55 such patients died. The male/female ratio was 0.86, and the mean age was 60.7 years. The duration of the last stay before death varied between 2 and 196 days (mean, 42.6 days). Death appeared predictable as the consequence of end-stage disease in all cases. The most frequent general clinical complaints were pain (64.8%), general fatigue (46.2%), and dyspnea (31.4%). The most frequent symptoms related to the brain tumors were consciousness deterioration (33%), headache (26%), cranial nerve palsy (19%), and delirium (19%). The symptoms in patients with carcinomatous meningitis were headache (63.6%), cranial nerve palsy (45.4%), epilepsy (27.2%), and nausea and vomiting (27.2%). The therapy tools used were chemotherapy in 9% and steroids and glycerol in 32.7%. Four patients who had leptomeningeal carcinomatosis suffered from hydrocephalus, and treatments for vasogenic edema or antalgics were less effective. In such cases, cerebrospinal fluid drainage may be effective if there are no space-occupying lesions. One patient had cortical atrophy with cognitive impairment and another had a cerebral infarction during admission. Optimization of the quality of life in its final stages requires efficient palliative care, which involves considerable psychological, sociological, technical, and financial burdens. Palliative management of brain metastases requires a multidisciplinary approach performed by a well-trained neuro-oncology team, and it is important to avoid any treatment that is harmful or has a poor toxicity/efficacy ratio to avoid inappropriate prolongation of dying.

End-of-life care in Spain: legal framework

Prominent cases affecting care at the end of life in critically ill patients have been reported in several European countries [1, 2]. These cases have fueled a necessary debate regarding the need of having a legal framework to appropriately deal with these issues [3, 4]. In Spain, there is no specific legislation regulating the withdrawal or withholding of treatment in end-of-life care or in critical patients on life support. However, the avoidance of inappropriate prolongation of life and the withdrawal or withholding of life support when the patient desires it or when it is considered futile is considered good clinical practice [5]. This decision takes place in the confidential context of the physician–patient relationship. A few months ago, a patient who was permanently a ventilator dependent because of a progressive muscle dystrophia, asked for ventilator withdrawal. This patient, who had always complete consciousness to take decisions, was admitted in a hospital owned by the church. The ecclesiastic hierarchy dealt with her petition and decided to transfer the patient to a public hospital, where ventilator support was withdrawn by her responsible physician. Such process is not considered euthanasia but withdrawal of life support. The case was widely commented on the press, but no judiciary process was carried out [6]. The Spanish Society of Intensive and Critical Care and Coronary Units (SEMICYUC) has published guidelines about end-of-life decisions [7]. A recent multicenter study showed that 71% of patients, who died in the ICU because of a multiple organ dysfunction syndrome, had some type of limitation of treatment [8]. Furthermore, the vast majority (over 95%) of critical care departments in Spain is made up of intensivists that have completed the Department of Health’s MIR (medicos internos y residentes) specialist training in intensive medicine and therefore these departments have also adopted the SEMICYUC’s guidelines. In Spain there are publications [9, 10] dealing with different aspects of therapeutic decisions in end-of-life care in the critically ill patients which are covered by diverse authors, including physicians, jurists, philosophers and nurses.

End-of-Life Decision Making, Organ Donation, and Critical Care Nurses

End-of-Life Decision Making, Organ Donation, and Critical Care Nurses

Cancer at the End Stages: Palliation Is Multifaceted

Cancer at the End Stages: Palliation Is Multifaceted

Palliative care on the intensive care unit

When futility of ongoing active treatments has become apparent in critically ill patients, effective palliative care must be instituted. Such care includes relief from the physical, emotional and spiritual aspects of dying. Five domains have been described; they are adequate pain and symptom relief, avoidance of inappropriate prolongation of dying, achieving a sense of control, having burdens relieved and strengthening relationships with loved ones. The mainstay of such care is frequently effective analgesia. Other physical provisions include sedation, temperature control, anti-emesis, reassurance (if conscious) and good basic care e.g. oral toilet, wound care, pressure area care, cleaning of soiled areas. Cultural and religious aspects must also be considered. Once analgesia and sedation are effective any intervention not advancing patients’ goals (i.e. ‘to have a good death’) should be eliminated. Critical care staff should also provide for the patient's family and have an understanding of the legalities of death e.g. certification, coroner, etc. and medico-legal examples of conflict. Senior clinicians therefore have a pivotal role in guiding an individual's care, minimizing conflict and educating others in both the practicalities of effective palliative care and the controversies surrounding the subject e.g. Doctrine of Double Effect and Euthanasia.

ROLES FOR THE CHURCH IN IMPROVING END-OF-LIFE CARE: PERCEPTIONS OF CHRISTIAN CLERGY AND LAITY

Although faith communities may seem to be logical places to discuss death and dying, few churches are engaged in extensive efforts to improve end-of-life care. To explore the meaning of a good death and potential roles for faith communities in this effort, the authors held focus groups involving 121 clergy and congregants affiliated with Christian churches in Honolulu. Participants' definitions of a good death were similar to those articulated in other studies, for example, pain is managed, inappropriate prolongation of dying is avoided, the family is present and supportive, conflicts are resolved, and spiritual/existential issues are addressed. Participants identified a number of roles for the church: (a) to help congregants prepare for death, both spiritually and practically; (b) to facilitate resolution of conflict and forgiveness; (c) to clarify if or how church theology should guide attitudes and practices related to death and dying; (d) to administer the appropriate rituals; and (e) to provide outreach to sick, dying, and bereaved members. A number of participants noted that attention to spiritual issues at life's end would be important to all people, and churches wanting to increase membership should expand offerings in this area. These findings suggest that faith communities can have a major impact on improving end-of-life care and that pastoral education include attention to these issues.

Quality end-of-life care: patients' perspectives.

Quality end-of-life care is increasingly recognized as an ethical obligation of health care providers, both clinicians and organizations. However, this concept has not been examined from the perspective of patients. To identify and describe elements of quality end-of-life care from the patient's perspective. Qualitative study using in-depth, open-ended, face-to-face interviews and content analysis. Toronto, Ontario. A total of 126 participants from 3 patient groups: dialysis patients (n = 48), people with human immunodeficiency virus infection (n = 40), and residents of a long-term care facility (n = 38). Participants' views on end-of-life issues. Participants identified 5 domains of quality end-of-life care: receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, relieving burden, and strengthening relationships with loved ones. These domains, which characterize patients' perspectives on end-of-life care, can serve as focal points for improving the quality of end-of-life care.