Presence Of Serious Illness Research Articles

Sense of Coherence at End of Life in Older People: An Interpretive Description.

As people age, losses accumulate (ie, the death of family and friends, the loss of agility, and the loss of independence). Such losses have an impact on one's Sense of Coherence, that is, one's ability to see the world as comprehensible, manageable, and meaningful. Antonovsky deemed Sense of Coherence as a mostly stable state by the age of 30 years. Until now, there has not been an investigation into how serial loss of resources affects older people as they near the end of life. Sense of Coherence was used as the theoretical framework for this study to answer the question of how older people maintain or regain a Sense of Coherence in the presence of serious illness as they near death. Data were gathered using semistructured interviews and guided by interpretive description. This investigation found new concepts that contribute to Antonovsky's midlevel theory of salutogenesis and the construct of Sense of Coherence. Those are Incomprehensibility and Serial Loss of General Resistance Resources. The results indicate that the crux of a strong Sense of Coherence for this population is excellent communication and a coherent "big-picture" conversation.

Emergency Department Admission Triggers Sustainably Generate High-Value Palliative Care Consultations (TH310A)

•Describe how admission triggers can be implemented in the ED to effectively facilitate earlier palliative care consultation during the inpatient course.•Demonstrate that specificity in trigger design can capture high value consultations while maintaining sustainable workflows. Capturing admitted patients for palliative care (PC) consultation earlier in their hospital course helps achieve better alignment with the quadruple aim. Emergency department (ED) admission triggers have been proposed to facilitate earlier engagement, however their impact is not adequately studied. Demonstrate that specific admission triggers can generate early palliative care consultations directly from the ED while maintaining sustainable workflows. ED admission triggers were derived from literature review and prior quality improvement initiatives. Only three criteria were implemented to ensure actionability and sustainability: presence of serious illness, chair/bedbound >50% of time, and unsurprised if the patient dies this hospitalization. Eligible patients met all three criteria. Any ED interdisciplinary staff could identify eligibility. After verifying, the emergency physician coupled the admission with a “heads-up” PC consult. PC evaluated the patient within 24 hours; they were not expected to call back or come to the ED. High specificity enabled the mature PC consult team to prioritize their fully-stretched resources. Institutional alignment acquired from all stakeholders (ED, ICU, hospitalists, administration) designated this workflow as “standard of care.” Data from 03/2018-06/2018 were tracked through the Palliative Care Quality Network registry. ED-initiated consults during this four-month pilot increased 180% year over year (50 vs.18, p=0.000). Compared to usual PC consults, ED-initiated consults were comparable in age, gender, and palliative performance scale; however, they had significantly shorter median length of stay prior to consultation (0 days vs. 4 days, p=0.000). Among live discharges, more ED-initiated consults received hospice services (51% vs. 38%, p=0.148). Eight planned admissions were avoided. Overall PC consult volume remained proportionately steady, although 21% now originated from the ED. ED-initiated consults were evenly distributed across weeks. Stakeholders valued this new workflow and approved continuing as “standard of care.” Emergency department admission triggers can effectively and sustainably drive earlier palliative care consultation to achieve the quadruple aim.

Pregnancy in Serious Illness: It's Not Just Medical Decision Making.

Pregnancy in the presence of serious illness and treatment can create a moral and ethical struggle. There is little literature to provide an ethical framework for decision making when women become pregnant while receiving aggressive care for any serious illness. The family and care team often have moral distress as they provide support and are integrally involved in decision making. A case study is presented to describe a complicated patient scenario and how all involved can develop emotional, moral, and ethical struggles as care is delivered. In clinical cases where nurses feel that their own ethical and moral frameworks are either in conflict with patient, family, or health care provider decisions, or feel that patient and family wishes conflict with one another or the health care system, emotions and distress rise to the surface. In these situations, nurses can advocate for standard practice and to use an ethical framework for decision making, such as the 4-box method, to help decrease moral and ethical struggles as technology continues to advance in health care.

Impact of Patient Affect on Physician Estimate of Probability of Serious Illness and Test Ordering.

The authors hypothesize patient facial affect may influence clinician pretest probability (PTP) estimate of cardiopulmonary emergency (CPE) and desire to order a computerized tomographic pulmonary angiogram (CTPA). This prospective study was conducted at three Indiana University-affiliated hospitals in two parts: collecting videos of patients undergoing CTPA for suspected acute pulmonary embolism watching a humorous video (August 2014-April 2015) and presenting the medical histories and videos to clinicians to determine the impact of patient facial affect on physicians' PTP estimate of CPE and desire to order a CTPA (June-November 2015). Patient outcomes were adjudicated as CPE+ or CPE- by three independent reviewers. Physicians completed a standardized test of facial affect recognition, read standardized medical histories, then viewed videos of the patients' faces. Clinicians marked their PTP estimate of CPE and desire for a CTPA before and after seeing the video on a visual analog scale (VAS). Fifty physicians completed all 73 videos. Seeing the patient's face produced a > 10% absolute change in PTP estimate of CPE in 1,204/3,650 (33%) cases and desire for a CTPA in 1,095/3,650 (30%) cases. The mean area under the receiver operating characteristic curve for CPE estimate was 0.55 ± 0.15, and the change in CPE VAS was negatively correlated with physicians' standardized test scores (r = -0.23). Clinicians may use patients' faces to make clinically important inferences about presence of serious illness and need for diagnostic testing. However, these inferences may fail to align with actual patient outcomes.

Significance of family life events in middle adolescence: A survey on Finnish community adolescents

Finnish middle adolescents (n=3242) were assessed for family characters, family life events, depression and frequent drunkenness. Odds ratios for maladjustment outcomes associated with each event were computed and logistic regression models were used to estimate the effect of confounders. In the presence of serious illness or injury of a family member, increasing conflicts between parents and financial difficulties in the family, the probability of depression was twice as high than without the presence of these events. Parental unemployment, parent getting involved with the law and financial difficulties in the family were associated with frequent drunkenness. The associations between life events and depression were fairly similar among boys and girls. Among girls there were several events associated with frequent drunkenness even when family structure and socio-economic status were accounted for, while among boys there were only few. The significance of associations between family life events and depression may vary between the specific events while the associations between family life events and frequent drunkenness may be better explained with cumulative stress. Both males and females react to family stress, but the symptoms presented may differ. In case of family adversities, both internalizing and externalizing outcomes must be screened for.

Family Function in Families of Children With Duchenne Muscular Dystrophy

This article investigates the relationships of child- and family-related variables with family function in families with children who have Duchenne muscular dystrophy. Child-related variables included level of disability (indicator: Barthel Index) and age at diagnosis. Family-related variables included caregiver health status (indicator: Duke Health Profile), family income and employment, family support (indicator: Family APGAR), family hardiness (indicator: Family Hardiness Index), and family functioning (indicator: Family Assessment Device). Family function displayed a significant correlation with age at diagnosis, but not with disability level. It was also significantly correlated with family hardiness, caregiver health status, and levels of family support, but not with income or employment variables. These findings highlight the need to assist families to cope with the presence of serious illness in their children.

Self-reported Sleep Quality is Associated With the Metabolic Syndrome

To determine whether a simple, structured self-report of overall sleep quality is associated with the presence of the metabolic syndrome and its component risk factors. An observational, cross-sectional study comparing global scores on the Pittsburgh Sleep Quality Index with concurrently collected measures of the components of the metabolic syndrome and presence or absence of the syndrome. The metabolic syndrome criterion of the American Heart Association/National Heart, Blood, and Lung Institute was adopted. University laboratory. Two hundred ten volunteers with a mean age of 46 years (57% men) screened for the presence of serious illness and related medications. N/A. All analyses were adjusted for sex and age. Logistic regression showed that poor global sleep-quality scores on the Pittsburgh Sleep Quality Index were related significantly to the presence of the metabolic syndrome-an increase of the global sleep score of 2.6 points (approximately 1 SD) was associated with an odds of having the metabolic syndrome of 1.44 (p = .04, confidence interval = 1.01-2.06). Linear-regression results showed that the Pittsburgh Sleep Quality Index global sleep-quality score was related significantly to waist circumference, body mass index, percentage of body fat, serum levels of insulin and glucose, and estimated insulin resistance. Self-reported global sleep quality is significantly related to the metabolic syndrome and several of its core components.

Fever in Geriatric Emergency Patients: Clinical Features Associated With Serious Illness

Study objective: To determine the clinical significance of fever in geriatric emergency department patients. Design: Case series with follow-up. Setting: Urban, university-affiliated community hospital. Participants: Consecutive patients over the age of 65 years who presented to the ED during a 12-month period with an oral temperature of 100.0°F (37.8°C) or higher. Results: We considered the following features indicators of serious illness: positive blood culture(s), related death within 1 month of ED visit, need for surgery or other invasive procedure, hospitalization for 4 or more days, IV antibiotics for 3 or more days, and repeat ED visit within 72 hours for related condition. Four hundred eighty-nine patients were eligible for study. Of the 470 patients with complete follow-up data, 357(76.0%) had indicators of serious illness. Clinical features found to be independently associated with serious illness included oral temperature of 103°F (39.4°C) or more, respiration rate of 30 or more, leukocytosis of 11.0×10 9/L or more, presence of an infiltrate, and pulse of 120 or more. At least one indicator of serious illness was present in 63 of 128 patients (49.6%) with none of these independently predictive clinical features. The most common final diagnoses were pneumonia (24.0%), urinary-tract infection (21.7%), and sepsis (12.8%). Conclusion: Fever among geriatric ED patients frequently marks the presence of serious illness. All such patients should be strongly considered for hospital admission, particularly when certain clinical features are present. The absence of abnormal findings does not reliably rule out the possibility of serious illness. [Marco CA, Schoenfeld CN, Hansen KN, Hexter DA, Stearns DA, Kelen GD: Fever in geriatric emergency patients: Clinical features associated with serious illness. Ann Emerg Med July 1995;26:18-24.]

Autoimmune neutropenia of infancy and early childhood.

Forty-one children were identified with autoimmune neutropenia of infancy and early childhood (absolute neutrophil count [ANC] less than 500/microliters and demonstrable serum antineutrophil antibodies). There were 21 boys and 20 girls; the median age at diagnosis was 11 months (range 5-38 months). No life-threatening infections occurred. There was a gradual upward trend in ANC in all patients over many months, with 87% having an ANC > 1000/microliters by 24 months from diagnosis. Among various clinical and laboratory parameters analyzed statistically, only younger age at diagnosis was associated with earlier neutrophil recovery. There was no association between degree or duration of neutropenia and sex, race, antibody reactivity, or presence of serious illness at diagnosis.

A typology of responses to illness in survivors of myocardial infarction.

One hundred and eighteen survivors of myocardial infarction were assigned scores on eight dimensions of illness behaviour recently described as arising in response to myocardial infarction. These data were subjected to a cluster analysis to produce an optimal solution of four homogeneous clusters of patients. The first contained patients who, on clinical grounds, appeared to be claiming illness as a highly significant and consequential occurrence in their lives; the second accepted illness but experienced a marked affective response to it; the third appeared to adopt a realistic approach to illness and be coping adequately; and the fourth seemed to be denying (or at least minimizing) both the presence of serious illness and its possible consequences. These findings were discussed in terms of their bearing on prognosis, within the context of abnormal illness behaviour.

Severity of illness and illness behaviour: A comparative study of coronary care patients

Patients entering a coronary care unit (CCU) usually fall into one of two groups; those with an unequivocal diagnosis of myocardial infarction (MI) who remain to be monitored in CCU for some days before discharge to a general medical ward, and those who fail to attract a diagnosis of MI or other serious illness and are rapidly discharged to a general ward. It was hypothesized that the former group would perceive the severity of their illness as being greater than that of the latter group, and would exhibit patterns of illness behaviour in accord with this perception. In particular, it was expected that patients with MI would exhibit a greater recognition of the presence of serious illness, a greater acceptance of the sick role and a more intense affective response to illness than patients without MI. These expectations were examined by comparing illness behaviour profiles of 120 survivors of MI, with identically obtained profiles of 40 persons admitted to a CCU with chest pain but rapidly discharged with neither a diagnosis of MI or other serious illness. Only the first, relating to the recognition of the presence of serious illness, was confirmed. In all other respects, patterns of illness behaviour among survivors of MI was no different from that among patients without MI. It would seem then that patterns of illness behaviour were more influenced by the element of experience common to the two groups, admission to a CCU, than by differences either in the actual severity of the illness or the degree to which this was recognized. This suggests in turn that patients discharged from a CCU without a diagnosis of MI, are none the less concerned about the integrity of their cardiovascular systems, and if psychological intervention has been shown to benefit patients with MI, it may also be indicated for those patients with the less serious illness.