Unwanted Care Research Articles

The Proportions, Regulations, and Training Plans of Male Midwives Worldwide: A Descriptive Study of 77 Countries

ObjectivesThe proportions of male midwives as well as regulations and training plans targeting male midwives were investigated.MethodsQuestionnaires were sent to 109 United Nations member countries where midwifery associations had opened their e-mail addresses. Respondents were persons in charge of midwifery education or policy recommended by midwifery associations, researchers, or acquaintances. The questionnaire inquired about the number of midwives and obstetrician-gynecologists by gender in the country, as well as regulations and training plans relevant to male ones. For those countries that either failed to respond or provided insufficient information, supplemental Internet searches were conducted.ResultsData from 77 countries were analyzed (57 countries returned the questionnaires, and data on another 20 were obtained through Internet searches). Of the 19 countries without male midwives, five did not allow men to become midwives. In 37 countries with male midwives whose proportion data were available, the median proportion was 0.63%. Respondents in 13 countries described regulations respecting women who unwanted care by male midwives and in other two explained training plans for male midwives considering their specific characteristics.ConclusionThe proportion of male midwives is small, and regulations and training plans for male midwives varied depending on social content in countries.

Professional or Patsy?

Professional or Patsy?

Empowering Patients with Alzheimer's Disease To Avoid Unwanted Medical Care: A Look At The Dementia Care Triad.

Patients with Alzheimer's disease and other types of dementia with acute medical problems, who have lost capacity and are without advance directives, are at risk of being over treated inhospitals. To deal with this growing demographic and ethical crisis, patients with dementia need to plan for their future medical care while they have capacity to do so. This article will examine the role of each member of the dementia care triad and how to empower the patient to participate in planning future medical care. A case will be made that physicians have the same professional disclosure obligations to dementia patients as they do to all other capable patients with terminal illnesses. Because there is little consensus about what facts should be included in a diagnostic disclosure, this article will offer a proposal to empower newly diagnosed patients with dementia with capacity to plan for their future medical care.

A Patient-Reported Outcome Instrument to Assess Symptom Burden and Predict Survival in Patients with Advanced Cancer: Flipping the Paradigm to Improve Timing of Palliative and End-of-Life Discussions and Reduce Unwanted Health Care Costs.

Discussions regarding palliative care and end-of-life care issues are frequently delayed past the time of usefulness, resulting in unwanted medical care. We sought to develop a patient-reported outcome (PRO) instrument that allows patients to voice their symptom burdens and facilitate timing of discussions. A seven-item PRO instrument (Cota Patient Assessed Symptom Score-7 item [CPASS-7]) covering physical performance status, pain, burden, and depression was administered (September 2015 through October 2016) with correlation to overall survival, correcting for time to complete survey since diagnosis. A total of 1,191 patients completed CPASS-7 at a median of 560 days following the diagnosis of advanced cancer. Of these patients, 49% were concerned that they could not do the things they wanted; 35% reported decreased performance status. Financial toxicity was reported by 39% of patients, with family burdens noted in 25%. Although depression was reported by 15%, 43% reported lack of pleasure. Pain was reported by 33%. The median CPASS-7 total symptom burden score was 16 (possible 0-112). With a median follow-up of 15 months from initial survey, 46% had died. Patients with symptom burden scores <29 and ≥29 had a 6-month overall survival rate of 87% and 67%, respectively, and 12-month survival rates of 72% and 50%. A one-point score increase resulted in a 1.8% increase in expected hazard. Patients with advanced cancer with higher levels of symptom burden, as self-reported on the CPASS-7, had inferior survival. The PRO facilitates identification of patients appropriate for reassessment of treatment goals and potentially palliative and end-of-life care in response to symptom burden concerns. A seven-item patient-reported outcome (PRO) instrument was administered to 1,191 patients with advanced cancers. Patients self-reporting higher levels of physical and psychological symptom burden had inferior overall survival rates. High individual item symptom PRO responses should serve as a useful trigger to initiate supportive interventions, but when scores indicate global problems, discussions regarding end-of-life care might be appropriate.

Limit, lean or listen? A typology of low-value care that gives direction in de-implementation.

BackgroundOveruse of unnecessary care is widespread around the world. This so-called low-value care provides no benefit for the patient, wastes resources and can cause harm. The concept of low-value care is broad and there are different reasons for care to be of low-value. Hence, different strategies might be necessary to reduce it and awareness of this may help in designing a de-implementation strategy. Based on a literature scan and discussions with experts, we identified three types of low-value care.ResultsThe type ineffective care is proven ineffective, such as antibiotics for a viral infection. Inefficient care is in essence effective, but is of low-value through inefficient provision or inappropriate intensity, such as chronic benzodiazepine use. Unwanted care is in essence appropriate for the clinical condition it targets, but is low-value since it does not fit the patients’ preferences, such as a treatment aimed to cure a patient that prefers palliative care. In this paper, we argue that these three types differ in their most promising strategy for de-implementation and that our typology gives direction in choosing whether to limit, lean or listen.ConclusionWe developed a typology that provides insight in the different reasons for care to be of low-value. We believe that this typology is helpful in designing a tailor-made strategy for reducing low-value care.

Defining and Ensuring Multidisciplinary High-Quality Patient-Centered Shared Decision-Making for Procedures: a Brief Review of the Current State

Defining and ensuring the quality of surgical decision making is extremely complex. This manuscript will provide a review of current state in this evolving area and a conceptual framework to help clinicians understand how to approach this issue. Recent reports support the hypothesis of the existence of significant decisional deficits. There are a number of factors identified that contribute to this: among these are lack of adequate metrics to define decisional quality, lack of training in this area for providers, and lack of compensation for the additional time it might take. A conceptual framework can assist the clinician having these discussions. The importance of decisional quality is increasingly being recognized. As we strive in the current health care environment to provide the right procedure for the right patient, ensuring the elimination of unnecessary and unwanted care that is not aligned with patient values and goals will become even more important. The constrained economics of health care and the increasing desire for patient advocacy, engagement, and high-quality communication with care givers lend support to this work.

Improving End-of-Life Care and Advance Care Planning for Frail Older Adults in Canad.

We present five Key Concepts that describe priorities for improving end-of-life care for frail older adults in Canada, and recommendations based on each Key Concept. Key Concept #1: Our end-of-life care system is focused on cancer, not frailty. Key Concept #2: We need better strategies to systematically identify frail older adults who would benefit from a palliative approach. Key Concept #3: The majority of palliative and end-of-life care will be, and should be, provided by clinicians who are not palliative care specialists. Key Concept #4: Organizational change and innovative funding models could deliver far better end-of-life care to frail individuals for less than we are currently spending. Key Concept #5: Improving the quality and quantity of advance care planning for frail older adults could reduce unwanted intensive care and costs at the end of life, and improve the experience for individuals and family members alike.

End-of-Life Conversations as a Legacy.

Advance directives such as living wills and health care powers of attorney are important documents that offer patients ways to avoid unwanted care when they are unable to express their wishes. Although health care professionals have increased focus on advance care planning in recent years, approximately two thirds of American adults do not have advance medical directives. In addition, 90% of individuals believe that talking to loved ones about end-of-life wishes is important, but only 27% have done so. It is important for nurses to understand the complex factors that influence how individuals make health care decisions and identify ways to encourage conversations with family, friends, and health care providers to help clarify patients' wishes for endof-life care. [Journal of Psychosocial Nursing and Mental Health Services, 56(1), 32-35.].

Honoring Patient Choices With Advance Care Planning

Patients in Hawai’i are spending their dying days in the hospital and the intensive care unit. In Hawai’i, as of 2014, inpatient spending during the hospitalization in which death occurred was $5518, and US national average was $3802; 18.5% died in the intensive care unit compared with the US national average of 14.4%. Hawai’i has a high elder population who frequently have longer length of stays and are being readmitted to our facilities; 26.7% of deaths occur in Hawai’i hospitals versus the national average of 21.0% from 2003 to 2014. Furthermore, these patients are often not receiving the care that they would choose if informed of their options. The objective of this quality improvement project was to develop, implement, and evaluate the usefulness of an advance care planning (ACP) approach to assist clinicians in identifying and honoring patient choices. A target patient population (“Last Stages”) was identified for the project, and an ACP registry was created. Retrospective chart review showed that, for Last Stages patients, ACP documentation increased from 28.90% to 87.03%, and Provider Orders for Life-Sustaining Treatment completion rates rose from 12.89% to 53.90% after implementation of the ACP approach. Of the patients admitted to the hospital with Provider Orders for Life-Sustaining Treatment, 94% of these patients’ documented wishes were honored. Advance care planning processes did improve clinician adherence to patient choices, reducing the risk of patients receiving unwanted care.

Wanted and Unwanted Care: The Double-Edged Sword of Partial Do-Not-Resuscitate Orders.

The interpretation of do-not-resuscitate orders (DNRs) may vary in nonarrest situations. To reduce ambiguity, many hospitals allow patients to elect partial DNRs. To investigate the effect of partial DNRs on physicians' willingness to perform cardiopulmonary resuscitation (CPR) and nonarrest procedures. Cross-sectional study using scenario-based questionnaires between October 2015 and March 2016. A partial DNR was identified as a DNR with Adult Emergency Protocols (AEP) order. Each survey presented 3 patient scenarios followed by 10 interventions. Preclerkship and clerkship medical students, and internal medicine residents at a single medical school, and hospitalists at a tertiary-care academic medical center. Responses from 275 of 366 (75.1%) eligible subjects were collected. Compared to the case with a full DNR, the presence of a partial DNR was positively associated with subjects' willingness to provide both nonarrest procedures and CPR (p < 0.05). The number of training or practice years was positively associated with a decision not to perform CPR: case 1 (odds ratio [OR], 1.09; confidence interval [CI], 1.04-1.16; p = 0.003); case 2 (OR, 1.07; CI, 1.01-1.14; p = 0.03); and case 3 (OR, 1.09; CI, 1.04-1.16; p < 0.001). A partial DNR made our respondents more willing to provide nonarrest procedures, but also CPR. These findings suggest an ongoing need to develop better means of incorporating patients' goals of care into orders that more faithfully guide care for both nonarrest and arrest situations.

Stop that Train! I Want to Get Off: Emergency Care for Patients with Advanced Dementia

Stop that Train! I Want to Get Off: Emergency Care for Patients with Advanced Dementia

Standardized Criteria for Palliative Care Consultation on a Solid Tumor Oncology Service Reduces Downstream Health Care Use.

Hospitalized patients with advanced cancer have a high symptom burden and need for support. Integration of palliative care (PC) improves symptom control and decreases unwanted health care use, yet many patients are never offered these services. In 2016, ASCO called for incorporation of PC into oncologic care for all patients with metastatic cancer. To improve the quality of cancer care, we developed standardized criteria, or triggers, for PC consultation on the inpatient solid tumor service. Patients were eligible for this prospective cohort study if they met at least one of the following eligibility criteria: had an advanced solid tumor; prior hospitalization within 30 days; hospitalization > 7 days; and active symptoms. During the intervention, patients who met the criteria received automatic PC consultation. When we compared patients in the intervention group with control subjects, there were increases in PC consultations (19 of 48 [39%] to 52 of 65 [80%]; P ≤ .001) and hospice referrals (seven of 48 [14%] to 17 of 65 [26%]; P = .03), and there were declines in 30-day readmission rates (17 of 48 [35%] to 13 of 65 [18%]; P = .04) and receipt of chemotherapy after discharge (21 of 48 [44%] to 12 of 65 [18%]; P = .03). There was an overall increase in support measures following discharge ( P = .004). Length of stay was unaffected. To our knowledge, this is the first study to demonstrate that among patients with advanced cancer admitted to an inpatient oncology service, the standardized use of triggers for PC consultation is associated with substantial impact on 30-day readmission rates, chemotherapy following discharge, hospice referrals, and use of support services following discharge. Expansion of this model to other hospitals and health systems should improve the value of cancer care.

Clinical Momentum in the Intensive Care Unit. A Latent Contributor to Unwanted Care.

Many older adults in the United States receive invasive medical care near the end of life, often in an intensive care unit (ICU). However, most older adults report preferences to avoid this type of medical care and to prioritize comfort and quality of life near death. We propose a novel term, "clinical momentum," to describe a system-level, latent, previously unrecognized property of clinical care that may contribute to the provision of unwanted care in the ICU. The example of chronic critical illness illustrates how clinical momentum is generated and propagated during the care of patients with prolonged illness. The ICU is an environment that is generally permissive of intervention, and clinical practice norms and patterns of usual care can promote the accumulation of multiple interventions over time. Existing models of medical decision-making in the ICU describe how individual signs, symptoms, or diagnoses automatically lead to intervention, bypassing opportunities to deliberate about the value of an intervention in the context of a patient's likely outcome or treatment preferences. We hypothesize that clinical momentum influences patients, families, and physicians to accept or tolerate ongoing interventions without consideration of likely outcomes, eventually leading to the delivery of unwanted care near the end of life. In the future, a mixed-methods research program could refine the conceptual model of clinical momentum, measure its impact on clinical practice, and interrupt its influence on unwanted care near the end of life.

A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions

Although many older adults prefer to avoid burdensome interventions with limited ability to preserve their functional status, aggressive treatments, including surgery, are common near the end of life. Shared decision making is critical to achieve value-concordant treatment decisions and minimize unwanted care. However, communication in the acute inpatient setting is challenging. To evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework as a strategy to change surgeon communication and promote shared decision making during high-stakes surgical decisions. Our prospective pre-post study was conducted from June 2014 to August 2015, and data were analyzed using a mixed methods approach. The data were drawn from decision-making conversations between 32 older inpatients with an acute nonemergent surgical problem, 30 family members, and 25 surgeons at 1 tertiary care hospital in Madison, Wisconsin. A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. We scored conversation transcripts using OPTION 5, an observer measure of shared decision making, and used qualitative content analysis to characterize patterns in conversation structure, description of outcomes, and deliberation over treatment alternatives. The study participants were patients aged 68 to 95 years (n = 32), 44% of whom had 5 or more comorbid conditions; family members of patients (n = 30); and surgeons (n = 17). The median OPTION 5 score improved from 41 preintervention (interquartile range, 26-66) to 74 after Best Case/Worst Case training (interquartile range, 60-81). Before training, surgeons described the patient's problem in conjunction with an operative solution, directed deliberation over options, listed discrete procedural risks, and did not integrate preferences into a treatment recommendation. After training, surgeons using Best Case/Worst Case clearly presented a choice between treatments, described a range of postoperative trajectories including functional decline, and involved patients and families in deliberation. Using the Best Case/Worst Case framework changed surgeon communication by shifting the focus of decision-making conversations from an isolated surgical problem to a discussion about treatment alternatives and outcomes. This intervention can help surgeons structure challenging conversations to promote shared decision making in the acute setting.

Improving end-of-life care: Recommendations from the IOM.

A 2014 consensus report by the Institute of Medicine offers recommendations for healthcare providers to decrease unwanted care and improve the quality of life at the end of life. This article discusses the recommendations of interest to advanced practice registered nurses.

Using a Palliative Care Framework for Seriously Ill Surgical Patients: The Example of Malignant Bowel Obstruction.

In the recent report Dying in America: Addressing Key End of Life Issues, 1 the Institute of Medicine declared improving access to palliative care for seriously ill patients a national priority to address the crisis of low-value health care for patients near the end of life. Patients report comfort, symptom control, and dignity as central to achieving a “good death,” yet increasing numbers experience pain, unwanted health care transitions, and intensive care near the end of life. Surgeons play a critical role as providers of end-of-life care. Among Medicare decedents, almost one-third have surgery in the year before death, many in the last week of life, 2 and up to 25% of patients diagnosed as having stage IV cancer undergo a surgical procedure. Palliative care, an approach to care focused on improving quality of life for patients with lifethreatening illness and their families, is associated with improved symptom management, improved communication, and fewer care transitions for seriously ill patients. Although surgeons routinely care for seriously ill patients, the role of palliative care in surgery remains poorly defined. 3 Herein, we use malignant bowel obstruction (MBO) as an example of how surgeons can integrate principles of palliative care to support surgical care for patients with life-threatening illness. Management of MBO exemplifies the convergence of surgery and palliative care. Although survival varies based on cancer type and prognostic features, MBO is typically a late complication of advanced cancer, with life expectancy limited to weeks or months after onset. 4 Patient suffering can be immense with their remaining days fraught with high symptom burden, impaired quality of life, and hospitalization. Depending on anatomical features of the obstruction, surgical palliation via resection, bypass, or venting gastrostomy may offer select patients significant gains in quality of life. 4,5 However, substantial personal cost may accompany the pursuit of symptom relief in the form of prolonged recovery or burdensome complications, diminishing the benefits of treatment. As surgeons are increasingly called on to provide palliative interventions to seriously ill patients, their patients would benefit from strategies commonly used in palliative care to deliver goal-concordant care that is informed by patients’ values and health care priorities.

Clinician Perspectives on Challenges to Patient Centered Care at the End of Life.

Discussions regarding patient preferences for resuscitation are often delayed and preferences may be neglected, leading to the receipt of unwanted medical care. To better understand barriers to the expression and realization of patients' end of life wishes, a preventive ethics team in one Veterans Affairs Medical Center conducted a survey of physicians, nurses, social workers, and respiratory therapists. Surveys were analyzed through qualitative analysis, using sorting methodologies to identify themes. Analysis revealed barriers to patient wishes being identified and followed, including discomfort conducting end-of-life discussions, difficulty locating patients' preferences in medical records, challenges with expiring do not resuscitate (DNR) orders, and confusion over terminology. Based on these findings, the preventive ethics team proposed new terminology for code status preferences, elimination of the local policy for expiration of DNR orders, and enhanced systems for storing and retrieving patients' end-of-life preferences. Educational efforts were initiated to facilitate implementation of the proposed changes.

Early discussion of advance directives for patients with newly diagnosed cancer.

91 Background: Although advance care planning and the completion of advance directives (ADs) are important methods to prevent unwanted aggressive care once patients have lost their decision-making capacity, only a minority of patients have ADs at the time of cancer diagnosis. Methods: We established a new multidisciplinary outpatient clinic to provide comprehensive care to patients with newly diagnosed cancer at the Inova Dwight and Martha Schar Cancer Institute in Northern Virginia. Improvement in advance care planning was chosen as one of the first quality improvement initiatives for 2015. We started the first PDSA cycle after creating the team, establishing the problem and goal statement, and reviewing the process map. We had three measures including: 1. Inquiring whether the patient has advance directives or not at the time of scheduling their first appointment, 2. Provide written information about advance directives at the patient’s first visit, 3. Obtain advance directives by the third office visit. The goal for each measure was 90%, 90%, and 50% by the end of 2015. Results: Between May-June 2015, 65 patients were evaluable. Baseline rates were 26%, 2%, and 12%, respectively for measures 1, 2, and 3. In July 2015, we convened a staff meeting to review each staff’s role in the process of advance care planning. The new patient schedulers had training and created a telephone script to effectively communicate advance directives information with patients. The front desk staff included written information about advance care planning in the new patient information folders. Clinical staff were asked to address any questions or concerns that patients have and to encourage patients to complete the ADs by next visit. After this intervention, the rates increased to 100%, 44%, and 33%, respectively for measures 1, 2, and 3 in August and September, 2015 (n = 45). Conclusions: Early discussion about the ADs for newly diagnosed cancer patients at our outpatient clinic showed improvement in the rate of completed ADs by a third office visit.

Early extubation and fast-track management of off-pump cardiac patients in the intensive care unit.

Off-pump surgery was the original approach to treating patients with cardiac disease in the era before cardiopulmonary bypass. With the advent and refinement of cardiopulmonary bypass, the use of this technique fell out of favor and was quickly surpassed by on-pump techniques. However, the limitations of bypass surgery, especially for coronary artery bypass procedures, was still significant, leading to renewed interest in this technique. Postoperative care for off-pump coronary artery bypass (OPCAB) surgery presents both a challenge and opportunity to the intensivist. OPCAB patients can be treated in a fast-track manner allowing rapid recovery and early extubation and discharge from the intensive care unit. This is supported through the use of protocols that help standardize care and set expectations for the post-cardiac care team. Importantly, complications that may delay recovery including hypothermia, hypotension, and bleeding must be recognized early and treated aggressively to prevent unwanted complications and intensive care delays. Finally, care of these patients has shifted to the post-anesthesia recovery room, making knowledge of the care of these patients in the early postoperative period essential for cardiac anesthesiologists. This article will discuss the care of OPCAB patients following surgery and include approaches to managing patients who return both intubated and extubated.

Perspectives concerning living wills in medical staff of a main regional hospital in Japan.

Objective: Living wills, written types of advanced directives, are now widespread in western countries, but in Japan, their recognition still remains restricted to a small part of the population. As an initial step to introduction of such patient-oriented medicine, we surveyed present recognition and acceptance patterns concerning living wills in a main regional hospital located in a suburban area of Tokyo.Methods: Without any preceding guidance on living wills, the questionnaire on living wills was distributed to all the staff working at JA Toride Medical Center in September 2013, and their responses were collected for analysis within one month.Results: Questionnaires were distributed to all hospital staff, 843 in total, and 674 responses (80.0% of distributed) were obtained. The term of living will was known by 304 (45.1%) of the respondents, and introduction of living wills to patients was accepted in 373 (55.3%) of the respondents, meanwhile, 286 (42.4%) respondents did not indicate their attitude toward living wills. As to styles of document form, 332 respondents (49.3%) supported selection of wanted or unwanted medical treatments and care from a prepared list, and 102 respondents (15.1%) supported description of living wills in free form. As preferred treatment options that should be provided as a checklist, cardiac massage (chest compression) and a ventilator were selected by more than half of the respondents. Based on their responses, we developed an original type of living wills available to patients visiting the hospital.Conclusions: Although not all the respondents were aware of living wills even in this main regional hospital, introduction of living wills to patients was accepted by many of the hospital staff. Awareness programs or information campaigns are needed to introduce living wills to support patient-centered medicine.