Journal of palliative medicine
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Reports describe patient and health care system benefits when clinicians engage in end-of-life conversations with patients diagnosed with life-limiting illnesses, yet most clinicians focus on life-preserving treatments and avoid conversations about end-of-life care. We describe patient-clinician communication practices about end-of-life care in patients with chronic obstructive pulmonary disease (COPD) using self-report questionnaires to: (1) characterize the content of patient-clinician communication about end-of-life care from the patient perspective, including topics that were not addressed and ratings of the quality of the communication for topics discussed and (2) determine whether clinician characteristics was associated with the absence of specific communication items addressed. ⋯ All end-of-life communication topics were underaddressed by clinicians, regardless of training, with four topics particularly unlikely to be discussed. End-of-life topics that are important to patients should be targeted for an intervention to facilitate improvement in clinicians' communication skills and practice and may improve patient satisfaction with clinician communication.
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In recent years numbers of referrals to intensive care units (ICU) throughout the United Kingdom has been increasing. A number of referrals to the ICU are considered to be inappropriate for a variety of reasons, including those patients who are felt to be either too well for admission, or have comorbidities making survival unlikely and aggressive interventions unsuitable. ⋯ The results suggest there are small numbers of patients with uncontrolled symptoms who could benefit from specialist input from the palliative care team. The identification of the imminently dying should facilitate appropriate communication of this by clinical staff and allow the relevant social, psychological, and spiritual preparations for death that are the hallmark of good care of the dying.
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Large gaps in the delivery of palliative care services exist in the outpatient setting, where there is a failure to address goals of care and to plan for and treat predictable crises. While not originally considered an ideal environment to deliver palliative care services, the emergency department presents a key decision point at which providers set the course for a patient's subsequent trajectory and goals of care. Many patients with serious and life-threatening illness present to emergency departments because symptoms, such as pain or nausea and vomiting, cannot be controlled at home, in an assisted living facility, or in a provider's office. Even for patients in whom goals of care are clear, families often need support for their loved one's physical as well as mental distress. The emergency department is often the only place that can provide needed interventions (e.g., intravenous fluids or pain medications) as well as immediate access to advanced diagnostic tests (e.g. computed tomography or magnetic resonance imaging). ⋯ Although some data on pilot programs are available, optimal models of delivery of emergency department-based palliative care have not been rigorously studied. Research is needed to determine how these services are best organized, what affect they will have on patients and caregivers, and whether they can decrease symptom burden and health care utilization.
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This study explores the distribution of public awareness, knowledge of availability, and readiness for palliative care services, and the perceived reliability of information resources as part of a nationwide palliative care implementation intervention in Japan (Outreach Palliative Care Trial of Integrated Regional Model [OPTIM]). ⋯ Findings show that the public awareness of palliative care services and their availability is insufficient, and cancer-related experiences affect awareness of cancer palliative care but not directly related to typical images for palliative care such as care for patients close to death.
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Review Case Reports
Acute renal failure requiring renal replacement therapy in the intensive care unit: impact on prognostic assessment for shared decision making.
A 69-year-old female was receiving renal replacement therapy (RRT) for acute renal failure (ARF) in an intensive care unit (ICU). Consultation was requested from the palliative medicine service to facilitate a shared decision-making process regarding goals of care. Clinician responsibility in shared decision making includes the formulation and expression of a prognostic assessment providing the necessary perspective for a spokesperson to match patient values with treatment options. ⋯ Data from the literature review provide baseline information that requires adjustment to reflect specific patient circumstances. The nature of the acute primary process, comorbidities, and severity of illness are key modifiers. Finally, the prognostic assessment is expressed during a family meeting using recommended principles of communication.