A 30-year-old gentleman with deafness and schizophrenia was admitted with multiple self-inflicted visceral stab wounds. He developed postoperative complications necessitating ongoing critical care. The parties involved were as follows: the patient, his parents, the critical care trauma service, the palliative and psychiatry consult services, and the ethics committee. Over the patient's hospital course, his parents struggled to reconcile his poor preinjury quality of life with his ongoing need for intensive medical intervention. The primary and consulting teams were required to integrate differing perspectives on the patient's past responsiveness to treatment and the extent to which additional efforts might advance his quality of life and limit his future suffering and suicidality. The patient's surrogate decision makers unanimously requested withdrawal of life support. An ethics committee convened to address the question of whether refractory schizophrenia can produce so poor a quality of life as to merit the withdrawal of life-sustaining measures after a suicide attempt. Consensus was achieved, and life-sustaining measures were subsequently withdrawn, allowing the patient to pass away peacefully in an inpatient hospice facility.
In the first 18 months, 16,570 ePOLST forms were generated across five states; 52% (8,548) included DNAR status, and 14% (2,311) also opted for comfort measures only. In patients with an ePOLST indicating DNAR, the alert was triggered approximately 200 times per month. Fifteen percent of the time, the ordering provider removed the apparently conflicting 'Full Code' status order and wrote an alternative code status order instead. This session will explore the principles and resources necessary to design and implement an ePOLST system. Updated data and detailed outcome analyses of the ePOLST clinical alert will be presented.
Describe the needs of DT-LVAD patients beyond their medical therapy and identify measures that support the multidisciplinary LVAD team. Destination therapy left ventricular assist devices (DT-LVAD) offer life in the setting of ultimate death with the device in situda trajectory that can be complicated for patients, caregivers, and providers. Advancements in LVAD technology and the growing concept of a truly multidisciplinary team have set the stage for a comprehensive program of support. However, with this life-sustaining therapy challenges persist in our endeavors to improve clinical and non-clinical outcomes. Significant challenges may arise for DT-LVAD patients, caregivers, and teams as patients transition from chronic LVAD support to comfort oriented care, in which a device may be properly functioning but the body weakening or a device decompensating in an otherwise stable patient. Although caregivers endure substantial burdens throughout the LVAD support trajectory, the level of caregiver burnout fluctuates and requires monitoring. Our focus in caring for this population must be twofolddon extending quality of life with this distinctive technology while simultaneously acknowledging the processes that will ultimately lead to end-of-life. Early and ongoing engagement of palliative care teams and DT-LVAD specific advance care planning (ACP) has the potential to augment patient-centered care and hone quality of life based interventions for patients and families. In this concurrent session, clinicians from a multidisciplinary team will define a novel approach to understanding the DT-LVAD advanced illness trajectory, reveal engaging strategies to break through barriers of complex ACP, uncover how bi-directional communication and education can enhance multidisciplinary team function, highlight the needs of DT-LVAD patients and caregivers beyond medical therapies, and discuss expanding options for approaching end-of-life care. Data from quality improvement work will provide an understanding of patient and caregiver quality of life approaching endof-life, clinician reported challenges, and system improvements in ACP processes. This session will offer clear strategies for redefining institutional best practices in collaborative and comprehensive DT-LVAD care.
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