Ensuring Competency in End-of-Life Care

Gunten, Charles F. von; Ferris, Frank D.; Emanuel, Linda L.

doi:10.1001/jama.284.23.3051

Cited by 221 publications

(44 citation statements)

References 39 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…A multidisciplinary team, with expertise in speech communication, palliative care, and critical care, identified best practice behaviors from the pedagogical literature on patient-doctor communication and shared decision making, with particular attention to end-of-life contexts. [15][16][17] We categorized the behaviors into two domains: emotion and discussion of end-of-life goals. We identified six behaviors used to handle emotions: naming an emotion; expressing understanding; showing respect; showing support; exploring the emotion, and articulating an ''I wish'' statement (a desire of the physician to accomplish something he/she could not control).…”

Section: Methodsmentioning

confidence: 99%

“…15 We identified nine cognitive steps involved in discussions about the patient's end-of-life goals: preparing for the discussion; assessing perception; asking for an invitation to disclose information; eliciting and responding to preferences; sharing prognostic information; asking if the patient had questions; checking for agreement with the plan; affirming the patient's decision, and asking if the patient needed familial or spiritual support. 16,17 As shown in Table 1, we coded 17 behaviors related to these 9 steps. To reliably identify these communication behaviors, we developed a detailed codebook containing definitions and examples for each of the 23 behaviors.…”

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

Communication Practices in Physician Decision-Making for an Unstable Critically Ill Patient with End-Stage Cancer

Alexander

Garrigues

Arnold

et al. 2010

Journal of Palliative Medicine

View full text Add to dashboard Cite

Background: Shared decision-making has become the standard of care for most medical treatments. However, little is known about physician communication practices in the decision making for unstable critically ill patients with known end-stage disease. Objective: To describe communication practices of physicians making treatment decisions for unstable critically ill patients with end-stage cancer, using the framework of shared decision-making. Design: Analysis of audiotaped encounters between physicians and a standardized patient, in a high-fidelity simulation scenario, to identify best practice communication behaviors. The simulation depicted a 78-year-old man with metastatic gastric cancer, life-threatening hypoxia, and stable preferences to avoid intensive care unit (ICU) admission and intubation. Blinded coders assessed the encounters for verbal communication behaviors associated with handling emotions and discussion of end-of-life goals. We calculated a score for skill at handling emotions (0-6) and at discussing end of life goals (0-16). Subjects: Twenty-seven hospital-based physicians. Results: Independent variables included physician demographics and communication behaviors. We used treatment decisions (ICU admission and initiation of palliation) as a proxy for accurate identification of patient preferences. Eight physicians admitted the patient to the ICU, and 16 initiated palliation. Physicians varied, but on average demonstrated low skill at handling emotions (mean, 0.7) and moderate skill at discussing end-of-life goals (mean, 7.4). We found that skill at discussing end-of-life goals was associated with initiation of palliation ( p ¼ 0.04). Conclusions:It is possible to analyze the decision making of physicians managing unstable critically ill patients with end-stage cancer using the framework of shared decision-making.

show abstract

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Communication Practices in Physician Decision-Making for an Unstable Critically Ill Patient with End-Stage Cancer

Alexander

Garrigues

Arnold

et al. 2010

Journal of Palliative Medicine

View full text Add to dashboard Cite

show abstract

“…Step Pathway) (34). This approach enables the sharing of information and experience about these cases, allows for discussion of the solutions and support among fellow physicians during the training meetings that are organized by HECs.…”

Section: Original Articlementioning

confidence: 99%

Proposal for a Hospital Ethics Committee at the Hacettepe University Hospitals, Turkey: A Mixed Method Study

Demir¹,

Büken²

2016

Acta Med Anatol

View full text Add to dashboard Cite

Introduction: Hospital Ethics Committees (HECs) were established to solve the ethical dilemmas experienced by health personnel in clinics. However, HECs also provide training on ethics, and develop ethics guidelines and institutional policies. HECs first appeared in the USA in the 1960s and had become widespread in Europe by the 1990s. In Turkey, the introduction of HECs is relatively recent and the number of committees is limited. The aim of this study was to identify the need for a HEC at the Hacettepe University Hospitals (HUHs) and to develop an appropriate model for the HEC. Methods:Both qualitative and quantitative research methods were used. As a part of the qualitative research, focus group interviews were conducted with physicians in the intensive care unit of the HUHs. Survey forms were prepared, with reference to the data, which were collected during these interviews. The quantitative research was conducted by distributing survey forms to all physicians working at the HUHs. Data were evaluated using SPSS v.11.5 software. Results: In total, 250 surveys were completed (participation ratio 25%). Physicians who participated in the research confirmed the need for an organization to provide training on ethics, to prepare ethics guidelines and to help solve ethical dilemmas. Conclusion: Here a model for a HEC is proposed, with reference to the needs and suggestions of the physicians who work at the HUHs. Keywords: Medical ethics, clinical ethics committee, hospital ethics committee, ethics consultation.

show abstract

“…9 These two cases suggest that there can be confusion as to what a do-not-resuscitate order implies. Each death appears to have had, as its proximate cause, a reversible and common drug error -a narcotic drug overdose leading to respiratory arrest and cardiovascular collapse.…”

Section: Casesmentioning

confidence: 99%

Should a reversible, but lethal, incident not be treated when a patient has a do-not-resuscitate order?

Hébert¹,

Selby

2013

CMAJ

View full text Add to dashboard Cite

Despite the frequency of use of do-notresuscitate orders, there is still uncertainty regarding their optimal use. We discuss a controversial issue concerning end-oflife care arising from two cases from the Office of the Chief Coroner for Ontario: What are the limits of medical therapy for patients who have a critical incident and for whom a do-not-resuscitate order has already been written? CasesCase 1 A 90-year-old woman lived independently, despite a history of stroke, congestive heart failure, emphysema, osteoporosis and hypothyroidism. After a fall in her residence during the winter, she presented to the emergency department of her local hospital where she was given long -acting morphine orally to control pain in her chest wall. With a diagnosis of pneumonia and renal failure, the patient was transferred to a ward, where the morphine was discontinued and hydromorphone was ordered in its place. Unfortunately, the patient received both analgesics. Two days after admission to the ward, she was found unrousable. Narcotic overdose was considered. After a single bolus dose of naloxone intravenously, the patient became alert; however, left alone for a few minutes, she was then found without vital signs. No further attempt at resuscitation was attempted because a do-notresuscitate order had been previously entered in her chart at her request. Case 2A 42-year-old woman who had received a diagnosis of breast cancer was found to have bony metastases four years later, for which she underwent hormonal treatment in conjunction with chemotherapy and radiotherapy. Esophageal stricture developed, and the patient required bougienage 11 and 12 years after the initial diagnosis. The year after the patient's last bougienage, she was admitted to hospital with dehydration, dysphagia and poorly controlled pain. In the emergency department, she received small doses of morphine intravenously. Upon transfer to the ward, the patient was inadvertently given hydromorphone instead of morphine. Shortly thereafter she was found not breathing. Resuscita tion was not performed because of a do-not -resuscitate order on her medical record. DiscussionPhysicians should be familiar with modern principles of end-of-life and palliative care for pa tients with terminal illnesses. Many guidelines have been developed and promulgated by professional societies and regulatory authorities.1 Central to highquality end-of-life care are the discussions physicians are encouraged to have with the patient and family, or substitute decision-maker, regarding the expected prognosis and the patient's wishes concerning end-of-life care. These discussions are particularly appropriate for patients with chronic illnesses and fragility for whom death would not be an unexpected outcome at any point. Resuscitation was originally devised for, and is most successful in, those circumstances where death due to cardiac arrest is unexpected and sudden (e.g., a near-drowning, sudden lethal arrhythmia).3 Cardiopulmonary resuscitation (CPR) subsequently became the default response ...

show abstract

Ensuring Competency in End-of-Life Care

Cited by 221 publications

References 39 publications

Communication Practices in Physician Decision-Making for an Unstable Critically Ill Patient with End-Stage Cancer

Communication Practices in Physician Decision-Making for an Unstable Critically Ill Patient with End-Stage Cancer

Proposal for a Hospital Ethics Committee at the Hacettepe University Hospitals, Turkey: A Mixed Method Study

Should a reversible, but lethal, incident not be treated when a patient has a do-not-resuscitate order?

Contact Info

Product

Resources

About