Integration of Palliative Care in the Context of Rapid Response

Nelson, Judith E.; Mathews, Kusum S.; Weissman, David E.; Brasel, Karen J.; Campbell, Margaret L.; Curtis, J. Randall; Frontera, Jennifer A.; Gabriel, Michelle; Hays, Ross M.; Mosenthal, Anne C.; Mulkerin, Colleen; Puntillo, Kathleen; Ray, Daniel E.; Weiss, Stefanie P.; Bassett, Rick; Boss, Renee D.; Lustbader, Dana

doi:10.1378/chest.14-0993

Cited by 37 publications

(16 citation statements)

References 57 publications

(23 reference statements)

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“…14 Recently, it has become apparent that rapid response teams need to play a more significant role in palliative care and that the personnel sometimes need to discuss code statuses with patients. 16 If the definitions of DNR and cardiac arrest differ between a patient’s doctor and an RRS physician, DNR orders may harm patients; hence, DNR and cardiac arrest should be clearly defined within hospitals when an RRS is introduced.…”

Section: Discussionmentioning

confidence: 99%

What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective

Hiraoka¹,

Homma²,

Norisue³

et al. 2016

IJGM

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BackgroundJapan has no official guidelines for do-not-resuscitate (DNR) orders. Therefore, we investigated the effect of DNR orders on physician decision making in relation to performing noncardiopulmonary resuscitation (CPR) and CPR procedures.MethodsA case-scenario-based questionnaire that included a case of advanced cancer, a case of advanced dementia, and a case of nonadvanced heart failure was administered to physicians. The questions determined whether physicians would perform different non-CPR procedures and CPR procedures in the presence or absence of DNR orders. The number of non-CPR procedures each physician would perform and the number of physicians who would perform each non-CPR and CPR procedure in the absence and presence of DNR ocrders were compared. Physicians from three Japanese municipal acute care hospitals participated.ResultsWe analyzed 111 of 161 (69%) questionnaires. Physicians would perform significantly fewer non-CPR procedures in the presence of DNR orders than in the absence of DNR orders for all three case scenarios (median [interquartile range] percentages: Case 1: 72% [45%–90%] vs 100% [90%–100%]; Case 2: 55% [36%–72%] vs 91% [63%–100%]; Case 3: 78% [55%–88%] vs 100% [88%–100%]). Fewer physicians would perform non-CPR and CPR procedures in the presence of DNR orders than in the absence of DNR orders. However, considerable numbers of physicians would perform electric shock treatment for ventricular fibrillation in the presence of DNR orders (Case 1: 26%; Case 2: 16%; Case 3: 20%).ConclusionDNR orders affect physician decision making about performing non-CPR procedures. Although some physicians would perform CPR for ventricular fibrillation in the presence of DNR orders, others would not. Therefore, a consensus definition for DNR orders should be developed in Japan, otherwise DNR orders may cause harm.

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Section: Discussionmentioning

confidence: 99%

What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective

Hiraoka¹,

Homma²,

Norisue³

et al. 2016

IJGM

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“…Furthermore, PC belongs in the PICU/ICU because virtually all critically ill patients exhibit some level of PC need throughout their hospitalization ( 4 , 5 , 14 , 31 ); to meet patients’ extensive PPC needs, PICUs may benefit from making PPC universally accessible through an IMOC. PC is indicated in a wide range of patients, not only those confronting the terminal stages of illness ( 4 ).…”

Section: Resistance To Pc In the Icumentioning

confidence: 99%

A Review of the Integrated Model of Care: An Opportunity to Respond to Extensive Palliative Care Needs in Pediatric Intensive Care Units in Under-Resourced Settings

Grunauer

Mikesell

2018

Front. Pediatr.

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It is estimated that 6.3 million children who die annually need pediatric palliative care (PPC) and that only about 10% of them receive the attention they need because about 98% of them live in under-resourced settings where PPC is not accessible. The consultative model and the integrated model of care (IMOC) are the most common strategies used to make PPC available to critically ill children. In the consultative model, the pediatric intensive care unit (PICU) team, the patient, or their family must request a palliative care (PC) consultation with the external PC team for a PICU patient to be evaluated for special care needs. While the consultation model has historically been more popular, issues related to specialist availability, referral timing, staff’s personal biases, misconceptions about PC, and other factors may impede excellent candidates from receiving the attention they need in a timely manner. Contrastingly, in the IMOC, family-centered care, PC tasks, and/or PC are a standard part of the treatment automatically available to all patients. In the IMOC, the PICU team is trained to complete critical and PC tasks as a part of normal daily operations. This review investigates the claim that the IMOC is the best model to meet extensive PPC needs in PICUs, especially in low-resource settings; based on an extensive review of the literature, we have identified five reasons why this model may be superior. The IMOC appears to: (1) improve the delivery of PPC and pediatric critical care, (2) allow clinicians to better respond to the care needs of patients and the epidemiological realities of their settings in ways that are consistent with evidence-based recommendations, (3) facilitate the universal delivery of care to all patients with special care needs, (4) maximize available resources, and (5) build local capacity; each of these areas should be further researched to develop a model of care that enables clinicians to provide pediatric patients with the highest attainable standard of health care. The IMOC lays out a pathway to provide the world’s sickest, most vulnerable children with access to PPC, a human right to which they are entitled by international legal conventions.

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“…Intensivist input can also be important for conditions that will probably result in ICU admission (e.g., transplantation or cardiac surgery), and also in the management of patients with severe chronic pathologies in an attempt to prevent deterioration requiring ICU admission. These teams can also help instigate discussion regarding goals of care for individual patients, including appropriateness (or not) of ICU admission and end-of-life decision-making [ 26 , 27 ]. The question of intermediate care units is a complex one--although this approach may initially seem to be a solution to limited ICU beds, there is little evidence that it is beneficial in terms of costs or outcomes [ 28 ].…”

Section: Paradigm Shiftsmentioning

confidence: 99%

Paradigm shifts in critical care medicine: the progress we have made

Vincent

Créteur

2015

Crit Care

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There have really been no single, major, advances in critical care medicine since the specialty came into existence. There has, however, been a gradual, continuous improvement in the process of care over the years, which has resulted in improved patient outcomes. Here, we will highlight just a few of the paradigm shifts we have seen in processes of critical care, including the move from small, closed units to larger, more open ICUs; from a paternal "dictatorship" to more "democratic" team-work; from intermittent to continuous, invasive to less-invasive monitoring; from "more" interventions to "less" thus reducing iatrogenicity; from consideration of critical illness as a single event to realization that it is just one part of a trajectory; and from "four walls" to "no walls" as we take intensive care outside the physical ICU. These and other paradigm shifts have resulted in improvements in the whole approach to patient management, leading to more holistic, humane care for patients and their families. As critical care medicine continues to develop, further paradigm shifts in processes of care are inevitable and must be embraced if we are to continue to provide the best possible care for all critically ill patients.

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Integration of Palliative Care in the Context of Rapid Response

Cited by 37 publications

References 57 publications

What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective

What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective

A Review of the Integrated Model of Care: An Opportunity to Respond to Extensive Palliative Care Needs in Pediatric Intensive Care Units in Under-Resourced Settings

Paradigm shifts in critical care medicine: the progress we have made

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Integration of Palliative Care in the Context of Rapid Response

Cited by 37 publications

References 57 publications

What is the true definition of a &quot;Do-Not-Resuscitate&quot; order? A Japanese perspective

What is the true definition of a &quot;Do-Not-Resuscitate&quot; order? A Japanese perspective

A Review of the Integrated Model of Care: An Opportunity to Respond to Extensive Palliative Care Needs in Pediatric Intensive Care Units in Under-Resourced Settings

Paradigm shifts in critical care medicine: the progress we have made

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What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective

What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective