Rethinking Fundamental Assumptions: SUPPORT'S Implications for Future Reform

Lynn, Joanne; Arkes, Hal R.; Stevens, Marguerite; Cohn, Felicia; Koenig, Barbara A.; Fox, Ellen; Dawson, Neal V.; Phillips, Russell S.; Hamel, Mary Beth; Tsevat, Joel

doi:10.1111/j.1532-5415.2000.tb03135.x

Cited by 122 publications

(63 citation statements)

References 50 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Indeed, some nursing home structures and processes (e.g., quarterly care plan meetings) might be altered to make consensus easier to achieve and maintain. Lynn and colleagues 35 report, "Rather than trying to have patients, one by one, state their preferences and shape their own health care, reform should first center on ensuring that persons who do not explicitly state their wishes still get treatment that is close to what most people would want." For example, the role of care plans could be reconceptualized to emphasize the routine integration of palliative care issues.…”

Section: Discussionmentioning

confidence: 97%

"Getting Everyone on the Same Page": Nursing Home Physicians' Perspectives on End-of-Life Care

Bern‐Klug

Gessert

Crenner

et al. 2004

Journal of Palliative Medicine

View full text Add to dashboard Cite

For the 12 physicians in this study consensus about the resident's status and an appropriate care plan are important features of good end-of-life care. Further research is needed to determine if other members of the health care team (i.e., residents, family members, nursing staff, social worker, etc.) also value consensus highly. It will be important to determine what barriers to consensus other team members identify. Based on the understanding generated from this study, a refinement of the general Education for Physicians on End-of-Life Care (EPEC) model describing the relationship between curative and palliative care is proposed for nursing homes. The refinement underscores the points at which the team might consider revisiting consensus about the resident's status and care plan.

show abstract

Section: Discussionmentioning

confidence: 97%

"Getting Everyone on the Same Page": Nursing Home Physicians' Perspectives on End-of-Life Care

Bern‐Klug

Gessert

Crenner

et al. 2004

Journal of Palliative Medicine

View full text Add to dashboard Cite

show abstract

“…Several factors, such as the context (setting and culture 41 ) and the vocational training of each professional, may affect the perception of the "criticality" of decision for older people with advanced dementia. Physicians may have different perceptions 33 that can be explored only through discussions with those directly involved in the decisionmaking process.…”

Section: Typology Of Critical Decisionsmentioning

confidence: 99%

Critical Decisions for Older People With Advanced Dementia: A Prospective Study in Long-Term Institutions and District Home Care

Toscani¹,

Steen²,

Finetti³

et al. 2015

Journal of the American Medical Directors Association

View full text Add to dashboard Cite

Objective. To describe and compare the decisions critical for survival or quality of life (CDs) made for patients with advanced dementia in nursing homes (NHs) and home care (HC) services.Design. Prospective cohort study with a follow-up of 6 months.Setting. Lombardy Region (NHs) and Reggio-Emilia and Modena Districts (HC), Italy.Participants. Patients (496 total; 315 in NHs and 181 in HC) with advanced dementia (Functional Assessment Staging Tool score >7) and expected survival >2 weeks.Measurements. At baseline, the patients' demographic data, date of admission and of dementia diagnosis, type of dementia, main co-morbidities, presence of pressure sores, ongoing treatments, and current prescriptions were abstracted from clinical records. At baseline and every 15 days thereafter, information regarding the patients' general condition and CDs (deemed critical by the doctor or team) was collected via interview with the doctor. For each CD, the physician reported the problem that led to the decision, the decision that was eventually made, the purpose of the decision, whether the decision had been discussed with and/or communicated to the family, who made the final decision, whether the decision was maintained after one week, whether it corresponded to what the doctor would have judged appropriate, and the expected survival of the patient (≤15 days).Results. For 267 of the 496 patients (53.8%; 60.3% in NHs and 42.5% at home), 644 CDs were made; for 95 patients, more than one CD was made. The problems that led to a CD were mainly infections (respiratory tract and other infections; 46.6%, 300/644 CDs); nutritional/hydration problems (20.6%; 133 CDs) and the worsening of a pre-existing disease (9.3%; 60 CDs). The most frequent type of decision concerned the prescription of antibiotics (overall 41.1%, 265/644; among NH patients 44.6%, 218/488; among HC patients, 30.2%, 47/156). The decision to hospitalize the patient was more frequently reported for HC than NH patients (25.5% vs. 3.1%). The most frequent purposes of the CDs in both settings were reducing symptoms or suffering (more so in NHs; 81.1 vs. 57.0% in HC) and prolonging survival (NH 27.5%; HC 23.1%; multiple purposes were possible). For 26 decisions (3.8%), the purpose was to ease death or not to prolong life. Conclusions.Decisions critical for the survival or quality of life of patients with advanced dementia were made for approximately half of the patients during a 6-month time frame, and such decisions were made more frequently in NHs than in HC. HC patients were more frequently hospitalized, and a sizeable minority of these patients were treated with the goal of prolonging survival. Italian patients with advanced dementia may benefit from the implementation of 5 palliative care principles, and HC patients may benefit from the implementation of measures to avoid hospitalizing patients near the end of life.

show abstract

“…42 Although some family members do not want to be involved in these decisions 43 despite patients' requests 44 and often display unstable preferences concurrent to an unwillingness to take responsibility for end-of-life decisions, 30,45 this perspective is supported by both regional ethical standards and legal liability issues. 19,21,30,37 It is also logical given the frequent disparity in opinions among physicians (< 10%), patients (40%) and families (32%) regarding their desire to use all available means to prolong life. 19 This reality is particularly interesting given the observation that the majority of HPB surgeons are willing to deliver invasive, costly and prolonged critical care in patients with severe complications and poor prognoses for 5-year survival.…”

Section: Discussionmentioning

confidence: 99%

Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey

et al. 2014

View full text Add to dashboard Cite

Background: Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors. Methods:We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care.Results: A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a universityaffiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experi ence, regional culture and training background impacted treatment (all p < 0.05). Conclusion:Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma. Contexte :Le traitement et les soins palliatifs pour l'adénocarcinome de la tête du pancréas sont complexes. Les décisions de fin de vie reposent sur un processus hautement variable qui dépend de multiples facteurs.Méthodes : Nous avons administré à des médecins un sondage international qualitatif à 40 questions afin de caractériser l'impact sur les soins exercé par différents facteurs, notamment médicaux, religieux, sociaux, relatifs à la formation et systémiques. Résultats :En tout, 258 cliniciens ont participé à ce sondage international. Les participants étaient en général des spécialistes (78 %), cumulaient en moyenne 16 ans d'expéri-ence dans le domaine hépatopancréatobiliaire (96 %) au sein d'un groupe affilié à une université (93 %). La plupart (91 %) ont dit croire que la résection est potentiellement curative. La majorité des cas faisaient l'objet de discussions préopératoires par des équipes multidisciplinaires (94 %) et en clinique d'évaluation médicale (68 %), mais rarement par une équipe de soins intensifs (21 %). Les soins palliatifs chirurgicaux peropératoires incluaient la double dérivation ou la non intervention en présence de tumeurs non résé-cables localement avancées (41 % et 49 % c. 14 % et 85 %, respectivement, chez les patients porteurs de métastases hépatiques). L'admission postopératoire aux soins ...

show abstract

Rethinking Fundamental Assumptions: SUPPORT'S Implications for Future Reform

Cited by 122 publications

References 50 publications

"Getting Everyone on the Same Page": Nursing Home Physicians' Perspectives on End-of-Life Care

"Getting Everyone on the Same Page": Nursing Home Physicians' Perspectives on End-of-Life Care

Critical Decisions for Older People With Advanced Dementia: A Prospective Study in Long-Term Institutions and District Home Care

Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey

Contact Info

Product

Resources

About