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author:("dodec, Peter")
1.  What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families 
The guideline-recommended elements to include in discussions about goals of care with patients with serious illness are mostly based on expert opinion. We sought to identify which elements are most important to patients and their families.
We used a cross-sectional study design involving patients from 9 Canadian hospitals. We asked older adult patients with serious illness and their family members about the occurrence and importance of 11 guideline-recommended elements of goals-of-care discussions. In addition, we assessed concordance between prescribed goals of care and patient preferences, and we measured patient satisfaction with goals-of-care discussions using the Canadian Health Care Evaluation Project (CANHELP) questionnaire.
Our study participants included 233 patients (mean age 81.2 yr) and 205 family members (mean age 60.2 yr). Participants reported that clinical teams had addressed individual elements of goals-of-care discussions infrequently (range 1.4%–31.7%). Patients and family members identified the same 5 elements as being the most important to address: preferences for care in the event of life-threatening illness, values, prognosis, fears or concerns, and questions about goals of care. Addressing more elements was associated with both greater concordance between patients’ preferences and prescribed goals of care, and greater patient satisfaction.
We identified elements of goals-of-care discussions that are most important to older adult patients in hospital with serious illness and their family members. We found that guideline-recommended elements of goals-of-care discussions are not often addressed by health care providers. Our results can inform interventions to improve the determination of goals of care in the hospital setting.
PMCID: PMC4259796  PMID: 25367427
3.  An Official American Thoracic Society Systematic Review: The Association between Health Insurance Status and Access, Care Delivery, and Outcomes for Patients Who Are Critically Ill 
Rationale: One in three Americans under 65 years of age does not have health insurance during some portion of each year. Patients who are critically ill and lack health insurance may be at particularly high risk of morbidity and mortality due to the high cost of intensive care.
Objectives: To systematically review the medical and nonmedical literature to determine whether differences in critical care access, delivery, and outcomes are associated with health insurance status.
Methods: Nine electronic databases (inception to 11 April 2008) were independently screened and abstracted in duplicate.
Measurements and Main Results: From 5,508 citations, 29 observational studies met eligibility criteria. Among the general U.S. population, patients who were uninsured were less likely to receive critical care services than those with insurance (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.55–0.56). Once admitted to the intensive care unit, patients who were uninsured had 8.5% (95% CI, 6.0–11.1) fewer procedures, were more likely to experience hospital discharge delays (OR 4.51; 95% CI, 1.46–13.93), and were more likely to have life support withdrawn (OR 2.80; 95% CI, 1.12–7.02). Lack of insurance may confer an independent risk of death for patients who are critically ill (OR 1.16; 95% CI, 1.01–1.33). Patients in managed care systems had 14.3% (95% CI, 11.5–17.2) fewer procedures in intensive care, but were also less likely to receive “potentially ineffective” care. Differences in unmeasured confounding factors may contribute to these findings.
Conclusions: Patients in the United States who are critically ill and do not have health insurance receive fewer critical care services and may experience worse clinical outcomes. Improving preexisting health care coverage, as opposed to solely delivering more critical care services, may be one mechanism to reduce such disparities.
PMCID: PMC3269233  PMID: 20430926
insurance; disparities; payer; critical care; intensive care; access; outcome; Medicare; managed care; Medicaid
4.  Defining priorities for improving end-of-life care in Canada 
High-quality end-of-life care should be the right of every Canadian. The objective of this study was to identify aspects of end-of-life care that are high in priority as targets for improvement using feedback elicited from patients and their families.
We conducted a multicentre, cross-sectional survey involving patients with advanced, life-limiting illnesses and their family caregivers. We administered the Canadian Health Care Evaluation Project (CANHELP) questionnaire along with a global rating question to measure satisfaction with end-of-life care. We derived the relative importance of individual questions on the CANHELP questionnaire from their association with a global rating of satisfaction, as determined using Pearson correlation coefficients. To determine high-priority issues, we identified questions that had scores indicating high importance and low satisfaction.
We approached 471 patients and 255 family members, of whom 363 patients and 193 family members participated, with response rates of 77% for patients and 76% for families. From the perspective of patients, high-priority areas needing improvement were related to feelings of peace, to assessment and treatment of emotional problems, to physician availability and to satisfaction that the physician took a personal interest in them, communicated clearly and consistently, and listened. From the perspective of family members, similar areas were identified as high in priority, along with the additional areas of timely information about the patient’s condition and discussions with the doctor about final location of care and use of end-of-life technology.
End-of-life care in Canada may be improved for patients and their families by providing better psychological and spiritual support, better planning of care and enhanced relationships with physicians, especially in aspects related to communication and decision-making.
PMCID: PMC2972350  PMID: 20921249
5.  Mind the gap: Opportunities for improving end-of-life care for patients with advanced heart failure 
The Canadian Journal of Cardiology  2009;25(11):635-640.
Patients with advanced heart failure (HF) experience progressive symptoms, decreased quality of life, and more frequent hospitalizations as they approach the end of life (EOL). Understanding patient perspectives and preferences regarding EOL issues is necessary to identify key opportunities for improving care.
To identify, from the patient’s perspective, the major opportunities for improving EOL care for patients hospitalized because of advanced HF.
A cross-sectional survey of patient perspectives regarding EOL care was administered via interview of 106 hospitalized patients who had advanced HF in five tertiary care centres across Canada. The study compared which aspects of EOL care patients rated as ‘extremely important’ and their level of satisfaction with these aspects of EOL care to identify key opportunities for improvement of care.
The greatest opportunities for improvement in EOL care were reducing the emotional and physical burden on family, having an adequate plan of care following discharge, effective symptom relief and opportunities for honest communication. The three most important issues ranked by patients were avoidance of life support if there was no hope for a meaningful recovery, communication of information by the doctor and avoidance of burden for the family.
Advanced care planning that seamlessly bridges hospital and home must be standard care for patients who have advanced HF. Components must include coordination of care, caregiver support, comprehensive symptom management, and effective communication regarding HF and EOL issues.
PMCID: PMC2776565  PMID: 19898695
Advanced care planning; End-of-life care; Heart failure
6.  Pneumothorax after insertion of central venous catheters in the intensive care unit: association with month of year and week of month 
Quality & Safety in Health Care  2007;16(4):252-255.
One of the complications associated with insertion of central venous catheters (CVCs) is pneumothorax (PTX). Because of housestaff inexperience, it was hypothesised that rates of PTX after insertion of CVCs in teaching hospitals would be highest in July and August and in the first week of the month (beginning of intensive care unit (ICU) rotation).
In a retrospective analysis of data from patients admitted to the ICU in two tertiary care teaching hospitals in British Columbia from 1999 to 2005, rates of PTX occurring after insertion of CVCs were calculated, and it was evaluated whether rates were increased during certain times of the year/month.
During this period, 3548 patients were admitted to these ICUs and had at least one CVC placed. 5816 CVCs were inserted; 113 PTX occurred within 2 days after insertions (1.9% per CVC). The rate during the last week of the month was greater (2.7%) than during the first, second or third weeks (1.7%, 1.8% and 1.4%, respectively). This effect persisted after controlling for the Acute Physiology and Chronic Health Evaluation II score, the number of catheters placed per patient, gender, age and hospital. Rates of PTX after catheter placement did not vary by the month of the year.
The rate of PTX after insertion of CVCs is greatest in the last week of the month. If this effect can be verified in other centres, increased supervision of residents at the end of ICU rotations when placing CVCs should be considered. Whether this effect applies to other patient safety outcomes in the ICU also needs further study.
PMCID: PMC2464953  PMID: 17693670
7.  Medication Error Reporting Systems: A Survey of Canadian Intensive Care Units 
Patients in the intensive care unit (ICU) have complex problems and experience many medical errors. Currently, little is known about the measurement of medication errors and adverse drug events in Canadian ICUs.
To investigate methods of measuring medication errors and adverse drug events in ICUs in Canada.
A questionnaire was constructed and uploaded to an online survey tool, SurveyMonkey. Through the mailing list software of the Critical Care Pharmacy Specialty Network of the Canadian Society of Hospital Pharmacists, the survey was sent by e-mail to 146 pharmacists working in 79 ICUs across Canada; 2 reminder e-mails followed. The survey was open from July 18 to September 18, 2007.
A total of 34 individual responses were received from 31 (39%) of the 79 ICUs. Responses were from academic hospitals (11/31 [35%]), community teaching hospitals (9/31 [29%]), and community nonteaching hospitals (11/31 [35%]). Twenty-six (84%) of the 31 responding ICUs had a process for tracking medication errors and adverse drug events: non-anonymous voluntary reporting (19 or 73%), direct observation (14 or 54%), anonymous voluntary reporting (12 or 46%), chart review (6 or 23%), computerized system (3 or 12%), trigger tools (2 or 8%), pharmacist intervention (2 or 8%), and weekly ICU “safety huddles” (1 or 4%). Fourteen (54%) of the 26 ICUs that had a method of measuring medication errors and adverse drug events had implemented changes to address identified problems.
Most respondents were measuring the frequency of medication errors and adverse drug events, but a wide variety of methods were in use. Only about half of the ICUs had implemented changes as a result of these measurements. There is an opportunity to improve standardization of the measurement of medication errors and adverse drug events in Canadian ICUs.
PMCID: PMC2832561  PMID: 22478949
medication safety; intensive care unit; reporting system; sécurité des médicaments; unité de soins intensifs; système de déclaration
8.  Toward optimal end-of-life care for patients with advanced chronic obstructive pulmonary disease: Insights from a multicentre study 
Understanding patients’ needs and perspectives is fundamental to improving end-of-life (EOL) care. However, little is known of what quality care means to patients who have advanced lung disease.
To describe ratings of importance and satisfaction with elements of EOL care, informational needs, decision-making preferences, obstacles to a preferred location of death, clinical outcomes, and health care use before and during an index hospital admission for patients who have advanced chronic obstructive pulmonary disease (COPD).
A questionnaire with regard to quality EOL care was administered to patients older than 55 years of age who had advanced medical disease in five Canadian teaching hospitals.
For 118 hospitalized patients who had advanced COPD, the following items were rated as extremely important for EOL care: not being kept alive on life support when there is little hope for meaningful recovery (54.9% of respondents), symptom relief (46.6%), provision of care and health services after discharge (40.0%), trust and confidence in physicians (39.7%), and not being a burden on caregivers (39.6%). Compared with patients who had metastatic cancer, patients with COPD had lower (P<0.05) satisfaction with care, interest in information about prognosis, cardiopulmonary resuscitation or mechanical ventilation, and referral rates to palliative care, whereas use of acute care services was higher (P<0.05) for patients who had advanced COPD.
Canadian patients who have advanced COPD identify several priorities for improving care. Avoidance of prolonged or unwanted life support requires more effective communication, decision making and goal setting. Patients also deserve better symptom control and postdischarge strategies to minimize perceived burdens on caregivers, emergency room visits and hospital admissions.
PMCID: PMC2679546  PMID: 18716686
Chronic obstructive pulmonary disease; Decision making; End-of-life care
9.  Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care 
Open Medicine  2009;3(2):e101-e110.
Seriously ill patients and their physicians often avoid discussing prognosis, which may compromise optimal end-of-life (EOL) care planning. The relation between prognosis discussion and patient and family satisfaction with EOL care is unknown.
Using a 5-domain questionnaire, we surveyed inpatients with cancer or end-stage medical disease and their families on their satisfaction with specific aspects of EOL care and their overall satisfaction with EOL care. Scores were standardized to 0–100 points. We compared the results based on whether or not a physician had discussed the patient’s prognosis with them, as well as on whether the patient and family member agreed on whether the patient was nearing the end of life. Supplementary questions were also asked (e.g., preferred location of death, willingness to discuss cardiopulmonary resuscitation).
Of 569 eligible patients and 176 eligible family members, 440 (77%) patients and 160 (91%) family members participated in the study. Overall, 18% of patients and 30.1% of families recalled a prognosis discussion with a physician. Patients who recalled such a discussion were more satisfied with overall care (76.1 v. 73.1 points, difference 3.0, 95% confidence interval [CI] 0.40 to 5.67, p = 0.02) and with communication and decision-making aspects of care (77.9 v. 72.4 points, difference 5.5, 95% CI 1.43 to 9.52, p = 0.008), and were more willing to discuss cardiopulmonary resuscitation status (69.6% v. 55.3%, difference 14.3, 95% CI 2.15 to 26.45, p = 0.03), than those who did not. Patients who were in accord with their family member as to whether they were nearing the end of life also showed significant satisfaction in these 3 areas. Family members’ overall satisfaction was also higher among those who recalled a prognosis discussion (75.3 v. 70.4 points, difference 4.9, 95% CI 0.53 to 9.24, p = 0.03). Multivariate analyses confirmed the significance of the relation between the prognosis discussion and overall satisfaction with care for both patients and family members.
Although discussions about prognosis occur infrequently for patients who have advanced terminal disease, such discussions with patients and their families may facilitate advance care planning and improve satisfaction with EOL care. Encouraging discussion regarding EOL status between the patient and family members may also lead to greater satisfaction with EOL care for patients.
PMCID: PMC2765767  PMID: 19946391
10.  What matters most in end-of-life care: perceptions of seriously ill patients and their family members 
Initiatives to improve end-of-life care are hampered by our nascent understanding of what quality care means to patients and their families. The primary purpose of this study was to describe what seriously ill patients in hospital and their family members consider to be the key elements of quality end-of-life care.
After deriving a list of 28 elements related to quality end-of-life care from existing literature, focus groups with experts and interviews with patients, we administered a face-to-face questionnaire to older patients with advanced cancer and chronic end-stage medical disease and their family members in 5 hospitals across Canada to assess their perspectives on the importance. We compared differences in ratings across various subgroups of patients and family members.
Of 569 eligible patients and 176 family members, 440 patients (77%) and 160 relations (91%) agreed to participate. The elements rated as “extremely important” most frequently by the patients were “To have trust and confidence in the doctors looking after you” (55.8% of respondents), “Not to be kept alive on life support when there is little hope for a meaningful recovery” (55.7%), “That information about your disease be communicated to you by your doctor in an honest manner” (44.1%) and “To complete things and prepare for life's end — life review, resolving conflicts, saying goodbye” (43.9%). Significant differences in ratings of importance between patient groups and between patients and their family members were found for many elements of care.
Seriously ill patients and family members have defined the importance of various elements related to quality end-of-life care. The most important elements related to trust in the treating physician, avoidance of unwanted life support, effective communication, continuity of care and life completion. Variation in the perception of what matters the most indicates the need for customized or individualized approaches to providing end-of-life care.
PMCID: PMC1389825  PMID: 16505458
11.  Prevention and diagnosis of venous thromboembolism in critically ill patients: a Canadian survey 
Critical Care  2001;5(6):336-342.
Venous thromboembolism (VTE) confers considerable morbidity and mortality in hospitalized patients, although few studies have focused on the critically ill population. The objective of this study was to understand current approaches to the prevention and diagnosis of deep venous thrombosis (DVT) and pulmonary embolism (PE) among patients in the intensive care unit (ICU).
Mailed self-administered survey of ICU Directors in Canadian university affiliated hospitals.
Of 29 ICU Directors approached, 29 (100%) participated, representing 44 ICUs and 681 ICU beds across Canada. VTE prophylaxis is primarily determined by individual ICU clinicians (20/29, 69.0%) or with a hematology consultation for challenging patients (9/29, 31.0%). Decisions are usually made on a case-by-case basis (18/29, 62.1%) rather than by preprinted orders (5/29, 17.2%), institutional policies (6/29, 20.7%) or formal practice guidelines (2/29, 6.9%). Unfractionated heparin is the predominant VTE prophylactic strategy (29/29, 100.0%) whereas low molecular weight heparin is used less often, primarily for trauma and orthopedic patients. Use of pneumatic compression devices and thromboembolic stockings is variable. Systematic screening for DVT with lower limb ultrasound once or twice weekly was reported by some ICU Directors (7/29, 24.1%) for specific populations. Ultrasound is the most common diagnostic test for DVT; the reference standard of venography is rarely used. Spiral computed tomography chest scans and ventilation–perfusion scans are used more often than pulmonary angiograms for the diagnosis of PE. ICU Directors recommend further studies in the critically ill population to determine the test properties and risk:benefit ratio of VTE investigations, and the most cost-effective methods of prophylaxis in medical–surgical ICU patients.
Unfractionated subcutaneous heparin is the predominant VTE prophylaxis strategy for critically ill patients, although low molecular weight heparin is prescribed for trauma and orthopedic patients. DVT is most often diagnosed by lower limb ultrasound; however, several different tests are used to diagnose PE. Fundamental research in critically ill patients is needed to help make practice evidence-based.
PMCID: PMC83855  PMID: 11737922
critical care; deep venous thrombosis; diagnosis; intensive care unit; prevention; pulmonary embolism; thromboembolism
16.  Antimicrobial therapeutic determinants of outcomes from septic shock among patients with cirrhosis 
Hepatology (Baltimore, Md.)  2012;56(6):2305-2315.
It is unclear whether practice-related aspects of antimicrobial therapy contribute to the high mortality from septic shock among patients with cirrhosis. We examined the relationship between aspects of initial empiric antimicrobial therapy and mortality in patients with cirrhosis and septic shock. This was a nested cohort study within a large retrospective database of septic shock from 28 medical centers in Canada, the United States, and Saudi Arabia by the Cooperative Antimicrobial Therapy of Septic Shock Database Research Group between 1996 and 2008. We examined the impact of initial empiric antimicrobial therapeutic variables on the hospital mortality of patients with cirrhosis and septic shock. Among 635 patients with cirrhosis and septic shock, the hospital mortality was 75.6%. Inappropriate initial empiric antimicrobial therapy was administered in 155 (24.4%) patients. The median time to appropriate antimicrobial administration was 7.3 hours (interquartile range, 3.2-18.3 hours). The use of inappropriate initial antimicrobials was associated with increased mortality (adjusted odds ratio [aOR], 9.5; 95% confidence interval [CI], 4.3-20.7], as was the delay in appropriate antimicrobials (aOR for each 1 hour increase, 1.1; 95% CI, 1.1-1.2). Among patients with eligible bacterial septic shock, a single rather than two or more appropriate antimicrobials was used in 226 (72.9%) patients and was also associated with higher mortality (aOR, 1.8; 95% CI, 1.0-3.3). These findings were consistent across various clinically relevant subgroups. Conclusion: In patients with cirrhosis and septic shock, inappropriate and delayed appropriate initial empiric antimicrobial therapy is associated with increased mortality. Monotherapy of bacterial septic shock is also associated with increased mortality. The process of selection and implementation of empiric antimicrobial therapy in this high-risk group should be restructured. (Hepatology 2012;56:2305–2315)
PMCID: PMC3556696  PMID: 22753144

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