Dignity Therapy for End-of-Life Care Patients: A Literature Review.

Dignity therapy as an intervention has been used for individuals receiving palliative care. The goal of this review is to explore the current state of empirical support to its use for end-of-life care patients. Data sources were articles extracted from search engines PubMed, Cochrane, Embase, CINAHL, Web of Science, and PsycINFO. The years searched were 2009 to 2019 (10-year period). The review process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results revealed the feasibility, acceptability, satisfaction, and effectiveness of dignity therapy for life-limiting cases/conditions of patients in different age groups. It also highlighted the importance of the therapy setting and the need to apply this in the cultural context. The meaning of dignity therapy to patients and their family care members also emerged. Findings showed most patients displayed the need to leave a legacy and from this their core values surfaced. In conclusion, this review highlighted the contribution of dignity therapy to the holistic care of patients who hope to leave a legacy. The therapy was also relevant to decrease the anxiety; depression, and burden of family members throughout the palliative care period of their loved ones

Venous Thromboembolism Prophylaxis on General Internal Medicine Units: Are Patients Well Served by Current Practice?

ABSTRACTBackground: Venous thromboembolism (VTE) is the most preventable hospital-associated complication, and implementation of appropriate VTE prophylaxis is a requirement for institutional accreditation. However, ambiguity and controversy exist within current recommendations, and greater clarity about and understanding of current utilization of VTE prophylaxis may be needed.Objectives: The primary objective was to assess the proportion of patients receiving appropriate VTE prophylaxis (right drug, dose, frequency, and duration) within 24 h after admission to general internal medicine units. The secondary objectives were to determine the proportion of at-risk patients who experienced adverse events (major bleeding or thrombotic events) in relation to appropriateness of prophylaxis, to describe reasons why VTE prophylaxis was inappropriate, and to compare these findings with local audit data.Methods: This cross-sectional study involved adult patients at moderate to very high risk of VTE who were discharged from general internal medicine units between January 1 and September 30, 2015, at the University of Alberta Hospital in Edmonton, Alberta. Patients with length of stay less than 72 h, those already receiving therapeutic anticoagulation, and those lacking documentation of renal function or weight were excluded. A paired t test was used to compare the study data with audit results.Results: Of 225 patients identified as being at risk of VTE, 179 (79.6%) received appropriate prophylaxis. The most common reasons why VTE prophylaxis was deemed inappropriate were not providing a mechanical method of prophylaxis for patients with bleeding contraindications (18/46 [39.1%]) and incorrect dose of pharmacologic prophylaxis (15/46 [32.6%]). The rate of appropriate VTE prophylaxis was lower than that reported in local audits (79.6% versus 97.6%; p = 0.002). Adverse events were less frequent among those receiving appropriate VTE prophylaxis than among those receiving inappropriate prophylaxis: 1.7% (3/179) versus 6.5% (3/46) for thrombotic events and 4.5% (8/179) versus 19.6% (9/46) for major bleeding.Conclusions: These results provide insight into current prescribing patterns for VTE prophylaxis and highlight the need for continued engagement of the health care team in the provision of appropriate VTE prophylaxis.RÉSUMÉContexte : La thromboembolie veineuse (TEV) est la complication iatrogénique la plus facilement évitable chez les patients hospitalisés. D’ailleurs, la mise en place d’une prophylaxie adéquate de la TEV est exigée pour obtenir l’agrément institutionnel. Cependant, l’ambiguïté qui plane sur les recommandations actuelles crée une certaine controverse. Il pourrait donc être nécessaire de clarifier l’utilisation de la prophylaxie de la TEV et de chercher à mieux la comprendre.Objectifs : L’objectif principal était d’évaluer la proportion de patients recevant la prophylaxie adéquate de la TEV (le bon médicament ainsi que la durée, la dose et la fréquence exactes) dans les 24 heures suivant l’admission aux services de médecine interne générale. Les objectifs secondaires étaient d’abord de déterminer la proportion de patients à risque ayant subi des événements indésirables (saignement important ou événement thrombotique) par rapport à la pertinence de la prophylaxie; ensuite, de décrire les raisons expliquant pourquoi la prophylaxie de la TEV était jugée inadéquate; et, enfin, de comparer ces résultats aux données de vérifications locales.Méthodes : La présente étude descriptive et transversale a été menée auprès de patients adultes qui présentaient un risque allant de modéré à très élevé de TEV et qui avaient reçu leur congé des services de médecine interne générale de l’Hôpital de l’Université de l’Alberta à Edmonton, en Alberta, entre le 1er janvier et le 30 septembre 2015. Les patients hospitalisés pendant moins de 72 heures, ceux qui recevaient déjà une anticoagulothérapie et ceux pour qui l’on ne disposait pas des renseignements sur le poids ou la fonction rénale ont été exclus. Un test t pour échantillons appariés a été utilisé pour effectuer la comparaison entre les données de l’étude et celles de la vérification.Résultats : Parmi les 225 patients identifiés comme étant à risque de TEV, 179 (79,6 %) ont reçu la prophylaxie adéquate. Les raisons les plus souvent évoquées pour juger inadéquate la prophylaxie de la TEV étaient l’absence du recours à une méthode mécanique pour les patients présentant des contre-indications liées au saignement (18/46 [39,1 %]) et la prescription de doses erronées (15/46 [32,6 %]). Le taux de prophylaxie adéquate de la TEV était plus faible que les valeurs observées dans les vérifications locales (79,6 % contre 97,6 %; p = 0.002). Les événements indésirables étaient moins fréquents chez les patients ayant reçu une prophylaxie adéquate de la TEV que chez ceux ayant reçu une prophylaxie inadéquate : 2,7 % (5/179) contre 6,5 % (3/46) pour les événements thrombotiques et 4,5 % (8/179) contre 19,6 % (9/46) pour les hémorragies importantes.Conclusions : Ces résultats offrent une meilleure compréhension des habitudes de prescription actuelle concernant la prophylaxie de la TEV. Ils soulignent aussi la nécessité d’une participation constante de l’équipe de soins de santé à la fourniture d’une prophylaxie adéquate de la TEV

Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead

Background: Little information exists about what primary care physicians (PCPs) and patients experience if patients are invited to read their doctors’ office notes. Objective: To evaluate the effect on doctors and patients of facilitating patient access to visit notes over secure Internet portals. Design: Quasi-experimental trial of PCPs and patient volunteers in a year-long program that provided patients with electronic links to their doctors’ notes. Setting: Primary care practices at Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington. Participants: 105 PCPs and 13 564 of their patients who had at least 1 completed note available during the intervention period. Measurements: Portal use and electronic messaging by patients and surveys focusing on participants’ perceptions of behaviors, benefits, and negative consequences. Results: 11 797 of 13 564 patients with visit notes available opened at least 1 note (84% at BIDMC, 92% at GHS, and 47% at HMC). Of 5391 patients who opened at least 1 note and completed a postintervention survey, 77% to 87% across the 3 sites reported that open notes helped them feel more in control of their care; 60% to 78% of those taking medications reported increased medication adherence; 26% to 36% had privacy concerns; 1% to 8% reported that the notes caused confusion, worry, or offense; and 20% to 42% reported sharing notes with others. The volume of electronic messages from patients did not change. After the intervention, few doctors reported longer visits (0% to 5%) or more time addressing patients’ questions outside of visits (0% to 8%), with practice size having little effect; 3% to 36% of doctors reported changing documentation content; and 0% to 21% reported taking more time writing notes. Looking ahead, 59% to 62% of patients believed that they should be able to add comments to a doctor’s note. One out of 3 patients believed that they should be able to approve the notes’ contents, but 85% to 96% of doctors did not agree. At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop. Limitations: Only 3 geographic areas were represented, and most participants were experienced in using portals. Doctors volunteering to participate and patients using portals and completing surveys may tend to offer favorable feedback, and the response rate of the patient surveys (41%) may further limit generalizability. Conclusion: Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption

Abstract TP72: The PRISMS Trial: Baseline Characteristics of the First 100 Subjects

Introduction: Ischemic stroke patients with mild deficits were largely excluded from pivotal trials of IV rt-PA. The balance of benefit versus risk of intravenous thrombolysis for this large, understudied patient cohort is uncertain. The PRISMS trial is underway to test the benefit of IV rt-PA for treatment of mild stroke. Objective: To characterize baseline features of the first 100 patients enrolled in this prospective cohort of exclusively mild stroke. Methods: The PRISMS trial is a Phase 3b, double-blind, 75-center, 948-subject study evaluating IV rt-PA administered within three hours of mild stroke onset to improve 90-day functional outcome (modified Rankin Scale 0 or 1). Mild stroke is defined as NIHSS ≤5 and not “clearly disabling” (i.e., inability to return to work or perform basic activities of daily living based on current deficits). Patients are randomized 1:1 to IV rt-PA 0.9 mg/kg with aspirin placebo or IV rt-PA placebo with aspirin 325 mg. Here we describe baseline characteristics, including clinical presentations by NIHSS item, of the first 100 enrolled patients. The study team remains fully blinded to patient treatment assignment and outcomes. Results: The 100th subject was enrolled on June 15, 2015. Baseline characteristics are presented in the Table. Median NIHSS was 2 (IQR 1-3). Clinical presentations of each patient by abnormal NIHSS items are shown in the Figure. Dysarthria, facial palsy, and sensory loss were the most common deficits. Conclusions: This initial 100-patient PRISMS cohort is consistent with expectations. Upon completion, the PRISMS trial will determine the benefit of IV rt-PA for mild stroke

Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons