24 research outputs found
Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care.
OBJECTIVES: To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill.
DATA SOURCES: A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term palliative care, supportive care, end-of-life care, withdrawal of life-sustaining therapy, limitation of life support, prognosis, or goals of care together with neurocritical care, neurointensive care, neurological, stroke, subarachnoid hemorrhage, intracerebral hemorrhage, or brain injury.
DATA EXTRACTION AND SYNTHESIS: We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting.
CONCLUSIONS: Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism
Establishing Goals of Care for Patients with Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project
CONTEXT: Few patients with dysphagia due to stroke receive early palliative care to align treatment goals with their values, as called for by practice guidelines, particularly before enteral access procedures for artificial nutrition. OBJECTIVES: To increase documented goals of care (GOC) discussions among acute stroke patients prior to feeding gastrostomy tube placement. METHODS: We undertook a rapid-cycle continuous quality improvement (CQI) process with interdisciplinary planning, implementation, and performance review to operationalize an upstream trigger for palliative care referral prompted by the speech and language pathology evaluation. RESULTS: Over a 6-month period, 21 patients underwent gastrostomy tube placement; 52% had pre-procedure GOC discussions post-intervention, with the rate of compliance increasing steadily from 13% (11/87, pre-intervention) to 100% (2/2) in the final 2 months. CONCLUSION: We effectively increased documented GOC discussions prior to feeding gastrostomy tube placement among stroke patients. Systems-based tools and education will enhance this upstream trigger model to ensure early palliative care for stroke patients
Recommended from our members
Outcomes after emergency abdominal surgery in patients with advanced cancer
BACKGROUND: There is increasing emphasis on the appropriateness and quality of acute surgical care for patients with serious illness and at the end of life. However, there is a lack of evidence regarding outcomes after emergent major abdominal surgery among patients with advanced cancer to guide treatment decisions. This analysis sought to characterize adverse outcomes (mortality, complications, institutional discharge) and to identify factors independently associated with 30-day mortality among patients with disseminated cancer who undergo emergent abdominal surgery for intestinal obstruction or perforation.
METHODS:This is a retrospective cohort study of 875 disseminated cancer patients undergoing emergency surgery for perforation (n = 499) or obstruction (n = 376) at hospitals participating in the American College of Surgeons' National Surgical Quality Improvement Program from 2005 to 2012. Predictors of 30-day mortality were identified using multivariate logistic regression.
RESULTS:Among patients who underwent surgery for perforation, 30-day mortality was 34%, 67% had complications, and 52% were discharged to an institution. Renal failure, septic shock, ascites, dyspnea at rest, and dependent functional status were independent preoperative predictors of death at 30 days. When complications were considered, postoperative respiratory complications and age (75-84 years) were also predictors of mortality.Patients who had surgery for obstruction had a 30-day mortality rate of 18% (n = 68), 41% had complications, and 60% were discharged to an institution. Dependent functional status and ascites were independent predictors of death at 30 days. In addition to these predictors, postoperative predictors of mortality included respiratory and cardiac complications. Few patients (4%) had do-not-resuscitate orders before surgery.
CONCLUSION:Emergency abdominal operations in patients with disseminated cancer are highly morbid, and many patients die soon after surgery. High rates of complications and low rates of preexisting do-not-resuscitate orders highlight the need for targeted interventions to reduce complications and integrate palliative approaches into the care of these patients