Exploring the Uptake of Advance Care Planning in Older Adults: An Integrative Review.

Palliative medicine and geriatric emergency care: challenges, opportunities, and basic principles.

To identify treatment-withholding intentions for 56 VA medicine inpatients who received a no-code order, 31 resident physicians who wrote the orders completed a checklist on which they indicated the interventions they intended to withhold from each patient. Review of patients' charts indicated that 24 (43%) contained no documentation of treatment limitation plans beyond the no-code order. To identify the general interpretations of no-code orders, “cross-covering” physicians indicated on a questionnaire the likelihood that they would withhold specific interventions from patients they were covering who had received a no-code order. Both the intention and interpretation of no-code orders were characterized by variability, and interpretation of the orders was characterized by uncertainty as well. Because of these discrepancies, we suggest a no-code order which provides greater specificity for individual patients.

Some treatment withold implications of no-code orders in an academic hospital

BACKGROUND Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. METHODS We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life). RESULTS Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes. CONCLUSION We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.

The influence of POLST on treatment intensity at the end of life: A systematic review.

Objectives:We quantified the 28-day mortality effect of preexisting do-not-resuscitate orders in ICUs.Design:Longitudinal, retrospective study of patients admitted to five ICUs at a tertiary university medical center (Beth Israel Deaconess Medical Center, BIDMC, Boston, MA) between 2001 and 2008.Int

Quantifying the Mortality Impact of Do-Not-Resuscitate Orders in the ICU.

Author(s): Martinez, Osvaldo; Puller, Justin | Abstract: Introduction: The use of peripherally inserted central catheters (PICC) has been integral to the advancement of medical care in both in-patient and out-patient arenas.1 However, our knowledge of PICC line complications remains incomplete, particularly in regard to venous perforation and extraluminal migration. Utilization of displaced catheters harbors lethal complications and is an infrequently reported phenomenon, with traumatic etiologies only referenced as possible mechanisms; however, to date no formal cases have been reported.5,6 Case Report: We report a case of a fall associated with extraluminal PICC migration and perforation causing mediastinitis and severe sepsis after total parenteral nutrition (TPN) infusion in a 54-year-old woman. Our patient required a right-sided PICC for long-term home TPN due to severe malnutrition following gastric bypass surgery. During a routine home care visit our patient was found tachypneic, hypoxic, and short of breath. Computed topography imaging in the emergency department (ED) identified the injury, likely related to the recent fall. The patient experienced a complicated hospital course after removal of the PICC. Although rare, PICC line migrations and perforations cause serious complications that should be considered by emergency physicians evaluating patients with chronic indwelling vascular access. Conclusion: Given the efficacy and widespread use of PICC lines, we present this case as a rarely reported but life-threatening complication that requires particular attention. Emergency physicians should be aware of such PICC line complications when encountering patients with chronic indwelling vascular access.

/pdf/mediastinitis-secondary-to-peripherally-inserted-central-1zuaiyhiby.pdf

Mediastinitis Secondary to Peripherally Inserted Central Catheter Migration and Perforation after Minor Trauma: A Case Report.

Background Concern exists that living wills are misinterpreted and may result in compromised patient safety. Objective To determine whether adding code status to a living will improves understanding and treatment decisions. Methods An Internet survey was conducted of General Surgery, and Family, Internal, and Emergency Medicine residencies between May and December 2009. The survey posed a fictitious living will with and without additional clarification in the form of code status. An emergent patient care scenario was then presented that included medical history and signs/symptoms. Respondents were asked to assign a code status and choose appropriate intervention. Questions were formatted as dichotomous responses. Correct response rate was based on legal statute. Significance of changes in response due to the addition of either clinical context (past medical history/signs/symptoms) or code status was assessed by contingency table analysis. Results Seven hundred sixty-eight faculty and residents at accredited training centers in 34 states responded. At baseline, 22% denoted “full code” as the code status for a typical living will, and 36% equated “full care” with a code status DNR. Adding clinical context improved correct responses by 21%. Specifying code status further improved correct interpretation by 28% to 34%. Treatment decisions were either improved 12–17% by adding code status (“Full Code,” “Hospice Care”) or worsened 22% (“DNR”). Conclusion Misunderstanding of advance directives is a nationwide problem. Addition of code status may help to resolve the problem. Further research is required to ensure safety, understanding, and appropriate care to patients.

TRIAD III: Nationwide Assessment of Living Wills and Do Not Resuscitate Orders

OBJECTIVE The aim of the study was to determine (1) whether do-not-resuscitate (DNR) orders created upon hospital admission or Physician Orders for Life-Sustaining Treatment (POLST) are consistent patient preferences for treatment and (2) patient/health care agent (HCA) awareness and agreement of these orders. METHODS We identified patients with DNR and/or POLST orders after hospital admission from September 1, 2017, to September 30, 2018, documented demographics, relevant medical information, evaluated frailty, and interviewed the patient and when indicated the HCA. RESULTS Of 114 eligible cases, 101 met inclusion criteria. Patients on average were 76 years old, 55% were female, and most white (85%). Physicians (85%) commonly created the orders. A living will was present in the record for 22% of cases and a POLST in 8%. The median frailty score of "4" (interquartile range = 2.5) suggested patients who require minimal assistance. Thirty percent of patients requested cardiopulmonary resuscitation and 63% wanted a trial attempt of aggressive treatment if in improvement is deemed likely. In 25% of the cases, patients/HCAs were unaware of the DNR order, 50% were unsure of their prognosis, and another 40% felt their condition was not terminal. Overall, 44% of the time, the existing DNR, and POLST were discordant with patient wishes and 38% were rescinded. Of the 6% not rescinded, further clarifications were required. Discordant orders were associated with younger, slightly less-frail patients. CONCLUSIONS Do-not-resuscitate and POLST orders can often be inaccurate, undisclosed, and discordant with patient wishes for medical care. Patient safety and quality initiatives should be adopted to prevent medical errors.

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records.

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Mediastinitis Secondary to Peripherally Inserted Central Catheter Migration and Perforation after Minor Trauma: A Case Report.

TRIAD III: Nationwide Assessment of Living Wills and Do Not Resuscitate Orders

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records.