Search

Background: Many patients in the intensive care unit are too unwell to participate in shared decision making or have not previously documented their wishes. In these situations, understanding the values of the general population could help doctors provide appropriate guidance to surrogate decision makers., Methods: Using a discrete choice experiment design, we conducted an online survey using an Australian panel. Participants were asked about their willingness to accept treatments, faced with a variety of possible outcomes and probabilities (low, moderate or high). The outcomes were across four domains: loss of functional autonomy, pain, cognitive disability and degree of burden on others. Demographic details, prior experience of intensive care unit and current health conditions were also collected. Data were analysed using logistic regression, predicting whether respondents choose to continue active treatment or not., Results: Nine hundred and eighty-four respondents, representative of age and sex completed the web-based survey. With the increasing likelihood of negative post-intensive care unit sequelae, there was a higher probability of the respondent preferring to stop ongoing active treatment, with the largest coefficients being on caring assistance and the need for full-time residential care. Those who identified as very religious, were younger or who had children under 5 years of age were more likely to choose to continue active treatment., Conclusions: Respondents valued their independence as the most important factor in deciding whether to receive ongoing medical treatments in the intensive care unit. When clinicians are unable to obtain specific patient information, they should consider framing their decision making around the likelihood of the patient achieving functional independence rather than survival.

Background: Achieving shared decision-making in the intensive care unit (ICU) is challenging because of limited patient capacity, leading to a reliance on surrogate decision-makers. Prior research shows that ICU staff members often perceive that patients receive inappropriate or futile treatments while some surrogate decision-makers of patients admitted to the ICU report inadequate communication with physicians. Therefore, understanding the perceptions of both ICU staff and surrogate decision-makers around wishes for ICU treatments is an essential component to improve these situations., Objectives: The objectives of this study were to compare perceptions of ICU staff with surrogate decision-makers about the intensity and appropriateness of treatments received by patients and analyse the causes of any incongruence., Methods: A multicentred, single-day survey of staff and surrogate decision-makers of ICU inpatients was conducted across four Australian ICUs in 2014. Patients were linked to a larger prospective observational study, allowing comparison of patient outcomes., Results: Twelve of 32 patients were identified as having a mismatch between staff and surrogate decision-maker perceptions. For these 12 patients, all 12 surrogate decision-makers believed that the treatment intensity the patient was receiving was of the appropriate intensity and duration. Mismatched patients were more likely to be emergency admissions to ICU compared with nonmismatched patients (0.0% vs 42.1%, p = 0.012) and have longer ICU admissions (7.5 vs 3, p = 0.022). There were no significant differences in perceived communication (p = 0.61)., Conclusions: Family members did not share the same perceptions of treatment with ICU staff. This may result from difficulty in prognostication; challenges in conveying poor prognoses to surrogate decision-makers; and the accuracy of surrogate decision-makers., (Copyright © 2018 Australian College of Critical Care Nurses Ltd. All rights reserved.)

Healthcare professionals have limited formal end-of-life care training despite the large proportion of hospital deaths. A retrospective review of 201 acute hospital deaths revealed 166 (82.6%) had documentation to suggest the patient was dying but this was performed late with a median time between documentation and death of 0.84 days. Furthermore, 132 (66%) patients received an intervention in the final 48 h of life. This highlights the need to improve the recognition and management of dying patients in acute hospitals., (© 2019 Royal Australasian College of Physicians.)

End-of-life care involves treatment and support offered to terminally ill individuals and their caregivers. Effective communication and decision-making, illness and symptom management, relationship with doctors, characteristics of the health care team, and the involvement and needs of caregivers have all been proposed to contribute to the quality of the end-of-life experience. This study sought to establish bereaved caregivers' experiences of the quality of the elements of end-of-life care delivered to their loved ones. Bereaved caregivers who had lost a loved one who was cared for in an acute care University-affiliated hospital, with 670 beds, located in the Australian Capital Territory during the previous 6−12 months (N=91), were surveyed using a modified version of the Canadian Health Care Evaluation Project questionnaire. The findings indicated that the bereaved caregivers were generally very satisfied with their loved one's end-of-life care. The age of the caregiver, the preferred location of death for both patient and caregiver, if death was expected, and religious affiliation were associated with satisfaction of the end-of-life care delivered. Key areas for improvement of end-of-life care included factors related to the relationships between doctors and those receiving care, characteristics of the health care team, illness management, communication and decision-making, and the involvement of caregivers. These findings have significant implications for this hospital and those seeking to improve outcomes in end-of-life care settings more widely, by providing baseline data on caregiver-evaluated care quality and identifying high-priority areas for targeted intervention. [ABSTRACT FROM AUTHOR]

Objectives: Those who work in health care organisations are a potentially valuable source of information about safety concerns, yet failures of voice are persistent. We propose the concept of 'voiceable concern' and offer an empirical exploration. Methods: We conducted a qualitative study involving 165 semi-structured interviews with a range of staff (clinical, non-clinical and at different hierarchical levels) in three hospitals in two countries. Analysis was based on the constant comparative method. Results: Our analysis shows that identifying what counts as a concern, and what counts as a occasion for voice by a given individual, is not a straightforward matter of applying objective criteria. It instead often involves discretionary judgement, exercised in highly specific organisational and cultural contexts. We identified four influences that shape whether incidents, events and patterns were classified as voiceable concerns: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability and normalisation. Determining what counted as a voiceable concern is not a simple function of the features of the concern; also important is whether the person who noticed the concern felt it was voiceable by them. Conclusions: Understanding how those who work in health care organisations come to recognise what counts as a voiceable concern is critical to understanding decisions and actions about speaking out. The concept of a voiceable concern may help to explain aspects of voice behaviour in organisations as well as informing interventions to improve voice. [ABSTRACT FROM AUTHOR]

Objective: To explore end-of-life care in the ward and intensive care unit (ICU) environment in nine Australian hospitals in a retrospective observational study. Methods: In total, 1693 in-hospital deaths, 356 in ICU, were reviewed, including patient demographics, advance care plans, life-sustaining treatments, recognition of dying by clinicians and evidence of the palliative approach to patient care. Results: Most patients (n = 1430, 84%) were aged ≥60 years, with a low percentage (n = 208, 12%) having an end-of-life care plan on admission. Following admission, 82% (n = 1391) of patients were recognised as dying, but the time between recognition of dying to death was short (ICU (staying 4–48 h) median 0.34 days (first quartile (Q1), third quartile (Q3): 0.16, 0.72); Ward (staying more than 48 h) median 2.1 days (Q1, Q3: 0.96, 4.3)). Although 41% (n = 621) patients were referred for specialist palliative care, most referrals were within the last few days of life (2.3 days (0.88, 5.9)) and 62% of patients (n = 1047) experienced active intervention in their final 48 h. Conclusions: Late recognition of dying can expose patients to active interventions and minimises timely palliative care. To attain alignment to the National Consensus Statement to improve experiences of end-of-life care, a nationally coordinated approach is needed. What is known about the topic?: The majority of Australian patient deaths occur in hospitals whose care needs to align to the Australian Commission on Safety and Quality in Health Care's National Consensus Statement, essential elements of safe and high - quality end - of - life care. What does this paper add?: The largest Australian study of hospital deaths reveals only 12% of patients have existing advance care plans, recognition of death is predominantly within the last 48 h of life, with 60% receiving investigations and interventions during this time with late symptom relief. What are the implications for practitioners?: Given the poor alignment with the National Consensus Statement, a nationally coordinated approach would improve the patient experience of end-of-life care. [ABSTRACT FROM AUTHOR]

The importance of employee voice—speaking up and out about concerns—is widely recognised as fundamental to patient safety and quality of care. However, failures of voice continue to occur, often with disastrous consequences. In this article, we argue that the enduring sociological concepts of the informal organisation and formal organisation offer analytical purchase in understanding the causes of such problems and how they can be addressed. We report a qualitative study involving 165 interviews across three healthcare organisations in two high-income countries. Our analysis emphasises the interdependence of the formal and informal organisation. The formal organisation describes codified and formalised elements of structures, procedures and processes for the exercise of voice, but participants often found it frustrating, ambiguous, and poorly designed. The informal organisation—the informal practices, social connections, and methods for making decisions that are key to coordinating organisational activity—could facilitate voice through its capacity to help people to understand complex processes, make sense of their concerns, and frame them in ways likely to prompt an appropriate organisational response. Sometimes the informal organisation compensated for gaps, ambiguities and inconsistencies in formal policies and systems. At the same time, the informal organisation had a dark side, potentially subduing voice by creating informal hierarchies, prioritising social cohesion, and providing opportunities for retaliation. The formal and the informal organisation are not exclusive or independent: they interact with and mutually reinforce each other. Our findings have implications for efforts to improve culture and processes in relation to voice in healthcare organisations, pointing to the need to address deficits in the formal organisation, and to the potential of building on strengths in the informal organisation that are crucial in supporting voice. • Healthcare organisations often struggle to access and make use of employee voice. • The concept of the 'informal organisation' helps to explain and address this issue. • Some aspects of informal organisation may facilitate voice; others inhibit it. • Informal and formal organisation interact with one another in complex ways. • Interventions to improve voice should anticipate and account for these interactions. [ABSTRACT FROM AUTHOR]