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To determine the 30- and 90-day outcomes of COVID-19 patients receiving tracheostomy and percutaneous endoscopic gastrostomy (PEG).Retrospective observational study.Multisite, inpatient.Hospitalized COVID-19 patients who received tracheostomy and PEG at four Boston hospitals.Tracheostomy and PEG placement.The primary outcome was mortality at 30 and 90 days post-procedure. Secondary outcomes included continued device presence, place of residence, complications, and rehospitalizations. Eighty-one COVID-19 patients with tracheostomy and PEG placement were included. At 90 days post-device placement, the mortality rate was 9.9%, 2.7% still had the tracheostomy, 32.9% still had the PEG, and 58.9% were at home.More than nine-in-10 patients in our population of COVID-19 patients who underwent tracheostomy and PEG were alive 90 days later and most were living at home. This study provides new information regarding the outcomes of this patient population that may serve as a step in guiding clinicians, patients, and families when making decisions regarding these devices.

El surel (Trachurus lathami) es un pez pelágico-costero que se captura de forma incidental durante la pesquería de caballa, constituyendo un descarte. La elaboración de conservas de surel descabezado y eviscerado es una estrategia utilizada para rentabilizar esta especie. Esta forma de comercialización genera una gran cantidad de residuos que constituyen una fuente rica de biocompuestos de interés comercial, entre los que se encuentran las proteínas y los ácidos grasos poliinsaturados de la serie omega-3. El objetivo del presente trabajo fue estudiar las fases acuosas proteica y oleosa lipídica obtenidas mediante hidrólisis enzimática de residuos de surel. Para la reacción se utilizaron las proteasas alcalinas comerciales Alcalase® 2.4L y Purazyme AS 60L. Las condiciones fueron pH 8.0 y 55 ºC, durante 2 h, en un reactor termostatizado. La fase acuosa obtenida mostró un contenido proteico de alrededor del 73 % con ambas enzimas. El rendimiento del aceite extraído fue de aproximadamente el 58 % con Alcalase® 2.4L y de alrededor del 68 % con Purazyme AS 60L. Dentro de los ácidos grasos poliinsaturados se destacó el contenido de eicosapentaenoico (EPA) y docosahexaenoico (DHA) para ambos aceites obtenidos. Esto sugiere que a partir de cabezas y vísceras de Trachurus lathami se pueden obtener compuestos de interés para el aprovechamiento integral de estas pesquerías.

Background: Serious illness conversations are part of advance care planning (ACP) and focus on prognosis, values, and goals in patients who are seriously ill. To be maximally effective, such conversations must be documented accurately and be easily accessible. Objectives: The two coprimary objectives of the study were to assess concordance between written documentation and recorded audiotaped conversations, and to evaluate adherence to the Serious Illness Conversation Guide questions. Methods: Data were obtained as part of a trial in patients with advanced cancer. Clinicians were trained to use a guide to conduct and document serious illness conversations. Conversations were audiotaped. Two researchers independently compared audiorecordings with the corresponding documentation in an electronic health record (EHR) template and free-text progress notes, and rated the degree of concordance and adherence. Results: We reviewed a total of 25 audiorecordings. Clinicians addressed 87% of the conversation guide elements. Prognosis was discussed least frequently, only in 55% of the patients who wanted that information. Documentation was fully concordant with the conversation 43% of the time. Concordance was best when documenting family matters and goals, and least frequently concordant when documenting prognostic communication. Most conversations (64%) were documented in the template, a minority (28%) only in progress notes and two conversations (8%) were not documented. Concordance was better when the template was used (62% vs. 28%). Conclusion: Clinicians adhered well to the conversation guide. However, key information elicited was documented and fully concordant less than half the time. Greater concordance was observed when clinicians used a prespecified template. The combined use of a guide and EHR template holds promise for ACP conversations.

Critical Illness Recovery Programs report low attendance. We aimed to provide information about postintensive care syndrome and to learn which patients would pursue help in a Critical Illness Recovery Clinic. All patients who checked in to our Lung Center were given a survey regarding their ICU experience and offered information about postintensive care syndrome and an appointment in the clinic. Nine hundred and twenty respondents reported having had an ICU experience: 37% of former ICU patients reported difficulty returning to their normal lives afterward compared with 21% who were family or close friends of a former ICU patient. Only 5% requested information and less than 1% requested a dedicated appointment. More than one of three former ICU patients and one in five close friends or relatives of former ICU patients reported difficulty returning to their normal lives after their ICU experience. Very few pursued the opportunity to learn more about it or seek help.

Background: Timely documentation of care preferences is an endorsed quality indicator for seriously ill patients admitted to intensive care units. Clinicians document their conversations about these preferences as unstructured free text in clinical notes from electronic health records. Aim: To apply deep learning algorithms for automated identification of serious illness conversations documented in physician notes during intensive care unit admissions. Design: Using a retrospective dataset of physician notes, clinicians annotated all text documenting patient care preferences (goals of care or code status limitations), communication with family, and full code status. Clinician-coded text was used to train algorithms to identify documentation and to validate algorithms. The validated algorithms were deployed to assess the percentage of intensive care unit admissions of patients aged ⩾75 that had care preferences documented within the first 48 h. Setting/participants: Patients admitted to one of five intensive care units. Results: Algorithm performance was calculated by comparing machine-identified documentation to clinician-coded documentation. For detecting care preference documentation at the note level, the algorithm had F1-score of 0.92 (95% confidence interval, 0.89 to 0.95), sensitivity of 93.5% (95% confidence interval, 90.0% to 98.0%), and specificity of 91.0% (95% confidence interval, 86.4% to 95.3%). Applied to 1350 admissions of patients aged ⩾75, we found that 64.7% of patient intensive care unit admissions had care preferences documented within the first 48 h. Conclusion: Deep learning algorithms identified patient care preference documentation with sensitivity and specificity approaching that of clinicians and computed in a tiny fraction of time. Future research should determine the generalizability of these methods in multiple healthcare systems.

The lung allocation score system in the United States and several European countries gives more weight to risk of death without transplantation than to survival following transplantation. As a result, centers transplant sicker patients, leading to increased length of initial hospitalization. The care of patients who have accumulated functional deficits or additional organ dysfunction during their prolonged stay can be ethically complex. Disagreement occurs between the transplant team, patients and families, and non-transplant health care professionals over the burdens of ongoing intensive intervention. These cases highlight important ethical issues in organ transplantation, including the nature and requirements of transplant informed consent, the limits of physician prognostication, patient autonomy and decision-making capacity following transplant, obligations to organ donors and to other potential recipients, and the impact of program metrics on individualized recipient care. We outline general ethical principles for the care of lung transplant recipients with prolonged hospitalization and give regulatory, research, and patient-centered recommendations for these cases.

Chronically critically ill patients have recurrent infections, organ dysfunction, and at least half die within 1 year. They are frequently cared for in long-term acute care hospitals, yet little is known about their experience in this setting. Our objective was to explore the understanding and expectations and goals of these patients and surrogates.We conducted semi-structured interviews with chronically critically ill long-term acute care hospital patients or surrogates. Conversations were recorded, transcribed, and analyzed.One long-term acute care hospital.Chronically critically ill patients, defined by tracheotomy for prolonged mechanical ventilation, or surrogates.Semi-structured conversation about quality of life, expectations, and planning for setbacks.A total of 50 subjects (30 patients and 20 surrogates) were enrolled. Thematic analyses demonstrated: 1) poor quality of life for patients; 2) surrogate stress and anxiety; 3) optimistic health expectations; 4) poor planning for medical setbacks; and 5) disruptive care transitions. Nearly 80% of patient and their surrogate decision makers identified going home as a goal; 38% were at home at 1 year.Our study describes the experience of chronically critically ill patients and surrogates in an long-term acute care hospital and the feasibility of patient-focused research in this setting. Our findings indicate overly optimistic expectations about return home and unmet palliative care needs, suggesting the need for integration of palliative care within the long-term acute care hospital. Further research is also needed to more fully understand the challenges of this growing population of ICU survivors.

On rounds in the long-term acute care hospital, I am surprised to see a familiar name on my list — a patient with respiratory failure whom I had initially admitted to our intensive care unit (ICU)....

Looking beyond Mortality in Transplantation Outcomes Despite an increasing emphasis on patient-centered outcomes in medicine, transplant centers do not systematically report information on health-r...

In a world moved by story, medicine — we like to believe — is still moved by measurement. That is why, when resident work-hour limits were implemented in 2003, catalyzed by the tragic death of Libb...

Context Documenting patients' advance care planning (ACP) wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about ACP documentation practices in the electronic health record. Objectives The objective of this study was to describe ACP documentation practices and the accessibility of documented discussions in the electronic health record. Methods Participants were primary care patients at the San Francisco Veterans Affairs Medical Center, were ≥60 years old, and had ≥2 chronic/serious health conditions. In this cross-sectional study, we assessed the prevalence of ACP documentation, including any legal forms/orders and discussions in the prior five years. We also determined accessibility of discussions (i.e., accessible centralized posting vs. inaccessible free text in progress notes). Results The mean age of 414 participants was 71 years (SD ± 8), 9% were women, 43% were nonwhite, and 51% had documented ACP including 149 (36%) with forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders lacked accompanying explanatory documentation. Most (55%) discussions were not easily accessible, including 70% of those documenting changes in treatment preferences from prior forms/orders. Conclusion Half of chronically ill, older participants had documented ACP, including one-third with documented discussions. However, half of the patients with completed legal forms/orders had no accompanying documented explanatory discussions, and the majority of documented discussions were not easily accessible, even when wishes had changed. Ensuring that patients' preferences are documented and easily accessible is an important patient safety and quality improvement target to ensure patients' wishes are honored.

To develop a set of clinically relevant recommendations to improve the state of advance care planning (ACP) documentation in the electronic health record (EHR).Advance care planning (ACP) is a key process that supports goal-concordant care. For preferences to be honored, clinicians must be able to reliably record, find, and use ACP documentation. However, there are no standards to guide ACP documentation in the electronic health record (EHR).We interviewed 21 key informants to understand the strengths and weaknesses of EHR documentation systems for ACP and identify best practices. We analyzed these interviews using a qualitative content analysis approach and subsequently developed a preliminary set of recommendations. These recommendations were vetted and refined in a second round of input from a national panel of content experts.Informants identified six themes regarding current inadequacies in documentation and accessibility of ACP information and opportunities for improvement.We offer a set of concise, clinically relevant recommendations, informed by expert opinion, to improve the state of ACP documentation in the EHR.

The U.S. transplant community is debating an approach to reducing geographic disparities in organ distribution: redrawing the liver-allocation map to reduce disparities among patients with similar disease severity, without increasing deaths on the waiting list.

Earlier clinician-patient conversations about patients' values, goals, and preferences in serious illness (ie, serious illness conversations) are associated with better outcomes but occur inconsistently in cancer care.To evaluate the efficacy of a communication quality-improvement intervention in improving the occurrence, timing, quality, and accessibility of documented serious illness conversations between oncology clinicians and patients with advanced cancer.This cluster randomized clinical trial in outpatient oncology was conducted at the Dana-Farber Cancer Institute and included physicians, advanced-practice clinicians, and patients with cancer who were at high risk of death.The primary outcomes (goal-concordant care and peacefulness at the end of life) are published elsewhere. Secondary outcomes are reported herein, including (1) documentation of at least 1 serious illness conversation before death, (2) timing of the initial conversation before death, (3) quality of conversations, and (4) their accessibility in the electronic medical record (EMR).We enrolled 91 clinicians (48 intervention, 43 control) and 278 patients (134 intervention, 144 control). Of enrolled patients, 58% died during the study (n=161); mean age was 62.3 years (95% CI, 58.9-65.6 years); 55% were women (n=88). These patients were cared for by 76 of the 91 enrolled clinicians (37 intervention, 39 control); years in practice, 11.5 (95% CI, 9.2-13.8); 57% female (n=43). Medical record review after patients' death demonstrated that a significantly higher proportion of intervention patients had a documented discussion compared with controls (96% vs 79%, P = .005) and intervention conversations occurred a median of 2.4 months earlier (median, 143 days vs 71 days, P .001). Conversation documentation for intervention patients was significantly more comprehensive and patient centered, with a greater focus on values or goals (89% vs 44%, P .001), prognosis or illness understanding (91% vs 48%, P .001), and life-sustaining treatment preferences (63% vs 32%, P = .004). Documentation about end-of-life care planning did not differ between arms (80% intervention vs 68% control, P = .08). Significantly more intervention patients had documentation that was accessible in the EMR (61% vs 11%, P .001).This communication quality-improvement intervention resulted in more, earlier, better, and more accessible serious illness conversations documented in the EMR. To our knowledge, this is the first such study to demonstrate improvement in all 4 of these outcomes.ClinicalTrials.gov identifier: NCT01786811.

Post–intensive care syndrome, a condition defined by new or worsening impairment in cognition, mental health, and physical function after critical illness, has emerged in the past decade as a common and life-altering consequence of critical illness. New strategies are urgently needed to mitigate the risk of neuropsychological and functional impairment common after critical illness and to prepare and support survivors on their road toward recovery. The present state of critical care survivorship is described, and postdischarge care delivery in the United States and the potential impact of the present-day fragmented model of care delivery are detailed. A novel strategy that uses peer support groups could more effectively meet the needs of survivors of critical illness and mitigate post–intensive care syndrome.

In September, representatives from 192 countries met at a UN conference on noncommunicable diseases, turning international attention from the devastation wrought by well-known epidemics such as those of AIDS and malaria to a quieter, though no less dangerous, threat.

Rationale: Idiopathic pulmonary fibrosis is often initially misdiagnosed. Delays in accessing subspecialty care could lead to worse outcomes among those with idiopathic pulmonary fibrosis. Objectives: To examine the association between delayed access to subspecialty care and survival time in idiopathic pulmonary fibrosis. Methods: We performed a prospective cohort study of 129 adults who met American Thoracic Society criteria for idiopathic pulmonary fibrosis evaluated at a tertiary care center. Delay was defined as the time from the onset of dyspnea to the date of initial evaluation at a tertiary care center. We used competing risk survival methods to examine survival time and time to transplantation. Measurements and Main Results: The mean age was 63 years and 76% were men. The median delay was 2.2 years (interquartile range 1.0–3.8 yr), and the median follow-up time was 1.1 years. Age and lung function at the time of evaluation did not vary by delay. A longer delay was associated with an increased risk of death independent of age, sex, forced vital capacity, third-party payer, and educational attainment (adjusted hazard ratio per doubling of delay was 1.3, 95% confidence interval 1.03 to 1.6). Longer delay was not associated with a lower likelihood of undergoing lung transplantation. Conclusions: Delayed access to a tertiary care center is associated with a higher mortality rate in idiopathic pulmonary fibrosis independent of disease severity. Early referral to a specialty center should be considered for those with known or suspected interstitial lung disease.

Early in my intern year, I admitted an 80-year-old man with pneumonia to the intensive care unit (ICU). He had hypotension and was struggling to breathe, and my senior resident and I told his family that it was touch and go. Their response: Do everything. He had repaired cars for a living, and he was a tough guy, a fighter. Ten days later, his condition had stabilized, but he was delirious and unable to breathe on his own. We told his family that if we were to continue, he'd need a tracheotomy and feeding tube. They agreed without question. We . . .

Whereas effective treatment for noncommunicable diseases may be too costly to disseminate globally, opioids for pain control are cheap to produce. Yet 80% of the population, including millions of patients with terminal cancer, lacks adequate access to pain treatment.

2 Background: Documenting patients’ advance care planning (ACP) wishes is essential to providing value aligned care, as is having this documentation readily accessible. Early ACP is increasingly being recognized as integral to oncologic care, however, little is known about current documentation practices. In this cross-sectional study, we describe ACP documentation practices and accessibility of documented ACP discussions in the electronic health record (EHR). Methods: Participants were recruited from outpatient clinics at the San Francisco VA, were ≥60 years old, with ≥2 chronic/serious conditions and ≥2 primary care visits in the past year. ACP documentation was abstracted from the EHR in 2013-2015 and included any prior legal forms/orders and ACP discussions documented within the prior five years. Frequency and type of ACP documentation was calculated using percentages and means. For discussions, author discipline and location of documentation was determined. Discussions were deemed “accessible” if documented in a designated ACP posting location or “not easily accessible” if recorded as free text in progress notes. Results: The mean age of 414 participants was 71 years (SD ± 8), 9% were women, 43% were non-white, and 51% had documented ACP including 149 (36%) with ACP forms and 138 (33%) with ACP discussions. Seventy-five (54%) discussions were documented by social workers and 49 (36%) by primary care providers. However, 76 (55%) discussions were not easily accessible. For 27 (18%) participants with advance directives, subsequent discussions documented a change in treatment preferences. Nineteen (70%) discussions reporting a change in wishes were not easily accessible. Conclusions: Half of chronically ill, older patients had documented ACP wishes, including a third with documented ACP discussions. Most discussions were documented by social workers and were not easily accessible, although discussions often represented changes from prior advance directives. Clinician education and EHR changes to ensure documented discussions are accessible are important patient-safety and quality improvement targets to ensure patients’ wishes are honored.

Despite advances in the development of novel pharmaceutical agents to treat idiopathic pulmonary fibrosis (IPF), there are no medical therapies known to resolve fibrosis or improve lung function in IPF. Therefore, lung transplantation remains the only life-saving therapy available to treat patients with IPF. However, a shortage of suitable donor organs limits the number of affected individuals who can undergo this procedure, and this shortage highlights the need to allocate donor lungs to those who are in the greatest need of a life-saving therapy yet ensure that those who undergo transplantation will have a reasonable expectation of long-term survival. Still, outcomes remain relatively poor for many patients after lung transplantation, although a sizable minority of patients can enjoy long-term survival after lung transplantation.

49 Background: Conversations about serious illness care goals are often inadequate and fail to address key elements of high-quality discussions. Methods: As part of a cluster-randomized trial of a multi-component communication intervention, we conducted a retrospective chart review of 147 deceased oncology patients to assess frequency and timing of documentation of end-of-life (EOL) conversations; charts of a subset of 20 intervention and 20 matched control patients underwent detailed review to assess quality. A systematically developed abstraction tool was used by two blinded researchers. The tool contained 25 elements reflecting four EOL conversation domains: goals/values, illness understanding/prognosis, EOL care planning, life-sustaining treatments. Results: Of 153 intervention patients, 44.4% died (n = 68); of 161 controls, 49.1% died (n = 79). Significantly more intervention patients than controls (92.7% vs 74.7%, p = 0.006) had at least 1 documented EOL discussion before death; intervention conversations occurred 3 months earlier (median 147 days vs 62 days, p = 0.003). 59.4% of intervention conversations were documented in a retrievable EHR location compared to 10.2% of controls (p = 0.001). In the detailed review, 85% (n = 17) of intervention and 40% (n = 8) of controls had at least 1 documented discussion about values/goals (p = 0.0001), with an average of 3.6 of 8 elements (0.7 of 8 for controls) (p = 0.0003). 85% percent (n = 17) of intervention and 30% (n = 6) of controls had at least 1 documented discussion about prognosis (p = 0.0014), with an average of 2.5 of 7 elements (0.5 of 7 for controls) (p = 0.001). 85% of intervention (n = 17) and 55% of controls (n = 11) had at least 1 documented discussion about EOL planning (p = 0.009). 55% of intervention and 30% of controls had at least 1 documented discussion about life-sustaining treatments (p = 0.20). Conclusions: The intervention resulted in more, earlier and better documentation of serious illness care goals. Across 3 of 4 domains of quality, intervention patients had more detailed information about their EOL care preferences, demonstrating that the intervention results in more patient-centered, comprehensive discussions. Clinical trial information: NCT01786811.

Some physicians now believe that considering costs as well as risks and benefits when making medical decisions serves not only the equitable distribution of services, but also the real interests of individual patients. How should that change medical education?

New limits on residents' duty hours have not resolved the controversy over their effects on education and patient care. Given the stakes, the benefits and risks of approaches to duty hours should be assessed as rigorously as we assess new drugs and devices.

Paternalism in discussing resuscitation status has given way to an approach in which patients may be asked to choose from a bewildering array of medical options, but physicians-in-training are rarely taught how to lead such conversations confidently and effectively.

39 Background: Patients with serious illness routinely receive treatments that are not aligned with their goals. Earlier clinical conversations about patients’ values and priorities lead to more goal-concordant care and improved quality of life, but these conversations often happen too late or not at all. The Serious Illness Care Program has designed a systematic approach to train and support clinicians in conducting more, earlier, and better conversations about goals of care with their patients. Objectives: Evaluate clinician adoption and acceptability of the training program and the Serious Illness Conversation Guide; determine the frequency, timing, and quality of goals of care documentation before death. Methods: Cluster-randomized trial including oncology clinicians and their patients. Intervention: clinician identification of high risk patients; 2½ hour clinician training on the Serious Illness Conversation Guide; email trigger/reminder; EMR documentation. Preliminary chart review to extract goals-of-care conversations for deceased patients in intervention and control. Results: 90 oncology clinicians: 47 intervention; 43 control. Of 47 intervention clinicians, 46 are trained and rate the training as effective (4.3/5). 97% of trained clinicians who have been triggered have adopted the Conversation Guide and find it acceptable (4.2/5). 342 patients enrolled: 176 intervention; 166 control; 38% have died (n = 131). A preliminary chart review revealed more goals-of-care conversations occurred before death in intervention compared to control (92% versus 70%, p = 0.0037); intervention conversations took place four months earlier than control (median 143 days versus 63 days, p = 0.0008). In addition, conversations were more patient centered (95% versus 45%, p < 0.001) and more readily retrievable in the EMR (68% versus 28%, p < 0.001). Conclusions: Preliminary data about the Serious Illness Care systematic approach demonstrate strong clinician adoption and acceptability. The intervention results in more, earlier, and better conversations about patient values and priorities, in addition to more patient-centered and retrievable documentation of goals of care in the medical record. Clinical trial information: NCT01786811.

The way I remember it now, I spent much of my medical internship doing things to people—uncomfortable, even unnecessary things—at odd hours to seem thorough on rounds.

In late July, we presented the case of a 6-year-old girl with persistent bilateral vesicoureteral reflux. Readers' votes in favor of watchful waiting, antibiotic prophylaxis, or surgical repair are shown by country.