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Introduction: Older adults often have multiple comorbidities; therefore, they are at high risk for adverse events after discharge. The 4Ms framework—what matters, medications, mentation, mobility—has been used in acute and ambulatory care settings to identify risk factors for adverse events in older adults, although it has not been used in the emergency department (ED).Weaimed to determine whether 1) use of the 4Ms worksheet would help emergency clinicians understand older adult patients’ goals of care and 2) use of the worksheet was feasible in the ED.Methods: We conducted a qualitative, descriptive study among patients aged ≥60 years and emergency clinicians from January–June 2022. Patients were asked to fill out a 4Ms worksheet; following this, semi-structured interviews were conducted with patients and clinicians separately. We analysed data to create codes, which were divided into categories and sub-categories.Results: A total of 20 older patients and 19 emergency clinicians were interviewed. We identified two categories based on our aims: understanding patient goals of care (sub-categories: clinician/ patient concordance; understanding underlying goals of care; underlying goals of care discrepancy) and use of 4Ms Worksheet (sub-categories: worksheet to discussion discrepancy; challenges using worksheet; challenge completing worksheet before discharge). Rates of concordance between patient and clinician on main concern/goal of care and underlying goals of care were 82.4% and 15.4%, respectively.Conclusion: We found that most patients and emergency clinicians agreed on the main goal of care, although clinicians often failed to elicit patients’ underlying goal(s) of care. Additionally, many patients preferred to have the interviewer fill out the worksheet for them. There was often discrepancy between what was written and what was discussed with the interviewer. More research is needed to determine the best way to integrate the 4Ms framework within emergency care.

Introduction: Advance Care Planning (ACP) refers to a process that includes Advance Care Directives (ACD) and Goals of Care (GOC), a practice widely used for over three decades. Following the findings of an audit and a cross-sectional study in 2019 and 2021 respectively, we implemented several educational and other interventional strategies aimed at enhancing staff awareness and emphasizing the importance of recognizing and documenting of ACD/GOC. The aim of this study was to evaluate the acknowledgement and use of ACD and GOC by Emergency Department (ED) staff following these interventions. Method: We used a mixed methods approach, incorporating both observational and cross-sectional designs with reflexive thematic analysis. Data extraction for the observational study took place between 1st April and 30th June 2023 focusing on a target population of randomly sampled adults aged ≥ 65 years. Demographics and other ACD and GOC related patients' clinical data were collected. Data collection for the cross-sectional study occurred between 19th July and 13th September 2023 targeting all ED staff. Information gathered included demographics, awareness about ACD and GOC, including storage location and implementation, as well as knowledge of Medical Treatment decision Makers (MTDM), a jurisdictional term identifying a person legally appointed to make healthcare decisions on behalf of someone who lacks decision-making capacity and other Victorian State legislative requirements were collected. Results: In the observational period, 22,335 patients attended the ED and 19% (n = 6546) qualified for inclusion from which a sample of 308 patients were randomly extracted. We found ACD documents were noted in the medical records of 6.5% of the sample, fewer than 8% identified in our previous study. There was no correlation between ACD record availability and age (p = 0.054; CI ranging from − 0.065 to 7.768). The response rate for the cross-sectional survey was 12% (n = 340) in contrast to earlier study with 28% (n = 476) respondents. Staff knowledge and familiarity with ACD was 25% and GOC 45%. Conclusion: After implementing interventions in staff education and ACP awareness, we found that ACD documentation did not improve. However, GOC documentation increased in the context of heightened institutional awareness and integration into the Electronic Medical Records (EMR). [ABSTRACT FROM AUTHOR]

Background: Approximately 6.7 million American adults are living with heart failure (HF). Current therapies are geared toward preventing progression and managing symptoms, as there is no cure. Multiple studies have shown the benefit of including palliative care (PC) in patients with HF to improve symptoms and quality of life. Heart failure guidelines recommend the inclusion of PC in therapy, but referrals are often delayed. A previous pilot project demonstrated increased involvement of PC when targeted education was given to patients with HF. Objective: Educate patients with HF on PC and examine the impact on PC consults, readmission, mortality, intensive care unit (ICU) transfers and evaluate sustainability of the intervention. Methods: Patients (n = 124) admitted to an academic hospital with a diagnosis of HF were asked to view an educational module on PC. Patients who completed the module were placed in the intervention group (n = 39). Patients who declined were placed in the usual care group (n = 38). The number of PC consults, re-admissions, mortality, and transfers to the ICU were compared among participants and those who declined. Results were compared to previous pilot project. Results: Eleven patients in the intervention group (IG) requested a PC consult vs one in the usual care group (UCG) (P =.006). There was no statistically significant difference in readmissions, mortality, or ICU transfers between groups. Conclusions: This sustainable project again demonstrated education on PC increases utilization of PC but does not statistically impact mortality, re-admissions, or transfers to higher levels of care. [ABSTRACT FROM AUTHOR]

Background: Modeled after the Physician Orders for Life Sustaining Treatment program, the Veterans Health Administration (VA) implemented the Life‐Sustaining Treatment (LST) Decisions Initiative to improve end‐of‐life outcomes by standardizing LST preference documentation for seriously ill Veterans. This study examined the associations between LST documentation and family evaluation of care in the final month of life for Veterans in VA nursing homes. Methods: Retrospective, cross‐sectional analysis of data for decedents in VA nursing homes between July 1, 2018 and January 31, 2020 (N = 14,575). Regression modeling generated odds for key end‐of‐life outcomes and family ratings of care quality. Results: LST preferences were documented for 12,928 (89%) of VA nursing home decedents. Contrary to our hypothesis, neither receipt of wanted medications and medical treatment (adjusted odds ratio [OR]: 0.85, 95% confidence interval [CI] 0.63, 1.16) nor ratings of overall care in the last month of life (adjusted OR: 0.96, 95% CI 0.76, 1.22) differed significantly between those with and without completed LST templates in adjusted analyses. Conclusions: Among Community Living Center (CLC) decedents, 89% had documented LST preferences. No significant differences were observed in family ratings of care between Veterans with and without documentation of LST preferences. Interventions aimed at improving family ratings of end‐of‐life care quality in CLCs should not target LST documentation in isolation of other factors associated with higher family ratings of end‐of‐life care quality. [ABSTRACT FROM AUTHOR]

Purpose: Code status orders are standard practice impacting end-of-life care for individuals. This study reviews the impact of a COVID unit on physician behaviors towards goal-concordant end-of-life care at an urban academic tertiary-care hospital. Methods: We conducted a retrospective cohort study of code status ordering on adult inpatients comparing the pre-pandemic period to patients who tested positive, negative and were not tested during the pandemic from January 1, 2019, to December 31, 2020. Results: We analyzed 59,471 unique patient encounters (n = 35,317 pre-pandemic and n = 24,154 during). 1,631 cases of COVID-19 were seen. The rate of code status orders among all inpatients increased from 22% pre-pandemic to 29% during the pandemic (P <.001). Code status orders increased for both patients who were COVID-negative (32% P <.001) and COVID-positive (65% P <.001). Being in a cohorted COVID unit increased code status ordering by an odds of 4.79 (P <.001). Compared to the pre-pandemic cohort, the COVID-positive cohort is less female (50% to 56% P <.001), more Black (66% to 61% P <.001), more Hispanic (6.5% to 5%) and less white (26% to 30% P <.001). Compared to Black patients, white patients had lower odds (.86) of code status ordering (P <.001). Other race/ethnicity categories were not significant. Conclusions: Code status ordering remains low. Compared to pre-pandemic rates, the frequency of orders placed significantly increased for all patients during the pandemic. The largest increase occurred in patients with COVID-19. This increase likely occurred due to protocols in the COVID unit and disease uncertainty. [ABSTRACT FROM AUTHOR]

AbstractBackgroundMethodsResultsConclusionsSome have hypothesized that talk about suffering can be used by clinicians to motivate difficult decisions, especially to argue for reducing treatment at the end of life. We examined how talk about suffering is related to decision-making for critically ill patients, by evaluating transcripts of conversations between clinicians and patients’ families.We conducted a secondary qualitative content analysis of audio-recorded family meetings from a multicenter trial conducted in the adult intensive care units of five hospitals from 2012–2017 to look at how the term “suffering” and its variants were used. A coding guide was developed by consensus-oriented discussion by four members of the research team. Two coders independently evaluated each transcript. We followed an inductive approach to data analysis in reviewing transcripts; findings were iteratively discussed among study authors until consensus on key themes was reached.Of 146 available transcripts, 34 (23%) contained the word “suffer” or “suffering” at least once, with 58 distinct uses. Clinicians contributed 62% of first uses. Among uses describing the suffering of persons, 57% (n = 24) were related to a decision, but only 42% (n = 10) of decision-relevant uses accompanied a proposal to limit treatment, and only half of treatment-limiting uses (n = 5) were initiated by clinicians. The target terms had a variety of implicit meanings, including poor prognosis, reduced functioning, pain, discomfort, low quality of life, and emotional distress. Suffering was frequently attributed to persons who were unconscious.Our results did not support the claim that the term “suffering” and its variants are used primarily by clinicians to justify limiting treatment, and the terms were not commonly used in our sample when decisions were requested. Still, when these terms were used, they were often used in a decision-relevant fashion. [ABSTRACT FROM AUTHOR]

Simple Summary: As more cancer patients with advanced disease present to the emergency department (ED), data on outcomes of cardiopulmonary resuscitation (CPR) are needed to help counsel patients before and during an acute event. We investigated the characteristics of cancer patients who required CPR, their outcomes, and how prior advanced care planning (ACP) influenced these outcomes. Few studies have specifically looked at these data in an emergency department, where medical history is limited and the need for acute intervention often precludes discussion of therapeutic limitations. We found cardiopulmonary resuscitation of cancer patients to be rare in the ED. Although the return of spontaneous circulation (ROSC) is often attained, very few patients survive to discharge. Patient characteristics, resuscitation success, overall mortality, and the cost of care did not differ between patients with and without ACP. However, patients with ACP had shorter hospital and intensive care unit (ICU) stays and higher rates of conversion to do-not-resuscitate (DNR) status post-resuscitation. Cardiopulmonary resuscitation (CPR) outcomes vary for patients with cancer. Here, we characterized cancer patients who underwent CPR in the emergency department (ED), their outcomes, and the effects of advanced care planning (ACP). The hospital databases and electronic medical records of cancer patients at a comprehensive cancer center who underwent CPR in the ED from 6 March 2016 to 31 December 2022 were reviewed for patient characteristics, return of spontaneous circulation (ROSC), conversion to do-not-resuscitate (DNR) status afterward, hospital and intensive care unit (ICU) length of stay, mortality, cost of hospitalization, and prior GOC discussions. CPR occurred in 0.05% of all ED visits. Of the 100 included patients, 67 patients achieved ROSC, with 15% surviving to hospital discharge. The median survival was 26 h, and the 30-day mortality rate was 89%. Patients with and without prior ACP had no significant differences in demographics, metastatic involvement, achievement of ROSC, or in-hospital mortality, but patients with ACP were more likely to change their code status to DNR and had shorter stays in the ICU or hospital. In conclusion, few cancer patients undergo CPR in the ED. Whether this results from an increase in terminally ill patients choosing DNR status requires further study. ACP was associated with increased conversion to DNR after resuscitation and decreased hospital or ICU stays without an increase in overall mortality. [ABSTRACT FROM AUTHOR]

Comprehensively defining end-of-life healthcare is a challenge due to the diverse areas of healthcare involved, the various stakeholders, and the range of patient options. This qualitative study examined many areas of end-of-life healthcare including quality, areas for improvement, and healthcare policy in Tennessee, in which the definition of end-of-life healthcare was a focus. Data were collected using semi-structured interviews with 19 participants who included end-of-life healthcare experts and Tennessee legislators. Through this research an operational definition of end-of-life healthcare, encompassing five concepts, was developed. Concepts include: a diagnosis, a timeframe, type of care, location of care, and planning for the future. When considered together, they are the embodiment of what end-of-life healthcare encompasses. Not in a one-fits-all definition, but individually tailored. An understanding of what end-of-life healthcare denotes is essential to maintaining open communication, high quality standards of care, and the protection of patient autonomy. [ABSTRACT FROM AUTHOR]

Background: Documenting goals of care in the electronic health record is meant to relay patient preferences to other clinicians. Evaluating the content and documentation of nurse and social worker led goals of care conversations can inform future goals of care initiative efforts. Methods: As part of the ADvancing symptom Alleviation with Palliative Treatment trial, this study analyzed goals of care conversations led by nurses and social workers and documented in the electronic health record. Informed by a goals of care communication guide, we identified five goals of care components: illness understanding, goals and values, end of life planning, surrogate, and advance directives. Forty conversation transcripts underwent content analysis. Through an iterative team process, we defined documentation accuracy as four categories: (1) Complete—comprehensive accurate documentation of the conversation, (2) Incomplete—partial documentation of the conversation, (3) Missing—discussed and not documented, and (4) Incorrect—misrepresented in documentation. We also defined—Not Discussed—for communication guide questions that were not discussed nor documented. A constant comparative approach was used to determine the presence or absence of conversation content in the documentation. Results: All five goals of care components were discussed in 67% (27/40) of conversation transcripts. Compared to the transcripts, surrogate (37/40, 93%) and advance directives (36/40, 90%) were often documented completely. Almost 40% of goals and values (15/40, 38%) and half of end of life planning (19/40, 48%) were incomplete. Illness understanding was missing (13/40, 33%), not discussed (13/40, 33%), or incorrect (2/40, 5%). Conclusion: Nurse and social worker led goals of care conversations discussed and documented most components of the goals of care communication guide. Further research may guide how best to determine the relative importance of accuracy, especially in the broad setting of incomplete, missing, and incorrect EHR documentation. [ABSTRACT FROM AUTHOR]

Goals of Care (GOC) is a longitudinal, multi-setting, and interprofessional practise aiming to guide the use of life-sustaining therapies. We documented the perspectives of different stakeholders regarding their roles in GOC intervention and explored the possibility of implementing an interprofessional approach in a healthcare and social services institution. We interviewed nurses, social workers, and relatives of deceased persons and analyzed the results using an analytical framework based on the 16 mechanisms of the Normalization Process Theory. We identified barriers to implementing a sustainable interprofessional approach to GOC, such as the lack of designated leaders responsible for supporting the day-to-day provision of this rather complex intervention, the difficulty of access to physicians in two of the three care settings under study, and the lack of a robust informational system. We also demonstrated that the GOC intervention is postponed until there is no uncertainty to deal with, i.e., at the end of life. Our study adds to an emerging body of literature criticising the concept of making advance medical directives itself. We advocated for the promotion of tools that would enable lay people to select and empower a supportive decision maker to better represent them in serious illness decision making. [ABSTRACT FROM AUTHOR]

Abstract Introduction Advance Care Planning (ACP) refers to a process that includes Advance Care Directives (ACD) and Goals of Care (GOC), a practice widely used for over three decades. Following the findings of an audit and a cross-sectional study in 2019 and 2021 respectively, we implemented several educational and other interventional strategies aimed at enhancing staff awareness and emphasizing the importance of recognizing and documenting of ACD/GOC. The aim of this study was to evaluate the acknowledgement and use of ACD and GOC by Emergency Department (ED) staff following these interventions. Method We used a mixed methods approach, incorporating both observational and cross-sectional designs with reflexive thematic analysis. Data extraction for the observational study took place between 1st April and 30th June 2023 focusing on a target population of randomly sampled adults aged ≥ 65 years. Demographics and other ACD and GOC related patients’ clinical data were collected. Data collection for the cross-sectional study occurred between 19th July and 13th September 2023 targeting all ED staff. Information gathered included demographics, awareness about ACD and GOC, including storage location and implementation, as well as knowledge of Medical Treatment decision Makers (MTDM), a jurisdictional term identifying a person legally appointed to make healthcare decisions on behalf of someone who lacks decision-making capacity and other Victorian State legislative requirements were collected. Results In the observational period, 22,335 patients attended the ED and 19% (n = 6546) qualified for inclusion from which a sample of 308 patients were randomly extracted. We found ACD documents were noted in the medical records of 6.5% of the sample, fewer than 8% identified in our previous study. There was no correlation between ACD record availability and age (p = 0.054; CI ranging from − 0.065 to 7.768). The response rate for the cross-sectional survey was 12% (n = 340) in contrast to earlier study with 28% (n = 476) respondents. Staff knowledge and familiarity with ACD was 25% and GOC 45%. Conclusion After implementing interventions in staff education and ACP awareness, we found that ACD documentation did not improve. However, GOC documentation increased in the context of heightened institutional awareness and integration into the Electronic Medical Records (EMR).

Objective: Palliative care consultation is relevant for patients requiring Venous-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO); however, evidence is limited to support its value. For this population, we compared length of stay (LOS) (primary outcome), operational metrics and goals of care (GOC) frequency before and after a collaboration between cardiothoracic (CT) surgery and Geriatrics and Palliative Medicine (GaP). Methods: Retrospective chart review of patients (18+) admitted to a quaternary center that required VA-ECMO between 2019-2021 and received GaP consultation. Demographics, LOS, times to consult, illness severity, GOC, and outcomes were analyzed. Results: 120 patients met inclusion criteria and 64 (53.3%) had GaP consultation. No differences were observed regarding demographics and insertion status (emergent vs elective). Median (IQR) days to GaP consult for 2019, 2020 and 2021 were 6.5 (4.0-14.5), 5.0 (2.0-11.0) and 3.0 (2.0-5.0), respectively (P =.006). Median days from insertion to consult for 2019, 2020 and 2021 were 6.0 (4.0-20.0), 3.0 (1.0-6.0) and 2.0 (1.0-4.0) (P =.003). Among survivors, over the 3-year course, median LOS was not statistically different. Between expired patients, median (IQR) LOS for 2019, 2020, and 2021 was 28.5 (23.0-40.0), 12.0 (8.0-14.0), 11.0 (5.0-17.0) days (P =.013). For patients not seen by GaP, 8 (14.3%) GOC notes were documented, compared with 42 (65.6%) for patients seen. Mortality was similar (53.6% vs 53.1% [GaP]). Conclusion: For patient on VA-ECMO, early GaP consultation may improve hospital LOS and GOC rates. We suggest organizations consider early palliative integration when instituting mechanical circulatory support. [ABSTRACT FROM AUTHOR]

RATIONALE: The prognosis of patients with lung cancer admitted to the intensive care unit (ICU) is often perceived as poor. We described the characteristics, management, and outcomes of critically ill patients with lung cancer and determined the predictors of mortality. METHODS: We retrospectively studied patients with lung cancer who were admitted to the ICU of a tertiary care hospital between 1999 and 2021 for the reasons other than routine postoperative care. We noted their characteristics, ICU management, and outcomes. We performed the multivariable logistic regression analysis to determine the predictors of hospital mortality. RESULTS: In the 23-year period, 306 patients with lung cancer were admitted to the ICU (median age = 63.0 years, 68.3% males, 45.6% with moderate/severe functional disability, most had advanced lung cancer, and median Acute Physiology and Chronic Health Evaluation II score = 24.0). Life support measures included invasive mechanical ventilation (47.1%), vasopressors (34.0%), and new renal replacement therapy (8.8%). Do-Not-Resuscitate orders were implemented during ICU stay in 30.1%. The hospital mortality was 43.8% with a significantly lower rate in patients admitted after 2015 (28.0%). The predictors of mortality were moderate/severe baseline disability (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.22, 5.78), advanced lung cancer (OR 8.36, 95% CI 1.81, 38.58), lactate level (OR 1.45, 95% CI 1.12, 1.88, invasive mechanical ventilation (OR 10.92, 95% CI 4.98, 23.95), and admission period after 2015 (OR 0.37, 95% CI 0.16, 0.85). CONCLUSIONS: The mortality rates in patients with lung cancer admitted to the ICU during a 23-year period decreased after 2015. Functional disability, advanced lung cancer stage, vasopressor use, and invasive mechanical ventilation predicted mortality.

Background: Comprehensive resuscitation plans document treatment recommendations, such as 'Not for cardiopulmonary resuscitation'. When created early in admission as a shared decision-making process, these plans support patient autonomy and guide future treatment. The characteristics of patients who have resuscitation plans documented, their timing, and associations with clinical outcomes remain unclear. Objectives: To characterise factors associated with resuscitation plan completion, early completion, and differences in mortality rates and Intensive Care Unit (ICU) admissions based on resuscitation plan status. Methods: This retrospective study analysed non-elective admissions to an Australian tertiary centre from January to June 2021, examining plan completion timing (early < 48 h, late > 48 h) and associations with mortality and ICU admission. Results: Of 13,718 admissions, 5745 (42%) had a resuscitation plan recorded. Most plans (89%) were completed early. Furthermore, 9% of patients died during admission, and 8.2% were admitted to the ICU. For those without resuscitation plans, 0.5% died (p < 0.001), and 9.7% were admitted to the ICU (p = 0.002). Factors associated with plan completion included a medical unit, in-hours admission, older age, female gender, limited English proficiency, and non-Indigenous status. Plans completed late (>48 h) correlated with a higher mortality (14% vs. 9%; p < 0.001) and more ICU admissions (25% vs. 6%; p < 0.001). Aboriginal and/or Torres Strait Islander patients were often overlooked for resuscitation documentation before death. No resuscitation plans were documented for 62% of ICU admissions. Conclusions: Important disparities exist in resuscitation plan completion rates across highly relevant inpatient and demographic groups. [ABSTRACT FROM AUTHOR]

Patients with advanced cancer can develop symptomatic hypoglycemia at the end of life which can be associated with significant distress. We report the case of a man with metastatic urothelial carcinoma who developed acute-onset, recurrent, and symptomatic hypoglycemia concerning for non-islet cell tumor hypoglycemia (NICTH). Hypoglycemic episodes were physically and emotionally distressing and refractory to glucose tablets and a low concentration of dextrose infusion. Based on symptom burden and goals of care, treatment was escalated to a concentrated dextrose infusion requiring a central venous line, oral corticosteroids, and subcutaneous somatotropin. He was transferred to the inpatient palliative service, and on this treatment regimen, did not have additional distressing hypoglycemia. For patients with metastatic cancer and symptomatic hypoglycemia, applying a palliative-based framework with discussion of prognosis, values, and goals will lead to goal-concordant care at the end of life that can include aggressive maintenance of euglycemia to relieve suffering. [ABSTRACT FROM AUTHOR]

Background: Prior studies reveal a lack of illness understanding and prognostic awareness among patients with hematological malignancies. We evaluated prognostic awareness and illness understanding among patients with acute leukemia and multiple myeloma (MM) and measured patient–hematologist discordance. Methods: We prospectively enrolled patients with acute leukemia and MM at Mount Sinai Hospital or Yale New Haven Hospital between August 2015 and February 2020. Patients were administered a survey assessing prognostic awareness, goals of care (GOC), and quality of life. Hematologists completed a similar survey for each patient. We assessed discordance across the cohort of patients and hematologists using the likelihood-ratio chi-square test and within patient–hematologist pairs using the kappa (κ) statistic. Results: We enrolled 185 patients (137 with leukemia and 48 with MM) and 29 hematologists. Among patients, 137 (74%) self-identified as White, 27 (15%) as Black, and 21 (11%) as Hispanic. Across the entire cohort, patients were significantly more optimistic about treatment goals compared with hematologists (p = 0.027). Within patient–hematologist pairs, hematologists were significantly more optimistic than patients with respect to line of treatment (κ = 0.03). For both leukemia and MM cohorts, patients were significantly more likely to respond "don't know" or deferring to a faith-based response with 88 (64%) and 34 (71%), respectively, compared with only 28 (20%) and 11 (23%) of hematologists, respectively. Conclusions: We observed significant discordance regarding prognosis and GOC among patients with hematological malignancies and their hematologists. These data support future interventions to improve prognostic understanding among this patient population to facilitate informed treatment choices. [ABSTRACT FROM AUTHOR]

Fellows in critical care medicine (CCM) routinely help patients and families navigate complex decisions near the end of life. These "late goals of care" (LGOC) discussions require rigorous skills training and impact patient care. Innovation is needed to ensure that fellow training in leading these discussions is centered on reproducible competency-based standards. The aims of this study were to (1) describe the development of a simulation-based mastery learning (SBML) curriculum for LGOC discussions and (2) set a defensible minimum passing standard (MPS) to ensure uniform skill acquisition among learners. We developed an SBML curriculum for CCM fellows structured around REMAP, a mnemonic outlining foundational components of effective communication around serious illness. A multidisciplinary expert panel iteratively created an LGOC discussion assessment tool. Pilot testing was completed to refine the checklist, set the MPS, and assess skill acquisition. The LGOC discussion assessment tool included an 18-item checklist and 6 scaled items. The tool produced reliable data (k ≥ 0.7 and ICC of ≥ 0.7). Using the Mastery Angoff method, the panel set the MPS at 87%. Ten CCM fellows participated in the pilot study. Performance on the checklist significantly improved from a median score of 52% (IQR 44%–72%) at pretest to 96% (IQR 82%–97%) at post-test (P = 0.005). The number of learners who met the MPS similarly improved from 10% during pre-testing to 70% during post-testing (P = 0.02). We describe the development of a LGOC SBML curriculum for CCM fellows which includes a robust communication skills assessment and the delineation of a defensible MPS. [ABSTRACT FROM AUTHOR]

Physicians, patients, and families alike perceive a need to improve how goals of care (GOC) decisions occur in chronic critical illness (CCI), but little is currently known about this decision-making process. How do intensivists from various health systems facilitate decision-making about GOC for patients with CCI? What are barriers to, and facilitators of, this decision-making process? We conducted semistructured interviews with a purposeful sample of intensivists from the United States and Canada using a mental models approach adapted from decision science. We analyzed transcripts inductively using qualitative description. We interviewed 29 intensivists from six institutions. Participants across all sites described GOC decision-making in CCI as a complex, longitudinal, and iterative process that involved substantial preparatory work, numerous stakeholders, and multiple family meetings. Intensivists required considerable time to collect information on prior events and conversations, and to arrive at a prognostic consensus with other involved physicians prior to meeting with families. Many intensivists stressed the importance of scheduling multiple family meetings to build trust and relationships prior to explicitly discussing GOC. Physician-identified barriers to GOC decision-making included 1-week staffing models, limited time and cognitive bandwidth, difficulty eliciting patient values, and interpersonal challenges with care team members or families. Potential facilitators included scheduled family meetings at regular intervals, greater interprofessional involvement in decisions, and consistent messaging from care team members. Intensivists described a complex time- and labor-intensive group process to achieve GOC decision-making in CCI. System-level interventions that improve how information is shared between physicians and decrease logistical and relational barriers to timely and consistent communication are key to improving GOC decision-making in CCI. [ABSTRACT FROM AUTHOR]

RATIONALE: The prognosis of patients with lung cancer admitted to the intensive care unit (ICU) is often perceived as poor. We described the characteristics, management, and outcomes of critically ill patients with lung cancer and determined the predictors of mortality. METHODS: We retrospectively studied patients with lung cancer who were admitted to the ICU of a tertiary care hospital between 1999 and 2021 for the reasons other than routine postoperative care. We noted their characteristics, ICU management, and outcomes. We performed the multivariable logistic regression analysis to determine the predictors of hospital mortality. RESULTS: In the 23-year period, 306 patients with lung cancer were admitted to the ICU (median age = 63.0 years, 68.3% males, 45.6% with moderate/severe functional disability, most had advanced lung cancer, and median Acute Physiology and Chronic Health Evaluation II score = 24.0). Life support measures included invasive mechanical ventilation (47.1%), vasopressors (34.0%), and new renal replacement therapy (8.8%). Do-Not-Resuscitate orders were implemented during ICU stay in 30.1%. The hospital mortality was 43.8% with a significantly lower rate in patients admitted after 2015 (28.0%). The predictors of mortality were moderate/severe baseline disability (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.22, 5.78), advanced lung cancer (OR 8.36, 95% CI 1.81, 38.58), lactate level (OR 1.45, 95% CI 1.12, 1.88, invasive mechanical ventilation (OR 10.92, 95% CI 4.98, 23.95), and admission period after 2015 (OR 0.37, 95% CI 0.16, 0.85). CONCLUSIONS: The mortality rates in patients with lung cancer admitted to the ICU during a 23-year period decreased after 2015. Functional disability, advanced lung cancer stage, vasopressor use, and invasive mechanical ventilation predicted mortality. [ABSTRACT FROM AUTHOR]

Purpose: For sexual and gender minority (SGM) individuals who identify as lesbian, gay, bisexual, transgender, queer, or any other sexual orientation or gender identity (LGBTQ+), the quality of palliative care can depend upon how clinicians view and communicate with this historically minoritized group. Prior literature has demonstrated that SGM patients access care at lower rates, and palliative care clinicians have suggested that SGM patients are more likely to experience discrimination than heterosexual patients. This study examined palliative care clinicians' perspectives and experiences regarding patient communication, care settings, the built environment, and inclusive care for SGM older adults with serious illness. Methods: The health disparities research framework informed a descriptive qualitative analysis of interview data with palliative care professionals (N = 20) across diverse healthcare settings within Colorado regarding their experiences and beliefs about communication and the care of SGM patients. Results: Three main themes emerged: (1) Limited sexual orientation and gender identity (SOGI) data collection; (2) Organizational and environmental inclusivity, and the "neutral" space viewed as safe; (3) Missing training platforms regarding SGM patients and a lack of opportunity to identify and discuss SGM patient needs. Conclusion: Study findings illuminated the following barriers to providing SGM-inclusive care: perspectives around (1) limitations and preferences regarding collection of SOGI data, (2) organizational and environmental inclusivity, and (3) education and training regarding cultural humility and communication with SGM patients. Findings indicate the need for multidimensional research to better understand and address SGM health disparities and promote equitable care. [ABSTRACT FROM AUTHOR]

The purpose of this article was to analyze the concept of "the fighter in the intensive care unit (ICU)" per the scientific literature and the impact this mentality has on care administered in the ICU. A literature review and a concept analysis based on Rodger's evolutionary method were performed to identify surrogate terms, antecedents, attributes, and consequences pertaining to the "fighter" in the ICU. Thirteen articles with a focus on "the fighter" were included in this analysis. There is a strong desire to remain optimistic and maintain high spirits as a coping mechanism in the face of extreme prognostic uncertainty. Themes that emerged from the literature were the need to find inner strength and persist in the face of adversity. The concept of "the fighter in the ICU" can serve as either adaptive or maladaptive coping, depending on the larger clinical picture. Patient experiences in the ICU are fraught with physical and psychological distress. How the patient and family unit cope during this anxiety-provoking time is based on the individual. Maintaining optimism and identifying asa fighter can be healthy ways to adapt to the circumstances. This concept analysis highlights the importance of holistic care and instilling hope particularly as patients may be nearing the end of life. [ABSTRACT FROM AUTHOR]

Due to the severity of hip fracture complications in the geriatric population, including major morbidity and mortality, it is crucial to establish treatment goals and manage expectations as a patient-centered multidisciplinary team. Goals of care (GOC) are personalized treatment programs designed to align with the individual patient's values and preferences. There is a paucity of literature on the topic of GOC discussions, especially regarding orthopaedic injuries. Therefore, this narrative review aims to provide an account of GOC discussions related to geriatric hip fractures. We reviewed articles published on GOC between 1978 and 2024. The articles were identified by searching PubMed and Google Scholar. We utilized the search terms GOC discussions and hip fracture, with additional descriptors including arthroplasty and geriatric. There were 11 articles that met the selection criteria and were published between 1978 and 2024. Five articles were published on GOC discussions in orthopaedic surgery, while the remaining 6 articles were published in non-orthopaedic fields. There was one systematic review, 2 narrative reviews, 6 observational studies, and 2 descriptive studies. Supplemental commentary from non-orthopaedic specialties and the fields of law and medical ethics was included to assist in highlighting barriers to GOC discussions and to explore potential strategies to enhance GOC discussions. Goals of care discussions provide a framework for treatment decisions based on an individual patient's values and cultural beliefs; however, these conversations may be limited by perceived time constraints, patient health care literacy, and physicians' misconceptions of what is most important to discuss. While no clear consensus was identified regarding strategies for improving GOC discussions in geriatric patients who have hip fractures, the authors recommend standardized training programs, expedited family meetings, multidisciplinary team involvement, assistive technology such as Outcome Prioritization Tool, and the incorporation of GOC discussions into institutional hip fracture pathways. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Communication about patients values, goals, and prognosis in serious illness (serious illness communication) is a cornerstone of person-centered care yet difficult to implement in practice. As part of Serious Illness Care Program implementation in five health systems, we studied the clinical culture-related factors that supported or impeded improvement in serious illness conversations. METHODS: Qualitative analysis of semi-structured interviews of clinical leaders, implementation teams, and frontline champions. RESULTS: We completed 30 interviews across palliative care, oncology, primary care, and hospital medicine. Participants identified four culture-related domains that influenced serious illness communication improvement: (1) clinical paradigms; (2) interprofessional empowerment; (3) perceived conversation impact; (4) practice norms. Changes in clinicians beliefs, attitudes, and behaviors in these domains supported values and goals conversations, including: shifting paradigms about serious illness communication from end-of-life planning to knowing and honoring what matters most to patients; improvements in psychological safety that empowered advanced practice clinicians, nurses and social workers to take expanded roles; experiencing benefits of earlier values and goals conversations; shifting from avoidant norms to integration norms in which earlier serious illness discussions became part of routine processes. Culture-related inhibitors included: beliefs that conversations are about dying or withdrawing care; attitudes that serious illness communication is the physicians job; discomfort managing emotions; lack of reliable processes. CONCLUSIONS: Aspects of clinical culture, such as paradigms about serious illness communication and inter-professional empowerment, are linked to successful adoption of serious illness communication. Further research is warranted to identify effective strategies to enhance clinical culture and drive clinician practice change.

Background: The Emergency Department (ED) has increasingly been recognized as an important site of care for older adults with unmet palliative care needs. Despite this, no clear model of care delivery has emerged. Aim: To assess the acceptability and feasibility of a scripted palliative care communication intervention in the ED directed by social workers. We hypothesized that the intervention would be feasible, acceptable to patients and ED social workers, and that the collection of patient outcomes would be possible. Design: A prospective, unblinded, pilot randomized clinical trial of older adults with serious illness presenting to the ED. Patients were randomized to either receive a social worker-directed palliative care intervention (n-65), which consisted of a conversation focused on patients goals, values, hopes and worries, or to usual care (n-52). The intervention was evaluated for feasibility and acceptability. Results: Of patients randomized to the intervention arm, 66% (43/65) completed a conversation with the social worker. Focus group feedback with the social workers further demonstrated the feasibility of these conversations. There was minimal (12%) loss to follow-up. Of the patients who received the intervention, the majority reported that they appreciated the social workers bringing up their goals for the future (77%), their social workers asking about their fears and worries (72%), and they liked the way the conversation was set up (81%). Social workers administered 95% of the conversation components. Conclusions: This pilot trial demonstrated the feasibility and acceptability of a social worker-directed, scripted palliative care communication intervention in a single urban, academic ED.

Background: The importance of dignity in health care is well described, yet limited interventions exist to improve dignity, particularly patient-driven interventions. Objectives: To test the hypothesis that patient-selected photographs at the bedside would impact patients' sense of dignity and clinicians' sense of meaningful work, stimulate conversation between patients and clinicians, and serve as a visual and patient-driven complement to the Patient Dignity Question (PDQ). Methods: Patients admitted to three units at an academic medical center displayed photographs above their head of bed and were interviewed for this study. We used thematic content analysis to compare themes extracted from patient interviews, the PDQ, and clinician surveys. Results: Eight themes emerged from patient interviews (n = 19): conveying goals, joy, capturing the patient's spirit, faith and spirituality, sense of belonging, physical appearance and health, stimulating conversation and meaningful connections, and humanizing the patient. The same themes emerged from the PDQ, with the exception of physical appearance and health. Notably, analysis of the clinician surveys (n = 40) yielded six similar themes: conveying goals, joy, stimulating conversation and meaningful connections, humanizing the patient, meaningful work, and compassion and empathy. Conclusions: Patient-selected photographs at the bedside impact both patients and clinicians by stimulating conversation and meaningful connections, humanizing patients, and fostering meaning and joy in work. Photographs and the PDQ provide a similar window into personhood, thereby supporting the use of a photograph as a visual and patient-driven complement to the PDQ.

Abstract Introduction The value of a short life characterized by disability has been hotly debated in the literature on fetal and neonatal outcomes. Methods We conducted a scoping review to summarize the available empirical literature on the experiences of families in the context of trisomy 13 and 18 (T13/18) with subsequent thematic analysis of the 17 included articles. Findings Themes constructed include (1) Pride as Resistance, (2) Negotiating Normalcy and (3) The Significance of Time. Interpretation Our thematic analysis was guided by the moral experience framework conceived by Hunt and Carnevale (2011) in association with the VOICE (Views On Interdisciplinary Childhood Ethics) collaborative research group. Relevance This article will be of interest and value to healthcare professionals and bioethicists who support families navigating the medically and ethically complex landscape of T13/18.

(1) Background: This observational cohort study describes the frequency, content, and satisfaction with advance care planning (ACP) conversations with healthcare providers (HCPs), as reported by patients with advanced colorectal cancer. (2) Methods: The patients were recruited from two tertiary cancer centers in Alberta, Canada. Using the My Conversations survey with previously validated questions, the patients were asked about specific ACP elements discussed, with which HCPs these elements were discussed, their satisfaction with these conversations, and whether they had a goals of care designation (GCD) order. We surveyed and analyzed data from the following four time points: enrollment, months 1, 2, and 3. (3) Results: In total, 131 patients were recruited. At enrollment, 24% of patients reported discussing at least one ACP topic. From enrollment to month 3, patients reported a high frequency of discussions (80.2% discussed fears, 71.0% discussed prognosis, 54.2% discussed treatment preferences at least once); however, only 44.3% of patients reported discussing what is important to them in considering health care preferences. Patients reported having ACP conversations most often with their oncologists (84.7%) and cancer clinic nurses (61.8%). Patients reported a high level of satisfaction with their ACP conversations, with over 80% of patients reported feeling heard and understood. From enrollment to month 3, there was an increase in the number of patients with a GCD order from 53% to 74%. (4) Conclusions: Patients reported more frequent conversations compared to the literature and clinical documentation. While the satisfaction with these conversations is high, there is room for quality improvement, particularly in eliciting patients’ personal goals for their treatment.

Abstract Background Prolonged intensive care unit (ICU) stay is associated with physical, cognitive, and psychological disabilities. The impact of baseline frailty on long-stay ICU patients remains uncertain. This study aims to investigate how baseline frailty influences mortality and post-ICU disability 6 months after critical illness in long-stay ICU patients. Methods In this retrospective cohort study, we assessed patients hospitalized for ≥ 7 days in the ICU between May 2018 and May 2021, following them for up to 6 months or until death. Based on the Clinical Frailty Scale (CFS) at ICU admissions, patients were categorized as frail (CFS ≥ 5), pre-frail (CFS 3–4) and non-frail (CFS 1–2). Kaplan–Meier curves and a multivariate Cox model were used to examine the association between frailty and mortality. At the 6 month follow-up, we assessed psychological, physical, cognitive outcomes, and health-related quality of life (QoL) using descriptive statistics and linear regressions. Results We enrolled 531 patients, of which 178 (33.6%) were frail, 200 (37.6%) pre-frail and 153 (28.8%) non-frail. Frail patients were older, had more comorbidities, and greater disease severity at ICU admission. At 6 months, frail patients presented higher mortality rates than pre-frail and non-frail patients (34.3% (61/178) vs. 21% (42/200) vs. 13.1% (20/153) respectively, p

Objective: Nurses have opportunities to engage in goals of care conversations that can promote palliative care communication. The purpose of this study was to describe nurses' experiences in goals of care communication as summarized in the literature and to present a conceptual model of communication pathways for nurses. Methods: An integrative review of the literature (2016–2022) addressing nurses' experiences in goals of care communication was conducted using PubMed, CINAHL, and PsychInfo databases. A total of 92 articles were retrieved. A total of 12 articles were included for this review after applying the inclusion and exclusion criteria. Results: Of the 12 articles, the majority were qualitative studies (n = 8). Qualitative analysis of findings from all articles revealed three dominant themes: nurses' ambiguous role responsibilities, goals of care as end-of-life communication, and the need for nurse communication training. Conclusion: This article suggests an innovative conceptual model for advancing nurse communication about goals of care to facilitate primary palliative care. Innovation: The framework characterizes two communication pathways for Advanced Practice Nurses who direct goals of care discussions and Registered Nurses who support goals of care communication. The model informs future communication training aimed at supporting primary palliative care.

Background: Many parents of children with advanced cancer report curative goals and continue intensive therapies that can compound symptoms and suffering. Factors that influence parents to choose palliation as the primary treatment goal are not well understood. The objective of this study was to examine experiences impacting parents' report of palliative goals adjusted for time. The authors hypothesized that awareness of poor prognosis, recall of oncologists' prognostic disclosure, intensive treatments, and burdensome symptoms and suffering would influence palliative goal‐setting. Methods: The authors collected prospective, longitudinal surveys from parents of children with relapsed/refractory neuroblastoma at nine pediatric cancer centers across the United States, beginning at relapse and continuing every 3 months for 18 months or until death. Hypothesized covariates were examined for possible associations with parental report of palliative goals. Generalized linear mixed models were used to evaluate factors associated with parents' report of palliative goals at different time points. Results: A total of 96 parents completed surveys. Parents were more likely to report a primary goal of palliation when they recalled communication about prognosis by their child's oncologist (odds ratio [OR], 52.48; p =.010). Treatment intensity and previous ineffective therapeutic regimens were not associated with parents' report of palliative goals adjusted for time. A parent who reported new suffering for their child was less likely to report palliative goals (OR, 0.13; p =.008). Conclusions: Parents of children with poor prognosis cancer may not report palliative goals spontaneously in the setting of treatment‐related suffering. Prognostic communication, however, does influence palliative goal‐setting. Evidence‐based interventions are needed to encourage timely, person‐centered prognostic disclosure in the setting of advanced pediatric cancer. Plain Language Summary: Many parents of children with poor‐prognosis cancer continue to pursue curative treatments that may worsen symptoms and suffering.Little is known about which factors influence parents to choose palliative care as their child's main treatment goal.To explore this question, we asked parents of children with advanced neuroblastoma across the United States to complete multiple surveys over time.We found that the intensity of treatment, number of treatments, and suffering from treatment did not influence parents to choose palliative goals.However, when parents remembered their child's oncologist talking about prognosis, they were more likely to choose palliative goals of care. The authors collected prospective, longitudinal surveys from parents of children with relapsed and/or refractory neuroblastoma at nine pediatric cancer centers across the United States to identify variables associated with parents' report of palliative goals across advancing illness. They found that parents of children with poor prognosis cancer may not report palliative goals spontaneously in the setting of treatment‐related suffering, but prognostic communication does influence palliative goal‐setting. [ABSTRACT FROM AUTHOR]

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Many patients admitted to intensive care units (ICUs) are at high risk of dying. We hypothesize that focused training sessions for ICU providers by palliative care (PC) certified experts will decrease aggressive medical interventions at the end of life. We designed and implemented a 6-session PC training program in communication skills and goals of care (GOC) meetings for ICU teams, including house staff, critical care fellows, and attendings. We then reviewed charts of ICU patients treated before and after the intervention. Forty-nine of 177 (28%) and 63 of 173 (38%) patients were identified to be at high risk of death in the pre- and postintervention periods, respectively, and were included based on the study criteria. Inpatient mortality (45% vs 33%; P =.24) and need for mechanical ventilation (59% vs 44%, P =.13) were slightly higher in the preintervention population, but the difference was not statistically significant. The proportion of patients in whom the decision not to initiate renal replacement therapy was made because of poor prognosis was significantly higher in the postintervention population (14% vs 67%, P =.05). There was a nonstatistically significant trend toward earlier GOC discussions (median time from ICU admission to GOC 4 vs 3 days) and fewer critical care interventions such as tracheostomies (17% vs 4%, P =.19). Our study demonstrates that directed PC training of ICU teams has a potential to reduce end of life critical care interventions in patients with a poor prognosis. [ABSTRACT FROM AUTHOR]

(1) Background: This observational cohort study describes the frequency, content, and satisfaction with advance care planning (ACP) conversations with healthcare providers (HCPs), as reported by patients with advanced colorectal cancer. (2) Methods: The patients were recruited from two tertiary cancer centers in Alberta, Canada. Using the My Conversations survey with previously validated questions, the patients were asked about specific ACP elements discussed, with which HCPs these elements were discussed, their satisfaction with these conversations, and whether they had a goals of care designation (GCD) order. We surveyed and analyzed data from the following four time points: enrollment, months 1, 2, and 3. (3) Results: In total, 131 patients were recruited. At enrollment, 24% of patients reported discussing at least one ACP topic. From enrollment to month 3, patients reported a high frequency of discussions (80.2% discussed fears, 71.0% discussed prognosis, 54.2% discussed treatment preferences at least once); however, only 44.3% of patients reported discussing what is important to them in considering health care preferences. Patients reported having ACP conversations most often with their oncologists (84.7%) and cancer clinic nurses (61.8%). Patients reported a high level of satisfaction with their ACP conversations, with over 80% of patients reported feeling heard and understood. From enrollment to month 3, there was an increase in the number of patients with a GCD order from 53% to 74%. (4) Conclusions: Patients reported more frequent conversations compared to the literature and clinical documentation. While the satisfaction with these conversations is high, there is room for quality improvement, particularly in eliciting patients' personal goals for their treatment. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic led to visitor restrictions in many hospitals. Since care in the surgical intensive care unit (SICU) often engages visitors as surrogate decision-makers, we investigated whether there was an association between COVID-19–related visitor restrictions, goals of care discussions (GOCD), and patient outcomes in SICU patients. We conducted a retrospective review of trauma and emergency general surgery (EGS) patients admitted to a rural tertiary SICU between July 2019 and April 2021, dividing patients into those admitted during COVID-19 visitor restrictions and those admitted at other times. Using univariate and multivariate logistic regression analyses, we compared the primary outcome, incidence of GOCD, and incidence of prolonged hospital (> 14 d) and intensive care unit length of stay (LOS, > 7 d) between the two groups. One hundred seventy nine of 368 study patients (48.6%) presented during restricted visitation. The proportion of GOCD was 38.0% and 36.5% in the restricted and nonrestricted visitation cohorts, respectively (P = 0.769). GOCD timing and outcomes were similar in both groups. The use of telecommunication increased during restricted visitation, as did the proportion of trauma patients admitted to the SICU. On multivariable logistic regression, age and patient category were independent predictors of GOCD. On outcomes analysis, visitor restriction was associated with prolonged hospital LOS for EGS patients (odds ratio 2.44, 95% confidence interval 1.01-5.91, P value 0.048). Restricted visitation was not associated with changes in frequency or outcome of GOCD, but was associated with prolonged hospital LOS among EGS patients who had SICU admissions. Further investigation of patient/surrogate satisfaction with virtual GOCD in the SICU setting is needed. • COVID-19 visitor restrictions led to increased use of telecommunication. • Visitor restrictions did not affect timing or outcomes of goals of care discussions. • Visitor restrictions may be associated with increased hospital length of stay. [ABSTRACT FROM AUTHOR]

Objectives: Implementation of advance care planning (ACP) in people with progressive multiple sclerosis (PwPMS) is limited. We aimed to involve users (PwPMS, significant others, and healthcare professionals involved in PwPMS care) in the evaluation and refinement of a booklet to be used during the ACP conversations. Methods: This qualitative study consisted of cognitive interviews with PwPMS and significant others and a focus group with healthcare professionals from three Italian centers. We analyzed the interviews using the framework method and the focus group using thematic analysis. Results: We interviewed 10 PwPMS (3 women; median age 54 years; median Expanded Disability Status Scale score 6.0) and three significant others (2 women; 2 spouses and one daughter). The analysis yielded three themes: booklet comprehensibility and clarity, content acceptability and emotional impact, and suggestions for improvement. Twelve healthcare professionals (7 neurologists, 3 psychologists, one nurse, and one physiotherapist) participated in the focus group, whose analysis identified two themes: booklet's content importance and clarity and challenges to ACP implementation. Based on analysis results, we revised the booklet (text, layout, and pictures) and held a second-round interviews with two PwPMS and one significant other. The interviewees agreed on the revisions but reaffirmed their difficulty in dealing with the topic and the need for a physician when using the booklet. Conclusions: Appraisal of the booklet was instrumental in improving its acceptability and understandability before using it in the ConCure-SM feasibility trial. Furthermore, our data reveal a lack of familiarity with ACP practice in the Italian context. [ABSTRACT FROM AUTHOR]

Introduction: The value of a short life characterized by disability has been hotly debated in the literature on fetal and neonatal outcomes. Methods: We conducted a scoping review to summarize the available empirical literature on the experiences of families in the context of trisomy 13 and 18 (T13/18) with subsequent thematic analysis of the 17 included articles. Findings: Themes constructed include (1) Pride as Resistance, (2) Negotiating Normalcy and (3) The Significance of Time. Interpretation: Our thematic analysis was guided by the moral experience framework conceived by Hunt and Carnevale (2011) in association with the VOICE (Views On Interdisciplinary Childhood Ethics) collaborative research group. Relevance: This article will be of interest and value to healthcare professionals and bioethicists who support families navigating the medically and ethically complex landscape of T13/18. [ABSTRACT FROM AUTHOR]

Background: Prolonged intensive care unit (ICU) stay is associated with physical, cognitive, and psychological disabilities. The impact of baseline frailty on long-stay ICU patients remains uncertain. This study aims to investigate how baseline frailty influences mortality and post-ICU disability 6 months after critical illness in long-stay ICU patients. Methods: In this retrospective cohort study, we assessed patients hospitalized for ≥ 7 days in the ICU between May 2018 and May 2021, following them for up to 6 months or until death. Based on the Clinical Frailty Scale (CFS) at ICU admissions, patients were categorized as frail (CFS ≥ 5), pre-frail (CFS 3–4) and non-frail (CFS 1–2). Kaplan–Meier curves and a multivariate Cox model were used to examine the association between frailty and mortality. At the 6 month follow-up, we assessed psychological, physical, cognitive outcomes, and health-related quality of life (QoL) using descriptive statistics and linear regressions. Results: We enrolled 531 patients, of which 178 (33.6%) were frail, 200 (37.6%) pre-frail and 153 (28.8%) non-frail. Frail patients were older, had more comorbidities, and greater disease severity at ICU admission. At 6 months, frail patients presented higher mortality rates than pre-frail and non-frail patients (34.3% (61/178) vs. 21% (42/200) vs. 13.1% (20/153) respectively, p < 0.01). The rate of withdrawing or withholding of care did not differ significantly between the groups. Compared with CFS 1–2, the adjusted hazard ratios of death at 6 months were 1.7 (95% CI 0.9–2.9) for CFS 3–4 and 2.9 (95% CI 1.7–4.9) for CFS ≥ 5. At 6 months, 192 patients were seen at a follow-up consultation. In multivariate linear regressions, CFS ≥ 5 was associated with poorer physical health-related QoL, but not with poorer mental health-related QoL, compared with CFS 1–2. Conclusion: Frailty is associated with increased mortality and poorer physical health-related QoL in long-stay ICU patients at 6 months. The admission CFS can help inform patients and families about the complexities of survivorship during a prolonged ICU stay. [ABSTRACT FROM AUTHOR]

In this segment of the emergency department (ED) palliative care (PC) case series, we present a patient with advanced cancer not yet followed by PC or on hospice, who presents to the ED overnight with worsening nausea, vomiting, and acute on chronic abdominal pain. The ED team works to stabilize and treat the patient, reaches out to his oncologist, and seeks remote support and guidance from the on-call PC clinician. After a rapid "just-in-time" training, the ED clinician is able to have a focused goals-of-care conversation with the patient and his family and make person-centered recommendations. The patient is briefly admitted to the intensive care unit for ongoing medical optimization and symptom management, and then subsequently discharged home on hospice in alignment with his elucidated goals. [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic resulted in introspection of the United States health care infrastructure, especially with advance care planning (ACP). Methods: This is a retrospective chart review assessing the frequency of ACP discussions and formal documents reflecting ACP wishes in an outpatient palliative medicine (PM) practice. The study site was at University Medical Center New Orleans from pre-COVID-19 surge (November 2019–February 2020) to months during and post-COVID-19 surge (March–April 2020). Results: Results showed an increase in ACP discussions during the post-COVID-19 months. Patients seen during the surge and post-COVID-19 months were more likely to discuss medical power of attorney (odds ratio [OR] = 1.78, p = 0.045) and preferred code status (OR = 2.82, p < 0.001). Conclusion: Our study showed that more ACP discussions were conducted post-COVID-19 versus pre-COVID-19. However, formal documents reflecting these wishes were lacking. These results can help guide ACP use in crisis periods and improve understanding of ACP discussions in an outpatient PM clinic. [ABSTRACT FROM AUTHOR]

Medical students are expected to gain competency in inquiring about patients' goals of care, per the Association of American Medical Colleges' Entrustable Professional Activities. While students may be part of teams that conduct routine code status discussions (CSDs), formal training in this skill prior to clinical clerkships is lacking. We aimed to address this training gap by designing a curriculum to teach preclinical medical students about routine CSDs. We designed and conducted an interactive workshop for preclinical medical students to learn about routine CSDs and practice this skill, using Kern's Six Steps to Curriculum Design. A qualitative and quantitative pre- and postsurvey was administered. A convergent, parallel, mixed methods analysis was performed. Students (n = 135) named more options for code status following the workshop (presurvey 1.3 vs. postsurvey 4.3, P < 0.01). There was an increase in the proportion of students reporting that they felt "somewhat comfortable" or "extremely comfortable" conducting a CSD (presurvey 19% vs. postsurvey 64%, P < 0.01), and a decrease in those reporting that they felt "extremely uncomfortable" or "somewhat uncomfortable" (presurvey 53% vs. postsurvey 18%, P < 0.01). Thematic analysis revealed that students were concerned about knowledge gaps, communication tools, personal discomfort, and upsetting patients or family. A workshop to train medical students to conduct routine CSDs can be included as part of a preclinical medical education curriculum. Students reported that the workshop increased their confidence in conducting CSDs and demonstrated an increase in corresponding knowledge, preparing them to deliver person-centered care on their clerkships. [ABSTRACT FROM AUTHOR]

Advance care planning (ACP) improves care for patients with chronic illnesses and reduces family stress. However, the impact of ACP interventions on healthcare professionals' well-being remains unknown. To systematically review the literature evaluating the impact of ACP interventions on healthcare professionals' well-being. We followed the Joanna Briggs Institute methodology for systematic reviews and registered the protocol in PROSPERO (CRD42022346354). We included primary studies in all languages that assessed the well-being of healthcare professionals in ACP interventions. We excluded any studies on ACP in psychiatric care and in palliative care that did not address goals of care. Searches were conducted on April 4, 2022, and March 6, 2023 in Embase, CINAHL, Web of Science, and PubMed. We used the Mixed Methods Appraisal Tool for quality analysis. We present results as a narrative synthesis because of their heterogeneity. We included 21 articles published in English between 1997 and 2021 with 17 published after 2019. All were conducted in high-income countries, and they involved a total of 1278 participants. Three reported an interprofessional intervention and two included patient partners. Studies had significant methodological flaws but most reported that ACP had a possible positive impact on healthcare professionals' well-being. This review is the first to explore the impact of ACP interventions on healthcare professionals' well-being. ACP interventions appear to have a positive impact, but high-quality studies are scarce. Further research is needed, particularly using more rigorous and systematic methods to implement interventions and report results. [ABSTRACT FROM AUTHOR]

Surgical palliative care (PC) facilitates communication between surgeons and patients/family about prognosis, symptom control, and therapeutic goals. Surgical critical care (SCC) fellows are at the forefront of the intensive care team; thus, we aim to assess previous and ongoing experiences in delivering PC by surveying fellows at a large academic center. Seventeen surveys were completed in which 59% of fellows reported no previous PC education. Six fellows (35%) reported participating in goals of care/end-of-life (GOC/EOL) discussions "a few times a year" during residency, while 41% responded the same for transitioning patients to comfort-focused care (CFC). When asked if respondents felt comfortable facilitating GOC/EOL discussions prior to fellowship, 7 (41%) answered "disagree" or "strongly disagree." Most fellows reported that more training in navigating GOC/EOL discussions (88%) and transitioning patients to CFC (76%) is needed. This assessment demonstrates variability in fellows' prior PC exposure and a strong desire for more structured training. [ABSTRACT FROM AUTHOR]

Patients with incurable cancers have an increasing number of comorbidities, which can lead to polypharmacy and its associated adverse events (drug-to-drug interaction, prescription of a potentially inappropriate medication, adverse drug event). Deprescribing is a patient-centered process aimed at optimizing patient outcomes by discontinuing medication(s) deemed no longer necessary or potentially inappropriate. Improved patient quality of life, risk reduction of side effects or worse clinical outcomes, and a decrease in healthcare costs are well-documented benefits of deprescribing. Deprescribing and advance care planning both require consideration of patients’ values, preferences, and care goals. Here, we provide an overview of comorbidities and associated polypharmacy risks in cancer patients, as well as useful tools and resources for deprescribing in daily practice, and we shed light on how deprescribing can facilitate advance care planning discussions with patients who have advanced cancer or a limited life expectancy.