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Taylor, Genevieve, Melissa Smith, Sarah Dotters-Katz, Arlene Davis, Wayne Price, and Jacquelyn Patterson. "Transitions in Care for Infants with Trisomy 13 or 18." American Journal of Perinatology 34, no. 09 (March 16, 2017): 887–94. http://dx.doi.org/10.1055/s-0037-1600912.
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Background and Objectives The scope of interventions offered to infants with trisomy 13 (T13) or trisomy 18 (T18) is increasing. We describe the spectrum of care provided, highlighting transitions in care for individual patients. Patients and Methods This is a single-center, retrospective cohort of infants with T13 or T18 born between 2004 and 2015. Initial care was classified as comfort care or intervention using prenatal counseling notes. Transitions in care were identified in the medical record. Results In this study, 25 infants were divided into two groups based on their care: neonates who experienced no transition in care and neonates who experienced at least one transition. Eleven neonates experienced no transition in care with 10 receiving comfort care. Fourteen neonates experienced at least one transition: three transitioned from comfort care to intervention and 11 from intervention to comfort care. The three initially provided comfort care were discharged home with hospice and readmitted. Among the 11 cases who transitioned from intervention to comfort care, 9 transitioned during the birth hospitalization, 6 had no prenatal suspicion for T13 or T18, and 5 experienced elective withdrawal of intensive care. Conclusion The spectrum of care for infants with T13 or T18 illustrates the need for individualized counseling that is on-going, goal directed, collaborative, and responsive.
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Downar, J., and J. Mikhael. "60. Using a pocket card to improve end-of-life care on clinical teaching units: A controlled trials." Clinical & Investigative Medicine 30, no. 4 (August 1, 2007): 61. http://dx.doi.org/10.25011/cim.v30i4.2821.
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Although palliative and end-of-life is a critical part of in-hospital medical care, residents often have very little formal education in this field. To determine the efficacy of a symptom management pocket card in improving the comfort level and knowledge of residents in delivering end-of-life care on medical clinical teaching units, we performed a controlled trial involving residents on three clinical teaching units.
Residents at each site were given a 5-minute questionnaire at the start and at the end of their medicine ward rotation. Measures of self-reported comfort levels were assessed, as were 5 multiple-choice questions reflecting key knowledge areas in end-of-life care. Residents at all three sites were given didactic teaching sessions covering key concepts in palliative and end-of-life care over the course of their medicine ward rotation. Residents at the intervention site were also given a pocket card with information regarding symptom management in end-of-life care.
Over 10 months, 137 residents participated on the three clinical teaching units. Comfort levels improved in both control (p < 0.01) and intervention groups (p < 0.01), but the intervention group was significantly more comfortable than the control group at the end of their rotations (z=2.77, p < 0.01). Knowledge was not significantly improved in the control group (p=0.07), but was significantly improved in the intervention group (p < 0.01). The knowledge difference between the two groups approached but did not reach statistical significance at the end of their rotation.
In conclusion, our pocket card is a feasible, economical educational intervention that improves resident comfort level and knowledge in delivering end-of-life care on clinical teaching units.
Oneschuk D, Moloughney B, Jones-McLean E, Challis A. The Status of Undergraduate Palliative Medicine Education in Canada: a 2001 Survey. Journal Palliative Care 2004; 20:32.
Tiernan E, Kearney M, Lynch AM, Holland N, Pyne P. Effectiveness of a teaching programme in pain and symptom management for junior house officers. Support Care Cancer 2001; 9:606-610.
Okon TR, Evans JM, Gomez CF, Blackhall LJ. Palliative Educational Outcome with Implementation of PEACE Tool Integrated Clinical Pathway. Journal of Palliative Medicine 2004; 7:279-295.
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McCracken, James A., Mohamed Nakeshbandi, Carline Sainvil, Eduard Porosnicu, and Roopali Sharma. "160. A Pre- and Post-intervention Study to Implement a Successful Antimicrobial Stewardship Program in Palliative Care." Open Forum Infectious Diseases 7, Supplement_1 (October 1, 2020): S89—S90. http://dx.doi.org/10.1093/ofid/ofaa439.205.
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Abstract Background In patients receiving palliative care, medical interventions are transitioned away from aggressive and curative attempts to less invasive and more comfort measures. Antimicrobial usage remains a challenging subject in palliative care decisions, where many physicians focus interventions on reduction of patient pain and discomfort, without consideration for adverse effects such as the development of antimicrobial resistance or patient-specific adverse drug events. With limited data on the comfort benefit, we aimed to assess antimicrobial use in patients at the end of life in our institution as well as the success of targeted stewardship interventions in palliative care patients. Methods Patients who expired between November 2018 and August 2019 were assessed retrospectively for antimicrobial use during their last 14 days of life. In January 2020, a prospective stewardship initiative began in collaboration with our institution’s palliative care team to focus antimicrobial interventions on patients involved in goals of care discussions. Results In our retrospective review of 200 patients, 139 (69.5%) of patients received antimicrobials in their last two weeks of life, with 50% having formal palliative care consultations. The most commonly used antimicrobials were piperacillin-tazobactam (64.7%) and vancomycin (60.4%), with primary indications being pneumonia (34.5%) and empiric coverage/sepsis (24.5%). Of note, 46% of antimicrobial regimens were eligible for optimization through stewardship initiatives. From January through February 2020, sixteen stewardship interventions were made on thirteen palliative care patients, with an 81.3% acceptance rate. Duration of therapy based on indication and discontinuation of antibiotics following transition to comfort measures only were the most frequent interventions made. Table 1. Baseline Characteristics Table 2. Antimicrobial Usage - Pre-intervention Table 3. Prospective Intervention Data Conclusion Close of half of patients receiving antimicrobials at the end of life are eligible for interventions to improve antibiotic regimens. These patients are often overlooked in antimicrobial stewardship, and, despite small sample size, our study shows the benefit of targeted stewardship in palliative care populations with an intervention acceptance rate of over 80%. Disclosures All Authors: No reported disclosures
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Pathoulas, James T., Kylie Blume, Justin Penny, Matthew Mansh, Nathan Rubin, and Ronda S. Farah. "Effectiveness of an Educational Intervention to Improve Medical Student Comfort and Familiarity With Providing Gender-Affirming Hormone Therapy." Family Medicine 53, no. 1 (January 8, 2021): 61–64. http://dx.doi.org/10.22454/fammed.2021.612374.
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Background and Objectives: Gender-affirming hormone therapy (GAHT) is a key component in the primary care of transgender and gender-nonconforming (TGNC) people. However, physicians are hesitant to initiate GAHT, citing a lack of knowledge. We developed an educational program for medical students and sought to investigate whether medical students’ comfort and familiarity with GAHT could increase after a short interactive program. Methods: Second-year medical students (N=54) at the University of Minnesota were recruited to attend an hour long interactive lecture on GAHT. We calculated mean change in pre- and postintervention 5-point Likert scale scores from a survey assessing comfort and familiarity with key concepts of GAHT to assess the effectiveness of the intervention. Results: Mean response score change increased significantly after the intervention around the use of chosen names (0.4±0.13, P<.017), the use of informed consent to initiate GAHT (1.8±0.20, P<.001), initiating and managing GAHT in the primary care setting (1.4±0.19, P<.001), medications used in GAHT (2.3±0.21, P<.001), and dosing (2.5±0.60, P<.001). Conclusions: GAHT can be initiated and managed in a primary care setting. There is a push to introduce GAHT in the preclinical years. After participating in a short interactive lecture on GAHT, second-year medical students reported increased comfort and familiarity with GAHT. Inclusion of GAHT in the preclinical curriculum does not require significant teaching time and is important knowledge for all future physicians.
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Pathoulas, James T., Kylie Blume, Justin Penny, Matthew Mansh, Nathan Rubin, and Ronda S. Farah. "Effectiveness of an Educational Intervention to Improve Medical Student Comfort and Familiarity With Providing Gender-Affirming Hormone Therapy." Family Medicine 53, no. 1 (January 8, 2021): 61–64. http://dx.doi.org/10.22454/fammed.2021.612374.
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Background and Objectives: Gender-affirming hormone therapy (GAHT) is a key component in the primary care of transgender and gender-nonconforming (TGNC) people. However, physicians are hesitant to initiate GAHT, citing a lack of knowledge. We developed an educational program for medical students and sought to investigate whether medical students’ comfort and familiarity with GAHT could increase after a short interactive program. Methods: Second-year medical students (N=54) at the University of Minnesota were recruited to attend an hour long interactive lecture on GAHT. We calculated mean change in pre- and postintervention 5-point Likert scale scores from a survey assessing comfort and familiarity with key concepts of GAHT to assess the effectiveness of the intervention. Results: Mean response score change increased significantly after the intervention around the use of chosen names (0.4±0.13, P<.017), the use of informed consent to initiate GAHT (1.8±0.20, P<.001), initiating and managing GAHT in the primary care setting (1.4±0.19, P<.001), medications used in GAHT (2.3±0.21, P<.001), and dosing (2.5±0.60, P<.001). Conclusions: GAHT can be initiated and managed in a primary care setting. There is a push to introduce GAHT in the preclinical years. After participating in a short interactive lecture on GAHT, second-year medical students reported increased comfort and familiarity with GAHT. Inclusion of GAHT in the preclinical curriculum does not require significant teaching time and is important knowledge for all future physicians.
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El-Jawahri, Areej, Lisa M. Podgurski, April F. Eichler, Scott R. Plotkin, Jennifer S. Temel, Susan L. Mitchell, Yuchiao Chang, Michael J. Barry, and Angelo E. Volandes. "Use of Video to Facilitate End-of-Life Discussions With Patients With Cancer: A Randomized Controlled Trial." Journal of Clinical Oncology 28, no. 2 (January 10, 2010): 305–10. http://dx.doi.org/10.1200/jco.2009.24.7502.
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Purpose To determine whether the use of a goals-of-care video to supplement a verbal description can improve end-of-life decision making for patients with cancer. Methods Fifty participants with malignant glioma were randomly assigned to either a verbal narrative of goals-of-care options at the end of life (control), or a video after the same verbal narrative (intervention) in this randomized controlled trial. The video depicts three levels of medical care: life-prolonging care (cardiopulmonary resuscitation [CPR], ventilation), basic care (hospitalization, no CPR), and comfort care (symptom relief). The primary study outcome was participants' preferences for end-of-life care. The secondary outcome was participants' uncertainty regarding decision making (score range, 3 to 15; higher score indicating less uncertainty). Participants' comfort level with the video was also measured. Results Fifty participants were randomly assigned to either the verbal narrative (n = 27) or video (n = 23). After the verbal description, 25.9% of participants preferred life-prolonging care, 51.9% basic care, and 22.2% comfort care. In the video arm, no participants preferred life-prolonging care, 4.4% preferred basic care, 91.3% preferred comfort care, and 4.4% were uncertain (P < .0001). The mean uncertainty score was higher in the video group than in the verbal group (13.7 v 11.5, respectively; P < .002). In the intervention arm, 82.6% of participants reported being very comfortable watching the video. Conclusion Compared with participants who only heard a verbal description, participants who viewed a goals-of-care video were more likely to prefer comfort care and avoid CPR, and were more certain of their end-of-life decision making. Participants reported feeling comfortable watching the video.
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Becker, Torben K., James F. Skiba, and Cemal B. Sozener. "An Educational Measure to Significantly Increase Critical Knowledge Regarding Interfacility Patient Transfers." Prehospital and Disaster Medicine 30, no. 3 (March 19, 2015): 244–48. http://dx.doi.org/10.1017/s1049023x15000266.
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AbstractBackgroundPatient transfers among medical facilities are high-risk situations. Despite this, there is very little training of physicians regarding the medical and legal aspects of transport medicine.ObjectivesTo examine the effects of a one hour, educational intervention on Emergency Medicine (EM) residents’ and Critical Care (CC) fellows’ knowledge regarding the medical and legal aspects of interfacility patient transfers.MethodsPrior to the intervention, physician knowledge regarding 12 key concepts in patient transfer was assessed using a pre-test instrument. A one hour, interactive, educational session followed immediately thereafter. Following the intervention, a post-intervention test was given between two and four weeks after delivery. Participants were also asked to describe any prior transportation-medicine-related education, their opinions as they relate to the relevance of the topic, and their comfort levels with patient transfers before and after the intervention.ResultsOnly a minority of participants had received any formal training in patient transfers prior to the intervention, despite dealing with patient transfers on a frequent, often daily, basis. Both groups improved in several categories on the post-intervention test. They reported improved comfort levels with the medicolegal aspects of interfacility patient transfers after the intervention and felt well-prepared to manage transfers in their daily practice.ConclusionA one hour, educational intervention objectively increased EM and CC physician trainees’ understanding of some of the medicolegal aspects of interfacility patient transfers. The study demonstrated a lack of previous training on this important topic and improved levels of comfort with transfers after study participation.BeckerTK, SkibaJF, SozenerCB. An educational measure to significantly increase critical knowledge regarding interfacility patient transfers. Prehosp Disaster Med. 2015;30(3):1-5
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Downar, James, Nancy McNaughton, Tarek Abdelhalim, Natalie Wong, Lauren Lapointe-Shaw, Dori Seccareccia, Kim Miller, et al. "Standardized patient simulation versus didactic teaching alone for improving residents’ communication skills when discussing goals of care and resuscitation: A randomized controlled trial." Palliative Medicine 31, no. 2 (July 10, 2016): 130–39. http://dx.doi.org/10.1177/0269216316652278.
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Background: Communication skills are important when discussing goals of care and resuscitation. Few studies have evaluated the effectiveness of standardized patients for teaching medical trainees to communicate about goals of care. Objective: To determine whether standardized patient simulation offers benefit over didactic sessions alone for improving skill and comfort discussing goals of care. Design and intervention: Single-blind, randomized, controlled trial of didactic teaching plus standardized patient simulation versus didactic teaching alone. Participants: First-year internal medicine residents. Main measures: Changes in communication comfort and skill between baseline and 2 months post-training assessed using the Consultation and Relational Empathy measure. Key results: We enrolled 94 residents over a 2-year period. Both groups reported a significant improvement in comfort when discussing goals of care with patients. There was no difference in Consultation and Relational Empathy scores following the workshop ( p = 0.79). The intervention group showed a significant increase in Consultation and Relational Empathy scores post-workshop compared with pre-workshop (35.0 vs 31.7, respectively; p = 0.048), whereas there was no improvement in Consultation and Relational Empathy scores in the control group (35.6 vs 36.0; p = 0.4). However, when the results were adjusted for baseline differences in Consultation and Relational Empathy scores in a multivariable regression analysis, group assignment was not associated with an improvement in Consultation and Relational Empathy score. Improvement in comfort scores and perception of benefit were not associated with improvements in Consultation and Relational Empathy scores. Conclusion: Simulation training may improve communication skill and comfort more than didactic training alone, but there were important confounders in this study and further studies are needed to determine whether simulation is better than didactic training for this purpose.
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Kaplow, R. "Use of nursing resources and comfort of cancer patients with and without do-not-resuscitate orders in the intensive care unit." American Journal of Critical Care 9, no. 2 (March 1, 2000): 87–95. http://dx.doi.org/10.4037/ajcc2000.9.2.87.
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BACKGROUND: Little is known about the level of comfort experienced by cancer patients with do-not-resuscitate orders and how use of nursing resources affects their comfort. OBJECTIVE: To explore the relationship between use of nursing resources and comfort in cancer patients with and without do-not-resuscitate orders in the intensive care unit. METHODS: The sample consisted of 30 adult patients who had do-not-resuscitate orders and 30 randomly selected patients who did not. Pairs consisting of 1 patient from each group were admitted to the study simultaneously and were evaluated during the same observation period. Level of comfort was assessed by using the PACU Behavioral Pain Rating Scale. Data on use of nursing resources, determined with the Therapeutic Intervention Scoring System, and on demographics and severity of illness were abstracted from the medical records. RESULTS: Chi-square analyses revealed no significant relationship between comfort and use of nursing resources. Differences between the 2 types of patients in comfort and in use of resources were not significant. Evaluation of the multivariate relationship between comfort and use of resources, with do-not-resuscitate status added as a further predictor variable, revealed no significant relationships. Severity of illness and a patient's number of visitors were predictors of use of nursing resources. CONCLUSIONS: Despite high use of nursing resources, nurses continue to focus on comfort as an outcome of care irrespective of patients' do-not-resuscitate status.
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Badger, James M. "Factors That Enable or Complicate End-of-Life Transitions in Critical Care." American Journal of Critical Care 14, no. 6 (November 1, 2005): 513–21. http://dx.doi.org/10.4037/ajcc2005.14.6.513.
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• Background Nurses in medical intensive care units are routinely involved in negotiations to maintain or withdraw life support. How nurses move from aggressively attempting to extend life to letting life end is not well understood. • Objective To explore nurses’ experiences of moving from cure- to comfort-oriented care and to describe factors that inhibit or facilitate such transitions. • Method A descriptive qualitative research design with brief observation of participants and focus group interviews was used. Participants were 19 female and 5 male nurses in an 18-bed medical intensive care unit in a 719-bed acute care hospital in the northeastern United States. • Results The transition point between cure- and comfort-oriented care was unclear. Nurses reported that the patient’s age, misunderstanding of the illness by the patient’s family, family discord, and shifting medical care decisions made end-of-life transitions difficult. Conversely, developing a consensus among patients, patients’ families, and staff about the direction of medical therapy; exhausting treatment options; and patients’ lack of response to aggressive medical interventions helped nurses move toward comfort care. • Conclusions The most distressing situations for staff were dealing with younger patients with an acute life-threatening illness and performing futile care on elderly patients. End-of-life transitions were difficult when patients’ families had conflicts or were indecisive about terminating treatment and when physicians kept offering options that were unlikely to change patients’ prognosis. The most important factor enabling nurses to move from cure- to comfort-oriented care was developing a consensus about the treatment.
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Tam, Vivian, John J. You, and Rachelle Bernacki. "Enhancing Medical Learners’ Knowledge of, Comfort and Confidence in Holding Serious Illness Conversations." American Journal of Hospice and Palliative Medicine® 36, no. 12 (July 21, 2019): 1096–104. http://dx.doi.org/10.1177/1049909119857988.
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Objectives: Having early discussions with seriously ill patients about their priorities and values can improve their peace of mind and family outcomes during bereavement; however, physicians and medical students report feeling underprepared to hold serious illness conversations. We evaluated the impact of the Serious Illness Care Program clinician training workshop on medical learners’ knowledge of comfort and confidence in holding such conversations. Methods: Eligible learners were penultimate- or final-year medical students or first-year residents of generalist programs (Family Medicine, Internal Medicine). Learners participated in a 2.5-hour workshop involving reflection on serious illness discussions, didactic teaching and demonstration of the Serious Illness Conversation Guide (SICG), role play with standardized patients, direct observation, and feedback from experts. Participants completed pre- and post-intervention questionnaires with Likert-type scale and open-ended questions, which were analyzed using paired t tests and qualitative content analysis, respectively. Results: We enrolled 25 learners. The intervention was associated with an increase in knowledge ( P < .001) and self-efficacy ( P < .001). All learners reported gaining new skills, with a majority specifically identifying a framework for structuring serious illness conversations in the qualitative analysis (n = 14, 56%). Participants stated the workshops would improve their comfort in holding serious illness conversations (n = 24, 96%), and that it would be valuable to integrate the workshops into their formal curricula (n = 23, 92%). Conclusions: Training on the use of the SICG is novel for medical students and first-year residents and associated with the improvement in their knowledge of and perceived capacity to hold serious illness conversations. This study suggests that the integration of SICG training into medical curricula may have educational value.
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Szekendi, Marilyn K., Jocelyn Vaughn, Beth McLaughlin, Carol Mulvenon, Karin Porter-Williamson, Chris Sydenstricker, and Mary Williamson. "Integrating Palliative Care to Promote Earlier Conversations and to Increase the Skill and Comfort of Nonpalliative Care Clinicians: Lessons Learned From an Interventional Field Trial." American Journal of Hospice and Palliative Medicine® 35, no. 1 (April 7, 2017): 132–37. http://dx.doi.org/10.1177/1049909117696027.
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While the uptake of palliative care in the United States is steadily improving, there continues to be a gap in which many patients are not offered care that explicitly elicits and respects their personal wishes. This is due in part to a mismatch of supply and demand; the number of seriously ill individuals far exceeds the workload capacities of palliative care specialty providers. We conducted a field trial of an intervention designed to promote the identification of seriously ill patients appropriate for a discussion of their goals of care and to advance the role of nonpalliative care clinicians by enhancing their knowledge of and comfort with primary palliative care skills. At 3 large Midwestern academic medical centers, a palliative care physician or nurse clinician embedded with a selected nonpalliative care service line or unit on a regularly scheduled basis for up to 6 months. Using agreed-upon criteria, patients were identified as being appropriate for a goals of care conversation; conversations with those patients and/or their families were then conducted with the palliative care specialist providing education, coaching, and mentoring to the nonpalliative care clinician, when possible. All of the sites increased the presence of palliative care within the selected service line or unit, and the nonpalliative care clinicians reported increased comfort and skill at conducting goals of care conversations. This intervention is a first step toward increasing patients’ access to palliative care to alleviate distress and to more consistently deliver care that honors patient and family preferences.
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Johnson, Nicolette, Zoë Nokomis, and Mary Ann Stark. "The Nurses’ Role in Providing Comfort During Childbirth Using Ambulation and Hydrotherapy." International Journal of Studies in Nursing 3, no. 1 (November 3, 2017): 123. http://dx.doi.org/10.20849/ijsn.v3i1.347.
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Providing care and comfort to women during childbirth is an important role. While medical interventions are available, all are associated with potential risks. Using nonpharmacologic means to support the normal process of birth, nurses may reduce the use of medical procedures and their potential complications. The purpose of this article is to discuss the use of two techniques that promote physiologic childbirth, ambulation and hydrotherapy, and the nurses’ role in providing comfort using these techniques in this important life event. Use of these techniques may delay or minimize the use of medical interventions while supporting the normal physiology of labor and birth.
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Butler, Samantha C., Kate Huyler, Aditya Kaza, and Chris Rachwal. "Filling a significant gap in the cardiac ICU: implementation of individualised developmental care." Cardiology in the Young 27, no. 9 (August 7, 2017): 1797–806. http://dx.doi.org/10.1017/s1047951117001469.
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AbstractMortality rates among children with CHD have significantly declined, although the incidence of neurological abnormalities and neurodevelopmental impairment has increased. Research has focussed on outcomes, with limited attention on prevention and intervention. Although some developmental differences and challenges seen in children with CHD are explained by the cumulative effect of medical complications associated with CHD, many sequelae are not easily explained by medical complications alone. Although cardiac intensive care is lifesaving, it creates high levels of environmental and tactile stimulation, which potentially contribute to adverse neurodevelopmental outcomes. The therapeutic method of individualised developmental care, such as the Newborn Individualized Developmental Care and Assessment Program, provides early support and preventive intervention based on each child’s behavioural signals of stress, comfort, and strength. Implementing developmental care practices in a cardiac ICU requires a thoughtful and well-planned approach to ensure successful adoption of practice changes. This paper reviews how developmental care was introduced in a paediatric inpatient cardiac service through multidisciplinary collaborative staff education, clinician support, child neurodevelopment assessment, parent support, and research initiatives. Given the known risk for children with CHD, cardiac medical professionals must shift their focus to not only assuring the child’s survival but also optimising development through individualised developmental care in the cardiac ICU.
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Kasven-Gonzalez, Nicole, Regine Souverain, and Susan Miale. "Improving quality of life through rehabilitation in palliative care: Case report." Palliative and Supportive Care 8, no. 3 (September 2010): 359–69. http://dx.doi.org/10.1017/s1478951510000167.
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AbstractObjective:Occupational and physical therapists can have a significant impact on the quality of life of terminally ill cancer patients. In the critical care setting, rehabilitation is often overlooked. However, occupational and physical therapists work with critically-ill patients to create realistic and meaningful goals for improving comfort, mobility, socialization skills, and ability to care for oneself regardless of disease state and medical status. The following case report describes rehabilitation intervention with a young woman diagnosed with osteosarcoma and leukemia during the final stage of her life.Method:This case report highlights the use of patient-centered goals and the importance of close collaboration between the patient, occupational therapist, and physical therapists to achieve a higher quality of life.Results:A collaborative effort by the occupational and physical therapists yielded positive outcomes as defined by the patient, patient family, and the medical staff in the critical care setting.Significance of results:Palliative care patients may benefit from occupational therapy (OT) and physical therapy (PT) intervention. Rehabilitation specialists are skilled at working with patients to set realistic and meaningful functional goals. Further study on rehabilitation treatment to improve quality of life among patients in palliative care is needed.
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Agrawal, Rishi, Parag Shah, Kathy Zebracki, Kathy Sanabria, Claire Kohrman, and Arthur F. Kohrman. "Barriers to Care for Children and Youth With Special Health Care Needs." Clinical Pediatrics 51, no. 1 (August 19, 2011): 39–45. http://dx.doi.org/10.1177/0009922811417288.
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Objective. To assess primary care pediatricians’ (PCPs’) perceptions of caring for children and youth with special health care needs (CYSHCN). Methods. Cross-sectional survey of Illinois pediatricians. Results. Thirty-five percent of surveys were returned and 26% were analyzed. The top 3 perceived barriers were insufficient time (72%), insufficient reimbursement (68%), and lack of support services (59%). Insufficient interest was the least cited barrier (19%). Preparedness to perform tasks related to care of CYSHCN ranged from 89% for accessing early intervention services to 24% for billing and coding. The percentage of PCPs somewhat or very comfortable providing primary care to patients with technology dependence ranged from 75% for blood glucose monitoring to 12% for dialysis. Conclusions. The issues of time, reimbursement, billing, and coding are perceived as significant barriers to the care CYSHCN. There is substantial variation in PCPs’ comfort in the care of CYSHCN who require the assistance of medical technologies.
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Roikjær, Stine Gundtoft, Charlotte Paaske Simonÿ, and Helle Ussing Timm. "Qualitative study to explore what patients with heart failure find significant during integrated palliative care sessions in a Danish clinic." BMJ Open 10, no. 12 (December 2020): e043955. http://dx.doi.org/10.1136/bmjopen-2020-043955.
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ObjectiveIn the field of palliative care (PC) as it is integrated into heart failure (HF) treatment, it is essential to explore the patient experience and build on this knowledge for the further development of PC practice and policy. Based on an intervention study, this paper explores what patients with HF find significant in integrated sessions using a narrative S’ approach.DesignWe conducted a semistructured interview study with a qualitative analysis focused on meaning making. The study follows the guidelines of Consolidated Criteria for Reporting Qualitative Research.Participants and settingThe inclusion criteria for the PC intervention were (1) a new diagnosis of HF, (2) follow-up treatment at this local Danish HF clinic and (3) informed consent to participate in the integrated PC intervention. The only exclusion criterion was if the patient was already engaged in a PC programme. 20 patients agreed to participate in the intervention, and 12 of these completed the S’ approach sessions and participated in this interview study.ResultsOverall, the analysis showed that the integrated S’ approach sessions were successful in joining an embodied patient perspective with a medical perspective. The thematic analysis resulted in three themes supporting the overall findings: sessions bring comfort, telling your story provides a sense of meaningfulness, and integrating perspectives of HF into everyday life.ConclusionThe method using the S’ approach in integrated PC and HF sessions was significant in various ways. First, patients experienced a calm and safe atmosphere and perceived that the nurse was truly interested in them. Second, the integrated sessions based on the S’ approach were able to bring comfort to lived physical, psychosocial and existential issues. Last, it allowed patients to combine their embodied understanding of HF with a medical perspective, thereby finding meaning in the sense of how everything is connected.
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Niehaus, Jason Z., Megan Palmer, Michelle LaPradd, Amy Haskamp, Amy Hatton, Caitlin Scanlon, and Adam B. Hill. "Pediatric Resident Perception and Participation in End-of-Life Care." American Journal of Hospice and Palliative Medicine® 37, no. 11 (March 20, 2020): 936–42. http://dx.doi.org/10.1177/1049909120913041.
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Background: Despite advances in medical care, pediatric deaths are still an unfortunate reality. Most of these deaths occur within a hospital setting. End-of-life care is an important part of medical care for children with serious illnesses. Despite the importance, pediatric providers report a lack of comfort surrounding end-of-life care. Objective: To assess categorical pediatric residents’ perceptions and participation in providing end-of-life care to dying children and their families. Study Design: This is a survey-based, descriptive, mixed-methods study. Survey was sent to categorical pediatric residents at Indiana University School of Medicine in June 2018 to obtain both quantitative and qualitative information on resident perception and participation in end-of-life care. Surveys were sent to 100 residents with a response rate of 68%. Setting/Participants: Pediatric residents at Indiana University School of Medicine. Results: The comfort and participation in end-of-life care are limited in all levels of pediatric training. Residents do not feel comfortable with 19 of 22 questions related to end-of-life care. Only 32% of residents felt their education prepared them to participate in end-of-life care. Almost one-fifth (19.5%) of residents report participating in zero aspect of end-of-life care. Themes discussed by residents include education, experience, communication, social norms, emotions, self-care, comfort, and family. Conclusion: More formalized education and training is needed to increase resident comfort with and participation in end-of-life care. Such future interventions should focus on communication surrounding difficult conversations and providing guidance for families.
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Choi, Daniel Y., Michael P. Wagner, Brian Yum, Deanna Pereira Jannat-Khah, Derek C. Mazique, Daniel J. Crossman, and Jennifer I. Lee. "Improving implantable cardioverter defibrillator deactivation discussions in admitted patients made DNR and comfort care." BMJ Open Quality 8, no. 4 (December 2019): e000730. http://dx.doi.org/10.1136/bmjoq-2019-000730.
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BackgroundUnintended shocks from implantable cardioverter defibrillators (ICDs) are often distressing to patients and family members, particularly at the end of life. Unfortunately, a large proportion of ICDs remain active at the time of death among do not resuscitate (DNR) and comfort care patients.MethodsWe designed standardised teaching sessions for providers and implemented a novel decision tool in the electronic medical record (EMR) to improve the frequency of discussions surrounding ICD deactivation over a 6-month period. The intended population was patients on inpatient medicine and cardiology services made DNR and/or comfort care. These rates were compared with retrospective data from 6 months prior to our interventions.ResultsAfter our interventions, the rates of discussions regarding deactivation of ICDs improved from 50% to 93% in comfort care patients and from 32% to 70% in DNR patients. The rates of deactivated ICDs improved from 45% to 73% in comfort care patients and from 29% to 40% in DNR patients.ConclusionStandardised education of healthcare providers and decision support tools and reminders in the EMR system are effective ways to increase awareness, discussion and deactivation of ICDs in comfort care and DNR patients.
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Kovacic, Nicole Lynn, David J. Gagnon, Richard R. Riker, Sijin Wen, and Gilles L. Fraser. "An Analysis of Psychoactive Medications Initiated in the ICU but Continued Beyond Discharge: A Pilot Study of Stewardship." Journal of Pharmacy Practice 33, no. 6 (February 27, 2019): 760–67. http://dx.doi.org/10.1177/0897190019830518.
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Background: Psychoactive medications (PM) are frequently administered in the intensive care unit (ICU) to provide comfort. Interventions focused on preventing their continuation after the acute phase of illness are needed. Objective: To determine the frequency that patients with ICU-initiated PM are continued upon ICU and hospital discharge. Methods: This single-center, prospective, observational study assessed consecutive adult ICU patients who received scheduled PM. Frequency of PM continued at ICU and hospital discharge was recorded. The patient’s primary treatment team was contacted by the pharmacist within 72 hours of ICU discharge to establish rationale for continued use or to suggest discontinuation. Results: Of the 60 patients included, 72% were continued on PM at ICU discharge and 30% at hospital discharge. The pharmacist contacted 40% of treatment teams after ICU discharge and intervention resulted in PM discontinued in 50% of patients. Post ICU discharge, the indication of 41% of patients’ PM was unknown by the non-ICU care team or incorrect. Medical ICU patients or those transferred to an outside facility were more likely remain on PM at hospital discharge. Conclusion: PM are frequently continued during transitions of care and often without knowledge of the initial indication. Future studies should establish effective PM stewardship methods.
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Nguyen, Linda, Shelly S. Lo, William Adams, and Paul J. Hutchison. "Effectiveness of a medical student-led, advanced care planning intervention in an inpatient cancer population." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): e24010-e24010. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.e24010.
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e24010 Background: In an effort to provide patients with care that aligns with their values and goals, patients are encouraged to complete advance directives (ADs). While research has shown the benefits of advanced care planning (ACP) sessions, few studies have examined the thematic content of ACP discussions in an inpatient hematology or oncology population. Methods: We enrolled patients admitted to the hematology and oncology unit of an academic medical center who had never completed a power-of-attorney for healthcare form. One medical student 1) helped patients complete a power-of-attorney for healthcare form and 2) performed semi-structured interviews that explored patient's values, beliefs about end-of-life care, and preferences for medical treatments. Interviews were audio-recorded, transcribed, and analyzed through thematic analysis. Subjects completed pre- and post- surveys assessing their knowledge and attitudes about ACP. Results: All 48 patients enrolled in the study completed an advance directive. There was no significant change between pre- and post- intervention surveys evaluating patients’ trust in their physicians or family members to choose the right treatments for them in a life-threatening situation. Similarly, there was no change in patients’ comfort level discussing advance care planning after the interview. 79.2% of patients agreed or strongly agreed that they would recommend this ACP conversation to family and friends. 35.5% of patients agreed or strongly agreed that having this ACP conversation made them anxious. In the qualitative arm of the study, analysis suggests that cancer patients are willing to undergo further treatment unless it burdens their loved ones or interferes with quality time spent with family and friends. Motivating factors for patients included their spirituality and ability to fulfill a responsibility in a defined role. Conclusions: An ACP intervention performed by a medical student can increase the number of advance directives among patients admitted to inpatient hematology and oncology units. While this intervention may be anxiety-provoking for patients, it can illuminate the relative value patients place on the quality of their life versus their longevity.
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Vidal, Marieberta. "Acute care medical interventions in the palliative care unit versus inpatient hospice." Journal of Clinical Oncology 35, no. 31_suppl (November 1, 2017): 88. http://dx.doi.org/10.1200/jco.2017.35.31_suppl.88.
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88 Background: In a survey of different cancer centers in the United States, only 23% reported having dedicated palliative care beds and hospital executives have reported not having further plans for expansion of their program. Barriers that are often cited include poor reimbursement for services, limited institutional support and resources. Patients admitted to an Acute Palliative care unit (APCU) benefit from the multidisciplinary approach that is evident in daily rounds, interdisciplinary team meetings, and family conferences. There could be occasionally misconceptions about the differences between inpatient hospice and an APCU. Even though the psychosocial component of palliative care is extremely important a significant amount of medical interventions also are necessary to provide patients and family with a sense of and optimal care during this time. Methods: A retrospective chart reviewed was performed in 100 consecutives patients admitted to the APCU and inpatient hospice prior to October 2013. From this data we identified the acute medical interventions ordered by the palliative Care specialist tduring the first 5 days of admission. Results: A total of 100 patients from the APCU and 100 patients from inpatient hospice were reviewed. In the APCU 100% of patients had iv fluids vs 7% in inpatient hospice. Antibiotics were given in 52% of APCU patients vs 2% in the inpatient hospice. Steroids were given in 48% of APCU patients vs 30% in inpatient hospices. (See Table). Conclusions: The APCU in comparison to inpatient hospices had higher rate of acute medical interventions with the most common been iv fluids, antibiotics, laboratory and radiologic diagnostic tests. This represent the importance of Acute Palliative Care Units in advanced cancer patients with complicated situations to achieve comfort when transitioning to EOL. [Table: see text]
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Neilly, Chia-Hui, Anne Rader, Sara Zielinski, Hiba Wehbe-Alamah, and Margaret Murray-Wright. "Using Transcultural Nursing Education to Increase Cultural Sensitivity and Cultural Assessment Documentation by Staff in an In-Home Chronic Disease Self-Management Program." Journal of Doctoral Nursing Practice 12, no. 1 (April 1, 2019): 16–23. http://dx.doi.org/10.1891/2380-9418.12.1.16.
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BackgroundDespite literature indicating that culturally sensitive care promotes a positive patient environment and may help improve outcomes, limited data exist on the documentation of patients' cultural concerns in electronic medical records (EMR).ObjectiveThe project's objective was to use an educational intervention to increase clinic staff's cultural sensitivity and cultural assessment documentation.MethodsResearchers conducted this 3-month project at a Midwestern clinic's in-home, self-care chronic disease management program. The voluntary sample of clinical staff (n= 8) received an educational intervention on transcultural nursing practices. Researchers administered the Transcultural Self-Efficacy Tool for the Multidisciplinary Healthcare Provider (TSET-MHP) to participants before and after the intervention. A pre- and postintervention EMR audit was completed on 128 charts to evaluate cultural assessment documentation.ResultsTSET-MHP cognitive and practical subscales scores increased postintervention. Affective subscales scores decreased slightly. Electronic cultural assessment documentation increased by 10%. An assessment questionnaire showed an increase in participants' cultural self-awareness and comfort with cultural assessment.ConclusionsAn educational intervention demonstrated an increase in providers' cultural awareness and cultural assessment documentation.Implications for NursingTranscultural nursing education may help increase providers' perceived cultural self-efficacy, which may improve cultural assessments and culturally competent care.
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Miller, David C., Amy M. Sullivan, Morgan Soffler, Brett Armstrong, Asha Anandaiah, Laura Rock, Jakob I. McSparron, Richard M. Schwartzstein, and Margaret M. Hayes. "Teaching Residents How to Talk About Death and Dying: A Mixed-Methods Analysis of Barriers and Randomized Educational Intervention." American Journal of Hospice and Palliative Medicine® 35, no. 9 (April 11, 2018): 1221–26. http://dx.doi.org/10.1177/1049909118769674.
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Objectives: We present a pilot study exploring the effects of a brief, 30-minute educational intervention targeting resident communication surrounding dying in the intensive care unit (ICU). We sought to determine whether simulation or didactic educational interventions improved resident-reported comfort, preparation, and skill acquisition. We also sought to identify resident barriers to using the word “dying.” Methods: In this mixed-methods prospective study, second- and third-year medical residents were randomized to participate in a simulation-based communication training or a didactic session. Residents completed a pre–post survey after the sessions evaluating the sessions and reflecting on their use of the word “dying” in family meetings. Results: Forty-five residents participated in the study. Residents reported increases in comfort (Mean [M]-pre = 3.3 [standard deviation: 0.6], M-post = 3.7 [0.7]; P < .01, Cohen d = 0.75) and preparation (M-pre = 3.4 [0.7], M-post = 3.9 [0.6]; P < .01, d = 1.07) using the word “dying” after both the simulation and didactic versions. Residents randomized to the simulation reported they were more likely to have learned new skills as compared to residents in the didactic (M-simulation = 2.2 [0.4], M-didactic = 1.9 [0.3]; P = .015, d = 0.80). They estimated that they used the word “dying” in 50% of their end-of-life (EOL) conversations and identified uncertain prognosis as the main barrier to explicitly stating the word “dying.” Conclusion: A 30-minute educational intervention improves internal medicine residents’ self-reported comfort and preparation in talking about death and dying in the ICU. Residents in simulation-based training were more likely to report they learned new skills as compared to the didactic session. Residents report multiple barriers to using the word “dying” EOL conversations.
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Zachariah, Finly, Linda Klein, Nancy Clifton-Hawkins, Becky Andrews, Andrea McQueary, Gaby Dillard, and Dawn Gross. "“It’s about the conversation”: A multidisciplinary intervention to support advance-care planning." Journal of Clinical Oncology 32, no. 31_suppl (November 1, 2014): 111. http://dx.doi.org/10.1200/jco.2014.32.31_suppl.111.
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111 Background: A recent California Healthcare Foundation study found that 60% of Californians highly valued “making sure their families are not burdened by tough decisions about their care." However, less than 50% have communicated their end-of-life wishes to their surrogate decision maker. 82% say it is important to have end-of-life wishes in writing, but only 23% say they have done so. At City of Hope National Cancer Medical Center (COH) the advance directive (AD) completion rate is less than 15%. The Department of Supportive Care Medicine Sheri & Les Biller Patient and Family Resource Center (BRC) is leading development of innovative strategies to foster Advance Care Planning (ACP) communication and documentation. Methods: A multi-specialty physician and interdisciplinary team assembled and designed a social media advertised 4-hour interactive event that was held in the BRC. Over 40 staff and volunteers facilitated individualized ACP conversations with the “Go Wish” cards, private consultations with social workers, showed novel COH ACP videos, provided multi-lingual ACP literature and advance directive documents available for completion with Notary support on-site. Results: Over 300 people attended, including patients, caregivers and COH staff. Forty-seven advance directives were completed (24 by patient/caregivers, 23 by COH staff). Twenty-nine Go Wish games were facilitated (2 in Spanish). Of the 52 attendees who completed exit evaluations, 44% were patients, 31% staff, and 11% were caregivers. Respondents reported that the event increased their comfort and likelihood of having conversations about ACP with others. Importantly, 38 of the 52 surveyed, did not have an AD prior to attending the event. Of those 38 attendees, 18 of them completed an AD at the event (or 47%). Conclusions: Advanced care planning is an all too often avoided conversation that results in increased distress of patients, families and providers. By proactively designing opportunities for facilitated conversations in dynamic and public arenas, fear and stigmas are diffused and the true focus and intent of discovering what people wish so the medical team, surrogates and family can ensure their values are honored and met become possible.
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Komotar, Ricardo J., J. Michael Schmidt, Robert M. Starke, Jan Claassen, Katja E. Wartenberg, Kiwon Lee, Neeraj Badjatia, E. Sander Connolly, and Stephan A. Mayer. "RESUSCITATION AND CRITICAL CARE OF POOR-GRADE SUBARACHNOID HEMORRHAGE." Neurosurgery 64, no. 3 (March 1, 2009): 397–411. http://dx.doi.org/10.1227/01.neu.0000338946.42939.c7.
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Abstract AS OUTCOMES HAVE improved for patients with aneurysmal subarachnoid hemorrhage, most mortality and morbidity that occur today are the result of severe diffuse brain injury in poor-grade patients. The premise of this review is that aggressive emergency cardiopulmonary and neurological resuscitation, coupled with early aneurysm repair and advanced multimodality monitoring in a specialized neurocritical care unit, offers the best approach for achieving further improvements in subarachnoid hemorrhage outcomes. Emergency care should focus on control of elevated intracranial pressure, optimization of cerebral perfusion and oxygenation, and medical and surgical therapy to prevent rebleeding. In the postoperative period, advanced monitoring techniques such as continuous electroencephalography, brain tissue oxygen monitoring, and microdialysis can detect harmful secondary insults, and may eventually be used as end points for goal-directed therapy, with the aim of creating an optimal physiological environment for the comatose injured brain. As part of this paradigm shift, it is essential that aggressive surgical and medical support be linked to compassionate end-of-life care. As neurosurgeons become confident that comfort care can be implemented in a straightforward fashion after a failed trial of early maximal intervention, the usual justification for withholding treatment (survival with neurological devastation) becomes less relevant, and lives may be saved as more patients recover beyond expectations.
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Ludden, Thomas, Lindsay Shade, Jeremy Thomas, Sveta Mohanan, Michael Leonard, and Hazel Tapp. "1276. Changes in Primary Care Pre-exposure Prophylaxis prescribing in a Large Healthcare System after the Implementation of an HIV Screening Alert and Educational Intervention." Open Forum Infectious Diseases 6, Supplement_2 (October 2019): S460. http://dx.doi.org/10.1093/ofid/ofz360.1139.
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Abstract Background The number of providers that prescribe pre-exposure prophylaxis (PrEP) for HIV remains low. Primary care providers (PCPs) are less knowledgeable than HIV providers (HIVPs) with regards to PrEP: fewer PCPs had heard of PrEP (76% vs. 98%), knew about prescribing PrEP (28% vs. 76%), or ever had prescribed it (17% vs. 64%). PCPs limited knowledge about PrEP and questions about insurance coverage were identified as barriers to prescribing PrEP. Additional information on changes in prescribing PrEP in primary care within a large healthcare system is limited. Methods 12 practices were part of a systemwide implementation of an HIV screening Electronic Medical Record (EMR) alert in October 2017 for patients ages 18–64. The 12 primary care practices were also included as part of an educational intervention regarding HIV prevention presented in the first quarter of 2018. As part of the educational intervention, information on prescribing PrEP was included along with resources for linkage-to-care and insurance coverage. The number of PrEP prescriptions were summarized for all 12 practices one year prior to the EMR alert and one-year post-EMR alert. Paired T-test statistics were used to test the number of patients prescribed PrEP by each practice pre- and post-EMR alert. The same analysis was conducted one-year pre- and post- the educational intervention. Results Across the 12 practices, 62 PrEP prescriptions were written one year prior to the implementation of the EMR alert (M=5.2, SD=7.3) and 88 post-EMR alert (M=7.3, SD=6.4), a 42% increase (P = 0.02). There were no differences in PrEP prescriptions one-year pre- and post- the educational intervention (n = 69). Conclusion While the number of PrEP prescriptions written showed significant increase after the implementation of the EMR alert, the overall number of prescriptions in primary care are still relatively low. While there has been national attention to increase PrEP prescribing through initiatives with local health departments, efforts to increase PrEP uptake require additional interventions above and beyond education interventions to increase the knowledge, comfort, and skills of providers to prescribe PrEP. Disclosures All authors: No reported disclosures.
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Caro, J. Jaime, Evan G. DeRenzo, C. Norman Coleman, David M. Weinstock, and Ann R. Knebel. "Resource Allocation After a Nuclear Detonation Incident: Unaltered Standards of Ethical Decision Making." Disaster Medicine and Public Health Preparedness 5, S1 (March 2011): S46—S53. http://dx.doi.org/10.1001/dmp.2011.14.
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ABSTRACTThis article provides practical ethical guidance for clinicians making decisions after a nuclear detonation, in advance of the full establishment of a coordinated response. We argue that the utilitarian maxim of the greatest good for the greatest number, interpreted only as “the most lives saved,” needs refinement. We take the philosophical position that utilitarian efficiency should be tempered by the principle of fairness in making decisions about providing lifesaving interventions and palliation. The most practical way to achieve these goals is to mirror the ethical precepts of routine clinical practice, in which 3 factors govern resource allocation: order of presentation, patient's medical need, and effectiveness of an intervention. Although these basic ethical standards do not change, priority is given in a crisis to those at highest need in whom interventions are expected to be effective. If available resources will not be effective in meeting the need, then it is unfair to expend them and they should be allocated to another patient with high need and greater expectation for survival if treated. As shortage becomes critical, thresholds for intervention become more stringent. Although the focus of providers will be on the victims of the event, the needs of patients already receiving care before the detonation also must be considered. Those not allocated intervention must still be provided as much appropriate comfort, assistance, relief of symptoms, and explanations as possible, given the available resources. Reassessment of patients' clinical status and priority for intervention also should be conducted with regularity.(Disaster Med Public Health Preparedness. 2011;5:S46-S53)
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Sjölander, Annica, Eva Jakobsson Ung, Töres Theorell, Åsa Nilsson, and Kjell-Arne Ung. "Hospital Design with Nature Films Reduces Stress-Related Variables in Patients Undergoing Colonoscopy." HERD: Health Environments Research & Design Journal 12, no. 4 (March 26, 2019): 186–96. http://dx.doi.org/10.1177/1937586719837754.
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Purpose: To examine whether patients’ experiences could be improved during colonoscopy by designing the examination room to include a digital screen showing calm nature films. Background: Colonoscopy is the gold standard for examination of the large intestine and the rectum. Around 50% of individuals invited for colorectal cancer screening choose to refrain from the screening due to fear and anxiety. It is therefore important to improve patients’ comfort during the procedure. Method: One of the four endoscopy rooms was rebuilt to include a large digital screen showing calm nature films. Patients were randomized to intervention (i.e., the room showing films) or control. During the colonoscopy, pulse and oxygen saturation were measured and the patients graded the intensity of pain and anxiety. Blood samples were taken regularly during the examination and were analyzed for glucose, cortisol, and prolactin. Results: The presence of calm nature films during colonoscopy decreased the release of cortisol, increased prolactin levels, and enhanced oxygen saturation. These effects were more apparent in patients who were unfamiliar with the procedure and the environment, patients who underwent the examination without analgesics or sedation, and patients whose examination procedure was relatively difficult and took a long time. Conclusions: The intervention described in this study is easy to implement and might help improve the patient experience during colonoscopy. However, this study was performed in a single health institution, and more studies are needed to further explore the role of film interventions in endoscopic and other medical procedures.
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Heyman, Janna, Linda White-Ryan, and Peggy Kelly. "THE IMPACT OF AN EDUCATION INTERVENTION: IMPROVING COMMUNICATION BETWEEN OLDER ADULTS AND HEALTH CARE PROVIDERS." Innovation in Aging 3, Supplement_1 (November 2019): S909. http://dx.doi.org/10.1093/geroni/igz038.3316.
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Abstract As people age, ensuing physical and psychological problems can increase, which makes it paramount to be comfortable discussing medical needs with health care professionals, particularly in light of the danger associated with misunderstanding medication use and combining alcohol with prescriptions and/or over the counter medications (National Institute on Aging, 2018). National studies found that about 40 percent of adults ages 65 and older drink alcohol and often do not understand the dangers of combining alcohol with medications (National Institute for Alcohol and Alcohol Abuse, 2008). An educational intervention was developed with a team of expert physicians, nurses, pharmacists and social workers who work in gerontology to focus on improving communication and addressing alcohol and medication use for older adults. A randomized controlled trial was conducted to assess whether the educational intervention improved older adults’ comfort in communicating with their health care providers, as well as their knowledge of the concomitant use of alcohol and prescription and over-the-counter (OTC) medications. Results of a MANCOVA showed that those in the intervention group showed larger increases in scores on communication with their health providers and knowledge about the implications of combining alcohol with prescription drugs than those in the control group (Wilks’ Lamda=.808, F(3,76)=6.039, p=.001<.05). In addition, linear regression models showed that the intervention was significantly associated with participants’ knowledge of the implications of combining alcohol with prescription drugs. The coefficient across models was approximately 1.00, which represented a substantial increase given the average score of 6.5.
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Milnes, Sharyn L., Yianni Mantzaridis, Nicholas B. Simpson, Trisha L. Dunning, Debra C. Kerr, Joan B. Ostaszkiewicz, Gerry T. Keely, Charlie Corke, and Neil R. Orford. "Values, preferences and goals identified during shared decision making between critically ill patients and their doctors." Critical Care and Resuscitation 23, no. 1 (March 1, 2021): 76–85. http://dx.doi.org/10.51893/2021.1.oa7.
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Objective: Examine values, preferences and goals elicited by doctors following goals-of-care (GOC) discussions with critically ill patients who had life-limiting illnesses. Design: Descriptive qualitative study using four-stage latent content analysis. Setting: Tertiary intensive care unit (ICU) in South Western Victoria. Participants: Adults who had life-limiting illnesses and were admitted to the ICU with documented GOC, between October 2016 and July 2018. Intervention: The iValidate program, a shared decision-making clinical communication education and clinical support program, for all ICU registrars in August 2015. Main outcome measures: Matrix of themes and subthemes categorised into values, preferences and goals. Results: A total of 354 GOC forms were analysed from 218 patients who had life-limiting illnesses and were admitted to the ICU. In the categories of values, preferences and goals, four themes were identified: connectedness and relational autonomy, autonomy of decision maker, balancing quality and quantity of life, and physical comfort. The subthemes — relationships, sense of place, enjoyment of activities, independence, dignity, cognitive function, quality of life, longevity and physical comfort — provided a matrix of issues identified as important to patients. Relationship, place, independence and physical comfort statements were most frequently identified; longevity was least frequently identified. Conclusion: Our analysis of GOC discussions between medical staff and patients who had life-limiting illnesses and were admitted to the ICU, using a shared decision-making training and support program, revealed a framework of values, preferences and goals that could provide a structure to assist clinicians to engage in shared decision making.
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Nogales, Josefina Muñoz, Madeline Valentine, Priscilla Rigos, Josephine Kim, Jinu KIm, Candice Alfano, Eleanor McGlinchey, Carol Ripple, and Amy Wolfson. "618 Qualitative analysis of bedtime challenges and parental interventions in foster care children." Sleep 44, Supplement_2 (May 1, 2021): A243. http://dx.doi.org/10.1093/sleep/zsab072.616.
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Abstract Introduction Sleep during childhood has a major impact on physiological, psychological, and cognitive development. Limited research has focused on vulnerable populations such as children in foster care. Foster care children endure placement instability, which may contribute to disrupted sleep patterns and unpredictability around bedtime (Leathers, et al., 2019). The Fostering Sleep study examined foster caregivers’ perceptions of children’s sleep challenges and strategies for improving sleep difficulties. Methods Foster caregivers of children ages 4–11 throughout the US were invited to complete the Qualtrics Sleep Health among Children in Foster Care Survey via foster care Facebook groups. The survey included quantitative and qualitative questions focused on sleep patterns and behaviors. Qualitative questions on barriers and opportunities to improve sleep were examined: what helps foster care children sleep well; what kinds of difficulties do foster care children experience at bedtime? Results 483 foster care parents responded. Responses to bedtime difficulties were coded using 27 categories (e.g., parasomnias, bedtime resistance, trouble self-soothing); responses to what helps your child sleep well were coded based on 22 categories (e.g., comfort items, melatonin, TV as in intervention, communication to reassure safety). The most prevalent sleep/bedtime difficulties were fear/anxiety (23.2%), nightmares (19.6%), environment (18.4%). For example, one parent responded: “He fears never waking up. He fears that the sun is not going to come back up. He fears that the bad guys will come get him.” Difficulties varied by age-- 4–5: fear/anxiety, destabilization from call/visit biological parent, nightmares; 6–9: nightmares, fear/anxiety, environment; 10–11: fear/anxiety, nightmares, emotional/behavioral difficulties. Most frequent parenting approaches were bedtime routine (63.0%), reading before bedtime (36.5%), physical reassurance (26.6%). Interventions also varied according to age-- 4–5: routine, reading, physical reassurance; 6–9: routine, reading, noise control; 10–11: routine, technology regulation, reading. Conclusion Foster caregivers reported fear/anxiety as most common bedtime difficulty and physical reassurance as most frequent parenting strategy for healthy sleep. Findings suggest that anxiety and fear often interfere with sleep and, in turn, physical reassurance as a helpful bedtime strategy. Undoubtedly, there is a need for sleep research and preventive interventions for children in foster care. Support (if any) Summer Student Research Support, Loyola University Maryland, College of Arts and Sciences
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Lukela, Michael P., Vikas I. Parekh, John W. Gosbee, Joel A. Purkiss, John Del Valle, and Rajesh S. Mangrulkar. "Competence in Patient Safety: A Multifaceted Experiential Educational Intervention for Resident Physicians." Journal of Graduate Medical Education 3, no. 3 (September 1, 2011): 360–66. http://dx.doi.org/10.4300/jgme-d-10-00164.1.
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Abstract Background The need to provide efficient, effective, and safe patient care is of paramount importance. However, most physicians receive little or no formal training to prepare them to address patient safety challenges within their clinical practice. Methods We describe a comprehensive Patient Safety Learning Program (PSLP) for internal medicine and medicine-pediatrics residents. The curriculum is designed to teach residents key concepts of patient safety and provided opportunities to apply these concepts in the “real” world in an effort to positively transform patient care. Residents were assigned to faculty expert-led teams and worked longitudinally to identify and address patient safety conditions and problems. The PSLP was assessed by using multiple methods. Results Resident team-based projects resulted in changes in several patient care processes, with the potential to improve clinical outcomes. However, faculty evaluations of residents were lower for the Patient Safety Improvement Project rotation than for other rotations. Comments on “unsatisfactory” evaluations noted lack of teamwork, project participation, and/or responsiveness to faculty communication. Participation in the PSLP did not change resident or faculty attitudes toward patient safety, as measured by a comprehensive survey, although there was a slight increase in comfort with discussing medical errors. Conclusions Development of the PSLP was intended to create a supportive environment to enhance resident education and involve residents in patient safety initiatives, but it produced lower faculty evaluations of resident for communication and professionalism and did not have the intended positive effect on resident or faculty attitudes about patient safety. Further research is needed to design or refine interventions that will develop more proactive resident learners and shift the culture to a focus on patient safety.
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Nilsson, Ulrica, Lena Lindell, Annika Eriksson, and Thomas Kellerth. "The Effect of Music Intervention in Relation to Gender During Coronary Angiographic Procedures: A Randomized Clinical Trial." European Journal of Cardiovascular Nursing 8, no. 3 (August 2009): 200–206. http://dx.doi.org/10.1016/j.ejcnurse.2009.01.001.
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Several studies have evaluated music interventions prior and after coronary angiography and percutaneous coronary intervention (PCI), but there is no clear evidence showing that music has an effect on patients during these procedures. The purpose was to investigate the effects of music on anxiety, angina, pain, relaxation, and comfort in patients during angiographic procedures and to evaluate gender differences. The study was a four-armed, prospective randomized controlled trial included 240 patients undergoing coronary angiography and/or PCI. Patients were allocated to receive relaxing music, MusiCure® or standard care during the procedure. Outcome measures were; puncture pain and the discomfort related to it, angina and the discomfort related to it, anxiety, experience of the sound environment, discomfort of lying still, and the doses of anxiolytics and analgesics during the procedure. No differences were found between the music and control groups regarding any of the trial endpoints or gender-related differences. The overall rating of the sound environment and feeling of relaxation was high. In conclusion, music intervention in patients undergoing angiographic procedures was highly feasible, but not effective in this study though the delivery of music went smoothly and did not disturb the examination and patients and staff alike looked favorably on it.
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Straus, Jolie, Sarah Coburn, Stephanie Maskell, Jessica Pappagianopoulos, and Kathryn Cantrell. "Medical Encounters for Youth With Autism Spectrum Disorder: A Comprehensive Review of Environmental Considerations and Interventions." Clinical Medicine Insights: Pediatrics 13 (January 2019): 117955651984281. http://dx.doi.org/10.1177/1179556519842816.
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Approximately 1 in 59 youth are currently diagnosed with autism spectrum disorder (ASD), a neurodevelopmental disorder. In comparison to typically developing peers, youth with ASD encounter hospitalization at higher rates due to their heightened health care needs. While visiting the hospital is a stressor for youth with neurotypical needs, the experience contains unique challenges for those with ASD. This systematic literature review highlights research that considers the psychosocial impact of the hospital environment on the coping and adjustment of youth with ASD. Specifically, the review focuses on recommendations and interventions that may be used by health care professionals while supporting this population as they encounter the health care system. Ninety-six articles were identified as meeting inclusion and exclusion criteria. The findings suggest that practicing clinicians should implement a wide variety of interventions for youth with ASD including diversion techniques, comfort positions, and picture schedules. Although there are published evidence-based interventions for supporting youth with ASD in the hospital, most clinicians lack ASD-specific training. This article concludes with recommendations for future research.
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Agostino, Holly, and Brett Burstein. "90 Perceived Barriers to the Provision of Adolescent Confidential Care in the Tertiary Care Setting." Paediatrics & Child Health 25, Supplement_2 (August 2020): e37-e37. http://dx.doi.org/10.1093/pch/pxaa068.089.
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Abstract Background A cornerstone of quality adolescent health care is assuring confidential time for adolescent patients. Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Several national societies endorse the need for confidential care at all health-related encounters with adolescents. Many adolescents have infrequent contact with the medical system other than unscheduled urgent care in pediatric hospitals. Little is known regarding the effectiveness and feasibility of providing confidential care to adolescents in a tertiary pediatric hospital setting. Objectives We hypothesized that significant variation exists in the frequency and quality of confidential care delivery for adolescents. This study sought to characterize clinician comfort with confidentiality provision as well as identification of potential predicators and barriers to providing confidential care for adolescents in a tertiary, pediatric hospital setting. Design/Methods We undertook a cross-sectional survey among Emergency Department (ED), Hospitalist and Resident physicians at an urban, academic pediatric center. Data was collected using a standardized, self-administered electronic questionnaire. Survey participants responded to multiple-choice questions to characterize their comfort and self-identified barriers to providing confidential care to adolescents. Results Response rate was 91% (n=72/79; 26 ED, 14 Hospitalists, 32 Residents). A majority of respondents were female (69%), under the age of 50 (60%) and within their first 10 years of practice (51%). Forty-seven percent of respondents reported being somewhat/very doubtful that confidential care was being consistently provided to adolescents. Eighty-nine percent of respondents identified barriers to the quantity or quality of confidential care provided. Factors most commonly reported to influence physician decision to provide confidential care were diagnosis (75%), time of visit (45%), and patient age (25%). Among attending physicians 60% reported that they usually/always provide confidential care to adolescents, and 83% ensure that their trainees offer confidential care; whereas only 31% of trainees reported usually/always providing confidential care themselves (p=0.01). Limits of confidentiality were more likely to be explained to adolescent patients compared to their parents (83% vs. 33%; p<0.001). The most common reasons identified limiting the provision of confidential care were insufficient time (21%), perceived parental resistance (26%), lack of private space (26%) and the belief that it is not necessary for all adolescent encounters (34%). Forty percent of respondents reported discussing sensitive topics with adolescents in front of family members. Among both attending physicians and trainees, only 45% felt they had received adequate training on how best to deliver confidential care and similarly, 75% in both groups reported a desire for additional training. Conclusion Survey results suggest inadequate provision of confidential care in an academic pediatric hospital, with several potentially modifiable barriers. Confidentiality-specific education likely represents an important intervention to optimize physician comfort and improve the delivery of appropriate confidential care for adolescents.
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Gutman, Gloria, and Brian de Vries. "Cultural and Institutional Considerations in Advance Care Planning in Long-Term Care Settings." Innovation in Aging 4, Supplement_1 (December 1, 2020): 754. http://dx.doi.org/10.1093/geroni/igaa057.2716.
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Abstract Advance Care Planning (ACP) is a process that supports individual’s understanding and sharing of personal values, life goals, and preferences regarding future medical care, so that they obtain care consistent with these during serious and chronic illness. While ACP is important for all, it is especially so for people who fall outside traditional, western, heteronormative contexts (e.g. who belong to ethnic, racial and/or sexual/gender minorities). This symposium draws from research conducted by the Diversity Access Team [part of a national project iCAN-ACP Improving Advance Care Planning for Frail Elderly Canadians]. The first paper presents results from focus groups conducted with loved ones of South Asian, Chinese and Lesbian, Gay, Bisexual, and Transgender (LGBT) older adults living in care homes; issues identified as barriers include starting ACP conversations too late (“my husband has severe dementia”), lack of consideration of cultural traditions and, in the case of LGBT older adults, their non-family support networks. The second paper draws from focus groups with care home staff, implicating their own training as a barrier to assisting residents/families with ACP as well as resident, family, institutional and cultural influences. A third paper reports on an educational intervention designed to increase staff understanding of ACP and comfort in assisting residents/families with ACP. The fourth paper reports feedback received on two ACP planning tools, reflecting the importance of minority group representation in visuals and text. Together, these papers underscore the importance of taking culture into consideration in framing and discussions of fostering ACP among minority populations.
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Anastasia, Gisella, Yoyo Suhoyo, Prattama Santoso Utomo, and Doni Widyandana. "THE USE OF REFLECTION FOR SPIRITUAL CARE LEARNING IN CLINICAL EDUCATION: A PILOT STUDY." Jurnal Pendidikan Kedokteran Indonesia: The Indonesian Journal of Medical Education 9, no. 3 (November 16, 2020): 279. http://dx.doi.org/10.22146/jpki.56923.
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Background: Indonesian society assume spirituality as an important aspect in life especially in sickness. Spiritual care can restore patients’ quality of life by providing them comfort, strength, and compassion. Because lack of education about spiritual care, doctors often feel not fully equipped. Reflection has proven to increase awareness of spiritual care, but the impact of this method still needs further research. This study aims to explore the impact of reflection on student awareness about spiritual care.Methods: This study used Interpretative Phenomenological Analysis with reflective writing and in-depth interview. Nine clinical medical students divided into four groups which was facilitated by clinical teacher. Intervention were three reflective writings interspersed with two small group discussion. The writings were analyzed using Transtheoretical Model to identify behavioral change then content analysis for the transcript to explore the study’s impact and the feasibility.Results: Five students increased their awareness because clinical experience, time-management, writing volume, and reflective thinking. Three students increase faster because learning from peers, engage with patient, and role-model. Two students increase slower because lack understanding of reflection and incorrect facilitators’ feedbacks. Two students stable because lack understanding of discussion and low engagement with patient. One student experienced a decrease because lack of task-commitment and interest. One student did not get awareness because difficulty interpreting emotions.Conclusion: Reflection method can be used to teach spiritual care to clinical medical students by considering several factors that might play a role. Further research with improvement to the method is still needed. Keywords: Spiritual care; spirituality; reflection; clinical medical student
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Dixon, Brian, Katherine Barboza, Ashley Jensen, Katelyn Bennett, Scott Sherman, and Mark Schwartz. "Measuring Practicing Clinicians’ Information Literacy." Applied Clinical Informatics 26, no. 01 (2017): 149–61. http://dx.doi.org/10.4338/aci-2016-06-ra-0083.
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SummaryBackground: As healthcare moves towards technology-driven population health management, clinicians must adopt complex digital platforms to access health information and document care. Objectives: This study explored information literacy, a set of skills required to effectively navigate population health information systems, among primary care providers in one Veterans’ Affairs (VA) medical center.Methods: Information literacy was assessed during an 8-month randomized trial that tested a population health (panel) management intervention. Providers were asked about their use and comfort with two VA digital tools for panel management at baseline, 16 weeks, and post-intervention. An 8-item scale (range 0-40) was used to measure information literacy (Cronbach’s α=0.84). Scores between study arms and provider types were compared using paired t-tests and ANOVAs. Associations between self-reported digital tool use and information literacy were measured via Pearson’s correlations.Results: Providers showed moderate levels of information literacy (M= 27.4, SD 6.5). There were no significant differences in mean information literacy between physicians (M=26.4, SD 6.7) and nurses (M=30.5, SD 5.2, p=0.57 for difference), or between intervention (M=28.4, SD 6.5) and control groups (M=25.1, SD 6.2, p=0.12 for difference). Information literacy was correlated with higher rates of self-reported information system usage (r=0.547, p=0.001). Clinicians identified data access, accuracy, and interpretability as potential information literacy barriers.Conclusions: While exploratory in nature, cautioning generalizability, the study suggests that measuring and improving clinicians’ information literacy may play a significant role in the implementation and use of digital information tools, as these tools are rapidly being deployed to enhance communication among care teams, improve health care outcomes, and reduce overall costs.
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Douglas, Maureen L., Jessica Simon, Sara N. Davison, Patricia Biondo, Sunita Ghosh, Aliya Kassam, and Konrad Fassbender. "Efficacy of Advance Care Planning Videos for Patients: A Randomized Controlled Trial in Cancer, Heart, and Kidney Failure Outpatient Settings." Medical Decision Making 41, no. 3 (January 15, 2021): 292–304. http://dx.doi.org/10.1177/0272989x20985836.
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Background Patient videos about advance care planning (ACP; hereafter “Videos”), were developed to support uptake of provincial policy and address the complexity of patients’ decision-making process. We evaluate self-administered ACP Videos, compare the studies’ choice of outcomes, show correlations between the patients’ ACP actions, and discuss implications for health care policy. Objective To test the efficacy of the Videos on patients’ ACP/goals of care designation conversations with a health care provider. Design, Setting, and Participants Using a 2-arm, 1:1 randomized controlled trial, we recruited outpatients with a diagnosis of kidney failure, heart failure, metastatic lung, gastrointestinal, or gynecological cancer from 22 sites. Analysis followed the intention-to-treat principle. Interventions Videos describing the ACP process and illustrating the resuscitative, medical, and comfort levels of care. Main Outcomes and Measures The primary outcome was the proportion of participants who reported having an ACP/goals of care designation (GCD) conversation with a health care provider by 3 mo. Outcomes were measured using the Behaviours in Advance Care Planning and Actions Survey, an online survey capturing ACP attitudes, processes, and actions. Results We analyzed 241 and 217 participants at baseline and 3 mo, respectively. The proportion of participants who had an ACP/GCD conversation with a health care provider by 3 mo was significantly different between study arms (46% intervention; 32% control; adjusted odds ratio, 1.83; P = 0.032). Adjusted for the quality of conversations, there was no significant difference. Conclusions Videos as stand-alone tools do not engage individuals in high-quality ACP. Pragmatic trials are necessary to evaluate their impact on downstream outcomes when integrated into intentional, comprehensive conversations with a health care provider. Considering the strong correlation between 2 activities (physicians discussing options, patients telling health care providers preferences), policy should focus on empowering patients to initiate these conversations.
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Christian, Elizabeth, Wendy Craig, and Kinna Thakarar. "1319. Examining PrEP Knowledge and Prescribing Likelihood Among Medical Residents Before and After PrEP Education." Open Forum Infectious Diseases 5, suppl_1 (November 2018): S403. http://dx.doi.org/10.1093/ofid/ofy210.1152.
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Abstract Background Pre-exposure prophylaxis (PrEP) is effective for HIV prevention, but prescribing rates remain low. We examined the effect of an educational intervention on PrEP knowledge and prescribing likelihood among medical residents. Methods This was a prospective study using a convenience sample of Internal Medicine and Internal Medicine-Pediatrics residents at a tertiary care center in Portland, Maine. Participants attended a resident-led teaching session on PrEP and completed pre- and post-session surveys. PrEP knowledge was measured with five questions (definition, evidence, patient selection criteria, medication choice, and guidelines), and prescribing likelihood was assessed on a Likert scale. Participants identified motivating factors and barriers to prescribing. Survey data were analyzed with McNemar’s test or a paired Student’s t test as appropriate. Results Thirty residents completed the study; of these, 24 (83%) had at least 1 patient that they considered at high risk for HIV, and 14 (46%) reported having >5 such patients. None had ever prescribed PrEP. Average PrEP knowledge score increased after the intervention (pre = 2.33 vs. post = 4.1, P < 0.001). After the intervention, more participants reported that they would be likely to prescribe PrEP (pre = 76% vs. post = 90%, P = 0.014), fewer identified unfamiliarity with PrEP guidelines as a barrier (pre = 73% vs. post = 27%, P < 0.001), and Òother residents are prescribing PrEPÓ became a significant motivating factor (pre = 47% vs. post = 70%, P = 0.04). Preceptor comfort with prescribing PrEP was a consistently important influence on prescribing likelihood (90% vs. 82%, P = 0.22). Conclusion Familiarity with PrEP is relevant to resident practice, and an educational intervention is effective in the short term for addressing inadequate knowledge as a barrier to offering PrEP. Resident practice is influenced by preceptors and peers, suggesting that it may be helpful to include attending physicians in future PrEP education efforts at our institution. Disclosures All authors: No reported disclosures.
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McCourt, Christine, Juliet Rayment, Susanna Rance, and Jane Sandall. "Place of Birth and Concepts of Wellbeing." Anthropology in Action 23, no. 3 (December 1, 2016): 17–29. http://dx.doi.org/10.3167/aia.2016.230303.
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AbstractThis article is based on analysis of a series of ethnographic case studies of midwifery units in England. Midwifery units1 are spaces that were developed to provide more home-like and less medically oriented care for birth that would support physiological processes of labour, women’s comfort and a positive experience of birth for women and their families. They are run by midwives, either on a hospital site alongside an obstetric unit (Alongside Midwifery Unit – AMU) or a freestanding unit away from an obstetric unit (Freestanding Midwifery Unit – FMU). Midwifery units have been designed and intended specifically as locations of wellbeing and although the meaning of the term is used very loosely in public discourse, this claim is supported by a large epidemiological study, which found that they provide safe care for babies while reducing use of medical interventions and with better health outcomes for the women. Our research indicated that midwifery units function as a protected space, one which uses domestic features as metaphors of home in order to promote a sense of wellbeing and to re-normalise concepts of birth, which had become inhabited by medical models and a preoccupation with risk. However, we argue that this protected space has a function for midwives as well as for birthing women. Midwifery units are intended to support midwives’ wellbeing following decades of professional struggles to maintain autonomy, midwife-led care2 and a professional identity founded on supporting normal, healthy birth. This development, which is focused on place of birth rather than other aspects of maternity care such as continuity, shows potential for restoring wellbeing on individual, professional and community levels, through improving rates of normal physiological birth and improving experiences of providing and receiving care. Nevertheless, this very focus also poses challenges for health service providers attempting to provide a ‘social model of care’ within an institutional context.1The term midwifery unit was adopted by the Birthplace research programme in place of the more popular term ‘birth centre’ to avoid ambiguity. In a midwifery unit care is not only provided by mid-wives but is also managed by midwives and does not normally include use of obstetric instruments or interventions. If a woman planning birth in a mid-wifery unit develops obstetric complications, or decides she wishes to have a medical intervention such as epidural pain relief, she is transferred for care to an obstetric unit. Some units called birth centres are not managed by midwives in this way.2Midwife-led care refers to care where the midwife, rather than an obstetrician or other professional is the lead professional, who takes responsibility for a woman’s maternity care through from pregnancy to postnatal. Following the Changing Childbirth report in 1993, this was re-established as the usual model for women classified as at low risk of pregnancy and birth complications.
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A.B., Adeyeni, Wennie J., Asonye C.C., Akintunde F.E., Sodimu J., and Kenai N.D. "The Effect of a Nurse-Led Training on Knowledge of Pain Assessment and Management Among Surgical Nurses, South-West, Nigeria." African Journal of Health, Nursing and Midwifery 4, no. 4 (July 20, 2021): 70–85. http://dx.doi.org/10.52589/ajhnm-tdhn7liu.
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Introduction: Pain is inevitable in most invasive procedures, which include surgery. Patients experiencing pains expect to have it relieved by their caregivers, most especially nurses. However, these expectations are not often met. The objective of the study was to determine the effect of pain assessment and management training programs on surgical nurses’ knowledge about pain in Obafemi Awolowo University Teaching Hospital, Ile-Ife. Material and Methods: The study utilized a one-group quasi-experimental pre and post-test design. The general formula was used to determine the sample size of 108 respondents out of a total population of 248 surgical nurses. A Self-Report Questionnaire (SRQ) and a Text Paper on Knowledge and Management of Pain (TPKMP) were used to assess the surgical nurses’ knowledge of pain and management pre and post-intervention. Descriptive and inferential statistics (t-test) were used for data presentation and analysis via SPSS version 20 at a 0.05 level of significance. Results: Research findings revealed significant differences between pre and post-intervention knowledge on pain assessment (p = 0.007), knowledge on non-pharmacological management (p= 0.00) and knowledge of pharmacological management of pain (p = 0.00), respectively. Conclusion: Nurses are concerned with assessing the patients´ subjective experiences and have a moral obligation to care for the patients in pain. Therefore, the study recommended that regular training and seminars on pain assessment and management should be organized for nurses to render services that ensure comfort and optimal health outcomes.
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Tofil, Nancy M., Kim W. Benner, Lynn Zinkan, Jeffrey Alten, Brian M. Varisco, and Marjorie Lee White. "Pediatric Intensive Care Simulation Course: A New Paradigm in Teaching." Journal of Graduate Medical Education 3, no. 1 (March 1, 2011): 81–87. http://dx.doi.org/10.4300/jgme-d-10-00070.1.
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Abstract Objective True pediatric emergencies are rare. Because resident work hours are restricted and national attention turns toward patient safety, teaching methods to improve physician performance and patient care are vital. We hypothesize that a critical-care simulation course will improve resident confidence and performance in critical-care situations. Interventions We developed a monthly pediatric intensive care unit simulation course for second-year pediatric residents that consisted of weekly 1-hour sessions during both of the residents' month-long pediatric intensive care unit rotations. All scenarios used high-fidelity pediatric simulators and immediate videotape-assisted debriefing sessions. In addition, simulated intraosseous line insertion and endotracheal intubations were also performed. Results All residents improved their comfort level and confidence in performing individual key resuscitation tasks. The largest improvements were seen with their perceived ability to intubate children and place intraosseous lines. Both of these skills improved from baseline and compared to third-year-resident controls who had pediatric intensive care unit rotations but no simulations (P = .05 and P = .07, respectively). Videotape reviews showed only 54% ± 12% of skills from a scenario checklist performed correctly. Conclusions Our simulation-based pediatric intensive care unit training course improves second-year pediatric residents' comfort level but not performance during codes, as well as their perceived intubation and intraosseous ability. Videotape reviews show discordance between objective performance and self-assessment. Further work is necessary to elucidate the reasons for this difference as well as the appropriate role for simulation in the new graduate medical education climate, and to create new teaching modalities to improve resident performance.
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Sobanski, Piotr Z., Bernd Alt-Epping, David C. Currow, Sarah J. Goodlin, Tomasz Grodzicki, Karen Hogg, Daisy J. A. Janssen, et al. "Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement." Cardiovascular Research 116, no. 1 (August 29, 2019): 12–27. http://dx.doi.org/10.1093/cvr/cvz200.
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Abstract Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons’ needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.
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Auriemma, Catherine L., Michael O. Harhay, Kimberley J. Haines, Frances K. Barg, Scott D. Halpern, and Sarah M. Lyon. "What Matters to Patients and Their Families During and After Critical Illness: A Qualitative Study." American Journal of Critical Care 30, no. 1 (January 1, 2021): 11–20. http://dx.doi.org/10.4037/ajcc2021398.
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Background Despite increased emphasis on providing higher-quality patient- and family-centered care in the intensive care unit (ICU), there are no widely accepted definitions of such care in the ICU. Objectives To determine (1) aspects of care that patients and families valued during their ICU encounter, (2) outcomes that patients and families prioritized after hospital discharge, and (3) outcomes perceived as equivalent to or worse than death. Methods Semistructured interviews (n = 49) of former patients of an urban, academic medical ICU and their family members. Two investigators reviewed all transcripts line by line to identify key concepts. Codes were created and defined in a codebook with decision rules for their application and were analyzed using qualitative content analysis. Results Salient themes were identified and grouped into 2 major categories: (1) processes of care within the ICU— communication, patient comfort, and a sense that the medical team was “doing everything” (ie, providing exhaustive medical care) and (2) patient and surrogate outcomes after the ICU—survival, quality of life, physical function, and cognitive function. Several outcomes were deemed worse than death: severe cognitive/physical disability, dependence on medical machinery/equipment, and severe/constant pain. Conclusion Although survival was important, most participants qualified this preference. Simple measures of mortality rates may not represent patient- or family-centered outcomes in evaluations of ICU-based interventions, and new measures that incorporate functional outcomes and patients’ and family members’ views of life quality are necessary to promote patient-centered, evidence-based care.
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Shumway, Nathan M., and Erika J. Struble. "Prospective survey study regarding the implementation of new communication skills curriculum for medical oncology trainees." Journal of Clinical Oncology 30, no. 15_suppl (May 20, 2012): 9058. http://dx.doi.org/10.1200/jco.2012.30.15_suppl.9058.
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9058 Background: After a diagnosis of cancer, many patients suffer from anxiety and distress from uncertainty of symptoms, treatments, and prognosis. Clinicians must recognize opportunities to explore concerns. This study assesses oncology trainees’ views about communication with cancer patients before (PRE) and after (POST) a 12 month curriculum. Methods: Medical oncology fellows were surveyed PRE and POST a communication curriculum consisting of case studies and 6 core lectures which included fundamentals, breaking bad news, transitions to palliative care, advanced care planning, conducting family conferences, and discussing treatment options and informed consent. A 5 point Likert-scale was used to measure fellows’ attitudes and comfort regarding communication PRE and POST with questions grouped according to core topics. (≤2 = trainee disagreement, 3=neutral opinion, and ≥ 4 indicated agreement). Results: PRE and POST surveys were completed by 11 and 8 trainees respectively. In PRE 100% felt communication skills were important and 63% believed these skills could be taught. 82% felt there was not enough time during most visits to address emotion. This decreased to 27% in POST. 18% PRE agreed they were comfortable recognizing coping mechanisms versus 100% POST. 45% felt comfortable eliciting values in PRE versus 87.5% POST. Only 1 fellow (9%) felt comfortable addressing futility in PRE versus 25% in POST. The median grouped score for fundamentals increased from 15 to 17 (p=0.016) and median grouped score for advance care plans and DNR increased from 11 to 13(p=0.026). Conclusions: There is a need to improve oncology communication skills. Our curriculum is just one approach. After intervention, the majority of fellows agreed there was enough time to address emotion and felt more comfortable recognizing coping mechanisms and eliciting values. Discussing futility remains difficult for our fellows. All fellows were more comfortable with fundamental communication skills and advance care plans after the curriculum. The extent the curriculum contributed to the change in survey results is unclear. Further research is needed to guide communication education of oncologists.
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Sundararajan, Sri Hari, Steven Calamita, Peter Girgis, Gregory Ngo, Srirajkumar Ranganathan, Marisa Giglio, Vyacheslav Gendel, Sharad Goyal, John Nosher, and Sudipta Roychowdhury. "Sequential Interventional Management of Osseous Neoplasms via Embolization, Cryoablation, and Osteoplasty." Journal of Oncology 2019 (April 14, 2019): 1–6. http://dx.doi.org/10.1155/2019/5247837.
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The purpose of this study is to determine if sequential interventional therapy can become a mainstay option in providing palliation from fastidious osseous neoplasms in patients with pain refractory to oral analgesia and radiotherapy. This retrospective monocentric study was approved by our institutional review board. Between July 2012 and August 2014, we reviewed 15 patients (6 women, 9 men; age range of 36-81 years) who underwent embolization followed by cryoablation, with or without osteoplasty. Patient demographics and tumor characteristics, including primary histology and the location of metastasis, were included in our review. Pain intensity at baseline, after radiotherapy, and after sequential interventional therapy was reviewed using the hospital electronic medical record. The use of oral analgesia and procedural complications was also noted. Data was then assessed for normality and a two-tailed Student’s t-test was performed on mean pain scores for difference phases of treatment. While radiotherapy offers pain relief with a mean pain score of 7.25 ±1.5 (p =<.0001), sequential interventional therapy results in better comfort as demonstrated by a mean pain score of 3.9 ± 2.6 (p=.0015). Moreover, all patients who reported oral analgesic use at presentation reported a decrease in their requirement after sequential interventional therapy. Embolization and cryoablation were performed in all patients, while osteoplasty was indicated in 6 cases. There was no difference in postprocedural pain intensity between patients who required osteoplasty and patients who did not (p = 0.7514). There were no complications observed during treatment. This retrospective study shows that sequential intervention with transarterial embolization, cryoablation, and osteoplasty is both safe and efficacious for bone pain refractory to the current standard of care. We demonstrated that this combination therapy has the potential to become an effective mainstay treatment paradigm in the palliative care of osseous neoplasm to improve quality of life.
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Hansen, Lissi, Teresa T. Goodell, Josi DeHaven, and MaryDenise Smith. "Nurses’ Perceptions of End-of-Life Care After Multiple Interventions for Improvement." American Journal of Critical Care 18, no. 3 (May 1, 2009): 263–71. http://dx.doi.org/10.4037/ajcc2009727.
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Background Nurses working in intensive care units may lack knowledge and skills in end-of-life care, find caring for dying patients and the patients’ families stressful, and lack support to provide this care.Objectives To describe nurses’ perceptions of (1) knowledge and ability, (2) work environment, (3) support for staff, (4) support for patients and patients’ families, and (5) stress related to specific work situations in the context of end-of-life care before (phase 1) and after (phase 2) implementation of approaches to improve end-of-life care. The approaches were a nurse-developed bereavement program for patients’ families, use of a palliative medicine and comfort care team, preprinted orders for the withdrawal of life-sustaining treatment, hiring of a mental health clinical nurse specialist, and staff education in end-of-life care.Methods Nurses in 4 intensive care units at a university medical center reported their perceptions of end-of-life care by using a 5-subscale tool consisting of 30 items scored on a 4-point Likert scale. The tool was completed by 91 nurses in phase 1 and 127 in phase 2.Results Improvements in overall mean scores on the 5 sub-scales indicated that the approaches succeeded in improving nurses’ perceptions. In phase 2, most of the subscale overall mean scores were higher than a desired criterion (<2.0, good). Analysis of variance indicated that some improvements occurred over time differently in the units; other improvements occurred uniformly.Conclusions Continued practice development is needed in end-of-life care issues.
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Ogando Portilla, N., S. M. Bañon González, and M. G. García Jiménez. "Multidisciplinary approach in old aged dying patients." European Psychiatry 41, S1 (April 2017): S581—S582. http://dx.doi.org/10.1016/j.eurpsy.2017.01.875.
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IntroductionOver centuries, clinicians have had the responsibility to take care of dying patients. Lately, the withdrawal of life sustaining treatments have assumed a main role in these patients because of ethical aspects. Competent patients have the right to refuse medical care but not always these rights are respected or even explained to them, especially if they are old or they don’t have any close family. A multidisciplinary team should agree on how they think it is best to care for the patient and whether withdrawal of medical interventions is appropriate by using patient's wishes.ObjectivesTo identify the most relevant aspects to deal with in old aged dying patients.MethodsSystematic literature review in Up-to-date and Pubmed.Clinical case 83 years-old-man with a gastric cancer state IV. Married with a woman with Dementia who is waiting for a long stay public residence. No children. No cognitive damage. Fatal prognosis with a need of permanent enteral nutrition, which, he doesn’t want to use and clinicians strongly recommends. Great anxiety and suffering. Decision making capacity. Wish to die.DiscussionPatients with the capacity to make medical decisions can refuse medical care even if this refusal results in their death. Sometimes, a “comfort measures only” can be a better option than trying to keep life. Old people with no family are often less informed and taken in count in making decisions. A symptom management, good patient-clinicians communication, psychosocial, spiritual, and practical support and respecting patient's wishes and decisions is a main goal in any medical care.Disclosure of interestThe authors have not supplied their declaration of competing interest.