Komal Patel Murali

Abstract

Background: In patients with serious illness, use of specialist palliative care may result in improved quality of life, patient and caregiver satisfaction and advance care planning, as well as lower health care utilization. However, evidence of efficacy is limited for patients with dementia, particularly in the setting of an acute hospitalization. Objective: To determine whether implementation of hospital-based specialist palliative care was associated with differences in treatment intensity outcomes for hospitalized patients with dementia. Design: Retrospective cohort study. Setting: Fifty-one hospitals in New York State that either did or did not implement a palliative care program between 2008 and 2014. Hospitals that consistently had a palliative care program during the study period were excluded. Participants: Hospitalized patients with dementia. Measurements: The primary outcome of this study was discharge to hospice from an acute hospitalization. Secondary outcomes included hospital length of stay, use of mechanical ventilation and dialysis, and days in intensive care. Difference-in-difference analyses were performed using multilevel regression to assess the association between implementing a palliative care program and outcomes, while adjusting for patient and hospital characteristics and time trends. Results: During the study period, 82,118 patients with dementia (mean (SD) age, 83.04 (10.04), 51,170 (62.21%) female) underwent an acute hospitalization, of which 41,227 (50.27%) received care in hospitals that implemented a palliative care program. In comparison to patients who received care in hospitals without palliative care, patients with dementia who received care in hospitals after the implementation of palliative care were more 35% likely to be discharged to hospice (adjusted odds ratio (aOR) = 1.35 (1.19–1.51), P <.001). No meaningful differences in secondary outcomes were observed. Conclusion: Implementation of a specialist palliative care program was associated with an increase in discharge to hospice following acute hospitalization in patients with dementia.

Abstract

Background: Serious illness is characterized by high symptom burden that negatively affects quality of life (QOL). Although palliative care research has highlighted symptom burden in seriously ill adults with cancer, symptom burden among those with noncancer serious illness and multiple chronic conditions has been understudied. Latent class analysis is a statistical method that can be used to better understand the relationship between severity of symptom burden and covariates, such as the presence of multiple chronic conditions. Although latent class analysis has been used to highlight subgroups of seriously ill adults with cancer based on symptom clusters, none have incorporated multiple chronic conditions. Objectives: The objectives of this study were to (a) describe the demographic and baseline characteristics of seriously ill adults at the end of life in a palliative care cohort, (b) identify latent subgroups of seriously ill individuals based on severity of symptom burden, and (c) examine variables associated with latent subgroup membership, such as QOL, functional status, and the presence of multiple chronic conditions. Methods: A secondary data analysis of a palliative care clinical trial was conducted. The latent class analysis was based on the Edmonton Symptom Assessment System, which measures nine symptoms on a scale of 0–10 (e.g., pain, fatigue, nausea, depression, anxiousness, drowsiness, appetite, well-being, and shortness of breath). Clinically significant cut-points for symptom severity were used to categorize each symptom item in addition to a categorized total score. Results: Three latent subgroups were identified (e.g., low, moderate, and high symptom burden). Lower overall QOL was associated with membership in the moderate and high symptom burden subgroups. Multiple chronic conditions were associated with statistically significant membership in the high symptom burden latent subgroup. Older adults between 65 and 74 years had a lower likelihood of moderate or high symptom burden subgroup membership compared to the low symptom burden class. Discussion: Lower QOL was associated with high symptom burden. Multiple chronic conditions were associated with high symptom burden, which underlines the clinical complexity of serious illness. Palliative care at the end of life for seriously ill adults with high symptom burden must account for the presence of multiple chronic conditions.

Abstract

Objective: Antibiotic use at the end of life (EoL) may introduce physiological as well as psychological stress and be incongruent with patients’ goals of care. Advance care planning (ACP) related to antibiotic use at the EoL helps improve goal-concordant care. Many nursing home (NH) residents are seriously ill. Therefore, we aimed to examine whether state and regional ACP initiatives play a role in the presence of “do not administer antibiotics” orders for NH residents at the EoL. Methods: We surveyed a random, representative national sample of 810 U.S. NHs (weighted n = 13,983). The NH survey included items on “do not administer antibiotics” orders in place and participation in infection prevention collaboratives. The survey was linked to state Physician Orders for Life-Sustaining Treatment (POLST) adoption status and resident, facility, and county characteristics data. We conducted multivariable regression models with state fixed effects, stratified by state POLST designation. Results: NHs in mature POLST states reported higher rates of “do not administer antibiotics” orders compared to developing POLST states (10.1% vs. 4.6%, respectively, p = 0.004). In mature POLST states, participation in regional collaboratives and smaller NH facilities (<100 beds) were associated with having “do not administer antibiotics” orders for seriously ill residents (β = 0.11, p = 0.006 and β = 0.12, p = 0.003, respectively). Discussion: NHs in states with mature POLST adoption that participated in infection control collaboratives were more likely to have “do not administer antibiotics” orders. State ACP initiatives combined with regional antibiotic stewardship initiatives may improve inappropriate antibiotic use at the EoL for NH residents.

Abstract

Background and Objectives: The Nurses Improving Care for Healthsystem Elders (NICHE) is a nurse-led education and consultation program designed to help health care organizations improve the quality of care for older adults. To conduct a scoping review of the evidence associated with the NICHE program to (a) understand how it influences patient outcomes through specialized care of the older adult and (b) provide an overview of implementation of the NICHE program across organizations as well as its impact on nursing professionals and the work environment. Research Design and Methods: Six databases were searched to identify NICHE-related articles between January 1992 and April 2019. After critical appraisal, 43 articles were included. Results: Four thematic categories were identified including specialized older adult care, geriatric resource nurse (GRN) model, work environment, and NICHE program adoption and refinement. Specialized older adult care, a key feature of NICHE programs, resulted in improved quality of care, patient safety, lower complications, and decreased length of stay. The GRN model emphasizes specialized geriatric care education and consultation. Improvements in the geriatric nurse work environment as measured by perceptions of the practice environment, quality of care, and aging-sensitive care delivery have been reported. NICHE program adoption and refinement focuses on the methods used to improve care, implementation and adoption of the NICHE program, and measuring its impact. Discussion and Implications: The evidence about the NICHE program in caring for older adults is promising but more studies examining patient outcomes and the impact on health care professionals are needed.

Abstract

Objective: Seriously ill adults with multiple chronic conditions (MCC) who receive palliative care may benefit from improved symptom burden, health care utilization and cost, caregiver stress, and quality of life. To guide research involving serious illness and MCC, palliative care can be integrated into a conceptual model to develop future research studies to improve care strategies and outcomes in this population. Methods: The adapted conceptual model was developed based on a thorough review of the literature, in which current evidence and conceptual models related to serious illness, MCC, and palliative care were appraised. Factors contributing to patients’ needs, services received, and service-related variables were identified. Relevant patient outcomes and evidence gaps are also highlighted. Results: Fifty-eight articles were synthesized to inform the development of an adapted conceptual model including serious illness, MCC, and palliative care. Concepts were organized into 4 main conceptual groups, including Factors Affecting Needs (sociodemographic and social determinants of health), Factors Affecting Services Received (health system; research, evidence base, dissemination, and health policy; community resources), Service-Related Variables (patient visits, service mix, quality of care, patient information, experience), and Outcomes (symptom burden, quality of life, function, advance care planning, goal-concordant care, utilization, cost, death, site of death, satisfaction). Discussion: The adapted conceptual model integrates palliative care with serious illness and multiple chronic conditions. The model is intended to guide the development of research studies involving seriously ill adults with MCC and aid researchers in addressing relevant evidence gaps.

Abstract

The phenomenon of end-of-life (EOL) decision-making is a lived experience by which individuals or families make decisions about care they will receive prior to death. A postmodern philosophical approach suggests EOL decision-making is a varied contextual phenomenon that is highly influenced by subjectivity. Thus, there is no specific definition for the phenomenon of EOL decision-making. Watson’s theory of human caring complements a postmodern approach in guiding the nursing process of caring for individuals as they experience EOL decision-making.

Abstract

Older adult immigrants are often socially isolated and vulnerable to poor health. Adult day service (ADS) centers could potentially facilitate social integration and address their long-term health care needs. The current review (a) identifies barriers to and facilitators of ADS use among immigrants, (b) explores how ADS programs impact older adult immigrants’ health and well-being, and (c) isolates the most effective culturally based components of ADS programs. An integrative review was conducted using Whittemore and Knafl’s methodology. Four databases were searched. Articles were critically appraised and data were organized within an ADS-specific framework. Functional impairment, race, gender, and degree of loneliness were all predictors of ADS use. ADS enhanced immigrants’ quality of life and provided fulfillment. Transportation, bilingual nurses, peer support, and cultural activities were deemed essential by participants. ADS can provide support to older adult immigrants by adding cultural elements to existing services and using nurses as cultural liaisons. More research is needed to assess the impact of ADS on disease outcomes, including dementia, and on immigrants in multi-ethnic settings.

Abstract

RationaleHospital chaplains provide spiritual care that helps patients facing serious illness cope with their symptoms and prognosis, yet because mechanically ventilated patients cannot speak, spiritual care of these patients has been limited.ObjectivesTo determine the feasibility and measure the effects of chaplain-led picture-guided spiritual care for mechanically ventilated adults in the intensive care unit (ICU).MethodsWe conducted a quasi-experimental study at a tertiary care hospital between March 2014 and July 2015. Fifty mechanically ventilated adults in medical or surgical ICUs without delirium or dementia received spiritual care by a hospital chaplain using an illustrated communication card to assess their spiritual affiliations, emotions, and needs and were followed until hospital discharge. Feasibility was assessed as the proportion of participants able to identify spiritual affiliations, emotions, and needs using the card. Among the first 25 participants, we performed semistructured interviews with 8 ICU survivors to identify how spiritual care helped them. For the subsequent 25 participants, we measured anxiety (on 100-mm visual analog scales [VAS]) immediately before and after the first chaplain visit, and we performed semistructured interviews with 18 ICU survivors with added measurements of pain and stress (on ±100-mm VAS).Measurements and main resultsThe mean (SD) age was 59 (±16) years, median mechanical ventilation days was 19.5 (interquartile range, 7-29 d), and 15 (30%) died in-hospital. Using the card, 50 (100%) identified a spiritual affiliation, 47 (94%) identified one or more emotions, 45 (90%) rated their spiritual pain, and 36 (72%) selected a chaplain intervention. Anxiety after the first visit decreased 31% (mean score change, -20; 95% confidence interval, -33 to -7). Among 28 ICU survivors, 26 (93%) remembered the intervention and underwent semistructured interviews, of whom 81% felt more capable of dealing with their hospitalization and 0% felt worse. The 18 ICU survivors who underwent additional VAS testing during semistructured follow-up interviews reported a 49-point reduction in stress (95% confidence interval, -72 to -24) and no significant change in physical pain that they attributed to picture-guided spiritual care.ConclusionsChaplain-led picture-guided spiritual care is feasible among mechanically ventilated adults and shows potential for reducing anxiety during and stress after an ICU admission.

Abstract

IntroductionSurvivors of critical illness face many potential long-term sequelae. Prior studies showed that early rehabilitation in the intensive care unit (ICU) reduces physical impairment and decreases ICU and hospital length of stay (LOS). However, these studies are based on a single ICU or were conducted with a small subset of all ICU patients. We examined the effect of an early rehabilitation program concurrently implemented in multiple ICUs on ICU and hospital LOS.MethodsAn early rehabilitation program was systematically implemented in five ICUs at the sites of two affiliated academic institutions. We retrospectively compared ICU and hospital LOS in the year before (1/2011-12/2011) and after (1/2012-12/2012) implementation.ResultsIn the pre- and post-implementation periods, respectively, there were a total of 3945 and 4200 ICU admissions among the five ICUs. After implementation, there was a significant increase in the proportion of patients who received more rehabilitation treatments during their ICU stay (p p p p ConclusionsA multi-ICU, coordinated implementation of an early rehabilitation program markedly increased rehabilitation treatments in the ICU and was associated with reduced ICU and hospital LOS as well as increased ICU admissions.