Ravi Taneja1,2,3,4, Robert Sibbald5,6, Launa Elliott7,6, Elizabeth Burke7, Kristen A Bishop5, Philip M Jones8,9, Mark Goldszmidt10,5. 1. Division of Critical Care, University of Western Ontario, London, ON, Canada. Ravi.taneja@lhsc.on.ca. 2. Department of Medicine, Division of Internal Medicine, University of Western Ontario, London, ON, Canada. Ravi.taneja@lhsc.on.ca. 3. Centre for Education Research and Innovation, University of Western Ontario, London, ON, Canada. Ravi.taneja@lhsc.on.ca. 4. London Health Sciences Centre, University Hospital, B2-223, 339 Windermere Road, London, ON, N6A 5A5, Canada. Ravi.taneja@lhsc.on.ca. 5. Centre for Education Research and Innovation, University of Western Ontario, London, ON, Canada. 6. Department of Clinical and Corporate Ethics, London Health Sciences Centre, London, ON, Canada. 7. Division of Critical Care, University of Western Ontario, London, ON, Canada. 8. Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada. 9. Department of Epidemiology & Biostatistics, University of Western Ontario, London, ON, Canada. 10. Department of Medicine, Division of Internal Medicine, University of Western Ontario, London, ON, Canada.
Abstract
PURPOSE: A discordance, predominantly towards overtreatment, exists between patients' expressed preferences for life-sustaining interventions and those documented at hospital admission. This quality improvement study sought to assess this discordance at our institution. Secondary objectives were to explore if internal medicine (IM) teams could identify patients who might benefit from further conversations and if the discordance can be reconciled in real-time. METHODS: Two registered nurses were incorporated into IM teams at a tertiary hospital to conduct resuscitation preference conversations with inpatients either specifically referred to them (group I, n = 165) or randomly selected (group II, n = 164) from 1 August 2016 to 31 August 2018. Resuscitation preferences were documented and communicated to teams prompting revised resuscitation orders where appropriate. Multivariable logistic regression was used to determine potential risk factors for discordance. RESULTS: Three hundred and twenty-nine patients were evaluated with a mean (standard deviation) age of 80 (12) and Charlson Comorbidity Index Score of 6.8 (2.6). Discordance was identified in 63/165 (38%) and 27/164 (16%) patients in groups I and II respectively. 42/194 patients (21%) did not want cardiopulmonary resuscitation (CPR) and 15/36 (41%) did not prefer intensive care unit (ICU) admission, despite these having been indicated in their initial preferences. 93% (84/90) of patients with discordance preferred de-escalation of care. Discordance was reconciled in 77% (69/90) of patients. CONCLUSION: Hospitalized patients may have preferences documented for CPR and ICU interventions contrary to their preferences. Trained nurses can identify inpatients who would benefit from further in-depth resuscitation preference conversations. Once identified, discordance can be reconciled during the index admission.
PURPOSE: A discordance, predominantly towards overtreatment, exists between patients' expressed preferences for life-sustaining interventions and those documented at hospital admission. This quality improvement study sought to assess this discordance at our institution. Secondary objectives were to explore if internal medicine (IM) teams could identify patients who might benefit from further conversations and if the discordance can be reconciled in real-time. METHODS: Two registered nurses were incorporated into IM teams at a tertiary hospital to conduct resuscitation preference conversations with inpatients either specifically referred to them (group I, n = 165) or randomly selected (group II, n = 164) from 1 August 2016 to 31 August 2018. Resuscitation preferences were documented and communicated to teams prompting revised resuscitation orders where appropriate. Multivariable logistic regression was used to determine potential risk factors for discordance. RESULTS: Three hundred and twenty-nine patients were evaluated with a mean (standard deviation) age of 80 (12) and Charlson Comorbidity Index Score of 6.8 (2.6). Discordance was identified in 63/165 (38%) and 27/164 (16%) patients in groups I and II respectively. 42/194 patients (21%) did not want cardiopulmonary resuscitation (CPR) and 15/36 (41%) did not prefer intensive care unit (ICU) admission, despite these having been indicated in their initial preferences. 93% (84/90) of patients with discordance preferred de-escalation of care. Discordance was reconciled in 77% (69/90) of patients. CONCLUSION: Hospitalized patients may have preferences documented for CPR and ICU interventions contrary to their preferences. Trained nurses can identify inpatients who would benefit from further in-depth resuscitation preference conversations. Once identified, discordance can be reconciled during the index admission.
Entities:
Keywords:
advance care planning; cardiopulmonary resuscitation; discordance; intensive care unit; resuscitation preference; shared decision-making
Authors: Jessica M Schmit; Lynne E Meyer; Jennifer M Duff; Yunfeng Dai; Fei Zou; Julia L Close Journal: BMC Med Educ Date: 2016-11-21 Impact factor: 2.463