Erik K. Fromme

Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon

To examine the relationship between Physician Orders for Life‐Sustaining Treatment (POLST) for Scope of Treatment and setting of care at time of death.

POLST registry do-not-resuscitate orders and other patient treatment preferences

1. Quill TE, Holloway R. Time-limited trials near the end of life. JAMA. 2011; 306(13):1483-1484. 2. Stevenson J, Abernethy AP, Miller C, Currow DC. Managing comorbidities in patients at the end of life. BMJ. 2004;329(7471):909-912. 3. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170(18):1648-1654. 4. Abernethy AP, Aziz NM, Basch E, et al. A strategy to advance the evidence base in palliative medicine: formation of a palliative care research cooperative group. J Palliat Med. 2010;13(12):1407-1413. 5. Nikles J, Mitchell G, Walters J, et al. Prioritising drugs for single patient (nof-1) trials in palliative care. Palliat Med. 2009;23(7):623-634.

Approaching patients and family members who hope for a miracle.

A clinical problem may arise when caring for patients or their surrogates who prefer continued aggressive care based on the belief that a miracle will occur, despite a clinicians belief that further medical treatment is unlikely to have any meaningful benefit. An evidence-based approach is provided for the clinician by breaking this complex clinical problem into a series of more focused clinical questions and subsequently answering them through a critical appraisal of the existing medical literature. Belief in miracles is found to be common in the United States and is an important determinant of how decisions are made for those with advanced illness. There is a growing amount of evidence that suggests end-of-life outcomes improve with the provision of spiritual support from medical teams, as well as with a proactive approach to medical decision making that values statements given by patients and family members.

Pediatric oncology providers perceptions of barriers and facilitators to early integration of pediatric palliative care

Pediatric patients experience significant symptoms during cancer treatment. Symptom management is frequently inadequate. We studied perceptions of pediatric oncology care providers regarding early integration of palliative care (PC) for pediatric patients to identify barriers and facilitators that might assist in understanding how care could be improved.

A Nationwide Analysis of Antibiotic Use in Hospice Care in the Final Week of Life

CONTEXT Antibiotic prescription in hospice patients is complicated by the focus on palliative rather than curative care and concerns regarding increasing antibiotic resistance. OBJECTIVES To estimate the antibiotic use in a national sample of hospice patients and identify facility and patient characteristics associated with antibiotic use in this population. METHODS This was an analysis of data from the 2007 National Home and Hospice Care Survey, a nationally representative sample of U.S. hospice agencies. We included data from 3884 patients who died in hospice care. The primary outcome measure was prevalence of antibiotic use in the last seven days of life. Diagnoses, including potential infectious indications for antibiotic use, were defined using International Classification of Diseases, Ninth Revision (ICD-9) codes. Chi-squared tests and t-tests were used to quantify associations of patient and facility characteristics with antibiotic use. RESULTS During the last seven days of life, 27% (95% CI: 24%-30%) of patients received at least one antibiotic and 1.3% (95% CI: 0.7%-2.0%) received three or more antibiotics. Among patients who received at least one antibiotic, 15% (95% CI: 10%-20%) had a documented infectious diagnosis compared with 9% (95% CI: 7%-11%), who had an infectious diagnosis but received no antibiotics. CONCLUSION In this nationally representative sample, 27% of hospice patients received an antibiotic during the last seven days of life, most without a documented infectious diagnosis. Further research is needed to elucidate the role of antibiotics in this patient population to maintain palliative care goals while reducing unnecessary antibiotic use.

Adverse experiences with implantable defibrillators in Oregon hospices.

Background: Implantable cardioverter-defibrillators (ICDs) improve survival in patients at risk for recurrent, sustained ventricular tachycardia or fibrillation. Unless deactivated, ICDs may deliver unwanted shocks to terminally ill patients near the time of death. This study sought to determine the frequency and nature of adverse experiences with ICDs in hospice programs and what preventative measures the programs had taken. Method: A mailed survey to all 50 Oregon Hospice Programs in August 2008. Results: 42 (84%) of 50 programs participated. In all 36 (86%) of 42 programs reported having taken care of a patient with an ICD in the preceding 4 years. The average number of patients with ICDs per program increased from 2.2 (SD 2.5) in 2005 and 2006 to 3.6 (SD 3.7) in 2007 and 2008. Of the 36 programs who had cared for a patient with an ICD, 31 (86%) reported having some kind of adverse experience. These ranged from unwanted shocks delivered (64%), patient/family distress related to the decision to deactivate the ICD (47%), and time delay in ICD deactivation (42%). Only 16 (38%) programs had policies for managing ICDs and only 19 (43%) routinely screened new patients for ICDs. Discussion: As patients near the end of their lives, receiving defibrillating shocks may no longer be consistent with their goals of care. Based on the high frequencies of potentially preventable adverse outcomes documented by this study, we propose that hospices routinely screen patients for ICDs and proactively adopt policies to manage them, rather than in response to an adverse event.

Concordance of Out-of-Hospital and Emergency Department Cardiac Arrest Resuscitation With Documented End-of-Life Choices in Oregon

STUDY OBJECTIVE Resuscitation measures should be guided by previous patient choices about end-of-life care, when they exist; however, documentation of these choices can be unclear or difficult to access. We evaluate the concordance of a statewide registry of actionable resuscitation orders unique to Oregon with out-of-hospital and emergency department (ED) care provided for patients found by emergency medical services (EMS) in out-of-hospital cardiac arrest. METHODS This was a retrospective cohort study of patients found by EMS providers in out-of-hospital cardiac arrest in 5 counties in 2010. We used probabilistic linkage to match patients found in out-of-hospital cardiac arrest with previously signed documentation of end-of-life decisions in the Oregon Physician Orders for Life-Sustaining Treatment (POLST) registry. We evaluated resuscitation interventions in the field and ED. RESULTS There were 1,577 patients found in out-of-hospital cardiac arrest, of whom 82 had a previously signed POLST form. Patients with POLST do-not-resuscitate orders for whom EMS was called had resuscitation withheld or ceased before hospital admission in 94% of cases (95% confidence interval [CI] 83% to 99%). Compared with patients with no POLST or known do-not-resuscitate orders, more patients with attempt resuscitation POLST orders had field resuscitation attempted (84% versus 60%; difference 25%; 95% CI 12% to 37%) and were admitted to hospitals (38% versus 17%; difference 20%; 95% CI 3% to 37%), with no documented misinterpretations of the form once CPR was initiated. CONCLUSION In this sample of patients in out-of-hospital cardiac arrest, out-of-hospital and ED care was generally concordant with previously documented end-of-life orders in the setting of critical illness. Further research is needed to compare the effectiveness of Oregons POLST system to other methods of end-of-life order documentation.

Discharge planning for palliative care patients: a qualitative analysis.

For patients hospitalized with life-threatening illnesses and their families, palliative care consultants can provide critical support by providing information about prognosis, ensuring that symptoms are managed, helping to clarify goals of care, and addressing psychosocial and spiritual concerns. However, once patients leave the hospital, many hospital-based palliative care teams (PCTs) cannot continue to play active roles in patient care. Gaps in discharge planning not only decrease quality of life for patients, but also translate into lack of support for caregivers. The palliative care population would be expected to benefit from a customized approach to hospital discharge. The aim of this study was to identify the range of health care experiences of family caregivers and patients who received palliative care consultations after they left the hospital, and to understand how PCTs might best prepare patients and caregivers for the post-hospital experience.

Developing an easy-to-use tablet computer application for assessing patient-reported outcomes in patients with cancer.

BackgroundIn order to be practically useful, computer applications for patients with cancer must be easily usable by people with limited computer literacy and impaired vision or dexterity. We describe the usability development process for an application that collects quality of life and symptom information from patients with cancer.MethodsUsability testing consisted of user testing with cancer patients to identify initial design problems and a survey to compare the computer applications ease of use between elderly and younger patients.ResultsIn user-testing phase, seven men aged 56 to 77 with prostate cancer were observed using the application and interviewed afterwards identifying several usability concerns. Sixty patients with breast, gastrointestinal, or prostate cancer participated in the ease of use survey, with 40% (n = 24) aged 65 or older. Younger patients reported significantly higher scores than elderly patients (14.0 vs. 10.8, p = .001), even when prior computer and touch screen use was controlled.ConclusionElderly users reported lower ease of use scores than younger users; however, their average rating was quite high—10.8 on a scale of −16 to +16. It may be unrealistic to expect elderly or less computer literate users to rate any application as positively as younger, more computer savvy users—perhaps it is enough that they rate the application positively and can use it without undue difficulties. We hope that our process can serve as a model for how to bridge the fields of computer usability and healthcare.

Quality of hospice care for individuals with dementia.

Patients with dementia constitute an increasing proportion of hospice enrollees, yet little is known about the quality of hospice care for this population. The aim of this study was to quantify differences in quality of care measures between hospice patients with and without dementia.