James Dionne-Odom

Palliative Care Consultations for Heart Failure Patients: How Many, When, and Why?

OBJECTIVE In preparation for development of a palliative care intervention for patients with heart failure (HF) and their caregivers, we aimed to characterize the HF population receiving palliative care consultations (PCCs). METHODS AND RESULTS Reviewing charts from January 2006 to April 2011, we analyzed HF patient data including demographic and clinical characteristics, Seattle Heart Failure scores, and PCCs. Using Atlas qualitative software, we conducted a content analysis of PCC notes to characterize palliative care assessment and treatment recommendations. There were 132 HF patients with PCCs, of which 37% were New York Heart Association functional class III and 50% functional class IV. Retrospectively computed Seattle Heart Failure scores predicted 1-year mortality of 29% [interquartile range (IQR) 19-45] and median life expectancy of 2.8 years [IQR 1.6-4.2] years. Of the 132 HF patients, 115 (87%) had died by the time of the audit. In that cohort the actual median time from PCC to death was 21 [IQR 3-125] days. Reasons documented for PCCs included goals of care (80%), decision making (24%), hospice referral/discussion (24%), and symptom management (8%). CONCLUSIONS Despite recommendations, PCCs are not being initiated until the last month of life. Earlier referral for PCC may allow for integration of a broader array of palliative care services.

A Hermeneutic Phenomenological Understanding of Men’s Healing From Childhood Maltreatment

Purpose: To describe and interpret men’s experience of healing from childhood maltreatment. Design: Hermeneutic phenomenological. Method: In-depth interviews. Community-based purposive, maximum variation sampling approach. Recruitment occurred through posting flyers and advertisements. Verbatim data were analyzed and themes of the meaning of healing were identified. Findings: The meaning of healing was interpreted as “moving beyond suffering.” Five themes were identified to capture the multidimensional nature of the phenomenon: (a) breaking through the masculine veneer, (b) finding meaning, (c) choosing to live well, (d) caring for the self using holistic healing methods, and (e) engaging in humanizing relationships. Conclusions: Men who survived childhood maltreatment have needs to heal holistically mind, body, and spirit. Meeting their needs requires the provision of highly compassionate humanistic healing environments and healing-promotive nursing care.

Predictors of Physical Restraint Use in Hospitalized Veterans at End of Life in the Acute Care Setting: An Analysis of Data from the BEACON Trial (TH318-C)

Objectives Gain an understanding of the prevalence of restraint use in dying patients. Understand what patient characteristics and care processes place a patient at greater risk for being restrained at time of death. Original Research Background: The use of physical restraints in dying patients should be limited to situations where patient death is unanticipated. Little is known about the prevalence or risk factors for restraint use at end of life. Research Objectives: To determine the prevalence and predictors of physical restraint use at the time of death in hospitalized adults. Design: conducted between 2005 and 2011. Setting/Participants: Data on the last seven days of life were abstracted from the medical records of 5,476 decedents from six Veterans Administration Medical Centers (VAMCs) in the southeast United States and from VA administrative databases. Methods: Based on literature and expert clinical opinion, we prospectively identified potential risk factors for restraint use at the time of death from among all variables collected during the trial. Factors included location of death, medications given, nasogastric tube, intravenous (IV) fluids infusing, family presence at time of death, and receipt of a palliative care consultation.

A Synthesis of Theoretical Models to Guide Decision Support Interventions for Surrogate Decision-Making at Adult End-of-Life (S720)

Abstract Background: Surrogate decision-makers (SDMs) take part in 1.5 million end-of-life (EOL) decisions per year. Most surrogates find the role burdensome, often do not make decisions concordant with patients’ wishes and suffer negative psychological after-effects months to years subsequently. Objective: To review the literature and synthesize theoretical models of surrogate decision-making at adult EOL to identify an explanatory foundation for decision support interventions. Design: Literature published up to December 2011 was reviewed using PubMed, MEDLINE, CINAHL and EMBASE using the search terms “surrogate,” “proxy,” “end-of-life,” “life support withdrawal/withholding” and “decision-making”. Study selection: Selection criteria included: (a) studies or integrative reports of the empirical and theoretical research relevant to EOL surrogate decision-making; (b) description of a model of how SDMs make decisions for decisionallyincapacitated adults at EOL and (c) diagrammatic depictions of SDM models specifying key concepts and theoretical relationships. Results: Eight theoretical models met the selection criteria. Data synthesis: Five key insights were that: 1) more consistency is needed between diagrammatic maps of surrogate decision-making and model descriptions; 2) models focused on description of concepts with a lesser focus on relational linkages and propositions; 3) there is a need for greater integration of ethical concepts and their relationships in conceptual maps; 4) there has been little emphasis on how theoretical frameworks might guide intervention development and 5) minimal attempts have been made to situate surrogate decision-making within a grander conceptual framework of decisionmaking. Conclusions: Several theories of surrogate decision-making at adult EOL have been proposed, but further theory development is needed for these models to serve as the foundation for designing decision support interventions.