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ABSTRACT: BACKGROUND: Many patients considered for transplantation die before receiving the organ, underlining the importance of providing high-quality symptomatic relief and communication for all transplant patients. METHODS: To study how consideration of transplantation affects the end-of-life care received by patients, care was evaluated by abstracting medical records for 496 adults who died in one high-volume transplant medical center between April 2005 and April 2006. Sixteen quality indicators from the Assessing Care of Vulnerable Elders set that focused on communication and symptom management were measured to calculate an overall patient-level quality score. We evaluated the predictors of quality of end-of-life care, with the main independent variable being whether the patient was being considered for transplantation. Restricting to patients who died an "expected death," we also evaluated the end-of-life treatments received. RESULTS: Twenty-five percent of decedent patients were considered for transplantation. In adjusted models, patients considered for transplantation received lower-quality end-of-life care, had longer hospital stays before death, and were more likely to receive aggressive life-sustaining treatments. CONCLUSIONS: Care models should incorporate an emphasis on symptom relief and communication along with transplant preparation.
Transplantation 11/2012; · 4.00 Impact Factor
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ABSTRACT: Aim: To understand provider practices around dyspnea assessment to inform the development of an electronic medical record (EMR)-based dyspnea assessment module in an inpatient palliative care consultation template. Design: Qualitative analysis of palliative care provider interviews. RESULTS: Three themes emerged: (1) integration of patient self-report of breathlessness with a clinical observation of dyspnea; (2) identification of patients for dyspnea assessment based on perceived patient need; and (3) variability in preferences for and use of existing severity scales for dyspnea. CONCLUSIONS: The assessment approaches described by providers underscore the challenge of developing an informatics tool that supports the natural clinical experience and facilitates standardized care. The complexity of the dyspnea assessment process and variation in provider practices necessitate a level of flexibility and choice to be built into a computer-based tool.
The American journal of hospice & palliative care 06/2012;
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ABSTRACT: Managing symptoms and communicating effectively are essential aspects of providing high-quality cancer care, especially among patients with advanced cancer. The purpose of this study is to apply novel quality indicators to measure the quality of supportive care provided to patients with advanced cancer who died in a large university medical center.
Cancer quality ASSIST is a comprehensive quality indicator (QI) set that includes 92 symptom and care planning indicators, of which we piloted 15 applicable to persons with advanced cancer who died in the hospital setting. We evaluated medical records of all adult terminal hospitalizations with lengths of stay ā„3 days at one university medical center between April 2005 and April 2006.
Of 496 decedents, 118 had advanced cancer (mean age 60, 54% male). Forty-five percent received chemotherapy or radiation in the month prior to or during admission. During the hospitalization, 56% of the patients spent time in the ICU (median length of stay 8 days), one in five received first-time hemodialysis, and 23% had a ventilator withdrawn anticipating death. The 118 patients triggered 596 quality indicators of which 476 passed (QI level pass rate 80%, range 50-100%). Pain assessment and management were consistently performed; however, other cancer supportive care needed improvement: 26% of patients not receiving cancer therapy who had nausea and vomiting received inadequate follow-up, more than one quarter of patients with dyspnea had this symptom inadequately addressed, and 29% of patients taking long-acting opioids were not prescribed a bowel regimen. Timely discussion of patient preferences upon admission to the ICU or initiation of mechanical ventilation occurred in 64 and 69% of cases, respectively.
This set of quality indicators can evaluate the quality of supportive and end-of-life care provided to inpatients dying with advanced cancer and identify aspects of care that need improvement.
Supportive Care in Cancer 04/2012; 20(9):2189-94. · 2.09 Impact Factor
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ABSTRACT: This study describes emergency physicians' perspectives on the challenges and benefits to providing palliative care in an academic, urban, public hospital in Los Angeles. Participants underwent a semi-structured interview on their training and experiences related to palliative care, perceptions of providing palliative care, and their recommendations for education and training in this area. Overall, respondents felt that palliative care is not prioritized appropriately, leading patients to be unaware of their options for end-of-life care. Providing educational materials and courses that have been developed from the ED perspective should be included in ongoing continuing medical education. Having a palliative care team that is responsive to the needs of the ED will further enhance collaboration with the ED. Future research should focus on understanding the range of benefits to having palliative care in the ED.
Journal of palliative medicine 12/2011; 14(12):1333-8. · 1.84 Impact Factor
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ABSTRACT: We sought to describe the documentation, frequency, and timing of discussions about patient preferences for care and to examine patterns of palliative care and hospice use among patients with advanced cancer.
We prospectively abstracted the medical records of 118 patients receiving care at a Veterans Administration (VA) facility from diagnosis of stage IV disease to 12 months postdiagnosis or death. We used univariate statistics to describe the type and frequency of documentation of patient preferences and palliative care/hospice referral. We calculated the time from diagnosis to the first documentation of preferences and the time from first documentation to death. We compared documentation of patient preferences between decedents and nondecedents using Ļ(2) tests.
The majority of patients (81%) had some documentation of their care preferences recorded, although decedents were significantly more likely to have had their preferences documented than nondecedents (96% v 60%; P < .000). Most (53%) patients did not have a formal advance directive documented in the medical record. The mean time from diagnosis to the first documentation of preferences was approximately 2 months. More than half of all patients (53%) and almost three-quarters of decedents (73%) had a palliative care consultation.
Despite high rates of preference documentation, there remains room for improvement. Providers may need to be helped to identify patients earlier in their trajectory for appropriate palliative care services, and future work should focus on developing useful alternatives to advance directives for adequately documenting patient preferences.
Journal of Oncology Practice 11/2011; 7(6):361-6.
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ABSTRACT: To translate a set of evidence-based clinical standards designed to allow paramedics to forego unnecessary and potentially harmful resuscitation attempts into a feasible new policy.
Policy documents, meeting minutes, and personal communications between a large urban Emergency Medical Services (EMS) agency serving all of Los Angeles County (LAC) and a research group were reviewed over 12 months.
LAC EMS and University of California, Los Angeles (UCLA) formed a partnership (the EMS-UCLA Collaborative) to develop and translate the standards into new EMS protocols. Clinical indicators considered appropriate and feasible by an expert panel were submitted to the agency for inclusion in the new policy.
The Collaborative submitted the results to the LAC EMS Commission and a physician advisory group for review. Of the 41 indicators approved by the expert panel, 22 would have resulted in changes to the current policy. All six involved asking family members about or honoring written and verbal Do Not Attempt Resuscitate requests, but only 4 of the 16 indicators based on clinical characteristics were included in the new policy. Ultimately, 10 of the 22 indicators that would have changed policy were approved and implemented.
By collaboration, a large EMS agency and a research team were able to develop and implement a revised resuscitation policy within 1 year.
Health Services Research 10/2011; 47(1 Pt 2):363-79. · 2.16 Impact Factor
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ABSTRACT: We assessed key aspects of the quality of end-of-life care using validated explicit process quality measures in an academic medical center (hospital and cancer center) before expanding to a broader palliative care initiative.
We evaluated 21 indicators most relevant to end-of-life care from the Cancer Quality-ASSIST supportive oncology indicator set for 238 patients with advanced/metastatic solid tumors who died between 2-15 months after diagnosis. These included outpatient and hospital indicators for cancer symptoms and information and care planning that met criteria for feasibility, reliability, and validity. We abstracted detailed information from medical records to specify the necessary data elements.
Overall adherence was 53% (95% confidence interval [CI], 50%-56%); this varied widely among indicators. Adherence was highest for pain indicators; in particular, 97% of eligible subjects' hospitalizations had documented screening for pain, and, after an outpatient pain medication was changed, 97% of patients had a pain assessment at the subsequent visit. For other symptoms, adherence ranged from 0% for documentation of life expectancy for patients starting parenteral or enteral nutrition to 87% for assessment of nausea or vomiting on hospital admission. For information and care planning, results ranged from 6% for documentation of ventilation preferences prior to intubation to 68% for documented communication of risks and benefits or prognosis prior to starting chemotherapy.
In conclusion, Cancer Quality-ASSIST indicators are useful for practical quality assessment of cancer end-of-life care in an academic medical center. These results will serve as useful data for targeting areas for quality improvement and measuring progress.
Journal of palliative medicine 03/2011; 14(4):451-7. · 1.84 Impact Factor
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ABSTRACT: Longitudinal studies examining care for seriously ill patients are needed to understand patients' experience of illness, evaluate interventions, and improve quality of care. Unfortunately, such studies face substantial methodological challenges.
This article describes such challenges and the strategies used to overcome them in a successfully implemented palliative care intervention trial for veterans.
Veterans admitted with a physician-estimated moderate-to-high one-year mortality risk were enrolled and followed up to three years, until death or study completion. Study protocols, procedures, and process data were intermittently analyzed to identify and develop strategies to address issues affecting study enrollment and interview completion rates.
Of 561 patients who were eligible, 400 (71%) enrolled in the study; 357 (87%) alive at the end of Month 1 completed interviews; and 254 (88%) alive at Month 6 completed interviews. Of the 208 patients who died during the study and had identified a caregiver, we were able to conduct an after-death interview with 154 (74%) caregivers. A variety of strategies, such as systematic tracking and check-in calls, minimizing respondent burden, and maintaining interviewer-respondent dyads over time, were used to maximize enrollment rates, data collection, and retention.
These data demonstrate that the use of diverse strategies and flexibility with regard to study protocols can result in successful recruitment, data collection, and retention of participants with serious illness. They thus show that longitudinal research can be successfully implemented with this population to evaluate interventions and examine patient experiences.
Journal of pain and symptom management 03/2011; 41(6):1003-14. · 2.42 Impact Factor
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ABSTRACT: Using the Assessing Symptoms Side Effects and Indicators of Supportive Treatment (ASSIST) quality indicators (QIs), we conducted a comprehensive evaluation of the quality of care provided in our institution to patients diagnosed with advanced cancer in 2006.
Patients diagnosed with a Stage IV solid tumor were identified from the hospital's cancer registry. Using data abstracted from medical records, care was assessed using 41 explicit QIs. Mean percent adherence to QIs was calculated overall, as well as across five clinical domains: (1) Pain, (2) Depression and Psychosocial Distress, (3) Dyspnea, (4) Treatment Toxicity, (5) Other Symptoms, and (6) Information and Care Planning.
The study cohort (nā=ā118) was almost all male (2% female) and mean age was 65.9 years (standard deviation [SD] 9.9 years). The most common cancers were lung and head and neck cancer (23% each); 17% had prostate cancer; 13% had colorectal cancer; and the rest (24%) had breast, esophageal, stomach, genitourinary, liver/biliary, or pancreas cancer. Patients received 51% (95% confidence interval [CI] 48%-54%) of recommended care. Adherence to recommended care within domains ranged from 38% (95% CI 35%-42%) for Other Symptoms to 79% (95% CI 73%-86%) for Information and Care Planning.
This study suggests that the quality of supportive care for patients with advanced cancer can be greatly improved. Future efforts should use the ASSIST indicators to evaluate the quality of supportive care in larger and more diverse cohorts of advanced cancer patients.
Journal of palliative medicine 03/2011; 14(5):573-7. · 1.84 Impact Factor
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ABSTRACT: To understand perceptions regarding their illness of patients who present to the Emergency Department at the end of life.
Semistructured one-on-one interviews were performed with a convenience sample of seriously ill, Emergency Department (ED) patients with advanced illness presenting to an urban, public hospital. A bilingual Latina health promoter used a predetermined discussion guide to conduct all interviews. Non-English- or Non-Spanish-speaking patients and those with uncontrolled symptoms or cognitive deficits were excluded. All interviews were recorded and transcribed, and grounded theory methodology was used to analyze the results.
Thirteen patients with advanced illness participated, 8 of whom were Spanish-speaking only. Because of difficulty accessing care and financial concerns, patients with advanced illness present to EDs when their pain or other symptoms are out of control. The majority derive great comfort and strength from their faith in God, who they believe determines their fate. Most listed spending time with family, and not being a burden, as most important at the end of life, and many expressed a preference to die at home surrounded by loved ones. Almost none had spoken to physicians about their care preferences.
Patients with advanced illness present to the ED of a safety net hospital when symptoms are out of control. They have many financial concerns, want to spend their remaining days with family, and do not want to be a burden. Most derive immense comfort from faith in God, but do not feel they have control over their own fate.
Journal of palliative medicine 02/2011; 14(3):293-6. · 1.84 Impact Factor
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ABSTRACT: Efforts to promote awareness and management of chronic pain have been accompanied by a troubling increase in prescription medication abuse. At the same time, some patients may misuse substances in an effort to manage chronic pain.
This study examines self-reported substance misuse for pain management among veterans and identifies the contributing factors.
We analyzed cross-sectional data from the Help Veterans Experience Less Pain study.
Of 343 veterans, 35.3% reported an aberrant pain management behavior (24% reported using alcohol, 11.7% reported using street drugs, and 16.3% reported sharing prescriptions to manage pain). Poorer mental health, younger age, substance use disorders (SUDs), number of nonpain symptoms, and greater pain severity and interference were associated with aberrant pain management behaviors. In multivariate analysis, SUDs (odds ratio [OR]: 3.9, 95% confidence interval [CI]: 2.3-6.7, P<0.000) and poorer mental health (OR: 2.3, 95% CI: 1.3-4.3, P=0.006) were associated with using alcohol or street drugs to manage pain; SUDs (OR: 2.4, 95% CI: 1.3-4.4, P=0.006) and pain interference (OR: 1.1, 95% CI: 1.0-1.2, P=0.047) were associated with prescription sharing; and SUDs (OR: 3.6, 95% CI: 2.2-6.1, P<0.000) and number of nonpain symptoms (OR: 6.5, 95% CI: 1.2-35.4, P=0.031) were associated with any aberrant pain management behavior.
Veterans with a history of SUDs, greater pain interference, more nonpain symptoms, and mental health concerns should be carefully managed to deter substance misuse for pain management.
Journal of pain and symptom management 01/2011; 41(5):848-58. · 2.42 Impact Factor
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ABSTRACT: Although pain ranks highly among reasons for seeking care, routine pain assessment is often inaccurate.
This study evaluated factors associated with nurses (e.g., registered) and other nursing support staff (e.g., licensed vocational nurses and health technicians) discordance with patients in estimates of pain in a health system where routine pain screening using a 0-10 numeric rating scale (NRS) is mandated.
This was a cross-sectional, visit-based, cohort study that included surveys of clinic outpatients (n=465) and nursing staff (n=94) who screened for pain as part of routine vital sign measurement during intake. These data were supplemented by chart review. We compared patient pain levels documented by the nursing staff (N-NRS) with those reported by the patient during the study survey (S-NRS).
Pain underestimation (N-NRS<S-NRS) occurred in 25% and overestimation (N-NRS>S-NRS) in 7% of the cases. Nursing staff used informal pain-screening techniques that did not follow established NRS protocols in half of the encounters. Pain underestimation was positively associated with more years of nursing staff work experience and patient anxiety or post-traumatic stress disorder and negatively associated with better patient-reported health status. Pain overestimation was positively associated with nursing staff's use of the full NRS protocol and with a distracting environment in which patient vitals were taken.
Despite a long-standing mandate, pain-screening implementation falls short, and informal screening is common.
Journal of pain and symptom management 11/2010; 40(5):723-33. · 2.42 Impact Factor
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Lisa R Shugarman,
Steven M Asch,
Lisa S Meredith,
Cathy D Sherbourne,
Emily Hagenmeier,
Li Wen,
Angela Cohen,
Lisa V Rubenstein,
Joy Goebel,
Andy Lanto, Karl A Lorenz
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ABSTRACT: Pain is a common, often undertreated problem among patients with palliative needs.
To evaluate clinician factors associated with intention to address diverse aspects of pain.
Clinicians reviewed a clinical vignette describing a frail elderly patient with advanced hormone-refractory metastatic prostate cancer, depression, and pain not on analgesic therapy. Clinicians were surveyed about their intentions for treatment.
All 280 primary care and specialist clinicians working in 19 hospital and community-based primary care, oncology, and cardiology clinics at eight geographically dispersed sites in two large VA hospital systems.
Endpoints were clinician intention to deliver guideline-concordant care: prescribe opioids/antidepressants, assess existential wellbeing, and offer mental health referral. Demographic and behavioral measures were evaluated in association with endpoints.
Of 208 (74%) responding practitioners, 189 were responsible for prescribing decisions. Of those, 86, 77, 75, and 69 were "very"/"somewhat likely" to prescribe opioids, antidepressants, refer to a mental health specialist, or assess existential wellbeing, respectively. Factors associated with greater intent to prescribe an opioid or antidepressant included female gender, being an attending physician, being a primary care clinician, and greater confidence in pain management skills. Greater trust in the validity of pain ratings was associated with intent to prescribe an antidepressant and assess existential wellbeing. Prescribing opioids was less likely if perceived as an administrative burden. Assessing existential wellbeing was less likely if time constraints were perceived a barrier to evaluating pain. Female gender was the only factor associated with intent to refer to a mental health specialist.
Our findings suggest useful targets for improving pain management include bolstering clinician confidence in pain management and their trust in pain ratings.
Pain Medicine 09/2010; 11(9):1365-72. · 2.35 Impact Factor
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Cancer 08/2010; 116(15):3533-6. · 4.77 Impact Factor
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ABSTRACT: Although measuring the quality of symptom management and end-of-life care could help provide a basis for improving supportive care for advanced cancer, few quality indicators in this area have been rigorously developed or evaluated.
The authors conducted a pilot evaluation of a comprehensive set of 92 supportive oncology quality indicators, Cancer Quality-ASSIST, including outpatient and hospital indicators for symptoms commonly related to cancer and its treatment and information and care planning. They operationalized the indicators and developed an electronic abstraction tool and extensive guidelines and training materials. Quality assurance nurses abstracted the medical records for 356 advanced cancer patients in 2 settings: a Veterans Administration hospital and an academic hospital and cancer center. The authors evaluated the indicators' feasibility, inter-rater reliability, and validity.
The authors successfully evaluated 78 indicators across the domains; results were similar in the 2 settings. They could not feasibly evaluate 3 indicators because of low prevalence; 22 indicators had significant inter-rater reliability issues, 9 had significant validity issues, and 3 had both reliability and validity issues, leaving a set of 41 indicators most promising for further testing and use in this population, with an overall kappa score of 0.85 for specified care.
Of 92 Cancer Quality-ASSIST quality indicators for symptoms, treatment toxicity, and information and care planning, 41 were sufficiently feasible, reliable, and valid to be used for patients with advanced cancer in these settings. This set of indicators shows promise for describing key supportive care processes in advanced cancer.
Cancer 07/2010; 116(13):3267-75. · 4.77 Impact Factor
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ABSTRACT: Patients in American hospitals receive intensive medical treatments. However, when lifesaving treatments are unsuccessful, patients often die in the hospital with distressing symptoms while receiving burdensome care. Systematic measurement of the quality of care planning and symptom palliation is needed.
Medical records were abstracted using 16 Assessing Care of Vulnerable Elders quality indicators within the domains of end-of-life care and pain management designed to measure the quality of the dying experience for adult decedents (n = 496) hospitalized for at least 3 days between April 2005 and April 2006 at a university medical center recognized for providing intensive care for the seriously ill.
Over half of the patients (mean age, 62 years; 47% were women) were admitted to the hospital with end-stage disease, and 28% were 75 years or older. One-third of the patients required extubation from mechanical ventilation prior to death, and 15% died while receiving cardiopulmonary resuscitation. Overall, patients received recommended care for 70% of applicable indicators (range, 25%-100%). Goals of care were addressed in a timely fashion for patients admitted to the intensive care unit approximately half of the time, whereas pain assessments (94%) and treatments for pain (95%) and dyspnea (87%) were performed with fidelity. Follow-up for distressing symptoms was performed less well than initial assessment, and 29% of patients extubated in anticipation of death had documented dyspnea assessments.
A practical, medical chart-based assessment identified discrete deficiencies in care planning and symptom palliation that can be targeted to improve care for patients dying in the hospital.
Archives of internal medicine 06/2010; 170(12):1057-63. · 11.46 Impact Factor
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Joy R Goebel,
Cathy D Sherbourne,
Steven M Asch,
Lisa Meredith,
Angela B Cohen,
Emily Hagenmaier,
Andy B Lanto,
Barbara Simon,
Lisa V Rubenstein,
Lisa R Shugarman, Karl A Lorenz
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ABSTRACT: Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain management. In this study, a clinical scenario ascertained nursing staff members' usual practice in addressing addiction fears for patients with concerns about the addictive potential of pain medication. One hundred forty-five Veterans Health Administration nursing staff members from eight ambulatory care sites were queried to identify variables associated with proclivity to address patient fears about addiction risks in a population where pain is prevalent and the risk for substance abuse is high. Regarding addressing addiction concerns, 66% of nursing staff were very likely, 16% somewhat likely, 9% unsure, 6% somewhat unlikely, and 2% very unlikely to take action. Health technicians were less likely to address addiction concerns than registered or licensed vocational nurses (odds ratio [OR] 0.116; p=.004). Nursing staff with more years' experience (OR 1.070; p=.005) and higher levels of self-efficacy/confidence (OR 1.380; p=.001) were more likely to engage in discussions related to addiction risks. Targeted efforts to improve pain management activities should focus on retaining experienced nursing staff in initial assessment positions and improving the skills and confidence of less experienced and less skilled staff.
Pain management nursing: official journal of the American Society of Pain Management Nurses 06/2010; 11(2):92-8. · 1.31 Impact Factor
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ABSTRACT: Establishing goals of care is important in advance care planning. However, such discussions require a significant time investment on the part of trained personnel and may be overwhelming for the patient. The Go Wish card game was designed to allow patients to consider the importance of common issues at the end of life in a nonconfrontational setting. By sorting through their values in private, patients may present to their provider ready to have a focused conversation about end-of-life care. We evaluated the feasibility of using the Go Wish card game with seriously ill patients in the hospital. Of 133 inpatients approached, 33 (25%) were able to complete the game. The "top 10" values were scored based on frequency and adjusted for rank. The value selected of highest importance by the most subjects was "to be free from pain." Other highly ranked values concerned spirituality, maintaining a sense of self, symptom management, and establishing a strong relationship with health care professionals. Average time to review the patient's rank list after the patient sorted their values in private was 21.8 minutes (range: 6-45 minutes). The rankings from the Go Wish game are similar to those from other surveys of seriously ill patients. Our results suggest that it is feasible to use the Go Wish card game even in the chaotic inpatient setting to obtain an accurate portrayal of the patient's goals of care in a time-efficient manner.
Journal of pain and symptom management 04/2010; 39(4):637-43. · 2.42 Impact Factor
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ABSTRACT: Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear.
To assess adherence to measures of pain management quality and identify associated patient and provider factors.
A cross-sectional visit-based study.
One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients.
We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that "patients want me to ask about pain" and "pain can have negative consequences on patient's functioning". Charts were more likely to document character of pain if providers agreed that "patients are able to rate their pain". Patients with musculoskeletal pain were less likely to have chart documentation of character of pain.
Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening.
Journal of General Internal Medicine 03/2010; 25(9):900-5. · 2.83 Impact Factor
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ABSTRACT: Despite potential harm to patients, families, and emergency personnel, a low survival rate, and high costs and intensity of care, attempting resuscitation after prehospital cardiac arrest is the norm, unless there are signs of irreversible death or the presence of a valid, state-issued DNR.
To determine whether there was a change in the rate of forgoing resuscitation attempts in prehospital cardiac arrest after implementation of a new policy allowing paramedics to forgo resuscitation based on a verbal family request or the presence of certain arrest characteristics.
All prehospital run sheets for cardiac arrest in Los Angeles County were reviewed for the first seven days of each month August 2006-January 2007 (pre-policy) and January-June 2008 (post-policy). Paramedics were more likely to forgo resuscitation attempts after the policy change (13.3% vs. 8.5%, p<0.01). In addition, the percentage of patients with documented signs of irreversible death decreased post-policy, from 50.4% to 35.8%, p<0.01. After adjustment for potential confounders (patient demographics, clinical characteristics and EMS factors), as well as exclusion of patients with signs of irreversible death, paramedics are significantly more likely to forgo a resuscitation, and less likely to attempt resuscitation, after the policy change (OR 1.67 [95% CI 1.07, 2.61], p=0.024).
Paramedics are more likely to forgo, and less likely to attempt, resuscitation in victims of cardiac arrest after implementation of a new policy. There was also an associated decrease in the percentage of patients who had signs of irreversible death, which might reflect a change in paramedic behavior.
Resuscitation 03/2010; 81(6):685-90. · 3.60 Impact Factor
