[Show abstract][Hide abstract] ABSTRACT: Heart failure (HF), one of the three leading causes of death, is a chronic, progressive, incurable disease. There is growing support for integration of palliative care's holistic approach to suffering, but insufficient understanding of how this would happen in the complex team context of HF care. This study examined how HF care teams, as defined by patients, work together to provide care to patients with advanced disease.
Team members were identified by each participating patient, generating team sampling units (TSUs) for each patient. Drawn from five study sites in three Canadian provinces, our dataset consists of 209 interviews from 50 TSUs. Drawing on a theoretical framing of HF teams as complex adaptive systems (CAS), interviews were analyzed using the constant comparative method associated with constructivist grounded theory.
This paper centers on the dominant theme of system practices, how HF care delivery is reported to work organizationally, socially, and practically, and describes two subthemes: "the way things work around here", which were commonplace, routine ways of doing things, and "the way we make things work around here", which were more conscious, effortful adaptations to usual practice in response to emergent needs. An adaptive practice, often a small alteration to routine, could have amplified effects beyond those intended by the innovating team member and could extend to other settings.
Adaptive practices emerged unpredictably and were variably experienced by team members. Our study offers an empirically grounded explanation of how HF care teams self-organize and how adaptive practices emerge from nonlinear interdependencies among diverse agents. We use these insights to reframe the question of palliative care integration, to ask how best to foster palliative care-aligned adaptive practices in HF care. This work has implications for health care's growing challenge of providing care to those with chronic medical illness in complex, team-based settings.
Full-text · Article · Aug 2015 · Journal of Multidisciplinary Healthcare
[Show abstract][Hide abstract] ABSTRACT: Palliative care is expanding its role into the surgical intensive care units (SICU). Embedding palliative philosophies of care into SICUs has considerable potential to improve the quality of care, especially in complex patient care scenarios. This article will explore palliative care, identifying patients/families who benefit from palliative care services, how palliative care complements SICU care, and opportunities to integrate palliative care into the SICU. Palliative care enhances the SICU team's ability to recognize pain and distress; establish the patient's wishes, beliefs, and values and their impact on decision making; develop flexible communication strategies; conduct family meetings and establish goals of care; provide family support during the dying process; help resolve team conflicts; and establish reasonable goals for life support and resuscitation. Educational opportunities to improve end-of-life management skills are outlined. It is necessary to appreciate how traditional palliative and surgical cultures may influence the integration of palliative care into the SICU. Palliative care can provide a significant, "value added" contribution to the care of seriously ill SICU patients.
No preview · Article · Sep 2013 · Seminars in Cardiothoracic and Vascular Anesthesia
[Show abstract][Hide abstract] ABSTRACT: CONTEXT: There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from the interviews with and survey researches on individual patients and providers. This work has been critically important in raising awareness on the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team. OBJECTIVES: To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team. METHODS: This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams. RESULTS: We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps. CONCLUSION: We anticipate that this innovative methodology will support ground-breaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.
No preview · Article · Sep 2012 · Journal of pain and symptom management
[Show abstract][Hide abstract] ABSTRACT: Being comfortable with death and communicating with patients near the end of life are important attributes in palliative care. We developed a hospice volunteer program to teach these attitudes and skills to preclinical medical students. Using a mixed-methods approach, validated surveys measured participants' and non-participants fear of death and communication apprehension regarding dying. Journals and focus groups examined participants' subjective experiences as their patient relationships evolved. Survey scores were significantly lower for participant hospice volunteers, indicating lower levels of death anxiety and communication apprehension regarding dying. An explanatory framework, using journals and focus groups, captured participants' sense of development over time into three categories: challenges, learning, and growth. This pilot project provides insight into the medical students' experiential learning as they participate in our hospice volunteer program.
No preview · Article · Sep 2012 · Journal of palliative care
[Show abstract][Hide abstract] ABSTRACT: A 78-year-old man presented with dyspnea and mild heart failure with Cheyne-Stokes respiration (CSR). Workup revealed inferolateral ischemia in the setting of significant triple vessel coronary disease, and nil else to adequately explain his dyspnea and eventual respiratory failure. After he underwent surgical revascularization, his ventricular function improved, leading to resolution of his respiratory failure and, of interest, his CSR. CSR is a central sleep apnea common in heart failure patients and has been associated with increased mortality. Here, we present the first English-literature report of CSR abating with surgical coronary revascularization, and briefly review the literature.
No preview · Article · Jan 2012 · The Canadian journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: The in-training evaluation report (ITER) is the most widely used approach to the evaluation of residents' clinical performance. Participants' attitudes toward the process may influence how they approach the task of resident evaluation. Whereas residents find ITERs most valuable when they perceive their supervisors to be engaged in the process, faculty attitudes have not yet been explored. The authors studied faculty supervisors' experiences and perceptions of the ITER process to gain insight into the factors that influence faculty engagement.
Using a grounded theory approach, semistructured interviews were completed in 2008 with a purposive sample of 17 faculty involved in resident evaluation at one Canadian medical school. Constant comparative analysis for emergent themes was conducted.
Three major themes emerged: (1) Faculty engagement was apparent, with a widely held view that ITERs were a worthwhile endeavor. (2) Fragmentation of the evaluation system compromised evaluators' ability to produce meaningful ITERs. Fragmentation appeared to be a system problem, elements of which included time constraints, inconsistency in approach to ITE, and lack of continuity between educational assignments. (3) Faculty found the challenge of giving negative feedback daunting and struggled to avoid harming residents.
Faculty engagement in the ITER process may be compromised by both system and interpersonal challenges. These challenges may render ITERs less meaningful than faculty intend. Training programs must complement ITE with other tools to achieve robust systems of evaluation.
No preview · Article · Jul 2010 · Academic medicine: journal of the Association of American Medical Colleges
[Show abstract][Hide abstract] ABSTRACT: Despite the fact that Canadian residency programmes are required to assess trainees' performance within the context of the CanMEDS Roles Framework, there has been no inquiry into the potential relationship between residents' perceptions of the framework and their in-training assessments (ITA). Using data collected during the study of ITA, we explored residents' perceptions of these competencies.
From May 2006-07, a purposive sample of 20 resident doctors from internal medicine, paediatrics, and surgery were interviewed about their ITA experiences. Data collection and analysis proceeded in an iterative fashion consistent with grounded theory. In April 2008, a summary of recurrent themes was presented during a focus group interview of another five residents to afford further elaboration and refinement of thematic findings.
The in-training assessment report (ITAR) was perceived as a primary source of residents' information on CanMEDS. Residents' familiarity with the set of competencies appeared to be quite limited and they possessed narrow definitions of the roles. Several trainees questioned the framework's relevance and some appeared confused about the overlapping nature of the roles. Although residents viewed the central Medical Expert role as the most relevant and important competency, they incorrectly perceived it as only involving the acquisition of medical and scientific knowledge. A visual rhetorical analysis of a typical ITAR suggests that the visual features found within this assessment tool may be misrepresenting the framework and the centrality of the Medical Expert role.
Resident doctors' knowledge of CanMEDS was found to be limited. The visual structure of the ITAR appears to be a factor in residents' apparent distortion of the CanMEDS construct from its original holistic philosophy.
No preview · Article · Sep 2009 · Medical Education
[Show abstract][Hide abstract] ABSTRACT: This review assesses the current opinion towards early palliative care in neurology and discusses the existing evidence base. A comprehensive literature search resulted in 714 publications with 53 being directly relevant to the scope of this review. The current literature reflects primarily expert opinion and describes a growing interest in the early introduction of palliative principles into neurological care. Early initiation of palliative interventions has the potential to improve quality of life, enhance symptom management and assist in advance care planning. Further data is required to determine whether this shift in philosophy has a positive impact on patient care.
Preview · Article · Jun 2009 · The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques
[Show abstract][Hide abstract] ABSTRACT: In-training evaluation reports (ITERs) often fall short of their goals of promoting resident learning and development. Efforts to address this problem through faculty development and assessment-instrument modification have been disappointing. The authors explored residents' experiences and perceptions of the ITER process to gain insight into why the process succeeds or fails.
Using a grounded theory approach, semistructured interviews were conducted with 20 residents. Constant comparative analysis for emergent themes was conducted.
All residents identified aspects of "engagement" in the ITER process as the dominant influence on the success of ITERs. Both external (evaluator-driven, such as evaluator credibility) and internal (resident-driven, such as self-assessment) influences on engagement were elaborated. When engagement was lacking, residents viewed the ITER process as inauthentic.
Engagement is a critical factor to consider when seeking to improve ITER use. Our articulation of external and internal influences on engagement provides a starting point for targeted interventions.
Full-text · Article · Oct 2008 · Academic medicine: journal of the Association of American Medical Colleges
[Show abstract][Hide abstract] ABSTRACT: To evaluate the role of methadone in the management of intractable neuropathic noncancer pain.
A case series of 50 consecutive noncancer pain patients who were seen at a tertiary care centre and treated with oral methadone for a variety of intractable neuropathic pain states.
The mean age was 52.7 years and the mean duration of follow-up was 13.9 months. Post-discectomy nerve root fibrosis, complex regional pain syndrome, peripheral neuropathy and central spinal cord pain syndromes were the most common diagnoses. Over 90% had been treated with one or more tricyclic antidepressants and anticonvulsants and a similar number had received other adjuvant analgesics. All patients had failed treatment with one or more conventional opioid analgesics (mean 2.8) at a mean maximal morphine dose of 384 mg (or equivalents) per day. Twelve patients had failed spinal cord stimulation. Nineteen patients (38%) did not tolerate initial methadone titration or thought their pain was worse on methadone. Five patients (10%) declared initial benefit but required repetitive dose escalation and eventually became non-responders. Twenty-six patients (52%) reported mild (4), moderate (15), marked (6) or complete (1) pain relief and continued on methadone at a mean maintenance dose of 159.8 mg/day for a mean duration of 21.3 months. Fourteen patients (28%) reported improved function on methadone relative to previous treatments.
Methadone appears to have unique properties including N-methyl-D-aspartate antagonist activity that may make it especially useful in the management of intractable neuropathic pain. This observation needs to be tested in randomized, controlled trials.
Full-text · Article · Sep 2005 · The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques
[Show abstract][Hide abstract] ABSTRACT: Segmental hyperhidrosis is an uncommon finding which is usually associated with irritation or infiltration of pre-ganglionic sympathetic fibres or the sympathetic chain.
We report two cases of segmental hyperhidrosis with striking clinical features.
In one case, a mesothelioma produced ipsilateral simultaneous underactivity and overactivity of sympathetic outflow and in the other case a thoracic central disc herniation was probably responsible for a band of sweating which clearly extended beyond the segmental level of injury.
Segmental hyperhidrosis should trigger a search for structural disease in the spinal and paraspinal region.
No preview · Article · Dec 1998 · The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques