scholarly journals 484 CHANGING PRACTICES OF DECISION MAKING REGARDING DO-NOT-ATTEMPT-CARDIOPULMONARY-RESUSCITATION ORDERS AMID THE COVID-19 PANDEMIC

2021 ◽  
Vol 50 (Supplement_2) ◽  
pp. ii1-ii4
Author(s):  
D Connellan ◽  
K Diffley ◽  
J McCabe ◽  
A Cotter ◽  
T McGinty ◽  
...  
Keyword(s):  
Decision Making ◽  
Cardiopulmonary Resuscitation ◽  
Older Patients ◽  
Case Fatality ◽  
Study Data ◽  
Resuscitation Orders ◽  
Cross Sectional ◽  
Chronic Renal Impairment ◽  
Hospitalised Patients ◽  
Resuscitation Status

Abstract Introduction The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation into focus. This study aims to analyse Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic. Methods This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st to May 31 s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period. Pre-COVID-19 pandemic DNACPR documentation rates were also examined. Factors associated with DNACPR order instatement during the first wave of the COVID-19 pandemic were identified. Results Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. 50% of DNAR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of 131 patients aged 65 years or over within the cohort admitted with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 patients ≥65 without COVID-19 (p < 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (p < 0.0001). Independent associations with DNACPR order documentation included increasing age (Odds Ratio [O.R.] 1.12; 95% CI 1.05-1.21); nursing home resident status (O.R. 3.57; 95% CI 1.02-12.50); frailty (O.R. 3.34; 95% CI 1.16-9.61) and chronic renal impairment (O.R. 5.49; 1.34-22.47). The case-fatality-rate of older patients with COVID-19 was 29.8% versus 5.4% without COVID-19. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived. Conclusion The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain clinical practice despite the pandemic.

Resuscitation status in psychogeriatric and general medical inpatients aged 65 years and older: a retrospective comparison study

2019 ◽  
Vol 43 (4) ◽  
pp. 432
Author(s):  
Jo Hill ◽  
Adam Gerace ◽  
Candice Oster ◽  
Shahid Ullah
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Older Patients ◽  
Total Sample ◽  
Competency Assessment ◽  
Medical Group ◽  
Resuscitation Orders ◽  
End Of Life Decision ◽  
Life Decision ◽  
Resuscitation Status

Objective The aims of the present study were to establish rates of resuscitation order documentation of patients aged ≥65 years from both psychogeriatric and general medical units and to compare patients on predictors of resuscitation status, particularly examining the effect of depression. Methods A retrospective case note audit of psychogeriatric (n=162) and general medical (n=135) unit admissions within a tertiary teaching hospital was performed. Multivariate logistic regression was used to determine significant clinical and demographic predictors of resuscitation status. Results Resuscitation orders were documented in more psychogeriatric (94.4%) than general medical (48.1%) files. Depression did not significantly predict resuscitation status in either group. Having undergone competency assessment significantly predicted resuscitation status for the total sample and separately for psychogeriatric and medical patients. Older age (overall sample), poorer prognosis (overall sample), living in residential care (overall sample and medical group) and self-consenting to resuscitation status (overall sample and medical group) significantly predicted resuscitation status. Conclusions Resuscitation orders were more frequently documented on the psychogeriatric unit. Further prospective analysis is needed of how resuscitation orders are made before depression is discounted as a predictor of end-of-life decision-making. What is known about the topic? Despite increased community, media and research attention to end-of-life decision-making, resuscitation preferences of older patients are often poorly documented. Existing research into patient clinical and demographic factors that influence end-of-life decision-making have largely focused on general medical rather than psychogeriatric settings. There is a need to investigate rates of resuscitation documentation in psychogeriatric and general medical units and specific factors associated with having a ‘do not attempt resuscitation’ order in place, particularly the effect of current depression on decision-making. What does this paper add? Resuscitation orders were more frequently documented on the psychogeriatric than medical unit. Depression was not a significant predictor of resuscitation status in either group of patients. Although having undergone a competency assessment, older age and poorer prognosis predicted not being for resuscitation for the total sample, living in residential care and self-consenting to resuscitation status predicted not being for resuscitation for the overall sample and the medical group specifically. What are the implications for practitioners? This paper suggests that the need for clinicians to ensure documentation of preferences is a focus of day-to-day work with older patients. Clinicians should consider patient competency in end-of-life decision-making and how factors associated with depression, such as helplessness, may be more closely related to resuscitation decision-making in older patients.

Doctors’ attitudes regarding not for resuscitation orders

2017 ◽  
Vol 41 (6) ◽  
pp. 680 ◽  
Author(s):  
Gaya Sritharan ◽  
Amber C. Mills ◽  
Michele R. Levinson ◽  
Anthea L. Gellie
Keyword(s):  
Decision Making ◽  
Palliative Care ◽  
Cardiopulmonary Resuscitation ◽  
Medical Emergency Team ◽  
Tertiary Hospital ◽  
Medical Emergency ◽  
Resuscitation Orders ◽  
Goals Of Care ◽  
Emergency Team ◽  
Training Materials

Objectives The aims of the present study were to investigate doctors’ attitudes regarding the discussion and writing of not for resuscitation (NFR) orders and to identify potential barriers to the completion of these orders. Methods A questionnaire-based convenience study was undertaken at a tertiary hospital. Likert scales and open-ended questions were directed to issues surrounding the discussion, timing, understanding and writing of NFR orders, including legal and personal considerations. Results Doctors thought the presence of an NFR order both should and does alter care delivered by nursing staff, particularly delivery of pain relief, nursing observations and contacting the medical emergency team. Eighty-five per cent of doctors believed they needed somebody else’s consent to write an NFR order (seeking of consent is not a requirement in most Australian jurisdictions). Conclusion There are complex barriers to the writing and implementation of NFR orders, including doctors’ knowledge around the need for consent when cardiopulmonary resuscitation is likely to be futile or excessively burdensome. Doctors also believed that NFR orders result in changes to goals-of-care, suggesting a confounding of NFR orders with palliative care. Furthermore, doctors are willing to write NFR orders where there is clear medical indication and the patient is imminently dying, but are otherwise reliant on patients and family to initiate discussion. What is known about the topic? Hospitalised elderly patients, in the absence of an NFR order, are known to have poor survival and outcomes following resuscitation. Further, Australian data on the prevalence of NFR forms show that only a minority of older in-patients have a written NFR order in their history. In Australian hospitals, NFR orders are completed by doctors. What does this paper add? To our knowledge, the present study is the first in Australia to qualitatively analyse doctors’ reasons to writing NFR orders. The open-text nature of this questioning has been important in eliciting doctors’ responses without hypothesis guessing bias. Further, we add to the literature on the breadth of considerations doctors may encounter with regard to NFR orders. What are the implications for practitioners? The findings indicate the issues impeding decision making around cardiopulmonary resuscitation relate to poor knowledge of the law, particularly around the issue of consent and confounding NFR orders with provision of palliative care. Such barriers to the completion of NFR orders expose elderly in-patients to futile and burdensome resuscitation events. The findings suggest consideration be given to education and training materials to inform doctors about jurisdictional law regarding resuscitation documentation, support decision making around cardiopulmonary resuscitation and promote goals-of-care discussions on admission.

Cardiopulmonary resuscitation: outcomes and decision-making processes for older adults

2017 ◽  
pp. 857-862
Author(s):  
Esther M. M. van de Glind ◽  
Barbara C. van Munster ◽  
Marije E. Hamaker
Keyword(s):  
Quality Of Life ◽  
Decision Making ◽  
Cardiopulmonary Resuscitation ◽  
Older Patients ◽  
Cardiopulmonary Arrest ◽  
Good Condition ◽  
Limiting Factor ◽  
Decision Making Processes ◽  
Meta Analyses

Cardiopulmonary resuscitation (CPR) was developed in the 1950s as a treatment for cardiopulmonary arrest. Outcome of CPR remains poor, particularly in older people, as demonstrated by two recent meta-analyses. The first addressed out-of-hospital resuscitation in patients aged 70 years and over, and found pooled overall rates of survival to discharge of 4.1%. For in-hospital resuscitation, the overall pooled rate of survival to discharge was 18.7% for patients aged 70–79 years, 15.4% for patients aged 80–89 years and 11.6% for those aged 90 or over. It is not clear if age alone is a limiting factor, or rather a marker of comorbidity. Overall, information about the quality of life after surviving CPR is lacking. Older patients should be adequately informed about their chances of survival in good condition in order to make a decision about the desirability of CPR.

scholarly journals Do not attempt resuscitation orders at the emergency department of a teaching hospital

2017 ◽  
Vol 15 (4) ◽  
pp. 409-414 ◽  
Author(s):  
Cássia Regina Vancini-Campanharo ◽  
Rodrigo Luiz Vancini ◽  
Marcelo Calil Machado Netto ◽  
Maria Carolina Barbosa Teixeira Lopes ◽  
Meiry Fernanda Pinto Okuno ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cardiopulmonary Resuscitation ◽  
Teaching Hospital ◽  
Past History ◽  
Advanced Age ◽  
Fisher Exact Test ◽  
Resuscitation Orders ◽  
Cross Sectional ◽  
Initial Rhythm ◽  
History Of

ABSTRACT Objective: To identify factors associated with not attempting resuscitation. Methods: A cross-sectional study conducted at the emergency department of a teaching hospital. The sample consisted of 285 patients; in that, 216 were submitted to cardiopulmonary resuscitation and 69 were not. The data were collected by means of the in-hospital Utstein Style. To compare resuscitation attempts with variables of interest we used the χ2 test, likelihood ratio, Fisher exact test, and analysis of variance (p<0.05). Results: No cardiopulmonary resuscitation was considered unjustifiable in 56.5% of cases; in that, 37.7% did not want resuscitation and 5.8% were found dead. Of all patients, 22.4% had suffered a previous cardiac arrest, 49.1% were independent for Activities of Daily Living, 89.8% had positive past medical/surgical history; 63.8% were conscious, 69.8% were breathing and 74.4% had a pulse upon admission. Most events (76.4%) happened at the hospital, the presumed cause was respiratory failure in 28.7% and, in 48.4%, electric activity without pulse was the initial rhythm. The most frequent cause of death was infection. The factors that influenced non-resuscitation were advanced age, history of neoplasm and the initial arrest rhythm was asystole. Conclusion: Advanced age, past history of neoplasia and asystole as initial rhythm were factors that significantly influenced the non-performance of resuscitation. Greater clarity when making the decision to resuscitate patients can positively affect the quality of life of survivors.

scholarly journals Laboratory-based surveillance of Pneumocystis jirovecii pneumonia in South Africa, 2006–2010i

2016 ◽  
Vol 31 (1) ◽  
pp. 8-13
Author(s):  
Desiree Du Plessis ◽  
Bhavani Poonsamy ◽  
Veerle Msimang ◽  
Leigh Davidsson ◽  
Cheryl Cohen ◽  
...  
Keyword(s):  
Demographic Data ◽  
Pneumocystis Carinii ◽  
Case Fatality ◽  
Sentinel Surveillance ◽  
Pneumocystis Jirovecii ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Full Spectrum ◽  
Cross Sectional ◽  
Hospitalised Patients ◽  
First Diagnosis

Background: We aimed to establish the characteristics of patients with confirmed Pneumocystis jirovecii pneumonia recruited by passive, sentinel laboratory-based surveillance.Method: The study design was prospective, observational, cross-sectional, laboratory-based sentinel surveillance. Laboratorybased surveillance of Pneumocystis jirovecii pneumonia (PJP), formerly known as Pneumocystis carinii pneumonia (PCP), was conducted in six South African provinces at 61 hospitals, of which 17 were sentinel sites, where surveillance officers collected clinical and demographic data from cases. A case was defined as a patient with a respiratory tract specimen that was confirmed positive for P. jirovecii by immunofluorescent microscopy or PCR test, either as a first diagnosis or ≥ 30 days after the last confirmed laboratory diagnosis of PJP. The chi-square test or Fisher’s exact test were used to compare the categorical variables.Results: From 2006–2010, 1 537 cases of PJP were recorded. Eighty-nine per cent (460/518) were found to be human immunodeficiency virus (HIV)-infected. This was a first diagnosis of HIV infection in 57% of the cases. The case fatality ratio was 34% (177/525). Recurrent infection was significantly more common in the 26- to 45-year age group, compared to children aged ≤ 5 years (odds ratio 1.7, 95% confidence interval: 1.1–2.8) (p 0.040). Treatment for tuberculosis was common in cases aged ≥ 5 years (37%, 85/229).Conclusion: PJP was the acquired immune deficiency syndrome-defining illness in more than half of the patients detected through laboratory-based surveillance. The high mortality rate and number of recurrent cases is noteworthy. This study may not have reflected the full spectrum of clinical presentation of the disease as case report forms were only completed for hospitalised patients at sentinel surveillance sites.

Twenty-Five Years of Violence: The Epidemiology of Terrorism in South America

2008 ◽  
Vol 23 (2) ◽  
pp. 128-132 ◽  
Author(s):  
Amado Alejandro Báez ◽  
Matthew D. Sztajnkrycer ◽  
Richard Zane ◽  
Ediza Giráldez
Keyword(s):  
South America ◽  
Emergency Preparedness ◽  
Statistical Significance ◽  
Case Fatality ◽  
Descriptive Study ◽  
Study Data ◽  
Global Public Health ◽  
Cross Sectional ◽  
Public Health Burden ◽  
Explosive Devices

AbstractIntroduction:Terrorism is a global public health burden. South Americans have been victims of terrorism for many decades.While the causes vary, the results are the same: death, disability, and suffering.The objective of this study was to perform a comprehensive, epidemiological, descriptive study of terrorist incidents in South America.Methods:This is a cross-sectional, descriptive study. Data from January 1971 to July 2006 was selected using the RAND Terrorism Chronology 1968–1997 and RAND®-Memorial Institute for Prevention of Terrorism (MIPT) Terrorism Incident database (1998–Present). Statistical significance was set at 0.05.Results:The database reported a total of 2,997 incidents in South American countries that resulted in 3,435 victims with injuries (1.15 per incident) and 1,973 fatalities (0.66 per incident). The overall case fatality ratio (CFR) was 35.8%. Colombia had the majority of incidents with 57.9% (1,734 of 2,997), followed by Peru with 363 (12.1%), and Argentina with 267 (8.9%). The highest individual CFR occurred in Paraguay (83.3%), and the lowest in Chile with 4.8%. Of the total injuries and deaths, Colombia had 66.1% (2,269 of 2,997) of all injuries and 75.2% (1,443 out of 1,920) of all deaths. Living in the country of Colombia was associated with a 16 times greater likelihood of becoming a victim of terrorist violence [odds ratio (OR) 16.15; 95% CI 13.45 to 19.40; p <0.0001].The predominant method of choice for terrorist incidents was the use of conventional explosives with 2,543 of 2,883 incidents (88.2%).Conclusions:Terrorist incidents in South America have accounted for nearly 2,000 deaths, with conventional explosive devices as the predominant method of choice. Understanding the nature of terrorist attacks and the medical consequences assist emergency preparedness and disaster management officials in allocating resources and preparing for potential future events.

scholarly journals Determinants of brand relevance in a B2B service purchasing context

2016 ◽  
Vol 31 (2) ◽  
pp. 193-204 ◽  
Author(s):  
Mariana Gomes ◽  
Teresa Fernandes ◽  
Amélia Brandão
Keyword(s):  
Decision Making ◽  
Decision Maker ◽  
Firm Size ◽  
Study Data ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Convenience Sample ◽  
Content Type ◽  
Industrial Services ◽  
Purchase Situation

Purpose – Brands have traditionally been regarded as a key asset and a source of competitive advantage in purchasing decisions, as customers are expected to prefer stronger brands to minimize risks. However, the role of brands in business markets is unclear and underresearched. The purpose of this study is to analyze the relevance of brands in a business-to-business (B2B) purchase setting and their key determinants. Design Methodology/approach – A research model was developed to explain brand relevance when compared with other decision factors in a B2B context. Based on the frameworks developed by Zablah et al. (2010) and Mudambi (2002), the model considers the purchase situation, decision-maker characteristics and firm size as determinants of brand relevance in the decision-making process. One of the most prominent Portuguese construction groups, which comprised three companies, was chosen for the sample of this study. Data were collected through a self-administered, online, cross-sectional survey, resulting in a convenience sample of 87 decision-makers. Findings – Findings suggest that attributes related with brands matter even in B2B rational decision-making processes. However, brands are not important to all organizational buyers or in all situations. Different purchase situations and decision-maker characteristics proved to have an impact on brand relevance, namely, brand reputation, prior purchases and brand awareness. Only firm size was not confirmed as a determinant of brand relevance in the B2B purchasing process. Originality/value – B2B brand research is scarce, especially for industrial services. By investigating the determinants of brand relevance in a B2B purchasing context, namely, in a construction services setting, this study contributes to bridging this literature gap. Moreover, the few studies on the subject have been largely descriptive in nature and managerially oriented, while this investigation emphasizes hypothesis testing through a proposed research framework. Also, in managerial terms, identifying determinants of the importance given to brands by organizational buyers is critical in deciding when investment in brand development is more likely to payoff.

scholarly journals Health-related preferences of older patients with multimorbidity: an evidence map

BMJ Open ◽  
2019 ◽  
Vol 9 (12) ◽  
pp. e034485
Author(s):  
Ana Isabel Gonzalez ◽  
Christine Schmucker ◽  
Julia Nothacker ◽  
Edith Motschall ◽  
Truc Sophia Nguyen ◽  
...  
Keyword(s):  
Decision Making ◽  
Goal Setting ◽  
Science Citation Index ◽  
Older Patients ◽  
Citation Index ◽  
Diagnostic Testing ◽  
Science Citation ◽  
Evidence Map ◽  
Cross Sectional ◽  
Health Related

ObjectivesTo systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence.DesignEvidence map (systematic review variant).Data sourcesMEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018.Study selectionStudies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions).Data extractionTwo independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software.ResultsThe 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9–9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies.ConclusionOur study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences.Trial registration numberOpen Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.

Zinc Depletion Increases Readmission in Older Patients: An Example of Interactions Between Nutrition and Disease

2017 ◽  
Vol 87 (1-2) ◽  
pp. 10-16 ◽  
Author(s):  
Salah Gariballa ◽  
Awad Alessa
Keyword(s):  
Nutritional Status ◽  
Inductively Coupled Plasma ◽  
Older Patients ◽  
Controlled Trial ◽  
Prognostic Indicators ◽  
Hospitalised Patients ◽  
Increased Risk ◽  
Co Morbidity ◽  
The Impact ◽  
Poor Nutrition

Abstract. Background: ill health may lead to poor nutrition and poor nutrition to ill health, so identifying priorities for management still remains a challenge. The aim of this report is to present data on the impact of plasma zinc (Zn) depletion on important health outcomes after adjusting for other poor prognostic indicators in hospitalised patients. Methods: Hospitalised acutely ill older patients who were part of a large randomised controlled trial had their nutritional status assessed using anthropometric, hematological and biochemical data. Plasma Zn concentrations were measured at baseline, 6 weeks and at 6 months using inductively- coupled plasma spectroscopy method. Other clinical outcome measures of health were also measured. Results: A total of 345 patients assessed at baseline, 133 at 6 weeks and 163 at 6 months. At baseline 254 (74%) patients had a plasma Zn concentration below 10.71 μmol/L indicating biochemical depletion. The figures at 6 weeks and 6 months were 86 (65%) and 114 (70%) patients respectively. After adjusting for age, co-morbidity, nutritional status and tissue inflammation measured using CRP, only muscle mass and serum albumin showed significant and independent effects on plasma Zn concentrations. The risk of non-elective readmission in the 6-months follow up period was significantly lower in patients with normal Zn concentrations compared with those diagnosed with Zn depletion (adjusted hazard ratio 0.62 (95% CI: 0.38 to 0.99), p = 0.047. Conclusions: Zn depletion is common and associated with increased risk of readmission in acutely-ill older patients, however, the influence of underlying comorbidity on these results can not excluded.

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