A survey of prognosis discussions held by health-care providers who request palliative care consultation

Chang, Amy; Datta-Barua, Indrany; McLaughlin, Beth; Daly, Barbara J.

doi:10.1177/0269216313514126

Cited by 9 publications

(7 citation statements)

References 27 publications

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“…Increasing hospitalist workload has been associated with increased length of stay for patients and a high financial cost to the exchequer. In this scenario, the desire to maintain acute hospital [ 70 ] performance (e.g. shorter length of stay, greater patient throughput) will be accompanied by a greater demand for immediate access to critical care services.…”

Section: Diurnal Variation In Responding To Clinical Deteriorationmentioning

confidence: 99%

“…Recognizing medical futility and discussing the transition [ 70 ] from acute care to limited or palliative care based on accurate prognosis remains a challenge for both patients and clinicians, especially at night. There is a potential for therapy to become fragmented [ 71 ] and less tailored to the patient as a result of diurnal variation in the number and seniority of physicians available to make urgent clinical decisions.…”

Section: Challenges To Hospital Management At Night: Interface Betweementioning

confidence: 99%

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Diurnal variation in the performance of rapid response systems: the role of critical care services—a review article

2016

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The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system’s afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT.There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor.The term “circadian variation/rhythm” applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states.For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.Electronic supplementary materialThe online version of this article (doi:10.1186/s40560-016-0136-5) contains supplementary material, which is available to authorized users.

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Section: Diurnal Variation In Responding To Clinical Deteriorationmentioning

confidence: 99%

Section: Challenges To Hospital Management At Night: Interface Betweementioning

confidence: 99%

Diurnal variation in the performance of rapid response systems: the role of critical care services—a review article

2016

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“…Prognostic uncertainty and a lack of confidence and training are key barriers to clinicians initiating prognostic conversations. 31,32 Our findings demonstrate how experienced clinicians negotiated uncertainty in end-of-life conversations with families. Clinicians used qualifying language to present their estimates as opinions rather than precise predictions, and provided descriptive or categorical time estimates rather than a specific timeline.…”

Section: Key Findingsmentioning

confidence: 73%

Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study

et al. 2020

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Background: When patients are likely to die in the coming hours or days, families often want prognostic information. Prognostic uncertainty and a lack of end-of-life communication training make these conversations challenging. Aim: The objective of this study is to understand how clinicians and the relatives/friends of patients at the very end of life manage uncertainty and reference time in prognostic conversations. Design: Conversation analysis of audio-recorded conversations between clinicians and the relatives/friends of hospice inpatients. Setting/participants: Experienced palliative care clinicians and relatives/friends of imminently dying hospice inpatients. Twenty-three recorded conversations involved prognostic talk and were included in the analysis. Results: Requests for prognostic information were initiated by families in the majority of conversations. Clinicians responded using categorical time references such as ‘days’, allowing the provision of prognostic estimates without giving a precise time. Explicit terms such as ‘dying’ were rare during prognostic discussions. Instead, references to time were understood as relating to prognosis. Relatives displayed their awareness of prognostic uncertainty when requesting prognostic information, providing clinicians with ‘permission’ to be uncertain. In response, clinicians often stated their uncertainty explicitly, but presented evidence for their prognostic estimates, based on changes to the patient’s function previously discussed with the family. Conclusion: Prognostic uncertainty was managed collaboratively by clinicians and families. Clinicians were able to provide prognostic estimates while being honest about the related uncertainty, in part because relatives displayed their awareness of uncertainty within their requests. The conversation analytic method identified contributions of both clinicians and families, and identified strategies based on real interactions, which could inform communication training.

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“…consultant /specialist) is present . Given the current structure, wherein residents or doctors‐in‐training manage the hospital after hours under the remote supervision of the specialist, advance care decisions are being deferred to the daytime when a senior practitioner is present. This deferral leads to the admission of some elderly patients to the ICU who would otherwise neither have needed nor secured an admission …”

Section: Discussionmentioning

confidence: 99%

Elderly patients are at high risk of night‐time admission to the intensive care unit following a rapid response team call

Sundararajan

Flabouris

Thompson

et al. 2016

Internal Medicine Journal

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Previous studies have shown that elderly patients (age ≥65 years) are less likely to be admitted to the intensive care unit following a rapid response team call and have high hospital mortality rates. This study has shown that elderly patients have a significantly higher probability of being admitted to an intensive care unit following a rapid response team call at night than during the day. However, at no time are they at greater risk than younger patients of incomplete vital sign recording, a failure to escalate care for acute deterioration or mortality.

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A survey of prognosis discussions held by health-care providers who request palliative care consultation

Cited by 9 publications

References 27 publications

Diurnal variation in the performance of rapid response systems: the role of critical care services—a review article

Diurnal variation in the performance of rapid response systems: the role of critical care services—a review article

Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study

Elderly patients are at high risk of night‐time admission to the intensive care unit following a rapid response team call

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