Maximal medical therapy and palliative care can work together: When are advanced care measures appropriate?

Swetz, Keith M.; Lyckholm, Laurie; Smith, Thomas J.

doi:10.1002/jhm.467

Cited by 5 publications

(3 citation statements)

References 33 publications

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“…25,26 In general, a PC consultation should not be considered equivalent to electing a "do-not-resuscitate" status, because maximal medical therapy with aggressive palliation of symptoms may occur concurrently even in the setting of such a status. 27 PC can also be useful in symptom management and emotional well being, even in patients where prognosis is reasonably favorable, if symptom and side effect burden exceeds the ability of the PAH providers to provide sufficient care. The results reported here are consistent with work by others 13-18 that demonstrate patients with PAH have markedly impaired QOL.…”

Section: Discussionmentioning

confidence: 98%

Symptom burden, quality of life, and attitudes toward palliative care in patients with pulmonary arterial hypertension: Results from a cross-sectional patient survey

Swetz

Shanafelt

Drozdowicz

et al. 2012

The Journal of Heart and Lung Transplantation

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Section: Discussionmentioning

confidence: 98%

Symptom burden, quality of life, and attitudes toward palliative care in patients with pulmonary arterial hypertension: Results from a cross-sectional patient survey

Swetz

Shanafelt

Drozdowicz

et al. 2012

The Journal of Heart and Lung Transplantation

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“…These patients may have tended to be more aggressive regarding their care and chose to be full code over DNR, although maximal medical therapy may still be consistent with a DNR status as long as the plan is consistent with the patient's goals of care 14 15. Alternatively, providers may not have been initiating code status discussions as frequently with patients on clinical trials.…”

Section: Discussionmentioning

confidence: 99%

End-of-life care in a population-based cohort of cancer patients: clinical trial participation versus standard of care

Thompson

Hugo

Swetz

et al. 2013

BMJ Support Palliat Care

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Objectives To evaluate end-of-life care in a cohort of oncology patients in Olmsted County, Minnesota, USA, and compare differences between patients participating in clinical trials and those not in clinical trials. Methods A population-based cohort of subjects with active oncological disease who died between 2000 and 2002 was constructed retrospectively using institutional databases. Clinical trial participation and care during the last 2 months of life were analysed. Results A total of 395 eligible patients were identified. In the 2 months prior to death, 94 (24%) patients received chemotherapy, 232 (59%) were hospitalised, 249 (63%) were in hospice and 315 (80%) had a do not resuscitate (DNR) code status. Only 8 (2%) patients received cardiopulmonary resuscitation (CPR) and 26 (7%) patients participated in a clinical trial. Patients in clinical trials were more likely to receive chemotherapy (69.2% vs 20.6%; p<0.001), undergo intubation/mechanical ventilation (15.4% vs 5.4%; p=0.040) and less likely to have DNR code status (50.0% vs 81.8%; p<0.001) when compared with patients not in clinical trials. However, no differences in hospice enrolment, days in hospice, days in the hospital, CPR or location of death were noted. Conclusions Although opportunities for improvement exist, high quality end-of-life care was found in this study of patients with active malignancy. A majority (over 60%) of patients enrolled in hospice prior to death, 80% had a DNR status and only 2% received CPR. Although clinical trial participants received more aggressive treatments during the last 2 months of life, they did not appear to have lower quality end-of-life care.

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“…chemotherapy, radiation, antibiotics, pressors, etc.) [23-27]. Withholding treatment at the end-of-life does not necessarily suggest that all care should be discontinued and patients who are DNR/DNI do not necessarily wish to forego ICU care.…”

Section: Discussionmentioning

confidence: 99%

Physician perspectives and compliance with patient advance directives: the role external factors play on physician decision making

et al. 2012

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BackgroundFollowing passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians’ decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients’ ability to comprehend complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored.MethodsAttendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents’ perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test.ResultsThree hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient’s AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to “pass away in peace.” Few (17%) would forgo an AD following a family’s request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician’s decision as to whether to comply with a patient’s AD.ConclusionsOur findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient’s initial wishes and preferences expressed by the AD.

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Maximal medical therapy and palliative care can work together: When are advanced care measures appropriate?

Cited by 5 publications

References 33 publications

Symptom burden, quality of life, and attitudes toward palliative care in patients with pulmonary arterial hypertension: Results from a cross-sectional patient survey

Symptom burden, quality of life, and attitudes toward palliative care in patients with pulmonary arterial hypertension: Results from a cross-sectional patient survey

End-of-life care in a population-based cohort of cancer patients: clinical trial participation versus standard of care

Physician perspectives and compliance with patient advance directives: the role external factors play on physician decision making

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