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Biomedical subjects

J Randall Curtis

Publications and source records attributed to J Randall Curtis.

At least 37 records · Page 2Linked to original sources
PubMed2006

Measuring intensive care nurses' perspectives on family-centered end-of-life care: evaluation of 3 questionnaires.

BACKGROUND: Attempts to improve end-of-life care increasingly focus on family-centered care, but few validated assessment tools exist. OBJECTIVES: To evaluate 3 new short questionnaires measuring nurses' perspectives on family-centered end-of-life care in the intensive care unit and to show the usefulness of the questionnaires. METHODS: Principal components analysis of data from 141 critical care nurses evaluating care given to families of 218 patients was used to develop domain scores for number of nursing activities with each family, number of barriers experienced, and nurses' satisfaction that the family's needs were met. Random effects models were used to test associations between critical care processes and outcome. RESULTS: Nursing activities fell into 2 domains: general and culture-related communication/support. Barriers consisted of 2 domains: patient/family barriers and system/team barriers. Meeting the needs of patients' families represented a single dimension. In a path model based on domain scores, general activities had significant associations with both nurse communication and meeting families' needs; patient/family barriers, with nurse communication; and nurse and physician communication, with meeting families' needs. In a path model based on total activities and barriers scores, total activities and total barriers had significant associations with nurse communication ratings and meeting families' needs. Patients' and nurses' characteristics were not significant independent predictors of meeting the needs of patients' families. CONCLUSIONS: The 3 questionnaires provide a consistent, valid picture of nurses' perspectives on family-centered critical care and may be useful in evaluating family care processes and outcomes and in targeting areas for improvement.

Adult↗
PubMed2005

International differences in end-of-life attitudes in the intensive care unit: results of a survey.

BACKGROUND: Important international differences exist in attitudes toward end-of-life issues in the intensive care unit. METHODS: A simple questionnaire survey was sent by e-mail to participants at an international meeting on intensive care medicine. Respondents were asked to choose 1 of 3 to 5 possible answers for each of 4 questions related to the treatment of a hypothetical patient in a vegetative state due to anoxic encephalopathy after cardiac arrest with no family and no advance directives. RESULTS: From 3494 valid addresses, 1961 complete questionnaires (56%) were received from 21 countries. Sixty-two percent of physicians from Northern and Central Europe said they involved nurses in end-of-life discussions compared with only 32% of physicians in Southern Europe, 38% in Brazil, 39% in Japan, and 29% in the United States (P<.001 for all comparisons). Written do-not-resuscitate orders were preferred in Northern and Central Europe, whereas oral orders took preference in Southern Europe, Turkey, and Brazil. One third of Japanese physicians said that they would not apply do-not-resuscitate orders. Most participants from Japan, Turkey, the United States, Southern Europe, and Brazil chose to treat the hypothetical patient with antibiotics if he/she developed septic shock, whereas in Northern Europe, Central Europe, Canada, and Australia, terminal withdrawal of mechanical ventilation and extubation were the more commonly chosen responses. CONCLUSIONS: In countries where intensive care medicine is relatively well developed, considerable differences remain in physicians' attitudes toward end-of-life care in the intensive care unit. Substantial work remains if an international consensus on these issues is to be reached.

Attitude to Death↗
PubMed2005

Long-term sequelae of critical illness: memories and health-related quality of life.

Impaired health-related quality of life after critical illness has been demonstrated in a number of studies. It is not clear exactly how or why critical illness and intensive care lead to impaired health status, but understanding this association is an important step to improving long-term outcomes of the critically ill. There is growing evidence that neuro-psychological symptoms play a significant role in this impairment and that management of patients in the intensive care unit (ICU) may influence these symptoms. This commentary examines a recent study and places this study in the context of previous studies suggesting that both amnesia and persisting nightmares of the ICU experience are associated with impaired quality of life. Further research is needed if we are effectively to understand, prevent and treat the negative sequelae of critical illness.

Amnesia↗
PubMed2005

Missed opportunities during family conferences about end-of-life care in the intensive care unit.

BACKGROUND: Improved communication with family members of critically ill patients can decrease the prolongation of dying in the intensive care unit (ICU), but few data exist to guide the conduct of this communication. OBJECTIVE: Our objective was to identify missed opportunities for physicians to provide support for or information to family during family conferences. METHODS: We identified ICU family conferences in four hospitals that included discussions about withdrawing life support or delivery of bad news. Fifty-one conferences were audiotaped, including 214 family members. Thirty-six physicians led the conferences and some physicians led more than one. We used qualitative methods to identify and categorize missed opportunities, defined as an occurrence when the physician had an opportunity to provide support or information to the family and did not. MAIN RESULTS: Fifteen family conferences (29%) had missed opportunities identified. These fell into three categories: opportunities to listen and respond to family; opportunities to acknowledge and address emotions; and opportunities to pursue key principles of medical ethics and palliative care, including exploration of patient preferences, explanation of surrogate decision making, and affirmation of nonabandonment. The most commonly missed opportunities were those to listen and respond, but examples from other categories suggest value in being aware of these opportunities. CONCLUSIONS: Identification of missed opportunities during ICU family conferences provides suggestions for improving communication during these conferences. Future studies are needed to demonstrate whether addressing these opportunities will improve quality of care.

Adult↗
PubMed2005

Death rounds: end-of-life discussions among medical residents in the intensive care unit.

PURPOSE: We introduced "Death Rounds," a monthly discussion of the issues and emotions surrounding the care of dying patients, into the intensive care unit (ICU) rotations for medical house staff. We surveyed participating residents to evaluate their satisfaction with these discussions. SUBJECTS AND METHODS: Death Rounds occurred at university-based teaching hospitals in Seattle, Washington and Salt Lake City, Utah, between October 2000 and March 2002. Residents who had attended Death Rounds were surveyed in April 2002. RESULTS: A 10-item survey was distributed by e-mail to 116 residents in Utah and Washington. Of 116 residents, 97 (84%) responded to the survey; 50 of these 97 had attended at least one Death Rounds. Of these 50, the majority reported that Death Rounds were worthwhile (76%) and that sessions should be incorporated into all ICU rotations (76%). CONCLUSIONS: Death Rounds provide a unique opportunity for residents to discuss the issues raised in caring for dying patients. This conference can be easily incorporated into the ICU curriculum. Most residents who participated in the survey indicated that they valued Death Rounds and believed that it should be included in all ICU rotations.

Adult↗
PubMed2005

Correspondence between patients' preferences and surrogates' understandings for dying and death.

We examined the agreement between hospice patients' preferences for desired experiences during the last week of life and their surrogates' understandings of those preferences (n=92 pairs). Analyses included percent agreement, intraclass correlation coefficients, and Bland-Altman plots. Demographic characteristics and communication measures associated with better agreement were identified using t-tests and analysis of variance. The median number of items on which patients and family members agreed was 14 of 30 (interquartile range, IQR 10, 16). Preferences with good agreement included both observable and non-observable experiences. Patients who reported having had conversations about treatment preferences and who reported that their surrogates knew their preferences reported higher agreement. Surrogates display a better understanding of what is important to patients at the end of life if they have had discussions about patient preferences. These discussions may enable surrogates and clinicians to more accurately follow patient preferences.

Advance Directives↗
PubMed2005

Communication about end-of-life care between language-discordant patients and clinicians: insights from medical interpreters.

BACKGROUND: Communication about health care and especially end-of-life care is difficult for clinicians and patients when they do not speak the same language. Our purpose was to improve understanding of how to approach discussions between language-discordant patients and clinicians about terminal or life-threatening illness. METHODS: We conducted a qualitative study with 4 focus groups with 43 professional medical interpreters. We asked open-ended questions concerning physician and interpreter communication about end-of-life care. Focus groups were audiotaped, transcribed, and analyzed using principles of grounded theory. Results were presented to an additional 3 focus groups with 25 medical interpreters to ensure that analyses represented interpreters' perspectives. RESULTS: We developed 3 frameworks for understanding high-quality language-discordant communication about end-of-life care. The first framework addresses physician and interpreter professionalism, including humanistic qualities and emotional support capabilities important for high quality care. The second framework is physician-centered and highlights communication skills, as well as coordination with other providers and cultural sensitivity. The third framework is interpreter-centered, focusing on role conflicts, including struggles concerning expectations to provide strict interpretation versus being a cultural broker. Interpreters' recommendations for improving quality of this care include pre-meetings with interpreters before encounters involving delivery of bad news and explicit discussions with interpreters about whether the clinician expects strict interpretation or cultural brokering. CONCLUSIONS: These results provide insights for physicians about how to improve end-of-life discussions with language-discordant patients and their families. Interpreter recommendations provide physicians and health care organizations with specific tools that may improve quality of communication about end-of-life discussions.

Adult↗
PubMed2005

Expressions of nonabandonment during the intensive care unit family conference.

PURPOSE: Palliative care consultants play an increasing role in assisting critical care clinicians with end-of-life communication in the intensive care unit (ICU). One of the ethical principles these consultants may apply to such communication is nonabandonment of the patient. Limited data exist concerning expressions of nonabandonment in the ICU family conference. This analysis examines expressions of nonabandonment during ICU family conferences. Our goal was to categorize these expressions and develop a conceptual model for understanding this issue as it arises in the ICU setting. METHODS: We identified family conferences in the ICUs of four hospitals. Conferences were eligible if the attending physician believed that discussion about withholding or withdrawing life support or the delivery of bad news was likely to occur. Fifty-one conferences were audiotaped, transcribed, and analyzed using grounded theory. RESULTS: We identified categories capturing expressions of nonabandonment in the ICU family conference. Clinicians expressed nonabandonment of the patient or family in three ways: alleviating suffering/ensuring comfort, allowing family members to be present at the bedside for the death, and being accessible to patients and families. Families expressed their own nonabandonment of the patient or concern about abandonment of the patient by the health care team in five ways: ensuring the patient's suffering is eased, being present at the bedside, ensuring the patient's end-of-life preferences are respected, ensuring that everything possible be done to cure the patient, and "letting go." These categories were placed into a conceptual model that differentiates explicit and implicit statements of nonabandonment. CONCLUSIONS: This paper describes categories and a conceptual model for understanding expressions of nonabandonment that may allow palliative care consultants to help critical care clinicians express nonabandonment and respond to families' expressions of nonabandonment in the ICU family conference. Future studies could use this model to develop a communication intervention for the ICU family conference.

Adult↗
PubMed2005

Interventions to improve care during withdrawal of life-sustaining treatments.

Withdrawal of life-sustaining therapies is a common occurrence in the intensive care unit (ICU) setting and also occurs in other hospital settings, long-term care facilities, and even at home. Many studies have documented dramatic geographic variations in the prevalence of withdrawal of life-sustaining therapies, and some evidence suggests this variation may be driven more by physician attitudes and biases than by factors such as patient preferences or cultural differences. A number of studies of interventions in the ICU setting have provided some evidence that withdrawal of life-sustaining therapies is a process of care that can be improved. The interventions have included routine ethics or palliative care consultations, routine family conferences, and standardized order protocol for withdrawal of life support. For some of the interventions, for example, ethics consultations or palliative care consultations, the precise mechanisms by which the process of care is improved are not clear. Furthermore, many of these studies have used surrogate outcomes for quality, such as ICU length of stay. Emerging research suggests more direct outcome measures may be useful, including family satisfaction with care and assessments of the quality of dying. Despite these relative limitations, these studies provide convincing evidence that withdrawal of life-sustaining therapy is a process of care that presents opportunities for quality improvement and that interventions are successful at improving this care. Further research is needed to identify and test the most appropriate and responsive outcome measures and to identify the most effective and cost-effective interventions.

Decision Making↗
PubMed2005

Care near the end-of-life in critically ill patients: a North American perspective.

PURPOSE OF REVIEW: End-of-life care for critically ill patients has emerged as an area in which significant quality improvement is possible. In this article, we present a North American perspective on recent research and quality improvement initiatives in this field. RECENT FINDINGS: Some of the most important recent developments in end-of-life care in the intensive care unit concern physician-patient-family communication. There is consensus between North American and European professional societies that a shared approach to decision-making by physicians and family members is optimal. The shared decision approach demands that physicians not only skillfully elicit the patient's treatment preferences but also effectively inform the family of the patient's clinical condition and prognosis. Moreover, the ultimate responsibility for end-of-life treatment decisions is shared between the physician and the patient or family. SUMMARY: This update presents a North American perspective on six topics of particular importance to end-of-life care in the intensive care unit: (a) The role of advance directives, (b) shared decision-making and the role of the family, (c) conflict and futility in the intensive care unit, (d) cultural aspects of end-of-life care, (e) multidisciplinary care in the intensive care unit, and (f) future directions for improving end-of-life care in the intensive care unit.

Advance Directives↗
PubMed2005

Association of depression and life-sustaining treatment preferences in patients with COPD.

STUDY OBJECTIVE: Depressive symptoms and reduced health-related quality of life are common in patients with severe COPD. Therefore, understanding the association between preferences for life-sustaining treatment and depression or quality of life is important in providing care. No prior studies have examined the effects of depression and quality of life on treatment preferences in this population. DESIGN AND PATIENTS: Cross-sectional study of 101 patients with oxygen-prescribed COPD. METHODS: Patients completed the St. George's Respiratory Questionnaire, Center for Epidemiologic Studies-Depression survey, and questions regarding their preferences for mechanical ventilation and cardiopulmonary resuscitation if needed to sustain life. RESULTS: Median age was 67.4 years, and median FEV1 was 26.3% predicted. Depression was significantly associated with preferences for resuscitation (50% of depressed patients and 23% of patients without depression refused resuscitation; p = 0.007), but was not associated with preferences for mechanical ventilation. Health-related quality of life was not associated with preferences for either resuscitation or mechanical ventilation. CONCLUSIONS: Clinicians caring for patients with oxygen-prescribed COPD should understand that health-related quality of life does not predict treatment preferences and should not influence clinicians' views of patients' treatment preferences. However, depression does appear to influence patients' treatment decisions for cardiopulmonary resuscitation, and improvement in depressive symptoms should trigger a reassessment of these preferences.

Aged↗
PubMed2005

Quality of dying and death in two medical ICUs: perceptions of family and clinicians.

OBJECTIVE: We compared perceptions of the quality of dying and death in the ICU across nurses, resident physicians, attending physicians, and family members. The aim was to obtain a surrogate assessment of the quality of the dying process and examine differences in the perceptions of different types of raters. DESIGN: Cross-sectional survey of family members and ICU clinicians conducted following the death of enrolled patients. SETTING: Two medical ICUs at academic tertiary care medical centers. PATIENTS: Patients dying in the ICU (n = 68). MEASUREMENTS AND RESULTS: The previously validated Quality of Dying and Death (QODD) instrument was modified for use in the ICU. Within 48 h of the time of death, the nurse, resident, and attending physician caring for the patient were asked to complete the QODD. One month following the death, a designated family member was contacted and the QODD was administered on the telephone. Family members and attending physicians gave the most favorable ratings of death, while nurses and residents provided less favorable ratings. Significant differences between these groups were notable (p < 0.01) on items related to patient autonomy: maintaining dignity, being touched by loved ones, and the overall quality of death. CONCLUSIONS: The perception of dying and death in the ICU varies considerably between nurses, attending physicians, resident physicians, and family members. Further studies are needed to explain these differences and determine the utility of the ICU QODD instrument for assessing and improving the quality of end-of-life care in the ICU.

Aged↗
PubMed2005

Treatment preferences for resuscitation and critical care among homeless persons.

CONTEXT: Homeless people are at increased risk of critical illness and are less likely to have surrogate decision makers when critically ill. Consequently, clinicians must make decisions independently or with input from others such as ethics committees or guardians. No prior studies have examined treatment preferences of homeless to guide such decision makers. DESIGN: Interviewer-administered, cross-sectional survey of homeless persons. SETTING: Homeless shelters in Seattle, WA. PARTICIPANTS: Two hundred twenty-nine homeless individuals with two comparison groups: 236 physicians practicing in settings where they are likely to provide care for homeless persons and 111 patients with oxygen-dependent COPD. MEASUREMENTS: Participants were asked whether they would want intubation with mechanical ventilation or cardiopulmonary resuscitation in their current health, if they were in a permanent coma, if they had severe dementia, or if they were confined to bed and dependent on others for all care. RESULTS: Homeless men were more likely to want resuscitation than homeless women (p < 0.002) in coma and dementia scenarios. Homeless men and women were both more likely to want resuscitation in these scenarios than physicians (p < 0.001). Nonwhite homeless were more likely to want resuscitation than white homeless people (p < 0.033), and both were more likely to want resuscitation than physicians (p < 0.001). Homeless are also more likely to want resuscitation than patients with COPD. The majority (80%) of homeless who reported not having family or not wanting family to make medical decisions prefer a physician make decisions rather than a court-appointed guardian. CONCLUSIONS: Homeless persons are more likely to prefer resuscitation than physicians and patients with severe COPD. Since physicians may be in the position of making medical decisions for homeless patients and since physicians are influenced by their own preferences when making decisions for others, physicians should be aware that, on average, homeless persons prefer more aggressive care than physicians. Hospitals serving homeless individuals should consider developing policies to address this issue.

Adult↗
PubMed2005

Barriers and facilitators to end-of-life care communication for patients with COPD.

OBJECTIVE: Patients with COPD frequently do not discuss end-of-life care with physicians; therefore, we sought to identify the barriers and facilitators to this communication as a first step to overcoming barriers and capitalizing on facilitators. DESIGN: Fifteen barriers and 11 facilitators to patient-physician communication about end-of-life care were generated from focus groups of patients with COPD. We subsequently conducted a cross-sectional study of 115 patients with oxygen-dependent COPD and their physicians to identify the common barriers and facilitators and examine the association of these barriers and facilitators with communication about end-of-life care. PARTICIPANTS AND SETTING: Patients with oxygen-dependent COPD were recruited from clinics at a university, county, and Veterans Affairs teaching hospital, and an oxygen delivery company. We also recruited the physician identified by each patient as the doctor primarily responsible for their lung disease. MEASUREMENTS AND RESULTS: Patients were interviewed by trained research interviewers. Physician data collection was completed by mail survey. Participation rates were 40% for patients and 86% for physicians. Only 32% of patients reported having a discussion about end-of-life care with their physician. Two of 15 barriers and 8 of 11 facilitators were endorsed by > 50% of patients. The most commonly endorsed barriers were "I'd rather concentrate on staying alive," and "I'm not sure which doctor will be taking care of me." Two barriers were significantly associated with lack of communication, as follows: "I don't know what kind of care I want," and "I'm not sure which doctor will be taking care of me." The greater the number of barriers endorsed by patients, the less likely they were to have discussed end-of-life care with physicians (p < 0.01), suggesting the validity of these barriers. Conversely, the more facilitators, the more likely patients were to report having had end-of-life discussions with their physicians (p < 0.001). CONCLUSION: Although patients endorsed many barriers and facilitators, few barriers were endorsed by most patients. Barriers and facilitators associated with communication are targets for interventions to improve end-of-life care, but such interventions will likely need to address the specific barriers relevant to individual patient-physician pairs.

Adult↗
PubMed2005

Quality of dying in the ICU: ratings by family members.

STUDY OBJECTIVES: To explore the quality of the dying experience and associations to higher quality ratings for people who died in an ICU. DESIGN: Retrospective study using medical record review and surveys of family members with the Quality of Dying and Death (QODD) instrument. SETTING: Four ICUs affiliated with a university and a Veterans Affairs Medical Center. PARTICIPANTS: Ninety-four family members of 38 ICU decedents. MEASUREMENTS AND RESULTS: We explored associations between components of the ICU experience and the overall rating of the quality of the dying experience. Overall, family members reported that symptoms were poorly controlled: pain under control most or all of the time in 47%, and breathing comfortably most or all of the time in 3% of patients. Families expressed a moderate and variable view of the quality of dying resulting in an overall ICU QODD score of 60 +/- 14 (on a scale of 0 to 100) [mean +/- SD]. Higher ICU QODD scores were associated with control of pain (r = 0.42, p = 0.009), control of events (r = 0.62, p < 0.001), a "preparation for death" aspect of the dying experience--feeling at peace with dying (r = 0.69, p < 0.001), and a "whole-person concern"--keeping one's dignity and self-respect (r = 0.50, p < 0.001). CONCLUSIONS: After adjusting for symptom and personal care scores, certain whole-person and preparation-for-death aspects of the dying process, and not aggressiveness of end-of-life care, remained the most associated to quality ratings. While future research should explore the important predictors of quality of dying in the ICU, this study suggests that care at the end of life in the ICU include not only managing pain, but also supporting dignity, respect, and peace, and maximizing patient control.

Adult↗
PubMed2005

Communication about palliative care for patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and disability worldwide. For many patients, maximal therapy for COPD produces only modest relief of disabling symptoms and these symptoms result in a significantly reduced quality of life. Despite the high morbidity and mortality, patients with COPD do not receive adequate palliative care. One reason these patients may receive poor quality palliative care is that patient-physician communication about palliative and EOL care is unlikely to occur. The purpose of this review is to summarize recent research regarding patient-physician communication about palliative care for patients with COPD. Understanding the barriers to this communication may be an important step to improving communication about EOL care and improving patient-centred outcomes. Two areas that may influence the quality of care received by patients with COPD are also highlighted: 1) the role of depression, a common problem in patients with COPD, in physician-patient communication; and 2) the role of advance care planning in this communication. Further research is needed to develop and test interventions that can enhance patient-physician communication about palliative and EOL care for patients with COPD, and we describe our perspective on a research agenda in each area.

Advance Care Planning↗