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Racial and Ethnic Differences in End-of-Life Care for Patients with End-Stage Renal Disease (746)
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Schedule with Abstracts
V. Conclusions. If the increase in deaths in winter is due to viral illness or respiratory bacterial illness, then frail patients are at greater risk, the more so if they reside in a long-term care facility. Cancer patients’ decline is more predictable after admission to hospice, and while infection may contribute to deaths in this group, the seasonal effect is negligible. VI. Implications for research, policy, or practice. Timely flu vaccinations (ie, Sept.-Oct.) must be encouraged in the frail elderly, regardless of place of residence or hospice admission status. We must also stress handwashing and other normal precautionary behavior around frail patients, particularly those in nursing facilities.
Reflections on Surrogacy: How Family Decision Makers View Their Role (745) Mary Ann Meeker, RN DNS, University at Buffalo, Holland, NY Objectives 1. Describe strategies family surrogate decision makers use to support themselves in this difficult role. 2. Identify surrogates’ perceived needs in relationship to healthcare providers. I. Background. Family decision makers perform critical roles in healthcare choices for people with advanced cancer. Our understanding of their needs and experiences is limited. II. Research Objectives. Describe family surrogates’ perceptions of their role and their needs as surrogates. III. Methods. Data for this prospective, longitudinal study were obtained through in-depth semi-structured interviews with the formally or informally identified family surrogate decision maker. Where possible, multiple interviews over time were conducted with the surrogate. Data were audio-recorded and transcribed verbatim. Qualitative descriptive content analysis informed by grounded theory methods of constant comparison for development and saturation of categories was conducted. IV. Results. Eighty-two interviews were conducted with 40 participants. Surrogates described how they came to be the decision maker, how they perceived their participation, and how they empowered themselves to engage in surrogacy. Participants in this study became surrogates for practical reasons, such as living closer or because there was no one else who could assist the ill person in this way. Many
Vol. 37 No.3 March 2009
described themselves as coming from a lineage of caring, serving people. Yet nearly all reported that being a surrogate was harder than they ever imagined. Surrogates engaged in paradoxical strategies to help them carry out the surrogate role effectively. For example, they recommended planning ahead and securing anticipatory guidance, and yet simultaneously emphasized the importance of “taking one day at a time.” V. Conclusions. Family surrogates perceived their involvement with the family member with advanced cancer as integral to the process of care. Although the amount of decision-making guidance they wanted from providers varied, all wanted their role recognized and respected. VI. Implications for research, policy, or practice. Understanding the experiences and perspectives of family decision makers will increase clinicians’ ability to interact effectively with them. Improved clinician interaction with family surrogates can improve outcomes for both the surrogates and the family members they assist.
Racial and Ethnic Differences in End-ofLife Care for Patients with End-Stage Renal Disease (746) Catherine Pham, Texas A&M University Health Sciences Center, College Station, TX; Laurence B. Mccullough, PhD, Center for Medical Ethics and Health Policy, Baylor College, Houston, TX; Robert O. Morgan, PhD, The Houston Center For Quality of Care & Utilization Studies, Houston, TX; Ursula Braun, MD MPH, Michael E. DeBakey VAMC, Bellaire, TX Objective 1. Discuss the differences in care by race/ethnicity for patients with end-stage renal disease. I. Background. Patients with end-stage renal disease are known to have different rates of receiving kidney transplants by race/ethnicity. No national data exist regarding racial/ethnic differences for patients with end-stage renal disease in the use of common life-sustaining interventions often given at the end of life. II. Research Objectives. To determine whether among veterans with end-stage renal disease the use of common life-sustaining treatments differed significantly by race/ethnicity. III. Methods. Design. Retrospective cohort study during fiscal years 1991-2007. Patients. Hospitalized veterans age 55 years or
Vol. 37 No.3 March 2009
Schedule with Abstracts
older with end-stage renal disease, on hemodialysis or peritoneal dialysis, identified by ICD-9 codes and CPT codes. Measurements. Utilization patterns by race/ ethnicity for five life-sustaining therapies. Logistic regression models evaluated differences among Caucasians, African Americans, and Hispanics, controlling for age, disease burden (using the Deyo score), and clustering of patients within VA medical centers. IV. Results. Among 14,252 veterans 99% were male, 70% were between 55 and 75 years old, and 30% were > 75 years. 63% died within 6 months of being identified for the study. 60.5% of patients were Caucasian; 34.5%, African American; and 5%, Hispanic. Both differences and commonalities were found by race/ethnicity. African Americans were less likely to be intubated (OR = .82 [.70-.86]; P = .0001), resuscitated (OR = .724 [.63-.83]; P = .0001), and had a trend toward receiving less ICU care (OR = .93 [.88-.99]; P = .019) than Caucasians; however, they were slightly more likely to receive transfusions. Hispanics were more likely to be transfused (OR = 1.214 [1.071-1.376]; P = .003), resuscitated (OR = 1.31 [1.02-1.68]; P = .035), or in the ICU (OR = 1.18 [1.04-1.34]; P = .013) than Caucasians. No differences were found for enteral feeding by race/ethnicity. Younger patients were more likely to receive intubation, resuscitation, or ICU care than older patients, but there was no difference for transfusion or enteral feeding by age group. V. Conclusions. Differences in level of end-oflife treatments were bidirectional for African Americans. VI. Implications for research, policy, or practice. In the absence of generally accepted, evidencebased standards for end-of-life care, these differences may or may not constitute disparities. However, it is of concern that African Americans received less intubation, resuscitation, and ICU care than Caucasians in light of many studies on patient preferences showing African Americans generally preferring more aggressive end-of-life care.
At These Rounds, Providers “Heal Themselves” (747) Julie M. Phillips, MD, Stratton VA Medical Center, Duanesburg, NY; Crystal Dea Moore, PhD MSW, Skidmore College, Latham, NY; Marian
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Boyajian, MS FNPC, Stratton VA Medical Center, Selkirk, NY; Nancy K. Nelson, RN, Stratton VA Medical Center, East Greenbush, NY Objectives 1. Recognize the value of holding an interdisciplinary forum (Schwartz Center Rounds) for providers to discuss emotional issues that arise during patient care. 2. Recognize the steps taken to implement the Schwartz Center Rounds at one’s facility. I. Background. The demands, stressors, and time constraints of the modern healthcare system can threaten clear communication and the delivery of compassionate care. Caregivers have few, if any, outlets where they can express and process their feelings. Furthermore, there is little formal training regarding how to respond to the difficult emotional issues that arise during patient care. The Schwartz Center, a Bostonbased nonprofit organization founded upon the vision of Kenneth B. Schwartz, is responding to these issues to promote compassionate health care. Mr. Schwartz died of lung cancer in 1995 at the age of 40. In the months that followed his diagnosis, in his own words, “the ordeal was punctuated by moments of exquisite compassion.” During his harrowing experience, “acts of kindness...made the unbearable bearable.” II. Case Description. The Schwartz Center Rounds, one of the Center’s initiatives, is an interdisciplinary forum. A team briefly presents a case and then the audience and panelists exchange experiences, thoughts, and feelings about the issue. The goal is to share experiences, receive support, and discuss strategies for providing compassionate care. Sample topics include having to tell someone it may be time to stop treatment, our fallibility as providers, self-regulating our attachment to patients, and when goals of care conflict. Evaluation studies have shown that the Schwartz Rounds can decrease feelings of caregiver isolation, promote interdisciplinary teamwork, and increase caregiver empathy toward patients and families. III. Conclusion. This poster will detail the steps of Schwartz Center Rounds implementation at the Stratton VA Medical Center in Albany, NY. The Rounds have been well received among the participants and we hope to get others thinking about how to implement such a helpful forum at their facility.
Schedule with Abstracts
V. Conclusions. If the increase in deaths in winter is due to viral illness or respiratory bacterial illness, then frail patients are at greater risk, the more so if they reside in a long-term care facility. Cancer patients’ decline is more predictable after admission to hospice, and while infection may contribute to deaths in this group, the seasonal effect is negligible. VI. Implications for research, policy, or practice. Timely flu vaccinations (ie, Sept.-Oct.) must be encouraged in the frail elderly, regardless of place of residence or hospice admission status. We must also stress handwashing and other normal precautionary behavior around frail patients, particularly those in nursing facilities.
Reflections on Surrogacy: How Family Decision Makers View Their Role (745) Mary Ann Meeker, RN DNS, University at Buffalo, Holland, NY Objectives 1. Describe strategies family surrogate decision makers use to support themselves in this difficult role. 2. Identify surrogates’ perceived needs in relationship to healthcare providers. I. Background. Family decision makers perform critical roles in healthcare choices for people with advanced cancer. Our understanding of their needs and experiences is limited. II. Research Objectives. Describe family surrogates’ perceptions of their role and their needs as surrogates. III. Methods. Data for this prospective, longitudinal study were obtained through in-depth semi-structured interviews with the formally or informally identified family surrogate decision maker. Where possible, multiple interviews over time were conducted with the surrogate. Data were audio-recorded and transcribed verbatim. Qualitative descriptive content analysis informed by grounded theory methods of constant comparison for development and saturation of categories was conducted. IV. Results. Eighty-two interviews were conducted with 40 participants. Surrogates described how they came to be the decision maker, how they perceived their participation, and how they empowered themselves to engage in surrogacy. Participants in this study became surrogates for practical reasons, such as living closer or because there was no one else who could assist the ill person in this way. Many
Vol. 37 No.3 March 2009
described themselves as coming from a lineage of caring, serving people. Yet nearly all reported that being a surrogate was harder than they ever imagined. Surrogates engaged in paradoxical strategies to help them carry out the surrogate role effectively. For example, they recommended planning ahead and securing anticipatory guidance, and yet simultaneously emphasized the importance of “taking one day at a time.” V. Conclusions. Family surrogates perceived their involvement with the family member with advanced cancer as integral to the process of care. Although the amount of decision-making guidance they wanted from providers varied, all wanted their role recognized and respected. VI. Implications for research, policy, or practice. Understanding the experiences and perspectives of family decision makers will increase clinicians’ ability to interact effectively with them. Improved clinician interaction with family surrogates can improve outcomes for both the surrogates and the family members they assist.
Racial and Ethnic Differences in End-ofLife Care for Patients with End-Stage Renal Disease (746) Catherine Pham, Texas A&M University Health Sciences Center, College Station, TX; Laurence B. Mccullough, PhD, Center for Medical Ethics and Health Policy, Baylor College, Houston, TX; Robert O. Morgan, PhD, The Houston Center For Quality of Care & Utilization Studies, Houston, TX; Ursula Braun, MD MPH, Michael E. DeBakey VAMC, Bellaire, TX Objective 1. Discuss the differences in care by race/ethnicity for patients with end-stage renal disease. I. Background. Patients with end-stage renal disease are known to have different rates of receiving kidney transplants by race/ethnicity. No national data exist regarding racial/ethnic differences for patients with end-stage renal disease in the use of common life-sustaining interventions often given at the end of life. II. Research Objectives. To determine whether among veterans with end-stage renal disease the use of common life-sustaining treatments differed significantly by race/ethnicity. III. Methods. Design. Retrospective cohort study during fiscal years 1991-2007. Patients. Hospitalized veterans age 55 years or
Vol. 37 No.3 March 2009
Schedule with Abstracts
older with end-stage renal disease, on hemodialysis or peritoneal dialysis, identified by ICD-9 codes and CPT codes. Measurements. Utilization patterns by race/ ethnicity for five life-sustaining therapies. Logistic regression models evaluated differences among Caucasians, African Americans, and Hispanics, controlling for age, disease burden (using the Deyo score), and clustering of patients within VA medical centers. IV. Results. Among 14,252 veterans 99% were male, 70% were between 55 and 75 years old, and 30% were > 75 years. 63% died within 6 months of being identified for the study. 60.5% of patients were Caucasian; 34.5%, African American; and 5%, Hispanic. Both differences and commonalities were found by race/ethnicity. African Americans were less likely to be intubated (OR = .82 [.70-.86]; P = .0001), resuscitated (OR = .724 [.63-.83]; P = .0001), and had a trend toward receiving less ICU care (OR = .93 [.88-.99]; P = .019) than Caucasians; however, they were slightly more likely to receive transfusions. Hispanics were more likely to be transfused (OR = 1.214 [1.071-1.376]; P = .003), resuscitated (OR = 1.31 [1.02-1.68]; P = .035), or in the ICU (OR = 1.18 [1.04-1.34]; P = .013) than Caucasians. No differences were found for enteral feeding by race/ethnicity. Younger patients were more likely to receive intubation, resuscitation, or ICU care than older patients, but there was no difference for transfusion or enteral feeding by age group. V. Conclusions. Differences in level of end-oflife treatments were bidirectional for African Americans. VI. Implications for research, policy, or practice. In the absence of generally accepted, evidencebased standards for end-of-life care, these differences may or may not constitute disparities. However, it is of concern that African Americans received less intubation, resuscitation, and ICU care than Caucasians in light of many studies on patient preferences showing African Americans generally preferring more aggressive end-of-life care.
At These Rounds, Providers “Heal Themselves” (747) Julie M. Phillips, MD, Stratton VA Medical Center, Duanesburg, NY; Crystal Dea Moore, PhD MSW, Skidmore College, Latham, NY; Marian
557
Boyajian, MS FNPC, Stratton VA Medical Center, Selkirk, NY; Nancy K. Nelson, RN, Stratton VA Medical Center, East Greenbush, NY Objectives 1. Recognize the value of holding an interdisciplinary forum (Schwartz Center Rounds) for providers to discuss emotional issues that arise during patient care. 2. Recognize the steps taken to implement the Schwartz Center Rounds at one’s facility. I. Background. The demands, stressors, and time constraints of the modern healthcare system can threaten clear communication and the delivery of compassionate care. Caregivers have few, if any, outlets where they can express and process their feelings. Furthermore, there is little formal training regarding how to respond to the difficult emotional issues that arise during patient care. The Schwartz Center, a Bostonbased nonprofit organization founded upon the vision of Kenneth B. Schwartz, is responding to these issues to promote compassionate health care. Mr. Schwartz died of lung cancer in 1995 at the age of 40. In the months that followed his diagnosis, in his own words, “the ordeal was punctuated by moments of exquisite compassion.” During his harrowing experience, “acts of kindness...made the unbearable bearable.” II. Case Description. The Schwartz Center Rounds, one of the Center’s initiatives, is an interdisciplinary forum. A team briefly presents a case and then the audience and panelists exchange experiences, thoughts, and feelings about the issue. The goal is to share experiences, receive support, and discuss strategies for providing compassionate care. Sample topics include having to tell someone it may be time to stop treatment, our fallibility as providers, self-regulating our attachment to patients, and when goals of care conflict. Evaluation studies have shown that the Schwartz Rounds can decrease feelings of caregiver isolation, promote interdisciplinary teamwork, and increase caregiver empathy toward patients and families. III. Conclusion. This poster will detail the steps of Schwartz Center Rounds implementation at the Stratton VA Medical Center in Albany, NY. The Rounds have been well received among the participants and we hope to get others thinking about how to implement such a helpful forum at their facility.