Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.
Dowell D, Haegerich T, Chou R. N Engl J Med. 2019;380:2285-2287.
Improving opioid prescribing is a complex challenge that requires multipronged approaches to achieve safe patient pain management. This commentary offers insights to help organizations effectively implement the Centers for Disease Control and Prevention guideline and notes how misapplication of recommendations have resulted in unintended consequences such as patient harm.
Williams H, Donaldson SL, Noble S, et al. Palliat Med. 2019;33:346-356.
Patients receiving palliative care are often medically complex and may be at increased risk for safety events, especially when cared for outside of routine clinic hours. In this mixed-methods study, researchers analyzed patient safety incident reports regarding patients who received inadequate palliative care during nights and weekends from primary care services in the United Kingdom. Incidents related to medications were common, accounting for 613 out of the 1072 safety events included in the study.
The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.
Hospitalized in the ICU after cardiac arrest and loss of cardiac function for 15 minutes, an older man experienced worsening neurological status. After extensive discussions about goals of care, the family agreed to a DNR order. Over the next week, his condition declined, and the family decided to transition to comfort measures. Orders were written but shortly thereafter, the family spoke with the ICU resident and reversed their decision. The resident canceled the terminal extubation orders without communicating the order change to other team members.
Found unconscious at home, an older woman with advanced dementia and end-stage renal disease was resuscitated in the field and taken to the emergency department, where she was registered with a temporary medical record number. Once her actual medical record was identified, her DNR/DNI status was identified. After recognizing this and having discussions with the family, she was transitioned to comfort care and died a few hours later. Two months later, the clinic called the patient's home with an appointment reminder.
When a 94-year-old woman presented for routine primary care, the intern caring for her discovered that the patient's code status was "full code" and that there was no documentation of discussions regarding her wishes for end-of-life care. The intern and his supervisor engaged the patient in an advance care planning discussion, during which she clarified that she would not want resuscitation or life-prolonging measures.
Kiesewetter I, Schulz C, Bausewein C, et al. BMC Palliat Care. 2016;15:75.
Adverse events in palliative care differ from those in other environments. This qualitative interview study of patients who received palliative care identified errors specific to this setting, including deviation from a patient's advance directive and error in prognosis. A recent WebM&M commentary discussed challenges to implementing advance directives.
Lang A, Toon L, Cohen SR, et al. Safety Health. 2015;1:3.
This qualitative study of palliative care recipients, family caregivers, and paid home health staff found that they conceive of safety as encompassing emotional as well as functional safety, and they accept some risk in order to remain in the home environment. This work emphasizes the need for setting-specific patient engagement to tailor safety efforts.
Dietz I, Plog A, Jox RJ, et al. J Palliat Med. 2014;17:331-7.
This survey of palliative care workers in Germany sought to identify common medical errors in this setting. The majority of errors were related to communication, system failures, and medication administration, including opioid overdose.
Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.
Advance care planning (ACP) has become an increasingly utilized process for exploring and communicating patients' preferences for end-of-life care. This multicenter audit of ACP practices across 12 hospitals in Canada found that even when patients and families have completed ACP, inpatient health care providers are not discussing these preferences during hospitalization nor are they documenting these decisions in the medical record. When there was chart documentation, it did not match the patients' expressed wishes more than two-thirds of the time. The majority of audited cases found that patients were prescribed more aggressive care than they would have preferred. An accompanying editorial argues that these types of "silent misdiagnoses" should be considered medical errors, noting that discussions about code status and ACP are "every bit as important to patient safety as a central line placement or a surgical procedure." A previous AHRQ WebM&M commentary discussed ACP and other tools for expressing end-of-life preferences.
Dietz I, Borasio GD, Molnar C, et al. J Palliat Med. 2013;16:74-81.
Patients receiving palliative care can be medically complex and often require medications considered high-risk (such as opioid pain medications). These factors are known to be associated with an increased risk of medical errors, but thus far, few studies have examined patient safety risks in palliative care patients. This survey of palliative medicine physicians in Germany found that most considered errors to be a significant problem in palliative care, and respondents cited medication errors and errors related to communication as the most common types of patient safety problems in the field. An AHRQ WebM&M case discusses a preventable adverse event that occurred in a palliative care patient.
Public reporting of mortality indicators forces hospitals to evaluate each death as a potentially poor outcome. This commentary discusses the tension between delivering high quality palliative care and the often paradoxical increase in mortality.
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.
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