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Core Elements of Goals of Care Initiatives Across Eight Health Systems.
No full textFor patients with serious illnesses, goals of care conversations improve quality of life and patient and family satisfaction and may reduce healthcare costs. However, these conversations often happen late in a serious illness or not at all. To better integrate goals of care into routine clinical practice, health systems across the country have implemented initiatives to increase and document these conversations. In this article, we describe the landscape of goals of care initiatives across eight large health systems in the U.S. and identify core elements for effective programs: 1) Defining the purpose of the initiative; 2) identifying the target patient population using patient diagnoses, artificial intelligence algorithms, or length of stay; 3) engaging key stakeholders, including patient, caregiver, frontline provider, and leadership; 4) encouraging the conversation through clinician and patient education and electronic health record (EHR) prompts; 5) documenting conversations within the EHR; 6) measuring data by building EHR and information technology infrastructure; and 7) planning for sustainability and scalability through leadership and funding support. These core elements can help inform how health systems plan goals of care initiatives, build infrastructure, and garner support to successfully implement these initiatives
A QI: Implementing PAWSS and CIWA Adherence Challenge in the Psychiatric Emergency Department
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Impact of ischaemia duration and clamping strategy in patients with solitary kidney undergoing partial nephrectomy.
No full textOBJECTIVES: To explore the effects of ischaemia time (IT) in a multicentre cohort of patients with solitary kidney (SK), treated with partial nephrectomy (PN) for a renal mass, on short- and long-term kidney function, haemorrhagic risk and pathological outcomes.
METHODS: This is an observational study of 426 patients with SK treated with on- and off-clamp PN for a single cT1-3 N0M0 renal mass from 2000 to 2023 at 19 global institutions. The primary outcomes were postoperative and 1-year renal function. The secondary outcomes of the study were haemorrhagic risk, defined as estimated blood loss (EBL) and peri-operative transfusions, and presence of positive surgical margins. The effect of IT and arterial clamping strategy was estimated using linear and logistic regressions for continuous and categorical outcomes, respectively.
RESULTS: On-clamp PN was performed in 56% of patients (n = 237). The median (interquartile range [IQR]) age, body mass index, preoperative estimated glomerular filtration rate (eGFR), clinical size and PADUA score were 65 (58-71) years, 27 (24-29) kg/m
CONCLUSIONS: In patients with SK, on-clamp PN did not affect long-term renal function and was associated with a modestly lower need for peri-operative transfusion. The routine use of the off-clamp technique is therefore not supported by these findings, although its selective application may remain appropriate in cases with a high risk of renal function decline
Neither Salve nor Solution: Clinical Ethics and the Struggle to Discover the Moral Life of Medicine.
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GLP-1 receptor agonists and next-generation metabolic hormone therapies in chronic kidney disease.
No full textChronic kidney disease (CKD) remains a major public health problem, with type 2 diabetes and obesity representing key risk factors worldwide. The complex pathophysiology and the metabolic risk factors shared between type 2 diabetes, obesity, CKD and cardiovascular disease have led to the concept of a cardiovascular-kidney-metabolic (CKM) syndrome. The treatment landscape for CKM changed dramatically when agents from several medication classes, originally developed as glucose-lowering therapies, were recognized to reduce the risk of multiple components of CKM syndrome. Incretin-based therapies, including glucagon-like peptide-1 receptor agonists (GLP-1RAs) and dual glucose-dependent insulinotropic-GLP-1RAs, have evolved from metabolic therapies to agents with either proven or potential protective effects on the kidney and heart. In addition to their potent metabolic actions that reduce hyperglycaemia and body weight, GLP-1RAs also lower the risk of major kidney, cardiovascular and mortality outcomes across broad populations with cardiovascular disease or CKD, with and without diabetes or obesity. GLP-1RAs have been combined with glucose-dependent insulinotropic agonism, as well as glucagon agonism or amylin analogues to further enhance their metabolic benefits. However, kidney and heart protection are not fully explainable by the metabolic actions of these agents. Rather, a growing body of evidence suggests that the systemic and local actions of incretins and metabolic hormones modulate multiple pathways that can promote inflammatory and fibrotic injury