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Article Synopsis
  • Pragmatic clinical trials (PCTs) focus on evaluating real-world effectiveness to address the limitations of traditional randomized clinical trials (RCTs), which often do not reflect actual medical practices.
  • There is a tension in PCTs between minimizing the burden on patients and healthcare institutions while ensuring comprehensive data collection, particularly regarding patient-reported outcomes for vulnerable populations.
  • The article suggests a risk-based approach to additional data collection in PCTs to better capture safety and patient experience outcomes, with examples from interventions aimed at improving end-of-life care, like the Liverpool Pathway and POLST in Oregon.
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An increasing recognition over the past five decades of the importance of patients' autonomy and the right to be able to choose to limit medical treatment at the end of life has led to the development of a number of documents related to advance care planning, including the advance directive, medical power of attorney, and portable orders for life-sustaining treatment (POLST). While these documents are important aspects of advance care planning, without having goals-of-care conversations, a specific plan, and necessary supports to achieve these goals, the documents alone offer a false promise. Healthcare professionals must be trained on how to have indepth goals-of-care conversations with patients and their families, and effectively document the decisions.

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"Has Anything Changed Since Then?": A Framework to Incorporate Prior Goals-of-Care Conversations Into Decision-Making for Acutely Ill Patients.

J Pain Symptom Manage

April 2021

Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, The University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

When assuming care for a seriously ill hospitalized patient, we should find documentation of previous decisions about goals of care so that our conversation takes advantage of previous discussions and reduces decision-making burden on the patient, particularly when the patient is clinically declining and time is short. This article presents a framework to help clinicians incorporate prior goals of care conversations into decision-making for an acutely ill patient. When there is strong evidence that a previous decision still applies, clinicians should, after a brief check-in about the previous decision with the patient, then present a plan consistent with their previous decision as a default option, to which they can opt out.

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The addition of a do-not-operate (DNO) section to current medical orders for life-sustaining treatment (MOLST) and physician orders for life-sustaining treatment (POLST) medical order forms would more completely document patients' wishes for invasive interventions at the end of life. We propose a modification of the MOLST and POLST forms, in addition to hospital and electronic medical records, to include a DNO section, in addition to preexisting do-not-resuscitate (DNR) and do-not-intubate (DNI) orders, with the goal of reducing suffering from nonbeneficial surgical interventions in patients with severe illness at the end of life.

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The Ethics Subcommittee of AMDA-The Society for Post-Acute and Long-Term Care Medicine ("The Society") presents arguments for and against Stopping Eating and Drinking by Advance Directives (SED by AD). SED by AD is a type of advance directive in which a proxy is instructed to stop offering food and fluids to a person when they reach a certain stage of dementia. Although most conversations regarding SED by AD focus on patient autonomy and the right to determine one's care, we propose that the ethical principle of justice-the obligation to treat all individuals equally regardless of race, gender, and physical or cognitive ability-is the decisive principle in this controversy.

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