Are Health-Care Providers Well Prepared in Providing Optimal End-of-Life Care to Critically Ill Patients? A Cross-Sectional Study at a Tertiary Care Hospital in the United States
Rajdev, Kartikeya; Loghmanieh, Nina; Farberov, Maria A; Demissie, Seleshi; Maniatis, Theodore
It is important for health-care providers to be comfortable in providing end-of-life (EOL) care to critically ill patients and realizing when continuing aggressive measures would be futile. Therefore, there is a need to understand health-care providers' self-perceived skills and barriers to providing optimum EOL care. A total of 660 health-care providers from medicine and surgery departments were asked via e-mail to complete an anonymous survey assessing their self-reported EOL care competencies, of which 238 responses were received. Our study identified several deficiencies in the self-reported EOL care competencies among health-care providers. Around 34% of the participants either disagreed (strongly disagree or disagree) or were neutral when asked whether they feel well prepared for delivering EOL care. Around 30% of the participants did not agree (agree and strongly agree) that they were well prepared to determine when to refer patients to hospice. 51% of the participants, did not agree (agree and strongly agree) that clear and accurate information is delivered by team members to patients/family. The most common barrier to providing EOL care in the intensive care unit was family not accepting the patient's poor prognosis. Nursing staff (registered nurse) had higher knowledge and attitudes mean competency scores than the medical staff. Attending physicians reported stronger knowledge competencies when compared to residents and fellows. More than half of the participants denied having received any previous training in EOL care. 82% of the participants agreed that training should be mandatory in this field. Most of the participants reported that the palliative care team is involved in EOL care when the patient is believed to be terminally ill. Apart from a need for a stronger training in the field of EOL care for health-care providers, the overall policies surrounding EOL and palliative care delivery require further evaluation and improvement to promote better outcomes in caring patients at the EOL.
Predicting biochemical response to clomiphene citrate in men with hypogonadism
Mazzola, Clarisse R; Katz, Darren J; Loghmanieh, Nina; Nelson, Christian J; Mulhall, John P
INTRODUCTION/BACKGROUND:Clomiphene citrate (CC) is as an effective treatment for men with hypogonadism (HG). Identifying the ideal candidate for this strategy has to date largely relied upon a patient's interest in preservation of testicular volume and spermatogenesis. AIM/OBJECTIVE:This analysis was undertaken to define if predictors existed of robust elevation in serum testosterone (T) levels in response to CC. METHODS:Seventy-six men with a diagnosis of HG (two separate early morning total T levels <300â€‰ng/dL) opting for CC therapy constituted the study population. Demographic, comorbidity data, and physical and laboratory characteristics were recorded. Laboratory tests were conducted 4 weeks after commencement and every 6 months thereafter. Multivariable analysis was conducted to define if predictors of biochemical response could be identified. Parameters included in the model were patient age, mean testicular volume, varicocele presence, and baseline total T, free T, and luteinizing hormone (LH) levels. MAIN OUTCOME MEASURE/METHODS:Successful biochemical response to CC, defined as an increase of â‰¥200â€‰ng/dL in total T level at â‰¥6 months after commencing CC, was the main outcome measure. RESULTS:Mean age was 46â€‰Â±â€‰22 years. Mean pretreatment testicular volume was 16â€‰Â±â€‰8â€‰mL. Mean baseline T and LH levels were 179â€‰Â±â€‰72â€‰ng/dL and 7.2â€‰Â±â€‰5.6â€‰IU/mL, respectively. Mean total T on CC was 467â€‰Â±â€‰190â€‰ng/dL. Forty-seven patients (62%) met the responder definition, with a mean increase in total T levels of 302â€‰Â±â€‰76 (204-464) ng/dL. In CC responders, the mean LH rise was 5.6â€‰Â±â€‰3.1â€‰IU/mL. On multivariable analysis, factors predictive of CC response included: mean testicular volume (adjusted [adj.] râ€‰=â€‰0.32, Pâ€‰<â€‰0.01), mean testicular volume â‰¥14â€‰mL (hazard ratio [HR] 2.2, Pâ€‰<â€‰0.01), LH level (adj. râ€‰=â€‰0.48, Pâ€‰<â€‰0.001), and LH level â‰¤6â€‰IU/mL (HR 3.5, Pâ€‰<â€‰0.001). CONCLUSION/CONCLUSIONS:These data indicate that two thirds of men with HG meet a robust responder definition and that pretreatment testicular volume and LH levels (in continuous and dichotomized fashions) are predictors of response.