Browsing by Author "Bosslet, Gabriel T."
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Item Aligning use of intensive care with patient values in the USA: past, present, and future.(Elsevier, 2019-07-01) Turnbull, Alison E; Bosslet, Gabriel T.; Kross, Erin K.; Medicine, School of MedicineFor more than three decades, both medical professionals and the public have worried that many patients receive non-beneficial care in US intensive care units during their final months of life. Some of these patients wish to avoid severe cognitive and physical impairments, and protracted deaths in the hospital setting. Recognising when intensive care will not restore a person’s health, and helping patients and families embrace goals related to symptom relief, interpersonal connection, or spiritual fulfilment are central challenges of critical care practice in the USA. We review trials from the past decade of interventions designed to address these challenges, and present reasons why evaluating, comparing, and implementing these interventions have been difficult. Careful scrutiny of the design and interpretation of past trials can show why improving goal concordant care has been so elusive, and suggest new directions for the next generation of research.Item Balancing Demands: Determinants of Burnout Reported by Fellows in Pulmonary and Critical Care Medicine(American Thoracic Society, 2021-01-29) O’Toole, Jacqueline; Zaeh, Sandra; Eakin, Michelle N.; Adelman, Mark H.; Ashton, Rendell W.; Daugherty Biddison, Lee; Bosslet, Gabriel T.; Burkart, Kristin M.; Doyle, Stephen T.; Khan, Malik M. Khurram S.; Lenz, Peter H.; McCallister, Jennifer W.; Rand, Cynthia S.; Riekert, Kristin A.; Soffler, Morgan I.; Winter, Gretchen R.; Sharp, Michelle; Medicine, School of MedicineBackground: Burnout is common among physicians who care for critically ill patients and is known to contribute to worse patient outcomes. Fellows training in pulmonary and critical care medicine (PCCM) have risk factors that make them susceptible to burnout; for example, clinical environments that require increased intellectual and emotional demands with long hours. The Accreditation Council for Graduate Medical Education has recognized the increasing importance of trainee burnout and encourages training programs to address burnout. Objective: To assess factors related to training and practice that posed a threat to the well-being among fellows training in PCCM and to obtain suggestions regarding how programs can improve fellow well-being. Methods: We conducted a qualitative content analysis of data collected from a prior cross-sectional electronic survey with free-response questions of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States. Fellows were asked what factors posed a threat to their well-being and what changes their training program could implement. Responses were qualitatively coded and categorized into themes using thematic analysis. Results: A total of 427 fellows (44% of survey respondents) completed at least one free-response question. The majority of respondents (60%) identified as male and white/non-Hispanic (59%). The threats to well-being and burnout were grouped into five themes: clinical burden, individual factors, team culture, limited autonomy, and program resources. Clinical burden was the most common threat discussed by fellows. Fellows highlighted factors contributing to burnout that specifically pertained to trainees including challenging interpersonal relationships with attending physicians and limited protected educational time. Fellows proposed solutions addressing clinical care, changes at the program or institution level, and organizational culture changes to improve well-being. Conclusion: This study provides insight into factors fellows report as contributors to burnout and decreased well-being in addition to investigating fellow-driven solutions toward improving well-being. These solutions may help pulmonary, PCCM, and critical care medicine program directors better address fellow well-being in the future.Item CEASE: A guide for clinicians on how to stop resuscitation efforts(ATS, 2015-03) Torke, Alexia M.; Bledsoe, Patricia; Wocial, Lucia D.; Bosslet, Gabriel T.; Helft, Paul R.; Department of Medicine, IU School of MedicineResuscitation programs such as Advanced Cardiac Life Support, Cardiac Life Support, Pediatric Advanced Life Support, and the Neonatal Resuscitation Program offer inadequate guidance to physicians who must ultimately decide when to stop resuscitation efforts. These decisions involve clinical and ethical judgments and are complicated by communication challenges, group dynamics, and family considerations. This article presents a framework, summarized in a mnemonic (CEASE: Clinical Features, Effectiveness, Ask, Stop, Explain), for how to stop resuscitation efforts and communicate that decision to clinicians and ultimately the patient’s family. Rather than a decision rule, this mnemonic represents a framework based on best evidence for when physicians are considering stopping resuscitation efforts and provides guidance on how to communicate that decision.Item Disclosing Medical Mistakes: A Communication Management Plan for Physicians(2013-04) Petronio, Sandra; Torke, Alexia M.; Bosslet, Gabriel T.; Isenberg, Steven; Wocial, Lucia D.; Helft, Paul R.Introduction: There is a growing consensus that disclosure of medical mistakes is ethically and legally appropriate, but such disclosures are made difficult by medical traditions of concern about medical malpractice suits and by physicians’ own emotional reactions. Because the physician may have compelling reasons both to keep the information private and to disclose it to the patient or family, these situations can be conceptualized as privacy dilemmas. These dilemmas may create barriers to effectively addressing the mistake and its consequences. Although a number of interventions exist to address privacy dilemmas that physicians face, current evidence suggests that physicians tend to be slow to adopt the practice of disclosing medical mistakes. Methods: This discussion proposes a theoretically based, streamlined, two-step plan that physicians can use as an initial guide for conversations with patients about medical mistakes. The mistake disclosure management plan uses the communication privacy management theory. Results: The steps are 1) physician preparation, such as talking about the physician’s emotions and seeking information about the mistake, and 2) use of mistake disclosure strategies that protect the physician-patient relationship. These include the optimal timing, context of disclosure delivery, content of mistake messages, sequencing, and apology. A case study highlighted the disclosure process. Conclusion: This Mistake Disclosure Management Plan may help physicians in the early stages after mistake discovery to prepare for the initial disclosure of a medical mistakes. The next step is testing implementation of the procedures suggested.Item The effect of in-person primary and secondary school instruction on county-level SARS-CoV-2 spread in Indiana(Oxford, 2021) Bosslet, Gabriel T.; Pollak, Micah; Jang, Jeong Hoon; Roll, Rebekah; Sperling, Mark; Khan, Babar; Medicine, School of MedicineBackground To determine the county-level effect of in-person primary and secondary school reopening on daily cases of SARS-CoV-2 in Indiana. Methods This is a county-level population-based study using a panel data regression analysis of the proportion of in-person learning to evaluate an association with community-wide daily new SARS-CoV-2 cases. The study period was July 12-October 6, 2020. We included 73 out of 92 (79.3%) Indiana counties in the analysis, accounting for 85.7% of school corporations and 90.6% of student enrollement statewide. The primary exposure was the proportion of students returning to in-person instruction. The primary outcome was the daily new SARS-CoV-2 cases per 100,000 residents at the county level. Results There is a statistically significant relationship between the proportion of students attending K-12 schools in-person and the county level daily cases of SARS-CoV-2 28 days later. For all ages, the coefficient of interest (β) is estimated at 3.36 (95% CI: 1.91—4.81; p < 0.001). This coefficient represents the effect of a change the proportion of students attending in-person on new daily cases 28 days later. For example, a 10 percentage point increase in K-12 students attending school in-person is associated with a daily increase in SARS-CoV-2 cases in the county equal to 0.336 cases/100,000 residents of all ages. Conclusion In-person primary and secondary school is associated with a statistically significant but proportionally small increase in the spread of SARS-CoV-2 cases.Item The Effect of In-Person Primary and Secondary School Instruction on County-Level Severe Acute Respiratory Syndrome Coronavirus 2 Spread in Indiana(Oxford University Press, 2022-01-07) Bosslet, Gabriel T.; Pollak, Micah; Jang, Jeong Hoon; Roll, Rebekah; Sperling, Mark; Khan, Barbara; Medicine, School of MedicineBackground: Our goal was to determine the county-level effect of in-person primary and secondary school reopening on daily cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Indiana. Methods: In this county-level, population-based study, we used a panel data regression analysis of the proportion of in-person learning to evaluate an association with community-wide daily new SARS-CoV-2 cases. The study period was 12 July 2020-6 October 2020. We included 73 of 92 (79.3%) Indiana counties in the analysis, accounting for 85.7% of school corporations and 90.6% of student enrollment statewide. The primary exposure was the proportion of students returning to in-person instruction. The primary outcome was the daily new SARS-CoV-2 cases per 100 000 residents at the county level. Results: There is a statistically significant relationship between the proportion of students attending K-12 schools in-person and the county level daily cases of SARS-CoV-2 28 days later. For all ages, the coefficient of interest (β) is estimated at 3.36 (95% confidence interval, 1.91 to 4.81; P < .001). This coefficient represents the effect of a change in the proportion of students attending in-person on new daily cases 28 days later. For example, a 10 percentage point increase in K-12 students attending school in-person is associated with a daily increase in SARS-CoV-2 cases in the county equal to 0.336 cases/100 000 residents of all ages. Conclusions: In-person primary and secondary school is associated with a statistically significant but proportionally small increase in the spread of SARS-CoV-2 cases.Item The Family Navigator: A pilot intervention to support intensive care unit family surrogates(American Association of Critical Care Nurses, 2016-11) Torke, Alexia M.; Wocial, Lucia D.; Johns, Shelley A.; Sachs, Greg A.; Callahan, Christopher M.; Bosslet, Gabriel T.; Slaven, James E.; Perkins, Susan M.; Hickman, Susan E.; Montz, Kianna; Burke, Emily; Medicine, School of MedicineBackground Although communication problems between family surrogates and intensive care unit (ICU) clinicians have been documented, there are few effective interventions. Nurses have the potential to play an expanded role in ICU communication and decision making. Objectives To conduct a pilot randomized controlled trial of the Family Navigator (FN), a distinct nursing role to address family members’ unmet communication needs early in an ICU stay. Methods An inter-disciplinary team developed the FN protocol. A randomized controlled pilot intervention trial of the FN was performed in a tertiary referral hospital ICU to test the feasibility and acceptability of the intervention. The intervention addressed informational and emotional communication needs through daily contact using structured clinical updates, emotional and informational support modules, family meeting support and follow-up phone calls. Results Twenty-six surrogate/patient pairs (13 per study arm) were enrolled. Surrogates randomized to the intervention had contact with the FN 90% or more of eligible patient days. All surrogates agreed or strongly agreed that they would recommend the FN to other families. Open-ended comments from both surrogates and clinicians were uniformly positive. For both groups, 100% of baseline data collection interviews and 81% of 6–8 week follow-up interviews were completed. Conclusions A fully integrated nurse empowered to facilitate decision making is a feasible intervention in the ICU setting. It is well-received by ICU families and staff. A larger randomized controlled trial is needed to demonstrate an impact on important outcomes, such as surrogate well-being and decision quality.Item How Surrogates Decide: A Secondary Data Analysis of Decision-Making Principles Used by the Surrogates of Hospitalized Older Adults(Springer Nature, 2017-12) Devnani, Rohit; Slaven, James E., Jr.; Bosslet, Gabriel T.; Montz, Kianna; Inger, Lev; Burke, Emily S.; Torke, Alexia M.; Biostatistics, School of Public HealthBACKGROUND: Many hospitalized adults do not have the capacity to make their own health care decisions and thus require a surrogate decision-maker. While the ethical standard suggests that decisions should focus on a patient's preferences, our study explores the principles that surrogates consider most important when making decisions for older hospitalized patients. OBJECTIVES: We sought to determine how frequently surrogate decision-makers prioritized patient preferences in decision-making and what factors may predict their doing so. DESIGN AND PARTICIPANTS: We performed a secondary data analysis of a study conducted at three local hospitals that surveyed surrogate decision-makers for hospitalized patients 65 years of age and older. MAIN MEASURES: Surrogates rated the importance of 16 decision-making principles and selected the one that was most important. We divided the surrogates into two groups: those who prioritized patient preferences and those who prioritized patient well-being. We analyzed the two groups for differences in knowledge of patient preferences, presence of advance directives, and psychological outcomes. KEY RESULTS: A total of 362 surrogates rated an average of six principles as being extremely important in decision-making; 77.8% of surrogates selected a patient well-being principle as the most important, whereas only 21.1% selected a patient preferences principle. Advance directives were more common to the patient preferences group than the patient well-being group (61.3% vs. 44.9%; 95% CI: 1.01-3.18; p = 0.04), whereas having conversations with the patient about their health care preferences was not a significant predictor of surrogate group identity (81.3% vs. 67.4%; 95% CI: 0.39-1.14; p = 0.14). We found no differences between the two groups regarding surrogate anxiety, depression, or decisional conflict. CONCLUSIONS: While surrogates considered many factors, they focused more often on patient well-being than on patient preferences, in contravention of our current ethical framework. Surrogates more commonly prioritized patient preferences if they had advance directives available to them.Item The Importance of Showing Our Work: Process Transparency in Dispute Resolution(ATS, 2019) Bosslet, Gabriel T.; Hart, Joanna L.; Turnbull, Alison E.; Medicine, School of MedicineItem Medical Societies Must Choose Professional Meeting Locations Responsibly in a Post- Roe World(American Thoracic Society, 2023) Lee, Alison G.; Maley, Jason; Hibbert, Kathryn; Akgün, Kathleen M.; Hauschildt, Katrina E.; Law, Anica; Kaminski, Naftali; Hayes, Margaret; Gesthalter, Yaron; Bosslet, Gabriel T.; Santhosh, Lekshmi; Witkin, Alison; Hills-Dunlap, Kelsey; Çoruh, Başak; Gershengorn, Hayley B.; Hardin, C. Corey; Medicine, School of Medicine