Clinical medicine (London, England)
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National guidelines provide advice for end-of-life care in patients with prolonged disorders of consciousness (PDOC). Following a Supreme Court judgment in July 2018, updated guidelines set out requirements to ensure that decisions to withdraw clinically assisted nutrition and hydration (CANH) are made responsibly in the absence of a mandatory application to the court. This retrospective 8-year cohort analysis of prospectively collected clinical data examines the experience and lessons learned from implementing the guidelines in the 80 PDOC patients who have died in one tertiary centre since 2014. ⋯ CANH was withdrawn in 39/80 (49%) of the patients, over half of whom were already imminently dying. Even in a centre where patients are referred for this purpose, elective CANH withdrawal is comparatively rare (just 14 patients since 2018). The requirements were met in all cases.
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The National Early Warning Score (NEWS), published in 2012, made no specific adjustments for older people. The updated NEWS2 (2017) incorporated new confusion as a category for consciousness. ⋯ We consider the evidence of NEWS and NEWS2 in assessment of the older person in different settings, including the potential benefits and limitations for care home residents. We suggest that NEWS2 may need adaptation for older people in future iterations, and that it should be used in conjunction with other clinical assessments, such as the Clinical Frailty Scale and the four 'A's test (4AT) for delirium.
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As more healthcare is provided in non-hospital settings, it is essential to support clinicians in recognising early signs of clinical deterioration to enable prompt intervention and treatment. There are intuitive reasons why the use of the National Early Warning Score 2 (NEWS2) in out-of-hospital settings may enhance the community response to acute illness by using a common language across healthcare. An additional advantage of the use of NEWS2 in community settings is that it is not disease specific and requires no expensive technology or great expertise to take a full set of observations that can be an indicator of clinical acuity. However, concerns have been expressed as NEWS2 was developed in acute hospital settings that it may not be applicable in community settings; this review shares some of the practical ways that NEWS2 can support clinical practice along with the emerging published evidence.
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The emergence of the COVID-19 pandemic resulted in a dramatic increase in acutely ill patients presenting to hospitals with life-threatening acute respiratory disease. There was an immediate need for effective triage systems to facilitate clinical decision making. This review assesses the performance of the National Early Warning Score 2 (NEWS2) in two contexts. ⋯ A NEWS2 of 5 had high short-term sensitivity within and was unlikely to miss patients with COVID-19 who go on to deteriorate, but this comes with moderate specificity. However, the specificity of these systems is likely underestimated because preventing deterioration is their purpose. NEWS2 is an adjunct to clinical decision making and has served that purpose during the COVID-19 pandemic, playing an important role in communicating illness severity, clinical deterioration, triaging patients to appropriate levels of care and prompting completion of treatment escalation plans for those with high scores and at imminent risk of deterioration.
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The National Early Warning Score (NEWS) has been widely adopted for use in clinical practice in the UK since its introduction in 2012. It is designed to improve patient safety. The original score was adapted in 2017 to improve patient safety further by introducing a separate score for oxygen saturation to be used in selected patients with respiratory diseases. In this article, evidence for the effectiveness of the improved score is reviewed.