Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care

Education for people with serious chronic respiratory diseases and their informal caregivers: how to address challenges that impact learning

PURPOSE OF REVIEW

Shared decision making is crucial in palliative care for people with serious chronic respiratory diseases and their informal caregivers. Patient education is a critical component in this process, as it provides patients and their informal caregivers the necessary knowledge for informed decisions regarding symptom management, coping with breathlessness, and advance care planning. However, education does not automatically lead to acquiring knowledge. This review describes challenges for education for people with serious chronic respiratory diseases and their informal caregivers and describes how learner-centered education can address these.

RECENT FINDINGS

People with serious chronic respiratory diseases and their informal caregivers face diverse information needs and learning challenges, with low health literacy and cognitive problems being common. Healthcare professionals can facilitate learner-centered education by enhancing motivation for knowledge acquisition by meeting information needs and learning preferences of patients and their informal caregivers, and by ensuring that information is understandable and readable for those with low health literacy and cognitive problems. E-health applications may serve as valuable tools in this process.

SUMMARY

Learner-centered education may enhance knowledge acquisition in people with serious chronic respiratory diseases and their informal caregivers aiming to gain control over symptoms and optimize shared decision making and advance care planning.

Embracing ambivalence and hesitation: a Ricoeurian perspective on anticipatory choice processes at the end of life

Especially older adults are increasingly stimulated to think about, talk about and record their preferences with regard to future (health)care decisions, preferably in a pro-active manner. In this paper, I analyse these anticipatory choice processes. My goal is twofold: Firstly, to provide a deeper understanding of what it actually means to decide in advance about end-of-life treatments or options. Secondly, to make a theoretical contribution to bioethics and ACP-theories by rethinking the concept of end-of-life choices from a phenomenological viewpoint. To achieve this, I start by presenting a case narrative that elucidates how these anticipatory choices are lived. Secondly, I map out a theoretical framework about choice based on the phenomenology of the will of Paul Ricoeur. Finally, guided by this Ricoeurian framework, I investigate the potential meaning of choice in the context of contemporary advance care planning trajectories. The analysis demonstrates that choice and agency always imply notions of passivity and uncontrollability. It also indicates the significant value of hesitation and ambivalence. Moreover, it highlights the importance of the notion of co-responsibility in the context of anticipated end-of-life choices, and the relevant distinction between a (willed) choice and a wish. To improve care and support regarding end-of-life trajectories and to promote meaningful conversations, it is imperative to integrate these underrated elements more substantially in our theories, language and practical approaches. I conclude by suggesting that, in order to do justice to the real-life complexities, we might even need to revise the notion of advance 'directives'.

Feasibility and acceptability of the ShareD dEciSIon making for patients with kidney failuRE to improve end-of-life care intervention: A pilot multicentre randomised controlled trial

Background

Kidney failure is associated with a high disease burden and high mortality rates. National and international guidelines recommend health professionals involve patients with kidney failure in making decisions about end-of-life care, but implementation of these conversations within kidney services varies. We developed the DESIRE (ShareD dEciSIon-making for patients with kidney failuRE to improve end-of-life care) intervention from our studies investigating multiple decision maker needs and experiences of end-of-life care in kidney services. The DESIRE intervention's three components are a training programme for health professionals, a patient decision aid, and a kidney service consultation held to facilitate shared decision-making conversations about planning end-of-life care.

Objectives

To assess the feasibility and acceptability of integrating the DESIRE intervention within kidney services.

Design

A pilot study using a multicentre randomised controlled design.

Setting

Four Danish nephrology departments.

Participants

Patients with kidney failure who were 75 years of age or above, their relatives, and health professionals.

Methods

Patients were randomised to either the intervention or usual care. Feasibility data regarding delivering the intervention, the trial design, and outcome measures were collected through questionnaires and audio recordings at four points in time: before, during, post, and 3 months after the intervention. Acceptability data were collected through semi-structured interviews with patients and relatives, as well as a focus group with health professionals post the intervention.

Results

Twenty-seven patients out of the 32 planned were randomised either to the intervention (n= 14) or usual care (n= 13). In addition, four relatives and 12 health professionals participated. Follow-up was completed by 81 % (n= 22) of patient participants. We found that both feasibility and acceptability data suggested health professionals improved their decision support and shared decision-making skills via the training. Patient and relative participants experienced the intervention as supporting a shared decision-making process; from audio recordings, we showed health professionals were able to support proactively decision-making about end-of-life care within these consultations. All stakeholders perceived the intervention to be effective in promoting shared decision-making and relevant for supporting end-of-life care planning.

Conclusions

Participant feedback indicated that the DESIRE intervention can be integrated into practice to support patients, relatives, and health professionals in planning end-of-life care alongside the management of worsening kidney failure. Minimising exhaustion and enhancing engagement with the intervention should be a focus for subsequent refinement of the intervention.

Registration

The study has been registered at ClinicalTrials.gov with the identifier: NCT05842772. Date of first recruitment: March 20, 2023.

Culturally Adapted RN-MD Collaborative SICP-Based ACP: Feasibility RCT in Advanced Cancer Patients

CONTEXT

Cultural adaptation is essential for optimizing programs centered around autonomy, such as the Serious Illness Care Program (SICP), especially for populations valuing family-involved decision-making.

OBJECTIVES

We aimed to evaluate the feasibility and efficacy of a culturally adapted SICP-based nurse-physician collaborative Advance Care Planning (ACP) intervention tailored for patients with advanced cancer who prefer family-involved decision-making.

METHODS

Oncology nurses, extensively trained and closely collaborating with physicians, conducted structured discussions with patients in the intervention group. The culturally adapted SICP-based ACP intervention was supplemented with trust-building, family involvement, and understanding of patient values. Primary inclusion criteria included patients within six weeks of initiating first-line palliative chemotherapy. Primary endpoints were achieving a 70% completion rate and assessing spiritual well-being (FACIT-Sp) at six months. Secondary endpoints included anxiety (GAD-7), depression (PHQ-9), quality of life (QOL) (CoQoLo), and ACP progress (ACP Engagement Scale) at the same interval.

RESULTS

Forty-one patients (67.2%) completed the six-month follow-up, falling short of the targeted completion rate. The least-squares mean change from baseline in spiritual well-being at six months was 3.00 in the intervention group and -2.22 in the standard care group (difference, 5.22 points; 95% confidence interval, 1.38-9.06; P = 0.009). Similar superiority of the intervention was observed in QOL and ACP progress.

CONCLUSION

Despite not meeting the targeted completion rate, the intervention group demonstrated enhanced spiritual well-being, QOL, and ACP progress. Our findings suggest revisions to the intervention manual to improve feasibility and to progress to an efficacy-focused randomized controlled trial.

Advance care planning readiness among community-dwelling older adults and the influencing factors: a scoping review

BACKGROUND

Advance care planning (ACP) is pivotal in mitigating end-of-life suffering and ensuring healthcare congruence with the values of older adults and dignity in death. Despite its paramount importance, the current readiness for ACP among community-dwelling older adults and the intricate influencing factors have yet to be explored.

OBJECTIVE

To review the literature focusing on ACP readiness among community-dwelling older adults and the influencing factors.

METHODS

A scoping review conducted using the Arksey and O'Malley (2005) framework. Electronic databases (PubMed, CINAHL, Cochrane, Web of Science, PsycINFO), as well as grey literature databases (OpenGrey and GreyLit.org) were searched to identify studies published in English between January 2012 and March 2023.

RESULTS

19 studies were selected, comprising 3 qualitative, 13 quantitative, 2 mixed-methods, and 1 review article. The study evaluated the readiness of older adults for ACP by examining their knowledge and attitudes. It categorizes influencing factors into intrinsic and extrinsic levels. This review revealed that the knowledge about ACP among older adults across all settings was limited. However, they had positive attitudes toward it. In addition, intrinsic factors including sociodemographic characteristics, psychological factors, and family relationships, along with extrinsic factors including health care professionals' attitudes and experience, as well as policies and laws, influenced the ACP readiness among older adults.

CONCLUSIONS

This study established the groundwork for future ACP intervention trials, providing a theoretical framework to guide their design and implementation. operationalization.

[Palliative neurology]

Palliative medicine represents the holistic multiprofessional treatment of severely and incurably ill people and their relatives, addressing their complex physical, psychological, social and spiritual needs. The central therapeutic goals are the quality of life and alleviation of suffering. In the course of many neurological diseases, high symptom burden, long and variable trajectories and unfavorable prognosis at times create a need for palliative care even at an early stage, which is currently still inadequately met. This can be countered by qualified neuropalliative care. In addition to intensifying interdisciplinary collaboration, this requires neurologists to have core competencies in palliative care. These include a team-oriented attitude, communication skills, expertise in symptom control and knowledge of biomedical ethics including palliative options at the end of life.

Perspectives of patients, partners, primary and hospital-based health care professionals on living with advanced cancer and systemic treatment

PURPOSE

An emerging group of patients lives longer with advanced cancer while receiving systemic treatment. This study aimed to investigate psychosocial aspects of living longer with advanced cancer, and experiences with psychosocial care, from the perspectives of patients, partners, and health care professionals (HCPs).

METHODS

From May to December 2020, participants were purposively selected. In-depth, semi-structured interviews were conducted by video or phone call, containing open questions regarding psychosocial aspects and psychosocial care in oncology. The data was analysed following thematic analysis, leading to overarching psychosocial themes and indications for optimal organisation of psycho-oncological care.

RESULTS

Fifteen patients, seven partners and eleven HCPs were interviewed. The main psychosocial aspects were increasing loss in several life domains, complexity of making life choices, ongoing uncertainty, and fluctuating fear and hope. Partners were affected by their loved ones' condition and reported to put themselves second for longer periods of time, while sometimes missing adequate support. HCPs were challenged by addressing the altering psychosocial needs of patients, and tools to identify those in need for psychosocial support are currently lacking.

CONCLUSIONS

Living longer with advanced cancer presents unique challenges for patients and their partners, as well as for HCPs in delivering optimal psychosocial care.

IMPLICATIONS FOR CANCER SURVIVORS

Identifying and addressing patients' psychosocial needs from an early stage on, appointing a central hospital-based contact person, limiting the waiting time between scans and consultations, and addressing the partners' wellbeing are suggestions to organise optimal psychosocial support in advanced cancer.

Differing needs for Advance Care Planning in the Veterans Health Administration: use of latent class analysis to identify subgroups to enhance Advance Care Planning via Group Visits for veterans

BACKGROUND

Advance Care Planning via Group Visits (ACP-GV) is a patient-centered intervention facilitated by a clinician using a group modality to promote healthcare decision-making among veterans. Participants in the group document a "Next Step" to use in planning for their future care needs. The next step may include documentation of preferences in an advance directive, discussing plans with family, or anything else to fulfill their ACP needs. This evaluation seeks to determine whether there are identifiable subgroups of group participants with differing needs prior to delivery of the ACP-GV program and, if so, to use information about the subgroups to enhance the program offered to veterans in United States Department of Veterans Affairs (VA) healthcare settings.

METHODS

We conducted a secondary analysis of national data from a quality improvement evaluation. Patient- and provider-level data from administrative healthcare records for VA users in all 50 states, territories, and the District of Columbia provides data on veterans attending ACP-GV during federal fiscal years 2018-2022 (N = 26,857). Latent class analysis seeks to identify the various subgroups of veterans based on their level of ACP self-efficacy before attending ACP-GV and any demographic differences across the resulting subgroups of veterans attending ACP-GV. ACP self-efficacy is derived from seven items obtained from a participant worksheet used during the group.

RESULTS

Analysis revealed two distinct groups of veterans, distinguishable by their pre-ACP-GV levels of one aspect of ACP self-efficacy: prior knowledge of ACP. Veterans with higher prior knowledge of ACP are associated with an identified next step focused on checking their current AD status and updating it, and veterans with lower ACP prior knowledge are associated with identifying a next step to discuss ACP more fully with family. Differences in age, sex, race, ethnicity, and marital status exist across subgroups of veterans.

CONCLUSION

Greater attention must be paid to ACP and veterans' prior knowledge of ACP to consistently encourage annual review and status updates.

Together but still alone - A qualitative study exploring how family members of persons with incurable oesophageal or gastric cancer manage everyday life

BACKGROUND

Cancer affects not only the person with the disease but those around them. Being a family member is described as strenuous and, often, associated with stress, anxiety and feelings of loneliness. There is a heightened risk of distress for family of those with fast-progressing, severe oesophageal or gastric cancer. Early palliative care involving family is vital yet often overlooked. In order to include family members in early palliative care their management in everyday life needs to be explored.

METHOD

Qualitative inductive interview study using content analysis guided by Graneheim and Lundman.

RESULT

The analysis resulted in the overarching theme "Managing the disease together but still alone". Three categories were identified: Adapting to the disease, Taking control of the situation, Processing emotions. Each category described family members management in various aspects of everyday life together with the ill person and alone.

CONCLUSION

The results may contribute to an awareness of family members' management of large parts of everyday life and, further, their feelings of loneliness, and indicates that family members should be included early in oesophageal or gastric cancer palliative care. Further studies are needed to develop the content of such family-inclusive early palliative care.

Factors influencing dementia patients' participation in advance care planning: A meta-analysis

OBJECTIVE

A meta-analysis was conducted based on the available evidence to determine the influencing factors associated with the participation of people with dementia in advance care planning.

METHODS

A keyword search was performed in seven databases, Web of Science, PubMed, Embase, Cochrane Library, CINAHL, Scopus, and Void, to search for eligible studies published from the time of library construction up to February 1, 2024, to examine the factors influencing the participation of dementia patients in advance care planning and its effects. The quality of the included studies was evaluated using the Newcastle-Ottawa Scale (NOS) and the assessment criteria of the Agency for Healthcare Research and Quality (AHRQ). After literature search, data extraction and quality assessment were completed independently by two researchers, meta-analysis was performed using Stata software 15.0 to pool the odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity between studies was assessed using the Cochran chi-square test (Cochran 's Q) and I2 values.

RESULTS

A total of 19 studies were included in this study, and Meta-analysis showed that 8 of the 16 influencing factors were statistically significant: Patients' gender (OR=1.17; 95%: 1.13-1.2), age (OR=1.07; 95%: 1.03-1.1), education (OR=1.98; 95%: 1.65-2.38), race (OR=2.61; 95%: 1.67-4.08), the severity of the dementia (OR=1.46; 95%: 1.34- 1.58), ability to perform activities of daily living (OR=0.99; 95%: 0.97-1.0), religious affiliation (OR=2.24; 95%: 1.23-4.06), and patient income(OR=2.10; 95%: 1.47-2.98) were associated with participation in advance care planning.

CONCLUSIONS

The participation of dementia patients in advance care planning is influenced by gender, age, education, race, dementia severity, ability to perform activities of daily living, religious affiliation and patient income. The results of the study can inform the development of targeted interventions for dementia patients, thereby reducing overtreatment of dementia patients at the end of life and improving patient adherence to hospice care.

Advance care planning before and during the COVID-19 pandemic: an observational cohort study of 73 675 patients' records

BACKGROUND

Advance care planning (ACP) was encouraged by policymakers throughout the COVID-19 pandemic. Little is known about use of ACP during this time.

AIM

To compare use of ACP before and during the COVID-19 pandemic.

DESIGN & SETTING

Retrospective, observational cohort study comparing the creation, use, and content of Electronic Palliative Care Coordination System (EPaCCS) records in London. Individuals aged ≥18 years with a Coordinate My Care record, created and published in the pre-pandemic period (1 January 2018-31 December 2019), wave 1 (W1; 20 March 2020-4 July 2020), interwave (IW; 5 July 2020-30 September 2020), and wave 2 (W2; 1 October 2020-5 March 2021).

METHOD

Patient demographics and components of ACP were compared using descriptive and comparative statistics.

RESULTS

In total, 73 675 records were included; 35 108 pre-pandemic, 21 235 W1, 6323 IW, and 9925 W2 (n = 1084 records not stratified as created and published in different periods). Most records were created in primary care (55.6% pre-pandemic, 75.5% W1, and 47.7% W2). Compared with the pre-pandemic period, the average weekly number of records created increased by 296.9% W1 (P<0.005), 35.1% IW, and 29.1% W2 (P<0.005). Patients with records created during the pandemic were younger (60.8% aged ≥80 years W1, 57.5% IW, 59.3% W2, 64.9% pre-pandemic [P<0.005]). Patients with records created in W1 had longer estimated prognoses at record creation (73.3% had an estimated prognosis of ≥1 year W1 versus 53.3% pre-pandemic [P<0.005]) and were more likely to be 'for resuscitation' (38.2% W1 versus 29.8% pre-pandemic [P<0.005]).

CONCLUSION

During the COVID-19 pandemic increased ACP activity was observed, especially in primary care, for younger people and those not imminently dying. Further research is needed to identify training and planning requirements as well as organisational and system changes to support sustained high-quality ACP within primary care.

Improving completion rate of advance care planning at a tertiary rheumatological centre in Singapore: a quality improvement project

Advanced care planning (ACP) is a series of ongoing voluntary discussions between patients, families and healthcare professionals to plan for their future healthcare needs. Despite patients with rheumatic diseases having high symptom burden and disease complications, the ACP completion rates in patients with rheumatic diseases remain low. In this quality improvement project, we aimed to increase the number of completed ACP in a tertiary referral rheumatology centre in Singapore from 0 to 1 per month. We showed a statistically significant increase in ACP completion across 1 year with two Plan-Do-Study-Act cycles. Further studies are needed to explore further interventions for ACP completion in patients with rheumatic diseases.

Use of antithrombotic therapy and the risk of cardiovascular outcomes and bleeding in cancer patients at the end of life: a Danish nationwide cohort study

BACKGROUND

Despite uncertain benefit-risk profile near the end of life, antithrombotic therapy (ATT) is prevalent in patients with terminal cancer.

OBJECTIVES

To examine adherence and persistence with ATT in terminally ill cancer patients and investigate risks of major and clinically relevant bleeding, venous thromboembolism (VTE), and arterial thromboembolism (ATE) by ATT exposure.

METHODS

Using a Danish nationwide cohort of terminal cancer patients, ATT adherence in the year following terminal illness declaration was measured by the proportion of days covered (PDC) by prescription. Discontinuation was defined as a treatment gap of ≥30 days between prescription renewals. One-year cumulative incidences of bleeding complications, VTE, and ATE were calculated, considering the competing risk of death.

RESULTS

During 2013-2022, 86 732 terminally ill cancer patients were identified (median age, 75 years; 47% female; median survival, 57 days). At terminal illness declaration, 37.5% were receiving ATT (66.6% platelet inhibitors, 23.0% direct oral anticoagulants, and 10.4% vitamin K antagonists [VKAs]). The mean PDC with ATT was 88% (SD, 30%), highest among platelet inhibitor users (mean PDC, 89%) and lowest among VKA users (73%). One-year ATT discontinuation incidence was 7.9% (95% CI, 7.7%-8.1%). Most patients continued ATT until death (74.8% platelet inhibitors, 58.8% direct oral anticoagulants, and 61.6% VKAs). Patients receiving ATT had a lower 1-year VTE risk but higher risks of ATE and major bleeding.

CONCLUSION

Despite uncertain benefit-risk profile, most terminally ill cancer patients continue ATT until the end of life. These findings provide insights into current ATT utilization and discontinuation dynamics in the challenging context of terminal illness.

Definition and recommendations of advance care planning: A Delphi study in five Asian sectors

BACKGROUND

In Confucian-influenced Asian societies, explicit end-of-life conversations are uncommon and family involvement in decision-making is crucial, which complicates the adoption of culturally sensitive advance care planning.

AIM

To develop a consensus definition of advance care planning and provide recommendations for patient-centered and family-based initiatives in Asia.

DESIGN

A five-round Delphi study was performed. The rating of a definition and 84 recommendations developed based on systematic reviews was performed by experts with clinical or research expertise using a 7-point Likert scale. A median = 1 and an inter-quartile range = 0-1 were considered very strong agreement and very strong consensus, respectively.

SETTING/PARTICIPANTS

The Delphi study was carried out by multidisciplinary experts on advance care planning in five Asian sectors (Hong Kong/Japan/Korea/Singapore/Taiwan).

RESULTS

Seventy-seven of 115 (67%) experts rated the statements. Advance care planning is defined as "a process that enables individuals to identify their values, to define goals and preferences for future medical treatment and care, to discuss these values, goals, and preferences with family and/or other closely related persons, and health-care providers, and to record and review these preferences if appropriate." Recommendations in the domains of considerations for a person-centered and family-based approach, as well as elements, roles and tasks, timing for initiative, policy and regulation, and evaluations received high levels of agreement and consensus.

CONCLUSIONS

Our definition and recommendations can guide practice, education, research, and policy-making in advance care planning for Asian populations. Our findings will aid future research in crafting culturally sensitive advance care planning interventions, ensuring Asians receive value-aligned care.

Understanding Nonpharmacologic Palliative Care for People With Serious COPD: The Individual and Organizational Perspective

TOPIC IMPORTANCE

This narrative review emphasizes the growing interest in palliative care for people with serious lung diseases such as COPD. It reflects on recent publications from the American Thoracic Society, the World Health Organization, and European Respiratory Society, with a focus on nonpharmacologic palliative care for people with COPD from both the health care professional and organizational perspective.

REVIEW FINDINGS

The concept of palliative care has changed over time and is now seen as applicable throughout the entire disease trajectory according to need, in conjunction with any disease-modifying therapies. Palliative care should pay attention to the needs of the person with COPD as well as the informal caregiver. Timely integration of palliative care with disease-modifying treatment requires assessment of needs at the individual level as well as organizational changes. High-quality communication, including advance care planning, is a cornerstone of palliative care.

SUMMARY

Therefore, services should be based on the understanding that palliative care is not only specific standardized actions and treatments, but rather a holistic approach that includes compassionate communication, treatment, and care addressing the patient and informal and formal caregivers. Living with and dying of COPD is much more than objective measurements. It is the sum of relationships with others and the experience of living in the best possible harmony with one's own values and hopes, despite having a serious illness.

Implementing Advance Care Planning and Care Coordination in the Care for People With Parkinson Disease: A Feasibility Study

ABSTRACT

BACKGROUND: For people with a moderate stage of Parkinson disease (PD), dedicated care coordination combined with advance care planning (ACP) is highly needed. However, evidence is lacking. The objective of this study was to assess the feasibility and acceptability of the study processes to inform a larger randomized controlled trial, aiming the effectiveness of a combined intervention on ACP and care coordination for people with PD. METHODS: Two nurse practitioners with expertise in PD followed training on a combined intervention on ACP and care coordination. Patients were invited to participate in several sessions for a period of 12 months. Feasibility of the study was surveyed covering sample recruitment, attrition rate, eligibility, intervention delivery, number of ACP sessions, type of intervention administration, and satisfaction with the intervention. RESULTS: In total, 27 patients were invited to participate, and 20 (74%) enrolled into the study, together with 11 family caregivers; 7 patients (35%) dropped out. Most patients were men (n = 20), with a mean age of 73.4 (SD 8.2) years. In total, 71 ACP sessions were held (3.6 sessions per patient on average), of which 41% of the sessions were conducted face-to-face at home, 44% at the hospital, 11% over telephone, and 4% via a videoconference call. Patients perceived the intervention not only as supportive but also as confronting. CONCLUSION: The ACP aspect of the intervention was useful and feasible to stimulate patients to think about their current care situation as well as about future care. Care coordination was less profoundly provided and discussed.

Views on advance care planning of family members of older adults with Turkish and Moroccan backgrounds: An exploratory interview study

BACKGROUND

Significantly fewer individuals with migration backgrounds than native-born individuals undertake advance care planning. Older adults with Turkish and Moroccan backgrounds represent one of the largest ageing non-Western minority groups in Europe. Their relatives could play important roles in facilitating or hindering advance care planning, but their views remain underexplored.

AIM

To explore advance care planning knowledge, experience, views, facilitators and barriers among older Turkish and Moroccan adults' relatives in Belgium.

DESIGN

Qualitative thematic analysis of semi-structured interview data.

SETTING/PARTICIPANTS

Twenty-two relatives of older Turkish and Moroccan adults in Brussels, Mechelen and Antwerp, recruited via general practitioners.

RESULTS

Participants had limited advance care planning knowledge and had not discussed it with healthcare professionals. Some found discussing end-of-life preferences with relatives beneficial; others opposed the discussion of specific topics or felt discussions were unnecessary, as they felt responsible for caregiving and trusted by their relatives to make future decisions. Barriers included personal and relational characteristics, emotional difficulty and perceived non-urgency. Facilitators included information in older adults' native languages, general practitioners' cautious initiation and the involvement of several family members.

CONCLUSIONS

Relatives of older people with Turkish and Moroccan backgrounds are unfamiliar with advance care planning and have highly variable views on it. People should be given opportunities to discuss advance care planning in a culturally appropriate manner, and the diversity of perspectives regarding whether and how to engage in such planning should be recognised.ClinicalTrials.gov no. NCT05241301.

Advance Care Planning (ACP) in Medicare Beneficiaries with Heart Failure

BACKGROUND

Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice.

OBJECTIVE

Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life.

DESIGN

This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020.

PARTICIPANTS

A total of 48,466 deceased patients diagnosed with heart failure on Medicare.

MAIN MEASURES

Billed advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services.

KEY RESULTS

In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter.

CONCLUSIONS

Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.

A website to support people with dementia and their family caregivers in advance care planning: Results of a mixed-method evaluation study

OBJECTIVE

This study aimed to evaluate a theory-based website to support people with dementia and their families in the advance care planning (ACP) process.

METHODS

We conducted an eight-week evaluation study with a convergent parallel mixed-methods design involving people with mild to moderate dementia and their family caregivers who used the website at their convenience. Interviews were conducted at baseline and after 8 weeks to evaluate usability, acceptability, feasibility, experiences, and effects on ACP knowledge, attitudes, perceived barriers to engaging in ACP, self-efficacy and skills to engage in ACP.

RESULTS

We included 52 participants (21 people with dementia and 31 family caregivers). In the interviews, all participants considered the website useful and valued the ACP content. Morever, participants reported that family caregivers mostly used the website alone or with the person with dementia. Participants' ACP knowledge, self-efficacy, and skills improved after 8 weeks compared the beginning of the study.

CONCLUSION

The website may be an ideal introduction for those wanting to start ACP, providing user-friendly content and features for initiating and exploring ACP.

PRACTICAL IMPLICATIONS

ACP in dementia requires a tailored approach. Extra support is crucial for website adoption, emphasising the role of family caregivers while respecting individuals' autonomy.

Palliative and End of Life Care: An Important Component of Supportive Oncology

Palliative care, an integral component of supportive oncology, enhances the quality of life for patients living with cancer. Whilst palliative care has historically been synonymous with the provision of care at the end of life, it is increasingly playing a role earlier in a patient's cancer journey; frequently in conjunction with administration of anticancer treatment. Although early integration has been shown to improve patient outcomes, service development remains in its infancy and consideration of challenges bears relevance. Addressing issues pertaining to resource allocation in addition to adequate training of staff will aid to ensure the provision of care that aligns with the goals and priorities of patients. This review presents the role of early palliative care within the realm of supportive oncology with respect to the evidence of benefit and ethical, clinical and practical considerations. Relevant papers have been chosen for inclusion on the basis of clinical relevance, timeliness and relevance to cancer patients and clinical teams involved in their care.

The Association Between Timely Documentation of Advance Care Planning, Hospital Care Consumption and Place of Death: A Retrospective Cohort Study

Objectives: (1) To describe ACPT implementation frequency in practice. (2) To assess associations of ACPT documentation with a) hospital care consumption, including systemic anti-tumor treatment in the last month(s) of life, and b) match between preferred and actual place of death, among oncology patients. Methods: A retrospective cohort study was performed. Data concerning ACPT documentation, hospital care consumption, and preferred and actual place of death were extracted from electronic patient records. Patients with completely documented ACPT (cACPT) and no ACPT were compared using multivariable logistic regression analyses. Results: ACPT was implemented in 64.5% (n = 793) of all deceased patients (n = 1230). In 17.6% (n = 216), preferred place of care or death was documented at least three months before death (cACPT). A cACPT was not associated with systemic anti-tumor treatment (Adjusted OR (AOR): 0.976; 95% CI: 0.642-1.483), but patients with cACPT had fewer diagnostic tests (AOR: 0.518; CI: 0.298-0.903) and less contacts with hospital disciplines (AOR: 0.545; CI: 0.338-0.877). In patients with cACPT, a match between preferred and actual place of death was found for 83% of the patients for whom the relevant information was available (n = 117/n = 141). In patients without ACPT, this information was mostly missing. Conclusion: Although the ACPT was implemented in two thirds of patients, timely documentation of preferred place of care or death is often missing. Yet, timely documentation of these preferences may promote out-hospital-death and save hospital care consumption.

Mindfulness to enhance quality of life and support advance care planning: a pilot randomized controlled trial for adults with advanced cancer and their family caregivers

BACKGROUND

Patients with advanced cancer and family caregivers often use avoidant coping strategies, such as delaying advance care planning discussions, which contribute to deterioration in their quality of life. Mindfulness-based interventions have shown promise in improving quality of life in this population but have rarely been applied to advance care planning. This pilot trial examined the preliminary efficacy of a group-based Mindfulness to Enhance Quality of Life and Support Advance Care Planning (MEANING) intervention for patient-caregiver dyads coping with advanced cancer. Primary outcomes were patient and caregiver quality of life or well-being, and secondary outcomes included patient advanced care planning engagement (self-efficacy and readiness) and other psychological and symptom outcomes.

METHODS

In this pilot trial, dyads coping with advanced cancer were recruited from five oncology clinics in the midwestern U.S. and randomized to six weekly group sessions of a mindfulness intervention (n = 33 dyads) or usual care (n = 22 dyads). Outcomes were assessed via surveys at baseline, post-intervention, and 1 month post-intervention. All available data were included in the multilevel models assessing intervention efficacy.

RESULTS

Patients in the MEANING condition experienced significant increases in existential well-being and self-efficacy for advance care planning across follow-ups, whereas usual care patients did not. Other group differences in outcomes were not statistically significant. These outcomes included other facets of patient well-being, caregiver quality of life, patient readiness for advance care planning, caregiver burden, and patient and caregiver depressive symptoms, anxiety, sleep disturbance, cognitive avoidance, and peaceful acceptance of cancer. However, only MEANING patients showed moderate increases in psychological well-being across follow-ups, and MEANING caregivers showed moderate increases in quality of life at 1-month follow-up. Certain psychological outcomes, such as caregiver burden at 1-month follow-up, also showed moderate improvement in the MEANING condition. Patients in both conditions reported small to moderate increases in readiness to engage in advance care planning.

CONCLUSIONS

A mindfulness-based intervention showed promise in improving quality-of-life and advance care planning outcomes in patients and caregivers coping with advanced cancer and warrants further testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03257007. Registered 22 August 2017, https://clinicaltrials.gov/ct2/show/NCT03257007 .

Supporting decision-making for individuals living with dementia and their care partners with knowledge translation: an umbrella review

Living with dementia requires decision-making about numerous topics including daily activities, such as advance care planning (ACP). Both individuals living with dementia and care partners require informed support for decision-making. We conducted an umbrella review to assess knowledge translation (KT) interventions supporting decision-making for individuals living with dementia and their informal care partners. Four databases were searched using 50 different search-terms, identifying 22 reviews presenting 32 KT interventions. The most common KT decision topic was ACP (N=21) which includes advanced care directives, feeding options, and placement in long-term care. The majority of KT interventions targeted care partners only (N=16), or both care partners and individuals living with dementia (N=13), with fewer interventions (N=3) targeting individuals living with dementia. Overall, our umbrella review offers insights into the beneficial impacts of KT interventions, such as increased knowledge and confidence, and decreased decisional conflicts.

Interprofessional collaboration during a specialised mobile palliative care service pilot in the rural area of Lucerne

Interprofessional collaboration in outpatient palliative care is critical to ensuring good quality of care in the home care sector. We investigated facilitators and barriers (FaBs) of interprofessional collaboration among healthcare professionals who participated in a 6-month pilot of a newly implemented specialised mobile palliative care service (SMPCS) in rural Lucerne. This study used a mixed-methods approach to collect (i) qualitative data on FaBs as perceived by nurses and primary care physicians (PCPs), and (ii) quantitative data across the entire interprofessional collaboration using a validated questionnaire expanded with 10 specific questions about the pilot. Identified facilitators of interprofessional collaboration were (i) use of standardised documents, (ii) clear allocation of responsibilities, (iii) regular exchange and clear communication and (iv) consideration of care coordination. Reported barriers were (i) a deficit of knowledge and experience of palliative care among PCPs and (ii) time constraints. This study provides valuable insights into FaBs of interprofessional collaboration in palliative care. Several recommendations can be drawn for how interprofessional collaboration may be optimised. Awareness of FaBs and their consideration in the implementation phase of new services can strengthen the foundation for a successful interprofessional collaboration.

Quality of Advance Care Planning in Long-Term Care and Transfers to Hospital at the End Of Life

OBJECTIVES

Our primary objective was to determine if more comprehensive advance care planning (ACP) documentation was associated with fewer transfers to hospital in the last year of life. Our secondary objective was to determine the impact of ACP processes and practices on hospital transfers in the last year of life.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Long-term care (LTC) residents in Ontario, Canada, 65 years and older who died between January 1, 2017, and May 30, 2018, and resided in a participating LTC home.

METHODS

We administered a survey to directors of care at LTC homes inquiring about ACP practices. Our exposure of interest was living in a home with comprehensive ACP documentation that includes information beyond preferences for cardiopulmonary resuscitation and hospital transfer. Our primary outcome was the number of transfers to hospital in the last year of life. We fit negative binomial regression models to determine the independent effect of comprehensive ACP and other indicators of ACP quality.

RESULTS

A total of 157 LTC homes with 6637 decedent residents were included in our study; 2942 lived in homes with comprehensive ACP documentation and 3695 had non-comprehensive ACP documents. Comprehensive documentation was not associated with fewer hospital transfers in the final year of life [incidence rat ratio (IRR), 1.00; 95% CI, 0.91-1.09]. ACP documentation update frequency, availability of ACP documents in the electronic medical record, referring to ACP documents during a health crisis, inclusion of resident values in ACP documents, and involvement of a multidisciplinary team were all associated with fewer transfers to hospital during follow-up in the last year of life.

CONCLUSIONS AND IMPLICATIONS

ACP documents that contain information beyond preferences for cardiopulmonary resuscitation and hospital transfer had no association with transfers to hospital, but high-quality ACP practices and processes were associated with fewer transfers.

Effects of nurse-led interventions on the physical and mental health among pre-frail or frail older adults: A systematic review

BACKGROUND

Globally, there is an increase in the number of older people living with frailty, thus effective strategies to prevent and manage frailty are of paramount importance. The effects of nurse-led interventions on the physical and mental health of (pre) frail people have not yet been systematically reviewed.

METHODS

We searched the PubMed, Web of Science, EMBASE, CINAHL, and the Cochrane Library from inception to 8 May 2024. Eligible studies included randomized controlled trials and quasi-experimental trials reporting the effects of nurse-led interventions on physical and mental health outcomes among (pre) frail people. Two researchers independently extracted trial data and assessed the risk of bias by using the risk of bias tool recommended by the Cochrane Back Review Group and the Methodological Index for Non-Randomized Studies.

RESULTS

14 randomized controlled trials and 6 quasi-experimental studies, encompassing 3943 participants, were included in the review. Nurse-led interventions included function-based care (cognitive behavioral therapy, exercise, and multi-domain intervention), personalized integrated care, and advance care planning. The reported outcomes were multiple with most results showing inconsistencies. Overall, function-based care showed more positive effects on physical outcomes (31/37, 84 %) and mental health (11/12, 92 %). However, the effectiveness of existing personalized integrated care and advance care planning might be limited.

CONCLUSIONS

Nurse-led interventions may effectively improve both physical and mental health among (pre) frail older adults, although effectiveness varies by intervention type. Nurses have the potential to play a leading role, both individually and within multidisciplinary teams, in alleviating the rising global burden of frailty. We need more well-designed randomized controlled trials to confirm the effectiveness of nurse-led interventions and identify the most effective type of interventions.

Racial and Ethnic Disparities in Serious Illness Conversation Quality during the COVID-19 Pandemic

CONTEXT

The COVID-19 pandemic disproportionately impacted non-Hispanic Black and Hispanic patients. However, little is known about the quality of serious illness communication in these communities during this time.

OBJECTIVE

We aimed to determine whether racial and ethnic disparities manifested in serious illness conversations during the pandemic.

METHODS

This was a retrospective, observational, cohort study of adult patients with a documented serious illness conversation from March 2020 to April 2021. Serious illness conversation documentation quality was assessed by counting the median number (IQR) of conversation domains and their elements included in the documentation. Domains included (1) values and goals, (2) prognosis and illness understanding, (3) end-of-life care planning, and (4) life-sustaining treatment preferences. A multivariable ordinal logistic regression analysis was conducted to assess associations between differences in serious illness documentation quality with patient race and ethnicity.

RESULTS

Among 291 patients, 149 (51.2%) were non-Hispanic White; 81 (27.8%) were non-Hispanic Black; and 61 (21.0%) were Hispanic patients. Non-Hispanic Black patients were associated with fewer domains (OR 0.46 [95% CI 0.25, 0.84]; P=.01) included in their serious illness conversation documentation compared to non-Hispanic White patients. Both non-Hispanic Black (OR 0.35 [95% CI 0.20, 0.62]; P<.001) and Hispanic patients (OR 0.29 [95% CI 0.14, 0.58]; P<.001) were associated with fewer elements in the values and goals domain compared to non-Hispanic White patients in their serious illness documentation.

CONCLUSION

During the COVID-19 pandemic, serious illness conversation documentation among non-Hispanic Black and Hispanic patients was less comprehensive compared to non-Hispanic White patients.

Education needs in palliative care and advance care planning of Italian residents in neurology: an online survey

BACKGROUND AND PURPOSE

Most neurological diseases have a chronic and progressive clinical course, with patients living for extended periods with complex healthcare needs. Evidence from other countries suggests that palliative care (PC) is insufficiently integrated in the care of these patients. This study aims to identify PC and advance care planning (ACP) knowledge and the perceived preparedness of Italian residents in neurology.

METHODS

This is a cross-sectional online survey of physicians attending the 36 Italian neurology residency programmes.

RESULTS

Of 854 residents, 188 (22%) participated. Their mean age was 28.4 ± 2.0 years; 49% were women; 45% were from the north, 23% from the centre and 32% from the south of Italy. Few residents (6%) reported that a teaching course in PC was part of the graduate programme, and 3% of the postgraduate programme. During their residency, 9% of participants received PC training, and 18% ACP training. Only 13% reported to have participated in the ACP process, half within their neurology residency programme. Residents considered PC support very/extremely important in all the pre-specified clinical situations, with values ranging between 78% and 96%. Over 70% of residents revealed education needs, particularly concerning ACP.

CONCLUSIONS

Our data confirm the need for improving PC training in the graduate and postgraduate curriculum. This, together with collaboration and joint training of neurology and PC, is essential to improve the quality and continuity of care and respond to the complex needs of people with neurological disorders causing severe disability.

Cancer patients have a reduced likelihood of dying in hospital with advance care planning in primary health care and a summarizing palliative plan: a prospective controlled non-randomized intervention trial

BACKGROUND

Advance care planning (ACP) allows patients to define their goals and preferences. Spending more time at home and less time in the hospital, along with avoiding death in the hospital, are often considered desirable outcomes of palliative care (PC). In 2015, 36% of cancer patients died in the hospital and 13% died at home in Norway.

METHOD

From 2015 to 2022, this prospective controlled non-randomized intervention trial observed 144 cancer patients with or without an organized ACP conversation in primary health care and a summarizing palliative plan (ClinicalTrials.gov Identifier: NCT02170168, 23 June 2014). The patients were identified through contact with the local cancer outpatient clinic or hospital-based PC team.

RESULTS

A total of 128 patients died during the observation period. Of these, 67 patients had an organized ACP conversation and summarizing palliative plan (intervention (I) group) and 61 had not (control (C) group). Dying in the hospital was significantly less common for patients in the I group compared to the C group (17.9% vs. 34.4%; X2 (1, n = 128) = 4.55, p = 0.033). There were no differences between the groups in terms of where they spent their time in the last 90 days of life (home, nursing home, or hospital). Most patients (62%) preferred to die at home. The observed differences between the groups regarding preferred and actual places of death did not reach statistical significance.

CONCLUSION

With organized ACP conversations in primary health care and a summarizing palliative plan, cancer patients died less often in the hospital in our observational study. A structured ACP approach integrating palliative care for cancer patients into primary health care can support patients´ preferences at the end of life.

Fundamentals of end-of-life communication as part of advance care planning for older people: An interview study with nursing staff

This exploratory interview study investigated nursing staff members' perspectives on the fundamentals of end-of-life communication with older people as part of advance care planning in home care, nursing home, and hospital settings. Separate semi-structured interviews were conducted with 17 nursing staff members about their experiences, opinions, and preferences before, during, and after end-of-life conversations. Overall themes clustering the fundamentals include preconditions such as feeling comfortable talking about the end of life and creating space for open communication. Fundamentals related to the actual conversation-such as using senses and applying associative communication techniques (e.g., using understandable language), following conversation phases, and being aware of interprofessional collaboration-were also considered important. This study emphasizes the importance of moving along with the older person as well as connecting, adapting, and letting go of control over the conversation's outcome. Many fundamentals can be traced back to the basics of nursing and the humanity of conversation.

[Advance care planning in the acute hospital: A qualitative analysis of terms and conditions]

Advance care planning in the acute hospital: A qualitative analysis of terms and conditions Abstract: Background: Advance Care Planning (ACP) is an internationally established concept aimed to facilitate anticipatory care planning in the event of future inability to consent. In Germany, ACP is currently not regularly offered to patients in acute care hospitals. Aim: We aimed to identify preconditions for implementation of ACP in acute care hospitals in Germany through review of the international literature and expert interviews. Methods: A systematic literature search was carried out in the databases MEDLINE and CINAHL for internationally used strategies for implementing ACP in acute care hospitals. Consecutively, a guide for interviews with experts to evaluate the strategies was developed. Interviews were analyzed by qualitative content analysis according to Mayring. Results: Out of 13 included publications, 17 preconditions were identified and assigned to 16 categories after evaluation by experts. In international ACP programs, it was described how to proceed and organize the ACP conversation. German experts emphasized that appropriate preconditions, such as sufficient time resources and training, must be granted, whereas the literature search revealed the conversation process and organization as important determinants. Conclusions: The implementation of ACP programs is conceivable, but requires specific conditions as legal regulation and defining and structuring of the processes.

Dyadic advance care planning: systematic review of patient-caregiver interventions and effects

INTRODUCTION

Family caregiver's involvement in advance care planning (ACP) is essential to provide high-quality end-of-life (EOL) care and to ease the surrogate decision-making burden. However, no systematic review has focused on existing ACP interventions involving patients and their families.

AIM

To systematically summarise current ACP interventions involving patients and their families.

METHODS

Five English and two Chinese databases were searched from inception to September 2022. The eligible studies were experimental studies describing original data. The Joanna Briggs Institute critical appraisal tools assessed the methodological quality. Narrative synthesis was conducted for data analysis.

RESULTS

In total, twenty-eight articles were included. Fifteen studies were randomised controlled trials, and the rest 13 studies were quasi-experimental studies. The data synthesis identified: (1) Key intervention components: strategies to promote ACP, ACP discussion and follow-up, as well as the role of family caregivers; (2) Effects on intended outcomes: interventions have shown benefit on completion of ACP actions, while inconsistent findings were found on the process outcomes and quality of EOL care. In addition, a logic model for patient-caregiver dyadic ACP was created, and the underlying mechanisms of action included well-preparation, open discussion and adequate support for plan/action.

CONCLUSIONS

This review provides comprehensive evidence about patient-caregiver dyadic ACP, a promising intervention to better prepare for EOL communication and decision-making. A logic model has been mapped to give a preliminary indication for future implementation. More empirical studies are needed to improve this model and culturally adapt it in a real-world setting.

Nurse-Led Advance Care Planning in Adults in the U.S.- A Scoping Review

BACKGROUND

Advance care planning involves discussing individuals' future medical treatment and care preferences. Nurses, due to their close relationships with patients and families, may be well-positioned to lead these discussions. Exploring the components and characteristics of nurse-led ACP interventions is essential for enhancing their implementation, effectiveness, and sustainability.

OBJECTIVE

This scoping review aimed to explore the characteristics of nurse-led ACP interventions in adult patients, identify the populations and settings where these interventions have been utilized, and the outcomes of these interventions in the U.S.

METHODS

A scoping review was conducted following Arksey and O'Malley's five-stage framework. Using keywords related to nurse-led ACP interventions, a comprehensive search was performed across PubMed, Web of Science, CINAHL, EMBASE, and PsycINFO databases.

RESULTS

Twelve studies met the inclusion criteria. These studies were conducted in varied settings. Registered nurses, oncology nurse navigators, and other specialized nurses primarily delivered nurse-led ACP interventions. The interventions ranged from one to two sessions and utilized various models and resources such as the Five Wishes and Respecting Choices.

CONCLUSIONS

Nurse-led ACP interventions have shown significant positive outcomes, including increased engagement in ACP, improved attitudes towards ADs, higher completion rates of ADs, and enhanced patient-surrogate congruence. These interventions are well-received by patients and can be implemented in diverse settings. However, a general guideline regarding nurse-led ACP interventions is needed to address the specific duration, sessions, and mode of delivery required for their optimal effectiveness.

End-of-life care in multiple system atrophy: UK survey of patients and families

OBJECTIVES

People with multiple system atrophy (MSA) and their carers may have many concerns about their disease and the future. This survey of people with MSA and their carers aimed to increase understanding of end-of-life care and palliative care for this group.

METHODS

A survey was undertaken by the MSA Trust of people living with MSA and carers of those with the condition between August and October 2022.

RESULTS

520 people responded: 215 people with MSA, 214 carers and 91 former carers. The modal class for age in people with MSA was 65-74 years, with 52% male. 76% of people living with MSA had thought to some extent about what they wanted to happen towards the end of their lives. 38% of respondents had discussed end-of-life care options with a healthcare professional and of those who had, over 81% found the conversation helpful. Nevertheless, for 37% of former carers, the death had been unexpected. Only a minority of people living with MSA had been referred for specialist palliative care. 65% of the former carers reported that they were satisfied with the quality of end-of-life care.

CONCLUSION

People with MSA and their carers continue to face many complex physical and emotional issues that would benefit from palliative care. Discussions about care at the end of life were generally perceived as helpful, but although the deterioration was often discussed, many families seemed unprepared for the death. Palliative care services were involved but this appeared limited.

Experiences with a national team-based learning program for advance care planning in pediatric palliative care

BACKGROUND

Advance Care Planning (ACP) enables patients and relatives to define and share values, goals and preferences for future medical treatment and care. The IMplementing Pediatric Advance Care Planning Toolkit (IMPACT), developed in the Netherlands, is a method for conducting ACP in pediatric palliative care. Healthcare professionals who were trained to use IMPACT, indicated their need for ongoing support to practice ACP communication skills optimally over time. Therefore, we developed a team-based learning program aimed at teaching participants how to transfer knowledge on ACP, continue practicing ACP communication skills and reflect on ACP conversations within their own team context. The aim of this study was to evaluate the program's transfer of knowledge as well as the professionals' experience and team reflection on ACP.

METHODS

A one-day IMPACT train-the-trainer course was developed and a selection of healthcare professionals (facilitators) from pediatric palliative care teams (PPCTs) from all seven Dutch university hospitals and the specialized Center for Pediatric Oncology were invited to participate. Hereafter, facilitators were asked to transfer their course-acquired knowledge to their team members (learners) by organizing two coaching-on-the-job sessions. A mixed-methods design, combining questionnaires and field notes, was used to evaluate the level of knowledge transfer and team reflection achieved.

RESULTS

Eighteen healthcare professionals in the role of facilitator participated in the train-the-trainer course. In seven PPCTs one (n = 3) or two (n = 4) coaching-on-the-job session(s) took place, attended by 29 and 17 learners, respectively. In the questionnaires, 11 facilitators indicated that they had to some extent transferred acquired knowledge to their team members as intended. Sixteen out of 21 learners who participated in at least one coaching-on-the-job session, reported (somewhat) increased self-confidence for conducting ACP conversations. The reported main strength of the program was practicing with/learning from colleagues whereas dealing with workload and variation in existing ACP skills within PPCTs need more attention.

CONCLUSIONS

The newly developed team-based learning program resulted in intended transfer of knowledge and methodical reflection on ACP in coaching-on-the-job sessions in most participating PPCTs. Planning coaching-on-the-job sessions regarding ACP in pediatric palliative care with multiple healthcare professionals is challenging and needs more emphasis in the training.

Service Provider Perspectives on Advance Care Planning Use in Rural Dementia Patients and Caregivers: A Qualitative Study

Advanced care planning (ACP) utilization remains very limited in rural communities compared to urban areas. ACP earlier in the disease trajectory is particularly important for people with dementia (PWD) due to its progressive nature affecting their decision-making ability. Considering the well-documented benefits of ACP in improving the quality of end-of-life (EOL) care, the rural vs. urban disparity may indicate poorer EOL quality for rural PWD. This study aimed to explore barriers and current resources for ACP of PWD from the perspectives of health or social service providers serving rural communities. Using a qualitative approach, semi-structured face-to-face interviews were conducted with 11 health or social service professionals serving older adults and their caregivers in rural Alabama. Thematic analysis revealed three major barriers: (1) lack of knowledge, (2) psychosocial barriers, and (3) limited access to healthcare. Participants also showed misconception that a lawyer or a notary is required for ACP. Two themes arose in the participants' recommendations to address the barriers: (1) providing ACP-relevant information and (2) addressing psychosocial stressors about ACP. This study highlighted an urgent need for social policy in ACP education for caregivers and service providers in rural settings.

Development and Validation of a Measure of Self-Efficacy for Advance Care Planning

Medical care received at end-of-life is often not aligned with individuals' values and care preferences. Much can get in the way of an individual communicating and documenting their preferences to care providers and close others, even if it is a goal to do so. The objective of this work was to develop a measure of Advance Care Planning Self-Efficacy (ACP SE) focused on three important behaviors: completing a living will, documenting a healthcare agent, and discussing quality versus quantity of life issues. Measure development was framed by the Transtheoretical Model (TTM) of behavior change. Following the completion of focus groups and formative qualitative work, an independent sample (N = 310, adults aged 50+) was randomly split into two halves for exploratory and confirmatory factor analyses (EFA/CFA). Multivariate analyses examined relationships between ACP SE and other TTM constructs. Results of the CFA demonstrated excellent internal consistency (α = .95) and good model fit (CFI = .89, RMSEA = .13). Self-efficacy was framed by the TTM as situation-specific confidence. Through the measure development process, it was found that confidence to do ACP was impacted by various situational and attitudinal variables. ACP Self-Efficacy was found to differ significantly by Stage of Change. This study produced a reliable and valid measure of situation-specific confidence for ACP grounded within the TTM that could enhance future interventions aimed at increasing participation in ACP.

[Palliative neurology]

Palliative medicine represents the holistic multiprofessional treatment of severely and incurably ill people and their relatives, addressing their complex physical, psychological, social and spiritual needs. The central therapeutic goals are the quality of life and alleviation of suffering. In the course of many neurological diseases, high symptom burden, long and variable trajectories and unfavorable prognosis at times create a need for palliative care even at an early stage, which is currently still inadequately met. This can be countered by qualified neuropalliative care. In addition to intensifying interdisciplinary collaboration, this requires neurologists to have core competencies in palliative care. These include a team-oriented attitude, communication skills, expertise in symptom control and knowledge of biomedical ethics including palliative options at the end of life.

Exploration of decision aids to support advance care planning: A scoping review

BACKGROUND

Advance care planning is a process through which people communicate their goals and preferences for future medical care. Due to the complexity of the decision-making process, decision aids can assist individuals in balancing potential benefits and risks of treatment options.

OBJECTIVE

While decision aids have the potential to better promote advance care planning, their characteristics, content and application effectiveness are unclear and lack systematic review. Therefore, we aimed to explore these three aspects and establish a foundation for future research.

DESIGN

Scoping review.

METHODS

This scoping review adheres to the framework proposed by Arksey and O'Malley and the PRISMA-ScR list. Six English-language databases were systematically searched from the time of construction until 1 December 2023. Two researchers conducted the article screening and data extraction, and the extracted data was presented in written tables and narrative summaries.

RESULTS

Of the 1479 titles and abstracts, 20 studies fulfilled the inclusion criteria. Types of decision aids were employed, mainly websites and videos. Decision aid's primary components center around 11 areas, such as furnishing information, exploring treatment and care preferences. The main manifestations were a significant increase in knowledge and improved recognition of patients' target value preferences. Among the aids, websites and videos for advance care planning have relatively high content acceptability and decision-making process satisfaction, but their feasibility has yet to be tested.

CONCLUSIONS

Decision aids were varied, with content focused on describing key information and exploring treatment and care preferences. Regarding application effects, the aids successfully facilitated the advance care planning process and improved the quality of participants' decisions. Overall, decision aids are efficient in improving the decision-making process for implementing advance care planning in cancer and geriatric populations. In the future, personalised decision aids should be developed based on continuous optimization of tools' quality and promoted for clinical application.

REPORTING METHOD

The paper has adhered to the EQUATOR guidelines and referenced the PRISMAg-ScR checklist.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a review without patient and public contribution.

REGISTRATION

https://doi.org/10.17605/OSF.IO/YPHKF, Open Science DOI: 10.17605/OSF.IO/YPHKF.

Interventions to promote readiness for advance care planning: A systematic review and meta-analysis

BACKGROUND

Advance care planning is recommended as part of standard medical services. Readiness, denoting stages of behavior change, exerts a substantial influence on its uptake. However, the characteristics and impacts of advance care planning interventions on readiness are not well-established.

METHOD

We systematically reviewed and conducted a meta-analysis of randomized controlled trials assessing the effects of advance care planning interventions on readiness. Studies were appraised using Joanna Briggs Institute Critical Appraisal tools. Meta-analyses were performed using mean difference of continuous variables or risk ratios of binary variables and their 95 % confidence interval as the pooled effect sizes.

RESULTS

Eight studies were included in this review and were all rated low quality. Meta-analysis showed that interventions resulted in slight improvement in overall readiness (mean difference = 0.19, 95 % confidence interval: 0.02-0.36) for advance care planning. However, statistically significant effects of interventions were not identified for readiness in relation to specific behaviors (appointment of a healthcare proxy, talking to a healthcare proxy, talking to a medical practitioner about living wills, and signing a living will).

CONCLUSION

Our meta-analyses demonstrated that interventions can improve the overall readiness for advance care planning, suggesting the necessity to integrate readiness into future health policies and clinical practices. Nevertheless, the absence of significant effects on specific behavioral readiness underscores the requirement for additional refinement in intervention design, advanced technologies, and theoretical foundations.

REGISTRATION

Not registered.

Incorporating advance care planning in dementia care

Recent policy focus in dementia care has been on living well with the condition; however, being able to die well with dementia is of equal importance. Advance care planning (ACP) enables people to consider, express and record their wishes and preferences for palliative and end of life care, however there is a low uptake of ACP in people with dementia. Although ACP discussions should be initiated as soon as possible after a diagnosis of dementia, there are other opportunities and transition points in the person's care during which health and social care professionals could promote, engage in and support ACP discussions. This article considers the importance of ACP in dementia care and uses a case study to explore opportunities for initiating and engaging in ACP with people with dementia.

'It's not making a decision, it's prompting the discussions': a qualitative study exploring stakeholders' views on the acceptability and feasibility of advance research planning (CONSULT-ADVANCE)

BACKGROUND

Health and care research involving people who lack capacity to consent requires an alternative decision maker to decide whether they participate or not based on their 'presumed will'. However, this is often unknown. Advance research planning (ARP) is a process for people who anticipate periods of impaired capacity to prospectively express their preferences about research participation and identify who they wish to be involved in future decisions. This may help to extend individuals' autonomy by ensuring that proxy decisions are based on their actual wishes. This qualitative study aimed to explore stakeholders' views about the acceptability and feasibility of ARP and identify barriers and facilitators to its implementation in the UK.

METHODS

We conducted semi-structured interviews with 27 researchers, practitioners, and members of the public who had participated in a preceding survey. Interviews were conducted remotely between April and November 2023. Data were analysed thematically.

RESULTS

Participants were supportive of the concept of ARP, with differing amounts of support for the range of possible ARP activities depending on the context. Six main themes were identified: (1) Planting a seed - creating opportunities to initiate/engage with ARP; (2) A missing part of the puzzle - how preferences expressed through ARP could help inform decisions; (3) Finding the sweet spot - optimising the timing of ARP; (4) More than a piece of paper - finding the best mode for recording preferences; (5) Keeping the door open to future opportunities - minimising the risk of unintended consequences; and (6) Navigating with a compass - principles underpinning ARP to ensure safeguarding and help address inequalities. Participants also identified a number of implementation challenges, and proposed facilitative strategies that might overcome them which included embedding advance research planning in existing future planning processes and research-focused activities.

CONCLUSIONS

This study provides a routemap to implementing ARP in the UK to enable people anticipating impaired capacity to express their preferences about research, thus ensuring greater opportunities for inclusion of this under-served group, and addressing the decisional burden experienced by some family members acting as proxies. Development of interventions and guidance to support ARP is needed, with a focus on ensuring accessibility.

Development and validation of a model to predict ceiling of care in COVID-19 hospitalized patients

BACKGROUND

Therapeutic ceiling of care is the maximum level of care deemed appropiate to offer to a patient based on their clinical profile and therefore their potential to derive benefit, within the context of the availability of resources. To our knowledge, there are no models to predict ceiling of care decisions in COVID-19 patients or other acute illnesses. We aimed to develop and validate a clinical prediction model to predict ceiling of care decisions using information readily available at the point of hospital admission.

METHODS

We studied a cohort of adult COVID-19 patients who were hospitalized in 5 centres of Catalonia between 2020 and 2021. All patients had microbiologically proven SARS-CoV-2 infection at the time of hospitalization. Their therapeutic ceiling of care was assessed at hospital admission. Comorbidities collected at hospital admission, age and sex were considered as potential factors for predicting ceiling of care. A logistic regression model was used to predict the ceiling of care. The final model was validated internally and externally using a cohort obtained from the Leeds Teaching Hospitals NHS Trust. The TRIPOD Checklist for Prediction Model Development and Validation from the EQUATOR Network has been followed to report the model.

RESULTS

A total of 5813 patients were included in the development cohort, of whom 31.5% were assigned a ceiling of care at the point of hospital admission. A model including age, COVID-19 wave, chronic kidney disease, dementia, dyslipidaemia, heart failure, metastasis, peripheral vascular disease, chronic obstructive pulmonary disease, and stroke or transient ischaemic attack had excellent discrimination and calibration. Subgroup analysis by sex, age group, and relevant comorbidities showed excellent figures for calibration and discrimination. External validation on the Leeds Teaching Hospitals cohort also showed good performance.

CONCLUSIONS

Ceiling of care can be predicted with great accuracy from a patient's clinical information available at the point of hospital admission. Cohorts without information on ceiling of care could use our model to estimate the probability of ceiling of care. In future pandemics, during emergency situations or when dealing with frail patients, where time-sensitive decisions about the use of life-prolonging treatments are required, this model, combined with clinical expertise, could be valuable. However, future work is needed to evaluate the use of this prediction tool outside COVID-19.

Psychometric testing of the training needs for advance care planning scale for clinicians and nurses

BACKGROUND

Studies have shown that Chinese Clinicians and nurses have positive attitudes toward ACP, but no local tools exist to assess their need for ACP knowledge and skills training. resulting in their inability to initiate ACP conversations as well as poor end-of-life care for patients. Therefore, this study aims to assess the needs of Chinese Clinicians and nurses for ACP knowledge and skills training and assess the validity and reliability of a questionnaire on the Training Needs for Advance Care Planning (TNACP) scale.

METHODS

From October to November 2021, 170 clinicians and nurses were pre-surveyed using a preliminary draft of the questionnaire. The responses were screened using item analysis, Cronbach's alpha coefficient, and the intraclass correlation coefficient (ICC) to describe the internal consistency and stability of the questionnaire. The Content validity index (CVI), Exploratory factor analysis (EFA) and Confirmatory factor analysis (CFA) were used to test the validity of the questionnaire.

RESULTS

After independent samples t-test analysis, Except for the entry "A2", the critical ratio between the two groups of the remaining 23 items was statistically significant (p < 0.05). Based on the above screening methods, the "A2" item was deleted, and the final number of questionnaire items was 23. The I-CVI was 0.79-1.00, and the S-CVI/Ave was 0.90. Three common factors were extracted-the cumulative contribution rate was 69.969%, and the factor loading of all items was 0.506-0.843 (all > 0.40). The results of confirmatory factor analysis showed that the Training Needs for Advance Care Planning (TNACP) scale model fit well(X2/df = 2.504, RMSEA = 0.092, GFI = 0.809, AGFI = 0.745, CFI = 0.931, IFI = 0.932, TLI = 0.916); the Cronbach's α = 0.888 for the total questionnaire, and the three dimensions of Cronbach's α were 0.729 to 0.959; and the ICC for the overall scores between the test-retest evaluations was 0.884 (p < 0.001).

CONCLUSIONS

The TNACP scale has good reliability and validity and can be used to assess Chinese Clinicians and nurses' training needs for implementing ACP.

Readiness for advance care planning and related factors in the general population: a cross sectional study in Iran

CONTEXT

Advance Care Planning (ACP), as a process for expressing and recording patients' preferences about end-of-life care, has received increasing attention in recent years. However, implementing ACP has been challenging in Iran.

OBJECTIVES

To assess the readiness for advance care planning and related factors in the general population of Iran.

METHODS

This cross-sectional study was conducted on the general population of Iran in 2022. The data was collected using demographic information questionnaire and The RACP Scale. The purpose and methodology of the research was explained to all participants, and upon their agreement an informed consent was obtained. Participants were invited to fill out the questionnaires wherever is more convenient for them, either alone or if needed, with the help of the researcher to protect their privacy. Chi-square, fisher exact test and multiple logistic Regression model were used to assess the effective factors on the RACP. The data were analyzed by SPSS software version 26.

RESULTS

A total of 641 people with an average age of 36.85 ± 12.05 years participated in this study. Of those, 377 (58.8%) had high RACP. The logistics model showed an association between the chance of readiness for receiving ACP with participants' education level, such that the chance of readiness in those with Master's or Ph.D. degrees was three times higher than those with a diploma (p = 0.00, OR:3.178(1.672, 6.043)). However, the chances of readiness in those with bachelor's degrees was not significantly different from those with a diploma (p = 0.936, OR: 0.984 (0.654, 1.479)). Moreover, the chance of readiness was 1.5 higher in participants over 40 years of age compared with participants under the age of 40 (P = 0.01, OR: 1.571(1.10, 2.23)).

CONCLUSION

According to the findings of this study, it can be concluded that there is a relatively RACP among people in Iranian society. The readiness of individuals for ACP increases by their age and education level. Therefore, by holding appropriate training intervention, we can increase the readiness of the public for ACP to improve their end-of-life outcome.

Factors Associated with Differences in Physicians' Attitudes toward Percutaneous Endoscopic Gastrostomy Feeding in Older Adults Receiving End-of-Life Care in Japan: A Cross-Sectional Study

Background

Although percutaneous endoscopic gastrostomy (PEG) placement is still widely practiced in Japan, studies from Western countries report that it is less beneficial for patients in end-of-life care with cognitive decline. Decisions regarding PEG placement are largely influenced by physician judgment.

Objectives

The aim of this study was to investigate the background and perceptions of Japanese physicians regarding PEG for older adults in end-of-life care and to identify the factors associated with differences in physician judgment regarding PEG.

Design

The study employed a cross-sectional design.

Setting/Subjects

A questionnaire on PEG for older adults in end-of-life care was sent to Japanese physicians. Logistic regression analysis was used to calculate the odds ratios (ORs) and confidence intervals (CIs) of the association between PEG recommendations and each factor.

Results

PEG placement was advised for bedridden patients and older adults with cognitive decline by 26% of the physicians who responded to the survey. Differences in physician perceptions of PEG feeding were associated with the recommendation for PEG, benefits of preventing aspiration pneumonia (OR: 4.9; 95% CI: 3.1-8.2), impact on post-discharge accommodation decisions (OR: 6.1; 95% CI: 1.9-30.9), and hesitancy to recommend a PEG placement (OR: 1.9; 95% CI: 1.3-4.5). Working in a facility with PEG placement (OR: 2.0; 95% CI: 1.2-3.5) was an associated background factor.

Conclusions

Differences in Japanese physicians' attitudes toward using PEG feeding for older adults in end-of-life care were significantly associated with differences in their perceptions of the impact of PEG feeding and working in a facility with PEG placement.

Normality and compassionate care: experiences from advanced cancer patients in their last time at home

BACKGROUND

Many cancer patients prefer to receive palliative treatment at home, as it allows them to be in a familiar and comfortable environment. Integrating Advance Care Planning (ACP) into routine practice in primary healthcare helps patients and their relatives prepare for end-of-life (EoL) care in accordance with patients' preferences. This includes the option to spend their final days at home if desired. The aim of this study was to gain insights from experiences of advanced seriously ill cancer patients at home while receiving palliative treatment and being engaged in ACP within primary healthcare settings.

METHOD

This study employed a qualitative design, utilizing individual, semi-structured interviews that were analysed through reflexive thematic analysis, employing an abductive approach with a latent-level focus. The study included interviews with 12 participants with cancer who were receiving palliative care, had an estimated lifetime under 3 months, and had undergone an organized ACP approach in primary healthcare, documented with a palliative plan.

RESULTS

Participants emphasized the importance of (1) Preserving normality at home, maintaining a sense of routine, comfort, and familiarity in the face of present and future challenges. The top obstacles for success identified by participants included (1a) The challenge of deterioration and the dual aspects of (1b) The value and burden of family caregivers. Cancer treatment placed a significant demand on patients due to side effects. Family caregivers played a crucial role for participants, providing support in daily life and serving as a key factor in the overall decision to which extend they are able to involve in support and care at home in the future. (2) Compassionate health care personnel (HCP) made a difference by fostering a culture of understanding participants' concerns, fears, and preferences, which was a key element that built and maintained trust for the participants. (3) Preparing for the future, especially EoL discussions initiated by healthcare personnel, was deemed important but, at times, uncomfortable for participants as it confronted them with reality. Guidance from ACP provided them with a sense of certainty and control.

CONCLUSION

Preserving normality at home, along with the desire to stay at home for as long as possible, is a crucial goal for advanced cancer patients. Consistent professional communication and care in primary healthcare play a key role in building and maintaining trust, as well as fostering a sense of certainty and control for the participants.

Collaborative advance care planning in palliative care: a randomised controlled trial

OBJECTIVE

An effective tool for establishing concordant end-of-life (EOL) care in patients with cancer is advance care planning (ACP). However, various barriers, including psychological obstacles, hamper the access to ACP. Therefore, a new conceptual model combining a psycho-oncological approach with structured ACP was developed. The effectiveness and efficiency of this new concept of collaborative ACP (col-ACP) is evaluated in the present randomised controlled trial in patients with palliative cancer.

METHODS

277 patients with palliative cancer and their relatives were randomised into three groups (1) collaborative ACP (col-ACP) consisting of a psycho-oncological approach addressing barriers to EOL conversations followed by a standardised ACP procedure, (2) supportive intervention (active control) and (3) standard medical care.

RESULTS

Patients in the col-ACP group completed advance directives (p<0.01) and healthcare proxies (p<0.01) significantly more often. Additionally, they felt better planned ahead for their future treatment (p<0.01) and were significantly more confident that their relatives were aware of their treatment wishes (p=0.03). In fact, their goals of care were known and highly fulfilled. However, patients' and caregivers' quality of life, patients' stress, depression and peace did not differ between the groups.

CONCLUSIONS

The new, well-received, concept of col-ACP improves readiness and access to ACP and results in more consistent EOL care. Further, even if no direct influence on quality of life could be proven, it supports patients in planning their treatment, making autonomous decisions and regaining self-efficacy in the face of life-limiting cancer. Therefore, a closer interlocking and information exchange between psycho-oncological and ACP services seems to be reasonable.

TRIAL REGISTRATION NUMBER

NCT03387436.