Advance Care Planning in terminally ill and frail older persons

Cancer in the elderly: is it time for palliative care in geriatric oncology?

BACKGROUND

Persons aged 65 and over are the fastest growing segment of the population in most Western countries. Although cancer-related death occurs far more commonly in older people than in any age group, studies on palliative care in older adults are lacking.

OBJECTIVE

This paper aims at evaluating the needs in elderly patients affected by cancer and the state of the art of the research in palliative care in this setting.

MATERIALS AND METHODS

A literature search was performed (PubMed) to identify relevant studies. Papers were reviewed for relevance to palliative care in the elderly.

RESULTS

Elderly who need palliative care are frequently disregarded as individuals and may experience discrimination because of their age. Palliative care for older patients relates particularly to multiple treatments for various conditions. This causes extra complexities for the researchers.

CONCLUSIONS

The aim of the study was not fully achieved due to the paucity of literature focusing upon these issues. The areas of investigation that need to be addressed comprise: establishing the prevailing symptoms in elderly patients, understanding patients' psychological/spiritual well-being and quality of life and elucidating the sources of caregiver burden, adapting research methodologies specifically for palliative care and comparing the needs and the outcomes of this age group to younger patients.

Preferences for end-of-life care: a nominal group study of people with dementia and their family carers

BACKGROUND

The wishes and preferences of people with dementia should inform decisions on future care. However, such decisions are often left to family carers and may not reflect those the person with dementia would have made for themselves. We know little about what influences agreement between people with dementia and their carers.

AIM

To explore whether people with dementia and their carers were able to generate and prioritise preferences for end-of-life care. We examined whether carers influenced the choices made by the persons with dementia.

DESIGN

Nominal group technique.

SETTING/PARTICIPANTS

People with dementia (n = 6), carers (n = 5) and dyads of people with dementia and carers (n = 6) attending memory assessment services.

METHODS

Three modified nominal group technique groups were conducted in five stages: (1) silent generation of ideas, (2) discussion, (3) further generation of ideas, (4) discussion and themeing and (5) ranking. The discussions were recorded, transcribed and analysed for thematic content using NVIVO8.

RESULTS

Quality of care, family contact, dignity and respect were ranked as significant themes by all groups. The analysis of transcripts revealed three main themes: quality of care, independence and control and carer burden. People with dementia had difficulty considering their future selves. Carers wanted much control at the end of life, raising issues of assisted dying and euthanasia.

CONCLUSIONS

Wishes and preferences of people with dementia and their family carers may differ. To ensure the wishes of people with dementia are respected, their views should be ascertained early in the disease before their ability to consider the future is compromised.

Completion of Advance Directives Among Low-Income Older Adults

This study examined the prevalence of completion of advance directives (ADs) and the effects of race/ethnicity on AD completion using a cross-sectional design. Low-income older adults (n = 256) who were residents of supportive housing facilities or members of a senior center were interviewed in person. About 20% of the participants had completed ADs. Knowledge and attitudes toward ADs, income, and previous experience in an intensive care unit significantly predicted the completion of ADs after controlling for other factors. Those with higher levels of knowledge, positive attitudes, or those with higher incomes were more likely to complete ADs than their counterparts. Findings suggest that as a proxy for multiple socioeconomic, social and cultural factors, race, and ethnicity need to be considered in planning end-of-life care.

What patients want

OBJECTIVE

Although most health care professionals im- or explicitly will assume that they tend to use patient-centered communication strategies, there are reasons to believe that this might not always be a valid assumption. In everyday practice, professionals' own value system is often the dominant steering guide. This Special Issue aims to bring together ongoing research and reflections about the quality of health care communication from the patients' own perspective. In short: what do patients want?

METHODS

This introduction presents a comprehensive overview of the papers in the special issue of Patient Education and Counseling within a framework that describes the collected papers according to the six functions of medical consultations, taking account of the studies' applied methodologies: quantitative versus qualitative.

RESULTS

Two functions of the medical consultation are strongly represented in the collected papers on the quality of communication from the patients' perspective: 'fostering the relationship' and 'information giving'. There is a remarkable difference between the qualiative and quantitative studies, showing that if patients are not limited to prestructured questionnaires but completely free to express themselves, they tend to focus on 'fostering the relationship' with an emphasis on personal attention, warmth and empathy.

CONCLUSIONS

Patients' needs and preferences for personalized and humane medical care cannot be overestimated. For the rest, patient diversity is striking, showing the limited usefulness of general communication guidelines for the other five functions of the medical consultation. Researchers should be aware that patients' views might be different dependent on the applied methodologies.

Dancing around death: hospitalist-patient communication about serious illness

Hospital physicians care for most seriously ill patients in the United States. We employed dimensional analysis to describe communication about death and dying in audio-recorded admission encounters between seriously ill patients and hospitalists. Acknowledging or not acknowledging the possibility of dying emerged as a key process. Acknowledgment was rare, and depended on synergistic communication behaviors between patient and physician. Facilitators included patients cuing for information and disclosing emotional distress, and physicians exploring the patient's understanding of his or her illness and emotional distress. When hospitalists focused on acute issues, stated that they were awaiting test results, and deferred to other physicians, discussion moved away from acknowledgment. Meaningful discussion of end-of-life issues, including goals and values, fears about death and dying, prognosis, and options for palliative care followed open acknowledgment. This acknowledgment process can serve as a guide for providers to sensitively and honestly discuss essential end-of-life issues.

After you: conversations between patients and healthcare professionals in planning for end of life care

BACKGROUND

This study explores with patients, carers and health care professionals if, when and how Advance Care Planning conversations about patients' preferences for place of care (and death) were facilitated and documented.

METHODS

The study adopted an exploratory case study design using qualitative interviews, across five services delivering palliative care to cancer and non-cancer patients within an urban and rural English region. The study recruited 18 cases made up of patients (N = 18; 10 men; 8 women; median age 75); nominated relatives (N = 11; 7 women; 4 men; median age 65) and healthcare professionals (N = 15) caring for the patient. Data collection included: 18 initial interviews (nine separate interviews with patients and 9 joint interviews with patients and relatives) and follow up interviews in 6 cases (involving a total of 5 patients and 5 relatives) within one year of the first interview. Five group interviews were conducted with 15 healthcare professionals; 8 of whom also participated in follow up interviews to review their involvement with patients in our study.

RESULTS

Patients demonstrated varying degrees of reticence, evasion or reluctance to initiate any conversations about end of life care preferences. Most assumed that staff would initiate such conversations, while staff were often hesitant to do so. Staff-identified barriers included the perceived risks of taking away hope and issues of timing. Staff were often guided by cues from the patient or by intuition about when to initiate these discussions.

CONCLUSIONS

This study provides insights into the complexities surrounding the initiation of Advance Care Planning involving conversations about end of life care preferences with patients who are identified as having palliative care needs, in particular in relation to the risks inherent in the process of having conversations where mortality must be acknowledged. Future research is needed to examine how to develop interventions to help initiate conversations to develop person centred plans to manage the end of life.