51
|
Palliative Care for Patients Dying in the Intensive Care Unit with Chronic Lung Disease Compared with Metastatic Cancer. Ann Am Thorac Soc 2017; 13:684-9. [PMID: 26784137 DOI: 10.1513/annalsats.201510-667oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
RATIONALE Palliative care has been focused largely on patients with cancer, and yet patients with chronic lung diseases also have high morbidity and mortality. The majority of deaths in intensive care units (ICUs) follow decisions to withhold or withdraw life-sustaining treatments, suggesting that palliative care is critically important in this setting. OBJECTIVES We explored differences in receipt of elements of palliative care among patients with interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) who die in ICUs compared with patients with cancer. METHODS We identified patients with COPD, ILD, or metastatic cancer who died in the ICUs of 15 Seattle-area hospitals between 2003 and 2008. We used robust multivariable logistic and linear regression to compare differences in receipt of elements of palliative care and length of stay. MEASUREMENTS AND MAIN RESULTS Compared with patients with cancer, patients with COPD were more likely to receive cardiopulmonary resuscitation before death and patients with ILD were less likely to have documentation of pain assessment in the last day of life. Patients with ILD and COPD were less likely to have a do-not-resuscitate order in place at the time of death and less likely to have documentation of discussions about prognosis than patients with cancer. Patients with COPD had longer hospital lengths of stay, and patients with COPD and ILD had longer ICU lengths of stay. CONCLUSIONS Among patients who die in the ICU, patients with ILD and COPD receive fewer elements of palliative care and have longer lengths of stay than patients with cancer. These findings identify areas for improvement in caring for patients with chronic lung diseases. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).
Collapse
|
52
|
Mc Veigh C, Reid J, Larkin P, Porter S, Hudson P. The experience of palliative care service provision for people with non-malignant respiratory disease and their family carers: An all-Ireland qualitative study. J Adv Nurs 2017; 74:383-394. [PMID: 28910509 DOI: 10.1111/jan.13453] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2017] [Indexed: 11/25/2022]
Abstract
AIM To explore specialist and generalist palliative care provision for people with non-malignant respiratory disease, in rural and urban areas in the North and Republic of Ireland. BACKGROUND Globally, palliative care is recommended as an appropriate healthcare option for people with advanced non-malignant lung disease. Yet, there is limited evidence regarding the integration of palliative care for this client group. DESIGN Qualitative study. METHODS Convenience sample of 17 bereaved carers and 18 healthcare professionals recruited from two rural and two urban sites on the Island of Ireland. Data were collected throughout 2012 and 2013 through semi-structured interviews with carers of patients with Chronic Obstructive Pulmonary Disease (N = 12), interstitial lung disease (N = 4) or bronchiectasis (N = 1) who had died 3-18 months previously; and four focus groups with healthcare professionals. Data were analysed using a thematic analysis framework. RESULTS Carers' interviews yielded three overarching themes: (1) lack of preparedness for death, due to ambiguity regarding disease trajectory; (2) lack of consistency in palliative care delivery, in relation with the receipt of generalist and specialist palliative care; and (3) role ambiguity, related to their caregiving role. Focus groups identified two overarching themes: (1) barriers to appropriate palliative care; and (2) the future direction of palliative care for patient with non-malignant respiratory disease. CONCLUSION The uncertain disease trajectory was not only experienced by carers but also healthcare professionals. Although referral to specialist palliative care services was perceived as increasing, the availability and coordination of generalist and specialist palliative care services were fragmented and varied dependent on geographical location.
Collapse
Affiliation(s)
- Clare Mc Veigh
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Joanne Reid
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Philip Larkin
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Sam Porter
- Department of Social Sciences and Social Work, Bournemouth University, Poole, UK
| | - Peter Hudson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK.,St Vincent's University Hospital and University of Melbourne, Melbourne, Vic., Australia
| |
Collapse
|
53
|
Jabbarian LJ, Zwakman M, van der Heide A, Kars MC, Janssen DJA, van Delden JJ, Rietjens JAC, Korfage IJ. Advance care planning for patients with chronic respiratory diseases: a systematic review of preferences and practices. Thorax 2017; 73:222-230. [DOI: 10.1136/thoraxjnl-2016-209806] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 08/22/2017] [Accepted: 09/18/2017] [Indexed: 11/04/2022]
Abstract
BackgroundAdvance care planning (ACP) supports patients in identifying and documenting their preferences and timely discussing them with their relatives and healthcare professionals (HCPs). Since the British Thoracic Society encourages ACP in chronic respiratory disease, the objective was to systematically review ACP practice in chronic respiratory disease, attitudes of patients and HCPs and barriers and facilitators related to engagement in ACP.MethodsWe systematically searched 12 electronic databases for empirical studies on ACP in adults with chronic respiratory diseases. Identified studies underwent full review and data extraction.ResultsOf 2509 studies, 21 were eligible: 10 were quantitative studies. Although a majority of patients was interested in engaging in ACP, ACP was rarely carried out. Many HCPs acknowledged the importance of ACP but were hesitant to initiate it. Barriers to engagement in ACP were the complex disease course of patients with chronic respiratory diseases, HCPs’ concern of taking away patients’ hopes and lack of continuity of care. The identification of trigger points and training of HCPs on how to communicate sensitive topics were identified as facilitators to engagement in ACP.ConclusionsIn conclusion, ACP is surprisingly uncommon in chronic respiratory disease, possibly due to the complex disease course of chronic respiratory diseases and ambivalence of both patients and HCPs to engage in ACP. Providing patients with information about their disease can help meeting their needs. Additionally, support of HCPs through identification of trigger points, training and system-related changes can facilitate engagement in ACP.Systematic review registration numberCRD42016039787.
Collapse
|
54
|
Bentur N, Sternberg S. Implementation of Advance Care Planning in Israel: A Convergence of Top-Down and Bottom-Up Processes. THE GERONTOLOGIST 2017; 59:420-425. [DOI: 10.1093/geront/gnx157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Netta Bentur
- Myers-JDC-Brookdale Institute, Jerusalem, Israel
| | - Shelley Sternberg
- Acute Care Geriatrics, Geriatric Division, the Ministry of Health, Jerusalem, Israel
| |
Collapse
|
55
|
Maddocks M, Lovell N, Booth S, Man WDC, Higginson IJ. Palliative care and management of troublesome symptoms for people with chronic obstructive pulmonary disease. Lancet 2017; 390:988-1002. [PMID: 28872031 DOI: 10.1016/s0140-6736(17)32127-x] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/29/2017] [Accepted: 07/07/2017] [Indexed: 12/30/2022]
Abstract
People with advanced chronic obstructive pulmonary disease (COPD) have distressing physical and psychological symptoms, often have limited understanding of their disease, and infrequently discuss end-of-life issues in routine clinical care. These are strong indicators for expert multidisciplinary palliative care, which incorporates assessment and management of symptoms and concerns, patient and caregiver education, and sensitive communication to elicit preferences for care towards the end of life. The unpredictable course of COPD and the difficulty of predicting survival are barriers to timely referral and receipt of palliative care. Early integration of palliative care with respiratory, primary care, and rehabilitation services, with referral on the basis of the complexity of symptoms and concerns, rather than prognosis, can improve patient and caregiver outcomes. Models of integrated working in COPD could include: services triggered by troublesome symptoms such as refractory breathlessness; short-term palliative care; and, in settings with limited access to palliative care, consultation only in specific circumstances or for the most complex patients.
Collapse
Affiliation(s)
- Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Natasha Lovell
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Sara Booth
- Department of Palliative Medicine, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Department of Oncology, University of Cambridge, Cambridge, UK
| | - William D-C Man
- Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK.
| |
Collapse
|
56
|
Rietjens JAC, Sudore RL, Connolly M, van Delden JJ, Drickamer MA, Droger M, van der Heide A, Heyland DK, Houttekier D, Janssen DJA, Orsi L, Payne S, Seymour J, Jox RJ, Korfage IJ. Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care. Lancet Oncol 2017; 18:e543-e551. [DOI: 10.1016/s1470-2045(17)30582-x] [Citation(s) in RCA: 404] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 01/31/2023]
|
57
|
Stephens AR, Wiener RS, Ieong MH. Comparison of Methods To Identify Advance Care Planning in Patients with Severe Chronic Obstructive Pulmonary Disease Exacerbation. J Palliat Med 2017; 21:284-289. [PMID: 28850288 DOI: 10.1089/jpm.2017.0251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is recommended for patients with chronic obstructive pulmonary disease (COPD). Yet, ACP documentation is often inaccessible at the time of impending respiratory failure, which may lead to unwanted and costly medical intensive care unit admissions. Electronic medical records (EMRs) contain directive fields and the ability to search for keywords and phrases, but these strategies to rapidly identify ACP have not been validated. OBJECTIVES The aim of this study is to identify the percentage of patients with severe COPD exacerbation who have outpatient ACP documentation and validate two EMR-based methods of rapidly identifying ACP documentation. DESIGN Retrospective cohort analysis. SETTING/SUBJECTS Patients who required medical intensive care unit admission for exacerbation of COPD at an urban safety-net hospital between 2009 and 2014 were observed. MEASUREMENTS We analyzed the sensitivity and specificity of two methods to rapidly identify outpatient ACP documentation: (1) documentation in the EMR directive field and (2) text string search of notes for key phrases, compared with a gold standard clinician review. RESULTS Our cohort (n = 311) was racially diverse and severely ill with obstructive lung disease. One hundred thirty-two patients (43%) had ACP documentation by gold standard chart review. Compared with a gold standard chart review, a parsimonious text string search was both sensitive (95%) and specific (97%), while the directive box was specific (100%), but not sensitive (54%), for identifying outpatient ACP documentation. CONCLUSIONS EMR directive fields may substantially underestimate ACP when used alone. As full clinician chart reviews are impractical in the emergent setting, text string searches may be a useful strategy to rapidly identify ACP discussions for clinical care and research.
Collapse
Affiliation(s)
- Amanda Renee Stephens
- 1 The Pulmonary Center, Boston University School of Medicine , Boston, Massachusetts
| | - Renda Soylemez Wiener
- 1 The Pulmonary Center, Boston University School of Medicine , Boston, Massachusetts.,2 Center for Healthcare Organization and Implementation Research , Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
| | - Michael H Ieong
- 1 The Pulmonary Center, Boston University School of Medicine , Boston, Massachusetts
| |
Collapse
|
58
|
Smith LJE, Moore E, Ali I, Smeeth L, Stone P, Quint JK. Prognostic variables and scores identifying the end of life in COPD: a systematic review. Int J Chron Obstruct Pulmon Dis 2017; 12:2239-2256. [PMID: 28814852 PMCID: PMC5546187 DOI: 10.2147/copd.s137868] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION COPD is a major cause of mortality, and the unpredictable trajectory of the disease can bring challenges to end-of-life care. We aimed to investigate known prognostic variables and scores that predict prognosis in COPD in a systematic literature review, specifically including variables that contribute to risk assessment of patients for death within 12 months. METHODS We conducted a systematic review on prognostic variables, multivariate score or models for COPD. Ovid MEDLINE, EMBASE, the Cochrane database, Cochrane CENTRAL, DARE and CINAHL were searched up to May 1, 2016. RESULTS A total of 5,276 abstracts were screened, leading to 516 full-text reviews, and 10 met the inclusion criteria. No multivariable indices were developed with the specific aim of predicting all-cause mortality in stable COPD within 12 months. Only nine indices were identified from four studies, which had been validated for this time period. Tools developed using expert knowledge were also identified, including the Gold Standards Framework Prognostic Indicator Guidance, the RADboud Indicators of Palliative Care Needs, the Supportive and Palliative Care Indicators Tool and the Necesidades Paliativas program tool. CONCLUSION A number of variables contributing to the prediction of all-cause mortality in COPD were identified. However, there are very few studies that are designed to assess, or report, the prediction of mortality at or less than 12 months. The quality of evidence remains low, such that no single variable or multivariable score can currently be recommended.
Collapse
Affiliation(s)
- Laura-Jane E Smith
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London
| | - Elizabeth Moore
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London
| | - Ifrah Ali
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London
| | - Liam Smeeth
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Patrick Stone
- Marie Curie Palliative Care Research Unit, University College London, UK
| | - Jennifer K Quint
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| |
Collapse
|
59
|
Smith TA, Disler RT, Jenkins CR, Ingham JM, Davidson PM. Perspectives on advance care planning among patients recently requiring non-invasive ventilation for acute respiratory failure: A qualitative study using thematic analysis. Palliat Med 2017; 31:566-574. [PMID: 28440124 DOI: 10.1177/0269216316670286] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Patients requiring non-invasive ventilation for acute-on-chronic respiratory failure due to chronic obstructive pulmonary disease or heart failure exacerbations may have a poor prognosis underscoring the importance of advance care planning. AIM We aimed to describe attitudes to, and experiences of, discussing the future among patients recently treated with non-invasive ventilation. DESIGN Qualitative research using thematic analysis. SETTINGS AND PARTICIPANTS Tertiary teaching hospital. Patients with acute hypercapnic respiratory failure requiring non-invasive ventilation. RESULTS Individuals recently treated with non-invasive ventilation describe feeling the future is beyond their control and instead controlled by their illness. Participants often recognised their poor prognosis but avoided discussing some difficult topics. The majority preferred not to undergo cardiopulmonary resuscitation but most had not discussed this with healthcare professionals. When participants voiced concerns about their future health to family members, they were met with polarised responses. Some encountered willingness for further discussion, while others met deflection, deterring further conversation. An overarching narrative of 'Looking through my illness to an uncertain but concerning future' unites these themes. CONCLUSION This study suggests opportunities and barriers for advance care planning in individuals with chronic disease. Patients' understanding of their prognosis and their attitudes to cardiopulmonary resuscitation suggests an opportunity for advance care planning. Structuring discussions around patients' preferences for care during future exacerbations may foster a sense of control over the future despite illness. The diversity of familial responses to patients' concerns about their future health has implications for advance care planning. These findings have the potential to improve care for patients with respiratory failure and suggest an important ongoing research agenda.
Collapse
Affiliation(s)
- Tracy A Smith
- 1 St Vincent's Clinical School, Faculty of Medicine, UNSW Australia, Sydney, NSW, Australia.,2 Department of Respiratory & Sleep Medicine, Westmead Hospital, Wentworthville, NSW, Australia
| | - Rebecca T Disler
- 3 Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.,4 ImPaCCT (Improving Palliative Care through Clinical Trials) NSW Palliative Care Collaborative Clinical Trials Group, Liverpool, NSW, Australia
| | - Christine R Jenkins
- 5 Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia.,6 The George Institute, Sydney, NSW, Australia
| | - Jane M Ingham
- 1 St Vincent's Clinical School, Faculty of Medicine, UNSW Australia, Sydney, NSW, Australia.,7 St Vincent's Health Network, Sydney, NSW, Australia
| | - Patricia M Davidson
- 3 Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.,8 Department of Acute and Chronic Care, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
60
|
Impact of Community Health Workers on Elderly Patients' Advance Care Planning and Health Care Utilization: Moving the Dial. Med Care 2017; 55:319-326. [PMID: 27875482 DOI: 10.1097/mlr.0000000000000675] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences. OBJECTIVE To evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment. RESEARCH DESIGN A year-long, pre-post intervention using lay community health workers [care coordinator assistants (CCAs)] trained to conduct and document ACP conversations with patients during home health visits with pre-post evaluation. SUBJECTS The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% white. MEASURES Documentation of ACP conversation in electronic health record fields and health care utilization outcomes. RESULTS In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least 1 discussion about ACP in the electronic health record. In the 1-year preintervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (hazard ratios, 0.66; 95% confidence interval, 0.45-0.97), and similar effects are apparent on ED use independent of age and prior ED use effects. CONCLUSIONS Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home health care providers. Having ACP conversation is associated with significant reduction in seeking urgent health care and in hospitalizations.
Collapse
|
61
|
Dingfield LE, Kayser JB. Integrating Advance Care Planning Into Practice. Chest 2017; 151:1387-1393. [PMID: 28283409 DOI: 10.1016/j.chest.2017.02.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 02/27/2017] [Accepted: 02/27/2017] [Indexed: 11/19/2022] Open
Abstract
Advanced respiratory diseases progress over time and often lead to death. As the condition worsens, patients may lose medical decision-making ability. Advance care planning (ACP) is a process in which patients receive information about their diagnosis and prognosis; discuss values, goals, and fears; articulate preferences about life-sustaining treatments and end-of-life care; and appoint a surrogate medical decision maker. This process may result in written documentation of patient preferences or the appointment of a health-care power of attorney (HCPOA). ACP discussions have multiple benefits for patients and their surrogate decision makers, including ensuring that the care provided is aligned with the patient's goals and preferences and decreasing stress, anxiety, and burden in surrogates. Time and provider comfort are often cited barriers to ACP, so it may be necessary for clinicians to gain experience in conversations and identify the patients most likely to benefit from ACP discussions. Two new Current Procedural Terminology (CPT) codes, 99497 and 99498, have been recognized by the Centers for Medicare and Medicaid Services (CMS) as of January 1, 2016 and are intended to incentivize clinicians to engage in ACP discussions with their patients earlier and with more frequency. This manuscript reviews the benefits and barriers to ACP in patients with advanced respiratory disease and provides guidance on the use of the new CPT codes for reimbursement of these conversations.
Collapse
Affiliation(s)
- Laura E Dingfield
- Palliative Care Service, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joshua B Kayser
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, and Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
62
|
Sinclair C, Auret KA, Evans SF, Williamson F, Dormer S, Wilkinson A, Greeve K, Koay A, Price D, Brims F. Advance care planning uptake among patients with severe lung disease: a randomised patient preference trial of a nurse-led, facilitated advance care planning intervention. BMJ Open 2017; 7:e013415. [PMID: 28237955 PMCID: PMC5337715 DOI: 10.1136/bmjopen-2016-013415] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Advance care planning (ACP) clarifies goals for future care if a patient becomes unable to communicate their own preferences. However, ACP uptake is low, with discussions often occurring late. This study assessed whether a systematic nurse-led ACP intervention increases ACP in patients with advanced respiratory disease. DESIGN A multicentre open-label randomised controlled trial with preference arm. SETTING Metropolitan teaching hospital and a rural healthcare network. PARTICIPANTS 149 participants with respiratory malignancy, chronic obstructive pulmonary disease or interstitial lung disease. INTERVENTION Nurse facilitators offered facilitated ACP discussions, prompted further discussions with doctors and loved ones, and assisted participants to appoint a substitute medical decision-maker (SDM) and complete an advance directive (AD). OUTCOME MEASURES The primary measure was formal (AD or SDM) or informal (discussion with doctor) ACP uptake assessed by self-report (6 months) and medical notes audit. Secondary measures were the factors predicting baseline readiness to undertake ACP, and factors predicting postintervention ACP uptake in the intervention arm. RESULTS At 6 months, formal ACP uptake was significantly higher (p<0.001) in the intervention arm (54/106, 51%), compared with usual care (6/43, 14%). ACP discussions with doctors were also significantly higher (p<0.005) in the intervention arm (76/106, 72%) compared with usual care (20/43, 47%). Those with a strong preference for the intervention were more likely to complete formal ACP documents than those randomly allocated. Increased symptom burden and preference for the intervention predicted later ACP uptake. Social support was positively associated with ACP discussion with loved ones, but negatively associated with discussion with doctors. CONCLUSIONS Nurse-led facilitated ACP is acceptable to patients with advanced respiratory disease and effective in increasing ACP discussions and completion of formal documents. Awareness of symptom burden, readiness to engage in ACP and relevant psychosocial factors may facilitate effective tailoring of ACP interventions and achieve greater uptake. TRIAL REGISTRATION NUMBER ACTRN12614000255684.
Collapse
Affiliation(s)
- Craig Sinclair
- Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia
| | - Kirsten Anne Auret
- Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia
| | - Sharon Frances Evans
- Rural Clinical School of Western Australia, University of Western Australia,Perth, Western Australia, Australia
| | - Fiona Williamson
- Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia
| | - Siobhan Dormer
- Respiratory Department, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Anne Wilkinson
- School of Nursing and Midwifery, Edith Cowan University, Perth, Western Australia, Australia
| | - Kim Greeve
- Department of Health, WA Cancer and Palliative Care Network, Perth, Western Australia, Australia
| | - Audrey Koay
- Department of Health, WA Cancer and Palliative Care Network, Perth, Western Australia, Australia
| | - Dot Price
- Western Australian Country Health Service, District Health Advisory Committee, Albany, Western Australia, Australia
| | - Fraser Brims
- Respiratory Department, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| |
Collapse
|
63
|
Dillon E, Chuang J, Gupta A, Tapper S, Lai S, Yu P, Ritchie C, Tai-Seale M. Provider Perspectives on Advance Care Planning Documentation in the Electronic Health Record: The Experience of Primary Care Providers and Specialists Using Advance Health-Care Directives and Physician Orders for Life-Sustaining Treatment. Am J Hosp Palliat Care 2017; 34:918-924. [PMID: 28196448 DOI: 10.1177/1049909117693578] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Advance care planning (ACP) is valued by patients and clinicians, yet documenting ACP in an accessible manner is problematic. OBJECTIVES In order to understand how providers incorporate electronic health record (EHR) ACP documentation into clinical practice, we interviewed providers in primary care and specialty departments about ACP practices (n = 13) and analyzed EHR data on 358 primary care providers (PCPs) and 79 specialists at a large multispecialty group practice. METHODS Structured interviews were conducted with 13 providers with high and low rates of ACP documentation in primary care, oncology, pulmonology, and cardiology departments. The EHR problem list data on Advance Health Care Directives (AHCDs) and Physician Orders for Life-Sustaining Treatment (POLST) were used to calculate ACP documentation rates. RESULTS Examining seriously ill patients ≥65 years with no preexisting ACP documentation seen by providers during 2013 to 2014, 88.6% (AHCD) and 91.1% (POLST) of 79 specialists had zero ACP documentations. Of 358 PCPs, 29.1% (AHCD) and 62.3% (POLST) had zero ACP documentations. Interviewed PCPs often believed ACP documentation was beneficial and accessible, while specialists more often did not. Specialists expressed more confusion about documenting ACP, whereas PCPs reported standard clinic workflows. Problems with interoperability between outpatient and inpatient EHR systems and lack of consensus about who should document ACP were sources of variations in practices. CONCLUSION Results suggest that providers desire standardized workflows for ACP discussion and documentation. New Medicare reimbursement for ACP and an increasing number of quality metrics for ACP are incentives for health-care systems to address barriers to ACP documentation.
Collapse
Affiliation(s)
- Ellis Dillon
- 1 Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| | - Judith Chuang
- 1 Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| | - Atul Gupta
- 2 Department of Economics, Stanford University, Stanford, CA, USA
| | - Sharon Tapper
- 3 Palo Alto Medical Foundation, Department of Palliative Care, Santa Cruz, CA, USA
| | - Steve Lai
- 4 Palo Alto Medical Foundation, Department of Palliative Care, Palo Alto, CA, USA
| | - Peter Yu
- 5 Hartford Health Care Cancer Institute, Memorial Sloan Kettering Cancer Alliance, Hartford, CT, USA
| | - Christine Ritchie
- 6 Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Ming Tai-Seale
- 1 Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| |
Collapse
|
64
|
Johnston B, Coole C, Jay Narayanasamy M. An end-of-life care nurse service for people with COPD and heart failure: stakeholders' experiences. Int J Palliat Nurs 2017; 22:549-559. [PMID: 27885910 DOI: 10.12968/ijpn.2016.22.11.549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND End-of-life care (EOLC) has historically been associated with cancer care. However, demographic changes indicate that future provision must also cater for other long term conditions (LTC). An EOLC-LTC service, delivered by palliative care nurses, is currently being piloted in one area in the East Midlands with patients with cardiac and respiratory disease. In order to inform future commissioning, it is important to gain the views and experiences of those involved with the service. AIMS This study aimed to explore patients, and their partners, views and experiences of the EOLC-LTC service. METHODS Semi-structured interviews were used as part of a case study design, involving six cases. Each case consisted of the patient, their nominated family member/carer and key healthcare professionals involved in their care as identified by the patient. This paper reports on the findings from the interviews conducted with the six patients and their family member/carers. Data were analysed thematically. RESULTS From the interviews, the following themes were identified: experiences managing a long term cardio-respiratory condition, the nurse service, building a close/therapeutic relationship and fragmentation and integration. CONCLUSIONS This study has shown that the EOLC-LTC service is welcomed and highly regarded by patients and their family members/carers. Further studies are required to explore the views and experiences of other key stakeholders and to evaluate how well the pilot operates within the wider care pathway.
Collapse
Affiliation(s)
- Bridget Johnston
- Florence Nightingale Foundation Professor of Clinical Nursing Practice Research, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow
| | - Carolyn Coole
- School of Health Sciences, University of Nottingham, Nottingham
| | | |
Collapse
|
65
|
Beck ER, McIlfatrick S, Hasson F, Leavey G. Nursing home manager's knowledge, attitudes and beliefs about advance care planning for people with dementia in long-term care settings: a cross-sectional survey. J Clin Nurs 2017; 26:2633-2645. [DOI: 10.1111/jocn.13690] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Esther-Ruth Beck
- Institute of Nursing and Health Research; University of Ulster; Newtownabbey UK
| | - Sonja McIlfatrick
- All Ireland Institute of Hospice and Palliative Care; University of Ulster; Newtownabbey UK
| | | | - Gerry Leavey
- University of Ulster and Bamford Centre for Mental Health; Londonderry UK
| |
Collapse
|
66
|
Abstract
Patients with chronic lung diseases suffer higher symptom burden, lower quality of life, and greater social isolation compared with patients with other diagnoses, such as cancer. These conditions may be alleviated by palliative care, yet palliative care is used less by patients with chronic lung disease compared with patients with cancer. Underuse is due, in part, to poor implementation of primary palliative care and inadequate referral to specialty palliative care. Lack of primary and specialty palliative care in patients with chronic lung disease falls short of the minimum standard of competent health care, and represents a disparity in health care and a social injustice. We invoke the ethical principles of justice and sufficiency to highlight the importance of this issue. We identify five barriers to implementing palliative care in patients with chronic lung disease: uncertainty in prognosis; lack of provider skill to engage in discussions about palliative care; fear of using opioids among patients with chronic lung disease; fear of diminishing hope; and perceived and implicit bias against patients with smoking-related lung diseases. We propose mechanisms for improving implementation of palliative care for patients with chronic lung disease with the goal of enhancing justice in health care.
Collapse
|
67
|
Lai PSM, Mohd Mudri S, Chinna K, Othman S. The development and validation of the advance care planning questionnaire in Malaysia. BMC Med Ethics 2016; 17:61. [PMID: 27756366 PMCID: PMC5069889 DOI: 10.1186/s12910-016-0147-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 10/11/2016] [Indexed: 11/26/2022] Open
Abstract
Background Advance care planning is a voluntary process whereby individual preferences, values and beliefs are used to aid a person in planning for end-of-life care. Currently, there is no local instrument to assess an individual’s awareness and attitude towards advance care planning. This study aimed to develop an Advance Care Planning Questionnaire and to determine its validity and reliability among older people in Malaysia. Methods The Advance Care Planning Questionnaire was developed based on literature review. Face and content validity was verified by an expert panel, and piloted among 15 participants. Our study was conducted from October 2013 to February 2014, at an urban primary care clinic in Malaysia. Included were those aged >50 years, who could understand English. A retest was conducted 2 weeks after the first administration. Results Participants from the pilot study did not encounter any problems in answering the Advance Care Planning Questionnaire. Hence, no further modifications were made. Flesch reading ease was 71. The final version of the Advance Care Planning Questionnaire consists of 66 items: 30 items were measured on a nominal scale, whilst 36 items were measured on a Likert-like scale; of which we were only able to validate 22 items, as the remaining 14 items were descriptive in nature. A total of 245 eligible participants were approached; of which 230 agreed to participate (response rate = 93.9 %). Factor analysis on the 22 items measured on a Likert-scale revealed four domains: “feelings regarding advance care planning”, “justifications for advance care planning”, “justifications for not having advance care planning: fate and religion”, and “justifications for not having advance care planning: avoid thinking about death”. The Cronbach’s alpha values for items each domain ranged from 0.637–0.915. In test-retest, kappa values ranged from 0.738–0.947. Conclusions The final Advance Care Planning Questionnaire consisted of 63 items and 4 domains. It was found to be a valid and reliable instrument to assess the awareness and attitude of older people in Malaysia towards advance care planning. Electronic supplementary material The online version of this article (doi:10.1186/s12910-016-0147-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Pauline Siew Mei Lai
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Salinah Mohd Mudri
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Karuthan Chinna
- Department of Social Preventive Medicine, Julius Centre, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sajaratulnisah Othman
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
68
|
Smith LJE, Ali I, Stone P, Smeeth L, Quint JK. Prognostic variables and scores identifying the last year of life in COPD: a systematic review protocol. BMJ Open 2016; 6:e011677. [PMID: 27633634 PMCID: PMC5030546 DOI: 10.1136/bmjopen-2016-011677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION People living with advanced chronic obstructive pulmonary disease (COPD) suffer from significant morbidity, reduced quality of life and high mortality, and are likely to benefit from many aspects of a palliative care approach. Prognostic estimates are a meaningful part of decision-making and better evidence for such estimates would facilitate advance care planning. We aim to provide quality evidence on known prognostic variables and scores which predict a prognosis in COPD of <12 months for use in the community. METHODS AND ANALYSIS We will conduct a systematic review of randomised or quasi-randomised controlled trials, prospective and retrospective longitudinal cohort and case-control studies on prognostic variables, multivariate scores or models for COPD. The search will cover the period up to April 2016. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with data extraction using fields from the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) checklist for multivariate models, and study quality will be assessed using a modified version of the Quality In Prognosis Studies (QUIPS) tool. ETHICS AND DISSEMINATION The results will be disseminated through peer-reviewed publications and national and international conference presentations. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42016033866.
Collapse
Affiliation(s)
- Laura-Jane E Smith
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London, London, UK
| | - Ifrah Ali
- Imperial College School of Medicine, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Unit, University College London, London, UK
| | - Liam Smeeth
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jennifer K Quint
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London, London, UK
| |
Collapse
|
69
|
Fakhri S, Engelberg RA, Downey L, Nielsen EL, Paul S, Lahdya AZ, Treece PD, Curtis JR. Factors Affecting Patients' Preferences for and Actual Discussions About End-of-Life Care. J Pain Symptom Manage 2016; 52:386-94. [PMID: 27265813 PMCID: PMC5023466 DOI: 10.1016/j.jpainsymman.2016.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/28/2016] [Accepted: 04/27/2016] [Indexed: 11/20/2022]
Abstract
CONTEXT Discussions about end-of-life care are often difficult for patients and clinicians, and inadequate communication poses a barrier to patients receiving the care they desire. OBJECTIVES To understand factors that facilitate end-of-life care discussions that guide interventions to improve care. METHODS We examined baseline data from an ongoing randomized trial to evaluate associations between patients' self-reported desire for, and occurrence of, discussions about end-of-life care and factors influencing these discussions. Factors included emotional symptoms and barriers and facilitators to discussions. The sample included patients with serious illness (n = 473) and their primary or specialty care clinicians (n = 128). Regression analyses were adjusted for confounders and clustered patients under clinicians. RESULTS Patients who endorsed each of three barriers to discussions were less likely to have had a discussion with their clinician (P-values ranging from <0.001 to 0.046). One facilitator (having had family/friends who died) was associated with past discussions (P = 0.037), and two facilitators were associated with wanting future discussion (P < 0.001): 1) concerns about future quality of life, 2) worries about being a burden on friends/family. Depression and anxiety were not associated with past discussions. However, patients with more anxiety were more likely to want future discussions (P = 0.001), as were patients with more depressive symptoms who had had discussions in the past (P < 0.001). CONCLUSION The occurrence of, and desire for, patient-clinician communication about end-of-life care is associated with patient factors including communication barriers and facilitators and symptoms of depression and anxiety. Understanding these factors may facilitate design of effective communication interventions.
Collapse
Affiliation(s)
- Shoaib Fakhri
- Cambia Palliative Care Center of Excellence and Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence and Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence and Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Cambia Palliative Care Center of Excellence and Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - Sudiptho Paul
- Cambia Palliative Care Center of Excellence and Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - Alexandria Z Lahdya
- Cambia Palliative Care Center of Excellence and Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - Patsy D Treece
- Cambia Palliative Care Center of Excellence and Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence and Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA.
| |
Collapse
|
70
|
Fryer S, Bellamy G, Morgan T, Gott M. "Sometimes I've gone home feeling that my voice hasn't been heard": a focus group study exploring the views and experiences of health care assistants when caring for dying residents. BMC Palliat Care 2016; 15:78. [PMID: 27543042 PMCID: PMC4992208 DOI: 10.1186/s12904-016-0150-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 08/14/2016] [Indexed: 11/12/2022] Open
Abstract
Background In most developed countries, Health Care Assistants comprise a significant, and growing, proportion of the residential aged care workforce. Despite the fact that they provide the majority of direct care for residents, little is known about a key care aspect of their work, namely their experience of caring for dying residents. Methods Twenty-six Health Care Assistants working in aged residential care facilities in Auckland, New Zealand participated in six focus group discussions. Focus groups were designed to explore the experiences of Health Care Assistants caring for imminently dying residents in aged care facilities and to identify barriers and facilitators to their work in this area. The focus groups were digitally recorded, transcribed verbatim and analysed using a general inductive approach. Results Participants confirmed that Health Care Assistants provide the majority of hands on care to dying residents and believed they had a valuable role to play at this time due to their unique ‘familial’ relationship with residents and families. However, it was apparent that a number of barriers existed to them maximising their contribution to supporting dying residents, most notably the lack of value placed on their knowledge and experience by other members of the multidisciplinary team. Whilst a need for additional palliative and end of life care education was identified, a preference was identified for hands on education delivered by peers, rather than the didactic education they currently receive. Conclusion Given ageing populations internationally coupled with a constrained health budget, the role of Health Care Assistants in most developed countries is likely to become even more significant in the short to medium term. This study makes a unique contribution to the international literature by identifying the barriers to caring for dying residents experienced by this valuable sector of the aged care workforce. These data have the potential to inform new, innovative, interventions to address the urgent need identified to improve palliative and end of life care management in aged care internationally.
Collapse
Affiliation(s)
- Susan Fryer
- Manukau Locality, Counties Manukau Health, Manukau, New Zealand
| | - Gary Bellamy
- North West London Clinical Research Network, London, England
| | - Tessa Morgan
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, University of Auckland, Auckland, New Zealand.
| |
Collapse
|
71
|
Integrating palliative care into primary care for patients with chronic, life-limiting conditions. Nurse Pract 2016; 41:42-8; quiz 49. [PMID: 26886272 DOI: 10.1097/01.npr.0000480588.01667.58] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
As longevity increases, individuals with chronic, life-limiting conditions will live longer with disease burden and functional decline. Nurse practitioners can integrate symptom management, early decision-making, and supportive care into the primary care setting to improve quality of life and decrease economic and emotional impact at the end of life.
Collapse
|
72
|
Enhancing the prospects for palliative care at the end of life: A statewide educational demonstration project to improve advance care planning. Palliat Support Care 2016; 14:641-651. [PMID: 27320687 DOI: 10.1017/s1478951516000353] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Although patients want to participate in discussions and decisions about their end-of-life care, studies show that providers frequently fail to invite them to explore advanced care preferences or goals for living. The purpose of our demonstration project was to provide education and coaching to individuals, health providers, and organizations across the state of Indiana intended to facilitate these conversations, documenting and honoring individuals' life goals and preferences for care during the final stages of life. METHOD Education and training engaged community members as well as healthcare providers to: (1) improve participant comfort and facility discussing end-of-life issues; (2) improve knowledge of healthcare choices, including palliative and hospice care; and (3) prepare all participants to explore and document personal values, life goals, and priorities as well as goals of care. RESULTS Between January of 2013 and June of 2015, the team educated close to 5,000 participants. Participants' ratings of the quality and perceived usefulness of the educational events ranged from 4 to 5 (using a 5-point scale, with 5 = most effective). Participant comments were overwhelmingly favorable and indicated an intention to put the advance care planning resources, communication skills, knowledge of palliative and hospice care, and personal renewal techniques into practice. SIGNIFICANCE OF RESULTS Participant motivation to foster advance care planning, discussions of palliative care, and end-of-life conversations was facilitated by the reframing of these conversations as identifying goals of care and priorities for living well during an important stage of life. Successful strategies included helping providers and patients to adopt a broader meaning for "sustaining hope" (not for cure, but for engaging in highly valued activities), developing provider communication skills and comfort in initiating potentially difficult discussions, engaging a new community health workforce who will develop trusting relationships with patients in home-based services, and fostering self-awareness and self-care among palliative care providers.
Collapse
|
73
|
Lilly EJ, Senderovich H. Palliative care in chronic obstructive pulmonary disease. J Crit Care 2016; 35:150-4. [PMID: 27481751 DOI: 10.1016/j.jcrc.2016.05.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/17/2016] [Accepted: 05/20/2016] [Indexed: 11/19/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is the only major worldwide cause of mortality that is currently increasing in prevalence. Furthermore, COPD is incurable, and the only therapy that has been shown to increase survival is oxygen therapy in selected patients. Compared to patients with cancer, patients with COPD experience similar levels of pain, breathlessness, fatigue, depression, and anxiety and have a worse quality of life but have comparatively little access to palliative care. When these patients do receive palliative care, they tend to be referred later than patients with cancer. Many disease, patient-, and provider-related factors contribute to this phenomenon, including COPD's unpredictable course, misperceptions of palliative care among patients and physicians, and lack of advance care planning discussions outside of crisis situations. A new paradigm for palliative care would introduce palliative treatments alongside, rather than at the exclusion of disease-modifying interventions. This integrated approach would circumvent the issue of difficult prognostication in COPD, as any patient would receive individualized palliative interventions from the time of diagnosis. These points will be covered in this review, which discusses the challenges in providing palliative care to COPD patients, the strategies to mitigate the challenges, management of common symptoms, and the evidence for integrated palliative care models as well as some suggestions for future development.
Collapse
Affiliation(s)
- Evan J Lilly
- Western University, Department of Family Medicine, London, Ontario, Canada
| | - Helen Senderovich
- Division of Palliative Care, Department Family and Community Medicine, University of Toronto, Baycrest Health Sciences System, Toronto, Ontario, Canada.
| |
Collapse
|
74
|
O’Hare AM, Szarka J, McFarland LV, Taylor JS, Sudore RL, Trivedi R, Reinke LF, Vig EK. Provider Perspectives on Advance Care Planning for Patients with Kidney Disease: Whose Job Is It Anyway? Clin J Am Soc Nephrol 2016; 11:855-866. [PMID: 27084877 PMCID: PMC4858488 DOI: 10.2215/cjn.11351015] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 01/21/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES There is growing interest in efforts to enhance advance care planning for patients with kidney disease. Our goal was to elicit the perspectives on advance care planning of multidisciplinary providers who care for patients with advanced kidney disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Between April and December of 2014, we conducted semistructured interviews at the Department of Veterans Affairs Puget Sound Health Care System with 26 providers from a range of disciplines and specialties who care for patients with advanced kidney disease. Participants were asked about their perspectives and experiences related to advance care planning in this population. Interviews were audiotaped, transcribed, and analyzed inductively using grounded theory. RESULTS The comments of providers interviewed for this study spoke to significant system-level barriers to supporting the process of advance care planning for patients with advanced kidney disease. We identified four overlapping themes: (1) medical care for this population is complex and fragmented across settings and providers and over time; (2) lack of a shared understanding and vision of advance care planning and its relationship with other aspects of care, such as dialysis decision making; (3) unclear locus of responsibility and authority for advance care planning; and (4) lack of active collaboration and communication around advance care planning among different providers caring for the same patients. CONCLUSIONS The comments of providers who care for patients with advanced kidney disease spotlight both the need for and the challenges to interdisciplinary collaboration around advance care planning for this population. Systematic efforts at a variety of organizational levels will likely be needed to support teamwork around advance care planning among the different providers who care for patients with advanced kidney disease.
Collapse
Affiliation(s)
- Ann M. O’Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Hospital and Specialty Medicine Service, and
- Departments of Medicine and
| | - Jackie Szarka
- Center of Innovation for Veteran-Centered and Value-Driven Care
| | | | | | - Rebecca L. Sudore
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, California
- Department of Medicine, San Francisco Department of Veterans Affairs Medical Center, San Francisco, California
| | - Ranak Trivedi
- Center for Innovation to Implementation, Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California
| | - Lynn F. Reinke
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Hospital and Specialty Medicine Service, and
| | | |
Collapse
|
75
|
De Vleminck A, Pardon K, Beernaert K, Houttekier D, Vander Stichele R, Deliens L. How Do General Practitioners Conceptualise Advance Care Planning in Their Practice? A Qualitative Study. PLoS One 2016; 11:e0153747. [PMID: 27096846 PMCID: PMC4838248 DOI: 10.1371/journal.pone.0153747] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 04/04/2016] [Indexed: 12/02/2022] Open
Abstract
Objectives To explore how GPs conceptualise advance care planning (ACP), based on their experiences with ACP in their practice. Methods Five focus groups were held with 36 GPs. Discussions were analysed using a constant comparative method. Results Four overarching themes in the conceptualisations of ACP were discerned: (1) the organisation of professional care required to meet patients’ needs, (2) the process of preparing for death and discussing palliative care options, (3) the discussion of care goals and treatment decisions, (4) the completion of advance directives. Within these themes, ACP was both conceptualised in terms of content of ACP and/or in terms of tasks for the GP. A specific task that was mentioned throughout the discussion of the four different themes was (5) the task of actively initiating ACP by the GP versus passively waiting for patients’ initiation. Conclusions This study illustrates that GPs have varying conceptualisations of ACP, of which some are more limited to specific aspects of ACP. A shared conceptualisation and agreement on the purpose and goals of ACP is needed to ensure successful implementation, as well as a systematic integration of ACP in routine practice that could lead to a better uptake of all the important elements of ACP.
Collapse
Affiliation(s)
- Aline De Vleminck
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- * E-mail:
| | - Koen Pardon
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kim Beernaert
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Dirk Houttekier
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Heymans Institute, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
76
|
Abstract
Health-care policy recognises the importance of engaging people in making decisions related to the management of their health. Advance care planning (ACP) offers a framework for decision making on end-of-life care. There are positive indicators that ACP enables health professionals to meet people's preferences. However, there are reports of insensitive attempts to engage people in end-of-life care decision making. District nurses are in the ideal position to facilitate ACP, as they have the opportunity to build relationships with the people they are caring for--an antecedent to sensitive ACP--and in recognising and fulfilling this role, they could ameliorate the risk of insensitive ACP. Distric nurse leaders also have a role to play in ensuring that organisational and environmental factors support appropriate ACP facilitation including: training, fostering a team culture that empowers district nurses to recognise and meet their ACP role, and advocating for appropriate ACP evaluation outcome measures.
Collapse
Affiliation(s)
- Michelle Boot
- Senior Lecturer in Cancer and Palliative Care, Buckinghamshire New University, England
| |
Collapse
|
77
|
Wong JSH, Gottwald M. Advance Care Planning Discussions in Chronic Obstructive Pulmonary Disease: A critical review. J Palliat Care 2016; 31:258-64. [PMID: 26856127 DOI: 10.1177/082585971503100408] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
78
|
Development of a complex intervention to support the initiation of advance care planning by general practitioners in patients at risk of deteriorating or dying: a phase 0-1 study. BMC Palliat Care 2016; 15:17. [PMID: 26868650 PMCID: PMC4750213 DOI: 10.1186/s12904-016-0091-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 02/08/2016] [Indexed: 11/13/2022] Open
Abstract
Background Most patients with life-limiting illnesses are treated and cared for over a long period of time in primary care and guidelines suggest that ACP discussions should be initiated in primary care. However, a practical model to implement ACP in general practice is lacking. Therefore, the objective of this study is to develop an intervention to support the initiation of ACP in general practice. Methods We conducted a Phase 0-I study according to the Medical Research Council (MRC) Framework. Phase 0 consisted of a systematic literature review about the barriers and facilitators for GPs to engage in ACP, focus groups with GPs were held about their experiences, attitudes and concerns regarding initiating ACP in general practice and a review of ACP interventions to identify potential components for the development of our intervention. In Phase 1, we developed a complex intervention to support the initiation of ACP in general practice in patients at risk of deteriorating or dying, based on the results of Phase 0. The complex intervention and its components were reviewed and refined by two expert panels. Results Phase 0 resulted in the identification of the factors inhibiting or enabling GPs’ initiation of ACP and important components underpinning existing ACP interventions. Based on these findings, an intervention was developed in Phase 1 consisting of: (1) a training for GPs in initiating and conducting ACP discussions, (2) a register of patients eligible for ACP discussions, (3) an educational booklet on ACP for patients to prepare the ACP discussions that includes general information on ACP, a section on the role of GPs in the process of ACP and a prompt list, (4) a conversation guide to support GPs in the ACP discussions and (5) a structured documentation template to record the outcomes of discussions. Conclusion Taking into account the barriers and facilitators for GPs to initiate ACP as well as the key factors underpinning successful ACP intervention in other health care settings, a complex intervention for general practice was developed, after gaining feedback from two expert panels. The feasibility and acceptability of the intervention will subsequently be tested in a Phase II study.
Collapse
|
79
|
Sanders JJ, Robinson MT, Block SD. Factors Impacting Advance Care Planning among African Americans: Results of a Systematic Integrated Review. J Palliat Med 2016; 19:202-27. [DOI: 10.1089/jpm.2015.0325] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Justin J. Sanders
- Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Ariadne Labs, Boston, Massachusetts
| | - Maisha T. Robinson
- Department of Neurology, University of California Los Angeles, Los Angeles, California
| | - Susan D. Block
- Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Ariadne Labs, Boston, Massachusetts
| |
Collapse
|
80
|
Chochinov HM, Johnston W, McClement SE, Hack TF, Dufault B, Enns M, Thompson G, Harlos M, Damant RW, Ramsey CD, Davison S, Zacharias J, Milke D, Strang D, Campbell-Enns HJ, Kredentser MS. Dignity and Distress towards the End of Life across Four Non-Cancer Populations. PLoS One 2016; 11:e0147607. [PMID: 26808530 PMCID: PMC4725711 DOI: 10.1371/journal.pone.0147607] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 01/06/2016] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE The purpose of this study was to identify four non-cancer populations that might benefit from a palliative approach; and describe and compare the prevalence and patterns of dignity related distress across these diverse clinical populations. DESIGN A prospective, multi-site approach was used. SETTING Outpatient clinics, inpatient facilities or personal care homes, located in Winnipeg, Manitoba and Edmonton, Alberta, Canada. PARTICIPANTS Patients with advanced Amyotrophic Lateral Sclerosis (ALS), Chronic Obstructive Pulmonary Disease (COPD), End Stage Renal Disease (ESRD); and the institutionalized alert frail elderly. MAIN OUTCOME MEASURE In addition to standardized measures of physical, psychological and spiritual aspects of patient experience, the Patient Dignity Inventory (PDI). RESULTS Between February 2009 and December 2012, 404 participants were recruited (ALS, 101; COPD, 100; ESRD, 101; and frail elderly, 102). Depending on group designation, 35% to 58% died within one year of taking part in the study. While moderate to severe loss of sense of dignity did not differ significantly across the four study populations (4-11%), the number of PDI items reported as problematic was significantly different i.e. ALS 6.2 (5.2), COPD 5.6 (5.9), frail elderly 3.0 (4.4) and ESRD 2.3 (3.9) [p < .0001]. Each of the study populations also revealed unique and distinct patterns of physical, psychological and existential distress. CONCLUSION People with ALS, COPD, ESRD and the frail elderly face unique challenges as they move towards the end of life. Knowing the intricacies of distress and how they differ across these groups broadens our understanding of end-of-life experience within non-cancer populations and how best to meet their palliative care needs.
Collapse
Affiliation(s)
- Harvey Max Chochinov
- Department of Psychiatry, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Manitoba Palliative Care Research Unit, CancerCare Manitoba, Winnipeg, Canada
| | - Wendy Johnston
- Neurology, Department of Medicine, Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Susan E. McClement
- Manitoba Palliative Care Research Unit, CancerCare Manitoba, Winnipeg, Canada
- College of Nursing, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Thomas F. Hack
- College of Nursing, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Brenden Dufault
- George and Fay Yee Center for Healthcare Innovation, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Murray Enns
- Department of Psychiatry, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Genevieve Thompson
- Manitoba Palliative Care Research Unit, CancerCare Manitoba, Winnipeg, Canada
- College of Nursing, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Mike Harlos
- Winnipeg Regional Health Authority, Palliative Care Program, Winnipeg, Canada
| | - Ronald W. Damant
- Division of Pulmonary Medicine, University of Alberta, Edmonton, Canada
| | - Clare D. Ramsey
- Department of Internal Medicine, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Sara Davison
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - James Zacharias
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
- Section of Nephrology, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Doris Milke
- CapitalCare, Edmonton, Canada
- Faculty of Nursing, University of Alberta, Edmonton, Canada
- Department of Psychology, University of Alberta, Edmonton, Canada
| | - David Strang
- Geriatric Medicine, University of Manitoba, Winnipeg, Canada
- Geriatrics Program, Winnipeg Regional Health Authority, Winnipeg, Canada
| | - Heather J. Campbell-Enns
- Manitoba Palliative Care Research Unit, CancerCare Manitoba, Winnipeg, Canada
- Interdisciplinary Cancer Control, Faculty of Health Sciences, Faculty of Graduate Studies, University of Manitoba, Winnipeg, Canada
| | - Maia S. Kredentser
- Manitoba Palliative Care Research Unit, CancerCare Manitoba, Winnipeg, Canada
- Department of Psychology, University of Manitoba, Winnipeg, Canada
| |
Collapse
|
81
|
Glogowska M, Simmonds R, McLachlan S, Cramer H, Sanders T, Johnson R, Kadam UT, Lasserson DS, Purdy S. "Sometimes we can't fix things": a qualitative study of health care professionals' perceptions of end of life care for patients with heart failure. BMC Palliat Care 2016; 15:3. [PMID: 26762266 PMCID: PMC4712523 DOI: 10.1186/s12904-016-0074-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 01/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although heart failure has a worse prognosis than some cancers, patients often have restricted access to well-developed end of life (EoL) models of care. Studies show that patients with advanced heart failure may have a poor understanding of their condition and its outcome and, therefore, miss opportunities to discuss their wishes for EoL care and preferred place of death. We aimed to explore the perceptions and experiences of health care professionals (HCPs) working with patients with heart failure around EoL care. METHODS A qualitative in-depth interview study nested in a wider ethnographic study of unplanned admissions in patients with heart failure (HoldFAST). We interviewed 24 HCPs across primary, secondary and community care in three locations in England, UK - the Midlands, South Central and South West. RESULTS The study revealed three issues impacting on EoL care for heart failure patients. Firstly, HCPs discussed approaches to communicating with patients about death and highlighted the challenges involved. HCPs would like to have conversations with patients and families about death and dying but are aware that patient preferences are not easy to predict. Secondly, professionals acknowledged difficulties recognising when patients have reached the end of their life. Lack of communication between patients and professionals can result in situations where inappropriate treatment takes place at the end of patients' lives. Thirdly, HCPs discussed the struggle to find alternatives to hospital admission for patients at the end of their life. Patients may be hospitalised because of a lack of planning which would enable them to die at home, if they so wished. CONCLUSIONS The HCPs regarded opportunities for patients with heart failure to have ongoing discussions about their EoL care with clinicians they know as essential. These key professionals can help co-ordinate care and support in the terminal phase of the condition. Links between heart failure teams and specialist palliative care services appear to benefit patients, and further sharing of expertise between teams is recommended. Further research is needed to develop prognostic models to indicate when a transition to palliation is required and to evaluate specialist palliative care services where heart failure patients are included.
Collapse
Affiliation(s)
- Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Rosemary Simmonds
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Sarah McLachlan
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.
| | - Helen Cramer
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Tom Sanders
- Section of Public Health, ScHARR, University of Sheffield, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Rachel Johnson
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Umesh T Kadam
- Health Services Research Unit, Innovation Centre 2, Keele University, Staffordshire, ST5 5NH, UK.
| | - Daniel S Lasserson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Sarah Purdy
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| |
Collapse
|
82
|
|
83
|
Gott M, Gardiner C, Small N, Payne S, Seamark D, Halpin D, Ruse C, Barnes S. The effect of the Shipman murders on clinician attitudes to prescribing opiates for dyspnoea in end-stage chronic obstructive pulmonary disease in England. PROGRESS IN PALLIATIVE CARE 2015. [DOI: 10.1179/096992610x12624290276700] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
84
|
A qualitative study of unmet healthcare needs in chronic obstructive pulmonary disease. A potential role for specialist palliative care? Ann Am Thorac Soc 2015; 11:1433-8. [PMID: 25302521 DOI: 10.1513/annalsats.201404-155bc] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Patients with chronic obstructive pulmonary disease (COPD) have high symptom burdens and poor health-related quality of life. The American Thoracic Society issued a consensus statement outlining the need for palliative care for patients with chronic respiratory diseases. A better understanding of the unmet healthcare needs among patients with COPD may help determine which aspects of palliative care are most beneficial. OBJECTIVES To identify the unmet healthcare needs of patients with COPD hospitalized for exacerbation using qualitative methods. METHODS We conducted 20 semistructured interviews of patients admitted for acute exacerbations of COPD focused on patient understanding of diagnosis and prognosis, effect of COPD on daily life and social relationships, symptoms, healthcare needs, and preparation for the end of life. Transcribed interviews were evaluated using thematic analysis. MEASUREMENTS AND MAIN RESULTS Six themes were identified. (1) Understanding of disease: Most participants correctly identified their diagnosis and recognized their symptoms worsening over time. Only half understood their disease severity and prognosis. (2) SYMPTOMS: Breathlessness was universal and severe. (3) Physical limitations: COPD prevented participation in activities. (4) Emotional distress: Depressive symptoms and/or anxiety were present in most participants. (5) Social isolation: Most participants identified social limitations and felt confined to their homes. (6) Concerns about the future: Half of participants expressed fear about their future. CONCLUSIONS There are many unmet healthcare needs among patients hospitalized for COPD exacerbation. Relief of symptoms, physical limitations, emotional distress, social isolation, and concerns about the future may be better managed by integrating specialist palliative care into our current care model.
Collapse
|
85
|
Pollock K, Wilson E. Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03310] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAdvance care planning (ACP) enables patients to consider, discuss and, if they wish, document their wishes and preferences for future care, including decisions to refuse treatment, in the event that they lose capacity to make decisions for themselves. ACP is a key component of UK health policy to improve the experience of death and dying for patients and their families. There is limited evidence about how patients and health professionals understand ACP, or when and how this is initiated. It is evident that many people find discussion of and planning for end of life care difficult, and tend to avoid the topic.AimTo investigate how patients, their relatives and health professionals initiate and experience discussion of ACP and the outcomes of advance discussions in shaping care at the end of life.Design and data collectionQualitative study with two workstreams: (1) interviews with 37 health professionals (general practitioners, specialist nurses and community nurses) about their experiences of ACP; and (2) longitudinal case studies of 21 patients with 6-month follow-up. Cases included a patient and, where possible, a nominated key relative and/or health professional as well as a review of medical records. Complete case triads were obtained for 11 patients. Four cases comprised the patient alone, where respondents were unable or unwilling to nominate either a family member or a professional carer they wished to include in the study. Patients were identified as likely to be within the last 6 months of life. Ninety-seven interviews were completed in total.SettingGeneral practices and community care settings in the East Midlands of England.FindingsThe study found ACP to be uncommon and focused primarily on specific documented tasks involving decisions about preferred place of death and cardiopulmonary resuscitation, supporting earlier research. There was no evidence of ACP in nearly half (9 of 21) of patient cases. Professionals reported ACP discussions to be challenging. It was difficult to recognise when patients had entered the last year of life, or to identify their readiness to consider future planning. Patients often did not wish to do so before they had become gravely ill. Consequently, ACP discussions tended to be reactive, rather than pre-emptive, occurring in response to critical events or evidence of marked deterioration. ACP discussions intersected two parallel strands of planning: professional organisation and co-ordination of care; and the practical and emotional preparatory work that patients and families undertook to prepare themselves for death. Reference to ACP as a means of guiding decisions for patients who had lost capacity was rare.ConclusionsAdvance care planning remains uncommon, is often limited to documentation of a few key decisions, is reported to be challenging by many health professionals, is not welcomed by a substantial number of patients and tends to be postponed until death is clearly imminent. Current implementation largely ignores the purpose of ACP as a means of extending personal autonomy in the event of lost capacity.Future workAttention should be paid to public attitudes to death and dying (including those of culturally diverse and ethnic minority groups), place of death, resuscitation and the value of anticipatory planning. In addition the experiences and needs of two under-researched groups should be explored: the frail elderly, including those who manage complex comorbid conditions, unrecognised as vulnerable cases; and those patients affected by stigmatised conditions, such as substance abuse or serious mental illness who fail to engage constructively with services and are not recognised as suitable referrals for palliative and end of life care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK
| |
Collapse
|
86
|
Celli BR, Decramer M, Wedzicha JA, Wilson KC, Agustí A, Criner GJ, MacNee W, Make BJ, Rennard SI, Stockley RA, Vogelmeier C, Anzueto A, Au DH, Barnes PJ, Burgel PR, Calverley PM, Casanova C, Clini EM, Cooper CB, Coxson HO, Dusser DJ, Fabbri LM, Fahy B, Ferguson GT, Fisher A, Fletcher MJ, Hayot M, Hurst JR, Jones PW, Mahler DA, Maltais F, Mannino DM, Martinez FJ, Miravitlles M, Meek PM, Papi A, Rabe KF, Roche N, Sciurba FC, Sethi S, Siafakas N, Sin DD, Soriano JB, Stoller JK, Tashkin DP, Troosters T, Verleden GM, Verschakelen J, Vestbo J, Walsh JW, Washko GR, Wise RA, Wouters EFM, ZuWallack RL. An Official American Thoracic Society/European Respiratory Society Statement: Research questions in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2015; 191:e4-e27. [PMID: 25830527 DOI: 10.1164/rccm.201501-0044st] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity, mortality, and resource use worldwide. The goal of this Official American Thoracic Society (ATS)/European Respiratory Society (ERS) Research Statement is to describe evidence related to diagnosis, assessment, and management; identify gaps in knowledge; and make recommendations for future research. It is not intended to provide clinical practice recommendations on COPD diagnosis and management. METHODS Clinicians, researchers, and patient advocates with expertise in COPD were invited to participate. A literature search of Medline was performed, and studies deemed relevant were selected. The search was not a systematic review of the evidence. Existing evidence was appraised and summarized, and then salient knowledge gaps were identified. RESULTS Recommendations for research that addresses important gaps in the evidence in all areas of COPD were formulated via discussion and consensus. CONCLUSIONS Great strides have been made in the diagnosis, assessment, and management of COPD as well as understanding its pathogenesis. Despite this, many important questions remain unanswered. This ATS/ERS Research Statement highlights the types of research that leading clinicians, researchers, and patient advocates believe will have the greatest impact on patient-centered outcomes.
Collapse
|
87
|
Houben CHM, Spruit MA, Schols JMGA, Wouters EFM, Janssen DJA. Patient-Clinician Communication About End-of-Life Care in Patients With Advanced Chronic Organ Failure During One Year. J Pain Symptom Manage 2015; 49:1109-15. [PMID: 25623920 DOI: 10.1016/j.jpainsymman.2014.12.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 11/24/2014] [Accepted: 12/20/2014] [Indexed: 01/24/2023]
Abstract
CONTEXT Patient-clinician communication is an important prerequisite to delivering high-quality end-of-life care. However, discussions about end-of-life care are uncommon in patients with advanced chronic organ failure. OBJECTIVES The aim was to examine the quality of end-of-life care communication during one year follow-up of patients with advanced chronic organ failure. In addition, we aimed to explore whether and to what extent quality of communication about end-of-life care changes toward the end of life and whether end-of-life care communication is related to patient-perceived quality of medical care. METHODS Clinically stable outpatients (n = 265) with advanced chronic obstructive pulmonary disease, chronic heart failure, or chronic renal failure were visited at home at baseline and four, eight, and 12 months after baseline to assess quality of end-of-life care communication (Quality of Communication questionnaire). Two years after baseline, survival status was assessed, and if patients died during the study period, a bereavement interview was done with the closest relative. RESULTS One year follow-up was completed by 77.7% of the patients. Quality of end-of-life care communication was rated low at baseline and did not change over one year. Quality of end-of-life care communication was comparable for patients who completed two year follow-up and patients who died during the study. The correlation between quality of end-of-life care communication and satisfaction with medical treatment was weak. CONCLUSION End-of-life care communication is poor in patients with chronic organ failure and does not change toward the end of life. Future studies should develop an intervention aiming at initiating high-quality end-of-life care communication between patients with advanced chronic organ failure and their clinicians.
Collapse
Affiliation(s)
- Carmen H M Houben
- Department of Research & Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands.
| | - Martijn A Spruit
- Department of Research & Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
| | - Jos M G A Schols
- Departments of Family Medicine and Health Services Research, Faculty of Health, Medicine and Life Sciences/CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Emiel F M Wouters
- Department of Research & Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands; Department of Respiratory Medicine, Maastricht UMC+, Maastricht, The Netherlands
| | - Daisy J A Janssen
- Department of Research & Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands; Centre of Expertise for Palliative Care, Maastricht UMC+, Maastricht, The Netherlands
| |
Collapse
|
88
|
Affiliation(s)
- Mary Godfrey
- Academic Unit of Elderly Care and Stroke Rehabilitation, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Julia Hackett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| |
Collapse
|
89
|
Affiliation(s)
- Sarah Russell
- Professional Doctorate Student, Centre for Research in Primary and Community Care, University of Hertfordshire, UK
| |
Collapse
|
90
|
Celli BR, Decramer M, Wedzicha JA, Wilson KC, Agustí A, Criner GJ, MacNee W, Make BJ, Rennard SI, Stockley RA, Vogelmeier C, Anzueto A, Au DH, Barnes PJ, Burgel PR, Calverley PM, Casanova C, Clini EM, Cooper CB, Coxson HO, Dusser DJ, Fabbri LM, Fahy B, Ferguson GT, Fisher A, Fletcher MJ, Hayot M, Hurst JR, Jones PW, Mahler DA, Maltais F, Mannino DM, Martinez FJ, Miravitlles M, Meek PM, Papi A, Rabe KF, Roche N, Sciurba FC, Sethi S, Siafakas N, Sin DD, Soriano JB, Stoller JK, Tashkin DP, Troosters T, Verleden GM, Verschakelen J, Vestbo J, Walsh JW, Washko GR, Wise RA, Wouters EF, ZuWallack RL. An official American Thoracic Society/European Respiratory Society statement: research questions in COPD. Eur Respir J 2015; 45:879-905. [DOI: 10.1183/09031936.00009015] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity, mortality, and resource use worldwide. The goal of this official American Thoracic Society (ATS)/European Respiratory Society (ERS) research statement is to describe evidence related to diagnosis, assessment and management; identify gaps in knowledge; and make recommendations for future research. It is not intended to provide clinical practice recommendations on COPD diagnosis and management.Clinicians, researchers, and patient advocates with expertise in COPD were invited to participate. A literature search of Medline was performed, and studies deemed relevant were selected. The search was not a systematic review of the evidence. Existing evidence was appraised and summarised, and then salient knowledge gaps were identified.Recommendations for research that addresses important gaps in the evidence in all areas of COPD were formulatedviadiscussion and consensus.Great strides have been made in the diagnosis, assessment and management of COPD, as well as understanding its pathogenesis. Despite this, many important questions remain unanswered. This ATS/ERS research statement highlights the types of research that leading clinicians, researchers, and patient advocates believe will have the greatest impact on patient-centred outcomes.
Collapse
|
91
|
Disler RT, Green A, Luckett T, Newton PJ, Inglis S, Currow DC, Davidson PM. Experience of advanced chronic obstructive pulmonary disease: metasynthesis of qualitative research. J Pain Symptom Manage 2014; 48:1182-99. [PMID: 24780181 DOI: 10.1016/j.jpainsymman.2014.03.009] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 03/13/2014] [Accepted: 04/02/2014] [Indexed: 11/16/2022]
Abstract
CONTEXT Chronic obstructive pulmonary disease (COPD) is a life-limiting illness. Despite best available treatments, individuals continue to experience symptom burden and have high health care utilization. OBJECTIVES To increase understanding of the experience and ongoing needs of individuals living with COPD. METHODS Medline, PsycINFO, CINAHL, and Sociological Abstracts were searched for articles published between January 1990 and June 2013. Metasynthesis of qualitative data followed the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Metasyntheses are increasingly used to gain understandings of complex research questions through synthesizing data from individual qualitative studies. Descriptive and analytical themes were developed through thematic synthesis and expert panel discussion of extracted primary quotes, not the primary data themselves. RESULTS Twenty-two studies were included. Four hundred twenty-two free codes were condensed into seven descriptive themes: better understanding of condition, breathlessness, fatigue, frailty, anxiety, social isolation, and loss of hope and maintaining meaning. These seven themes were condensed further into three analytical themes that described the experience and ongoing needs of individuals with COPD: the need for better understanding of condition, sustained symptom burden, and the unrelenting psychological impact of living with COPD. CONCLUSION Combining discrete qualitative studies provided a useful perspective of the experience of living with COPD over the past two decades. Further studies into the ongoing needs of individuals with COPD are unlikely to add to this well-established picture. Future research should focus on solutions through the development of interventions that address patients' ongoing needs.
Collapse
Affiliation(s)
- Rebecca T Disler
- University of Technology Sydney, Ultimo, New South Wales, Australia; Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.
| | - Anna Green
- University of Technology Sydney, Ultimo, New South Wales, Australia; Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia; ImPaCCT (Improving Palliative Care through Clinical Trials), South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Tim Luckett
- University of Technology Sydney, Ultimo, New South Wales, Australia; Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia; ImPaCCT (Improving Palliative Care through Clinical Trials), South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Phillip J Newton
- University of Technology Sydney, Ultimo, New South Wales, Australia; Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Sally Inglis
- University of Technology Sydney, Ultimo, New South Wales, Australia
| | - David C Currow
- Discipline, Palliative, and Supportive Services, Flinders Centre for Clinical Change, Flinders University, Adelaide, South Australia, Australia
| | - Patricia M Davidson
- ImPaCCT (Improving Palliative Care through Clinical Trials), South Western Sydney Clinical School, Liverpool, New South Wales, Australia; Department of Acute and Chronic Care, School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
92
|
"The unpredictable death"-The last year of life for patients with advanced COPD: Relatives' stories. Palliat Support Care 2014; 13:1213-22. [PMID: 25315360 DOI: 10.1017/s1478951514001151] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The end stage of chronic obstructive pulmonary disease (COPD) is described as prolonged, and the symptom burden for patients with COPD is often high. It progresses slowly over several years and can be punctuated by abrupt exacerbations that sometimes end in sudden death or a recovery of longer or shorter duration. This makes it difficult to identify the critical junctures in order to prognosticate the progress and time of death. Patients with COPD often express a fear that the dying process is going to be difficult. There is a fear that the dyspnea will worsen and lead to death by suffocation. The present article aimed to retrospectively describe the final year of life for patients with advanced COPD with a focus on death and dying from the perspective of relatives. METHOD Interviews were conducted with the relatives of deceased family members who had advanced COPD. In total, 13 interviews were conducted and analyzed by means of content analysis. RESULT All relatives described the patients as having had a peaceful death that did not correspond with the worry expressed earlier by both the patients and themselves. During the final week of life, two different patterns in the progress of the illness trajectory emerged: a temporary improvement where death was unexpected and a continued deterioration where death was inevitable. SIGNIFICANCE OF RESULTS The patients and their relatives lived with uncertainty up until the time of death. Little support for psychosocial and existential needs was available. It is essential for the nurse to create relationships with patients and relatives that enable them to talk about dying and death on their own terms.
Collapse
|
93
|
Barocas JA, Erlandson KM, Belzer BK, Hess T, Sosman J. Advance directives among people living with HIV: room for improvement. AIDS Care 2014; 27:370-7. [PMID: 25307722 DOI: 10.1080/09540121.2014.963019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
While HIV has become a largely chronic disease, age-associated comorbidities are prevalent in people living with HIV (PLWH). Therefore, PLWH are appropriate for advance care planning (ACP) and advance directives (ADs) completion. We sought to characterize AD completion among outpatient PLWH. We conducted a retrospective chart review of PLWH who receive their routine care at the University of Wisconsin HIV clinic. Data were extracted from the electronic health record. Variables were entered into a stepwise multivariate logistic regression model to assess which factors were independently associated with AD completion. Five hundred and eighty eight charts were reviewed. Eighty-one percent of subjects were male and 72% were white; mean age was 46.8 years. ADs were completed by 134 subjects and 6.7% of those were completed at the HIV clinic. In the final multivariate model, those who had completed an AD were more likely to be older than age 45; ever been diagnosed with AIDS; have cardiovascular disease, neurologic disorder, chronic kidney disease, or malignancy. In this study, a small percentage of patients had documented ADs, with only a small proportion completed in the HIV clinic. The HIV clinic is an underutilized resource to offer ACP. Interventions are needed to provide the necessary ACP resources for PLWH.
Collapse
Affiliation(s)
- Joshua A Barocas
- a Department of Medicine , University of Wisconsin School of Medicine and Public Health , Madison , WI , USA
| | | | | | | | | |
Collapse
|
94
|
Lovell A, Yates P. Advance Care Planning in palliative care: a systematic literature review of the contextual factors influencing its uptake 2008-2012. Palliat Med 2014; 28:1026-35. [PMID: 24821708 DOI: 10.1177/0269216314531313] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advance Care Planning is an iterative process of discussion, decision-making and documentation about end-of-life care. Advance Care Planning is highly relevant in palliative care due to intersecting clinical needs. To enhance the implementation of Advance Care Planning, the contextual factors influencing its uptake need to be better understood. AIM To identify the contextual factors influencing the uptake of Advance Care Planning in palliative care as published between January 2008 and December 2012. METHODS Databases were systematically searched for studies about Advance Care Planning in palliative care published between January 2008 and December 2012. This yielded 27 eligible studies, which were appraised using National Institute of Health and Care Excellence Quality Appraisal Checklists. Iterative thematic synthesis was used to group results. RESULTS Factors associated with greater uptake included older age, a college degree, a diagnosis of cancer, greater functional impairment, being white, greater understanding of poor prognosis and receiving or working in specialist palliative care. Barriers included having non-malignant diagnoses, having dependent children, being African American, and uncertainty about Advance Care Planning and its legal status. Individuals' previous illness experiences, preferences and attitudes also influenced their participation. CONCLUSION Factors influencing the uptake of Advance Care Planning in palliative care are complex and multifaceted reflecting the diverse and often competing needs of patients, health professionals, legislature and health systems. Large population-based studies of palliative care patients are required to develop the sound theoretical and empirical foundation needed to improve uptake of Advance Care Planning in this setting.
Collapse
Affiliation(s)
- Allison Lovell
- Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia Specialist Palliative Care Service, Division of Internal Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Patsy Yates
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| |
Collapse
|
95
|
Burge AT. Advance care planning education in pulmonary rehabilitation: a qualitative study exploring participant perspectives. Palliat Med 2014; 28:1069-70. [PMID: 24821707 DOI: 10.1177/0269216314532702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Angela T Burge
- Physiotherapy Department, The Alfred, Prahran, VIC, Australia
| |
Collapse
|
96
|
Ahluwalia SC, Bekelman DB, Huynh AK, Prendergast TJ, Shreve S, Lorenz KA. Barriers and strategies to an iterative model of advance care planning communication. Am J Hosp Palliat Care 2014; 32:817-23. [PMID: 24988894 DOI: 10.1177/1049909114541513] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Early and repeated patient-provider conversations about advance care planning (ACP) are now widely recommended. We sought to characterize barriers and strategies for realizing an iterative model of ACP patient-provider communication. METHODS A total of 2 multidisciplinary focus groups and 3 semistructured interviews with 20 providers at a large Veterans Affairs medical center. Thematic analysis was employed to identify salient themes. RESULTS Barriers included variation among providers in approaches to ACP, lack of useful information about patient values to guide decision making, and ineffective communication between providers across settings. Strategies included eliciting patient values rather than specific treatment choices and an increased role for primary care in the ACP process. CONCLUSIONS Greater attention to connecting providers across the continuum, maximizing the potential of the electronic health record, and linking patient experiences to their values may help to connect ACP communication across the continuum.
Collapse
Affiliation(s)
- Sangeeta C Ahluwalia
- Oregon State University, Corvallis, OR, USA VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - David B Bekelman
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, CO, USA School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Alexis K Huynh
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Thomas J Prendergast
- Portland VA Medical Center, Portland, OR, USA Oregon Health and Science University, Portland, OR, USA
| | | | - Karl A Lorenz
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
97
|
Schroedl C, Yount S, Szmuilowicz E, Rosenberg SR, Kalhan R. Outpatient palliative care for chronic obstructive pulmonary disease: a case series. J Palliat Med 2014; 17:1256-61. [PMID: 24933590 DOI: 10.1089/jpm.2013.0669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) have well-documented symptoms that affect quality of life. Professional societies recommend palliative care for such patients, but the optimal way of delivering this care is unknown. OBJECTIVE To describe an outpatient palliative medicine program for patients with COPD. DESIGN Retrospective case series. SETTING/SUBJECTS Thirty-six patients with COPD followed in a United States academic outpatient palliative medicine clinic. MEASUREMENTS Descriptive analysis of sociodemographic data, disease severity and comorbidities, treatments, hospitalizations, mortality, topic discussion, and symptom assessment. RESULTS Thirty-six patients (representing 5% of the total number of patients with COPD seen in a specialty pulmonary clinic) were seen over 11 months and followed for 2 years. Seventy-seven percent of patients were Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 3-4 and 72% were on oxygen at home. No patients had documented advanced directives at the initial visit but documentation increased to 61% for those who had follow-up appointments. The most commonly documented topics included symptoms (100%), social issues (94%), psychological issues (78%), and advance care planning (75%). Of symptoms assessed, pain was the least prevalent (51.6%), and breathlessness and fatigue were the most prevalent (100%). Symptoms were often undertreated prior to the palliative care appointment. During the 3-year study period, there were 120 hospital admissions (median, 2) and 12 deaths (33%). CONCLUSIONS The patients with COPD seen in the outpatient palliative medicine clinic had many comorbid conditions, severe illness, and significant symptom burden. Many physical and psychological symptoms were untreated prior to the palliative medicine appointment. Whether addressing these symptoms through a palliative medicine intervention affects outcomes in COPD is unknown but represents an important topic for future research.
Collapse
Affiliation(s)
- Clara Schroedl
- 1 Asthma and COPD Program, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | | | | | | | | |
Collapse
|
98
|
Specialist respiratory physicians' attitudes to and practice of advance care planning in COPD. A pilot study. Respir Med 2014; 108:935-9. [DOI: 10.1016/j.rmed.2013.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 08/23/2013] [Accepted: 12/05/2013] [Indexed: 11/24/2022]
|
99
|
|
100
|
Gaspar C, Alfarroba S, Telo L, Gomes C, Bárbara C. End-of-life care in COPD: a survey carried out with Portuguese pulmonologists. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:123-30. [PMID: 24661960 DOI: 10.1016/j.rppneu.2014.01.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/03/2014] [Accepted: 01/11/2014] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION End-of-life (EoL) care is a major component in the management of patients with advanced COPD. Patient-physician communication is essential in this process. AIM To evaluate the practice of Portuguese Pulmonologists in EoL communication and palliative care in COPD. METHODS An on-line survey was sent to physicians affiliated to the Portuguese Pneumology Society. RESULTS We obtained 136 answers from 464 eligible participants (29.3%). About half of the physicians reported that they have rarely introduced EoL discussions with their COPD patients (48.5%). Most had never/rarely suggested decision-making on the use of invasive mechanical ventilation (68.4%). Discussions were described as occurring mostly during/after a major exacerbation (53.7%). Only 37.5% of participants reported treating dyspnoea with opioids frequently/always. Only 9.6% stated that they never/rarely treated anxiety/depression. Most participants perceive the discussion of EoL issues as being difficult/very difficult (89.0%). The reasons most frequently given were feeling that patients were not prepared for this discussion (70.0%), fear of taking away a patient's hope (58.0%) and lack of training (51.0%). CONCLUSION Patient and medical staff EoL communication in COPD is still not good enough. Training in this area and the creation of formal protocols to initiate EoL have been identified as major factors for improvement.
Collapse
Affiliation(s)
- C Gaspar
- Serviço de Pneumologia do Centro Hospitalar Lisboa Norte, EPE - Hospital Pulido Valente, Lisbon, Portugal.
| | - S Alfarroba
- Serviço de Pneumologia do Centro Hospitalar Lisboa Norte, EPE - Hospital Pulido Valente, Lisbon, Portugal
| | - L Telo
- Serviço de Pneumologia do Centro Hospitalar Lisboa Norte, EPE - Hospital Pulido Valente, Lisbon, Portugal
| | - C Gomes
- Serviço de Pneumologia do Centro Hospitalar Lisboa Norte, EPE - Hospital Pulido Valente, Lisbon, Portugal
| | - C Bárbara
- Serviço de Pneumologia do Centro Hospitalar Lisboa Norte, EPE - Hospital Pulido Valente, Lisbon, Portugal; Centro de Estudos Doenças Crónicas (CEDOC), Faculdade de Ciências Médicas da Universidade Nova de Lisboa, Lisbon, Portugal
| |
Collapse
|