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Lin CP, Evans CJ, Koffman J, Armes J, Murtagh FEM, Harding R. The conceptual models and mechanisms of action that underpin advance care planning for cancer patients: A systematic review of randomised controlled trials. Palliat Med 2019; 33:5-23. [PMID: 30362897 PMCID: PMC6291906 DOI: 10.1177/0269216318809582] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND: No systematic review has focused on conceptual models underpinning advance care planning for patients with advanced cancer, and the mechanisms of action in relation to the intended outcomes. AIM: To appraise conceptual models and develop a logic model of advance care planning for advanced cancer patients, examining the components, processes, theoretical underpinning, mechanisms of action and linkage with intended outcomes. DESIGN: A systematic review of randomised controlled trials was conducted, and was prospectively registered on PROSPERO. Narrative synthesis was used for data analysis. DATA SOURCES: The data sources were MEDLINE, CINAHL, PsycINFO, EMBASE, CENTRAL, PROSPERO, CareSearch, and OpenGrey with reference chaining and hand-searching from inception to 31 March 2017, including all randomised controlled trials with advance care planning for cancer patients in the last 12 months of life. Cochrane quality assessment tool was used for quality appraisal. RESULTS: Nine randomised controlled trials were included, with only four articulated conceptual models. Mechanisms through which advance care planning improved outcomes comprised (1) increasing patients' knowledge of end-of-life care, (2) strengthening patients' autonomous motivation, (3) building patients' competence to undertake end-of-life discussions and (4) enhancing shared decision-making in a trustful relationship. Samples were largely highly educated Caucasian. CONCLUSION: The use of conceptual models underpinning the development of advance care planning is uncommon. When used, they identify the individual behavioural change. Strengthening patients' motivation and competence in participating advance care planning discussions are key mechanisms of change. Understanding cultural feasibility of the logic model for different educational levels and ethnicities in non-Western countries should be a research priority.
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Affiliation(s)
- Cheng-Pei Lin
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Catherine J Evans
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,2 Sussex Community NHS Foundation Trust, Brighton, UK
| | - Jonathan Koffman
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Jo Armes
- 3 School of Health Sciences, University of Surrey, Guildford, UK
| | - Fliss E M Murtagh
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,4 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Richard Harding
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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102
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Tuffrey-Wijne I, Davidson J. Excellence in palliative and end-of-life care provision for people with intellectual disability. Int J Palliat Nurs 2018; 24:598-610. [PMID: 30571253 DOI: 10.12968/ijpn.2018.24.12.598] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND: People with an intellectual disability experience significant inequalities in end-of-life and palliative care provision. AIMS: To identify the key characteristics of practice initiatives and case reports that have won a UK award for the outstanding provision of end-of-life care for people with ID (2008-2018). METHODS: Thematic content analysis of the written nominations for award winners and those highly commended (n=25). FINDINGS: Four themes were identified: (1) Good practice was dependent on 'champions' with drive, enthusiasm and determination, supported by committed organisations and managers. (2) Collaboration was essential, including collaboration with families. (3) Care was highly individualised, putting the person's story at the centre. (4) There was a focus on staff training and use of specifically designed or adapted tools. CONCLUSION: The good practice examples are encouraging. Focus is now needed on ensuring that good practice is sustained, replicated and embedded within policies and organisational cultures. Currently, it remains over-dependent on committed individuals within organisations.
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Abstract
Since the latter part of the twentith century, international research, education and practice of advance care planning has experienced a diversity of developments and defintions. Whilst this variety may seem bewildering, a continued commitment to accurate, focussed research enables better care through better understanding and better evidence.
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Affiliation(s)
- Sarah Russell
- 1 Hospice UK, London, UK.,2 University of Southampton, Southampton, UK
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104
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O'Halloran P, Noble H, Norwood K, Maxwell P, Shields J, Fogarty D, Murtagh F, Morton R, Brazil K. Advance Care Planning With Patients Who Have End-Stage Kidney Disease: A Systematic Realist Review. J Pain Symptom Manage 2018; 56:795-807.e18. [PMID: 30025939 PMCID: PMC6203056 DOI: 10.1016/j.jpainsymman.2018.07.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 01/02/2023]
Abstract
CONTEXT Patients with end-stage kidney disease have a high mortality rate and disease burden. Despite this, many do not speak with health care professionals about end-of-life issues. Advance care planning is recommended in this context but is complex and challenging. We carried out a realist review to identify factors affecting its implementation. OBJECTIVES The objectives of this study are 1) to identify implementation theories; 2) to identify factors that help or hinder implementation; and 3) to develop theory on how the intervention may work. METHODS We carried out a systematic realist review, searching seven electronic databases: Medline, Embase, CINAHL, PsycINFO, Cochrane Library, Google Scholar, and ScienceDirect. RESULTS Sixty-two papers were included in the review. CONCLUSION We identified two intervention stages-1) training for health care professionals that addresses concerns, optimizes skills, and clarifies processes and 2) use of documentation and processes that are simple, individually tailored, culturally appropriate, and involve surrogates. These processes work as patients develop trust in professionals, participate in discussions, and clarify values and beliefs about their condition. This leads to greater congruence between patients and surrogates; increased quality of communication between patients and professionals; and increased completion of advance directives. Advance care planning is hindered by lack of training; administrative complexities; pressures of routine care; patients overestimating life expectancy; and when patients, family, and/or clinical staff are reluctant to initiate discussions. It is more likely to succeed where organizations treat it as core business; when the process is culturally appropriate and takes account of patient perceptions; and when patients are willing to consider death and dying with suitably trained staff.
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Affiliation(s)
- Peter O'Halloran
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, Belfast, United Kingdom.
| | - Helen Noble
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, Belfast, United Kingdom
| | - Kelly Norwood
- School of Psychology, Ulster University, Coleraine Campus, Coleraine, United Kingdom
| | - Peter Maxwell
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Health Sciences Building, Belfast, United Kingdom; Regional Nephrology Unit, Belfast City Hospital, Belfast, United Kingdom
| | - Joanne Shields
- Regional Nephrology Unit, Belfast City Hospital, Belfast, United Kingdom
| | - Damian Fogarty
- Regional Nephrology Unit, Belfast City Hospital, Belfast, United Kingdom
| | - Fliss Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull, United Kingdom
| | - Rachael Morton
- Sydney Medical School, University of Sydney, NSW, Australia
| | - Kevin Brazil
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, Belfast, United Kingdom
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105
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Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018; 19:e588-e653. [DOI: 10.1016/s1470-2045(18)30415-7] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/16/2018] [Accepted: 05/22/2018] [Indexed: 02/06/2023]
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Kezirian AC, McGregor MJ, Stead U, Sakaluk T, Spring B, Turgeon S, Slater J, Murphy JM. Advance Care Planning in the Nursing Home Setting: A Practice Improvement Evaluation. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2018; 14:328-345. [PMID: 30653404 DOI: 10.1080/15524256.2018.1547673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This study evaluated a practice improvement initiative conducted over a 6 month period in 15 Canadian nursing homes. Goals of the initiative included: (1) use the Plan-Do-Study-Act (PDSA) model to improve advance care planning (ACP) within the sample of nursing homes; (2) investigate whether improved ACP practice resulted in a change in residents' hospital use and ACP preferences for home-based care; (3) engage participating facilities in regular data collection to inform the initiative and provide a basis for reflection about ACP practice and; (4) foster a team-based participatory care culture. The initiative entailed two cycles of learning sessions followed by implementation of ACP practice improvement projects in the facilities using a PDSA approach by participating clinicians (e.g., physicians, social workers, nurses). Clinicians reported significantly increased confidence in many dimensions of ACP activities. Rates of hospital use and resident preference for home-based care did not change significantly. The initiative established routine data collection of outcomes to inform practice change, and successfully engaged physicians and non-physician clinicians to work together to improve ACP practices. Results suggest recurrent PDSA cycles that engage a 'critical mass' of clinicians may be warranted to reinforce the standardization of ACP in practice.
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Affiliation(s)
- Alexis C Kezirian
- a Department of Family Practice , University of British Columbia , Vancouver , British Columbia , Canada
| | - Margaret J McGregor
- a Department of Family Practice , University of British Columbia , Vancouver , British Columbia , Canada
- b Family Practice Research Office , Vancouver Coastal Health Research Institute's Centre for Clinical Epidemiology and Evaluation , Vancouver , British Columbia , Canada
- e Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Umilla Stead
- c Practice Support Program, General Practice Services Committee , Government of British Columbia and Doctors of British Columbia , Vancouver , British Columbia , Canada
| | - Timothy Sakaluk
- a Department of Family Practice , University of British Columbia , Vancouver , British Columbia , Canada
| | - Beverly Spring
- a Department of Family Practice , University of British Columbia , Vancouver , British Columbia , Canada
| | - Sue Turgeon
- a Department of Family Practice , University of British Columbia , Vancouver , British Columbia , Canada
| | - Jay Slater
- a Department of Family Practice , University of British Columbia , Vancouver , British Columbia , Canada
| | - Janice M Murphy
- d Health Research Consultant , Balfour , British Columbia , Canada
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107
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McDermott E, Selman LE. Cultural Factors Influencing Advance Care Planning in Progressive, Incurable Disease: A Systematic Review With Narrative Synthesis. J Pain Symptom Manage 2018; 56:613-636. [PMID: 30025936 DOI: 10.1016/j.jpainsymman.2018.07.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/05/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
CONTEXT Advance care planning (ACP) can improve end-of-life outcomes, but low uptake indicates it is less acceptable to patients of some cultural backgrounds. OBJECTIVES The objectives of this study were to explore how cultural factors influence ACP for patients with progressive, incurable disease and how ACP might be made cross-culturally appropriate. METHOD We conducted a systematic literature review using narrative synthesis. Protocol was registered prospectively (PROSPERO CRD42017060441). Key words and subject headings of six databases (AMED, PsycINFO, Embase, Ovid MEDLINE, CINAHL, and Cochrane) were searched without time restrictions. Eligible studies reported original research published in full that included adult participants with progressive, incurable disease or their formal or informal caregivers. Study quality was assessed using the Mixed Methods Appraisal Tool. RESULTS Eight hundred and eighteen studies were screened. Twenty-seven were included: 20 quantitative, four qualitative, and three mixed methods. Most (20/30) studies were conducted in the U.S., where nonwhite ethnicity was associated with lower acceptability of formal, documented ACP processes. Cultural factors affecting ACP acceptability included religiosity, trust in the health care system, patient and clinician comfort discussing death, and patient attitudes regarding decision-making. Informal, communication-focused approaches to ACP appear more cross-culturally acceptable than formal processes. Clinician education in cultural competence is recommended. Study limitations included use of unvalidated tools and convenience samples and lack of reflexivity. CONCLUSION Many interconnected cultural factors influence the acceptability of ACP in progressive, incurable disease, although specific mechanisms remain unclear. A communication-focused approach to ACP may better meet the needs of culturally diverse populations.
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Affiliation(s)
- Ella McDermott
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Lucy Ellen Selman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
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108
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Couples affected by dementia and their experiences of advance care planning: a grounded theory study. AGEING & SOCIETY 2018. [DOI: 10.1017/s0144686x1800106x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractGlobal policy places emphasis on the implementation and usage of advance care planning (ACP) to inform decision making at the end of life. For people with dementia, where its use is encouraged at the point of diagnosis, utilisation of ACP is relatively poor, particularly in parts of Europe. Using a constructivist grounded theory methodology, this study explores the ways in which co-residing couples considered ACP. Specifically, it seeks to understand the ways in which people with dementia and their long-term co-residing partners consider and plan, or do not plan, for future medical and social care. Sixteen participants were interviewed. They identified the importance of relationships in the process of planning alongside an absence of formal service support and as a result few engaged in ACP. The study recognises the fundamental challenges for couples in being obliged to consider end-of-life issues whilst making efforts to ‘live well’. Importantly, the paper identifies features of the ACP experience of a relational and biographical nature. The paper challenges the relevance of current global policy and practice, concluding that what is evident is a process of ‘emergent planning’ through which couples build upon their knowledge of dementia, their networks and relationships, and a number of ‘tipping points’ leading them to ACP. The relational and collective nature of future planning is also emphasised.
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109
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Jimenez G, Tan WS, Virk AK, Low CK, Car J, Ho AHY. Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons. J Pain Symptom Manage 2018; 56:436-459.e25. [PMID: 29807158 DOI: 10.1016/j.jpainsymman.2018.05.016] [Citation(s) in RCA: 295] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/16/2018] [Accepted: 05/18/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Advance care planning (ACP) involves important decision making about future medical needs. The high-volume and disparate nature of ACP research makes it difficult to grasp the evidence and derive clear policy lessons for policymakers and clinicians. AIM The aim of this study was to synthesize ACP research evidence and identify relevant contextual elements, program features, implementation principles, and impacted outcomes to inform policy and practice. DESIGN An overview of systematic reviews using the Cochrane Handbook of Systematic Reviews of Interventions was performed. Study quality was assessed using a modified version of the AMSTAR (A MeaSurement Tool to Assess Reviews) tool. DATA SOURCES MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE were searched for ACP-related research from inception of each database to April 2017. Searches were supplemented with gray literature and manual searches. Eighty systematic reviews, covering over 1660 original articles, were included in the analysis. RESULTS Legislations, institutional policies, and cultural factors influence ACP development. Positive perceptions toward ACP do not necessarily translate into more end-of-life conversations. Many factors related to patients' and providers' attitudes, and perceptions toward life and mortality influence ACP implementation, decision making, and completion. Limited, low-quality evidence points to several ACP benefits, such as improved end-of-life communication, documentation of care preferences, dying in preferred place, and health care savings. Recurring features that make ACP programs effective include repeated and interactive discussion sessions, decision aids, and interventions targeting multiple stakeholders. CONCLUSIONS Preliminary evidence highlights several elements that influence the ACP process and provides a variety of features that could support successful, effective, and sustainable ACP implementation. However, this evidence is compartmentalized and limited. Further studies evaluating ACP as a unified program and assessing the impact of ACP for different populations, settings, and contexts are needed to develop programs that are able to unleash ACP's full potential.
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Affiliation(s)
- Geronimo Jimenez
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Woan Shin Tan
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; NTU Institute of Health Technologies (HealthTech), Interdisciplinary Graduate School, Nanyang Technological University, Singapore, Singapore; Health Services and Outcomes Research Department, National Healthcare Group, Singapore, Singapore
| | - Amrit K Virk
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Chan Kee Low
- Economics Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore
| | - Josip Car
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Andy Hau Yan Ho
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Psychology Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore; Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
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110
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Rabow MW, McGowan M, Small R, Keyssar R, Rugo HS. Advance Care Planning in Community: An Evaluation of a Pilot 2-Session, Nurse-Led Workshop. Am J Hosp Palliat Care 2018; 36:143-146. [PMID: 30153741 DOI: 10.1177/1049909118797612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND: Engaging patients in advance care planning (ACP) is challenging but crucial to improving the quality of end-of-life care. Group visits and multiple patient-clinician interactions may promote advance directive (AD) completion. OBJECTIVE: Facilitate ACP discussions with patients and caregivers and the creation of notarized AD's at a comprehensive cancer center. DESIGN: Two-session, nurse-led ACP workshops for patients and their family caregivers. SETTING/PARTICIPANTS: The workshop was offered to patients with cancer at a comprehensive cancer center and their family caregivers. MEASUREMENTS: Validated 4-question ACP engagement survey, creation of a notarized AD by end of the workshop, and semistructured interviews. RESULTS: Thirty-five patients participated in 10 workshops held March 2017 to February 2018. Median age was 52. Of 35, 24 (68.5%) patients completed pre- and postworkshop evaluation surveys. Mean preworkshop ACP readiness was 3.64 of 5; postworkshop readiness increased to 4.26 of 5 ( P = .001). Of 26, 17 (65.4%) of the patients who attended both workshop sessions had a new notarized AD scanned into the electronic medical record at the completion of the workshop series. Three family caregivers completed and had their own ADs notarized. Patient and family member response was overwhelmingly positive, with participants citing opportunities for group discussion and inclusion of family caregivers as important. CONCLUSIONS: The ACP workshop was well received by participants and increased ACP readiness, discussion, and completion. Attendance at the workshop was low and barriers to attending workshops must be explored.
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Affiliation(s)
- Michael W Rabow
- 1 Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Marilyn McGowan
- 2 Georgetown University School of Medicine, Washington, DC, USA
| | - Rebecca Small
- 1 Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Redwing Keyssar
- 3 Jewish Family and Children's Services, San Francisco, CA, USA
| | - Hope S Rugo
- 4 Division of Hematology and Oncology, Department of Medicine, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA, USA
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111
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Nakazato K, Wakui T, Hirayama R, Shimada C. [Factors related to parent-child communication about end-of-life care -A survey of adult children with an elderly parent]. Nihon Ronen Igakkai Zasshi 2018; 55:378-385. [PMID: 30122704 DOI: 10.3143/geriatrics.55.378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM In Japan, because adult children are expected to perform a key role in decision-making on end-of-life care for older adults, conversing with parents on their wished-for end-of-life care can help these children to become prepared for this filial responsibility. Our aim in this study was to explore how likely Japanese adult children were to discuss end-of-life care with their parents as well as correlates of such discussions. METHODS We conducted an online survey using a sample of 1,590 adult children with at least one living parent aged 65 or older. We analyzed data from 1,010 children who responded during three consecutive days in October, 2015. RESULTS A small portion of our participants (22.8%) had discussed end-of-life care with their parents. Logistic regression analysis revealed that such discussions were likely in son-mother (Odds Ratio 〈OR〉 = 3.01) and daughter-mother (OR = 3.15) dyads compared with son-father ones as the reference. Occurrence of such discussions was also associated with having older parents (OR = 1.03), parental experience of severe diseases (OR = 1.47), parent-child coresiding (OR = 2.08), a higher level of perceived necessity for (OR = 1.36) and a lower level of emotional avoidance of (OR = 0.68) end-of-life communication. CONCLUSION Generally, adult children rarely discuss end-of-life care with their aging parents, suggesting the need to promote such familial communication while considering both children's and parents' circumstances.
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State of advance care planning research: A descriptive overview of systematic reviews. Palliat Support Care 2018; 17:234-244. [PMID: 30058506 DOI: 10.1017/s1478951518000500] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To provide an overview of the current state of research of advance care planning (ACP), highlighting most studied topics, publication time, quality of studies and reported outcomes, and to identify gaps to improve ACP receptivity, utilization, implementation, and outcomes. METHOD Cochrane methodology for conducting overviews of systematic reviews. Study quality was assessed using a modified version of the Assessing the Methodological Quality of Systematic Reviews tool. The following databases were searched from inception to April 2017: MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE. Searches were supplemented with gray literature and manual searches. RESULT Eighty systematic reviews, covering 1,662 single articles, show that ACP-related research focuses on nine main topics: (1) ACP as part of end-of-life or palliative care interventions, (2) care decision-making; (3) communication strategies; (4) factors influencing ACP implementation; (5) ACP for specific patient groups, (6) ACP effectiveness; (7) ACP experiences; (8) ACP cost; and (9) ACP outcome measures. The majority of this research was published since 2014, its quality ranges from moderate to low, and reports on documentation, concordance, preferences, and resource utilization outcomes. SIGNIFICANCE OF RESULTS Despite the surge of ACP research, there are major knowledge gaps about ACP initiation, timeliness, optimal content, and impact because of the low quality and fragmentation of the available evidence. Research has mostly focused on discrete aspects within ACP instead of using a holistic evaluative approach that takes into account its intricate working mechanisms, the effects of systems and contexts, and the impacts on multilevel stakeholders. Higher quality studies and innovative interventions are needed to develop effective ACP programs and address research gaps.
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Vanderhaeghen B, Van Beek K, De Pril M, Bossuyt I, Menten J, Rober P. What do hospitalists experience as barriers and helpful factors for having ACP conversations? A systematic qualitative evidence synthesis. Perspect Public Health 2018; 139:97-105. [PMID: 30010486 DOI: 10.1177/1757913918786524] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Hospitalists seem to struggle with advance care planning implementation. One strategy to help them is to understand which barriers and helpful factors they may encounter. AIMS: This review aims to give an overview on what hospitalists experience as barriers and helpful factors for having advance care planning conversations. METHOD: A systematic synthesis of the qualitative literature was conducted. DATA SOURCES: A bibliographic search of English peer-reviewed publications in PubMed, Embase, CINAHL, Central, PsycINFO, and Web of Science was undertaken. RESULTS: Hospitalists report lacking communication skills which lead to difficulties with exploring values and wishes of patients, dealing with emotions of patients and families and approaching the conversation about letting a patient die. Other barriers are related to different interpretations of the concept advance care planning, cultural factors, like being lost in translation, and medicolegal factors, like fearing prosecution. Furthermore, hospitalists report that decision-making is often based on irrational convictions, and it is highly personal. Physician and patient characteristics, like moral convictions, experience, and personality play a role in the decision-making process. Hospitalists report that experience and learning from more experienced colleagues is helpful. Furthermore, efficient multidisciplinary co-operation is helping. CONCLUSION: This systematic review shows that barriers are often related to communication issues and the convictions of the involved hospitalist. However, they seem to be preventable by creating a culture where experienced professionals can be consulted, where convictions can be questioned, and where co-operation within and between organizations is encouraged. This knowledge can serve as a basis for implementation.
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Affiliation(s)
- Birgit Vanderhaeghen
- Palliative Support Team, University Hospitals Leuven, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Karen Van Beek
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
- Department of Radiation-Oncology and Palliative Care, University Hospitals Leuven, Leuven, Belgium
| | - Mieke De Pril
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
| | - Inge Bossuyt
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
| | - Johan Menten
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
- Department of Radiation-Oncology and Palliative Care, University Hospitals Leuven, Leuven, Belgium
| | - Peter Rober
- UPC KU Leuven, Leuven, Belgium
- Institute for Family and Sexuality Studies, Department of Neurosciences, School of Medicine, KU Leuven, Leuven, Belgium
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Piers R, Albers G, Gilissen J, De Lepeleire J, Steyaert J, Van Mechelen W, Steeman E, Dillen L, Vanden Berghe P, Van den Block L. Advance care planning in dementia: recommendations for healthcare professionals. BMC Palliat Care 2018; 17:88. [PMID: 29933758 PMCID: PMC6014017 DOI: 10.1186/s12904-018-0332-2] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/10/2018] [Indexed: 01/08/2023] Open
Abstract
Background Advance care planning (ACP) is a continuous, dynamic process of reflection and dialogue between an individual, those close to them and their healthcare professionals, concerning the individual’s preferences and values concerning future treatment and care, including end-of-life care. Despite universal recognition of the importance of ACP for people with dementia, who gradually lose their ability to make informed decisions themselves, ACP still only happens infrequently, and evidence-based recommendations on when and how to perform this complex process are lacking. We aimed to develop evidence-based clinical recommendations to guide professionals across settings in the practical application of ACP in dementia care. Methods Following the Belgian Centre for Evidence-Based Medicine’s procedures, we 1) performed an extensive literature search to identify international guidelines, articles reporting heterogeneous study designs and grey literature, 2) developed recommendations based on the available evidence and expert opinion of the author group, and 3) performed a validation process using written feedback from experts, a survey for end users (healthcare professionals across settings), and two peer-review groups (with geriatricians and general practitioners). Results Based on 67 publications and validation from ten experts, 51 end users and two peer-review groups (24 participants) we developed 32 recommendations covering eight domains: initiation of ACP, evaluation of mental capacity, holding ACP conversations, the role and importance of those close to the person with dementia, ACP with people who find it difficult or impossible to communicate verbally, documentation of wishes and preferences, including information transfer, end-of-life decision-making, and preconditions for optimal implementation of ACP. Almost all recommendations received a grading representing low to very low-quality evidence. Conclusion No high-quality guidelines are available for ACP in dementia care. By combining evidence with expert and user opinions, we have defined a unique set of recommendations for ACP in people living with dementia. These recommendations form a valuable tool for educating healthcare professionals on how to perform ACP across settings.
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Affiliation(s)
- Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium.,End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Gwenda Albers
- Flanders Federation for Palliative Care, Vilvoorde, Belgium
| | - Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, ACHG, KU Leuven, Leuven, Belgium
| | - Jan Steyaert
- Department of Sociology, University of Antwerp, Antwerp, Belgium.,Flemish Expertise Centre on Dementia Care, Antwerp, Belgium
| | - Wouter Van Mechelen
- Department of Public Health and Primary Care, ACHG, KU Leuven, Leuven, Belgium
| | - Els Steeman
- Academic Centre for Nursing and Midwifery, KULeuven, Leuven, Belgium
| | - Let Dillen
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Brussels, Belgium.
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115
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Lawrence S, Robinson A, Eagar K. Identification of the trajectory of functional decline for advance care planning in a nursing home population. Australas J Ageing 2018; 36:E14-E20. [PMID: 28925098 DOI: 10.1111/ajag.12454] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify diagnostic groups and the form of the trajectory of functional decline that has the potential to enhance advance care planning (ACP) in a nursing home (NH) population. METHODS Retrospective, longitudinal study with dependent variable (function) derived from the Resident Classification Scale (RCS), 1997-2008. Trajectory modelling used linear and curvilinear terms. RESULTS The organ failure or other residents have a linear average functional decline. The organ failure residents had an average decline of 6.5 points per year and average function score at death of 68.6, CI [62.4, 74.8]. The cancer and frailty residents had significant curvilinear terms. The frailty residents had a slower rate of decline at 9.54 points per year and were most care dependent at death, with an average function score of 77.1, CI [73.8, 80.9]. CONCLUSION Functional change is a measurable variable for a predictive tool to enhance ACP for NH residents based on their diagnosis.
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Affiliation(s)
- Suanne Lawrence
- Faculty of Health, School of Health Sciences, University of Tasmania, Hobart, Tasmania, Australia
| | - Andrew Robinson
- Faculty of Health, Wicking Dementia Research and Education Centre, School of Health Sciences, University of Tasmania, Hobart, Tasmania, Australia
| | - Kathy Eagar
- Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
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116
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Osagiede O, Colibaseanu DT, Spaulding AC, Frank RD, Merchea A, Kelley SR, Uitti RJ, Ailawadhi S. Palliative Care Use Among Patients With Solid Cancer Tumors: A National Cancer Data Base Study. J Palliat Care 2018; 33:149-158. [PMID: 29807486 DOI: 10.1177/0825859718777320] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Palliative care has been increasingly recognized as an important part of cancer care but remains underutilized in patients with solid cancers. There is a current gap in knowledge regarding why palliative care is underutilized nationwide. OBJECTIVE To identify the factors associated with palliative care use among deceased patients with solid cancer tumors. METHODS Using the 2016 National Cancer Data Base, we identified deceased patients (2004-2013) with breast, colon, lung, melanoma, and prostate cancer. Data were described as percentages. Associations between palliative care use and patient, facility, and geographic characteristics were evaluated through multivariate logistic regression. RESULTS A total of 1 840 111 patients were analyzed; 9.6% received palliative care. Palliative care use was higher in the following patient groups: survival >24 months (17% vs 2%), male (54% vs 46%), higher Charlson-Deyo comorbidity score (16% vs 8%), treatment at designated cancer programs (74% vs 71%), lung cancer (76% vs 28%), higher grade cancer (53% vs 24%), and stage IV cancer (59% vs 13%). Patients who lived in communities with a greater percentage of high school degrees had higher odds of receiving palliative care; Central and Pacific regions of the United States had lower odds of palliative care use than the East Coast. Patients with colon, melanoma, or prostate cancer had lower odds of palliative care than patients with breast cancer, whereas those with lung cancer had higher odds. CONCLUSIONS Palliative care use in solid cancer tumors is variable, with a preference for patients with lung cancer, younger age, known insurance status, and higher educational level.
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Affiliation(s)
- Osayande Osagiede
- 1 Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | | | - Aaron C Spaulding
- 1 Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Ryan D Frank
- 3 Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- 2 Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Scott R Kelley
- 4 Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ryan J Uitti
- 5 Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Sikander Ailawadhi
- 6 Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
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117
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Sable-Smith A, Arnett KR, Nowels MA, Colborn K, Lum HD, Nowels D. Interactions with the healthcare system influence advance care planning activities: results from a representative survey in 11 developed countries. Fam Pract 2018; 35:307-311. [PMID: 29140508 PMCID: PMC5965096 DOI: 10.1093/fampra/cmx113] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIM To identify factors associated with completion of Advance Care Planning (ACP) by patients seen in primary care in developed countries. We hypothesized that the quality of primary care is associated. METHOD We analysed respondent reported individual and healthcare utilization factors associated with the completion of ACP activities from the 2014 Commonwealth Fund International Health Policy Survey of Older Adults in 11 Countries. The primary outcome is the combined number of ACP activities completed. ACP activities included discussion of treatment preferences, documentation of healthcare wishes, or documentation of a surrogate decision maker. A quality of primary care index was calculated. RESULTS Respondents averaged 69 years old. Most were women, graduated high school, rated their income as average or higher, and rated their health as good or better. A minority reported multimorbidity, accessed the emergency department or hospital, or were informal caregivers. Out of 25530 survey respondents, 13409 (53%) reported completion of any ACP activity; 11579 (45%) had discussed treatment preferences. Generalized linear mixed model results suggest that hospitalization (rate ratio [RR] 1.18), multimorbidity (RR 1.16), informal caregiving (RR 1.13), higher education level (RR 1.14), income (RR 1.05), access to higher quality primary care (RR 1.04) and ED visits (RR 1.04) were associated with higher rates of ACP activities. Male gender (RR 0.85) and higher perceived health status (RR 0.96) were associated with lower rates. CONCLUSIONS In this international study, individuals with greater interaction with the healthcare system through hospitalization, multimorbidity, access to quality primary care and informal caregiving reported more ACP activities.
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Affiliation(s)
| | - Kelly R Arnett
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Molly A Nowels
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Kathryn Colborn
- University of Colorado School of Medicine, Aurora, CO, USA
- Colorado School of Public Health, Aurora, CO, USA
| | - Hillary D Lum
- University of Colorado School of Medicine, Aurora, CO, USA
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
| | - David Nowels
- University of Colorado School of Medicine, Aurora, CO, USA
- Correspondence to: David Nowels, Department of Family Medicine, University of Colorado School of Medicine, 12631 E. 17th. Ave., Rm. 3501, Aurora, CO 80045–0508, USA; E-mail:
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118
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Hjorth NE, Haugen DF, Schaufel MA. Advance care planning in life-threatening pulmonary disease: a focus group study. ERJ Open Res 2018; 4:00101-2017. [PMID: 29796390 PMCID: PMC5958273 DOI: 10.1183/23120541.00101-2017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 03/24/2018] [Indexed: 11/27/2022] Open
Abstract
Advance care planning (ACP) is a communication process for mapping a patient's wishes and priorities for end-of-life care. In preparation for the introduction of ACP in Norway, we wanted to explore the views of Norwegian pulmonary patients on ACP. We conducted four focus group interviews in a Norwegian teaching hospital, with a sample of 13 patients suffering from chronic obstructive pulmonary disease, lung cancer or lung fibrosis. Analysis was by systematic text condensation. Participants' primary need facing end-of-life communication was “the comforting safety”, implying support, information and transparency, with four underlying themes: 1) provide good team players; 2) offer conversations with basic information; 3) seize the turning point; and 4) balance transparency. Good team players were skilled communicators knowledgeable about treatment and the last phase of life. Patients preferred dialogues at the time of diagnosis and at different “turning points” in the disease trajectory and being asked carefully about their needs for communication and planning. Transparency was important, but difficult to balance. ACP for patients with life-threatening pulmonary disease should rest upon an established patient–doctor/nurse relationship and awareness of turning points in the patient's disease progression. Individually requested and tailored information can support and empower patients and their relatives. Advance care planning may increase patients' feeling of “a comforting safety”, meeting their need for support, information and transparencyhttp://ow.ly/DMQJ30jdIPt
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Affiliation(s)
- Nina Elisabeth Hjorth
- Sunniva Centre for Palliative Care, Haraldsplass Deaconess Hospital, Bergen, Norway.,Palliative Care Team, Centre for Pain Management and Palliative Care, Haukeland University Hospital, Bergen, Norway
| | - Dagny Faksvåg Haugen
- Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Medicine K1, University of Bergen, Bergen, Norway
| | - Margrethe Aase Schaufel
- Dept of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway.,Research Unit for General Practice, Uni Research Health, Bergen, Norway
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119
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Does implementation matter if comprehension is lacking? A qualitative investigation into perceptions of advance care planning in people with cancer. Support Care Cancer 2018; 26:3765-3771. [DOI: 10.1007/s00520-018-4241-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 04/26/2018] [Indexed: 10/16/2022]
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120
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Clark MA, Person SD, Gosline A, Gawande AA, Block SD. Racial and Ethnic Differences in Advance Care Planning: Results of a Statewide Population-Based Survey. J Palliat Med 2018; 21:1078-1085. [PMID: 29658817 DOI: 10.1089/jpm.2017.0374] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Few studies have focused on racial and ethnic differences in advance care planning other than advance directives among population-based samples of adults across the lifespan. METHODS Using data from a statewide random-digit dial telephone survey of adults 18 years or older (n = 1851), we investigated racial and ethnic differences in (1) designation of a healthcare agent (HCA); and (2) communication of goals, values, and preferences for end-of-life care with healthcare providers, a HCA, or other family members and friends. RESULTS Less than half (44%, 95% confidence interval [CI] = 41.3%-47.0%) of all participants had named a HCA. In multivariable analyses, participants who identified as Hispanic (adjusted odds ratio [aOR] = 0.4, 95% CI = 0.2-0.7) or non-Hispanic other (aOR = 0.6, 95% CI = 0.4-0.9) were less likely than non-Hispanic whites to have named a HCA. Only 14.5% (95% CI = 12.6%-16.5%) of all participants had ever had a conversation with a healthcare provider about their end-of-life care wishes, with no differences by race/ethnicity. Over half (53.9%, 95% CI = 51.0%-56.8%) of all participants reported having had conversations with someone other than a healthcare provider about their end-of-life wishes. In multivariable analyses, non-Hispanic whites were more likely than Hispanics (aOR = 0.5, 95% CI = 0.3-0.7), black/African Americans (aOR = 0.5, 95% CI = 0.3-0.9), and non-Hispanic others (aOR = 0.7, 95% CI = 0.5-1.0) to report having had such conversations. CONCLUSIONS Racial and ethnic minorities may be disadvantaged in the quality of care they receive if they have a serious illness and are unable to make decisions for themselves because most have not talked to anyone about their goals, values, or preferences for care.
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Affiliation(s)
- Melissa A Clark
- 1 Department of Quantitative Health Sciences, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Sharina D Person
- 1 Department of Quantitative Health Sciences, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Anna Gosline
- 2 Blue Cross Blue Shield of Massachusetts , Boston, Massachusetts
| | - Atul A Gawande
- 3 Department of Surgery, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts.,4 Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health , Boston, Massachusetts
| | - Susan D Block
- 3 Department of Surgery, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts.,4 Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health , Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,6 Center for Palliative Care, Harvard Medical School , Boston, Massachusetts
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121
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Colibaseanu DT, Osagiede O, Spaulding AC, Frank RD, Merchea A, Mathis KL, Parker AS, Ailawadhi S. The Determinants of Palliative Care Use in Patients With Colorectal Cancer: A National Study. Am J Hosp Palliat Care 2018; 35:1295-1303. [PMID: 29580075 DOI: 10.1177/1049909118765092] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Palliative care is associated with improved survival and quality of life, but its use among patients with colorectal cancer varies nationwide and the determinants of those variations are not clear. OBJECTIVE To determine the factors associated with palliative care use among patients who died of colorectal cancer. METHODS Deceased patients treated for colorectal cancer (2004-2013) were identified within the National Cancer Database. Multivariable logistic regression was used to evaluate patient and institutional characteristics associated with palliative care use. Patients were classified based on their length of survival (<6 months, 6-24 months, and 24+ months) to provide timing context. RESULTS A total of 287 923 patients were analyzed. Overall, 4.3% of the patients received palliative care. Patients who received palliative care were more likely to be younger, recently diagnosed, treated at academic hospitals, and have stage IV disease. Patients living in Mountain and Pacific regions had higher odds of palliative care receipt than those in the East Coast. Patients without insurance had higher odds of palliative care if they survived <24 months. Insurance coverage through Medicaid was associated with increased palliative care use among patients who survived 6 to 24 months. Patients who survived <6 months and lived >9 miles from the institution received more palliative care. CONCLUSION Palliative care use among patients with colorectal cancer is associated with a younger age, a more recent year of diagnosis, insurance status, academic hospitals, and living in Mountain and Pacific regions.
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Affiliation(s)
| | - Osayande Osagiede
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Aaron C Spaulding
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Ryan D Frank
- 3 Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- 1 Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Kellie L Mathis
- 4 Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexander S Parker
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Sikander Ailawadhi
- 5 Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA
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122
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Booker R, Simon J, Biondo P, Bouchal SR. Perspectives on advance care planning in haematopoietic stem cell transplantation: a qualitative study. Int J Palliat Nurs 2018; 24:132-144. [DOI: 10.12968/ijpn.2018.24.3.132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Reanne Booker
- Nurse Practitioner, Alberta Health Services, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jessica Simon
- Associate Professor, Palliative Care Physician, Department of Oncology, University of Calgary, Calgary, Alberta
| | - Patricia Biondo
- Research Manager, Advance Care Planning CRIO Program, University of Calgary, Calgary, Alberta
| | - Shelley Raffin Bouchal
- Associate Dean (Graduate Programmes), Associate Professor, Faculty of Nursing, University of Calgary, Alberta
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123
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Mudge AM, Douglas C, Sansome X, Tresillian M, Murray S, Finnigan S, Blaber CR. Risk of 12-month mortality among hospital inpatients using the surprise question and SPICT criteria: a prospective study. BMJ Support Palliat Care 2018; 8:213-220. [DOI: 10.1136/bmjspcare-2017-001441] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 01/04/2023]
Abstract
ObjectivesPeople with serious life-limiting disease benefit from advance care planning, but require active identification. This study applied the Gold Standards Framework Proactive Identification Guidance (GSF-PIG) to a general hospital population to describe high-risk patients and explore prognostic performance for 12-month mortality.MethodsProspective cohort study conducted in a metropolitan teaching hospital in Australia. Hospital inpatients on a single day aged 18 years and older were eligible, excluding maternity and neonatal, mental health and day treatment patients. Data sources included medical record and structured questions for medical and nursing staff. High-risk was predefined as positive response to the surprise question (SQ) plus two or more SPICT indicators of general deterioration. Descriptive variables included demographics, frailty and functional measures, treating team, advance care planning documentation and hospital utilisation. Primary outcome for prognostic performance was 12-month mortality.ResultsWe identified 540 eligible inpatients on the study day and 513 had complete data (mean age 60, 54% male, 30% living alone, 19% elective admissions). Of these, 191 (37%) were high-risk; they were older, frailer, more dependent and had been in hospital longer than low-risk participants. Within 12 months, 92 participants (18%) died (72/191(38%) high-risk versus 20/322(6%) low-risk, P<0.001), providing sensitivity 78%, specificity 72%, positive predictive value 38% and negative predictive value 94%. SQ alone provided higher sensitivity, adding advanced disease indicators improved specificity.ConclusionsThe GSF-PIG approach identified a large minority of hospital inpatients who might benefit from advance care planning. Future studies are needed to investigate the feasibility, cost and impact of screening in hospitals.
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124
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McInerney F, Doherty K, Bindoff A, Robinson A, Vickers J. How is palliative care understood in the context of dementia? Results from a massive open online course. Palliat Med 2018; 32:594-602. [PMID: 29235386 PMCID: PMC5851129 DOI: 10.1177/0269216317743433] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND A palliative approach to the care of people with dementia has been advocated, albeit from an emergent evidence base. The person-centred philosophy of palliative care resonates with the often lengthy trajectory and heavy symptom burden of this terminal condition. AIM To explore participants' understanding of the concept of palliative care in the context of dementia. The participant population took an online course in dementia. DESIGN The participant population took a massive open online course on 'Understanding Dementia' and posted answers to the question: 'palliative care means …' We extracted these postings and analysed them via the dual methods of topic modelling analysis and thematic analysis. SETTING/PARTICIPANTS A total of 1330 participants from three recent iterations of the Understanding Dementia Massive Open Online Course consented to their posts being used. Participants included those caring formally or informally for someone living with dementia as well as those with a general interest in dementia Results: Participants were found to have a general awareness of palliative care, but saw it primarily as terminal care, focused around the event of death and specialist in nature. Comfort was equated with pain management only. Respondents rarely overtly linked palliative care to dementia. CONCLUSIONS A general lack of palliative care literacy, particularly with respect to dementia, was demonstrated by participants. Implications for dementia care consumers seeking palliative care and support include recognition of the likely lack of awareness of the relevance of palliative care to dementia. Future research could access online participants more directly about their understandings/experiences of the relationship between palliative care and dementia.
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Affiliation(s)
- Fran McInerney
- Faculty of Health, Wicking Dementia Research & Education Centre, University of Tasmania, Hobart, TAS, Australia
| | - Kathleen Doherty
- Faculty of Health, Wicking Dementia Research & Education Centre, University of Tasmania, Hobart, TAS, Australia
| | - Aidan Bindoff
- Faculty of Health, Wicking Dementia Research & Education Centre, University of Tasmania, Hobart, TAS, Australia
| | - Andrew Robinson
- Faculty of Health, Wicking Dementia Research & Education Centre, University of Tasmania, Hobart, TAS, Australia
| | - James Vickers
- Faculty of Health, Wicking Dementia Research & Education Centre, University of Tasmania, Hobart, TAS, Australia
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125
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Reversals and limitations on high-intensity, life-sustaining treatments. PLoS One 2018; 13:e0190569. [PMID: 29489814 PMCID: PMC5830043 DOI: 10.1371/journal.pone.0190569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 12/18/2017] [Indexed: 11/19/2022] Open
Abstract
Importance Critically ill patients often receive high-intensity life sustaining treatments (LST) in the intensive care unit (ICU), although they can be ineffective and eventually undesired. Determining the risk factors associated with reversals in LST goals can improve patient and provider appreciation for the natural history and epidemiology of critical care and inform decision making around the (continued) use of LSTs. Methods This is a single institution retrospective cohort study of patients receiving life sustaining treatment in an academic tertiary hospital from 2009 to 2013. Deidentified patient electronic medical record data was collected via the clinical data warehouse to study the outcomes of treatment limiting Comfort Care and do-not-resuscitate (DNR) orders. Extended multivariable Cox regression models were used to estimate the association of patient and clinical factors with subsequent treatment limiting orders. Results 10,157 patients received life-sustaining treatment while initially Full Code (allowing all resuscitative measures). Of these, 770 (8.0%) transitioned to Comfort Care (with discontinuation of any life-sustaining treatments) while 1,669 (16%) patients received new DNR orders that reflect preferences to limit further life-sustaining treatment options. Patients who were older (Hazard Ratio(HR) 1.37 [95% CI 1.28–1.47] per decade), with cerebrovascular disease (HR 2.18 [95% CI 1.69–2.81]), treated by the Medical ICU (HR 1.92 [95% CI 1.49–2.49]) and Hematology-Oncology (HR 1.87 [95% CI 1.27–2.74]) services, receiving vasoactive infusions (HR 1.76 [95% CI 1.28, 2.43]) or continuous renal replacement (HR 1.83 [95% CI 1.34, 2.48]) were more likely to transition to Comfort Care. Any new DNR orders were more likely for patients who were older (HR 1.43 [95% CI 1.38–1.48] per decade), female (HR 1.30 [95% CI 1.17–1.44]), with cerebrovascular disease (HR 1.45 [95% CI 1.25–1.67]) or metastatic solid cancers (HR 1.92 [95% CI 1.48–2.49]), or treated by Medical ICU (HR 1.63 [95% CI 1.42–1.86]), Hematology-Oncology (HR 1.63 [95% CI 1.33–1.98]) and Cardiac Care Unit-Heart Failure (HR 1.41 [95% CI 1.15–1.72]). Conclusion Decisions to reverse or limit treatment goals occurs after more than 1 in 13 trials of LST, and is associated with older female patients, receiving non-ventilator forms of LST, cerebrovascular disease, and treatment by certain medical specialty services.
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Vanderhaeghen B, Bossuyt I, Opdebeeck S, Menten J, Rober P. Toward Hospital Implementation of Advance Care Planning: Should Hospital Professionals Be Involved? QUALITATIVE HEALTH RESEARCH 2018; 28:456-465. [PMID: 29059015 DOI: 10.1177/1049732317735834] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In Belgium, Advance Care Planning (ACP) is not well implemented in hospital practice. One of the premises for successful implementation is involving the adopters in the implementation process. In hospital, important adopters of ACP are physicians, nurses, social workers, and psychologists. First, this study wants to understand what the characteristics are of ACP in hospital, according to professionals. Second, this study aims to give an insight in the experienced value of ACP. Third, the experienced barriers to have ACP conversations are explored. Twenty-four interviews were taken and analyzed with Content Analysis based on Grounded Theory. Three independent external auditors surveilled the analysis. ACP in hospital exists by the grace of the initiative of the actors involved in the case. Professionals perceive fields of tension between one another; barriers to ACP communication. ACP is mainly considered valuable because it is a process that creates time for exploration and reflection.
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127
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Collins JW, Zoucha R, Lockhart JS, Mixer SJ. Cultural Aspects of End-of-Life Care Planning for African Americans: An Integrative Review of Literature. J Transcult Nurs 2018; 29:578-590. [PMID: 29357786 DOI: 10.1177/1043659617753042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Advance directive completion rates among the general population are low. Studies report even lower completion rates among African Americans are affected by demographic variables, cultural distinctives related to patient autonomy, mistrust of the health care system, low health literacy, strong spiritual beliefs, desire for aggressive interventions, importance of family-communal decision making, and presence of comorbidities. An integrative review was conducted to synthesize nursing knowledge regarding cultural perspectives of end-of-life and advance care planning among African Americans. Twenty-four articles were reviewed. Nurses educate patients and families about end-of-life planning as mandated by the Patient Self-Determination Act of 1991. Implementation of advance directives promote patient and family centered care, and should be encouraged. Clinicians must be sensitive and respectful of values and practices of patients of diverse cultures, and initiate conversations with open-ended questions facilitating patient trust and sharing within the context of complex beliefs, traditions, and lifeways.
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Affiliation(s)
- John W Collins
- 1 University of Michigan-Flint, School of Nursing, Flint, MI, USA
| | - Rick Zoucha
- 2 Duquesne University School of Nursing, Pittsburgh, PA, USA
| | | | - Sandra J Mixer
- 3 University of Tennessee-Knoxville, College of Nursing, Knoxville, TN, USA
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128
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Kassam A, Douglas ML, Simon J, Cunningham S, Fassbender K, Shaw M, Davison SN. Behaviors in Advance Care Planning and ACtions Survey (BACPACS): development and validation part 1. BMC Palliat Care 2017; 16:56. [PMID: 29166904 PMCID: PMC5700663 DOI: 10.1186/s12904-017-0236-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 11/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although advance care planning (ACP) is fairly well understood, significant barriers to patient participation remain. As a result, tools to assess patient behaviour are required. The objective of this study was to improve the measurement of patient engagement in ACP by detecting existing survey design issues and establishing content and response process validity for a new survey entitled Behaviours in Advance Care Planning and ACtions Survey (BACPACS). METHODS We based our new tool on that of an existing ACP engagement survey. Initial item reduction was carried out using behavior change theories by content and design experts to help reduce response burden and clarify questions. Thirty-two patients with chronic diseases (cancer, heart failure or renal failure) were recruited for the think aloud cognitive interviewing with the new, shortened survey evaluating patient engagement with ACP. Of these, n = 27 had data eligible for analysis (n = 8 in round 1 and n = 19 in rounds 2 and 3). Interviews were audio-recorded and analyzed using the constant comparison method. Three reviewers independently listened to the interviews, summarized findings and discussed discrepancies until consensus was achieved. RESULTS Item reduction from key content expert review and conversation analysis helped decrease number of items from 116 in the original ACP Engagement Survey to 24-38 in the new BACPACS depending on branching of responses. For the think aloud study, three rounds of interviews were needed until saturation for patient clarity was achieved. The understanding of ACP as a construct, survey response options, instructions and terminology pertaining to patient engagement in ACP warranted further clarification. CONCLUSIONS Conversation analysis, content expert review and think aloud cognitive interviewing were useful in refining the new survey instrument entitled BACPACS. We found evidence for both content and response process validity for this new tool.
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Affiliation(s)
- Aliya Kassam
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
| | - Maureen L Douglas
- Advance Care Planning CRIO Program, Division of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Jessica Simon
- Department of Oncology, Community Health Sciences and Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shannon Cunningham
- Alberta Innovates, Performance Management and Evaluation, Edmonton, AB, Canada
| | | | - Marta Shaw
- Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Sara N Davison
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Tripken JL, Elrod CS. Young Adults’ Perspectives on Advance Care Planning. Am J Hosp Palliat Care 2017; 35:627-634. [DOI: 10.1177/1049909117727456] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jennifer L. Tripken
- Department of Health and Human Performance, Marymount University, Arlington, VA, USA
| | - Cathy S. Elrod
- Department of Physical Therapy, Marymount University, Arlington, VA, USA
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Yamaguchi T, Maeda I, Hatano Y, Mori M, Shima Y, Tsuneto S, Kizawa Y, Morita T, Yamaguchi T, Aoyama M, Miyashita M. Effects of End-of-Life Discussions on the Mental Health of Bereaved Family Members and Quality of Patient Death and Care. J Pain Symptom Manage 2017; 54:17-26.e1. [PMID: 28450216 DOI: 10.1016/j.jpainsymman.2017.03.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/02/2017] [Accepted: 03/17/2017] [Indexed: 11/24/2022]
Abstract
CONTEXT End-of-life discussions are crucial for providing appropriate care to patients with advanced cancer at the end of their lives. OBJECTIVES The objective of this study was to explore associations between end-of-life discussions and bereaved families' depression and complicated grief and the quality of patient death and end-of-life care. METHODS A nationwide questionnaire survey of bereaved family members was conducted between May and July 2014. A total of 13,711 bereaved family members of cancer patients who were cared for by specialist palliative care services at 75 institutions throughout Japan and died before January 2014 participated. We evaluated the prevalence of depression (defined as the Patient Health Questionnaire-9 ≥ 10) and complicated grief (defined as the Brief Grief Questionnaire ≥ 8) in bereaved family members. Moreover, we evaluated the quality of death and end-of-life care with the Good Death Inventory and the Care Evaluation Scale, respectively. RESULTS A total of 9123 questionnaires were returned (response rate 67%), and 80.6% of the respondents reported that they had end-of-life discussions. After propensity score-weighted adjustment, the results showed that bereaved family members who had end-of-life discussions had a lower frequently of depression (17.3% vs. 21.6%; P < 0.001) and complicated grief (13.7% vs. 15.9%; P = 0.03). End-of-life discussions were associated with better quality of death (the Good Death Inventory score, 47.2 ± 8.5 vs. 46.1 ± 9.4; P < 0.001) and end-of-life care (the Care Evaluation Scale score, 84.1 ± 11.4 vs. 78.9 ± 14.3; P < 0.001). CONCLUSION End-of-life discussions may contribute to reducing depression and complicated grief in bereaved family members and enable patients to experience quality end-of-life care and a good death.
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Affiliation(s)
- Takashi Yamaguchi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan; Department of Palliative Care, Hyogo Prefectural Kakogawa Medical Center, Kakogawa, Japan.
| | - Isseki Maeda
- Gratia Hospice, Gratia Research and Clinical Education (GRACE) Center, Gratia Hospital, Minoh, Japan
| | - Yutaka Hatano
- Department of Psychosomatic Medicine, Kinki University Hospital, Osaka-Sayama, Japan
| | - Masanori Mori
- Department of Laboratory Medicine, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Maho Aoyama
- Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Mitsunori Miyashita
- Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
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Abstract
ABSTRACTObjective:Advanced care plans (ACPs) are designed to convey the wishes of patients with regards to their care in the event of incapacity. There are a number of prerequisites for creation of an effective ACP. First, the patient must be aware of their condition, their prognosis, the likely trajectory of the illness, and the potential treatment options available to them. Second, patient input into ACP must be free of any coercive factors. Third, the patient must be able to remain involved in adapting their ACP as their condition evolves. Continued use of familial determination and collusion within the local healthcare system, however, has raised concerns that the basic requirements for effective ACP cannot be met.Method:To assess the credibility of these concerns, we employed a video vignette approach depicting a family of three adult children discussing whether or not to reveal a cancer diagnosis to their mother. Semistructured interviews with 72 oncology patients and 60 of their caregivers were conducted afterwards to explore the views of the participants on the different positions taken by the children.Results:Collusion, family-centric decision making, adulteration of information provided to patients, and circumnavigation of patient involvement appear to be context-dependent. Patients and families alike believe that patients should be told of their conditions. However, the incidence of collusion and familial determination increases with determinations of a poor prognosis, a poor anticipated response to chemotherapy, and a poor premorbid health status. Financial considerations with respect to care determinations remain secondary considerations.Significance of results:Our data suggest that ACPs can be effectively constructed in family-centric societies so long as healthcare professionals continue to update and educate families on the patient's situation. Collusion and familial intervention in the decision-making process are part of efforts to protect the patient from distress and are neither solely dependent on cultural nor an “all-or-nothing” phenomenon. The response of families are context-dependent and patient-specific, weighing the patient's right to know and prepare and the potential distress it is likely to cause. In most cases, the news is broken gently over time to allow the patient to digest the information and for the family to assess how well they cope with the news. Furthermore, the actions of families are dependent upon their understanding of the situation, highlighting the need for continued engagement with healthcare professionals.
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Omondi S, Weru J, Shaikh AJ, Yonga G. Factors that influence advance directives completion amongst terminally ill patients at a tertiary hospital in Kenya. BMC Palliat Care 2017; 16:9. [PMID: 28118824 PMCID: PMC5264302 DOI: 10.1186/s12904-017-0186-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/19/2017] [Indexed: 11/14/2022] Open
Abstract
Background An advance directive (AD) is a written or verbal document that legally stipulates a person’s health care preference while they are competent to make decisions for themselves and is used to guide decisions on life-sustaining treatment in the event that they become incapacitated. AD can take the form of a living will, a limitation of care document, a do-not-resuscitate order, or an appointment of a surrogate by durable power of attorney. The completion rate of AD varies from region to region, and it is influenced by multiple factors. The objectives of this study were to determine the proportion of terminally ill patients with AD and to identify the factors that influence the completion of AD amongst terminally ill patients at a tertiary hospital in Kenya. Methods The study was a retrospective survey. All available records of terminally ill patients seen at Aga Khan University Hospital, Nairobi, between July 2010 and December 2015, and that met the inclusion criteria were included in the study. Results In total, 216 records of terminally ill patients were analyzed: 89 records were of patients that had AD and 127 records were of patients that did not have AD. The proportion of terminally ill patients that had completed AD was 41.2%. The factors that were associated with the completion of AD on bivariate analysis were history of ICU admission, history of endotracheal intubation, functional status of the patient, the medical specialty taking care of the patient, patient’s caregiver discussing the AD with the patient, and a palliative specialist review. On multivariate regression analysis, discussion of AD with a caregiver and patient’s functional impairment were the factors with statistically significant association with completion of AD. Conclusions The proportion of terminally ill patients that had AD in their medical records was significant. However, most terminally ill patients did not have AD. Our data, perhaps the first on the subject in East Africa, suggest that most of the factors associated with AD completion mirrored those seen in other regions of the world. Discussion between patient and their physician and patient’s functional impairment were the factors independently associated with completion of AD. Therefore, physicians need to be aware of the importance of discussions of AD with their patients.
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Affiliation(s)
| | - John Weru
- Aga Khan University-Kenya, Nairobi, Kenya
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Travers A, Taylor V. What are the barriers to initiating end-of-life conversations with patients in the last year of life? Int J Palliat Nurs 2017; 22:454-462. [PMID: 27666307 DOI: 10.12968/ijpn.2016.22.9.454] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Improving end of life care is a national imperative. Unsatisfactory care persists particularly in acute hospitals, with shortcomings, variability in communication and advance care planning identified as fundamental issues. This review explored the literature to identify what is known about the barriers to initiating end-of-life conversations with patients from the perspective of doctors and nurses in the acute hospital setting. METHOD Six electronic databases were searched for potentially relevant records published between 2008 and 2015. Studies were included if the authors reported on barriers to discussing end of life with families or patients as described by doctors or nurses in hospital settings, excluding critical care. RESULTS Of 1267 potentially relevant records, 12 were included in the review. Although there is limited high-quality evidence available, several barriers were identified. Recurrent themes within the literature related to a lack of education and training, difficulty in prognostication, cultural differences and perceived reluctance of the patient or family. CONCLUSIONS This study illustrated that, in addressing barriers to communication, consideration needs to be extended to include how to embed good communication practice between patients and health professionals into the culture of this setting. Board level commitment is required to raise awareness of, and familiarity with, policies and protocols concerning communication and end-of-life care. Communication training should include practical skills and tools, opportunities to explore the personal beliefs of practitioners and managing their emotions, opportunities to analyse the local organisational (physical and social environment) and team barriers.
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Affiliation(s)
- Alice Travers
- Staff Nurse Central Manchester NHS Trust/MClin Res Student University of Manchester
| | - Vanessa Taylor
- Deputy Head of Nursing, Midwifery and Professional Programmes, University of York
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Gilissen J, Pivodic L, Smets T, Gastmans C, Vander Stichele R, Deliens L, Van den Block L. Preconditions for successful advance care planning in nursing homes: A systematic review. Int J Nurs Stud 2016; 66:47-59. [PMID: 27987411 DOI: 10.1016/j.ijnurstu.2016.12.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/06/2016] [Accepted: 12/06/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES There is growing evidence of the potential effectiveness of advance care planning. Yet important knowledge gaps remain regarding the preconditions for successful implementation of advance care planning in the nursing home setting. We aim to identify the preconditions related to successful advance care planning in the nursing home setting. By specifying those, we would be able to make well-founded choices for the future design and planning of advance care planning intervention programs. DESIGN A systematic review. DATA SOURCES PubMed, PsycINFO, EMBASE and CINAHL. REVIEW METHODS Two authors independently screened publications. One author assessed methodological quality and extracted textual data, which was double-checked for a random sample. We extracted textual data and used thematic synthesis to identify "preconditions", defined as requirements, conditions and elements necessary to achieve the desired outcome of advance care planning, i.e. attaining concordance between residents' preferences and actual care or treatment received at the end of life. MAIN FINDINGS Based on 38 publications, we identified 17 preconditions at five different levels: resident, family, health-care professional, facility and community. Most preconditions were situated on multiple levels but the majority addressed professionals and the nursing home itself. We summarized preconditions in five domains: to have sufficient knowledge and skills, to be willing and able to participate in advance care planning, to have good relationships, to have an administrative system in place, and contextual factors supporting advance care planning within the nursing home. CONCLUSION There are multiple preconditions related to successfully implementing advance care planning in the complex nursing home setting that operate at micro, meso and macro level. Future interventions need to address these multiple domains and levels in a whole-system approach in order to be better implementable and more sustainable, while simultaneously target the important role of the health-care professional and the facility itself.
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Affiliation(s)
- Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium.
| | - Lara Pivodic
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium.
| | - Tinne Smets
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 Box 7001, 3000 Leuven, Belgium
| | | | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium; Department of Medical Oncology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
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135
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Fukui S, Morita T, Yoshiuchi K. Development of a Clinical Tool to Predict Home Death of a Discharged Cancer Patient in Japan: a Case-Control Study. Int J Behav Med 2016; 24:584-592. [DOI: 10.1007/s12529-016-9619-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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136
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Fritz L, Dirven L, Reijneveld JC, Koekkoek JAF, Stiggelbout AM, Pasman HRW, Taphoorn MJB. Advance Care Planning in Glioblastoma Patients. Cancers (Basel) 2016; 8:E102. [PMID: 27834803 PMCID: PMC5126762 DOI: 10.3390/cancers8110102] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/20/2016] [Accepted: 11/02/2016] [Indexed: 12/27/2022] Open
Abstract
Despite multimodal treatment with surgery, radiotherapy and chemotherapy, glioblastoma is an incurable disease with a poor prognosis. During the disease course, glioblastoma patients may experience progressive neurological deficits, symptoms of increased intracranial pressure such as drowsiness and headache, incontinence, seizures and progressive cognitive dysfunction. These patients not only have cancer, but also a progressive brain disease. This may seriously interfere with their ability to make their own decisions regarding treatment. It is therefore warranted to involve glioblastoma patients early in the disease trajectory in treatment decision-making on their future care, including the end of life (EOL) care, which can be achieved with Advance Care Planning (ACP). Although ACP, by definition, aims at timely involvement of patients and proxies in decision-making on future care, the optimal moment to initiate ACP discussions in the disease trajectory of glioblastoma patients remains controversial. Moreover, the disease-specific content of these ACP discussions needs to be established. In this article, we will first describe the history of patient participation in treatment decision-making, including the shift towards ACP. Secondly, we will describe the possible role of ACP for glioblastoma patients, with the specific aim of treatment of disease-specific symptoms such as somnolence and dysphagia, epileptic seizures, headache, and personality changes, agitation and delirium in the EOL phase, and the importance of timing of ACP discussions in this patient population.
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Affiliation(s)
- Lara Fritz
- Department of Neurology, Haaglanden Medical Center, P.O. BOX 432, 2501 CK The Hague, The Netherlands.
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
| | - Jaap C Reijneveld
- Department of Neurology, VU University Medical Center, P.O. BOX 7057, 1007 MB Amsterdam, The Netherlands.
- Department of Neurology, Academic Medical Center, P.O. BOX 22660, 1100 DD Amsterdam, The Netherlands.
| | - Johan A F Koekkoek
- Department of Neurology, Haaglanden Medical Center, P.O. BOX 432, 2501 CK The Hague, The Netherlands.
- Department of Neurology, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
| | - Anne M Stiggelbout
- Department of Medical Decision Making/Quality of Care, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
| | - H Roeline W Pasman
- Department of Public and Occupational Health, VU University Medical Center, P.O. BOX 7057, 1007 MB Amsterdam, The Netherlands.
| | - Martin J B Taphoorn
- Department of Neurology, Haaglanden Medical Center, P.O. BOX 432, 2501 CK The Hague, The Netherlands.
- Department of Neurology, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
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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.
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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
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Biondo PD, Lee LD, Davison SN, Simon JE. How healthcare systems evaluate their advance care planning initiatives: Results from a systematic review. Palliat Med 2016; 30:720-9. [PMID: 26908645 DOI: 10.1177/0269216316630883] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Advance care planning initiatives are being implemented across healthcare systems around the world, but how best to evaluate their implementation is unknown. AIM To identify gaps and/or redundancies in current evaluative strategies to help healthcare systems develop future evaluative frameworks for ACP. DESIGN Systematic review. METHODS Peer-reviewed and gray literature searches were conducted till February 2015 to answer: "What methods have healthcare systems used to evaluate implementation of advance care planning initiatives?" A PICOS framework was developed to identify articles describing the implementation and evaluation of a health system-level advance care planning initiative. Outcome measures were mapped onto a conceptual quality indicator framework based on the Institute of Medicine and Donabedian models of healthcare quality. RESULTS A total of 46 studies met inclusion criteria for analysis. Most articles reported on single parts of a healthcare system (e.g. continuing care). The most common outcome measures pertained to document completion, followed by healthcare resource use. Patient-, family-, or healthcare provider-reported outcomes were less commonly measured. Concordance measures (e.g. dying in place of choice) were reported by only 26% of studies. The conceptual quality indicator framework identified gaps and redundancies in measurement and is presented as a potential foundation from which to develop a comprehensive advance care planning evaluation framework. CONCLUSION Document completion is frequently used to evaluate advance care planning program implementation; capturing the quality of care appears to be more difficult. This systematic review provides health system administrators with a comprehensive summary of measures used to evaluate advance care planning and may identify gaps in evaluation within their local context.
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Affiliation(s)
- Patricia D Biondo
- Advance Care Planning Collaborative Research and Innovation Opportunities Program (ACP CRIO), University of Calgary, Calgary, AB, Canada
| | - Lydia D Lee
- Advance Care Planning Collaborative Research and Innovation Opportunities Program (ACP CRIO), University of Calgary, Calgary, AB, Canada
| | - Sara N Davison
- Advance Care Planning Collaborative Research and Innovation Opportunities Program (ACP CRIO), University of Calgary, Calgary, AB, Canada Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jessica E Simon
- Advance Care Planning Collaborative Research and Innovation Opportunities Program (ACP CRIO), University of Calgary, Calgary, AB, Canada Departments of Oncology, Medicine, and Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Weathers E, O’Caoimh R, Cornally N, Fitzgerald C, Kearns T, Coffey A, Daly E, O’Sullivan R, McGlade C, Molloy D. Advance care planning: A systematic review of randomised controlled trials conducted with older adults. Maturitas 2016; 91:101-9. [DOI: 10.1016/j.maturitas.2016.06.016] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/11/2016] [Accepted: 06/22/2016] [Indexed: 10/21/2022]
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140
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Sarabia-Cobo CM, Pérez V, de Lorena P, Nuñez MJ, Domínguez E. Decisions at the end of life made by relatives of institutionalized patients with dementia. Appl Nurs Res 2016; 31:e6-e10. [DOI: 10.1016/j.apnr.2016.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/14/2016] [Accepted: 02/14/2016] [Indexed: 11/16/2022]
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Is cancer a good way to die? A population-based survey among middle-aged and older adults in the United Kingdom. Eur J Cancer 2016; 56:172-178. [PMID: 26920822 PMCID: PMC4788505 DOI: 10.1016/j.ejca.2015.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/03/2015] [Accepted: 12/10/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Despite improved outcomes, cancer remains widely feared, often because of its association with a long and protracted death as opposed to the quick death that people associate with that other common cause of adult mortality: heart disease. Former editor-in-chief of the BMJ Richard Smith's view that 'cancer is the best way to die' therefore attracted much criticism. We examined middle-aged and older adults' agreement with this view and compared their attitudes towards dying from cancer versus heart disease in terms of which was a good death. METHODS This study was part of an online survey (February 2015) in a United Kingdom (UK) population sample of 50- to 70-year olds (n = 391), with sampling quotas for gender and education. Five characteristics of 'a good death' were selected from the end-of-life literature. Respondents were asked to rate the importance of each characteristic for their own death to ensure their relevance to a population sample and the likelihood of each for death from cancer and heart disease. We also asked whether they agreed with Smith's view. RESULTS At least 95% of respondents considered the selected five characteristics important for their own death. Death from cancer was rated as more likely to provide control over what happens (p < 0.001), control over pain and other symptoms (p < 0.01), time to settle affairs (p < 0.001), and time to say goodbye to loved ones (p < 0.001) compared with death from heart disease, but there were no differences in expectation of living independently until death (p > 0.05). Almost half (40%) agreed that cancer is 'the best way to die', with no differences by age (p = 0.40), gender (p = 0.85), or education (p = 0.27). CONCLUSION Despite the media commotion, a surprisingly high proportion of middle-aged and older adults viewed cancer as 'the best way to die' and rated cancer death as better than heart disease. Given that one in two of us are likely to be diagnosed with cancer, conversations about a good death from cancer may in a small way mitigate fear of cancer. Future research could explore variations by type of cancer or heart disease and by previous experience of these illnesses in others.
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142
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Davies A, Todd J, Bailey F, Gregory A, Waghorn M. Good concordance between patients and their non-professional carers about factors associated with a ‘good death’ and other important end-of-life decisions. BMJ Support Palliat Care 2016; 9:340-345. [DOI: 10.1136/bmjspcare-2015-001085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/12/2016] [Accepted: 04/27/2016] [Indexed: 11/04/2022]
Abstract
ObjectivesThe aim of this study was to investigate concordance between patients and non-professional carers about factors associated with a ‘good death’ and other end-of-life decisions.MethodsPatients completed a questionnaire about end-of-life care issues, and were asked to rank the importance of factors linked to a ‘good death’. Carers also completed a questionnaire about end-of-life care issues relating to the patient, and whether or not they agreed with those choices (ie, medical treatments, PPD). Carers were also asked to rank the importance of factors linked to a ‘good death’ to the patient, and to them personally at that point in time.ResultsOnly 69% of patients stated they had discussed their preferences for end-of-life care with their respective carer. The rankings were similar for the patient and the carer's views of what was important for the patient, although the patients ranked ‘to be involved in decisions about my care’ as less important than the carers, while the carers ranked ‘to have sorted out my personal affairs’ as less important than the patients.ConclusionsWhen discussions around end-of-life choices do occur, carers generally appear to agree with the patients' preferences around end-of-life treatment, and preferred place of death.
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143
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Brighton LJ, Bristowe K. Communication in palliative care: talking about the end of life, before the end of life. Postgrad Med J 2016; 92:466-70. [DOI: 10.1136/postgradmedj-2015-133368] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 04/17/2016] [Indexed: 01/22/2023]
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Van den Heuvel LAMC, Hoving C, Schols JMGA, Spruit MA, Wouters EFM, Janssen DJA. Barriers and facilitators to end-of-life communication in advanced chronic organ failure. Int J Palliat Nurs 2016; 22:222-9. [DOI: 10.12968/ijpn.2016.22.5.222] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Ciska Hoving
- Assistant Professor at Department of Health Promotion
| | - Jos MGA Schols
- Professor of Old Age Medicine, Department of General Practice and Department of Health Services Research, Faculty of Health Medicine and Life Sciences/CAPHRI, Maastricht University, Netherlands
| | - Martijn A Spruit
- Scientific Advisor, Department of Research and Education, CIRO, Horn, Netherlands
| | - Emiel FM Wouters
- Professor of Respiratory Medicine, Department of Respiratory Medicine
| | - Daisy JA Janssen
- Elderly Care Physician, Centre of Expertise for Palliative Care; both at Maastricht University Medical Centre+ (MUMC+), the Netherlands, and, Department of Research and Education, CIRO, Horn, the Netherlands
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145
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Bollig G, Gjengedal E, Rosland JH. They know!-Do they? A qualitative study of residents and relatives views on advance care planning, end-of-life care, and decision-making in nursing homes. Palliat Med 2016; 30:456-70. [PMID: 26396227 PMCID: PMC4838176 DOI: 10.1177/0269216315605753] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Residents living in long-term care facilities are a vulnerable population. For many residents, a nursing home is their place of death. Palliative care and end-of-life decisions are important components of their care provision. AIM To study the views of cognitively able residents and relatives on advance care planning, end-of-life care, and decision-making in nursing homes. DESIGN A qualitative study with in-depth interviews with nursing home residents and focus group interviews with relatives of nursing home residents. Analysis is based on interpretive description. SETTING/PARTICIPANTS In total, 43 informants from nine nursing homes participated in the study (25 nursing home residents and 18 relatives). All included residents had capacity to provide informed consent and lived in long-term care. RESULTS The main findings of this study were the differing views about decision-making and advance care planning of residents and relatives. Residents do trust relatives and staff to make important decisions for them. The relatives are in contrast insecure about the residents' wishes and experience decision-making as a burden. The majority of the residents had not participated in advance care planning. None of the residents stated challenges connected to end-of-life care or mentioned the wish for euthanasia. CONCLUSION Although most residents seem to be satisfied with decision-making and end-of life care, there is a need for systematic advance care planning. Advance care planning could help to explore future wishes for care and ease decision-making for the relatives, physicians, and staff and should be offered to all cognitively able nursing homes residents.
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Affiliation(s)
- Georg Bollig
- Department of Clinical Medicine, University of Bergen, Bergen, Norway Sunniva Centre for Palliative Care, Department of Internal Medicine, Haraldsplass Deaconess Hospital Bergen, Bergen, Norway Department of Anesthesiology, Intensive Care, Palliative Medicine and Pain Therapy, HELIOS Klinikum Schleswig, Schleswig, Germany
| | - Eva Gjengedal
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway Molde University College, Molde, Norway
| | - Jan Henrik Rosland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway Sunniva Centre for Palliative Care, Department of Internal Medicine, Haraldsplass Deaconess Hospital Bergen, Bergen, Norway
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146
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Kim YS, Escobar GJ, Halpern SD, Greene JD, Kipnis P, Liu V. The Natural History of Changes in Preferences for Life-Sustaining Treatments and Implications for Inpatient Mortality in Younger and Older Hospitalized Adults. J Am Geriatr Soc 2016; 64:981-9. [PMID: 27119583 DOI: 10.1111/jgs.14048] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To compare changes in preferences for life-sustaining treatments (LSTs) and subsequent mortality of younger and older inpatients. DESIGN Retrospective cohort study. SETTING Kaiser Permanente Northern California (KPNC). PARTICIPANTS Individuals hospitalized at 21 KPNC hospitals between 2008 and 2012 (N = 227,525). MEASUREMENTS Participants were divided according to age (<65, 65-84, ≥85). The effect of age on adding new and reversing prior LST limitations was evaluated. Survival to inpatient discharge was compared according to age group after adding new LST limitations. RESULTS At admission, 18,254 (54.2%) of those aged 85 and older, 18,349 (20.8%) of those aged 65 to 84, and 3,258 (3.1%) of those younger than 65 had requested that the use of LST be limited. Of the 187,664 participants who initially did not request limitations on the use of LST, 15,932 (8.5%) had new LST limitations added; of the 39,861 admitted with LST limitations, 3,017 (7.6%) had these reversed. New limitations were more likely to be seen in older participants (aged 65-84, odds ratio (OR) = 2.27, 95% confidence interval (CI) = 2.16-2.39; aged ≥85, OR = 6.43, 95% CI = 6.05-6.84), and reversals of prior limitations were less likely to be seen in older individuals (aged 65-84, OR = 0.73, 95% CI = 0.65-0.83; aged ≥85, OR = 0.46, 95% CI = 0.41-0.53) than in those younger than 65. Survival rates to inpatient discharge were 71.7% of subjects aged 85 and older who added new limitations, 57.2% of those aged 65 to 84, and 43.4% of those younger than 65 (P < .001). CONCLUSION Changes in preferences for LSTs were common in hospitalized individuals. Age was an important determinant of likelihood of adding new or reversing prior LST limitations. Of subjects who added LST limitations, those who were older were more likely than those who were younger to survive to hospital discharge.
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Affiliation(s)
- Yan S Kim
- Division of Research and Systems Research Initiative, Kaiser Permanente Northern California, Oakland, California
| | - Gabriel J Escobar
- Division of Research and Systems Research Initiative, Kaiser Permanente Northern California, Oakland, California
| | - Scott D Halpern
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Fostering Improvement in End-of-Life Decision Science Program, Leonard David Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John D Greene
- Division of Research and Systems Research Initiative, Kaiser Permanente Northern California, Oakland, California
| | - Patricia Kipnis
- Division of Research and Systems Research Initiative, Kaiser Permanente Northern California, Oakland, California.,Decision Support, Kaiser Foundation Health Plan, Oakland, California
| | - Vincent Liu
- Division of Research and Systems Research Initiative, Kaiser Permanente Northern California, Oakland, California
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147
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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.
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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
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148
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End-Of-Life Decisions in Chronic Disorders of Consciousness: Sacrality and Dignity as Factors. NEUROETHICS-NETH 2016. [DOI: 10.1007/s12152-016-9257-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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149
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Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, Everitt H, Kennedy A, Qureshi N, Rogers A, Peacock R, Murray E. Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews. Implement Sci 2016; 11:40. [PMID: 27001107 PMCID: PMC4802575 DOI: 10.1186/s13012-016-0396-4] [Citation(s) in RCA: 287] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 02/28/2016] [Indexed: 12/02/2022] Open
Abstract
Background This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care. Design This study is a systematic review of reviews. Methods MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted and synthesised using guidelines for meta-synthesis. Results Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term “cause” or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed “causes” in terms of “barriers and facilitators” to implementation. We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders’ buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the “fit” between the intervention and the context is critical in determining the success of implementation. Conclusions This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here. Systematic review registration PROSPERO CRD42014009410 Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0396-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rosa Lau
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, Upper 3rd floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
| | - Fiona Stevenson
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, Upper 3rd floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Bie Nio Ong
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Krysia Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Hazel Everitt
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anne Kennedy
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Nadeem Qureshi
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Anne Rogers
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | | | - Elizabeth Murray
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, Upper 3rd floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
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150
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Abele P, Morley JE. Advance Directives: The Key to a Good Death? J Am Med Dir Assoc 2016; 17:279-83. [PMID: 26952570 DOI: 10.1016/j.jamda.2016.01.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Patricia Abele
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St Louis, MO
| | - John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St Louis, MO; Division of Endocrinology, Saint Louis University School of Medicine, St Louis, MO.
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