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McMahan RD, Hickman SE, Sudore RL. What Clinicians and Researchers Should Know About the Evolving Field of Advance Care Planning: a Narrative Review. J Gen Intern Med 2024; 39:652-660. [PMID: 38169025 PMCID: PMC10973287 DOI: 10.1007/s11606-023-08579-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
Advance care planning (ACP) has been recognized as crucial by patients, families, and clinicians; however, different definitions and measurements have led to inconsistencies in practice and mixed evidence in the literature. This narrative review explores ACP's evolution, innovations, and outcomes using thematic analysis to synthesize data from randomized controlled trials, reviews, and editorials. Key findings include (1) ACP has evolved over the past several decades from a sole focus on code status and advance directive (AD) forms to a continuum of care planning over the life course focused on tailored preparation for patients and surrogate decision-makers and (2) ACP measurement has evolved from traditional outcome metrics, such as AD completion, to a comprehensive outcomes framework that includes behavior change theory, systems, implementation science, and a focus on surrogate outcomes. Since the recent development of an ACP consensus definition and outcomes framework, high-quality trials have reported mainly positive outcomes for interventions, especially for surrogates, which aligns with the patient desire to relieve decision-making burden for loved ones. Additionally, measurement of "clinically meaningful" ACP information, including documented goals of care discussions, is increasingly being integrated into electronic health records (EHR), and emerging, real-time assessments and natural language processing are enhancing ACP evaluation. To make things easier for patients, families, and care teams, clinicians and researchers can use and disseminate these evolved definitions; provide patients validated, easy-to-use tools that prime patients for conversations and decrease health disparities; use easy-to-access clinician training and simple scripts for interdisciplinary team members; and document patients' values and preferences in the medical record to capture clinically meaningful ACP so this information is available at the point of care. Future efforts should focus on efficient implementation, expanded reimbursement options, and seamless integration of EHR documentation to ensure ACP's continued evolution to better serve patients and their care partners.
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Affiliation(s)
- Ryan D McMahan
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Veterans Administration Medical Center, San Francisco, CA, USA.
| | - Susan E Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
- Indiana University Center for Aging Research, Regenstrief Institute Inc, Indianapolis, IN, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Veterans Administration Medical Center, San Francisco, CA, USA
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2
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Hughes B, Philips M, Holme V. Understanding advance care planning for children and young people: a survey of health professionals. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:786-792. [PMID: 37682768 DOI: 10.12968/bjon.2023.32.16.786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
BACKGROUND A range of polices, documentation, and practices are associated with advance care planning. However, there is a shortage of research to understand advance care planning from a professional viewpoint. AIMS To explore the views and experiences of health professionals of the advance care planning process with children and young people. METHODS An online questionnaire was used to collect data, which were analysed thematically. FINDINGS Key findings related to barriers and facilitators to initiating and documenting advance care planning: understanding the process and the condition of the patient; how advance care planning works in practice; and access to relevant, affordable training options. CONCLUSION Additional training and standardised documentation can help support the initiation and use of advance care planning, reduce misperceptions, and generate greater confidence in participating in the process. A larger multidisciplinary team, with better communication, will support improved relationships between professionals which will filter down to the families.
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Affiliation(s)
- Ben Hughes
- Lecturer, Faculty of Health and Wellbeing, University of Bolton
| | - Matthew Philips
- Paediatric Registrar ST7, Royal Blackburn Teaching Hospital, East Lancashire Hospitals NHS Trust
| | - Vanessa Holme
- Consultant Paediatrician, East Lancashire Hospitals NHS Trust
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3
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Waseem H, Keegan J, Farrell K, Hwang DY, Oliver B, Olm-Shipman C, Pepin R, Mecchella J. Implementation of a Standardized Shared Decision-making Bundle to Improve Communication Practices in the Neurocritical Care Unit. Neurol Clin Pract 2023; 13:e200120. [PMID: 36865641 PMCID: PMC9973293 DOI: 10.1212/cpj.0000000000200120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/01/2022] [Indexed: 01/19/2023]
Abstract
Background and Objective Shared decision-making (SDM) aligns patient preferences with health care team treatment goals. This quality improvement initiative implemented a standardized SDM bundle within a neurocritical care unit (NCCU), where unique demands make existing, provider-driven SDM practices challenging. Methods An interprofessional team defined key issues, identified barriers, and created change ideas to drive implementation of an SDM bundle using the Institute for Healthcare Improvement Model for Improvement framework incorporating Plan-Do-Study-Act cycles. The SDM bundle included (1) a health care team huddle pre-SDM and post-SDM conversation; (2) a social worker-driven SDM conversation with the patient family, including core standardized communication elements to ensure consistency and quality; and (3) an SDM documentation tool within the electronic medical record to ensure the SDM conversation was accessible to all health care team members. The primary outcome measure was percentage of SDM conversations documented. Results Documentation of SDM conversations improved by 56%, from 27% to 83% pre/postintervention. Average time to documentation decreased by 4 days, from day 9 preintervention to day 5 postintervention. There was no significant change in NCCU length of stay, nor did palliative care consultation rates increase. Postintervention, SDM team huddle compliance was 94.3%. Discussion A team-driven, standardized SDM bundle that integrates with health care team workflows enabled SDM conversations to occur earlier and resulted in improved documentation of SDM conversations. Team-driven SDM bundles have the potential to improve communication and promote early alignment with patient family goals, preferences, and values.
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Affiliation(s)
- Hena Waseem
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - Joshua Keegan
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - Kelly Farrell
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - David Y Hwang
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - Brant Oliver
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - Casey Olm-Shipman
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - Renee Pepin
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - John Mecchella
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
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4
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van der Velden NCA, Smets EMA, Hagedoorn M, Applebaum AJ, Onwuteaka-Philipsen BD, van Laarhoven HWM, Henselmans I. Patient-Caregiver Dyads' Prognostic Information Preferences and Perceptions in Advanced Cancer. J Pain Symptom Manage 2023; 65:442-455.e2. [PMID: 36731806 DOI: 10.1016/j.jpainsymman.2023.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/04/2023]
Abstract
CONTEXT Prognostic information is considered important for advanced cancer patients and primary informal caregivers to prepare for the end of life. Little is known about discordance in patients' and caregivers' prognostic information preferences and prognostic perceptions, while such discordance complicates adaptive dyadic coping, clinical interactions and care plans. OBJECTIVES To investigate the extent of patient-caregiver discordance in prognostic information preferences and perceptions, and the factors associated with discordant prognostic perceptions. METHODS We conducted secondary analyses of a cross-sectional study (PROSPECT, 2019-2021). Advanced cancer patients (median overall survival ≤12 months) from seven Dutch hospitals and caregivers completed structured surveys (n = 412 dyads). RESULTS Seven percent of patient-caregiver dyads had discordant information preferences regarding the likelihood of cure; 24%-25% had discordant information preferences regarding mortality risk (5/2/1 year). Seventeen percent of dyads had discordant perceptions of the likelihood of cure; 12%-25% had discordant perceptions of mortality risk (5/2/1 year). Dyads with discordant prognostic information preferences (P < 0.05) and dyads in which patients reported better physical functioning (P < 0.01) were significantly more likely to perceive the one-year mortality risk discordantly. CONCLUSION Physicians should be sensitive to discordant prognostic information preferences and prognostic perceptions among patient-caregiver dyads in advanced cancer care.
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Affiliation(s)
- Naomi C A van der Velden
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam (N.C.A.V., E.M.A.S, I.H.), Amsterdam, The Netherlands; Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands.
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam (N.C.A.V., E.M.A.S, I.H.), Amsterdam, The Netherlands; Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands
| | - Mariët Hagedoorn
- Department of Health Psychology, University Medical Center Groningen, University of Groningen (M.H), The Netherlands
| | - Allison J Applebaum
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center (A.J.A), New York, New York, USA
| | - Bregje D Onwuteaka-Philipsen
- Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC location Vrije Universiteit Amsterdam (B.D.O-P, I.H.), Amsterdam, The Netherlands
| | - Hanneke W M van Laarhoven
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands; Department of Medical Oncology, Amsterdam UMC location University of Amsterdam (H.W.M.L), Amsterdam, The Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam (N.C.A.V., E.M.A.S, I.H.), Amsterdam, The Netherlands; Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands
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Guccione L, Fullerton S, Gough K, Hyatt A, Tew M, Aranda S, Francis J. Why is advance care planning underused in oncology settings? A systematic overview of reviews to identify the benefits, barriers, enablers, and interventions to improve uptake. Front Oncol 2023; 13:1040589. [PMID: 37188202 PMCID: PMC10175822 DOI: 10.3389/fonc.2023.1040589] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/24/2023] [Indexed: 05/17/2023] Open
Abstract
Background Advance care planning (ACP) centres on supporting people to define and discuss their individual goals and preferences for future medical care, and to record and review these as appropriate. Despite recommendations from guidelines, rates of documentation for people with cancer are considerably low. Aim To systematically clarify and consolidate the evidence base of ACP in cancer care by exploring how it is defined; identifying benefits, and known barriers and enablers across patient, clinical and healthcare services levels; as well as interventions that improve advance care planning and are their effectiveness. Methods A systematic overview of reviews was conducted and was prospectively registered on PROSPERO. PubMed, Medline, PsycInfo, CINAHL, and EMBASE were searched for review related to ACP in cancer. Content analysis and narrative synthesis were used for data analysis. The Theoretical Domains Framework (TDF) was used to code barriers and enablers of ACP as well as the implied barriers targeted by each of the interventions. Results Eighteen reviews met the inclusion criteria. Definitions were inconsistent across reviews that defined ACP (n=16). Proposed benefits identified in 15/18 reviews were rarely empirically supported. Interventions reported in seven reviews tended to target the patient, even though more barriers were associated with healthcare providers (n=40 versus n=60, respectively). Conclusion To improve ACP uptake in oncology settings; the definition should include key categories that clarify the utility and benefits. Interventions need to target healthcare providers and empirically identified barriers to be most effective in improving uptake. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?, identifier CRD42021288825.
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Affiliation(s)
- Lisa Guccione
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
- *Correspondence: Lisa Guccione,
| | - Sonia Fullerton
- Sir Peter MacCallum Department of Oncology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
- Department of Oncology, Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Karla Gough
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Amelia Hyatt
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
- School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Michelle Tew
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Sanchia Aranda
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Jill Francis
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
- School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
- Ottawa Hospital research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
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Zhu Y, Olchanski N, Cohen JT, Freund KM, Faul JD, Fillit HM, Neumann PJ, Lin PJ. Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life. J Alzheimers Dis 2023; 96:1183-1193. [PMID: 37955089 PMCID: PMC10777481 DOI: 10.3233/jad-230692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits. OBJECTIVE This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia. METHODS This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions. RESULTS Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences. CONCLUSIONS Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.
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Affiliation(s)
- Yingying Zhu
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Natalia Olchanski
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Joshua T. Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Karen M. Freund
- Center for Health Equity Research, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Jessica D. Faul
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | | | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Pei-Jung Lin
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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Fenton ATHR, Fletcher KM, Kizildag D, Borstelmann NA, Kessler D, Cronin C, Revette AC, Wright AA, Frank E, Enzinger AC. Cancer Caregivers' Prognostic and End-of-Life Communication Needs and Experiences and their Impact. J Pain Symptom Manage 2023; 65:16-25. [PMID: 36198337 PMCID: PMC9790036 DOI: 10.1016/j.jpainsymman.2022.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/20/2022] [Accepted: 09/27/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Family caregivers of patients with advanced cancer are integrally involved in communications regarding prognosis and end-of-life (EOL) planning and care. Yet little research has examined caregivers' communication experiences or the impact of these experiences on patients and caregivers at EOL. OBJECTIVES Investigate cancer caregivers' communication experiences and potential impact on patient and caregiver outcomes. METHODS Semistructured interviews with bereaved family cancer caregivers (N=19) about their communication needs and experiences as their loved one approached EOL and died. Audiotaped interviews were transcribed and thematically analyzed for communication-related themes. RESULTS Caregivers described fulfilling many important communication roles including information gathering and sharing, advocating, and facilitating-often coordinating communication with multiple partners (e.g., patient, family, oncology team, hospital team). Caregivers reported that, among the many topics they communicated about, prognosis and EOL were the most consequential and challenging. These challenges arose for several reasons including caregivers' and patients' discordant communication needs, limited opportunity for caregivers to satisfy their personal communication needs, uncertainty regarding their communication needs and responsibilities, and feeling unacknowledged by the care team. These challenges negatively impacted caregivers' abilities to satisfy their patient-related communication responsibilities, which shaped many outcomes including end-of-life decisions, care satisfaction, and bereavement. CONCLUSION Caregivers often facilitate essential communication for patients with advanced cancers yet face challenges successfully fulfilling their own and patients' communication needs, particularly surrounding prognostic and end-of-life conversations. Future research and interventions should explore strategies to help caregivers navigate uncertainty, create space to ask sensitive questions, and facilitate patient-caregiver discussions about differing informational needs.
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Affiliation(s)
| | | | - Deniz Kizildag
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | | | - Anna C Revette
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alexi A Wright
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
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Skolarus LE, Lin CC, Kelley AS, Burke JF. National End-of-Life-Treatment Preferences are Stable Over Time: National Health and Aging Trends Study. J Pain Symptom Manage 2022; 64:e189-e194. [PMID: 35764201 DOI: 10.1016/j.jpainsymman.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/21/2022]
Abstract
CONTEXT Advance Care Planning is a process of understanding and sharing preferences regarding future medical care. OBJECTIVE To explore individual and national stability of end-of-life treatment preferences among a sample of older adults. METHODS National Health and Aging Trends Study is a nationally representative sample of older adults. In 2012, a random sample, and in 2018, the entire sample were queried on end-of-life treatment preferences defined as acceptance or rejection of life prolonging treatment (LPT) if they had a serious illness and were at the end of their life and in severe pain or had severe disability. Using a cohort design, we explored individual trends in preferences for LPT among those with responses in both waves (pain scenario: N = 606, disability scenario: N = 628) and, using a serial cross-sectional design, national trends in LPT among the entire sample (1702 older adults in wave 2 and 4342 in wave 8). RESULTS In the cohort study, individual preferences were stable over time (overall percent agreement = 86% for disability and 76% for pain scenarios), particularly for older adults who would reject LPT in wave 2 (overall agreement 92% for disability and 86% for pain). In the serial cross-sectional study, national trends in preferences for receipt of LPT were stable over time in the pain (27.4% vs. 27.0%, P = 0.80) and disability (15.8% vs. 15.7%, P = 0.99) scenarios. CONCLUSIONS We found that national trends in preferences for end-of-life treatment did not substantially change over time and may be stable within individual older adults.
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Affiliation(s)
- Lesli E Skolarus
- Department of Neurology (L.E.S., C.C.L.), Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan, USA.
| | - Chun Chieh Lin
- Department of Neurology (L.E.S., C.C.L.), Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine (A.S.K.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J Peters VA Medical Center (A.S.K.), Bronx, New York, USA
| | - James F Burke
- Department of Neurology (J.F.B.), Health Services Research Program, Ohio State University, Columbus, Ohio, USA
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Fried TR. Giving up on the objective of providing goal-concordant care: Advance care planning for improving caregiver outcomes. J Am Geriatr Soc 2022; 70:3006-3011. [PMID: 35974460 PMCID: PMC9588724 DOI: 10.1111/jgs.18000] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/08/2022] [Accepted: 07/17/2022] [Indexed: 01/07/2023]
Abstract
The merits and effectiveness of advance care planning (ACP) continue to be debated a full 30 years after the passage of the Patient Self-Determination Act. This act gave patients the right to create advance directives, with the objective of ensuring that the care they received at the end of life was consistent with their preferences and goals. ACP has definitively moved beyond the completion of advance directives to encompass the identification of a healthcare agent and the facilitation of communication among patients, surrogates, and clinicians. Nonetheless, the provision of goal-concordant care remains a primary objective for ACP. This article argues that this cannot and should not be the objective for ACP. Patients' goals change, and the provision of goal-concordant care is sometimes incompatible with other critical determinants of appropriate care. Instead, ACP should focus on the objective of improving caregiver outcomes. Surrogate decision-making by caregivers is associated with an elevated risk of post-traumatic stress disorder and other adverse outcomes, and these outcomes can be improved with ACP. ACP focused on caregivers involves helping caregivers to understand how they can help to shape the final chapter in a patient's life story, preventing caregivers from making promises they cannot keep, and preparing them to use all relevant information at the time decisions need to be made.
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Affiliation(s)
- Terri R Fried
- Department of Medicine, Yale School of Medicine, and VA Connecticut Healthcare System, New Haven, Connecticut, USA
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10
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Diggle MFJ, Schutz S, Butcher D. Bereaved Caregivers' Experiences of End of Life Care For People With Advanced Heart Failure: A Narrative Synthesis. OMEGA-JOURNAL OF DEATH AND DYING 2022:302228221124636. [PMID: 36113134 DOI: 10.1177/00302228221124636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Heart Failure is a life-limiting condition with a poor and uniquely unpredictable prognosis. The aim of this review is to present and synthesise the current evidence around bereaved caregivers' experiences of end of life care for people with Heart Failure. METHODS A systematic review of the literature was conducted using four electronic databases (CINHAL, Medline, BND, PsycINFO). Data was analysed and presented using a narrative synthesis approach. RESULTS Eight articles were included within this review. Themes included: Limited and inadequate communication around the condition (including prognosis, preparations for death and the aim of palliative care), the burden of caregiving, and the limited provision of services and formal support. CONCLUSION Bereaved caregivers experience unique and significant challenges when caring for someone dying from Heart Failure. However, further research is required to greater understand the experiences of bereaved caregivers of people with Heart Failure.
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Affiliation(s)
- Melanie F J Diggle
- Oxford School of Nursing and Midwifery, Faculty of Health and Life Sciences, Oxford Brookes University, UK
| | - Sue Schutz
- Oxford School of Nursing and Midwifery, Faculty of Health and Life Sciences, Oxford Brookes University, UK
| | - Dan Butcher
- Oxford School of Nursing and Midwifery, Faculty of Health and Life Sciences, Oxford Brookes University, UK
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Ishibashi T, Kazawa K, Jahan Y, Moriyama M. Factors That Facilitate Discussion and Documentation of End-of-Life Care among Community-Dwelling Older Adults: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074273. [PMID: 35409955 PMCID: PMC8998236 DOI: 10.3390/ijerph19074273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 12/10/2022]
Abstract
We aimed to clarify the regional cultural characteristics in areas with different death rates at home, and to identify factors that influence the discussion and documentation of end-of-life care (EOLC) among community-dwelling older adults. This study was a cross-sectional study using a self-administered questionnaire survey, and participants were Japanese older adults. A chi-square test and multiple regression analysis were conducted. Among the 227 respondents, 143 were analyzed. There were no statistical differences by area. Participants who had intentions to discuss EOLC tended to discuss EOLC with their families and family doctors and tended to create documents to show their wills on EOLC (p < 0.05). The following factors that influence the intentions to discuss EOLC were extracted: experience in providing EOLC; information on EOLC; having religious and spiritual beliefs, and not avoiding the subject of death as part of beliefs related to life and death. These results indicate that beliefs and intentions regarding EOLC may be similar across Japan. Moreover, our findings suggest that to increase the interest of older adults on EOLC, it is important to provide opportunities for older adults to share and discuss information about EOLC with healthcare professionals and others who have experience providing EOLC.
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Affiliation(s)
- Tomoyuki Ishibashi
- Division of Nursing Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (T.I.); (Y.J.); (M.M.)
| | - Kana Kazawa
- Department of Medicine for Integrated Approach to Social Inclusion, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan
- Correspondence:
| | - Yasmin Jahan
- Division of Nursing Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (T.I.); (Y.J.); (M.M.)
| | - Michiko Moriyama
- Division of Nursing Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (T.I.); (Y.J.); (M.M.)
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12
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Waldrop DP, McGinley JM. Beyond Advance Directives: Addressing Communication Gaps and Caregiving Challenges at Life's End. J Pain Symptom Manage 2022; 63:415-422. [PMID: 34662723 DOI: 10.1016/j.jpainsymman.2021.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/24/2021] [Accepted: 09/30/2021] [Indexed: 11/23/2022]
Abstract
CONTEXT The premise of advance directives and care planning is to help people articulate and document their wishes so surrogate decision-makers and providers can honor them. However, beyond the completion of such a document, underlying challenges are often unaddressed OBJECTIVES: The overall purpose of the study was to investigate how communication, including but not limited to the completion of advance directives, and caregiving influenced family caregivers' experiences. Communication gaps and caregiving challenges that were unaddressed by advance directives are presented. METHODS Non-dominant simultaneous mixed-methods (QUAL-QUAN) were used to explore how end-of-life events influenced family caregivers. In-depth interviews were conducted with 108 caregivers about 4 months following the death of a family member who was in hospice care. RESULTS A majority (n = 90; 84.9%) had specific wishes about end-of-life treatment. Patients had a completed: Health Care Proxy-101 (93.3%); Living Will-43 (39.8%); Do Not Resuscitate orders (DNR)-82 (75.9%) and Medical Orders for Life Sustaining Treatment-40 (37%). A majority (n = 83; 76.9%) of caregivers said that they had "enough" or "just the right amount" of information to prepare for the patients' death. Five themes illustrated caregivers' experiences: Family Conflict; Patient/Family-Provider Conflict; Uncertainty, Caregiving Realities; Awareness-Avoidance of Dying. CONCLUSION A majority of had an advance directive, yet caregivers expressed feeling unprepared for decision-making, caregiving and discussing it with the dying person. The advance directive and care planning process fell short of providing needed communication, knowledge and preparation; it can be an opportunity for teaching, learning, preparing and supporting families at life's end.
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Affiliation(s)
- Deborah P Waldrop
- University at Buffalo School of Social Work (D.P.W.), Buffalo, New York, USA.
| | - Jacqueline M McGinley
- Binghamton University (J.M.M.), College of Community & Public Affairs, Department of Social Work, Binghamton, New York, USA
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13
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Serey K, Cambriel A, Pollina-Bachellerie A, Lotz JP, Philippart F. Advance Directives in Oncology and Haematology: A Long Way to Go-A Narrative Review. J Clin Med 2022; 11:jcm11051195. [PMID: 35268299 PMCID: PMC8911354 DOI: 10.3390/jcm11051195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 12/04/2022] Open
Abstract
Patients living with cancer often experience serious adverse events due to their condition or its treatments. Those events may lead to a critical care unit admission or even result in death. One of the most important but challenging parts of care is to build a care plan according to the patient’s wishes, meeting their goals and values. Advance directives (ADs) allow everyone to give their preferences in advance regarding life sustaining treatments, continuation, and withdrawal or withholding of treatments in case one is not able to speak their mind anymore. While the absence of ADs is associated with a greater probability of receiving unwanted intensive care around the end of their life, their existence correlates with the respect of the patient’s desires and their greater satisfaction. Although progress has been made to promote ADs’ completion, they are still scarcely used among cancer patients in many countries. Several limitations to their acceptance and use can be detected. Efforts should be made to provide tailored solutions for the identified hindrances. This narrative review aims to depict the situation of ADs in the oncology context, and to highlight the future areas of improvement.
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Affiliation(s)
- Kevin Serey
- Anesthesiology and Intensive Care Medicine Department, APHP—Ambroise Paré University Hospital, 92100 Boulogne-Billancourt, France;
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
| | - Amélie Cambriel
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Anesthesiology and Intensive Care Medicine Department, APHP—Tenon University Hospital, 75020 Paris, France
| | - Adrien Pollina-Bachellerie
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Anesthesiology and Intensive Care Medicine Department, Toulouse Hospitals, 31000 Toulouse, France
| | - Jean-Pierre Lotz
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Pôle Onco-Hématologie, Service D’oncologie Médicale et de Thérapie Cellulaire, APHP—Hôpitaux Universitaires de L’est Parisien, 75020 Paris, France
| | - François Philippart
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Medical and Surgical Intensive Care Department, Groupe Hospitalier Paris Saint Joseph, 185 Rue R. Losserand, 75674 Paris, France
- Correspondence: ; Tel.: +33-1-44-12-30-85
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14
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Motamedi M, Brandenburg C, Bakhit M, Michaleff ZA, Albarqouni L, Clark J, Ooi M, Bahudin D, Chróinín DN, Cardona M. Concerns and potential improvements in end-of-life care from the perspectives of older patients and informal caregivers: a scoping review. BMC Geriatr 2021; 21:729. [PMID: 34930177 PMCID: PMC8690959 DOI: 10.1186/s12877-021-02680-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/29/2021] [Indexed: 12/19/2022] Open
Abstract
Background Overtreatment in advanced age i.e. aggressive interventions that do not improve survival and are potentially harmful, can impair quality of care near the end of life (EOL). As healthcare provider perspectives on care quality may differ from that of service users, the aim of this study was to explore the views of older patients near EOL or their caregivers about the quality of health care at the EOL based on their lived experience, and to identify healthcare service improvements. Methods Medline and backward citation searches were conducted for qualitative or quantitative studies reported on the views of patients and/or informal caregivers about EOL care quality. Thematic analysis was used to summarise qualitative data (primary analysis); narrative and tabulations were used to summarise quantitative data (secondary analysis). Results Thirty articles met the inclusion criteria. Five main qualitative themes regarding quality care emerged: (1) Effective communication between clinicians and patients/caregivers; (2) Healthcare that values patient preferences and shared decision making; (3) Models of care that support quality of life and death with dignity; (4) Healthcare services that meet patient expectations; and (5) Support for informal caregivers in dealing with EOL challenges. The quantitative articles supported various aspects of the thematic framework. Conclusion The findings of this study show that many of the issues highlighted by patients or bereaved relatives have persisted over the past two decades. There is an urgent need for comprehensive evaluation of care across the healthcare system and targeted redesign of existing EOL care pathways to ensure that care aligns with what patients and informal caregivers consider high-quality patient-centred care at the EOL. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02680-2.
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Affiliation(s)
- Mina Motamedi
- Australian Centre for Health Engagement Evidence and Values (ACHEEV), University of Wollongong, Wollongong, NSW, Australia
| | - Caitlin Brandenburg
- Allied Health Services, Gold Coast University Hospital, Southport, QLD, Australia.,Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Mina Bakhit
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD, Australia
| | - Zoe A Michaleff
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD, Australia
| | - Loai Albarqouni
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD, Australia
| | - Justin Clark
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD, Australia
| | - Meidelynn Ooi
- Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Danial Bahudin
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Danielle Ní Chróinín
- Department of Geriatric Medicine, Liverpool Hospital, Liverpool, NSW, Australia.,South Western Sydney Clinical School, UNSW Sydney, Sydney, NSW, Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD, Australia. .,Bond EBP Professorial Unit, Gold Coast University Hospital, QLD, Southport, Australia.
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15
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Kotwal AA, Barnes DE, Volow A, Li B, Boscardin J, Sudore RL. Engaging Diverse Older Adults With Cognitive Impairment and Caregivers in Advance Care Planning: A Pilot Study of the Interactive PREPARE Website. Alzheimer Dis Assoc Disord 2021; 35:342-349. [PMID: 34310443 PMCID: PMC8604734 DOI: 10.1097/wad.0000000000000465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/05/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Engaging patients with cognitive impairment in advance care planning (ACP), including completing advance directives and naming health care proxies, before they lose decision-making capacity is important. METHODS We determined the feasibility of the PREPAREforYourCare.org ACP program among 20 diverse older adults with mild-to-moderate cognitive impairment and their caregivers in a 1-week, pre-post pilot. We examined ease-of-use, satisfaction, and feasibility using validated scales, and change in ACP Engagement scores, including knowledge, contemplation, self-efficacy, and readiness subscales (5-point scales), from baseline to 1-week. RESULTS Participants were on average 70 years old (SD=9.0), 45% Spanish-speaking, 60% had limited health literacy, and 15% felt comfortable using the internet. Patients and caregivers rated PREPARE a mean of 8.6 (SD=1.6) and 9.4 (SD=1.1) on the 10-point ease-of-use scale, 4.7 (SD=0.4) and 4.7 (SD=0.3) on the 5-point satisfaction scale, and 4.9 (SD=0.4) and 4.8 (SD=0.6) on the 5-point feasibility scale, respectively. ACP engagement scores increased for 16 of 20 (80%) patients (P=0.03) and 16 of 20 (80%) caregivers (P=0.18). Caregivers experienced increased knowledge (3.8 to 4.7, P=0.002) and self-efficacy (3.6 to 4.5, P=0.034) for ACP. DISCUSSION The PREPARE website was feasible and may facilitate ACP engagement among diverse older adults with cognitive impairment and their caregivers.
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Affiliation(s)
- Ashwin A. Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - Deborah E. Barnes
- Weill Institute for Neurosciences, Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Aiesha Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - Brookelle Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
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16
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Mah K, Swami N, O'Connor B, Hannon B, Rodin G, Zimmermann C. Early palliative intervention: effects on patient care satisfaction in advanced cancer. BMJ Support Palliat Care 2021; 12:218-225. [PMID: 33419858 DOI: 10.1136/bmjspcare-2020-002710] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/01/2020] [Accepted: 12/09/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE In a cluster-randomised controlled trial of early palliative care (EPC) in advanced cancer, EPC was robustly associated with increased patient satisfaction with care. The present study evaluated mediational mechanisms underlying this EPC effect, including improved physical and psychological symptoms and quality of life, as well as relationships with healthcare providers and preparation for end of life. METHOD Participants with advanced cancer (n=461) completed measures at baseline and then monthly to 4 months. Mediational analyses, using a robust bootstrapping approach, focused on 3-month and 4-month follow-up data. RESULTS At 3 months, EPC decreased psychological symptoms, which resulted in greater satisfaction either directly (βindirect effect=0.05) or through greater quality of life (βindirect effect=0.02). At 4 months, EPC increased satisfaction through improved quality of life (βindirect effect=0.08). Physical symptom management showed no significant mediational effects at either time point. Better relationships with healthcare providers consistently mediated the EPC effect on patient satisfaction at 3 and 4 months, directly (βindirect effect=0.13-0.16) and through reduced psychological symptoms and/or improved quality of life (βindirect effect=0.00-0.02). At 4 months, improved preparation for end-of-life mediated EPC effects on satisfaction by enhancing quality of life (βindirect effect=0.01) or by reducing psychological symptoms and thereby increasing quality of life (βindirect effect=0.02). CONCLUSION EPC increases satisfaction with care in advanced cancer by attending effectively to patients' emotional distress and quality of life, enhancing collaborative relationships with healthcare providers, and addressing concerns about preparation for end-of-life. TRIAL REGISTRATION NUMBER NCT01248624.
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Affiliation(s)
- Kenneth Mah
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Brenda O'Connor
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada .,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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17
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Cipolletta S, Reggiani M. End-of-life care after the legal introduction of advance directives: A qualitative study involving healthcare professionals and family caregivers of patients with amyotrophic lateral sclerosis. Palliat Med 2021; 35:209-218. [PMID: 33112196 DOI: 10.1177/0269216320967280] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Advance care planning and advance directives play a key role in the care of life-threatening illnesses such as amyotrophic lateral sclerosis. AIM The aim of the present study is to explore how the introduction of these features by law improves the experience of end-of-life care. DESIGN Five focus groups were conducted in Italy 1 year after the new law on advance directives was introduced. SETTING/PARTICIPANTS Purposive sampling was used to recruit 24 health professionals and 23 family caregivers of patients with amyotrophic lateral sclerosis, for a total of 47 participants. RESULTS The thematic analysis, conducted through the use of ATLAS.ti software, identified four thematic areas: best practices, managing difficulties, care relationships and proposals. The results indicated a lack of organization, collaboration and continuity on the part of healthcare services and professionals, a lack of information on palliative care, advance care planning, and advance directives. End-of-life care is often left to the good will of the individual professional. Difficulties can also derive from ethical dilemmas concerning end-of-life decision-making and from a lack of communication and relationships between health professionals, patients and their families. CONCLUSION The introduction of advance directives by law has not been sufficient to improve end-of-life care. In order to make legal regulation effective, the organization of healthcare services needs to be improved and clearer procedures have to be implemented and shared with patients and families.
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Rodi H, Detering K, Sellars M, Macleod A, Todd J, Fullerton S, Waller A, Nolte L. Exploring advance care planning awareness, experiences, and preferences of people with cancer and support people: an Australian online cross-sectional study. Support Care Cancer 2020; 29:3677-3688. [DOI: 10.1007/s00520-020-05878-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/05/2020] [Indexed: 01/05/2023]
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19
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Iglesias K, Busnel C, Dufour F, Pautex S, Séchaud L. Nurse-led patient-centred intervention to increase written advance directives for outpatients in early-stage palliative care: study protocol for a randomised controlled trial with an embedded explanatory qualitative study. BMJ Open 2020; 10:e037144. [PMID: 32958487 PMCID: PMC7511622 DOI: 10.1136/bmjopen-2020-037144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Discussing the evolution of life-threatening diseases and end-of-life issues remains difficult for patients, relatives and professionals. Helping people discuss and formalise their preferences in end-of-life care, as planned in the Go Wish intervention, could reduce health-related anxiety in the advance care planning (ACP) and advance directive (AD) process. The aims of this study are (1) to test the effectiveness of the Go Wish intervention among outpatients in early-stage palliative care and (2) to understand the role of defence mechanisms in end-of-life discussions among nurses, patients and relatives. METHODS AND ANALYSIS A mixed-methods study will be performed. A cluster randomised controlled trials with three parallel arms will be conducted with 45 patients with chronic progressive diseases impacting life expectancy in each group: (1) Group A, Go Wish intervention for patients and their relatives; (2) Group A, Go Wish intervention for patients alone and (3) Group B, for patients (with a waiting list), who will receive the standardised information on ADs (usual care). Randomisation will be at the nurse level as each patient is referred to one of the 20 participating nurses (convenience sample of 20 nurses). A qualitative study will be conducted to understand the cognitive and emotional processes and experiences of nurses, patients and relatives confronted with end-of-life discussions. The outcome measurements include the completion of ADs (yes/no), anxiety, quality of communication about end-of-life care, empowerment, quality of life and attitudes towards ADs. ETHICS AND DISSEMINATION The study protocol has been approved by the Human Research Ethics Committee of the Canton of Geneva, Switzerland (no. 2019-00922). The findings will be disseminated to practice (nurses, patients and relatives), to national and international scientific conferences, and peer-reviewed journals covering nursing science, psychology and medicine. TRIAL REGISTRATION NUMBER NCT04065685.
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Affiliation(s)
- Katia Iglesias
- School of Health Sciences (HEdS-FR), HES-SO University of Applied Sciences and Arts Western Switzerland, Friourg, Switzerland
| | - Catherine Busnel
- Geneva Institution for Homecare and Assistance (imad), Geneva, Switzerland
| | - Florian Dufour
- School of Management and Engineering Vaud (HEIG-VD), HES-SO University of Applied Sciences and Arts Western Switzerland, Yverdon, Switzerland
| | - Sophie Pautex
- Division of Palliative Medicine, Department of rehabilitation and geriatrics, University Hospitals Geneva, Geneva, Switzerland
| | - Laurence Séchaud
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
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20
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Houchens N, Gupta A. Quality and safety in the literature: September 2020. BMJ Qual Saf 2020; 29:780-784. [DOI: 10.1136/bmjqs-2020-011887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 06/27/2020] [Indexed: 11/04/2022]
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21
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Resick JM, Arnold RM, Sudore RL, Farrell D, Belin S, Althouse AD, Ferrell B, Hammes BJ, Chu E, White DB, Rak KJ, Schenker Y. Patient-centered and efficacious advance care planning in cancer: Protocol and key design considerations for the PEACe-compare trial. Contemp Clin Trials 2020; 96:106071. [PMID: 32739493 PMCID: PMC7510772 DOI: 10.1016/j.cct.2020.106071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/05/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Failure to deliver care near the end of life that reflects the needs, values and preferences of patients with advanced cancer remains a major shortcoming of our cancer care delivery system. METHODS A mixed-methods comparative effectiveness trial of in-person advance care planning (ACP) discussions versus web-based ACP is currently underway at oncology practices in Western Pennsylvania. Patients with advanced cancer and their caregivers are invited to enroll. Participants are randomized to either (1) in-person ACP discussions via face-to-face visits with a nurse facilitator following the Respecting Choices® Conversation Guide or (2) web-based ACP using the PREPARE for your care™ web-based ACP tool. The trial compares the effect of these two interventions on patient and family caregiver outcomes (engagement in ACP, primary outcome; ACP discussions; advance directive (AD) completion; quality of end-of-life (EOL) care; EOL goal attainment; caregiver psychological symptoms; healthcare utilization at EOL) and assesses implementation costs. Factors influencing ACP effectiveness are assessed via in-depth interviews with patients, caregivers and clinicians. DISCUSSION This trial will provide new and much-needed empirical evidence about two patient-facing ACP approaches that successfully overcome limitations of traditional written advance directives but entail very different investments of time and resources. It is innovative in using mixed methods to evaluate not only the comparative effectiveness of these approaches, but also the contexts and mechanisms influencing effectiveness. Data from this study will inform clinicians, payers and health systems seeking to adopt and scale the most effective and efficient ACP strategy in real-world oncology settings.
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Affiliation(s)
- Judith M Resick
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Robert M Arnold
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA; San Francisco Veterans Affairs Health Care System, SFVAMC 4150 Clement Street, #151R, San Francisco, CA 94121, USA.
| | - David Farrell
- People Designs, Inc., 1304 Broad Street, Durham, NC 27705, USA.
| | - Shane Belin
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Andrew D Althouse
- Center for Research on Health Care Data Center, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Suite 300, Pittsburgh, PA 15213, USA.
| | - Betty Ferrell
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope Medical Center, 1500 Duarte Road, Duarte, CA 91010, USA.
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, PO Box 258, Oregon, WI 53575-0258, USA.
| | - Edward Chu
- Department of Medicine, Division of Hematology-Oncology and Cancer Therapeutics Program, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Douglas B White
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, USA.
| | - Kimberly J Rak
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 3520 Fifth Ave, Suite100, Pittsburgh, PA 15213, USA.
| | - Yael Schenker
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
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Nagelschmidt K, Leppin N, Seifart C, Rief W, von Blanckenburg P. Systematic mixed-method review of barriers to end-of-life communication in the family context. BMJ Support Palliat Care 2020; 11:253-263. [DOI: 10.1136/bmjspcare-2020-002219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 11/03/2022]
Abstract
BackgroundCommunication about the end of life is especially important in the family context, as patients and their families are considered as the care unit in palliative care. Open end-of-life communication can positively affect medical, psychological and relational outcomes during the dying process for patient and family. Regardless of the benefits of end-of-life conversations, many patients and their family caregivers speak little about relevant end-of-life issues.AimTo identify barriers that hinder or influence the discussion of end-of-life issues in the family context.DesignA systematic mixed-method review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.Data sourcesA systematic search of PsycInfo, CINAHL, PubMed and Web of Science was conducted and extended with a hand search. Peer-reviewed primary studies reporting on the barriers to or difficulties in end-of-life conversations experienced by terminally ill patients and/or family caregivers were included in this review.Results18 qualitative and two quantitative studies met the inclusion criteria. The experiences of n=205 patients and n=738 family caregivers were analysed qualitatively; n=293 patients and n=236 caregivers were surveyed in the questionnaire studies. Five overarching categories emerged from the extracted data: emotional, cognitive, communicative, relational and external processes can hinder end-of-life communication within the family. The most frequently reported barriers are emotional and cognitive processes such as protective buffering or belief in positive thinking.ConclusionsResearch on end-of-life communication barriers in the family context is scarce. Further research should enhance the development of appropriate assessment tools and interventions to support families with the challenges experienced regarding end-of-life conversations.
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Miyashita J, Kohno A, Cheng SY, Hsu SH, Yamamoto Y, Shimizu S, Huang WS, Kashiwazaki M, Kamihiro N, Okawa K, Fujisaki M, Tsai JS, Fukuhara S. Patients' preferences and factors influencing initial advance care planning discussions' timing: A cross-cultural mixed-methods study. Palliat Med 2020; 34:906-916. [PMID: 32356489 DOI: 10.1177/0269216320914791] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although advance care planning discussions are increasingly accepted worldwide, their ideal timing is uncertain and cultural factors may pertain. AIM To evaluate timing and factors affecting initiation of advance care planning discussions for adult patients in Japan and Taiwan. DESIGN Mixed-methods questionnaire survey to quantitatively determine percentages of patients willing to initiate advance care planning discussions at four stages of illness trajectory ranging from healthy to undeniably ill, and to identify qualitative perceptions underlying preferred timing. SETTING/PARTICIPANTS Patients aged 40-75 years visiting outpatient departments at four Japanese and two Taiwanese hospitals were randomly recruited. RESULTS Overall (of 700 respondents), 72% (of 365) in Japan and 84% (of 335) in Taiwan (p < 0.001) accepted discussion before illness. In Japan, factors associated with willingness before illness were younger age and rejection of life-sustaining treatments; in Taiwan, older age, stronger social support, and rejection of life-sustaining treatments. Four main categories of attitudes were extracted: the most common welcomed discussion as a wise precaution, responses in this first category outnumbered preference for postponement of discussion until imminent end of life, acceptance of the universal inevitability of death, and preference for discussion at healthcare providers' initiative. CONCLUSION The majority of patients are willing to begin discussion before their health is severely compromised; about one out of five patients are unwilling to begin until clearly facing death. To promote advance care planning, healthcare providers must be mindful of patients' preferences and factors associated with acceptance and reluctance to initiate advance care planning.
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Affiliation(s)
- Jun Miyashita
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ayako Kohno
- Department of Health Informatics, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Su-Hsuan Hsu
- Department of Family Medicine, Taipei City Hospital, Taipei, Taiwan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sayaka Shimizu
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Wei-Sheng Huang
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | | | - Noriki Kamihiro
- The Kansai Centre for Family Medicine, Kanai Hospital, Kyoto, Japan
| | - Kaoru Okawa
- Department of Home Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Masami Fujisaki
- Department of General Medicine, Medical Center Narita Hospital, Chiba, Japan
| | - Jaw-Shiun Tsai
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Shunichi Fukuhara
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Levoy K, Buck H, Behar-Zusman V. The Impact of Varying Levels of Advance Care Planning Engagement on Perceptions of the End-of-Life Experience Among Caregivers of Deceased Patients With Cancer. Am J Hosp Palliat Care 2020; 37:1045-1052. [PMID: 32281390 DOI: 10.1177/1049909120917899] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Advance care planning (ACP) is used to prepare patients and caregivers for future "in the moment" decisions at the end-of-life. Patients with cancer generally do not engage in all 3 components of ACP (documented living will, health-care surrogate, end-of-life discussions); however, little is known about the impact of these varying levels of ACP engagement on caregivers postdeath. OBJECTIVE To examine the relationship between varying levels of ACP engagement and caregivers' perceptions of cancer decedents' end-of-life experiences. METHODS A secondary analysis of the 2002 to 2014 waves of the Health and Retirement Study data using structural equation modeling was conducted. Five levels of ACP engagement were defined: full (discussions/documents), augmented discussions, documents only, discussions only, and no engagement. RESULTS Among the 2172 cancer death cases, the analyzed sample included 983 cases where end-of-life decisions occurred. Compared to no ACP, all levels of ACP were significantly associated with caregivers' positive perceptions of cancer decedents' end-of-life experiences (P ≤ .001), controlling for sex, race, and Hispanic ethnicity (R 2 = .21). However, the relative impact of each level of ACP engagement was not equal; full engagement (β = .61) was associated with a greater impact compared to each of the partial levels of engagement (augmented discussions [β = .33], documents only [β = .17], discussions only [β = .17]). CONCLUSION Partial ACP engagement, not just nonengagement, serves as an important clinically modifiable target to improve the end-of-life care experience among patients with cancer and the perceptions of those experiences among bereaved caregivers.
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Affiliation(s)
- Kristin Levoy
- NewCourtland Center for Transitions and Health, 6572University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Harleah Buck
- 7831University of South Florida College of Nursing, Tampa, FL, USA
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Dang MTT, Ahmed Z, Betcher JM, Kadakia S, Wisniewski SJ, Sealey JW. Do Not Let it Be the Last: End-of-Life Care Decisions in the Primary Care Clinic. Spartan Med Res J 2019; 4:9204. [PMID: 33655164 PMCID: PMC7746112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/15/2019] [Indexed: 09/16/2024] Open
Abstract
CONTEXT For many patients, end-of-life care (EOLC) wishes are unknown and are generally only brought up during healthcare crises. During such healthcare episodes, loved ones are often distraught, and as such, can find it difficult to focus on details surrounding the event. The best place for these discussions may be in non-acute settings including primary care clinics. The purpose of this study was to examine how well a sample of patients (N = 177) in three Michigan-based primary care teaching clinics thought they and their loved ones were prepared in terms of having their EOLC wishes known. METHODS Prospective data were collected from three Internal Medicine teaching clinics in the Metro-Detroit area through an anonymous written survey addressing EOLC issues in a 16-item cross-sectional study. Respondents were adult patients at one of three participating primary care clinics. Perceived preparedness for EOLC was measured by: 1) possibly having had a prior EOLC discussion with a healthcare provider 2) having created an Advance Directive, such as a Durable Power of Attorney (DPOA) or Living Will with medical decision preferences, 3) reported preferences for quality versus quantity of life, and 4) preferences for CPR and other specific life-sustaining interventions. RESULTS In this sample, 77 (43.5%) of 177 respondents had discussed their EOLC wishes with a provider. Regarding Advance Directives, 63/177 (35.6%) had established a DPOA, and 59/177 (22%) had made a Living Will. The majority of respondents preferred quality over quantity of life. The most difficult EOLC questions included the decision for CPR, tracheostomy, and PEG tube placement. CONCLUSIONS Based on these results, EOLC discussions probably occur infrequently in the primary care or other healthcare settings. Most survey responses indicated that sample patients were unprepared concerning the details of future EOLC decisions. Engagement of such discussions should be a part of routine visits in the primary care clinic and should be re-visited when there is a change in a patient's health. Further larger-scale studies using validated surveys are required in this vitally important area of practice. Key Words: advance care planning, end-of-life care conversations, primary care.
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Affiliation(s)
| | - Zohair Ahmed
- Authority Health, Department of Internal Medicine
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Schichtel M, Wee B, Perera R, Onakpoya I, Albury C, Barber S. Clinician-targeted interventions to improve advance care planning in heart failure: a systematic review and meta-analysis. Heart 2019; 105:1316-1324. [PMID: 31118199 DOI: 10.1136/heartjnl-2019-314758] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Advance care planning (ACP) is widely advocated to contribute to better outcomes for patients suffering from heart failure. But clinicians appear hesitant to engage with ACP. Our aim was to identify interventions with the greatest potential to engage clinicians with ACP in heart failure. METHODS A systematic review and meta-analysis. We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index and PsycINFO for randomised controlled trials (RCTs) from inception to January 2018. Three reviewers independently extracted data, assessed risk of bias (Cochrane risk of bias tool), the quality of evidence (GRADE) and intervention synergy according to Template for Intervention Description and Replication. ORs were calculated for pooled effects. RESULTS Of 14 175 articles screened, we assessed the full text of 131 studies. 13 RCTs including 3709 participants met all of the inclusion criteria. The intervention categories of patient-mediated interventions (OR 5.23; 95% CI 2.36 to 11.61), reminder systems (OR 3.65; 95% CI 1.47 to 9.04) and educational meetings (OR 2.35; 95% CI 1.29 to 4.26) demonstrated a favourable effect to engage clinicians with the completion of ACP. CONCLUSION The review provides evidence from 13 published RCTs and suggests that interventions that involve patients to change clinical practice, reminder systems and educational meetings have the greatest effect in improving the implementation of ACP in heart failure.
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Affiliation(s)
- Markus Schichtel
- Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Bee Wee
- Sir Michael Sobell House Study Centre, Oxford University Hospital Trust NHS, Oxford, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Charlotte Albury
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Barber
- Oxford Health NHS, Broadshires Health Centre, Carterton, Oxfordshire, UK
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Ingravallo F, de Nooijer K, Pucci V, Casini C, Miccinesi G, Rietjens JAC, Morino P. Discussions about palliative sedation in hospice: Frequency, timing and factors associated with patient involvement. Eur J Cancer Care (Engl) 2019; 28:e13019. [DOI: 10.1111/ecc.13019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 12/04/2018] [Accepted: 01/17/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Francesca Ingravallo
- Department of Medical and Surgical Sciences (DIMEC)University of Bologna Bologna Italy
| | - Kim de Nooijer
- Department of Public HealthErasmus University Medical Center Rotterdam the Netherlands
| | - Valentina Pucci
- Department of Medical and Surgical Sciences (DIMEC)University of Bologna Bologna Italy
| | - Cinzia Casini
- Palliative Care Coordination, Toscana Centrale Local Health TrustHospice Convento delle Oblate Florence Italy
| | - Guido Miccinesi
- Clinical Epidemiology UnitOncological network, prevention and research Institute (ISPRO) Florence Italy
| | - Judith A. C. Rietjens
- Department of Public HealthErasmus University Medical Center Rotterdam the Netherlands
| | - Piero Morino
- Palliative Care Coordination, Toscana Centrale Local Health TrustHospice Convento delle Oblate Florence Italy
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Bern-Klug M, Singh J, Liu J, Shinkunas L. Prospect Theory Concepts Applied to Family Members of Nursing Home Residents with Cancer: A Good Ending Is a Gain. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2019; 15:34-54. [PMID: 30892139 DOI: 10.1080/15524256.2019.1580242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Family members are often involved in medical decision-making on behalf of a nursing home resident. Prospect theory provides a framework for understanding how people weigh decisions. In the current study, prospect theory concepts are used to build understanding about how family members weigh medical decisions for an NH resident diagnosed with cancer. This is a secondary analysis of qualitative interview data from 24 family members of nursing home residents. Prospect theory concepts of gain, loss, risk, and reference point were used deductively in qualitative content analysis. Themes were developed by comparing content related to these four concepts, across the transcripts from the 24 participants. Three themes comprise the main findings, including "Don't prolong this," "A good ending is a gain," and "Experience can facilitate seeing the big picture." Prospect theory concepts applied to decisions faced by family members were useful in building an understanding of what participants considered as gains, losses, risks, and reference points. Many participants framed the medical decisions within the larger context of the resident's life and concluded that jeopardizing the chance for a peaceful dying process was too high a risk. Medical interventions were selected or avoided because of the impact on a comfortable dying process; considered a gain. Advance care planning discussions and goals of care discussions can benefit by directly addressing what residents/patients, families, and health practitioners consider outcomes worth pursuing and avoiding.
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Affiliation(s)
| | - Jaswinder Singh
- b Mercy Medical Center , Nurse Intern , Des Moines , Iowa , USA
| | - Jinyu Liu
- c Social Work , Columbia University , New York , New York , USA
| | - Laura Shinkunas
- d Program in Bioethics and Humanities, Carver College of Medicine , University of Iowa , Iowa City , Iowa , USA
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Schubart JR, Reading JM, Penrod J, Stewart RR, Sampath R, Lehmann LS, Levi BH, Green MJ. Family Caregivers' Characterization of Conversations Following an ACP Event. Am J Hosp Palliat Care 2018; 35:1161-1167. [PMID: 30071784 DOI: 10.1177/1049909118760302] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) has been shown to benefit patients and families, yet little is known about how an ACP event impacts communication and conversation about end-of-life treatment wishes and the content of such conversations between patients and family caregivers. OBJECTIVE To characterize post-ACP conversations regarding medical wishes between seriously ill patients and their family caregivers. PARTICIPANTS Patients with advanced illness and family caregivers. OUTCOME MEASURED Post-ACP conversations. DESIGN As part of a larger randomized controlled trial, dyads consisting of seriously ill patients and their identified family caregiver engaged in ACP and created an advance directive for the patient. Approximately 4 to 6 weeks later, semistructured interviews were conducted with the family caregivers to elucidate the subsequent communications regarding medical wishes. If the dyad did not have any conversations post-ACP, reasons and barriers were explored. RESULTS The majority of dyads (131/188, 69.7%) had 2 to 3 conversations lasting 3 to 5 minutes each in the weeks immediately following ACP. These conversations most commonly addressed general patient wishes about quality of life and specific medical treatments. The most common reasons for not having conversations were a general discomfort with the topic (13/57, 22.8%) and previously having discussed medical wishes (16/57, 28.1%). CONCLUSION The ACP events promote conversation regarding quality of life, general wishes at the end of life, and specific medical wishes. Barriers to conversation following ACP were similar to barriers to ACP in general, suggesting that a more intentional focus on addressing these barriers pre- and post-ACP may be necessary to improve communication.
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Affiliation(s)
- Jane R Schubart
- Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, PA, USA.,Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA.,Department of Medicine, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jean M Reading
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Janice Penrod
- College of Nursing, The Pennsylvania State University, University Park, PA, USA
| | - Renee R Stewart
- Department of Humanities, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Ramya Sampath
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Lisa S Lehmann
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.,National Center for Ethics in Health Care Veterans Health, Washington, DC, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Benjamin H Levi
- Department of Humanities, The Pennsylvania State University College of Medicine, Hershey, PA, USA.,10 Department of Pediatrics, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Michael J Green
- Department of Medicine, The Pennsylvania State University College of Medicine, Hershey, PA, USA.,Department of Humanities, The Pennsylvania State University College of Medicine, Hershey, PA, USA
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Bellamy G, Stock J, Schofield P. Acceptability of Paper-Based Advance Care Planning (ACP) to Inform End-of-Life Care Provision for Community Dwelling Older Adults: A Qualitative Interview Study. Geriatrics (Basel) 2018; 3:geriatrics3040088. [PMID: 31011123 PMCID: PMC6371084 DOI: 10.3390/geriatrics3040088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/22/2018] [Accepted: 11/28/2018] [Indexed: 11/16/2022] Open
Abstract
This paper reports the findings from a study to investigate health care professionals’ views regarding the use and acceptability of two similar paper-based advance care planning (ACP) documents designed for older adults in their last year of life to inform end-of-life care provision. Participants’ views of using PEACE (Proactive Elderly Persons Advisory Care), a nurse led model with community geriatrician oversight, and PACe (proactive anticipatory care plan), a general practitioner (GP) led model implemented by two clinical commissioning groups (CCGs) as part of a wider pilot to determine their ability to improve end-of-life care provision, were explored. Hospital admission avoidance matrons took part in face to face interviews and care staff employed in private residential care homes took part in individual telephone interviews to explore their views of using the PEACE tool. Telephone interviews were conducted with GPs to explore their views of PACe. GPs and admission avoidance matrons were employed by CCGs and all study participants were recruited from the South East of England, where data collection took place in 2015. The data were analysed thematically. Findings from the study demonstrate how both tools provide a focus to ACP discussions to inform individual end-of-life care preferences. The importance of relationships was a pivotal theme established, trusting inter-professional relationships to enable multidisciplinary teamwork and a prior relationship with the older person (or their proxy in the case of cognitive impairment) to enable such conversations in the first place. Both tools enabled participants to think critically and reflect on their own practice. Notwithstanding participants’ views to improve their layout, using a paper-based approach to deliver streamlined ACP and end-of-life care was a theme to emerge as a potential barrier, and highlighted problems with accessing paper-based documentation, accuracy and care co-ordination in the context of multidisciplinary team working. The value of technology in overcoming this barrier and underpinning ACP as a means to help simplify service provision, promote integrated professional practice and provide seamless care, was put forward as a way forward.
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Affiliation(s)
- Gary Bellamy
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford CM1 1SQ, UK.
| | - Jennifer Stock
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK.
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK.
| | - Patricia Schofield
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford CM1 1SQ, UK.
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Fried TR, Redding CA, Martino S, Paiva A, Iannone L, Zenoni M, Blakley LA, Rossi JS, O'Leary J. Increasing engagement in advance care planning using a behaviour change model: study protocol for the STAMP randomised controlled trials. BMJ Open 2018; 8:e025340. [PMID: 30099405 PMCID: PMC6089328 DOI: 10.1136/bmjopen-2018-025340] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Advance care planning (ACP) is a key component of high-quality end-of-life care but is underused. Interventions based on models of behaviour change may fill an important gap in available programmes to increase ACP engagement. Such interventions are designed for broad outreach and flexibility in delivery. The purpose of the Sharing and Talking about My Preferences study is to examine the efficacy of three behaviour change approaches to increasing ACP engagement through two related randomised controlled trials being conducted in different settings (Veterans Affairs (VA) medical centre and community). METHODS AND ANALYSIS Eligible participants are 55 years or older. Participants in the community are being recruited in person in primary care and specialty outpatient practices and senior living sites, and participants in the VA are recruited by telephone. In the community, randomisation is at the level of the practice or site, with all persons at a given practice/site receiving either computer-tailored feedback with a behaviour stage-matched brochure (computer-tailored intervention (CTI)) or usual care. At the VA, randomisation is at the level of the participant and is stratified by the number of ACP behaviours completed at baseline. Participants are randomised to one of four groups: CTI, motivational interviewing, motivational enhancement therapy or usual care. The primary outcome is completion of four key ACP behaviours: identification of a surrogate decision maker, communication about goals, completing advance directives and ensuring documents are in the medical record. Analysis will be conducted using mixed effects models, taking into account the clustered randomisation for the community study. ETHICS AND RANDOMISATION The studies have been approved by the appropriate Institutional Review Boards and are being overseen by a Safety Monitoring Committee. The results of these studies will be disseminated to academic audiences and leadership in in the community and VA sites. TRIAL REGISTRATION NUMBERS NCT03137459 and NCT03103828.
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Affiliation(s)
- Terri R Fried
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Colleen A Redding
- Cancer Prevention Research Center, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island, USA
- Psychology Department, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island, USA
| | - Steven Martino
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Psychology Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Andrea Paiva
- Cancer Prevention Research Center, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island, USA
- Psychology Department, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island, USA
| | - Lynne Iannone
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Program on Aging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Maria Zenoni
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Program on Aging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Laura A Blakley
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Psychology Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Joseph S Rossi
- Cancer Prevention Research Center, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island, USA
- Psychology Department, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island, USA
| | - John O'Leary
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Program on Aging, Yale School of Medicine, New Haven, Connecticut, USA
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32
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Lunder U, Červ B, Kodba-Čeh H. Impact of advance care planning on end-of-life management. Curr Opin Support Palliat Care 2018; 11:293-298. [PMID: 28957882 DOI: 10.1097/spc.0000000000000306] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to critically appraise the recent evidence on different aspects of impact of advance care planning (ACP) in palliative care and to reflect on further implications on practice and research in the future. RECENT FINDINGS Evidence about various ACP impacts is rapidly growing and most common outcome measures are still advance directive completion, change in hospital admission rate and patients' and families' views and experiences with ACP. Mainly descriptive studies bring new information of ACP impact for specific groups of patients, their families, settings, countries, contexts, staff and healthcare system as such. It is not yet clear who and when would best conduct ACP, from general practitioners (GPs) to specialists in the hospitals and even lay-navigators for cancer patients; from early ACP conversations to critical ACP in acute events at the end-of-life. The need for ACP impacts high-quality evidence is becoming more urgent because latest future projections are showing higher palliative care needs than previously expected. SUMMARY Recent studies on various ACP impacts reveal variety of outcomes for different patient groups and settings, and are contributing to a wider picture of ACP situation around the world. However, high-quality evidence on ACP impact is still urgently expected in times of growing need for system-level changes for effective ACP implementation.
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Affiliation(s)
- Urška Lunder
- Research Department, University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
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Lay Patient Navigators’ Perspectives of Barriers, Facilitators and Training Needs in Initiating Advance Care Planning Conversations With Older Patients With Cancer. J Palliat Care 2018; 33:70-78. [DOI: 10.1177/0825859718757131] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Context: Respecting Choices is an evidence-based model of facilitating advance care planning (ACP) conversations between health-care professionals and patients. However, the effectiveness of whether lay patient navigators can successfully initiate Respecting Choices ACP conversations is unknown. As part of a large demonstration project (Patient Care Connect [PCC]), a cohort of lay patient navigators underwent Respecting Choices training and were tasked to initiate ACP conversations with Medicare beneficiaries diagnosed with cancer. Objectives: This article explores PCC lay navigators’ perceived barriers and facilitators in initiating Respecting Choices ACP conversations with older patients with cancer in order to inform implementation enhancements to lay navigator-facilitated ACP. Methods: Twenty-six lay navigators from 11 PCC cancer centers in 4 states (Alabama, George, Tennessee, and Florida) completed in-depth, one-on-one semistructured interviews between June 2015 and August 2015. Data were analyzed using a thematic analysis approach. Results: This evaluation identifies 3 levels—patient, lay navigator, and organizational factors in addition to training needs that influence ACP implementation. Key facilitators included physician buy-in, patient readiness, and navigators’ prior experience with end-of-life decision-making. Lay navigators’ perceived challenges to initiating ACP conversations included timing of the conversation and social and personal taboos about discussing dying. Conclusion: Our results suggest that further training and health system support are needed for lay navigators playing a vital role in improving the implementation of ACP among older patients with cancer. The lived expertise of lay navigators along with flexible longitudinal relationships with patients and caregivers may uniquely position this workforce to promote ACP.
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Walker E, McMahan R, Barnes D, Katen M, Lamas D, Sudore R. Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety. J Pain Symptom Manage 2018; 55:256-264. [PMID: 28943360 PMCID: PMC5794631 DOI: 10.1016/j.jpainsymman.2017.09.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Documenting patients' advance care planning (ACP) wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about ACP documentation practices in the electronic health record. OBJECTIVES The objective of this study was to describe ACP documentation practices and the accessibility of documented discussions in the electronic health record. METHODS Participants were primary care patients at the San Francisco Veterans Affairs Medical Center, were ≥60 years old, and had ≥2 chronic/serious health conditions. In this cross-sectional study, we assessed the prevalence of ACP documentation, including any legal forms/orders and discussions in the prior five years. We also determined accessibility of discussions (i.e., accessible centralized posting vs. inaccessible free text in progress notes). RESULTS The mean age of 414 participants was 71 years (SD ± 8), 9% were women, 43% were nonwhite, and 51% had documented ACP including 149 (36%) with forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders lacked accompanying explanatory documentation. Most (55%) discussions were not easily accessible, including 70% of those documenting changes in treatment preferences from prior forms/orders. CONCLUSION Half of chronically ill, older participants had documented ACP, including one-third with documented discussions. However, half of the patients with completed legal forms/orders had no accompanying documented explanatory discussions, and the majority of documented discussions were not easily accessible, even when wishes had changed. Ensuring that patients' preferences are documented and easily accessible is an important patient safety and quality improvement target to ensure patients' wishes are honored.
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Affiliation(s)
- Evan Walker
- Department of Medicine, UCSF, San Francisco, California.
| | - Ryan McMahan
- UCSF School of Medicine, San Francisco, California
| | - Deborah Barnes
- San Francisco Veterans Affairs Medical Center, San Francisco, California; Department of Psychiatry, UCSF, San Francisco, California; Department of Epidemiology & Biostatistics, UCSF, San Francisco, California
| | - Mary Katen
- Division of Geriatrics, Department of Medicine, UCSF, San Francisco, California
| | - Daniela Lamas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
| | - Rebecca Sudore
- San Francisco Veterans Affairs Medical Center, San Francisco, California; Division of Geriatrics, Department of Medicine, UCSF, San Francisco, California
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Patient-family EoL communication and its predictors: Reports from caregivers of Latino patients in the rural U.S.-Mexico border region. Palliat Support Care 2017; 16:520-527. [PMID: 29072148 DOI: 10.1017/s147895151700092x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Family caregivers play an important role in end-of-life (EoL) decision making when the patient is unable to make his/her own decisions. While communication about EoL care between patients and family is perhaps a first step toward advance care planning (ACP)/EoL decisions, not every culture puts great value on open communication about this topic. The aims of the present study were to explore EoL communication and the aspects of communication among caregivers of Latino patients in the rural United States (U.S.)-Mexico border region. METHOD This study analyzed data from a hospice needs assessment collected from 189 family caregivers of Latino patients at a home health agency in a rural U.S.-Mexico border region. Bivariate tests and logistic regression were used to address our aims. RESULTS About half of the family caregivers (n = 96, 50.8%) reported to have ever engaged in EoL discussion with patients. Significant predictors of EoL discussion included life-sustaining treatment preference (odds ratio [OR] = 0.44, p < 0.05); knowledge of an advance directive (AD) (OR = 5.50, p < 0.01); and distrust of physicians (OR = 0.29, p < 0.01). Caregivers who preferred extending the life of their loved one even if he/she had to rely on life supports were less likely to engage in EoL communication. Also, caregivers who worried that physicians might want to stop treatments (i.e., "pull the plug") too soon were less likely to do so. Conversely, caregivers who had knowledge about ADs were more likely to engage in EoL communication. SIGNIFICANCE OF RESULTS EoL communication is a complex process influenced by individual, social, and cultural values and the beliefs of both the patient and his/her family. Inclusion of family caregivers in the ACP process and facilitating culturally tailored EoL communication between patients and family caregivers is important.
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Berns SH, Camargo M, Meier DE, Yuen JK. Goals of Care Ambulatory Resident Education: Training Residents in Advance Care Planning Conversations in the Outpatient Setting. J Palliat Med 2017; 20:1345-1351. [PMID: 28661787 DOI: 10.1089/jpm.2016.0273] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Advance care planning (ACP) discussions often occur in the inpatient setting when patients are too ill to participate in decision making. Although the outpatient setting is the preferred time to begin these discussions, few physicians do so in practice. Many internal medicine (IM) residents report inadequate training as a barrier to having outpatient ACP discussions. OBJECTIVE To assess whether a novel curriculum entitled Goals of Care Ambulatory Resident Education (GOCARE) improved resident physicians' understanding of and preparedness for conducting ACP discussions in the outpatient setting. DESIGN The curriculum was delivered over four weekly three-hour small group sessions to IM residents. Each session included didactics, a demonstration of skills, and a simulated patient communication laboratory that emphasized deliberate practice. SETTING/SUBJECTS IM residents from an urban, academic ambulatory care practice. MEASUREMENTS Impact of the intervention was evaluated using a retrospective pre-post design. Residents completed surveys immediately after the course and six months later. RESULTS Forty-two residents participated in the curriculum and 95% completed the postcourse survey. Residents' self-rated level of preparedness increased for ACP discussions overall (4.0 pre vs. 5.2 post on 7-point Likert scale) and for communication steps involved in ACP (p < 0.001). Fifty-nine percent of participants completed the six-month follow-up survey. Residents' self-rated preparedness to engage in outpatient ACP discussions remained high (4.5 pre vs. 5.5 post at six months p < 0.001). Residents also reported increased use of ACP communication skills (p < 0.001) six months later. CONCLUSIONS The GOCARE curriculum provides an alternative model of communication training that can be integrated into residency training and improve residents' skills in outpatient ACP discussions.
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Affiliation(s)
- Stephen H Berns
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Marianne Camargo
- 2 Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Diane E Meier
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Jacqueline K Yuen
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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Park EM, Deal AM, Yopp JM, Edwards T, Stephenson EM, Hailey CE, Nakamura ZM, Rosenstein DL. End-of-life parental communication priorities among bereaved fathers due to cancer. PATIENT EDUCATION AND COUNSELING 2017; 100:1019-1023. [PMID: 28012678 PMCID: PMC5400699 DOI: 10.1016/j.pec.2016.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/22/2016] [Accepted: 12/12/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To elicit widowed fathers' perspectives on which domains of parenting-related communication they consider most important for dying parents to discuss at the end of life (EOL). METHODS Two hundred seventy nine fathers widowed by cancer completed a survey about their own depression and bereavement symptoms, their wife's illness, and EOL parental communication priorities. Chi square and Fisher's exact tests and logistic regression were used to evaluate relationships between maternal EOL characteristics and fathers' responses to parenting-related EOL communication priorities. RESULTS Fathers identified raising children in a manner that reflected maternal wishes, whether/how to talk with children about their mother's death, and how the mother wanted to be remembered as the most important EOL communication domains. Fathers who reported that their dying wives were worried about the children were more likely to prioritize raising children in ways that reflect her wishes (p=0.01). Other EOL characteristics were not associated with communication domains. CONCLUSIONS Communicating with children and maintaining emotional connection with the deceased parent are important priorities for bereaved fathers who lost a spouse to cancer. PRACTICE IMPLICATIONS Health care providers working with seriously ill parents may improve family outcomes by supporting communication at the EOL between co-parents.
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Affiliation(s)
- Eliza M Park
- Department of Psychiatry, University of North Carolina, 170 Manning Drive, CB 7305, Chapel Hill, NC 27599, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center Biostatistics Core Facility, University of North Carolina, 450 West Drive, Chapel Hill, NC 27514, USA
| | - Justin M Yopp
- Department of Psychiatry, University of North Carolina, 170 Manning Drive, CB 7305, Chapel Hill, NC 27599, USA
| | - Teresa Edwards
- H. W. Odum Institute for Research in Social Science, University of North Carolina at Chapel Hill, 208 N. Raleigh St., CB3355, Chapel Hill, NC 27599, USA
| | - Elise M Stephenson
- School of Medicine, University of North Carolina, 321 S. Columbia St., Chapel Hill, NC 27516, USA
| | - Claire E Hailey
- School of Medicine, University of North Carolina, 321 S. Columbia St., Chapel Hill, NC 27516, USA
| | - Zev M Nakamura
- Department of Psychiatry, University of North Carolina, 170 Manning Drive, CB 7305, Chapel Hill, NC 27599, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina, 170 Manning Drive, CB 7305, Chapel Hill, NC 27599, USA; Department of Medicine, University of North Carolina, 125 MacNider Hall, CB7005, Chapel Hill NC 27599, USA
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Fried T, Zenoni M, Iannone L. A Dyadic Perspective on Engagement in Advance Care Planning. J Am Geriatr Soc 2016; 65:172-178. [PMID: 27910091 DOI: 10.1111/jgs.14497] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To understand the perspectives of both patients and the person who would make medical decisions for them if they were unable (surrogates) on their participation in advance care planning (ACP). DESIGN Qualitative cross-sectional study. SETTING Community. PARTICIPANTS Thirty-one veterans age 55 years and older and their surrogates. MEASUREMENTS In interviews conducted with both the veteran and surrogate, they were asked to discuss their participation in four ACP activities: communication about life-sustaining treatment, communication about views on quality of life, completion of a living will, and appointment of a healthcare proxy. They were asked about barriers to and facilitators of ACP engagement. When they did not agree about engagement, they each provided their perspective on what they believed had or had not occurred. RESULTS Many of the same barriers to and facilitators of engagement were discussed by both patients and surrogates. These included difficulty thinking about dying, differences in values, and experiences with others that demonstrated the ability of ACP to decrease burden or avoid conflict. Reasons for disagreements in perceptions about whether communication had occurred included surrogates' need for more detailed information, surrogates' lack of readiness to hear what the patient was saying, and surrogates' reliance on what they know about the patient. For some dyads, participation in the study prompted additional communication, resulting in a better shared understanding of ACP engagement. CONCLUSION Surrogates can both impede and facilitate engagement in ACP, and they can hold different perceptions from patients regarding this engagement. Efforts to promote ACP may be most successful if they assess and address both patients' and surrogates' attitudes and help to facilitate clear communication between them.
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Affiliation(s)
- Terri Fried
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Maria Zenoni
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lynne Iannone
- Program on Aging, Yale School of Medicine, New Haven, Connecticut
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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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Narang AK, Wright AA, Nicholas LH. Trends in Advance Care Planning in Patients With Cancer: Results From a National Longitudinal Survey. JAMA Oncol 2016; 1:601-8. [PMID: 26181909 DOI: 10.1001/jamaoncol.2015.1976] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Advance care planning (ACP) may prevent end-of-life (EOL) care that is nonbeneficial and discordant with patient wishes. Despite long-standing recognition of the merits of ACP in oncology, it is unclear whether participation in ACP by patients with cancer has increased over time. OBJECTIVES To characterize trends in durable power of attorney (DPOA) assignment, living will creation, and participation in discussions of EOL care preferences and to explore associations between ACP subtypes and EOL treatment intensity as reflected in EOL care decisions and terminal hospitalizations. DESIGN, SETTING, AND PARTICIPANTS We analyzed prospectively collected survey data from 1985 next-of-kin surrogates of Health and Retirement Study (HRS) participants with cancer who died between 2000 and 2012, including data from in-depth "exit" interviews conducted with the surrogates after the participant's death. The HRS is a nationally representative, biennial, longitudinal panel study of US residents older than 50 years. Trends in ACP subtypes were tested, and multivariable logistic regression models examined for associations between ACP subtypes and measures of treatment intensity. MAIN OUTCOMES AND MEASURES Trends in the surrogate-reported frequency of DPOA assignment, living will creation, and participation in discussions of EOL care preferences; associations between ACP subtypes and both surrogate-reported EOL care decisions and terminal hospitalizations. RESULTS From 2000 to 2012, there was an increase in DPOA assignment (52% to 74%, P = .03), without significant change in use of living wills (49% to 40%, P = .63) or EOL discussions (68% to 60%, P = .62). Surrogate reports that patients received "all care possible" at EOL increased during the period (7% to 58%, P = .004), and rates of terminal hospitalizations were unchanged (29% to 27%, P = .70). Limiting or withholding treatment was associated with living wills (adjusted odds ratio [AOR], 2.51; 95% CI, 1.53-4.11; P < .001) and EOL discussions (AOR, 1.93; 95% CI, 1.53-3.14; P = .002) but not with DPOA assignment. CONCLUSIONS AND RELEVANCE Use of DPOA increased significantly between 2000 and 2012 but was not associated with EOL care decisions. Importantly, there was no growth in key ACP domains such as discussions of care preferences. Efforts that bolster communication of EOL care preferences and also incorporate surrogate decision makers are critically needed to ensure receipt of goal-concordant care.
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Affiliation(s)
- Amol K Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexi A Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts3Harvard Medical School, Boston, Massachusetts
| | - Lauren H Nicholas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland5Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Sudore R, Le GM, McMahan R, McMahon R, Feuz M, Katen M, Barnes DE. The advance care planning PREPARE study among older Veterans with serious and chronic illness: study protocol for a randomized controlled trial. Trials 2015; 16:570. [PMID: 26654250 PMCID: PMC4676815 DOI: 10.1186/s13063-015-1055-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/12/2015] [Indexed: 11/10/2022] Open
Abstract
Background Advance care planning (ACP) is a process whereby patients prepare for medical decision-making. The traditional objective of ACP has focused on the completion of advance directives. We have developed a new paradigm of ACP focused on preparing patients and their loved ones for communication and informed medical decision-making. To operationalize this new paradigm of ACP, we created an interactive, patient-centered website called PREPARE (www.prepareforyourcare.org) designed for diverse older adults. Methods/Design This randomized controlled trial with blinded outcome assessment is designed to determine the efficacy of PREPARE to engage older Veterans in the ACP process. Veterans who are ≥ 60 years of age, have ≥ two medical conditions, and have seen a primary care physician ≥ two times in the last year are being randomized to one of two study arms. The PREPARE study arm reviews the PREPARE website and an easy-to-read advance directive. The control arm only reviews the advance directive. The primary outcome is documentation of an advance directive and ACP discussions. Other clinically important outcomes using validated surveys include ACP behavior change process measures (knowledge, contemplation, self-efficacy, and readiness) and a full range of ACP action measures (identifying a surrogate, identifying values and goals, choosing leeway or flexibility for the surrogate, communicating with clinicians and surrogates, and documenting one’s wishes). We will also assess satisfaction with decision-making and Veteran activation within primary care visits by direct audio recording. To examine the outcomes at 1 week, 3 months, and 6 months between the two study arms, we will use mixed effects linear, Poisson, or negative binomial regression and mixed effects logistic regression. Discussion This study will determine whether PREPARE increases advance directive completion rates and engagement with the ACP process. If PREPARE is efficacious, it could prove to be an easy and effective intervention to help older adults engage in the ACP process within or outside of the medical environment. PREPARE may also help older adults communicate their medical wishes and goals to their loved ones and clinicians, improve medical decision-making, and ensure their wishes are honored over the life course. Trial registration ClinicalTrials.gov NCT01550731. Registered on 8 December 2011.
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Affiliation(s)
- Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, 3333 California St. Suite 380, San Francisco, CA, 94143, USA. .,San Francisco Veterans Administration Medical Center, 4150 Clement Street, #151R, San Francisco, CA, 94121, USA.
| | - Gem M Le
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, 3333 California St. Suite 380, San Francisco, CA, 94143, USA. .,Division of General Internal Medicine, San Francisco General Hospital, Center for Vulnerable Populations, University of California, San Francisco, 2789 25th Street Suite 350, San Francisco, CA, 94110, USA.
| | - Ryan McMahan
- San Francisco Veterans Administration Medical Center, 4150 Clement Street, #151R, San Francisco, CA, 94121, USA.
| | - Ryan McMahon
- San Francisco Veterans Administration Medical Center, 4150 Clement Street, #151R, San Francisco, CA, 94121, USA.
| | - Mariko Feuz
- San Francisco Veterans Administration Medical Center, 4150 Clement Street, #151R, San Francisco, CA, 94121, USA.
| | - Mary Katen
- San Francisco Veterans Administration Medical Center, 4150 Clement Street, #151R, San Francisco, CA, 94121, USA.
| | - Deborah E Barnes
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, 3333 California St. Suite 380, San Francisco, CA, 94143, USA. .,Department of Psychiatry, University of California, San Francisco, CA, USA. .,Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA.
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Johnson S, Butow P, Kerridge I, Tattersall M. Advance care planning for cancer patients: a systematic review of perceptions and experiences of patients, families, and healthcare providers. Psychooncology 2015; 25:362-86. [PMID: 26387480 DOI: 10.1002/pon.3926] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/10/2015] [Accepted: 07/07/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients with advanced cancer may benefit from end of life (EOL) planning, but there is evidence that their willingness and desire to engage in advance care planning (ACP) varies. The reasons for this remain poorly understood. Previous reviews on ACP most commonly report outcome measures related to medical interventions and type of care. Synthesis of the literature, which aims to illuminate the salient characteristics of ACP and investigates the psychological and social features of preparation for the EOL, is required. METHODS We searched Medline, EMBASE, PsychINFO, CINAHL, and the Cochrane Central Register of Controlled Trials for studies on perceptions or experiences regarding ACP of adults with cancer, family, friends, or professionals caring for this group. Databases were searched from earliest records to 19 November 2014. A thematic analysis of the literature generated conceptual themes. RESULTS Of the 2483 studies identified, 40 were eligible for inclusion. Studies addressed the relational nature of ACP, fear surrounding ACP, the conceptual complexity of autonomy, and the influence of institutional culture and previous healthcare experiences on ACP. CONCLUSIONS The complex social and emotional environments within which EOL planning is initiated and actioned are not sufficiently embedded within standardized ACP. The notion that ACP is concerned principally with the 'right' to self-determination through control over treatment choices at the EOL may misrepresent the way that ACP actually occurs in cancer care and ultimately conflict with the deeper concerns and needs of patients, who experience ACP as relational, emotional, and social.
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Affiliation(s)
- Stephanie Johnson
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology and Department of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Phyllis Butow
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology and Department of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Ian Kerridge
- Centre for Values, Ethics and the Law in Medicine (Velim), School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Martin Tattersall
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology and Department of Medicine, University of Sydney, Sydney, NSW, Australia
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van Soest-Poortvliet MC, van der Steen JT, de Vet HCW, Hertogh CMPM, Onwuteaka-Philipsen BD, Deliens LHJ. Factors related to establishing a comfort care goal in nursing home patients with dementia: a cohort study among family and professional caregivers. J Palliat Med 2015; 17:1317-27. [PMID: 25226515 DOI: 10.1089/jpm.2014.0205] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Many people with dementia die in long-term care settings. These patients may benefit from a palliative care goal, focused on comfort. Admission may be a good time to revisit or develop care plans. OBJECTIVE To describe care goals in nursing home patients with dementia and factors associated with establishing a comfort care goal. DESIGN We used generalized estimating equation regression analyses for baseline analyses and multinomial logistic regression analyses for longitudinal analyses. SETTING Prospective data collection in 28 Dutch facilities, mostly nursing homes (2007-2010; Dutch End of Life in Dementia study, DEOLD). RESULTS Eight weeks after admission (baseline), 56.7% of 326 patients had a comfort care goal. At death, 89.5% had a comfort care goal. Adjusted for illness severity, patients with a baseline comfort care goal were more likely to have a religious affiliation, to be less competent to make decisions, and to have a short survival prediction. Their families were less likely to prefer life-prolongation and more likely to be satisfied with family-physician communication. Compared with patients with a comfort care goal established later during their stay, patients with a baseline comfort care goal also more frequently had a more highly educated family member. CONCLUSIONS Initially, over half of the patients had a care goal focused on comfort, increasing to the large majority of the patients at death. Optimizing patient-family-physician communication upon admission may support the early establishing of a comfort care goal. Patient condition and family views play a role, and physicians should be aware that religious affiliation and education may also affect the (timing of) setting a comfort care goal.
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Affiliation(s)
- Mirjam C van Soest-Poortvliet
- 1 Department of General Practice & Elderly Care Medicine, VU University Medical Center , EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
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Relaxation Techniques for People with Chronic Obstructive Pulmonary Disease: A Systematic Review and a Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2015; 2015:628365. [PMID: 26339268 PMCID: PMC4539049 DOI: 10.1155/2015/628365] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/28/2015] [Indexed: 11/17/2022]
Abstract
Introduction. Chronic Obstructive Pulmonary Disease (COPD) people suffer from severe physical impairments, which often elicit significant psychological distress and impact their quality of life. This meta-analysis aimed to assess evidence from the scientific literature on the effects of relaxation techniques. Methods. We investigated 9 databases to select 25 RCTs. Studies included both inpatients and outpatients with COPD. Both respiratory and psychological outcomes were considered. Results. Relaxation techniques showed a little positive effect on the value of the percentage of predicted FEV1 (d = 0.20; 95% Cl: 0.40--0.01) as well as a slight effect on levels of both the anxiety (d = 0.26; 95% Cl: 0.42-0.10) and depression (d = 0.33; 95% Cl: 0.53-0.13). The higher effect size was found in the quality of life value (d = 0.38; 95% Cl: 0.51-0.24). The assessed quality of the studies, based on the PEDro Scale, was generally medium/high. Conclusion. Relaxation training can have a moderate impact on both psychological well-being and respiratory function, resulting in noticeable improvements in both. Although higher quality research is required, our results sustain the importance of relaxation techniques as a tool to manage COPD.
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Pollock K, Wilson E. Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03310] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAdvance care planning (ACP) enables patients to consider, discuss and, if they wish, document their wishes and preferences for future care, including decisions to refuse treatment, in the event that they lose capacity to make decisions for themselves. ACP is a key component of UK health policy to improve the experience of death and dying for patients and their families. There is limited evidence about how patients and health professionals understand ACP, or when and how this is initiated. It is evident that many people find discussion of and planning for end of life care difficult, and tend to avoid the topic.AimTo investigate how patients, their relatives and health professionals initiate and experience discussion of ACP and the outcomes of advance discussions in shaping care at the end of life.Design and data collectionQualitative study with two workstreams: (1) interviews with 37 health professionals (general practitioners, specialist nurses and community nurses) about their experiences of ACP; and (2) longitudinal case studies of 21 patients with 6-month follow-up. Cases included a patient and, where possible, a nominated key relative and/or health professional as well as a review of medical records. Complete case triads were obtained for 11 patients. Four cases comprised the patient alone, where respondents were unable or unwilling to nominate either a family member or a professional carer they wished to include in the study. Patients were identified as likely to be within the last 6 months of life. Ninety-seven interviews were completed in total.SettingGeneral practices and community care settings in the East Midlands of England.FindingsThe study found ACP to be uncommon and focused primarily on specific documented tasks involving decisions about preferred place of death and cardiopulmonary resuscitation, supporting earlier research. There was no evidence of ACP in nearly half (9 of 21) of patient cases. Professionals reported ACP discussions to be challenging. It was difficult to recognise when patients had entered the last year of life, or to identify their readiness to consider future planning. Patients often did not wish to do so before they had become gravely ill. Consequently, ACP discussions tended to be reactive, rather than pre-emptive, occurring in response to critical events or evidence of marked deterioration. ACP discussions intersected two parallel strands of planning: professional organisation and co-ordination of care; and the practical and emotional preparatory work that patients and families undertook to prepare themselves for death. Reference to ACP as a means of guiding decisions for patients who had lost capacity was rare.ConclusionsAdvance care planning remains uncommon, is often limited to documentation of a few key decisions, is reported to be challenging by many health professionals, is not welcomed by a substantial number of patients and tends to be postponed until death is clearly imminent. Current implementation largely ignores the purpose of ACP as a means of extending personal autonomy in the event of lost capacity.Future workAttention should be paid to public attitudes to death and dying (including those of culturally diverse and ethnic minority groups), place of death, resuscitation and the value of anticipatory planning. In addition the experiences and needs of two under-researched groups should be explored: the frail elderly, including those who manage complex comorbid conditions, unrecognised as vulnerable cases; and those patients affected by stigmatised conditions, such as substance abuse or serious mental illness who fail to engage constructively with services and are not recognised as suitable referrals for palliative and end of life care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK
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van Soest-Poortvliet MC, van der Steen JT, de Vet HCW, Hertogh CMPM, Deliens L, Onwuteaka-Philipsen BD. Comfort goal of care and end-of-life outcomes in dementia: A prospective study. Palliat Med 2015; 29:538-46. [PMID: 25690602 DOI: 10.1177/0269216315570409] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many people with dementia die in a nursing home. A comfort care goal may be beneficial. Little research has examined the relationship between care goals and outcome. AIM To investigate whether family satisfaction with end-of-life care and quality of dying is associated with whether or not dementia patients have a comfort goal shortly after admission. DESIGN AND SETTING Prospective data collection from 28 long-term care facilities (the Dutch End of Life in Dementia study). We included 148 patients who died after prospective follow-up. Main outcomes were family satisfaction (End-of-Life in Dementia-Satisfaction with Care scale; range: 10-40) and quality of dying (End-of-Life in Dementia-Comfort Assessment in Dying; range: 14-42). We performed generalized estimating equations regression analyses to analyze whether these outcomes are associated with a comfort goal established shortly after admission compared with another or no care goal as reported by the physician. RESULTS Families of patients were more satisfied with end-of-life care when a comfort goal was established shortly after admission. We found this pattern only for patients who died within 6 months of admission (adjusted b: 4.5; confidence interval: 2.8, 6.3 vs -1.2; confidence interval: -3.0, 0.6 for longer stay). For quality of dying, no such association was found. CONCLUSION We found that family satisfaction with care is related to a comfort care goal shortly after admission, but quality of dying did not. Establishing a comfort goal at an early stage may be important to the family. Advance care planning interventions should be studied for their effects on patient and family outcome.
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Affiliation(s)
- Mirjam C van Soest-Poortvliet
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Jenny T van der Steen
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Henrica C W de Vet
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Luc Deliens
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Brussels, Belgium
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Lampert R. Discussions around goals of care: An ethical imperative. Trends Cardiovasc Med 2015; 26:44-5. [PMID: 26022729 DOI: 10.1016/j.tcm.2015.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 04/20/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Rachel Lampert
- Yale School of Medicine, Section of Cardiovascular Medicine, New Haven, CT.
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Dilemmas in end-stage heart failure. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2015; 12:57-65. [PMID: 25678905 PMCID: PMC4308459 DOI: 10.11909/j.issn.1671-5411.2015.01.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/04/2014] [Accepted: 11/11/2014] [Indexed: 12/24/2022]
Abstract
Heart failure (HF), a complex clinical syndrome due to structural or functional disorder of the heart, is a major global health issue, with a prevalence of over 5.8 million in the USA alone, and over 23 million worldwide. As a leading cause of hospitalizations among patients aged 65 years or older, HF is a major consumer of healthcare resources, creating a substantial strain on the healthcare system. This paper discusses the epidemiology of HF, financial impact, and multifaceted predicaments in end-stage HF care. A search was conducted on the U.S. National Library of Medicine website (www.pubmed.gov) using keywords such as end-stage heart failure, palliative care, ethical dilemmas. Despite the poor prognosis of HF (worse than that for many cancers), many HF patients, caregivers, and clinicians are unaware of the poor prognosis. In addition, the unpredictable clinical trajectory of HF complicates the planning of end-of-life care, such as palliative care and hospice, leading to underutilization of such resources. In conclusion, ethical dilemmas in end-stage HF are numerous, embroiling not only the patient, but also the caregiver, healthcare team, and society.
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Meghani SH, Hinds PS. Policy brief: The Institute of Medicine report Dying in America: Improving quality and honoring individual preferences near the end of life. Nurs Outlook 2015; 63:51-9. [DOI: 10.1016/j.outlook.2014.11.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 11/13/2014] [Indexed: 11/29/2022]
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