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Spear S, Little E, Tapp A, Nancarrow C, Morey Y, Warren S, Verne J. Attitudes towards advance care planning amongst community-based older people in England. PLoS One 2024; 19:e0306810. [PMID: 39167589 PMCID: PMC11338439 DOI: 10.1371/journal.pone.0306810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 06/24/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Advance care planning has been advocated as a way for people to have their wishes recorded and respected in relation to types of treatment and place of care. However, uptake in England remains low. AIMS To examine the views of older, well, adults towards Advance Care Plans (ACPs) and planning for end-of-life care, in order to inform national policy decisions. METHODS A mixed methods approach was adopted, involving individual and mini-group qualitative interviews (n = 76, ages 45-85), followed by a quantitative survey (n = 2294, age 55+). The quantitative sample was based on quotas in age, gender, region, socio-economic grade, and ethnicity, combined with light weighting to ensure the findings were representative of England. RESULTS Knowledge and understanding of advance care planning was low, with only 1% of survey respondents reporting they had completed an ACP for themselves. Common reasons for not putting wishes into writing were not wanting/needing to think about it now, the unpredictability of the future, trusting family/friends to make decisions, and financial resources limiting real choice. CONCLUSION Whilst advance care planning is seen as a good idea in theory by older, well, adults living in the community, there is considerable reticence in practice. This raises questions over the current, national policy position in England, on the importance of written ACPs. We propose that policy should instead focus on encouraging ongoing conversations between individuals and all those (potentially) involved in their care, about what is important to them, and on ensuring there are adequate resources in community networks and health and social care systems, to be responsive to changing needs.
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Affiliation(s)
- Sara Spear
- Faculty of Business and Law, St Mary’s University, London, England
- Bristol Business School, University of the West of England, Bristol, England
| | - Ed Little
- Bristol Business School, University of the West of England, Bristol, England
| | - Alan Tapp
- Bristol Business School, University of the West of England, Bristol, England
| | - Clive Nancarrow
- Bristol Business School, University of the West of England, Bristol, England
| | - Yvette Morey
- Bristol Business School, University of the West of England, Bristol, England
| | - Stella Warren
- Bristol Business School, University of the West of England, Bristol, England
| | - Julia Verne
- OHID, Department for Health and Social Care, London, England
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Zhang P, Nketsiah E, Noh H. Service Provider Perspectives on Advance Care Planning Use in Rural Dementia Patients and Caregivers: A Qualitative Study. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2024; 67:825-840. [PMID: 38709892 DOI: 10.1080/01634372.2024.2351071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 04/30/2024] [Indexed: 05/08/2024]
Abstract
Advanced care planning (ACP) utilization remains very limited in rural communities compared to urban areas. ACP earlier in the disease trajectory is particularly important for people with dementia (PWD) due to its progressive nature affecting their decision-making ability. Considering the well-documented benefits of ACP in improving the quality of end-of-life (EOL) care, the rural vs. urban disparity may indicate poorer EOL quality for rural PWD. This study aimed to explore barriers and current resources for ACP of PWD from the perspectives of health or social service providers serving rural communities. Using a qualitative approach, semi-structured face-to-face interviews were conducted with 11 health or social service professionals serving older adults and their caregivers in rural Alabama. Thematic analysis revealed three major barriers: (1) lack of knowledge, (2) psychosocial barriers, and (3) limited access to healthcare. Participants also showed misconception that a lawyer or a notary is required for ACP. Two themes arose in the participants' recommendations to address the barriers: (1) providing ACP-relevant information and (2) addressing psychosocial stressors about ACP. This study highlighted an urgent need for social policy in ACP education for caregivers and service providers in rural settings.
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Affiliation(s)
- Peiyuan Zhang
- School of Social Work, University of Maryland, Baltimore, Maryland, USA
| | - Ebow Nketsiah
- School of Social Work, St. Louis University, St. Louis, Missouri, USA
| | - Hyunjin Noh
- School of Social Work, University of Alabama, Tuscaloosa, Alabama, USA
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Lenko RA, Hoffman GJ, Robinson-Lane SG, Silveira MJ, Voepel-Lewis T. Achieving goal-concordant care: Formal and informal advance care planning for White, Black, and Hispanic older adults. J Am Geriatr Soc 2024; 72:2412-2422. [PMID: 38760957 PMCID: PMC11323214 DOI: 10.1111/jgs.18971] [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] [Received: 01/03/2024] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Advance care planning (ACP) aims to ensure that patients receive goal-concordant care (GCC), which is especially important for racially or ethnically minoritized populations at greater risk of poor end-of-life outcomes. However, few studies have evaluated the impact of advance directives (i.e., formal ACP) or goals-of-care conversations (i.e., informal ACP) on such care. This study aimed to examine the relationship between each of formal and informal ACP and goal-concordant end-of-life care among older Americans and to determine whether their impact differed between individuals identified as White, Black, or Hispanic. METHODS We conducted a retrospective cohort study using 2012-2018 data from the biennial Health and Retirement Study. We examined the relationships of interest using two, separate multivariable logistic regression models. Model 1 regressed a proxy report of GCC on formal and informal ACP and sociodemographic and health-related covariates. Model 2 added interaction terms between race/ethnicity and the two types of ACP. RESULTS Our sample included 2048 older adults. There were differences in the proportions of White, Black, and Hispanic decedents who received GCC (83.1%, 75.3%, and 71.3%, respectively, p < 0.001) and in the use of each type of ACP by racial/ethnic group. In model 1, informal compared with no informal ACP was associated with higher odds of GCC (adjusted odds ratio = 1.38 [95% confidence interval, 1.05-1.82]). In model 2, Black decedents who had formal ACP were more likely to receive GCC than those who did not, but there were no statistically significant differences between decedents of different racial/ethnic groups who had no ACP, informal ACP only, or both types of ACP. CONCLUSIONS Our results build on previous work by indicating the importance of incorporating goals-of-care conversations into routine healthcare for older adults and encouraging ACP usage among racially and ethnically minoritized populations who use ACP tools at lower rates.
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Affiliation(s)
- Rachel A Lenko
- Department of Nursing, Calvin University School of Health, Grand Rapids, Michigan, USA
| | - Geoffrey J Hoffman
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Sheria G Robinson-Lane
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Maria J Silveira
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Terri Voepel-Lewis
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
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Young Y, Perre T, Shayya A, Barnes V, O'Grady T. Unveiling the Influencers: An Exploration of Factors Determining Advance Directive Completion Among Community-Dwelling Adults. Am J Hosp Palliat Care 2024; 41:762-770. [PMID: 37937749 DOI: 10.1177/10499091231213636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
INTRODUCTION Advance directives (AdvDirs) align end-of-life care with personal values, averting unnecessary treatments. This study explores factors influencing AdvDir completion. METHODS We conducted a cross-sectional study with community-dwelling adults (n = 166) age range 18-93, using a survey to gather sociodemographics, beliefs, and AdvDir experiences. Multivariate logistic regression quantifies associations between selected covariates and AdvDir completion. RESULTS We found that 36% of respondents had completed AdvDirs. The majority were comfortable discussing death (77%) and end-of-life care (84%) and recognized the importance of AdvDirs (79%). Age, education level, self-perceived health status, exposure to end-of-life planning, and the preference to limit treatment in potential future Alzheimer's scenarios significantly influenced AdvDir completion. CONCLUSION In conclusion, the study highlights: (1) The need for age-specific, personalized AdvDir education initiatives, and (2) The necessity of intensified AdvDir awareness efforts, particularly for individuals favoring unlimited treatment in Alzheimer's or dementia scenarios.
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Affiliation(s)
- Yuchi Young
- Department of Health Policy, Management, & Behavior, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
| | - Taylor Perre
- Home Care Association of New York State (HCA), Albany, NY, USA
| | - Ashley Shayya
- Department of Health Policy, Management, & Behavior, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
| | - Virgile Barnes
- Department of Health Policy, Management, & Behavior, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
| | - Thomas O'Grady
- Department of Epidemiology and Biostatistics, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
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Hart DE. Advance directives need full legal status in persons with dementia. Nurs Ethics 2024:9697330241247320. [PMID: 38711348 DOI: 10.1177/09697330241247320] [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: 05/08/2024]
Abstract
Currently, in the United States, there is no legal obligation for medical professionals or civil courts to uphold patients' Advance Directives (ADs) regarding end-of-life care. The applicability and standing of ADs prepared by Alzheimer's patients is a persistent issue in bioethics. Those who argue against giving ADs full status take two main approaches: (1) appealing to beneficence on behalf of the Alzheimer's patient and (2) claiming that there is no longer any personal equivalence between the AD's creator and the subject of the AD. In this paper, I present profound arguments against both approaches. Firstly, I argue that the principle of beneficence cannot apply in the case of Alzheimer's patients, and, secondly, that the moral and legal authority of the AD need not depend on strict equivalence of personal identity. I conclude by arguing that valid ADs protect the dignity and autonomy of Alzheimer's patients and that, therefore, there are moral obligations to uphold ADs which should be reflected in public policy and legislation.
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Roberts RL, Cherry KD, Mohan DP, Statler T, Kirkendall E, Moses A, McCraw J, Brown III AE, Fofanova TY, Gabbard J. A Personalized and Interactive Web-Based Advance Care Planning Intervention for Older Adults (Koda Health): Pilot Feasibility Study. JMIR Aging 2024; 7:e54128. [PMID: 38845403 PMCID: PMC11089888 DOI: 10.2196/54128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/28/2024] [Accepted: 03/14/2024] [Indexed: 06/10/2024] Open
Abstract
Background Advance care planning (ACP) is a process that involves patients expressing their personal goals, values, and future medical care preferences. Digital applications may help facilitate this process, though their use in older adults has not been adequately studied. Objective This pilot study aimed to evaluate the reach, adoption, and usability of Koda Health, a web-based patient-facing ACP platform, among older adults. Methods Older adults (aged 50 years and older) who had an active Epic MyChart account at an academic health care system in North Carolina were recruited to participate. A total of 2850 electronic invitations were sent through MyChart accounts with an embedded hyperlink to the Koda platform. Participants who agreed to participate were asked to complete pre- and posttest surveys before and after navigating through the Koda Health platform. Primary outcomes were reach, adoption, and System Usability Scale (SUS) scores. Exploratory outcomes included ACP knowledge and readiness. Results A total of 161 participants enrolled in the study and created an account on the platform (age: mean 63, SD 9.3 years), with 80% (129/161) of these participants going on to complete all steps of the intervention, thereby generating an advance directive. Participants reported minimal difficulty in using the Koda platform, with an overall SUS score of 76.2. Additionally, knowledge of ACP (eg, mean increase from 3.2 to 4.2 on 5-point scale; P<.001) and readiness (eg, mean increase from 2.6 to 3.2 on readiness to discuss ACP with health care provider; P<.001) significantly increased from before to after the intervention. Conclusions This study demonstrated that the Koda Health platform is feasible, had above-average usability, and improved ACP documentation of preferences in older adults. Our findings indicate that web-based health tools like Koda may help older individuals learn about and feel more comfortable with ACP while potentially facilitating greater engagement in care planning.
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Affiliation(s)
| | | | | | - Tiffany Statler
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Eric Kirkendall
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | - Adam Moses
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | - Jennifer McCraw
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | - Andrew E Brown III
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | | | - Jennifer Gabbard
- Section of Gerontology and Geriatric Medicine, School of Medicine, Wake Forest University, Winston-Salem, NC, United States
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Tompkins J, Connors H, Robinson D. Seize the Data: An Analysis of Guardianship Annual Reports. J Aging Soc Policy 2024:1-18. [PMID: 38704667 DOI: 10.1080/08959420.2024.2349494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 03/13/2024] [Indexed: 05/06/2024]
Abstract
Courts have a legal and ethical duty to monitor adult guardianship cases to protect the rights of individuals with guardians. Aging and disability advocates have been recommending improvements to adult guardianship monitoring for decades. The aim of this study is to examine annual guardianship reporting procedures in each state. Using the National Guardianship Association's (NGA) Standards of Practice as a guide, we summarize what is missing from adult guardianship annual report forms in each state. Since 2000, the NGA Standards have been the benchmark for guiding guardianship best practices, making it a valuable tool for guardianship reporting and monitoring. Results show that most states are not collecting thorough data on adults with guardians, their guardians, or the guardian-client relationship. Additionally, many existing annual report forms may be difficult to complete due to confusing question structure and reading levels that are above the national average, especially since most adult guardians are nonprofessional guardians. Improved reporting procedures would help courts monitor guardianships more effectively, ensure that the rights of individuals with guardians are being protected, and provide meaningful data on the overall state of guardianship. Limitations and plans for future research are also discussed.
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Beltran SJ, Molina O, Chapple R. Enhancing End-of-Life Care Knowledge Among Older Spanish-Speaking Adults: Results From a Pilot Educational Intervention on Advance Care Planning and Care Options. Am J Hosp Palliat Care 2024:10499091241246057. [PMID: 38621826 DOI: 10.1177/10499091241246057] [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: 04/17/2024] Open
Abstract
BACKGROUND Disparities in advance care planning (ACP) among older Latinos necessitate targeted interventions to enhance engagement and knowledge in end-of-life care. This study aimed to evaluate the effectiveness of a resource-efficient, culturally tailored educational intervention in improving ACP readiness and knowledge among older Latino adults in the community. METHODS A quasi-experimental pretest-posttest design was used to assess the impact of the intervention. The study involved community-dwelling older Latinos (aged 61-94) in the U.S. attending community wellness centers. Measures included participants' knowledge of ACP, care options, familiarity with hospice and palliative care, and attitudes toward hospice, assessed using pre- and post-intervention surveys. RESULTS Statistically significant improvements were observed in ACP knowledge, understanding of care options, and attitudes towards hospice and palliative care post-intervention. Demographic factors influenced knowledge scores, with no significant gender differences in the intervention's efficacy. CONCLUSIONS The educational intervention effectively enhanced end-of-life care planning readiness and knowledge among older Latinos. The study highlights the potential for sustainable, accessible, and culturally sensitive educational strategies to reduce disparities in ACP knowledge and possibly engagement.
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Affiliation(s)
- Susanny J Beltran
- School of Social Work, University of Central Florida, Orlando, FL, USA
| | - Olga Molina
- School of Social Work, University of Central Florida, Orlando, FL, USA
| | - Reshawna Chapple
- School of Social Work, University of Central Florida, Orlando, FL, USA
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Issa TZ, McCurdy MA, Lee Y, Lambrechts MJ, Sherman MB, Kalra A, Goodman P, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. The Impact of Socioeconomic Status on the Presence of Advance Care Planning Documents in Patients With Acute Cervical Spinal Cord Injury. J Am Acad Orthop Surg 2024; 32:354-361. [PMID: 38271675 DOI: 10.5435/jaaos-d-23-00763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/27/2023] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Patients presenting with spinal cord injury (SCI) often times have notable deficits or polytrauma and may require urgent decision making for early management. However, their presentation may affect decision-making ability. Although advance care planning (ACP) may help guide spine surgeons as to patient preferences, the rate at which they are available and disparities in ACP completion are still not understood. The objective of this study was to evaluate disparities in the completion of ACP among patients with acute SCI. METHODS All patients presenting with cervical SCI to the emergency department at an urban, tertiary level I trauma center from 2010 to 2021 were identified from a prospective database of all consults evaluated by the spine service. Each patient's medical record was reviewed to assess for the presence of ACP documents such as living will, power of attorney, or advance directive. Community-level socioeconomic status was assessed using the Distressed Communities Index. Bivariable and multivariable analyses were performed. RESULTS We identified 424 patients: 104 (24.5%) of whom had ACP. Patients with ACP were older (64.8 versus 56.5 years, P = 0.001), more likely White (78.8% versus 71.9%, P = 0.057), and present with ASIA Impairment Scale grade A SCI (21.2% versus 12.8%, P = 0.054), although the latter two did not reach statistical significance. On multivariable logistic regression, patients residing in at-risk communities were significantly less likely to have ACP documents compared with those in prosperous communities (odds ratio [OR]: 0.29, P = 0.03). Although patients living in distressed communities were less likely to complete ACP compared with those in prosperous communities (OR 0.50, P = 0.066), this did not meet statistical significance. Female patients were also less likely to have ACP (OR: 0.43, P = 0.005). CONCLUSION Female patients and those from at-risk communities are markedly less likely to complete ACP. Attention to possible disparities during admission and ACP discussions may help ensure that patients of all backgrounds have treatment goals documented.
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Affiliation(s)
- Tariq Z Issa
- From the Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA (Issa, McCurdy, Lee, Sherman, Kalra, Goodman, Canseco, Hilibrand, Vaccaro, Schroeder, and Kepler), the Feinberg School of Medicine, Northwestern University, Chicago, IL (Issa), and the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO (Lambrechts)
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Walkner T, Karr DW, Murray S, Heeren A, Berry-Stoelzle M. Participation in Advance Care Planning Among Medically At-Risk Rural Veterans: Protocol for a Personalized Engagement Model. JMIR Res Protoc 2024; 13:e55080. [PMID: 38608267 PMCID: PMC11053389 DOI: 10.2196/55080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Many of the challenges in advanced care planning (ACP) conversations are linked to the waxing and waning progress of serious illnesses. Conversations with patients about future medical care decisions by a surrogate decision maker have historically been left until late in the patient's disease trajectory. These conversations often happen at a time when the patient is already very ill. The challenge in effective early ACP and serious illness conversations is to create a situation where patients appreciate the link between current and future medical care. Setting the stage to make these conversations more accessible includes using telehealth to have conversations at the patient's place of choice. The personalization used includes addressing the current medical and social needs of the patient and ensuring that expressed needs are addressed as much as possible. Engaging patients in these conversations allows the documentation of patient preferences in the electronic health record (EHR), providing guidelines for future medical care. OBJECTIVE The objective of our telehealth serious illness care conversations program was to successfully recruit patients who lacked up-to-date documentation of ACP in their EHR. Once these patients were identified, we engaged in meaningful, structured conversations to address the veterans' current needs and concerns. We developed a recruitment protocol that increased the uptake of rural veterans' participation in serious illness care conversations and subsequent EHR documentation. METHODS The recruitment protocol outlined herein used administrative data to determine those patients who have not completed or updated formal ACP documentation in the EHR and who are at above-average risk for death in the next 3-5 years. The key features of the telehealth serious illness care conversations recruitment protocol involve tailoring the recruitment approach to address current patient concerns while emphasizing future medical decision-making. RESULTS As of September 2022, 196 veterans had completed this intervention. The recruitment method ensures that the timing of the intervention is patient driven, allowing for veterans to engage in ACP at a time and place convenient for them and their identified support persons. CONCLUSIONS The recruitment protocol has been successful in actively involving patients in ACP conversations, leading to an uptick in completed formal documentation of ACP preferences within the EHR for this specific population. This documentation is then available to the medical team to guide future medical care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/55080.
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Affiliation(s)
- Tammy Walkner
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, United States
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, United States
| | - Daniel W Karr
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, United States
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, United States
| | - Sarah Murray
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, United States
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, United States
| | - Amanda Heeren
- Iowa City VA Health Care System, Iowa City, IA, United States
- Department of Psychiatry, Carver College of Medicine, Unviersity of Iowa, Iowa City, IA, United States
| | - Maresi Berry-Stoelzle
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, United States
- Vaughan Institute, Tippie College of Business, University of Iowa, Iowa City, IA, United States
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Weber V, Hübner A, Pflock S, Schamberger L, Somasundaram R, Boehm L, Bauer W, Diehl-Wiesenecker E. Advance directives in the emergency department-a systematic review of the status quo. BMC Health Serv Res 2024; 24:426. [PMID: 38570808 PMCID: PMC10993583 DOI: 10.1186/s12913-024-10819-1] [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] [Received: 04/12/2023] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Providing individualised healthcare in line with patient wishes is a particular challenge for emergency healthcare professionals. Documentation of patient wishes (DPW), e.g. as advance directives, can guide clinicians in making end-of-life decisions that respect the patient's wishes and autonomy. However, patient centered decisions are hindered by limited availability of DPWs in emergency settings. OBJECTIVE This systematic review aims to congregate present data on recorded rates for DPW existence and availability in the emergency department (ED) as well as contributing factors for these rates. METHODS We searched MEDLINE, Google Scholar, Embase and Web of Science databases in September 2023. Publications providing primary quantitative data on DPW in the ED were assessed. Publications referring only to a subset of ED patients (other than geriatric) and investigating DPW issued after admission were excluded. RESULTS A total of 22 studies from 1996 to 2021 were included in the analysis. Most were from the US (n = 12), followed by Australia (n = 4), Canada (n = 2), South Korea, Germany, the United Kingdom and Switzerland (n = 1 each). In the general adult population presenting to the ED, 19.9-27.8% of patients reported having some form of DPW, but only in 6.8% or less it was available on presentation. In the geriatric population, DPW rates (2.6-79%) as well as their availability (1.1-48.8%) varied widely. The following variables were identified as positive predictors of having DPW, among others: higher age, poorer overall health, as well as sociodemographic factors, such as female gender, having children, being in a relationship, higher level of education or a recent previous presentation to hospital. CONCLUSIONS Existence and availability of a recorded DPW among ED patients was low in general and even in geriatric populations mostly well below 50%. While we were able to gather data on prevalence and predictors, this was limited by heterogeneous data. We believe further research is needed to explore the quality of DPW and measures to increase both rates of existence and availability of DPW in the ED.
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Affiliation(s)
- Vincent Weber
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Aurelia Hübner
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sandra Pflock
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lukas Schamberger
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Rajan Somasundaram
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lennert Boehm
- Emergency Department, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Wolfgang Bauer
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eva Diehl-Wiesenecker
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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Landau AY, Venkatram C, Song J, Topaz M, Klitzman R, Shang J, Stone P, McDonald M, Cohen B. Home Care Clinicians' Perspectives on Advance Care Planning for Patients at Risk for Becoming Incapacitated With No Evident Advance Directives or Surrogates. J Hosp Palliat Nurs 2024; 26:74-81. [PMID: 38340056 PMCID: PMC10940180 DOI: 10.1097/njh.0000000000000998] [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: 02/12/2024]
Abstract
Advance care planning is important and timely for patients receiving home health services; however, opportunities to facilitate awareness and engagement in this setting are often missed. This qualitative descriptive study elicited perspectives of home health nurses and social workers regarding barriers and facilitators to creating advance care plans in home health settings, with particular attention to patients with few familial or social contacts who can serve as surrogate decision-makers. We interviewed 15 clinicians employed in a large New York City-based home care agency in 2021-2022. Participants reported a multitude of barriers to supporting patients with advance care planning at the provider level (eg, lack of time and professional education, deferment, discomfort), patient level (lack of knowledge, mistrust, inadequate support, deferment, language barriers), and system level (eg, discontinuity of care, variations in advance care planning documents, legal concerns, lack of institutional protocols and centralized information). Participants noted that greater socialization and connection to existing educational resources regarding the intended purpose, scope, and applicability of advance directives could benefit home care patients.
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Wilkin K, Fang ML, Sixsmith J. Implementing advance care planning in palliative and end of life care: a scoping review of community nursing perspectives. BMC Geriatr 2024; 24:294. [PMID: 38549045 PMCID: PMC10976700 DOI: 10.1186/s12877-024-04888-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 03/13/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Advance care planninganning (ACP) is a priority within palliative care service provision. Nurses working in the community occupy an opportune role to engage with families and patients in ACP. Carers and family members of palliative patients often find ACP discussions difficult to initiate. However, community nurses caring for palliative patients can encourage these discussions, utilising the rapport and relationships they have already built with patients and families. Despite this potential, implementation barriers and facilitators continue to exist. To date, no research synthesis has captured the challenges community nurses face when implementing ACP, nor the facilitators of community nurse-led ACP. Considering this, the review question of: 'What factors contribute to or hinder ACP discussion for nurses when providing care to palliative patients?' was explored. METHOD To capture challenges and facilitators, a global qualitative scoping review was undertaken in June 2023. The Arksey and O'Malley framework for scoping reviews guided the review methodology. Six databases were searched identifying 333 records: CINAHL (16), MEDLINE (45), PUBMED (195), EMBASE (30), BJOCN (15), IJOPN (32). After de-duplication and title and abstract screening, 108 records remained. These were downloaded, hand searched (adding 5 articles) and subject to a full read. 98 were rejected, leaving a selected dataset of 15 articles. Data extracted into a data extraction chart were thematically analysed. RESULTS Three key themes were generated: 'Barriers to ACP', 'Facilitators of ACP' and 'Understanding of professional role and duty'. Key barriers were - lack of confidence, competence, role ambiguity and prognostic uncertainty. Key facilitators concerned the pertinence of the patient-practitioner relationship enabling ACP amongst nurses who had both competence and experience in ACP and/or palliative care (e.g., palliative care training). Lastly, nurses understood ACP to be part of their role, however, met challenges understanding the law surrounding this and its application processes. CONCLUSIONS This review suggests that community nurses' experience and competence are associated with the effective implementation of ACP with palliative patients. Future research is needed to develop interventions to promote ACP uptake in community settings, enable confidence building for community nurses and support higher standards of palliative care via the implementation of ACP.
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Affiliation(s)
| | - Mei Lan Fang
- School of Health Sciences, University of Dundee, Dundee, Scotland
- Urban Studies and Department of Gerontology, Simon Fraser University, Vancouver, Canada
| | - Judith Sixsmith
- School of Health Sciences, University of Dundee, Dundee, Scotland.
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Matthieu MM, Taylor LD, Adkins DA, Williams JS, Hu B, Oliver CM, McCullough JA, Mallory MJ, Smith ID, Painter JT, Ounpraseuth ST, Garner KK. Adopting the RE-AIM analytic framework for rural program evaluation: experiences from the Advance Care Planning via Group Visits (ACP-GV) national evaluation. FRONTIERS IN HEALTH SERVICES 2024; 4:1210166. [PMID: 38590731 PMCID: PMC10999534 DOI: 10.3389/frhs.2024.1210166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 02/27/2024] [Indexed: 04/10/2024]
Abstract
Introduction To support rigorous evaluation across a national portfolio of grants, the United States Department of Veterans Affairs (VA) Office of Rural Health (ORH) adopted an analytic framework to guide their grantees' evaluation of initiatives that reach rural veterans and to standardize the reporting of outcomes and impacts. Advance Care Planning via Group Visits (ACP-GV), one of ORH's Enterprise-Wide Initiatives, also followed the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. ACP-GV is a national patient-centered intervention delivered in a large, veterans integrated healthcare system. This manuscript describes how RE-AIM was used to evaluate this national program and lessons learned from ORH's annual reporting feedback to ACP-GV on their use of the framework to describe evaluation impacts. Methods We used patient, provider, and site-level administrative health care data from the VA Corporate Data Warehouse and national program management databases for federal fiscal years (FY) spanning October 1, 2018-September 30, 2023. Measures included cumulative and past FY metrics developed to assess program impacts. Results RE-AIM constructs included the following cumulative and annual program evaluation results. ACP-GV reached 54,167 unique veterans, including 19,032 unique rural veterans between FY 2018 to FY 2023. During FY 2023, implementation adherence to the ACP-GV model was noted in 91.7% of program completers, with 55% of these completers reporting a knowledge increase and 14% reporting a substantial knowledge increase (effectiveness). As of FY 2023, 66 ACP-GV sites were active, and 1,556 VA staff were trained in the intervention (adoption). Of the 66 active sites in FY 2023, 27 were sites previously funded by ORH and continued to offer ACP-GV after the conclusion of three years of seed funding (maintenance). Discussion Lessons learned developing RE-AIM metrics collaboratively with program developers, implementers, and evaluators allowed for a balance of clinical and scientific input in decision-making, while the ORH annual reporting feedback provided specificity and emphasis for including both cumulative, annual, and rural specific metrics. ACP-GV's use of RE-AIM metrics is a key step towards improving rural veteran health outcomes and describing real world program impacts.
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Affiliation(s)
- Monica M. Matthieu
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
- School of Social Work, Saint Louis University, Saint Louis, MO, United States
| | - Laura D. Taylor
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, United States
| | - David A. Adkins
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
| | - J. Silas Williams
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
| | - Bo Hu
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
| | - Ciara M. Oliver
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
| | - Jane Ann McCullough
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, United States
| | - Mary J. Mallory
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, United States
| | - Ian D. Smith
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
| | - Jacob T. Painter
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
- Division of Pharmaceutical Evaluation & Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Songthip T. Ounpraseuth
- Department of Biostatistics, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Kimberly K. Garner
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, United States
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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15
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Siconolfi D, Thomas EG, Chen EK, Haberlen SA, Friedman MR, Ware D, Meanley S, Brennan-Ing M, Brown AL, Egan JE, Bolan R, Stosor V, Plankey M. Advance Care Planning Among Sexual Minority Men: Sociodemographic, Health Care, and Health Status Predictors. J Aging Health 2024; 36:147-160. [PMID: 37249419 PMCID: PMC10687306 DOI: 10.1177/08982643231177725] [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: 05/31/2023]
Abstract
Objectives: Advance care planning (ACP) specifies decision-making surrogates and preferences for serious illness or end-of-life medical care. ACP research has largely neglected sexual minority men (SMM), a population that experiences disparities in health care and health status. Methods: We examined formal and informal ACP among SMM ages 40+ in the Multicenter AIDS Cohort Study (N = 1,071). Results: For informal ACP (50%), younger SMM and men with past cardiovascular events had greater odds of planning; single men had lower odds of planning. For formal ACP (39%), SMM with greater socioeconomic status had greater odds of planning; SMM who were younger, of racial/ethnic minority identities, who were single or in a relationship without legal protections, and who lacked a primary care home had lower odds of planning. Discussion: Findings warrant further exploration of both informal and formal planning. More equitable, culturally-humble engagement of SMM may facilitate access, uptake, and person-centered planning.
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Affiliation(s)
| | | | | | | | - M Reuel Friedman
- Rutgers School of Public Health, Rutgers University, Newark, NJ, USA
| | - Deanna Ware
- Georgetown University Medical Center, Washington, DC, USA
| | - Steven Meanley
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Mark Brennan-Ing
- Brookdale Center for Healthy Aging, Hunter College, New York, NY, USA
| | - Andre L Brown
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - James E Egan
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | | | - Valentina Stosor
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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16
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Patel A, Bowman CA, Prause N, Kilaru SM, Nguyen A, Kogekar N, Cohen C, Channen L, Harty A, Perumalswami P, Dietrich D, Schiano T, Woodrell C, Agarwal R. Outcomes of a 3-Year Quality Improvement Study to Improve Advance Care Planning in Patients With Decompensated Cirrhosis. Am J Gastroenterol 2024; 119:580-583. [PMID: 37934193 PMCID: PMC10904002 DOI: 10.14309/ajg.0000000000002570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/26/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION To report outcomes of a 3-year quality improvement pilot study to improve advance directive (AD) completion. METHODS The pilot consisted of champions, education, electronic health record templates, and workflow changes. We assessed changes, predictors, and effects of AD completion. RESULTS The pilot led to greater (8.3%-36%) and earlier AD completion, particularly among those divorced, with alcohol-associated liver disease, and with higher Model of End-Stage Liver Disease-Sodium score. Decedents whose AD specified nonaggressive goals experienced lower hospital lengths of stay. DISCUSSION Advance care planning initiatives are feasible and may reduce health care utilization among decedents requesting less aggressive care.
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Affiliation(s)
- Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
- Department of Gastroenterology, Hepatology, and Nutrition, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Chip A. Bowman
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University New York Presbyterian Hospital, New York, New York, USA
| | - Nicole Prause
- Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Saikiran M. Kilaru
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Andrew Nguyen
- Department of Gastroenterology and Hepatology, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Nina Kogekar
- Division of Gastroenterology, Montefiore Medical Center, Bronx, New York, USA
| | - Cynthia Cohen
- Division of Gastroenterology and Hepatology, Westchester Medical Center
| | - Lindsay Channen
- Warren Alpert Medical School of Brown University in Providence, Providence, Rhode Island, USA
| | - Alyson Harty
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ponni Perumalswami
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Douglas Dietrich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas Schiano
- Recanati Miller Transplant Institute, Mount Sinai Hospital, New York, New York, USA
| | - Christopher Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Ritu Agarwal
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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17
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Choi S, Ko H. Factors affecting advance directives completion among older adults in Korea. Front Public Health 2024; 12:1329916. [PMID: 38371241 PMCID: PMC10869548 DOI: 10.3389/fpubh.2024.1329916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/15/2024] [Indexed: 02/20/2024] Open
Abstract
Objective Advance directives (ADs) provide an opportunity for patients to enhance the quality of their end-of-life care and prepare for a dignified death by deciding treatment plans. The purpose of this study was to explore the multiple factors that influence the advance directives completion among older adults in South Korea. Methods This was a secondary analysis of a cross-sectional study of 9,920 older adults. The differences in ADs based on subjects' sociodemographic characteristics, health-related characteristics, and attitude toward death were tested using the chi-squared and t-test. A multinomial logistic regression model was used to identify the influencing factor of ADs. Results The number of chronic diseases, number of prescribed medications, depression, insomnia, suicide intention, and hearing, vision, or chewing discomfort were higher in the ADs group compared to the non-ADs group. The influencing factors of the signing of ADs included men sex, higher education level, exercise, death preparation education, lower awareness of dying-well, and experience of fracture. Conclusion Information dissemination regarding ADs should be promoted and relevant authorities should consider multiple options to improve the physical and psychological health of older adults, as well as their attitude toward death to increase the ADs completion rate.
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Affiliation(s)
| | - Hana Ko
- College of Nursing, Gachon University, Yeonsu-gu, Incheon, Republic of Korea
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18
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Kirkpatrick H, Buccheri RK, Sharifi C. Advance Care Planning Engagement Strategies for Primary Care Providers Seeing Diverse Patient Populations: A Scoping Review. J Hosp Palliat Nurs 2024; 26:E20-E29. [PMID: 38096444 DOI: 10.1097/njh.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Diverse patients are less likely than Whites to have advance care planning. The primary purpose of this scoping review was to summarize recent evidence about advance care planning engagement interventions for primary care providers working with diverse patients. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for Scoping Reviews (PRISMA-ScR) Checklist was followed. Peer-reviewed articles published in English since 2000 reporting the results of studies testing intervention programs in primary care to improve advance care planning with adult, racially diverse populations were included. Searches were conducted in 5 online databases and yielded 72 articles. Gray literature yielded 23 articles. Two authors independently reviewed the abstracts of 72 articles determining that 9 articles met the aim of this review. These studies were analyzed by communication tools and other resources, population, intervention, primary outcomes, instruments, and primary findings and organized into 3 categories: ( a ) provider-focused interventions, ( b ) patient-focused interventions, and ( c ) multilevel interventions. Improvement in advance care planning outcomes can be achieved for racially diverse populations by implementing targeted advance care planning engagement interventions for both providers and patients. These interventions can be used in primary care to increase advance care planning for diverse patients. More research is needed that evaluates best practices for integrating advance care planning into primary care workflows.
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19
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Li L, Barnes DE, Nouri S, Shi Y, Volow AM, Feuz M, Li BH, Sudore RL. Surrogate decision-makers from historically marginalized populations have lower levels of preparedness for care planning. J Am Geriatr Soc 2024; 72:559-566. [PMID: 38193805 PMCID: PMC10922733 DOI: 10.1111/jgs.18732] [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] [Received: 05/31/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Surrogate preparedness for medical decision-making is an important part of care planning. This study examined preparedness and engagement among historically marginalized surrogates. METHODS Surrogates were included if they were named medical decision-makers by patients ≥55 years at a San Francisco safety-net and Veterans Affairs hospital. We assessed preparedness for medical decision-making by asking if surrogates had been formally asked to be the medical decision-maker, if patients had discussed medical wishes with surrogates, and if the surrogate role and these medical wishes had been documented. We assessed surrogate confidence and readiness using a modified Surrogate ACP Engagement Survey. We used Wilcoxon rank-sum tests to measure the association of engagement scores with surrogate characteristics. RESULTS Of 422 surrogates, their mean age was 53 years (SD ±14.5), 73% were from minoritized groups, 38% were Spanish-speaking, and 15% had limited health literacy. For preparedness outcomes, 13% of surrogates were not formally asked to play this role, 46% reported the patient had not discussed end-of-life medical wishes, and 51% reported there had been no formal documentation of the surrogate role. Surrogates reported higher confidence 4.43/5 (SD ± 0.64) than readiness 3.70 (1.22) for decision-making (p < 0.001). Confidence and readiness scores were lower among historically marginalized participants. CONCLUSION More resources are needed to prepare surrogate decision-makers from historically marginalized communities for discussing patient's goals of care and treatment preferences.
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Affiliation(s)
- Lingsheng Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Deborah E. Barnes
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
| | - Sarah Nouri
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Ying Shi
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Aiesha M. Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Mariko Feuz
- University of Iowa-Des Moines Internal Medicine Residency Program, Des Moines, IA, USA
| | - Brookelle H. Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
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20
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Golmohammadi M, Ebadi A, Ashrafizadeh H, Rassouli M, Barasteh S. Factors related to advance directives completion among cancer patients: a systematic review. BMC Palliat Care 2024; 23:3. [PMID: 38166983 PMCID: PMC10762918 DOI: 10.1186/s12904-023-01327-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients. METHODS A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior. RESULTS Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics". CONCLUSION The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.
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Affiliation(s)
- Mobina Golmohammadi
- Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hadis Ashrafizadeh
- Student Research Committee, Faculty of Nursing, Dezful University of Medical Sciences, Dezful, Iran
| | - Maryam Rassouli
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Salman Barasteh
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
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21
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Kim B, Lee J, Choi YS. Public awareness of advance care planning and hospice palliative care: a nationwide cross-sectional study in Korea. BMC Palliat Care 2023; 22:205. [PMID: 38151721 PMCID: PMC10752019 DOI: 10.1186/s12904-023-01333-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023] Open
Abstract
CONTEXT Advance care planning (ACP) and hospice palliative care (HPC) have potential benefits for individuals and health systems. Public awareness of them might increase their acceptance. OBJECTIVES To examine public awareness of ACP and HPC and related factors including individuals' experience of health care among Korean population. METHODS A cross-sectional study based on a nationally representative sample was conducted. Data from participants aged 15 years or older were examined. Socio-demographic characteristics, health-related factors, health care experience in the past year, and awareness of ACP and HPC were analyzed. Subgroup analysis was conducted to determine associations between specific experiences during outpatient visit and awareness of ACP and HPC. RESULTS Of a total of 13,546 subjects, 39.3% and 35.7% reported awareness of ACP and HPC, respectively. About half (48.6%) of participants reported that they were completely unaware of ACP or HPC. Recent outpatient visit was positively associated with HPC awareness. Participants were more likely to recognize ACP or HPC if they had experience in hospitalization and health checkup over the past year and had trust in the medical system. Conversely, participants who had inadequate health care access due to cost burden showed low awareness of ACP and HPC. CONCLUSION There was a lack of public awareness of ACP and HPC. There were significant differences depending on various factors, especially individual health care experiences. Appropriate interventions are needed to facilitate discussion of ACP and HPC, thereby increasing public awareness.
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Affiliation(s)
- Boram Kim
- Division of Health Policy, Bureau of Health Policy, Ministry of Health and Welfare, Sejong-si, Republic of Korea
| | - Junyong Lee
- Department of Family Medicine, Veterans Health Service (VHS) Medical Center, Seoul, Republic of Korea
| | - Youn Seon Choi
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Republic of Korea.
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22
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Dolmans RGF, Robertson FC, Eijkholt M, van Vliet P, Broekman MLD. Palliative Care in Severe Neurotrauma Patients in the Intensive Care Unit. Neurocrit Care 2023; 39:557-564. [PMID: 37173560 PMCID: PMC10689547 DOI: 10.1007/s12028-023-01717-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/17/2023] [Indexed: 05/15/2023]
Abstract
Traumatic brain injury (TBI) is a significant cause of mortality and morbidity worldwide and many patients with TBI require intensive care unit (ICU) management. When facing a life-threatening illness, such as TBI, a palliative care approach that focuses on noncurative aspects of care should always be considered in the ICU. Research shows that neurosurgical patients in the ICU receive palliative care less frequently than the medical patients in the ICU, which is a missed opportunity for these patients. However, providing appropriate palliative care to neurotrauma patients in an ICU can be difficult, particularly for young adult patients. The patients' prognoses are often unclear, the likelihood of advance directives is small, and the bereaved families must act as decision-makers. This article highlights the different aspects of the palliative care approach as well as barriers and challenges that accompany the TBI patient population, with a particular focus on young adult patients with TBI and the role of their family members. The article concludes with recommendations for physicians for effective and adequate communication to successfully implement the palliative care approach into standard ICU care and to improve quality of care for patients with TBI and their families.
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Affiliation(s)
- Rianne G F Dolmans
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Faith C Robertson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Marleen Eijkholt
- Department of Ethics and Law in Healthcare, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter van Vliet
- Department of Intensive Care Medicine, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Marike L D Broekman
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, The Netherlands
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23
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McLeod-Sordjan R. Death Preparedness: Development and Initial Validation of the Advance Planning Preparedness Scale. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231212998. [PMID: 37922539 DOI: 10.1177/00302228231212998] [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: 11/07/2023]
Abstract
Delayed advance planning and costs of life sustaining treatments at end of life significantly contribute to the economic burden of healthcare. Clinician barriers include perceptions of inappropriate timing, lack of skills in end-of-life communication and viewing readiness as a behavior rather than a death attitude. This study developed and validated a measurement of psychological preparedness for advance directive completion. Confirmatory factor analysis (N = 543) of a 35 item pool (Cronbach α = .96) supported five sub-scales; psychological comfort (α = .87), desire to know (α = .88), thinking (α = .84), willingness (α = .82) and existential reflection (α = .79) with a possible common factor (α = .84). Results suggested significant predictors of completing directives in 30 days included discussion (OR .08, p < .001), preparedness (OR 4.08, p = .03) and uncertainty (OR 4.37, p = .02). APP = 35 is a reliable and valid measure with utility to assess readiness for completion of EOL documents.
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Affiliation(s)
- Renee McLeod-Sordjan
- Division of Medical Ethics, Department of Medicine, Northwell Health, Manhasset, NY, USA
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Bansal VV, Kim D, Reddy B, Witmer HDD, Dhiman A, Godley FA, Ong CT, Clark S, Ulrich L, Polite B, Shergill A, Malec M, Eng OS, Tun S, Turaga KK. Early Integrated Palliative Care Within a Surgical Oncology Clinic. JAMA Netw Open 2023; 6:e2341928. [PMID: 37934497 PMCID: PMC10630898 DOI: 10.1001/jamanetworkopen.2023.41928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/18/2023] [Indexed: 11/08/2023] Open
Abstract
Importance Advance directive (AD) designation is an important component of advance care planning (ACP) that helps align care with patient goals. However, it is underutilized in high-risk surgical patients with cancer, and multiple barriers contribute to the low AD designation rates in this population. Objective To assess the association of early palliative care integration with changes in AD designation among patients with cancer who underwent surgery. Design, Setting, and Participants This cohort study was a retrospective analysis of a prospectively maintained registry of adult patients who underwent elective surgery for advanced abdominal and soft tissue malignant tumors at a surgical oncology clinic in a comprehensive cancer center with expertise in regional therapeutics between June 2016 and May 2022, with a median (IQR) postoperative follow-up duration of 27 (15-43) months. Data analysis was conducted from December 2022 to April 2023. Exposure Integration of ACP recommendations and early palliative care consultations into the surgical workflow in 2020 using electronic health records (EHR), preoperative checklists, and resident education. Main Outcomes and Measures The primary outcomes were AD designation and documentation. Multivariable logistic regression was performed to assess factors associated with AD designation and documentation. Results Among the 326 patients (median [IQR] age 59 [51-67] years; 189 female patients [58.0%]; 243 non-Hispanic White patients [77.9%]) who underwent surgery, 254 patients (77.9%) designated ADs. The designation rate increased from 72.0% (131 of 182 patients) before workflow integration to 85.4% (123 of 144 patients) after workflow integration in 2020 (P = .004). The AD documentation rate did not increase significantly after workflow integration in 2020 (48.9% [89 of 182] ADs documented vs 56.3% [81 of 144] ADs documented; P = .19). AD designation was associated with palliative care consultation (odds ratio [OR], 41.48; 95% CI, 9.59-179.43; P < .001), palliative-intent treatment (OR, 5.12; 95% CI, 1.32-19.89; P = .02), highest age quartile (OR, 3.79; 95% CI, 1.32-10.89; P = .01), and workflow integration (OR, 2.05; 95% CI, 1.01-4.18; P = .048). Patients who self-identified as a race or ethnicity other than non-Hispanic White were less likely to have designated ADs (OR, 0.36; 95% CI, 0.17-0.76; P = .008). AD documentation was associated with palliative care consulation (OR, 4.17; 95% CI, 2.57- 6.77; P < .001) and the highest age quartile (OR, 2.41; 95% CI, 1.21-4.79; P = .01). Conclusions and Relevance An integrated ACP initiative was associated with increased AD designation rates among patients with advanced cancer who underwent surgery. These findings demonstrate the feasibility and importance of modifying clinical pathways, integrating EHR-based interventions, and cohabiting palliative care physicians in the surgical workflow for patients with advanced care.
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Affiliation(s)
- Varun V. Bansal
- Division of Surgical Oncology, Yale School of Medicine, New Haven, Connecticut
| | - Daniel Kim
- Pritzker School of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Biren Reddy
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Hunter D. D. Witmer
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Ankit Dhiman
- Department of Surgery, Medical College of Georgia, Augusta
| | - Frederick A. Godley
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Cecilia T. Ong
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Sandra Clark
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Leah Ulrich
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Blase Polite
- Department of Medicine, Section of Hematology and Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Ardaman Shergill
- Department of Medicine, Section of Hematology and Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Monica Malec
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Oliver S. Eng
- Department of Surgery, Division of Surgical Oncology, University of California, Irvine
| | - Sandy Tun
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Kiran K. Turaga
- Division of Surgical Oncology, Yale School of Medicine, New Haven, Connecticut
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Gupta S, Chen BJ, Suolang D, Cooper R, Faigle R. Advance directives among community-dwelling stroke survivors. PLoS One 2023; 18:e0292484. [PMID: 37847705 PMCID: PMC10581473 DOI: 10.1371/journal.pone.0292484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/21/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE Advance directives (ADs) are integral to health care, allowing patients to specify surrogate decision-makers and treatment preferences in case of loss of capacity. The present study sought to identify determinants of ADs among stroke survivors. METHODS In this cross-sectional study (Care Attitudes and Preferences in Stroke Survivors [CAPriSS]), community-dwelling stroke survivors were surveyed on ADs; validated scales were used to query palliative care knowledge and attitudes towards life-sustaining treatments. Logistic regression was used to determine variables associated with ADs. RESULTS Among 562 community-dwelling stroke survivors who entered the survey after screening questions confirmed eligibility, 421 (74.9%) completed survey components with relevant variables of interest. The median age was 69 years (IQR 58-75 years); 53.7% were male; and 15.0% were Black. Two hundred and fifty-one (59.6%) respondents had ADs. Compared to stroke survivors without ADs, those with ADs were more likely to be older (median age 72 vs. 61 years; p<0.001), White (91.2% vs. 75.9%, p<0.001), and male (58.6% vs. 46.5%, p = 0.015), and reported higher education (p<0.001) and income (p = 0.011). Ninety-eight (23.3%) participants had "never heard of palliative care". Compared to participants without ADs, participants with ADs had higher Palliative Care Knowledge Scale (PaCKS) scores (median 10 [IQR 5-12] vs. 7 [IQR 0-11], p<0.001), and lower scores on the Attitudes Towards Life-Sustaining Treatments Scale (indicating a more negative attitude towards life-sustaining treatments; median 23 [IQR 18-28] vs. 29 [IQR 24-35], p<0.001). Multivariable logistic regression identified age (OR 1.62 per 10 year increase, 95% CI 1.30-2.02; p<0.001), prior advance care planning discussion with a physician (OR 1.73, 95% CI 1.04-2.86; p = 0.034), PaCKS scores (OR 1.06 per 1 point increase, 95% CI 1.01-1.12; p = 0.018), and Attitudes Towards Life-Sustaining Treatments Scale scores (OR 0.91 per 1 point increase, 95% CI 0.88-0.95; p<0.001) as variables independently associated with ADs. CONCLUSIONS Age, prior advance care planning discussion with a physician, palliative care knowledge, and attitudes towards life-sustaining treatments were independently associated with ADs.
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Affiliation(s)
- Soumya Gupta
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Bridget J. Chen
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Deji Suolang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Rachel Cooper
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Otto RB, Fields NL, Bennett M, Anderson KA. Positive Aging and Death or Dying: A Scoping Review. THE GERONTOLOGIST 2023; 63:1497-1509. [PMID: 36744720 DOI: 10.1093/geront/gnad006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES This scoping review aims to examine the extent and the manner in which research that utilizes successful, active, productive, and healthy aging framework(s) includes death or dying. RESEARCH DESIGN AND METHODS An examination of peer-reviewed academic journal articles was conducted following Joanna Briggs Institute's methodological standards for scoping reviews and conforming to Arskey and O'Malley's 5-stage framework. The initial search resulted in 1,759 articles for review, and following the rigorous screening, 35 studies were included for the final review. A qualitative thematic analysis was used to identify how research utilizes the concepts of death and dying in the context of 4 positive aging models. RESULTS The core themes identified include (a) the absence of death and dying dimensions in positive aging models; (b) older adults' outlooks on death and dying while aging well; (c) religious and spiritual dimensions of aging well; (d) negative consequences of positive aging models without death and dying dimensions; and (e) the future of death and dying in positive aging models. DISCUSSION AND IMPLICATIONS The review delivers a critique by researchers on the noticeable absence of death and dying processes within the framework of successful, active, productive, and healthy aging models. These findings represent a rich opportunity for future research on these concepts.
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Affiliation(s)
- Robin Brown Otto
- School of Social Work, University of Texas at Arlington, Arlington, Texas, USA
| | - Noelle L Fields
- School of Social Work, University of Texas at Arlington, Arlington, Texas, USA
| | - Michael Bennett
- School of Social Work, University of Texas at Arlington, Arlington, Texas, USA
| | - Keith A Anderson
- Department of Social Work, University of Mississippi, Oxford, Mississippi, USA
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Gelfman LP, Barnes DE, Goldstein N, Volow AM, Shi Y, Li B, Sudore RL. Quality and Satisfaction With Advance Care Planning Conversations Among English- and Spanish-Speaking Older Adults. J Palliat Med 2023; 26:1380-1385. [PMID: 37335910 PMCID: PMC10551762 DOI: 10.1089/jpm.2022.0565] [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] [Accepted: 04/17/2023] [Indexed: 06/21/2023] Open
Abstract
Background: Little is known about the patient-reported quality of and satisfaction with advance care planning (ACP) conversations with surrogates and clinicians among English- and Spanish-speaking older adults, or the potential disparities associated with ACP communication satisfaction. Objectives: To determine patients' perceived quality of and satisfaction with ACP surrogate/clinician conversations and associated patient characteristics. Design: Cross-sectional baseline data were used from two ACP trials, 2013-2017. Outcomes included self-reported ACP conversation quality ("general" vs. "detailed") and communication satisfaction (5-point Likert scale). Associations were determined by chi-squared and t-tests. Setting/Subjects: Subjects were primary care patients ≥55 years with chronic/serious illness in the United States. Results: Of 1398 patients, mean age was 65.6 years (±7.7), 46% women, 32% Spanish speaking, 34% had limited health literacy, and 589 (42%) reported conversations with surrogates and 216 (15%) with clinicians. Of these, less than half rated the conversations as detailed high quality (clinician: 43%; surrogate: 37%). Five-point communication satisfaction scores were higher with detailed versus general conversations (e.g., surrogates: 4.4 vs. 4.1, p = 0.001; clinicians: 4.4 vs. 4.2, p = 0.18) and more often reported by men versus women [(4.4 (0.8) vs. 4.0 (1.0), p = 0.003]; those with adequate versus limited health literacy [4.4 (0.8) vs. 4.0 (0.9), p = 0.002]; and English versus Spanish speakers [4.5 (0.7) vs. 3.5 (0.9), p < 0.001]. Conclusions: Among English- and Spanish-speaking older adults, ACP conversations were infrequent and most were general in quality. Higher quality detailed conversations resulted in greater communication satisfaction. Interventions are needed to improve conversation quality, particularly for Spanish-speaking patients and those with limited health literacy. Trial Registrations: ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941.
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Affiliation(s)
- Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Deborah E. Barnes
- Department of Psychiatry and University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Nathan Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aiesha M. Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ying Shi
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Tooba R, Rose S, Modlin C, Liang C, Mascha EJ, Perez-Protto S. Using Preanesthesia Clinic Visits to Improve Advance Directives Completion: An Interrupted Time Series Analysis. Anesth Analg 2023; 137:906-916. [PMID: 37450641 DOI: 10.1213/ane.0000000000006533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Advance directives documentation can increase the likelihood that patient's wishes are respected if they become incapacitated. Unfortunately, completion rates are suboptimal overall, and disparities may exist, especially for vulnerable groups. We assessed whether implementing an initiative to standardize advance directives discussions during preanesthesia visits was associated with changes in rates of advance directives completion over time, and whether the association depends on race, insurance type, or income. METHODS We conducted a before-after interrupted time series evaluation between January 1, 2015 and June 30, 2019 in a single-center, outpatient preanesthesia clinic. Participants were adults who visited the preanesthesia clinic at Cleveland Clinic and had >1 comorbidity before a noncardiac surgery of either medium or high risk. The intervention in March of 2017 consisted of training staff to help patients complete and witness advance directives documents during visits. We measured advance directives completion, by race, payor, and income (using the 2019 Federal Poverty Line). We assessed the confounder-adjusted association between intervention (pre versus post) and proportion of patients completing advanced directives over time using segmented regression to compare slopes between periods and assess changes at start of the intervention. We used similar models to assess whether changes depended on race, insurance type, or income level. RESULTS We included 26,368 visits from 22,430 patients. We analyzed financial status for 16,788 visits from 14,274 patients who had address data. There were 11,242 (43%) visits preintervention and 15,126 (57%) visits postintervention. Crude completion rates for advance directives increased from 29% to 78%, with odds of completion an estimated 18 times higher than preintervention (odds ratio [95% CI] of 18 [16-21]; P < 0.001). Regarding race, Black patients had lower completion rates preintervention than White patients, although the gap steadily closed after the intervention ( P = .001). Postintervention, both race groups immediately increased, with no difference in amount of increase ( P = .17) or postintervention change in slope difference ( P = .17). Regarding insurance, patients with Medicaid had lower preintervention completion rates than those with private. Intervention was associated with increases in both groups, but the difference in slopes ( P = .43) or proportions ( P = .23) between the groups did not change after intervention. Regarding the Federal Poverty Line, the completion rate gap between those below (<100%) and above (139%-400%) narrowed by approximately half (0.51: 95% CI, 0.27-0.98; P = .04). CONCLUSIONS Standardizing advance directives discussions during preanesthesia visits was associated with more patients completing advance directives, particularly in vulnerable patient groups.
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Affiliation(s)
- Rubabin Tooba
- From the Department of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas
| | - Susannah Rose
- Center for Bioethics and Safety, Quality and Patient Experience, Clinical Transformation, Cleveland Clinic, Cleveland, Ohio
| | | | - Chen Liang
- Departments of Quantitative Health and Sciences
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward J Mascha
- Departments of Quantitative Health Sciences
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Silvia Perez-Protto
- Departments of Intensive Care & Resuscitation
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Ossowski S, Lyon L, Linehan E, Gordon NP, Egorova O, Mark B, Beringer K, Abbe T, Shirazi A, Weldon C, Trosman J, Ravelo A, Liu R. Advance Directives for Patients With Breast Cancer: Applying the Right Info/Right Care/Right Patient/Right Time Oncology Model. Perm J 2023; 27:30-36. [PMID: 37255340 PMCID: PMC10502389 DOI: 10.7812/tpp/22.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Background Advance directives (AD) are an important component of life care planning for patients undergoing treatment for cancer; however, there are few effective interventions to increase AD rates. In this quality improvement project, the authors integrated AD counseling into a novel right info/right care/right patient/right time (4R) sequence of care oncology delivery intervention for breast cancer patients in an integrated health care delivery system. Methods The authors studied two groups of patients with newly diagnosed breast cancer who attended a multidisciplinary clinic and underwent definitive surgery at a single facility. The usual care (UC) cohort (N = 139) received care from October 1, 2019 to September 30, 2020. The 4R cohort (N = 141) received care from October 1, 2020 to September 30, 2121 that included discussing AD completion with a health educator prior to surgery. The authors used bivariate analyses to assess whether the AD intervention increased AD completion rates and to identify factors influencing AD completion. Results The UC and 4R cohorts were similar in age, gender, race/ethnicity, interpreter need, Elixhauser comorbidity index, National Comprehensive Cancer Network distress score ≥ 5, surgery type, stage, histology, grade, and Estrogen receptor/Progesterone receptor/ human epidermal growth factor receptor 2 (ER/PR/HER2) status. AD completion rates prior to surgery were significantly higher for the 4R vs UC cohort (73.8%, 95% confidence interval [CI] [66.5%-81.0%] vs 15.1%, 95% CI [9.2%-21.1%], p < .01) and did not significantly differ by age, race, need for interpreter, or distress scores. Conclusion Incorporation of a health educator discussion into a 4R care sequence plan significantly increased rates of time-sensitive AD completion.
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Affiliation(s)
- Stephanie Ossowski
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Liisa Lyon
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Elizabeth Linehan
- Department of Surgery, The Permanente Medical Group, San Francisco, CA, USA
| | - Nancy P Gordon
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Olga Egorova
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Becky Mark
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Kimberly Beringer
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Thea Abbe
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Aida Shirazi
- Kaiser Permanente, Department of Graduate Medical Education, San Francisco, CA, USA
| | | | - Julia Trosman
- Center for Business Models in Healthcare, Chicago, IL, USA
| | - Arliene Ravelo
- Department of Hematology & Oncology, The Permanente Medical Group, Walnut Creek, CA, USA
| | - Raymond Liu
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
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Younan S, Cardona M, Sahay A, Willis E, Ni Chroinin D. Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned. FRONTIERS IN HEALTH SERVICES 2023; 3:1242413. [PMID: 37780404 PMCID: PMC10541151 DOI: 10.3389/frhs.2023.1242413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023]
Abstract
Background The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice. Methods We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus. Results From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems. Conclusion The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.
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Affiliation(s)
- Sarah Younan
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, NSW, Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare, Bond University, Gold Coast, QLD, Australia
| | - Ashlyn Sahay
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Mackay, QLD, Australia
| | - Eileen Willis
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Mackay, QLD, Australia
| | - Danielle Ni Chroinin
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, UNSW, Sydney, NSW, Australia
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Zingmond DS, Powell D, Jennings LA, Liang LJ, Escarce JJ, Parikh P, Wenger NS. Changes over time in POLST use and content by race and ethnicity among California nursing home residents. J Am Geriatr Soc 2023; 71:2779-2787. [PMID: 37092747 PMCID: PMC10524124 DOI: 10.1111/jgs.18374] [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] [Received: 09/29/2022] [Revised: 03/08/2023] [Accepted: 03/27/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Physician Orders for Life-Sustaining Treatment (POLST) are commonly used for nursing home (NH) residents. Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust. Because national efforts focus on addressing the underpinnings of racial and ethnic differences in treatment (i.e., access to care and trust), we describe POLST use and content by race and ethnicity. METHODS California requires NHs to document POLST completion and content in the Minimum Data Set. We describe POLST completion and content for all California NH residents from 2011 to 2016 (N = 1,120,376). Adjusting for resident characteristics, we compared changes in completion rate and differences by race and ethnicity in POLST content-orders for cardiopulmonary resuscitation (CPR), do not resuscitate (DNR), CPR with full treatment, DNR with selective treatment or comfort orders, and if unsigned. RESULTS POLST completion increased across all racial and ethnic groups from 2011 to 2016; by 2016, NH residents had a POLST two-thirds or more of the time. In 2011, Black residents had a POLST with a CPR order 30.4% of the time, Hispanic residents 25.6%, and White residents 19.7%. By 2016, this grew to 42.5%, 38.2%, and 28.1%, respectively, with Black and Hispanic residents demonstrating larger increases than White residents (p < 0.001). Increases over time in POLST with CPR and full treatment were greater for Black and Hispanic residents compared to White residents. The increase in POLST with DNR and DNR with Selective treatment and Comfort orders was greater for White compared to Black patients (p < 0.001). Unsigned POLST with CPR and DNR orders decreased across all racial and ethnic groups. CONCLUSIONS Racial and ethnic differences in POLST intensity of care orders increased between 2011 and 2016 suggesting that efforts to mitigate factors underlying differences were ineffective. Studies of newer POLST data are imperative.
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Affiliation(s)
- David S Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Lee A Jennings
- Reynolds Section of Geriatrics, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Li-Jung Liang
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jose J Escarce
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Punam Parikh
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Hickman SE, Lum HD, Walling AM, Savoy A, Sudore RL. The care planning umbrella: The evolution of advance care planning. J Am Geriatr Soc 2023; 71:2350-2356. [PMID: 36840690 PMCID: PMC10958534 DOI: 10.1111/jgs.18287] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Susan E. Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Hillary D. Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Center, Colorado, Aurora, USA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, School of Medicine, University of California Los Angeles, California, Los Angeles, USA
- VA Greater Los Angeles Health System, Los Angeles, California, USA
| | - April Savoy
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco, San Francisco, California, USA
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Korkmaz Yaylagul N, Demirdas FB, Melo P, Silva R. Opinions of Older Individuals on Advance Care Planning and Factors Affecting Their Views: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105780. [PMID: 37239509 DOI: 10.3390/ijerph20105780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/28/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Abstract
The objective of this systematic review is to present older individuals' views on the advance care planning (ACP) process and the factors affecting those opinions. The review contains search terms predetermined in the databases of CINAHL, MEDLINE (via PubMed), Academic Search Ultimate, Web of Science, Master FILE, and TR Dizin over the last 10 years (1 January 2012-31 December 2021) in English and Turkish. The studies were included in the research using inclusion (sample age ≥ 50, focusing on individuals' opinions on ACP) and exclusion (articles whose samples consisted of individuals with a specific disease, non-research articles) criteria. Quality assessment was conducted using the Mixed Methods Appraisal Tool. A narrative synthesis was used to collate findings. The most striking results are the positive perspectives increasing in parallel with the individuals' level of knowledge and experience about ACP. Variables affecting their views are advanced age, marital status, socioeconomic status, perception of remaining life expectancy, self-perceived health, number and stage of chronic diseases, religion, and cultural characteristics. This study offers guidance on the application and dissemination of ACP, empowering the use of this practice given the perspectives of older adults on ACP and the factors that affect them that the data show.
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Affiliation(s)
- Nilufer Korkmaz Yaylagul
- Department of Gerontology, Faculty of Health Sciences, University of Akdeniz, Antalya 07070, Turkey
| | - Fatma Banu Demirdas
- Department of Gerontology, Faculty of Health Sciences, University of Turgut Ozal, Malatya 44210, Turkey
| | - Pedro Melo
- Institute of Health Sciences, Universidade Católica Portuguesa, 4200-450 Porto, Portugal
- Centre for Interdisciplinary Research in Health, Universidade Católica Portuguesa, 4200-450 Porto, Portugal
| | - Rosa Silva
- Center for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
- Porto Nursing School (ESEP), 4200-450 Porto, Portugal
- Portugal Center for Evidence Based Practice, A JBI Center of Excellence (PCEBP), 3030 Coimbra, Portugal
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Matthieu MM, Ounpraseuth ST, Williams JS, Hu B, Adkins DA, Taylor LD, Oliver CM, Smith RM, Painter JT, McCullough JA, Garner KK. "Advancing" Advance Care Planning to Veterans in the Veterans Health Administration. Mil Med 2023; 188:786-791. [PMID: 35801841 DOI: 10.1093/milmed/usac196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/20/2022] [Accepted: 06/21/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The completion rate of Advance Directive (ADs) in the Veterans Health Administration (VHA) is unknown. There is substantial literature on the need for effective Advance Care Planning (ACP) that leads to an AD to ensure that health care preferences for patients are known. Advance Directive are essential to consider since ACP, which explains and plans Advance Directive, does not reach all individuals. Health inequities, such as those experienced in rural areas, continue to exist. While ACP may disproportionately affect rural-residing veterans and their providers, a VHA program was specifically designed to increase ACP engagement with rural veterans and to address several systemic barriers to ACP. MATERIALS AND METHODS This descriptive analysis seeks to identify patient, provider, and geographic characteristics associated with higher rates of ACP participation in VHA. An observational examination of the profile of veterans and the types of ACP (e.g., individual or in groups) using administrative data for all beneficiaries receiving VHA health care services in federal fiscal year (FY) 2020 was conducted as part of a national program evaluation. The measures include patient-level data on demographics (e.g., race, ethnicity, gender), unique patient identifiers (e.g., name, social security number), geographic characteristics of patient's location (e.g., rurality defined as Rural-Urban Commuting Areas [RUCA]), VHA priority group; provider-level data (e.g., type of document definition, clinic stop codes, visit date used to verify Advance Care Planning via Group Visits [ACP-GV] attendance; data not shown), and electronic health record note titles that indicated the presence of ACP in VHA (e.g., "Advance Directive [AD] Discussion" note title, "ACP-GV CHAR 4 code"). Pearson's chi-square statistics were used for between-group comparisons based on a two-sided test with a significance level of 0.05. RESULTS The overall rate of AD discussions among unique VHA users in FY2020 was 5.2% (95% CI: 5.2%-5.2%) and for Advance Care Planning via Group Visits, which targets rural veterans using groups, it was 1.8% (95% CI: 1.8%-1.9%). Advance Directive discussions in VHA are more successful at reaching middle age (M = 64; SD = 16), African Americans, males, veterans living in urban areas, and veterans with a VA disability (Priority Group 1-4). Advance Care Planning delivered in groups is reaching slightly younger veterans under the age of 75 years (M = 62; SD = 15), African Americans, females, disabled veterans (e.g., Priority Group 1-4), and more veterans residing in rural communities compared to the national population of VHA users. CONCLUSION Advance Directive discussion rates are low across VHA, yet intentional efforts with ACP via group visits are reaching veterans who are considered underserved owing to residing in rural areas. Advance Care Planning needs to be a well-informed clinical priority for VHA to engage with the entire veteran population and to support the completion of ADs.
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Affiliation(s)
- Monica M Matthieu
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
- School of Social Work, Saint Louis University, St. Louis, MO 63103, USA
| | - Songthip T Ounpraseuth
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - J Silas Williams
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
| | - Bo Hu
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, AR 72205, USA
| | - David A Adkins
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
| | | | - Ciara M Oliver
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
| | - Robin M Smith
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
| | - Jacob T Painter
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
- Division of Pharmaceutical Evaluation & Policy, University of Arkansas for Medical Sciences, College of Pharmacy, Little Rock, AR 72205, USA
| | - Jane Ann McCullough
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, North Little Rock, AR 72118, USA
| | - Kimberly K Garner
- Department of Psychiatry, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, AR 72205, USA
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, North Little Rock, AR 72118, USA
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Hong N, Root A, Handel B. The Role of Information and Nudges on Advance Directives and End-of-Life Planning: Evidence From a Randomized Trial. Med Care Res Rev 2023; 80:283-292. [PMID: 36935565 DOI: 10.1177/10775587231157800] [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: 03/21/2023]
Abstract
Despite the substantial personal and economic implications of end-of-life decisions, many individuals fail to document their wishes, which often leads to patient dissatisfaction and unnecessary medical spending. We conducted a randomized trial of 1,200 patients aged 55 years and older to facilitate advance directive (AD) completion and better understand why patients fail to engage in high-value planning. We found that including a physical AD form with paper letters as a nudge to decrease hassle costs increased AD completion by 9.0 percentage points (95% confidence interval [CI] = [4.2, 13.9] percentage points). The intervention was especially effective for individuals aged 70 years and older, as AD completion increased by 17.5 percentage points (95% CI = [5.7, 9.4] percentage points). When compared with the impact of costless electronic reminders, each additional AD completion from the letter interventions costs as little as US$37. Our findings suggest that simple, inexpensive interventions with paper communication as behavioral nudges can be effective, especially in older populations.
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Affiliation(s)
- Nianyi Hong
- Congressional Budget Office, Washington, DC, USA
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Khan IA, Magnuson JA, Ciesielka KA, Levicoff EA, Cohen-Rosenblum A, Krueger CA, Fillingham YA. Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record. Clin Orthop Relat Res 2023; 481:312-321. [PMID: 35973119 PMCID: PMC9831155 DOI: 10.1097/corr.0000000000002354] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Advanced care planning documents provide a patient's healthcare team and loved ones with guidance on patients' treatment preferences when they are unable to advocate for themselves. A substantial proportion of patients will die within a few months of experiencing a hip fracture, but despite the importance of such documents, patients undergoing surgery for hip fracture seldom have discussions documented in the medical records regarding end-of-life care during their surgical admission. To the best of our knowledge, the proportion of patients older than 65 years treated with surgery for hip fractures who have advanced care planning documents in their electronic medical record (EMR) has not been explored, neither has the association between socioeconomic status and the presence of those documents in the EMR. Determining this information can help to identify opportunities to promote advanced care planning. QUESTIONS/PURPOSES (1) What percentage of patients older than 65 years who undergo hip fracture surgery have completed advanced care planning documents uploaded in the EMR before or during their surgical hospitalization, or at any timepoint (before admission, during admission, and after admission)? (2) Are patients from distressed communities less likely to have advanced care planning documents in the EMR than patients from wealthier communities, after controlling for economic well-being as measured by the Distressed Communities Index? (3) What percentage of patients older than 65 years with hip fractures who died during their hospitalization for hip fracture surgery had advanced care planning documents uploaded in the EMR? METHODS This was a retrospective, comparative study conducted at two geographically distinct hospitals: one urban Level I trauma center and one suburban Level II trauma center. Between 2017 and 2021, these two centers treated 850 patients for hip fractures. Among those patients, we included patients older than 65 years who were treated with open reduction and internal fixation, intramedullary nailing, hemiarthroplasty, or THA for a fragility fracture of the proximal femur. Based on that, 83% (709 of 850) of patients were eligible; a further 6% (52 of 850) were excluded because they had codes other than ICD-9 820 or ICD-10 S72.0, and another 2% (17 of 850) had incomplete datasets, leaving 75% (640 of 850) for analysis here. Most patients with incomplete datasets were in the prosperous Distressed Communities Index category. Among patients included in this study, the average age was 82 years, 70% (448 of 640) were women, and regarding the Distressed Communities Index, 32% (203 of 640) were in the prosperous category, 25% (159 of 640) were in the comfortable category, 15% (99 of 640) were in the mid-tier category, 5% (31 of 640) were in the at-risk category, and 23% (145 of 640) were in the distressed category. The primary outcome included the presence of advanced care planning documents (advanced directives, healthcare power of attorney, or physician orders for life-sustaining treatment) in the EMR before surgery, during the surgical admission, or at any time. The Distressed Communities Index was used to indicate economic well-being, and patients were identified as being in one of five Distressed Communities Index categories (prosperous, comfortable, mid-tier, at-risk, and distressed) based on ZIP Code. An exploratory analysis was conducted to determine variables associated with the presence of advanced care planning documents in the EMR. A multivariate regression was then performed for patients who did or did not have advanced care planning documents in their medical record at any time. The results are presented as ORs with the associated 95% confidence interval (CI). RESULTS Nine percent (55 of 640) of patients had advanced care planning documents in the EMR preoperatively or during their surgical admission, and 22% (142 of 640) of patients had them in the EMR at any time. After controlling for potential confounding variables such as age, laterality (left or right hip), hospital type, and American Society of Anesthesiologists (ASA) classification, we found that patients in Distressed Communities Index categories other than prosperous had ORs lower than 0.7, with patients in the distressed category (OR 0.4 [95% CI 0.2 to 0.7]; p < 0.01) and comfortable category (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.01) having a substantially lower odds of having advanced care planning documents in their EMR. Patients aged 86 to 95 years (OR 1.9 [95% CI 1.1 to 3.4]), those 96 years and older (OR 4.0 [95% CI 1.7 to 9.5]), and those with a higher ASA classification (OR 1.6 [95% CI 1.1 to 2.3]) had a higher odds of having advanced care planning documents in the EMR at any time. Among 14 patients who experienced in-hospital mortality, two had advanced care planning documents uploaded into their EMR, whereas 12 of 14 who died in the hospital did not have advanced care planning documents uploaded into their EMR. CONCLUSION Orthopaedic surgeons should counsel patients regarding the risk for postoperative complications after fragility hip fracture surgery and engage in shared decision-making regarding advanced care planning documents with patients or, if the patients are unable, with their families. Additionally, implementing virtual education about advanced care planning documents and using easy-to-read forms may facilitate the completion of advanced care planning documents by patients older than 65 years, especially patients with low economic well-being. Limitations of this study include having a restricted number of patients in the at-risk and mid-tier Distressed Communities Index categories and a restricted number of patients identifying as non-White races/ethnicities. Future research should evaluate the effect of advanced care document presence in the EMR on end-of-life care intensity in patients treated for fragility hip fractures. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Irfan A. Khan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Justin A. Magnuson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kerri-Anne Ciesielka
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric A. Levicoff
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Anna Cohen-Rosenblum
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Chad A. Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Yale A. Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Dassel KB, Iacob E, Utz RL, Supiano KP, Fuhrmann H. Promoting Advance Care Planning for Persons with Dementia: Study Protocol for the LEAD (Life-Planning in Early Alzheimer's and Other Dementias) Clinical Trial. OBM INTEGRATIVE AND COMPLIMENTARY MEDICINE 2023; 8:26. [PMID: 37859668 PMCID: PMC10586385 DOI: 10.21926/obm.icm.2301004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Due to the insidious progression of Alzheimer's disease and related dementias (ADRD), surrogate decision-makers typically make medical and long-term-care decisions for a care recipient, most often a family care partner. Unfortunately, many care recipient/care partner dyads have failed to engage in advance care planning or have lost the opportunity to do so due to the cognitive decline of the care recipient. To address this need, our team created a validated dementia-focused advance care planning tool known as the LEAD Guide (Life-Planning in Early Alzheimer's and Other Dementias). With funding from the National Alzheimer's Association and in consultation with our community advisory board, we developed a preliminary web-based intervention. This intervention integrates the LEAD Guide with self-paced educational modules that lead dyads through conversations and dementia-focused advance care planning processes. In this concept paper, we describe the aims of our funded R01 clinical trial (National Institute on Aging), where we aim to refine our preliminary web-based platform for use in a 5-month mixed-method NIH Stage-1 behavioral intervention. Using a sample of diverse community-based ADRD dyads (n = 60), we aim to: 1) describe the acceptability, usability, and feasibility of the intervention, 2) assess the initial efficacy of the intervention on the primary outcome (decision-making self-efficacy), and secondary outcomes (relationship quality, subjective well-being, anxiety) as perceived by both the care recipient and the care partner, and 3) examine advance care planning congruence as a mechanism of action. The LEAD clinical trial addresses public health challenges by guiding and supporting families through challenging advance care planning conversations, facilitating the transfer of knowledge regarding care preferences and values from the care recipient to the care partner, with the ultimate goal of improving the quality of life for both individuals with ADRD and their care partners.
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Affiliation(s)
- Kara B. Dassel
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
| | - Eli Iacob
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
| | - Rebecca L. Utz
- University of Utah, College of Social and Behavioral Sciences, 260 South Central Campus Drive, Salt Lake City, UT, USA
| | | | - Hollie Fuhrmann
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
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Haines KL, Nguyen BP, Antonescu I, Freeman J, Cox C, Krishnamoorthy V, Kawano B, Agarwal S. Insurance Status and Ethnicity Impact Health Disparities in Rates of Advance Directives in Trauma. Am Surg 2023; 89:88-97. [PMID: 33877932 DOI: 10.1177/00031348211011115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Advanced directives (ADs) provide a framework from which families may understand patient's wishes. However, end-of-life planning may not be prioritized by everyone. This analysis aimed to determine what populations have ADs and how they affected trauma outcomes. METHODS Adult trauma patients recorded in the American College of Surgeons Trauma Quality Improvement Program (TQIP) from 2013-2015 were included. The primary outcome was presence of an AD. Secondary outcomes included mortality, length of stay (LOS), mechanical ventilation, ICU admission/LOS, withdrawal of life-sustaining measures, and discharge disposition. Multivariable logistic regression models were developed for outcomes. RESULTS 44 705 patients were included in the analyses. Advanced directives were present in 1.79% of patients. The average age for patients with ADs was 77.8 ± 10.7. African American (odds ratio (OR) .53, confidence intervals [CI] .36-.79) and Asian (OR .22, CI .05-.91) patients were less likely to have ADs. Conversely, Medicaid (OR 1.70, CI 1.06-2.73) and Medicare (OR 1.65, CI 1.25-2.17) patients were more likely to have ADs as compared to those with private insurance. The presence of ADs was associated with increased hospital mortality (OR 2.84, CI 2.19-3.70), increased transition to comfort measures (OR 2.87, CI 2.08-3.95), and shorter LOS (CO -.74, CI -1.26-.22). Patients with ADs had an increased odds of hospice care (OR 4.24, CI 3.18-5.64). CONCLUSION Advanced directives at admission are uncommon, particularly among African Americans and Asians. The presence of ADs was associated with increased mortality, use of mechanical ventilation, admission to the ICU, withdrawal of life-sustaining measures, and hospice. Future research should target expansion of ADs among minority populations to alleviate disparities in end-of-life treatment.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Benjamin P Nguyen
- Department of Surgery, 20868Kaweah Delta Health Care District, Medical Center, Visalia, CA, USA
| | - Ioana Antonescu
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Jennifer Freeman
- Department of Surgery, 3402TCU and UNTHSC School of Medicine, Fort Worth, TX, USA
| | - Christopher Cox
- Division of Pulmonary Critical Care, Department of Medicine, 22957Duke University Medical Center, Durham, NC, USA
| | - Vijay Krishnamoorthy
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Brad Kawano
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
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Quintiliani LM, Murray GF, Waite K, Salerno K, Gignac GA, Yuh D, Volandes A, Paasche-Orlow MK. "I'm in My Feelings Now": Examination of Advance Care Planning Video Declarations by People with Advanced Cancer from a Safety Net Hospital. J Palliat Med 2023; 26:28-34. [PMID: 35708552 DOI: 10.1089/jpm.2021.0674] [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: 01/11/2023] Open
Abstract
Background: Advance care planning (ACP) is underutilized among those with advanced cancer, leading to the potential of not receiving goal-concordant care. Objectives: To understand the experience of patients in creating a video declaration (ViDec) of their ACP preferences and their family member/caregivers' perceptions after viewing their ViDec. Design: Qualitative study among patients and family members/caregivers. Setting/Subjects: Patients were recruited from a large safety net hospital in the United States. Patients with any type of advanced cancer were enrolled to create a ViDec and participate in an individual interview. Patients also identified a family member/caregiver to participate. Measurements: Content and perceptions of usefulness of ViDecs among patients and family members/caregivers. Results: In total, 32 patients participated. Patients had a mean age of 61 (10) years, 15 (47%) were women, 14 (44%) were Black or African American, and 12 (37%) had a high school education or less; 25 family members/caregivers participated. Across all ViDecs, the most common theme pertained to ACP for preferred medical treatments (97%). We describe three case studies of patient and caregiver pairs to represent salient dimensions of our data: (1) high perceived usefulness of ViDec, (2) populations at risk for not receiving goal-concordant care, and (3) varied responses to ViDec among family members/caregivers. Recommendations to improve the ViDec process included providing structured prompts to patients. Conclusions: These case studies highlight the potential high-perceived usefulness of ViDecs across patients and caregivers. ViDecs have the potential to improve care among patients with advanced cancer.
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Affiliation(s)
- Lisa M Quintiliani
- Department of Medicine, Boston University, Boston, Massachusetts, USA.,Sections of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Genevra F Murray
- Sections of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Katherine Waite
- Sections of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Kathleen Salerno
- Sections of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Gretchen A Gignac
- Department of Medicine, Boston University, Boston, Massachusetts, USA.,Sections of Hematology and Medical Oncology, Boston Medical Center, Boston, Massachusetts, USA
| | - David Yuh
- Department of Medicine, Boston University, Boston, Massachusetts, USA.,Sections of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,ACP Decisions Non-Profit Foundation Newtown, Massachustts, USA
| | - Michael K Paasche-Orlow
- Department of Medicine, Boston University, Boston, Massachusetts, USA.,Sections of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
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Lenko R, Voepel-Lewis T, Robinson-Lane SG, Silveira MJ, Hoffman GJ. Racial and Ethnic Differences in Informal and Formal Advance Care Planning Among U.S. Older Adults. J Aging Health 2022; 34:1281-1290. [PMID: 35621163 PMCID: PMC9633341 DOI: 10.1177/08982643221104926] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine advance care planning (ACP) trends among an increasingly diverse aging population, we compared informal and formal ACP use by race/ethnicity among U.S. older adults (≤65 years). METHODS We used Health and Retirement Study data (2012-2018) to assess relationships between race/ethnicity and ACP type (i.e., no ACP, informal ACP only, formal ACP only, or both ACP types). We reported adjusted risk ratios with 95% confidence intervals. RESULTS Non-Hispanic Black and Hispanic respondents were 1.77 (1.60, 1.96) and 1.76 (1.55, 1.99) times as likely, respectively, to report no ACP compared to non-Hispanic White respondents. Non-Hispanic Black and Hispanic respondents were 0.74 (0.71, 0.78) and 0.74 (0.69, 0.80) times as likely, respectively, to report using both ACP types as non-Hispanic White respondents. DISCUSSION Racial/ethnic differences in ACP persist after controlling for a variety of barriers to and facilitators of ACP which may contribute to disparities in end-of-life care.
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Affiliation(s)
- Rachel Lenko
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing
| | - Terri Voepel-Lewis
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing
| | - Sheria G. Robinson-Lane
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing
| | - Maria J. Silveira
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan
| | - Geoffrey J. Hoffman
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing
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Jones S, Mulaikal TA. End of Life: What Is the Anesthesiologist's Role? Adv Anesth 2022; 40:1-14. [PMID: 36333041 DOI: 10.1016/j.aan.2022.07.007] [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: 11/07/2022]
Abstract
Anesthesiologists receive extensive training in the area of perioperative care and the specialized skills required to maintain life during surgery and complex procedures. Integrated into almost every facet of contemporary medicine, they interact with patients at multiple stages of their health care journeys. While traditionally thought of as the doctors best equipped to save lives, they may also be some of the best doctors to help navigate the chapters at the end of life. Successfully navigating end-of-life care, particularly in the COVID-19 era, is a complicated task. Competing ethical principles of autonomy and nonmaleficence may often be encountered as sophisticated medical technologies offer the promise of extending life longer than ever before seen. From encouraging patients to actively engage in advance care planning, normalizing the conversations around the end of life, employing our skills to relieve pain and suffering associated with dying, and using our empathy and communication skills to also care for the families of dying patients, there are many ways for the anesthesiologist to elevate the care provided at the end of life. The aim of this article is to review the existing literature on the role of the anesthesiologist in end-of-life care, as well as to encourage future development of our specialty in this area.
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Affiliation(s)
- Stephanie Jones
- Columbia University Irving Medical Center, Division of Critical Care Medicine, 622 W. 168th St, New York, NY 10032, USA
| | - Teresa A Mulaikal
- Division of Cardiothoracic and Critical Care, Columbia University Medical Center, 622 W. 168th St., PH 5 Stem 133, New York, NY 10032, USA.
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Tsang M, Gan S, Boscardin J, Wong ML, Walter LC, Smith AK. The epidemiology of preexisting geriatric and palliative conditions in older adults with poor prognosis cancers. J Am Geriatr Soc 2022; 70:3402-3412. [PMID: 36259424 PMCID: PMC9772051 DOI: 10.1111/jgs.18039] [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] [Received: 03/23/2022] [Revised: 06/19/2022] [Accepted: 08/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Older patients with poor prognosis cancers have complex needs that can benefit from geriatrics and palliative care principles. Because they are not routinely assessed, the prevalence of preexisting geriatric and palliative conditions in this population is unknown. METHODS We used the nationally representative Health and Retirement Study (HRS) linked with Medicare claims (1998-2016) to identify adults aged ≥65 years diagnosed with poor prognosis cancers (cancers with a median survival ≤1 year). Using the HRS interview before the first Medicare cancer claim, we used survey-weighted descriptive statistics and modified Poisson regression analysis to examine the prevalence of the following clinically significant conditions: functional impairment, difficulty with mobility, falls and injurious falls, social support, cognition, advance care planning, use of pain or sleep medications, and presence of pain or breathlessness. RESULTS Of 2105 participants (mean age 76, 53% women, 34% lung cancer, 21% gastrointestinal cancer), the median survival was 9.6 months. Approximately 65% had difficulty climbing stairs (95% CI 63%-67%), 49% had no advance directive (95% CI 45%-54%), 35% lived alone (95% CI 33%-37%), 36% fell in the last 2 years (95% CI 34%-38%), and 32% rated their memory as poor (95% CI 29%-34%). After adjusting for gender, cancer type, and HRS survey time before the first Medicare claim for a poor prognosis cancer, functional impairment and falls were highest among adults aged 85+. Adults aged 65-74 years were less likely to have an advance directive. After adjusting for age, cancer type, and HRS survey time, women had a higher rate of pain and physical impairment. In exploratory analyses, race and socioeconomic status predicted difficulty with mobility and instrumental activities of daily living, living alone, and advance directive completion. CONCLUSIONS Due to a high prevalence across multiple domains, all older adults with poor prognosis cancers should be assessed for geriatric and palliative care conditions.
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Affiliation(s)
- Mazie Tsang
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, California, USA
| | - Siqi Gan
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Melisa L. Wong
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, California, USA
| | - Louise C. Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Alexander K. Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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Luth EA, Manful A, Weissman JS, Reich A, Ladin K, Semco R, Ganguli I. Practice Billing for Medicare Advance Care Planning Across the USA. J Gen Intern Med 2022; 37:3869-3876. [PMID: 35083654 PMCID: PMC9640523 DOI: 10.1007/s11606-022-07404-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/05/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Medicare introduced billing codes in 2016 to encourage clinicians to engage in advance care planning (ACP) and promote goal-concordantend-of-life care, but uptake has been modest. While prior research examined individual-level factors in ACP billing, organization-level factors associated with physician practices billing for ACP remain unknown. OBJECTIVE Examine the role of practices in ACP billing. DESIGN Retrospective cohort study analyzing 2016-2018 national Medicare data. PARTICIPANTS A total of 53,926 practices with at least 10 attributed Medicare beneficiaries. MAIN MEASURES Outcomes were practice-level ACP billing (any use by the practice) and ACP use rate by practice-attributed beneficiaries. Practice characteristics were number of beneficiaries attributed to the practice; percentage of beneficiaries by race, Medicare-Medicaid dual enrollment, sex, and age; practice size; and specialty mix. KEY RESULTS Fifteen percent of practices billed for ACP. In adjusted models, we found higher odds of ACP billing and higher ACP use rates among practices with more primary care physicians (billing AOR: 10.01, 95%CI: 8.81-11.38 for practices with 75-100% (vs 0) primary care physicians), and those serving more Medicare beneficiaries (billing AOR: 4.55, 95%CI 4.08-5.08 for practices with highest (vs lowest) quintile of beneficiaries), and larger shares of female beneficiaries (billing AOR: 3.06, 95% CI 2.01-4.67 for 75-100% (vs <25%) female ). CONCLUSIONS Several years after Medicare introduced ACP reimbursements for physicians, relatively few practices bill for ACP. ACP billing was more likely in large practices with a greater percentage of primary care physicians. To increase ACP billing uptake, policymakers and health system leaders might target interventions to larger practices where a small number of physicians already bill for ACP and to specialty practices that serve as the primary source of care for seriously ill patients.
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Affiliation(s)
| | - Adoma Manful
- Vanderbilt University, Nashville, TN, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Amanda Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, MA, USA
| | | | - Ishani Ganguli
- Harvard Medical School and Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
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Prevalence and predictors of advance directive among terminally ill patients in Taiwan before enactment of Patient Right to Autonomy Act: a nationwide population-based study. BMC Palliat Care 2022; 21:178. [PMID: 36224654 PMCID: PMC9554959 DOI: 10.1186/s12904-022-01069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Signing advance directives (ADs) ensures that terminally ill patients receive end-of-life care, according to their wishes, thereby promoting human dignity and sparing them from unnecessary suffering. Despite the enactment of the Hospice Palliative Care Act in Taiwan in 2000, the completion rates of ADs have been found to be low among patients with chronic illness conditions. To date, limited existing research is available regarding the factors associated with AD completion in terminally ill patients in Taiwan. To explore signed AD characteristics, compare differences in signing ADs between patients with and without cancer, and examine the factors associated with signing ADs in terminally ill patients. METHODS A nationwide study was conducted using data collected via a retrospective review of medical death records from 18 randomly selected hospitals in the northern, central, and southern parts of Taiwan. We collected 200 records, including both cancer and non-cancer-related deaths, from each hospital. Univariate and multivariate logistics regressions were conducted to examine factors associated with signing advance directives among all patients- with and without cancer. RESULTS Among the 3004 reviewed medical records, 79% had signed ADs, with most (95%) being signed by patients' caregivers. A higher education level (OR = 1.52, 95% CI = 1.10, 2.08, p = 0.010); cancer diagnosis (OR = 2.37, 95% CI = 1.79, 3.16, p < 0.001); having family members (OR = 5.62, 95% CI = 2.95, 10.69, p < 0.001), care homes (OR = 4.52, 95% CI = 1.97, 10.38, p < 0.001), friends, or maids (OR = 3.82, 95% CI = 1.76, 8.29, p = 0.001) as primary caregivers; and patients knowing about their poor prognosis (OR = 15.39, 95% CI = 5.66, 41.83, p < 0.001) were associated with a higher likelihood of signing ADs. CONCLUSIONS Patients with non-malignant chronic illnesses were less likely to have ADs signed by either patients or family caregivers than those with cancer, with the lowest likelihood observed in patients with cardiovascular diseases. Whenever possible, primary caregivers should be involved in discussing ADs with patients, and the importance of truth telling should be reinforced. Following these principles, each patient's end-of-life care preferences can be respected, thereby promoting quality of care before the patient's death.
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Van Scoy LJ, Levi BH, Bramble C, Calo W, Chinchilli VM, Currin L, Grant D, Hollenbeak C, Katsaros M, Marlin S, Scott AM, Tucci A, VanDyke E, Wasserman E, Witt P, Green MJ. Comparing two advance care planning conversation activities to motivate advance directive completion in underserved communities across the USA: The Project Talk Trial study protocol for a cluster, randomized controlled trial. Trials 2022; 23:829. [PMID: 36180899 PMCID: PMC9523194 DOI: 10.1186/s13063-022-06746-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 09/13/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is a process involving conversations between patients, loved ones, and healthcare providers that consider patient preferences for the types of medical therapies received at the end of life. Underserved populations, including Black, Hispanic, rural, and low-income communities are less likely to engage in ACP than other communities, a health inequity that results in lower-quality care and reduced hospice utilization. The purpose of this trial is to compare efficacy of two interventions intended to motivate ACP (particularly advance directive completion) for those living in underserved communities. METHODS This 3-armed cluster, randomized controlled mixed methods design is being conducted in 75 community venues in underserved communities across the USA. The goal of the trial is to compare the efficacy of two interventions at motivating ACP. Arm 1 uses an end-of-life conversation game (Hello); Arm 2 uses a nationally utilized workshop format for ACP conversations (The Conversation Project); and Arm 3 uses an attention control game (TableTopics). Events are held in partnership with 75 local community-based host organizations and will involve 1500 participants (n=20 per event). The primary outcome is completion of a visually verified advance directive at 6 months post-event. Primary analyses compare efficacy of each intervention to each other and the control arm. Secondary mixed methods outcomes include (a) other ACP behaviors and engagement; (b) communication quality; (c) impact of sociocultural environment on ACP (via qualitative interviews); and (d) implementation and sustainability. Subgroup analyses examine outcomes for Black, Hispanic, and rural groups in particular. DISCUSSION This trial will add to the evidence base behind various conversational ACP interventions, examine potential mechanisms of action for such interventions, and provide qualitative data to better understand the sociocultural environment of how community-based ACP interventions are experienced by underserved populations. Results will also provide important data for future researchers to learn whether visual verification of advance directives is necessary or whether reliance on self-reported outcomes is of comparable value. Data from this study will inform ways to effectively motivate underserved communities to participate in advance care planning. TRIAL REGISTRATION ClinicalTrials.gov NCT04612738. Registered on October 12, 2020. All information from the WHO Trial Registration Data Set can be found within the protocol.
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Affiliation(s)
- Lauren J. Van Scoy
- Department of Medicine, Penn State College of Medicine, 500 University Dr., H-041, Hershey, PA 17033-0850 USA
- Department of Humanities, Penn State College of Medicine, 500 University Drive, Hershey, PA 17036 USA
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Academic Support Building, Suite 2200, Mail Code A210, Hershey, PA 17033 USA
| | - Benjamin H. Levi
- Department of Humanities, Penn State College of Medicine, 500 University Drive, Hershey, PA 17036 USA
- Department of Pediatrics, Penn State College of Medicine, Suite 4400, Mail Code A444, Hershey, PA 17033 USA
| | - Cindy Bramble
- Hospice Foundation of America, 1707 L St. NW, Suite 220, Washington, DC, 20036 USA
| | - William Calo
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Academic Support Building, Suite 2200, Mail Code A210, Hershey, PA 17033 USA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Academic Support Building, Suite 2200, Mail Code A210, Hershey, PA 17033 USA
| | - Lindsey Currin
- Hospice Foundation of America, 1707 L St. NW, Suite 220, Washington, DC, 20036 USA
| | - Denise Grant
- Hospice Foundation of America, 1707 L St. NW, Suite 220, Washington, DC, 20036 USA
| | - Christopher Hollenbeak
- Department of Health Policy and Administration, The Pennsylvania State University, 604E Donald H. Ford Bldg., University Park, PA 16802 USA
| | - Maria Katsaros
- Department of Medicine, Penn State College of Medicine, 500 University Dr., H-041, Hershey, PA 17033-0850 USA
| | - Sara Marlin
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Academic Support Building, Suite 2200, Mail Code A210, Hershey, PA 17033 USA
| | - Allison M. Scott
- Department of Communication, University of Kentucky, 275 Blazer Dining Hall, University of Kentucky, Lexington, KY 40506 USA
| | - Amy Tucci
- Hospice Foundation of America, 1707 L St. NW, Suite 220, Washington, DC, 20036 USA
| | - Erika VanDyke
- Department of Medicine, Penn State College of Medicine, 500 University Dr., H-041, Hershey, PA 17033-0850 USA
| | - Emily Wasserman
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Academic Support Building, Suite 2200, Mail Code A210, Hershey, PA 17033 USA
| | - Pamela Witt
- Department of Medicine, Penn State College of Medicine, 500 University Dr., H-041, Hershey, PA 17033-0850 USA
| | - Michael J. Green
- Department of Medicine, Penn State College of Medicine, 500 University Dr., H-041, Hershey, PA 17033-0850 USA
- Department of Humanities, Penn State College of Medicine, 500 University Drive, Hershey, PA 17036 USA
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Carbonell E, Zonsius MC, Rodriguez-Morales G, Newman M, Emery-Tiburcio EE. Addressing What Matters Aligning care with the priorities of older adults and their caregivers. Home Healthc Now 2022; 40:258-263. [PMID: 36048219 DOI: 10.1097/nhh.0000000000001112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This article is the second in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute and originally appearing in the American Journal of Nursing, Volume 122, issue 1, as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Carbonell, E., et al. Addressing What Matters. Am J Nurs 2022; 122(1): 54-58.
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Affiliation(s)
- Ellen Carbonell
- Ellen Carbonell is a program manager and assistant professor, Michelle Newman is a program manager, and Grisel Rodriguez-Morales is a manager and assistant professor in the Department of Social Work and Community Health at Rush University Medical Center in Chicago, where Mary C. Zonsius is an associate professor in the College of Nursing and Erin E. Emery-Tiburcio is an associate professor in the Department of Psychiatry and Behavioral Sciences
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Song J, Topaz M, Landau AY, Klitzman R, Shang J, Stone P, McDonald M, Cohen B. Using natural language processing to identify acute care patients who lack advance directives, decisional capacity, and surrogate decision makers. PLoS One 2022; 17:e0270220. [PMID: 35816481 PMCID: PMC9273092 DOI: 10.1371/journal.pone.0270220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/06/2022] [Indexed: 11/19/2022] Open
Abstract
The prevalence of patients who are Incapacitated with No Evident Advance Directives or Surrogates (INEADS) remains unknown because such data are not routinely captured in structured electronic health records. This study sought to develop and validate a natural language processing (NLP) algorithm to identify information related to being INEADS from clinical notes. We used a publicly available dataset of critical care patients from 2001 through 2012 at a United States academic medical center, which contained 418,393 relevant clinical notes for 23,904 adult admissions. We developed 17 subcategories indicating reduced or elevated potential for being INEADS, and created a vocabulary of terms and expressions within each. We used an NLP application to create a language model and expand these vocabularies. The NLP algorithm was validated against gold standard manual review of 300 notes and showed good performance overall (F-score = 0.83). More than 80% of admissions had notes containing information in at least one subcategory. Thirty percent (n = 7,134) contained at least one of five social subcategories indicating elevated potential for being INEADS, and <1% (n = 81) contained at least four, which we classified as high likelihood of being INEADS. Among these, n = 8 admissions had no subcategory indicating reduced likelihood of being INEADS, and appeared to meet the definition of INEADS following manual review. Among the remaining n = 73 who had at least one subcategory indicating reduced likelihood of being INEADS, manual review of a 10% sample showed that most did not appear to be INEADS. Compared with the full cohort, the high likelihood group was significantly more likely to die during hospitalization and within four years, to have Medicaid, to have an emergency admission, and to be male. This investigation demonstrates potential for NLP to identify INEADS patients, and may inform interventions to enhance advance care planning for patients who lack social support.
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Affiliation(s)
- Jiyoun Song
- Columbia University School of Nursing, New York, New York, United States of America
| | - Maxim Topaz
- Columbia University School of Nursing, New York, New York, United States of America
- Data Science Institute, Columbia University, New York, New York, United States of America
- Visiting Nurse Service of New York, New York, New York, United States of America
| | - Aviv Y. Landau
- Data Science Institute, Columbia University, New York, New York, United States of America
- Columbia School of Social Work, New York, New York, United States of America
| | - Robert Klitzman
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
- Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Jingjing Shang
- Columbia University School of Nursing, New York, New York, United States of America
| | - Patricia Stone
- Columbia University School of Nursing, New York, New York, United States of America
| | - Margaret McDonald
- Visiting Nurse Service of New York, New York, New York, United States of America
| | - Bevin Cohen
- Center for Nursing Research and Innovation, Mount Sinai Health System, New York, New York, United States of America
- Department of Geriatric and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
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Attivissimo LA, Friedman MI, Williams M, Rimar A, Nouryan C, Patel V, Kozikowski A, Zhang M, Pekmezaris R. Goals of care conversation education program: An intervention to help health care professionals break bad news to patients with advanced illness. GERONTOLOGY & GERIATRICS EDUCATION 2022; 43:407-417. [PMID: 33627035 DOI: 10.1080/02701960.2021.1893171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The purpose of the study was to measure the effectiveness of communication skills intervention results for healthcare professionals. A multi-site pretest-posttest survey assessing the efficacy of a Goals of Care conversation education program. The program aimed to educate healthcare professionals concerning having Goals of Care conversations with patients and families. This research was implemented in a large healthcare organization in the Northeastern United States. This study found significant differences between pretests and posttests across professions, palliative care specialty, degree types, and years of experience in the participant's self-reported ability and comfort levels in having conversations about Goals of Care with patients and families. Providing education on Goals of Care was effective in improving the knowledge and comfort of health care professionals with conducting advanced illness conversations.
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Affiliation(s)
| | - M Isabel Friedman
- Department of Clinical Transformation, Northwell, Lake Success, New York, USA
| | - Myia Williams
- Department of Medicine, Northwell Health, Manhasset, New York, USA
| | - Alexander Rimar
- Department of Medicine, Long Island Jewish Medical Center, Queens, New York, USA
| | - Christian Nouryan
- Department of Medicine, Northwell Health, Manhasset, New York, USA
- Department of Medicine, The Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Vidhi Patel
- Department of Medicine, Northwell Health, Manhasset, New York, USA
| | - Andrzej Kozikowski
- Department of Medicine, Northwell Health, Manhasset, New York, USA
- Department of Medicine, The Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Meng Zhang
- Department of Medicine, The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Renee Pekmezaris
- Department of Medicine, Northwell Health, Manhasset, New York, USA
- Department of Medicine, The Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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Noh H, Lee HY, Luo Y, Lee LH. Willingness to Discuss End-of-Life Care Wishes Among Rural Black/African American Residents of the Alabama Black Belt. J Appl Gerontol 2022; 41:1763-1772. [PMID: 35506710 DOI: 10.1177/07334648221084174] [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: 11/15/2022] Open
Abstract
Willingness for end-of-life discussion and related factors among rural Blacks/African Americans of the Alabama Black Belt have not been well-studied. This study aims to assess their willingness for the discussion and examine its relationship with social determinants of health (SDH) and demographic factors. A cross-sectional survey was conducted with a convenience sampling of 182 participants. Most participants were willing to discuss end-of-life wishes with family (77.1%) or doctors (72.1%). Controlling for demographics, results from binary logistic regressions showed those with hospice awareness were more likely to have willingness for discussion with family (OR = 10.07, p < .01) and doctors (OR = 7.23, p < .05). Those who were older (50+) were less likely to have willingness for discussion with doctors (OR = 0.19, p < .05), whereas those who were more socially isolated were less likely to have willingness for discussion with family (OR = 0.53, p < .05). Therefore, end-of-life discussion efforts should focus on older, socially isolated individuals and consider hospice awareness.
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Affiliation(s)
- Hyunjin Noh
- The University of Alabama School of Social Work, Tuscaloosa, AL, USA
| | - Hee Y Lee
- The University of Alabama School of Social Work, Tuscaloosa, AL, USA
| | - Yan Luo
- The University of Alabama School of Social Work, Tuscaloosa, AL, USA
| | - Lewis H Lee
- The University of Alabama School of Social Work, Tuscaloosa, AL, USA
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Ludwick R, Bakerjian D, Zalon ML, Melander SD, Crist JD. Advance care planning at life milestones. Nurs Outlook 2022; 70:451-457. [PMID: 35440365 DOI: 10.1016/j.outlook.2022.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/02/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022]
Abstract
Much progress has been made in advance care planning (ACP), especially related to end of life and palliative care. These advances have moved thinking about ACP from a checklist approach to an upstream recognition that ACP is an iterative process that should begin early in adulthood and be revisited with each milestone or life-changing event. It is recognized that there are many stages and milestones in adult life that contribute to changing loci of responsibility and life goals. These changes impact how individuals view their lives, the complexity of health care, and the myriad of health conditions they may encounter. ACP discussions should routinely be started and reexamined at the time of key life events like starting a career or a marriage and not delayed until hospitalization, the occurrence of a serious accident, or the development of a catastrophic illness.
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Affiliation(s)
- Ruth Ludwick
- Kent State University, College of Nursing, Kent, OH.
| | - Deb Bakerjian
- Betty Irene Moore School of Nursing at UC Davis, Sacramento, CA
| | - Margarete L Zalon
- Health Informatics Program, Department of Nursing, University of Scranton, Scranton, PA
| | - Sheila D Melander
- MSN and DNP Faculty and Practice Affairs, University of Kentucky College of Nursing, Lexington, KY
| | - Janice D Crist
- College of Nursing, The University of Arizona, Tucson, AZ
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