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Winnifrith T, Millington-Sanders C, Husbands E, Haros J, Ballinger H. Proactive advance care planning conversations in general practice: a quality improvement project. BMJ Open Qual 2024; 13:e002679. [PMID: 38977313 DOI: 10.1136/bmjoq-2023-002679] [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: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 07/10/2024] Open
Abstract
Advance care planning (ACP) is a process of discussion, reflection and communication, enabling planning for future medical treatment. Despite evidence of benefits of ACP to patients, families and the healthcare system, many die without an opportunity for such conversations, particularly those living with progressive non-malignant conditions. The Royal College of General Practitioners and Marie Curie Daffodil Standards launched in 2020 provide primary care with a structure for improving end-of-life care, including delivery of ACP. Proactive identification of patients is integral to the approach.We report on a quality improvement project which aimed to assess the take-up rate and acceptability in general practice of a timely and personalised ACP conversation using a 'What matters to you' (WMTY) framework, and to ensure that different diagnostic and demographic groups were included.Patients without previous ACP and potentially in the last year of life were offered an ACP conversation; a survey sought feedback.81% accepted the offer and in most cases, future care guidance was documented using the recognised format in Gloucestershire for recording ACP conversations, the Recommended Summary for Emergency Care and Treatment (ReSPECT) plan. Clinician and patient satisfaction was high.We concluded that an ACP discussion using a 'WMTY' format was highly acceptable to most. With recognised enablers in place and known barriers minimised, valuable personalised conversations occurred. Reframing the conversation to focus on how someone wants to live, while including their priorities for death, could alter how such conversations are perceived by clinicians and the public. It could remove negative associations (such as linking these conversations with an imminent death), which may increase motivation for all to initiate discussions.ACP conversations are evidenced best practice and could become routine in general practice with adjustments to practice processes and clinician education; the Daffodil Standards facilitate continued quality improvement.
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Affiliation(s)
| | | | - Emma Husbands
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
| | - Jane Haros
- Gloucestershire Health and Care NHS FoundationTrust, Brockworth, UK
| | - Helen Ballinger
- Gloucestershire Health and Care NHS FoundationTrust, Brockworth, UK
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Levy C, Esmaeili A, Smith D, Hogikyan RV, Periyakoil VS, Carpenter JG, Sales A, Phibbs CS, Murray A, Ersek M. Life-sustaining treatment decisions and family evaluations of end-of-life care for Veteran decedents in Department of Veterans Affairs nursing homes. J Am Geriatr Soc 2024. [PMID: 38970392 DOI: 10.1111/jgs.19050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Modeled after the Physician Orders for Life Sustaining Treatment program, the Veterans Health Administration (VA) implemented the Life-Sustaining Treatment (LST) Decisions Initiative to improve end-of-life outcomes by standardizing LST preference documentation for seriously ill Veterans. This study examined the associations between LST documentation and family evaluation of care in the final month of life for Veterans in VA nursing homes. METHODS Retrospective, cross-sectional analysis of data for decedents in VA nursing homes between July 1, 2018 and January 31, 2020 (N = 14,575). Regression modeling generated odds for key end-of-life outcomes and family ratings of care quality. RESULTS LST preferences were documented for 12,928 (89%) of VA nursing home decedents. Contrary to our hypothesis, neither receipt of wanted medications and medical treatment (adjusted odds ratio [OR]: 0.85, 95% confidence interval [CI] 0.63, 1.16) nor ratings of overall care in the last month of life (adjusted OR: 0.96, 95% CI 0.76, 1.22) differed significantly between those with and without completed LST templates in adjusted analyses. CONCLUSIONS Among Community Living Center (CLC) decedents, 89% had documented LST preferences. No significant differences were observed in family ratings of care between Veterans with and without documentation of LST preferences. Interventions aimed at improving family ratings of end-of-life care quality in CLCs should not target LST documentation in isolation of other factors associated with higher family ratings of end-of-life care quality.
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Affiliation(s)
- Cari Levy
- Department of Veterans Affairs, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Aryan Esmaeili
- Department of Veterans Affairs, Palo Alto, California, USA
| | - Dawn Smith
- Veteran Experience Center, Department of Veterans Affairs, Philadelphia, Pennsylvania, USA
| | - Robert V Hogikyan
- Department of Veterans Affairs, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Joan G Carpenter
- Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Anne Sales
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - Ciaran S Phibbs
- Department of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California, USA
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Andrew Murray
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Mary Ersek
- Veteran Experience Center, Department of Veterans Affairs, Philadelphia, Pennsylvania, USA
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Wong HJ, Seow H, Gayowsky A, Sutradhar R, Wu RC, Lim H. Advance Directives Change Frequently in Nursing Home Residents. J Am Med Dir Assoc 2024; 25:105090. [PMID: 38885932 DOI: 10.1016/j.jamda.2024.105090] [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: 04/03/2024] [Revised: 05/10/2024] [Accepted: 05/10/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVES To describe the rate, timing, and pattern of changes in advance directives (ADs) of do not resuscitate (DNR) and do not hospitalize (DNH) orders among new admissions to nursing homes (NHs). DESIGN A retrospective cohort study. SETTING AND PARTICIPANTS Admissions to all publicly funded NHs in Ontario, Canada, between January 1, 2013, and December 31, 2017. METHODS Residents were followed until discharged from incident NH stay, death, or were still present at the end of study (December 31, 2019). They were categorized into 3 mutually exclusive baseline composite AD groups: Full Code, DNR Only, and DNR+DNH. We used Poisson regression models to estimate the incidence rate ratios of AD change between different AD groups and different decision makers for personal care, adjusted for baseline clinical and sociodemographic variables. RESULTS A total of 102,541 NH residents were eligible for inclusion. Residents with at least 1 AD change accounted for 46% of Full Code, 30% of DNR Only, and 25% of DNR+DNH group. Median time to first AD change ranged between 26 and 55 weeks. For Full Code and DNR Only residents, the most frequent change was to an AD 1 level lower in aggressiveness or intervention, whereas for DNR+DNH residents the most frequent change was to DNR Only. About 16% of residents had 2 or more AD changes during their stay. After controlling for covariates, residents with a DNR-only order or DNR+DNH orders at admission and those with a surrogate decision maker were associated with lower AD change rates. CONCLUSIONS AND IMPLICATIONS Measuring AD adherence rates that are documented only at a particular time often underestimates the dynamics of AD changes during a resident's stay and results in an inaccurate measure of the effectiveness of AD on resident care. There should be more frequent reviews of ADs as they are quite dynamic. Mandatory review after an acute change in a resident's health would ensure that ADs are current.
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Affiliation(s)
- Hannah J Wong
- School of Health Policy & Management, York University, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | - Hsien Seow
- ICES, Toronto, Ontario, Canada; Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | | | - Rinku Sutradhar
- ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Robert C Wu
- Division of General Internal Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hilda Lim
- Mon Sheong Long-Term Care Centre, Richmond Hill, Ontario, Canada; Yee Hong Centre, Scarborough, Ontario, Canada
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Loggers SAI, Van Balen R, Willems HC, Gosens T, Polinder S, Ponsen KJ, Van de Ree CLP, Steens J, Verhofstad MHJ, Zuurmond RG, Joosse P, Van Lieshout EMM. The Quality of Dying in Frail Institutionalized Older Patients After Nonoperative and Operative Management of a Proximal Femoral Fracture: An In-Depth Analysis. Am J Hosp Palliat Care 2024; 41:583-591. [PMID: 37403839 PMCID: PMC11032625 DOI: 10.1177/10499091231180556] [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: 07/06/2023] Open
Abstract
Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, little is known about the quality of dying (QoD) while this is an integral part of palliative care and could influence decision making on nonoperative- (NOM) or operative management (OM). To identify the QoD in frail patients with a proximal femoral fracture. Data from the prospective FRAIL-HIP study, that studied the outcomes of NOM and OM in institutionalized older patients ≥70 years with a limited life expectancy who sustained a proximal femoral fracture, was analyzed. This study included patients who died within the 6-month study period and whose proxies evaluated the QoD. The QoD was evaluated with the Quality of Dying and Death (QODD) questionnaire resulting in an overall score and 4 subcategory scores (Symptom control, Preparation, Connectedness, and Transcendence). In total 52 (64% of NOM) and 21 (53% of OM) of the proxies responded to the QODD. The overall QODD score was 6.8 (P25-P75 5.7-7.7) (intermediate), with 34 (47%) of the proxies rating the QODD 'good to almost perfect'. Significant differences in the QODD scores between groups were not noted (NOM; 7.0 (P25-P75 5.7-7.8) vs OM; 6.6 (P25-P75 6.1-7.2), P = .73). Symptom control was the lowest rated subcategory in both groups. The QoD in frail older nursing home patients with a proximal femoral fracture is good and humane. QODD scores after NOM are at least as good as OM. Improving symptom control would further increase the QoD.
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Affiliation(s)
- Sverre A. I. Loggers
- Department of Surgery, Northwest Clinics Alkmaar, Alkmaar, the Netherlands
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Romke Van Balen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Hanna C. Willems
- Geriatrics Section, Department of Internal Medicine, Amsterdam UMC Location AMC, Amsterdam, the Netherlands
| | - Taco Gosens
- Department of Orthopaedic Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Kornelis J. Ponsen
- Department of Surgery, Northwest Clinics Alkmaar, Alkmaar, the Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
| | | | - Jeroen Steens
- Department of Orthopaedic Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands
| | - Michael H. J. Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Pieter Joosse
- Department of Surgery, Northwest Clinics Alkmaar, Alkmaar, the Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
| | - Esther M. M. Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Lou Y. End-of-life care discussions with healthcare providers and dying experiences: A latent class analysis using the health and retirement study. Arch Gerontol Geriatr 2024; 119:105319. [PMID: 38171033 DOI: 10.1016/j.archger.2023.105319] [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: 10/03/2023] [Revised: 12/12/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND The impact of provider-patient end-of-life care conversations on the dying experience as a multi-dimensional concept among non-White population is understudied. The study examines whether such discussions are effective at improving end-of-life experiences among U.S. older adults with diverse backgrounds. METHODS The analytic sample featured 9,733 older adults who died between 2002 and 2019 in the Health and Retirement Study. Latent class analysis was used with sixteen end-of-life indicators, including service utilization of seven aggressive and supportive care, symptom management, and quality of care. Multinomial logistic regression was conducted to estimate the effects of provider-patient end-of-life discussions on the predicted membership. RESULTS Three types of end-of-life experiences were identified. People in "minimum service user with good death" (44.54 %) were least likely to use any type of medical care, either aggressive or comforting, and had best end-of-life symptom management and quality of care. Intensive care users (20.70 %) are characterized by very high use of aggressive treatments and low use of supportive care. "Extensive service user with uncomfortable death" (34.76 %) had high likelihoods of using both aggressive and comforting care and had the worst dying experience. Older adults who discussed their end-of-life wishes with providers were 49 % and 51 % more likely to be an intensive care user and extensive service user with uncomfortable death, respectively, rather than a minimum service user with good death. CONCLUSION Discussing end-of-life care wishes with providers is associated with worse end-of-life experiences. Efforts are needed to facilitate early initiation and effectiveness of the provider-patient end-of-life care conversation.
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Affiliation(s)
- Yifan Lou
- School of Medicine, Department of Internal Medicine, Yale University, 300 George, 7th Floor, New Haven, CT 06511, United States.
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Lo YT, Wang JJ, Yang YC, Yu CY, Chang CM, Yang YP. Effects of Advance Care Planning on End-of-Life Indicators for Nursing Home Residents-An Experimental Study with a Retrospective Chart Review. Geriatrics (Basel) 2024; 9:42. [PMID: 38667509 PMCID: PMC11050193 DOI: 10.3390/geriatrics9020042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Advance care planning (ACP) has the potential to improve the outcomes of end-of-life care for residents in nursing homes. The aim of this study was to determine whether an ACP program was beneficial for nursing home residents by assessing end-of-life indicators. An experimental study with a retrospective chart review was conducted. In total, 37 residents in the intervention group participated in an institutional advance care planning program for 1 year, and their chart data over 1 year were collected following the completion of the program; 33 residents in the control group had died within 1 year before the start date of program, and their chart data were reviewed retrospectively. Chi-square and t tests were used to examine four indicators of the quality of end-of-life care. Compared with the control group, the intervention group had a higher proportion of do-not-resuscitate directives, hospice care before death, and deaths in the nursing home, and fewer hospitalizations and deaths in an emergency department. ACP programs may improve the quality of end-of-life care for nursing home residents in Taiwan. Further research across different long-term care facilities is warranted.
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Affiliation(s)
- Yu-Tai Lo
- Department of Geriatrics and Gerontology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan; (Y.-T.L.); (Y.-C.Y.); (C.-M.C.)
| | - Jin-Jy Wang
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Yi-Ching Yang
- Department of Geriatrics and Gerontology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan; (Y.-T.L.); (Y.-C.Y.); (C.-M.C.)
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
| | - Chiu-Yen Yu
- Department of Gerontological and Long-Term Care Business, Fooyin University, Kaohsiung 831, Taiwan;
| | - Chia-Ming Chang
- Department of Geriatrics and Gerontology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan; (Y.-T.L.); (Y.-C.Y.); (C.-M.C.)
- Department of Medicine & Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
| | - Ya-Ping Yang
- Department of Nursing, National Tainan Junior College of Nursing, Tainan 700, Taiwan
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Smith R, Merlo G, Broadbent AM, Lock C, Mickan S, Morgan N. Development and implementation of the Specialist Palliative Care in Aged Care (SPACE) Project across Queensland. AUST HEALTH REV 2024; 48:201-206. [PMID: 38467110 DOI: 10.1071/ah23272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/20/2024] [Indexed: 03/13/2024]
Abstract
There is an urgent and unmet need for specialist palliative care services in residential aged care. The Specialist Palliative Care in Aged Care (SPACE) Project aimed to improve palliative and end-of-life care for older people living in residential aged care facilities in Queensland. A representative working group developed a series of service principles around palliative care practice in aged care (comprehensive resident-focused care, streamlined service, and capacity building). Funding was allocated by population to the health services in Queensland to adapt and implement models of care aligned with these principles. SPACE successfully implemented a variety of decentralised models of care across Queensland. The critical elements for the success of SPACE were the use of an expert working group to define the core innovation, networking and implementation support from the central project team and community of practice, and adaptable models of care led by local facilitators. Lessons learned from this real-world case study could be adopted to guide and ensure the successful implementation and sustainability of future complex interventions in healthcare settings, both nationally and internationally.
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Affiliation(s)
- Rebecca Smith
- Townsville University Hospital, Douglas, Qld, Australia; and Healthcare Improvement Unit, Clinical Excellence Queensland, Queensland Health, Brisbane, Qld, Australia
| | - Gregory Merlo
- Healthcare Improvement Unit, Clinical Excellence Queensland, Queensland Health, Brisbane, Qld, Australia
| | - Andrew M Broadbent
- Healthcare Improvement Unit, Clinical Excellence Queensland, Queensland Health, Brisbane, Qld, Australia; and Gold Coast Hospital and Health Service, Southport, Qld, Australia; and Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld, Australia
| | - Caitlin Lock
- Voluntary Dying Unit, Clinical Excellence Queensland, Queensland Health, Brisbane, Qld, Australia
| | - Sharon Mickan
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld, Australia
| | - Nicola Morgan
- Healthcare Improvement Unit, Clinical Excellence Queensland, Queensland Health, Brisbane, Qld, Australia; and Gold Coast Hospital and Health Service, Southport, Qld, Australia; and Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld, Australia
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Gomes Souza L, Bouba DA, Corôa RDC, Dofara SG, Robitaille V, Blanchette V, Kastner K, Bergeron F, Guay-Bélanger S, Izumi SS, Totten AM, Archambault P, Légaré F. The Impact of Advance Care Planning on Healthcare Professionals' Well-being: A Systematic Review. J Pain Symptom Manage 2024; 67:173-187. [PMID: 37827454 DOI: 10.1016/j.jpainsymman.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/08/2023] [Accepted: 09/16/2023] [Indexed: 10/14/2023]
Abstract
CONTEXT Advance care planning (ACP) improves care for patients with chronic illnesses and reduces family stress. However, the impact of ACP interventions on healthcare professionals' well-being remains unknown. OBJECTIVE To systematically review the literature evaluating the impact of ACP interventions on healthcare professionals' well-being. METHODS We followed the Joanna Briggs Institute methodology for systematic reviews and registered the protocol in PROSPERO (CRD42022346354). We included primary studies in all languages that assessed the well-being of healthcare professionals in ACP interventions. We excluded any studies on ACP in psychiatric care and in palliative care that did not address goals of care. Searches were conducted on April 4, 2022, and March 6, 2023 in Embase, CINAHL, Web of Science, and PubMed. We used the Mixed Methods Appraisal Tool for quality analysis. We present results as a narrative synthesis because of their heterogeneity. RESULTS We included 21 articles published in English between 1997 and 2021 with 17 published after 2019. All were conducted in high-income countries, and they involved a total of 1278 participants. Three reported an interprofessional intervention and two included patient partners. Studies had significant methodological flaws but most reported that ACP had a possible positive impact on healthcare professionals' well-being. CONCLUSION This review is the first to explore the impact of ACP interventions on healthcare professionals' well-being. ACP interventions appear to have a positive impact, but high-quality studies are scarce. Further research is needed, particularly using more rigorous and systematic methods to implement interventions and report results.
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Affiliation(s)
- Lucas Gomes Souza
- Department of Social and Preventive Medicine (L.G.S., D.A.B.), Faculty of Medicine, Université Laval, Québec, Canada, and VITAM, Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, QC, Canada
| | - Dalil Asmaou Bouba
- Department of Social and Preventive Medicine (L.G.S., D.A.B.), Faculty of Medicine, Université Laval, Québec, Canada, and VITAM, Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, QC, Canada
| | - Roberta de Carvalho Corôa
- Department of Family Medicine and Emergency Medicine (R.C.C.), VITAM, Centre de recherche en santé durable, Unité de soutien au système de santé apprenant, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Suélène Georgina Dofara
- VITAM, Centre de recherche en santé durable (S.G.B., S.G.D.), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, QC, Canada
| | - Vincent Robitaille
- Faculty of Medicine, Université Laval (V.R.), VITAM, Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, QC, Canada
| | - Virginie Blanchette
- Department of Human Kinetics and Podiatric Medicine (V.B.), Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | | | | | - Sabrina Guay-Bélanger
- VITAM, Centre de recherche en santé durable (S.G.B., S.G.D.), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, QC, Canada
| | | | - Annette M Totten
- Department of Medical Informatics and Clinical Epidemiology (A.M.T.), School of Medicine, Oregon Health & Science University, Portland, OR
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine (P.A.), Faculty of Medicine, Université Laval, VITAM, Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Québec, QC, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine (F.L.), Faculty of Medicine, Université Laval, VITAM, Centre de recherche en santé durable, Researcher, Centre de recherche du CHU de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, QC, Canada.
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Hirooka K, Fukahori H, Ninomiya A, Fukui S, Takahashi K, Anzai T, Ishibashi T. Impact of family involvement and an advance directive to not hospitalize on hospital transfers of residents in long-term care facilities. Arch Gerontol Geriatr 2024; 117:105183. [PMID: 37690255 DOI: 10.1016/j.archger.2023.105183] [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: 04/03/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE With the rapidly aging population, the number of residents transferred to hospitals from long-term care facilities (LTCFs) is increasing globally. The objective of this study was to investigate the association between family involvement and an advance directive (AD) for not hospitalizing and hospital transfers among LTCF residents with dementia. METHOD Using the InterRAI assessment database from September 2014 to June 2019, we included 874 residents from 16 LTCFs in Japan. RESULTS Of the 874 participants, 19.0% had an AD for not hospitalizing, and 20.5% were transferred to hospitals. An AD for not hospitalizing decreased the likelihood of hospital transfers (p = 0.005). Multilevel logistic regression analysis showed that family involvement was not associated with hospital transfers (odds ratio [OR]: 1.18; 95% confidence interval [CI]: 0.77-1.80), while an AD for not hospitalizing was significantly associated with decreased hospital transfers (OR: 0.50; 95% CI: 0.28-0.89) among the LTCF residents. CONCLUSIONS Although ADs are not legally defined in Japan, we found that an AD for not hospitalizing decreased hospital transfers. Given that many older people tend to hesitate to express their wishes in clinical decision-making situations in Japan, regular discussions are necessary to help them express their care preferences while also documenting the discussions to ensure the residents receive high-quality care.
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Affiliation(s)
- Kayo Hirooka
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan; The Dia Foundation for Research on Ageing Societies, Tokyo, Japan.
| | - Hiroki Fukahori
- Division of Gerontological Nursing, Faculty of Nursing and Medical Care, Keio University, Kanagawa, Japan
| | - Ayako Ninomiya
- The Dia Foundation for Research on Ageing Societies, Tokyo, Japan; Division of Fundamental Nursing, Josai International University, Chiba, Japan
| | - Sakiko Fukui
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan; The Dia Foundation for Research on Ageing Societies, Tokyo, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatsuhiko Anzai
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
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Toyoda Y, Tokumasu A, Minato Y, Sone T, Oshiro K, Kojima H, Nishikawa M. Relationship between implementation of systematic advance care planning and the quality of death among nursing home residents: a survey. Palliat Care Soc Pract 2024; 18:26323524231219519. [PMID: 38188460 PMCID: PMC10771744 DOI: 10.1177/26323524231219519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 11/22/2023] [Indexed: 01/09/2024] Open
Abstract
Background Advance care planning (ACP) is beneficial for the quality of death (QOD). However, the effects of ACP on the QOD may vary across cultures. Objectives This study aimed to explore the relationship between the 15-step ACP program and the QOD among Japanese nursing home residents. Design A cross-sectional survey. Methods A cross-sectional survey was conducted among the family members of 39 nursing home residents who died between April 2017 and March 2019 by distributing the survey questionnaire by post. The survey included questions about the QOD of residents, and responses were evaluated using the Good Death Inventory (GDI) scale. Results Responses were obtained from 30 of the 39 bereaved families (76.9%). Data were analyzed using hierarchical clustering to determine five groups and conduct multiple comparisons. The following three domains of interest were identified: 'Dying in a favorite place', 'Good relationship with the medical staff', and 'Independence'. GDI scores were significantly higher for residents with higher ACP completion rates than for those with lower rates (p < 0.01). Residents who had taken ACP interviews had significantly higher GDI scores (p < 0.01) than those who had not taken interviews. Conclusion Overall, these findings suggest that systematic ACP might be related to the QOD among Japanese nursing home residents in the above mentioned three domains. Limitations of the present study were small sample size, cross-sectional survey design as opposed to a cohort survey design, and multiple biases, including the emotional instability of bereaved family members, the length of stay of the residents, the degree of dementia of the residents, and their tendency to talk about the place of death and to develop good relationships with the medical staff.
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Affiliation(s)
- Yoshie Toyoda
- Sawayaka-no Sato Special Nursing Home for the Elderly, Aichi, Japan
| | - Aya Tokumasu
- Sawayaka-no Sato Special Nursing Home for the Elderly, Aichi, Japan
| | - Yuki Minato
- Sawayaka-no Sato Special Nursing Home for the Elderly, Aichi, Japan
| | - Takayasu Sone
- Sawayaka-no Sato Special Nursing Home for the Elderly, Aichi, Japan
| | | | - Hideki Kojima
- National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Mitsunori Nishikawa
- End-of-Life Care Team, National Center for Geriatrics and Gerontology, Morioka-cho, 7-430, Obu, Aichi 474-8511, Japan
- Aioi Geriatric Health Services Facility, Aichi, Japan
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11
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Kita K, Kuroda K, Saito M, Kuroda M, Ogawa D, Kuroiwa M. Family Physicians' Perspectives and Practices on Advance Care Planning in Regional Cities in Japan and the United States: A Convergent Parallel Mixed-Methods Study. Cureus 2024; 16:e53260. [PMID: 38435895 PMCID: PMC10905047 DOI: 10.7759/cureus.53260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Advance care planning (ACP) has been widely recognized and practiced worldwide since the 1990s. However, only a few studies have compared clinicians' international perceptions of and experiences with ACP. Therefore, this study explored the perceptions and practices of family physicians (FPs) regarding ACP in Japan and the United States. METHODS We conducted a convergent parallel mixed-methods study using a cross-sectional web-based anonymous questionnaire survey to examine how the perceptions and practices of ACP differ between Japanese and American FPs working in regional cities. RESULTS Responses from 20 and 19 FPs in Japan and the United States were obtained, respectively. Both FP groups received ACP training during their residency and practiced ACP with the highest regard for the patient's wishes and values. Quantitative analysis revealed that American FPs placed more emphasis on documentation and patient language skills. Qualitative analysis revealed that Japanese FPs equally emphasized communication with patients' families and with patients. We merged the results of both analyses and hypothesized that the variations in the FPs' approaches to ACP might reflect variations in their backgrounds, such as health insurance systems, cultures, and values in the two countries, rather than differences between individual physicians. CONCLUSION Our study showed that both Japanese and American FPs respect patients' wishes in ACP, with some differences in their perceptions and practices. Therefore, FPs should understand and be flexible with their patients' values and cultural backgrounds as intercultural translators while following appropriate management procedures for successful ACP.
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Affiliation(s)
- Keiichiro Kita
- General Internal Medicine, Toyama University Hospital, Toyama, JPN
| | - Kaku Kuroda
- Family Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Mayuko Saito
- General Internal Medicine, Toyama University Hospital, Toyama, JPN
| | - Moe Kuroda
- Public Health, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Daishi Ogawa
- Internal Medicine, Nanto Municipal Hospital, Nanto, JPN
| | - Maiko Kuroiwa
- General Internal Medicine, Toyama University Hospital, Toyama, JPN
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12
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Yang F, Leng A, Wang J, Jing J, Leiter RE, Sharma RK, Krakauer EL, Jia Z. Association Between Primary Decision-Maker and Care Intensity Among Patients With Advanced Cancer in Mainland China. Am J Hosp Palliat Care 2023; 40:1349-1356. [PMID: 36598338 DOI: 10.1177/10499091221150768] [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: 01/05/2023] Open
Abstract
Purpose: In China, decisions regarding the treatment of seriously ill patients are usually made by family caregivers. This study aimed to explore the association between the primary decision-makers and the intensity of care given to patients with advanced cancer in China. Methods: We conducted a survey of family members and other caregivers representing 828 cancer patients who died between July 2013 and July 2016. The survey asked: "After the physician conveyed that the disease is incurable, what treatment did the patient and caregiver prefer?" and "Who was the primary decision-maker?" We compared the treatment intensity with locus of decision-making using multivariable logistic regression, adjusting for socio-demographic and clinical covariates informed. Results: Of the 792 patients in our sample, the majority were male (67·2%), 60 years or older (64·0%), married (82·2%), lived with family (98·2%), had medical insurance (94·8%), earned below-average income (53·5%), lived rurally (61·5%), had a gastrointestinal cancer diagnosis (50·8%), experienced moderate or severe pain (86·3%), never received palliative care (80·4%) and had caregivers as primary decision-makers (70·6%). We found that patients were more likely to receive intensive disease-modifying treatments when the primary decision-maker were their children (adjusted odds ratio [AOR] = 1·86, 95% CI:1·26-2·74), spouse (AOR = 2·04, 95% CI:1·26-3·30), or other caregivers (AOR = 3·46, 95% CI:1·24-9·69). Conclusions: When patients with advanced cancer in China did not make their own medical decisions, they were more likely to receive intensive disease-modifying treatments at the end-of-life. Actions should be taken to better understand and ensure that caregivers' decisions reflect the values and presence of patients.
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Affiliation(s)
- Fei Yang
- Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen, China
| | - Anli Leng
- School of Political Science and Public Administration, Shandong University, Jinan, China
| | - Jian Wang
- Dong Fureng Institute of Economic and Social Development, Wuhan University, Wuhan, China
| | - Jun Jing
- Department of Sociology and Public Health Research Center, Tsinghua University, Beijing, China
| | - Richard E Leiter
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Eric L Krakauer
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Zhimeng Jia
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
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13
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Smith MA, Brøchner AC, Nedergaard HK, Jensen HI. "Gives peace of mind" - Relatives' perspectives of end-of-life conversations. Palliat Support Care 2023:1-8. [PMID: 37982296 DOI: 10.1017/s1478951523001633] [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: 11/21/2023]
Abstract
OBJECTIVES Planning for end-of-life (EOL) and future treatment and care through advance care planning (ACP) is being increasingly implemented in different healthcare settings, and interest in ACP is growing. Several studies have emphasized the importance of relatives participating in conversations about wishes for EOL and being included in the process. Likewise, research has highlighted how relatives can be a valuable resource in an emergency setting. Although relatives have a significant role, few studies have investigated their perspectives of ACP and EOL conversations. This study explores relatives' experiences of the benefits and disadvantages of having conversations about wishes for EOL treatment. METHODS Semi-structured telephone interviews were held with 29 relatives who had participated in a conversation about EOL wishes with a patient and physician 2 years prior in a variety of Danish healthcare settings. The relatives were interviewed between September 2020 and June 2022. Content analysis was performed on the qualitative data. RESULTS The interviews revealed two themes: "gives peace of mind" and "enables more openness and common understanding of EOL." Relatives found that conversations about EOL could help assure that patients were heard and enhance their autonomy. These conversations relieved the relatives of responsibility by clarifying or confirming the patients' wishes, and they also made the relatives reflect on their own wishes for EOL. Moreover, they helped patients and relatives address other issues regarding EOL and made wishes more visible across settings. SIGNIFICANCE OF RESULTS The results indicate that conducting conversations about wishes for EOL treatment and having relatives participate in those conversations were perceived as beneficial for both relatives and patients. Involving relatives in ACP should be prioritized by physicians and healthcare personnel when holding conversations about EOL.
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Affiliation(s)
- Mette A Smith
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Anne C Brøchner
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Helene K Nedergaard
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Hanne I Jensen
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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14
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Quail P, Keller H, Vucea V, Heckman G, Sasan M, Boscart V, Ramsey C, Garland A. A Qualitative Study of Nursing Home Staff Lived Experience With Advance Care Planning. J Am Med Dir Assoc 2023; 24:1761-1766. [PMID: 37536660 DOI: 10.1016/j.jamda.2023.06.027] [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: 02/28/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE Advance care planning (ACP) within nursing homes (NHs) is an integral component of resident-centered care yet remains an ongoing area for improvement. This study explored health care providers' experiences when facilitating ACP discussions with residents and their families. DESIGN Interpretive description was used to explore meanings and generate knowledge that is applicable for clinical contexts. SETTING AND PARTICIPANTS A purposive sample of 27 staff members (2 directors of care, 3 assistant directors of care, 1 nurse practitioner, 11 registered nurses, 3 registered practical nurses, and 7 social workers) from 29 NHs located across 3 Canadian provinces that participated in cluster-randomized intervention study to improve ACP. METHODS Semistructured interviews were conducted between January and July 2020. Interpretive description methods were used for analysis. RESULTS Three themes were identified. "Navigating Relational Tensions During ACP with Families" captures the relational tensions that participants experienced while navigating ACP processes with residents and their families. The second theme, "Where's the Doctor?" highlights the general lack of physician involvement in ACP discussions and the subsequent pressures faced by participants when supporting residents and families. The last theme, "Crises Change the Best Laid Plans," illustrates the challenges participants face when trying to adhere to existing care plans during residents' medical crises. CONCLUSION AND IMPLICATIONS Participants' experiences indicate that current ACP processes in NHs do not meet the needs of residents, families, or care teams. Additional support from physicians and changes to structural processes are needed to support resident-centered end-of-life planning within this care context.
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Affiliation(s)
- Patrick Quail
- Department of Family Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada.
| | - Heather Keller
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Vanessa Vucea
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - George Heckman
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Mehar Sasan
- McMaster University, Hamilton, Ontario, Canada
| | - Veronique Boscart
- Conestoga College, Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Clare Ramsey
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allan Garland
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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15
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Aasen ERHV, Søvik ML, Størdal K, Lee A. Are We on the Same Page? Exploring Pediatric Patients' Involvement With Advance Care Planning. J Pain Symptom Manage 2023; 66:e353-e363. [PMID: 37054956 DOI: 10.1016/j.jpainsymman.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND According to the UN Convention on the Rights of the Child, children have a right to be heard. This also applies to patients in pediatric palliative care (PPC). The aim of this literature review was to explore what is known about the involvement of children (<14 years of age), adolescents and young adults (AYAs) in advance care planning (ACP) in PPC. METHODS A search was conducted in PubMed including publications from January 1, 2002 until December 31, 2021. The identified citations had to report on ACP or related terms in any PPC context. RESULTS A total of n = 471 unique reports were identified. Final inclusion criteria were met by n = 21 reports, including children and AYAs with diagnoses related to oncology, neurology, HIV/AIDS and cystic fibrosis. Nine reports were from randomized controlled studies, investigating ACP methodology. The main findings were: 1) caregivers are included more often than children and adolescents in ACP, 2) some studies indicate an incongruence between AYAs and their caregivers regarding ACP and treatment preferences, 3) although the process evokes a wide range of emotions, ACP is perceived as helpful by many AYAs CONCLUSION: The majority of studies about ACP in PPC do not include children and AYAs. Whether incongruence reported in some studies between AYAs and their caregivers regarding treatment preferences could be reduced by ACP should be further explored, including the involvement of children and adolescents in ACP, and the impact of pediatric ACP on patient outcomes in PPC.
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Affiliation(s)
| | - Marte Løvaas Søvik
- Faculty of Medicine (E.R.H.V.A., M.L.S.), University of Oslo, Oslo, Norway
| | - Ketil Størdal
- Department of Pediatric Research (K.S.), Faculty of Medicine, University of Oslo, Oslo, Norway; Division of Pediatric and Adolescent Medicine (K.S., A.L.), Oslo University Hospital, Oslo, Norway
| | - Anja Lee
- Division of Pediatric and Adolescent Medicine (K.S., A.L.), Oslo University Hospital, Oslo, Norway.
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16
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Keddem S, Ayele R, Ersek M, Murray A, Griffith M, Morawej S, Kutney-Lee A. Barriers and facilitators to goals of care conversations with Veteran residents of community nursing homes. J Am Geriatr Soc 2023; 71:2539-2548. [PMID: 37036028 DOI: 10.1111/jgs.18365] [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: 10/07/2022] [Revised: 03/01/2023] [Accepted: 03/19/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Despite evidence that structured goals of care conversations (GoCCs) and documentation of life-sustaining treatment (LST) preferences improve the delivery of goal-concordant care for seriously ill patients, rates of completion remain low among nursing home residents. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program aims to improve the consistent documentation of LST preferences among Veterans receiving care in veterans affairs (VA)-paid community nursing homes (CNH); however, the barriers and facilitators of completing and documenting GoCCs in this unique context of care have not been described. METHODS We conducted semi-structured, qualitative interviews with key stakeholders of the VA CNH programs located at six VA Medical Centers between July 2021 and July 2022. With a rapid approach to analysis, interview transcripts were reduced into memo templates using the Tailored Implementation for Chronic Disease Checklist and coded and analyzed using qualitative data analysis software. RESULTS The 40 participants consisted of nurses (n = 13), social workers (n = 25), and VA physicians (n = 2). Most participants felt confident about conducting GoCC; however, several barriers were identified. At the staff level, our results indicated inconsistent completion of GoCC and documentation due to a lack of training, confusion about roles and responsibilities, and challenging communication within the VA as well as with CNH. At the organizational level, there was a lack of standardization across sites for how LST preferences were documented. At the patient level, we found key barriers related to patient and family readiness and issues finding surrogate decision makers. While COVID-19 brought end-of-life issues to the forefront, lockdowns hindered communication about the goals of care. CONCLUSION Findings from this pre-implementation evaluation revealed multi-level barriers in conducting and documenting GoCCs with Veterans receiving VA-paid CNH care, as well as several facilitators that can be used to inform strategies for improvement.
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Affiliation(s)
- Shimrit Keddem
- Center for Health Equity, Research & Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Family Medicine & Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Roman Ayele
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
- University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Mary Ersek
- Center for Health Equity, Research & Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Andrew Murray
- Center for Health Equity, Research & Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Matthew Griffith
- University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
- Pulmonary and Critical Care Medicine Section, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Sabrina Morawej
- Center for Health Equity, Research & Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Ann Kutney-Lee
- Center for Health Equity, Research & Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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Handler J, Lee OJ, Chatrath S, McGarvey J, Fitch T, Jose D, Vozenilek J. Can a 5-to-90-day Mortality Predictor Perform Consistently Across Time and Equitably Across Populations? J Med Syst 2023; 47:67. [PMID: 37395923 PMCID: PMC10317873 DOI: 10.1007/s10916-023-01962-z] [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: 01/03/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023]
Abstract
Advance care planning (ACP) facilitates end-of-life care, yet many die without it. Timely and accurate mortality prediction may encourage ACP. However, performance of predictors typically differs among sub-populations (e.g., rural vs. urban) and worsens over time ("concept drift"). Therefore, we assessed performance equity and consistency for a novel 5-to-90-day mortality predictor across various demographies, geographies, and timeframes (n = 76,812 total encounters). Predictions were made for the first day of included adult inpatient admissions on a retrospective dataset. AUC-PR remained at 29% both pre-COVID (throughout 2018) and during COVID (8 months in 2021). Pre-COVID-19 recall and precision were 58% and 25% respectively at the 12.5% certainty cutoff, and 12% and 44% at the 37.5% cutoff. During COVID-19, recall and precision were 59% and 26% at the 12.5% cutoff, and 11% and 43% at the 37.5% cutoff. Pre-COVID, compared to the overall population, recall was lower at the 12.5% cutoff in the White, non-Hispanic subgroup and at both cutoffs in the rural subgroup. During COVID-19, precision at the 12.5% cutoff was lower than that of the overall population for the non-White and non-White female subgroups. No other significant differences were seen between subgroups and the corresponding overall population. Overall performance during COVID was unchanged from pre-pandemic performance. Although some comparisons (especially precision at the 37.5% cutoff) were underpowered, precision at the 12.5% cutoff was equitable across most demographies, regardless of the pandemic. Mortality prediction to prioritize ACP conversations can be provided consistently and equitably across many studied timeframes and sub-populations.
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Affiliation(s)
- Jonathan Handler
- Clinical Intelligence and Advanced Data Lab, OSF Healthcare System, 1306 N Berkeley Ave, Peoria, IL, 61603, USA.
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Olivia J Lee
- University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Sheena Chatrath
- University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Jeremy McGarvey
- Ministry Healthcare Analytics, OSF HealthCare System, Peoria, IL, USA
| | - Tyler Fitch
- Internal Medicine and Pediatrics, OSF Healthcare System, Peoria, IL, USA
| | - Divya Jose
- Business Intelligence Consulting, Indus Group, Wheeling, IL, USA
| | - John Vozenilek
- University of Illinois College of Medicine at Peoria, Peoria, IL, USA
- OSF Innovation, OSF Healthcare System, Peoria, IL, USA
- University of Illinois College of Engineering, Urbana Champaign, Champaign, IL, USA
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Islam Z, Pollock K, Patterson A, Hanjari M, Wallace L, Mururajani I, Conroy S, Faull C. Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-135. [PMID: 37464868 DOI: 10.3310/jvfw4781] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background This study explored whether or not, and how, terminally ill patients from ethnically diverse backgrounds and their family caregivers think ahead about deterioration and dying, and explored their engagement with health-care professionals in end-of-life care planning. Objective The aim was to address the question, what are the barriers to and enablers of ethnically diverse patients, family caregivers and health-care professionals engaging in end-of-life care planning? Design This was a qualitative study comprising 18 longitudinal patient-centred case studies, interviews with 19 bereaved family caregivers and 50 public and professional stakeholder responses to the findings. Setting The study was set in Nottinghamshire and Leicestershire in the UK. Results Key barriers - the predominant stance of patients was to live with hope, considering the future only in terms of practical matters (wills and funerals), rather than the business of dying. For some, planning ahead was counter to their faith. Health-care professionals seemed to feature little in people's lives. Some participants indicated a lack of trust and experienced a disjointed system, devoid of due regard for them. However, religious and cultural mores were of great importance to many, and there were anxieties about how the system valued and enabled these. Family duty and community expectations were foregrounded in some accounts and concern about being in the (un)care of strangers was common. Key enablers - effective communication with trusted individuals, which enables patients to feel known and that their faith, family and community life are valued. Health-care professionals getting to 'know' the person is key. Stakeholder responses highlighted the need for development of Health-care professionals' confidence, skills and training, Using stories based on the study findings was seen as an effective way to support this. A number of behavioural change techniques were also identified. Limitations It was attempted to include a broad ethnic diversity in the sample, but the authors acknowledge that not all groups could be included. Conclusions What constitutes good end-of-life care is influenced by the intersectionality of diverse factors, including beliefs and culture. All people desire personalised, compassionate and holistic end-of-life care, and the current frameworks for good palliative care support this. However, health-care professionals need additional skills to navigate complex, sensitive communication and enquire about aspects of people's lives that may be unfamiliar. The challenge for health-care professionals and services is the delivery of holistic care and the range of skills that are required to do this. Future work Priorities for future research: How can health professionals identify if/when a patient is 'ready' for discussions about deterioration and dying? How can discussions about uncertain recovery and the need for decisions about treatment, especially resuscitation, be most effectively conducted in a crisis? How can professionals recognise and respond to the diversity of faith and cultural practices, and the heterogeneity between individuals of beliefs and preferences relating to the end of life? How can conversations be most effectively conducted when translation is required to enhance patient understanding? Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. X. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Zoebia Islam
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Anne Patterson
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Matilda Hanjari
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Louise Wallace
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
| | - Irfhan Mururajani
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Christina Faull
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
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19
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Wang X, Huang XL, Wang WJ, Liao L. Advance care planning for frail elderly: are we missing a golden opportunity? A mixed-method systematic review and meta-analysis. BMJ Open 2023; 13:e068130. [PMID: 37247960 DOI: 10.1136/bmjopen-2022-068130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVE The aim is to integrate quantitative and qualitative evidence to understand the effectiveness and experience of advance care planning (ACP) for frail elderly. DESIGN A mixed-methods systematic review and meta-analysis was conducted. Quality evaluation was conducted using critical appraisal tools from the Joanna Briggs Institute. Data were synthesised and pooled for meta-analysis or meta-aggregation as needed. DATA SOURCES An electronic search of MEDLINE, CINAHL, Embase, PubMed, PsycINFO, and Cochrane Library databases from January 2003 to April 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included experimental and mixed-methods studies. The quantitative component attempts to incorporate a broader study design. The qualitative component aids in comprehending the participant's experience with ACP and its efficacy. DATA EXTRACTION AND SYNTHESIS Two independent reviewers undertook screening, data extraction and quality assessment. The quantitative and qualitative data were synthesised and integrated using a convergent segregated approach. RESULTS There were 12 158 articles found, and 17 matched the inclusion criteria. The quality of the quantitative component of most included studies (6/10) was rated as low, and the qualitative component of half included studies (4/8) was rated as moderate. The meta-analysis showed that the intervention of ACP for frail elderly effectively increases readiness, knowledge and process of ACP behaviours. The meta-aggregation showed that the participants hold a positive attitude towards ACP and think it facilitates expressing their preferences for the medical decision. CONCLUSION ACP is an effective and feasible strategy to facilitate frail elderly to express their healthcare wishes timely and improve their outcomes. This study could provide proof for a better understanding of the subject and help direct future clinical practice. More well-designed randomised controlled trials evaluating the most effective ACP interventions and tools are needed for the frail elderly population. PROSPERO REGISTRATION NUMBER CRD42022329615.
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Affiliation(s)
- Xinying Wang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Xin-Lin Huang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Wei-Jia Wang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Li Liao
- University of South China School of Nursing, Hengyang, Hunan, China
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20
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Xu X, Chau PH, Cheung DST, Ho MH, Lin CC. Preferences for end-of-life care: A cross-sectional survey of Chinese frail nursing home residents. J Clin Nurs 2023; 32:1455-1465. [PMID: 35933614 DOI: 10.1111/jocn.16483] [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: 04/29/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 11/27/2022]
Abstract
AIM AND OBJECTIVES To assess (1) the experience, knowledge and preferences of end-of-life care among frail nursing home residents and (2) the preferences of residents' family caregivers. BACKGROUND Globally, nursing homes are becoming an important place where many older people will receive their end-of-life care. Thus, assessing the end-of-life care preferences among nursing home residents is crucial. DESIGN Cross-sectional survey. METHODS Residents aged ≥65 years, with frail or pre-frail status (n = 286) in 34 nursing homes were interviewed using a structured questionnaire. Descriptive statistics were used to describe the outcomes and regression analyses were used to evaluate factors related to the outcomes. Kappa statistics were used to examine the agreement between the preferences among 21 residents and their family caregivers. The manuscript was guided by the STROBE checklist. RESULTS 5.9% and 10.5% of the participants had heard of advance care planning and advance directive respectively. After explanations of the terms by the research team, 42.3% of the participants preferred advance care planning, whereas 22.0% preferred advance directive. The top reason for not preferring advance care planning/advance directive is perceiving them as 'not necessary'. Nursing homes were the most preferred place to receive end-of-life care (41.6%). Whereas hospitals were the most preferred place for death (36.0%). The agreement among resident and family caregiver dyads ranged from none to minimal in most outcomes. CONCLUSIONS This study revealed the lack of awareness around advance care planning and advance directive among frail nursing home residents. Future research should focus on developing effective educational interventions to enhance the residents' awareness of these topics. RELEVANCE TO CLINICAL PRACTICE To increase awareness among nursing home residents, more educational programs should be implemented. Frail older residents might not see the relevance of advance care planning; interventions need to include both current and future care to increase its relevance.
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Affiliation(s)
- Xinyi Xu
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Pui Hing Chau
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Denise Shuk Ting Cheung
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Mu-Hsing Ho
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chia-Chin Lin
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong.,Alice Ho Miu Ling Nethersole Charity Foundation Professorship in Nursing, Hong Kong, Hong Kong
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21
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Colucciello NA, Kowalkowski MA, Kooken M, Wardi G, Taylor SP. Passing the SNF Test: A Secondary Analysis of a Sepsis Transition Intervention Trial Among Patients Discharged to Post-Acute Care. J Am Med Dir Assoc 2023; 24:742-746.e1. [PMID: 36918147 DOI: 10.1016/j.jamda.2023.02.009] [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: 08/31/2022] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVES Sepsis survivors discharged to post-acute care facilities experience high rates of mortality and hospital readmission. This study compared the effects of a Sepsis Transition and Recovery (STAR) program vs usual care (UC) on 30-day mortality and hospital readmission among sepsis survivors discharged to post-acute care. DESIGN Secondary analysis of a multisite pragmatic randomized clinical trial. SETTING AND PARTICIPANTS Sepsis survivors discharged to post-acute care. METHODS We conducted a secondary analysis of patients from the IMPACTS (Improving Morbidity During Post-Acute Care Transitions for Sepsis) randomized clinical trial who were discharged to post-acute care. IMPACTS evaluated the effectiveness of STAR, a nurse-navigator-led program to deliver best practice post-sepsis care. Subjects were randomized to receive either STAR or UC. The primary outcome was 30-day readmission and mortality. We also evaluated hospital-free days alive as a secondary outcome. RESULTS Of 691 patients enrolled in IMPACTS, 175 (25%) were discharged to post-acute care [143 (82%) to skilled nursing facilities, 12 (7%) to long-term acute care hospitals, and 20 (11%) to inpatient rehabilitation]. Of these, 87 received UC and 88 received the STAR intervention. The composite 30-day all-cause mortality and readmission endpoint occurred in 26 (29.9%) patients in the UC group vs 18 (20.5%) in the STAR group [risk difference -9.4% (95% CI -22.2 to 3.4); adjusted odds ratio 0.58 (95% CI 0.28 to 1.17)]. Separately, 30-day all-cause mortality was 8.1% in the UC group compared with 5.7% in the STAR group [risk difference -2.4% (95% CI -9.9 to 5.1)] and 30-day all-cause readmission was 26.4% in the UC group compared with 17.1% in the STAR program [risk difference -9.4% (95% CI -21.5 to 2.8)]. CONCLUSIONS AND IMPLICATIONS There are few proven interventions to reduce readmission among patients discharged to post-acute care facilities. These results suggest the STAR program may reduce 30-day mortality and readmission rates among sepsis survivors discharged to post-acute care facilities.
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Affiliation(s)
| | - Marc A Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Maria Kooken
- Department of Pediatrics, Atrium Health, Charlotte, NC, USA
| | - Gabriel Wardi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Stephanie P Taylor
- Department of Internal Medicine, Atrium Health, Charlotte, NC, USA; Department of Internal Medicine, Wake Forest School of Medicine, Charlotte, NC, USA
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22
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Fassmer AM, Allers K, Helbach J, Zuidema S, Freitag M, Zieschang T, Hoffmann F. Hospitalization of German and Dutch Nursing Home Residents Depend on Different Long-Term Care Structures: A Systematic Review on Periods of Increased Vulnerability. J Am Med Dir Assoc 2023; 24:609-618.e6. [PMID: 36898411 DOI: 10.1016/j.jamda.2023.01.030] [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: 11/15/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVE To investigate proportions of hospitalized nursing home residents during periods of increased vulnerability, ie, the first 6 months after institutionalization and the last 6 months before death, and comparing the figures between Germany and the Netherlands. DESIGN Systematic review, registered in PROSPERO (CRD42022312506). SETTING AND PARTICIPANTS Newly admitted or deceased residents. METHODS We searched MEDLINE via PubMed, EMBASE, and CINAHL from inception through May 3, 2022. We included all observational studies that reported the proportions of all-cause hospitalizations among German or Dutch nursing home residents during these defined vulnerable periods. Study quality was assessed using the Joanna Briggs Institute's tool. We assessed study and resident characteristics and outcome information and descriptively reported them separately for both countries. RESULTS We screened 1856 records for eligibility and included 9 studies published in 14 articles (Germany: 8; Netherlands: 6). One study for each country investigated the first 6 months after institutionalization. A total of 10.2% of the Dutch and 42.0% of the German nursing home residents were hospitalized during this time. Overall, 7 studies reported on in-hospital deaths, with proportions ranging from 28.9% to 29.5% for Germany and from 1.0% to 16.3% for the Netherlands. Proportions for hospitalization in the last 30 days of life ranged from 8.0% to 15.7% (Netherlands: n = 2) and from 48.6% to 58.0% (Germany: n = 3). Only German studies assessed the differences by age and sex. Although hospitalizations were less common at older ages, they were more frequent in male residents. CONCLUSIONS AND IMPLICATIONS During the observed periods, the proportion of nursing homes residents being hospitalized differed greatly between Germany and the Netherlands. The higher figures for Germany can probably be explained by differences in the long-term care systems. There is a lack of research, especially for the first months after institutionalization, and future studies should examine the care processes of nursing home residents following acute events in more detail.
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Affiliation(s)
- Alexander M Fassmer
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany.
| | - Katharina Allers
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Jasmin Helbach
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Sytse Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michael Freitag
- Division of General Practice, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Tania Zieschang
- Division of Geriatrics, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Falk Hoffmann
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
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Charmillot PA, Van den Block L, Oosterveld-Vlug M, Pautex S. Perceptions of healthcare professional about the "PACE Steps to Success" palliative care program for long-term care: A qualitative study in Switzerland. Nurs Open 2023. [PMID: 36840609 DOI: 10.1002/nop2.1683] [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: 09/30/2021] [Revised: 01/15/2023] [Accepted: 02/04/2023] [Indexed: 02/26/2023] Open
Abstract
AIM This study aimed to examine the healthcare professionals' perceptions after implementing the "PACE Steps to Success" program in the French-speaking part of Switzerland. DESIGN A qualitative descriptive study. METHODS Thematic analysis of semi-structured face-to-face and group interviews with health professionals, PACE coordinators, and managers purposely invited in the four long-term home facilities that had previously participated in the PACE cluster randomized clinical trial intervention group. RESULTS The PACE program implementation has improved communication with residents regarding end-of-life issues and helped identify patients' needs. The introduction of codified tools can complete internal tools and support decision-making. In addition, the training has promoted inter-professional collaboration, particularly in the case of care assistants, by defining each profession's specific responsibilities in providing care for older adults.
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Affiliation(s)
| | | | - Mariska Oosterveld-Vlug
- Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sophie Pautex
- Palliative Medicine Division, University Hospital Geneva, University of Geneva, Geneva, Switzerland
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Searle B, Barker RO, Stow D, Spiers GF, Pearson F, Hanratty B. Which interventions are effective at decreasing or increasing emergency department attendances or hospital admissions from long-term care facilities? A systematic review. BMJ Open 2023; 13:e064914. [PMID: 36731926 PMCID: PMC9896242 DOI: 10.1136/bmjopen-2022-064914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE UK long-term care facility residents account for 185 000 emergency hospital admissions each year. Avoidance of unnecessary hospital transfers benefits residents, reduces demand on the healthcare systems but is difficult to implement. We synthesised evidence on interventions that influence unplanned hospital admissions or attendances by long-term care facility residents. METHODS This is a systematic review of randomised controlled trials. PubMed, MEDLINE, EMBASE, ISI Web of Science, CINAHL and the Cochrane Library were searched from 2012 to 2022, building on a review published in 2013. We included randomised controlled trials that evaluated interventions that influence (decrease or increase) acute hospital admissions or attendances of long-term care facility residents. Risk of bias and evidence quality were assessed using Cochrane Risk Of Bias-2 and Grading of Recommendations Assessment, Development and Evaluation. RESULTS Forty-three randomised studies were included in this review. A narrative synthesis was conducted and the weight of evidence described with vote counting. Advance care planning and goals of care setting appear to be effective at reducing hospitalisations from long-term care facilities. Other effective interventions, in order of increasing risk of bias, were: nurse practitioner/specialist input, palliative care intervention, influenza vaccination and enhancing access to intravenous therapies in long-term care facilities. CONCLUSIONS Factors that affect hospitalisation and emergency department attendances of long-term care facility residents are complex. This review supports the already established use of advance care planning and influenza vaccination to reduce unscheduled hospital attendances. It is likely that more than one intervention will be needed to impact on healthcare usage across the long-term care facility population. The findings of this review are useful to identify effective interventions that can be combined, as well as highlighting interventions that either need evaluation or are not effective at decreasing healthcare usage. PROSPERO REGISTRATION NUMBER CRD42020169604.
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Affiliation(s)
- Ben Searle
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Robert O Barker
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel Stow
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Gemma F Spiers
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Pearson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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25
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Shi S, Largent EA, McCreedy E, Mitchell SL. Design Considerations for Embedded Pragmatic Clinical Trials of Advance Care Planning Interventions for Persons Living With Dementia. J Pain Symptom Manage 2023; 65:e155-e163. [PMID: 36423803 PMCID: PMC9875559 DOI: 10.1016/j.jpainsymman.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/23/2022]
Abstract
Advance care planning (ACP) is an important part of comprehensive care for persons living with dementia (PLWD). While many trials have established the efficacy of ACP in improving end-of-life communication and documentation of care preferences, there remains a gap in clinical usage. Embedded pragmatic clinical trials (ePCTs) may facilitate the uptake of evidence-based care into existing healthcare by deploying efficacious ACP interventions into real-world settings. However rigorous conduct of ePCTs of ACP for PLWD presents several unique methodological considerations. Here we describe a framework for the construction of these research studies, with a focus on distinguishing between the target of study: the PLWD, their care partners, or both. We outline specific considerations at each step of the research study process including 1) participant identification/eligibility, 2) participant recruitment/enrollment, 3) intervention implementation, and 4) outcome selection/ascertainment. These considerations are weighed in further detail by describing the approaches from three published trials. Specifically, we consider how potential challenges were overcome by tradeoffs in study design. Finally, we offer directions for future growth to advance ePCTs for ACP among PLWD and catalyze future research.
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Affiliation(s)
- Sandra Shi
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research (S.S., S.L.M.), Boston, MA, USA.
| | - Emily A Largent
- University of Pennsylvania Perelman School of Medicine (E.A.L.), Philadelphia, PA, USA
| | - Ellen McCreedy
- Brown University School of Public Health (E.M.), Providence, RI, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research (S.S., S.L.M.), Boston, MA, USA
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26
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Promoting advance care planning (ACP) in community health clinics in Israel: Perceptions of older adults with pro-ACP attitudes and their family physicians. Palliat Support Care 2023; 21:83-92. [PMID: 35109955 DOI: 10.1017/s1478951521001942] [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
OBJECTIVE We examined barriers and facilitators to patient-family physician discussions in Israel about advance care planning, including preparation of an advance directive by adults over age 65, as part of a program in two community health clinics which afforded family physicians the opportunity to dedicate time to such discussions with patients. To the best of our knowledge, the program is the first of its kind in Israel. METHOD We used thematic analyses of qualitative data collected through 22 interviews with patients with pro-advanced care planning attitudes and three focus groups with eleven family physicians. RESULTS Overall, three themes in the interviews with patients and two themes in the focus groups with physicians emerged. The program gave people with pro-advanced care planning attitudes the opportunity to follow through with their ideas. We found that patients viewed their family physicians as facilitators and that the use of an information leaflet was an effective way to promote advance directives. Family physicians expressed positive attitudes toward assisting patients in the preparation of advance directives and welcomed an allotment of time for this endeavor as part of their schedule but expressed hesitation about assisting patients concerning legal and moral issues. SIGNIFICANCE OF RESULTS A pro-advanced care planning attitude is not enough for patients to complete the process of creating an advance directive; patients need active encouragement and intervention in order to turn their ideas into action. More patient and physician education are necessary to enable patients to protect their right to self-determination in end-of-life medical decision-making and to support physicians as facilitators of the process.
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Preferred Place of End-of-Life Care Based on Clinical Scenario: A Cross-Sectional Study of a General Japanese Population. Healthcare (Basel) 2023; 11:healthcare11030406. [PMID: 36766981 PMCID: PMC9914905 DOI: 10.3390/healthcare11030406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
In Japan, which has an aging society with many deaths, it is important that people discuss preferred place for end-of-life care in advance. This study aims to investigate whether the preferred place of end-of-life care differs by the assumed clinical scenario. This clinical scenario-based survey used data from a nationwide survey conducted in Japan in December 2017. Participants aged 20 years and older were randomly selected from the general population. The survey contained questions based on three scenarios: cancer, end-stage heart disease, and dementia. For each scenario, respondents were asked to choose the preferred place of end-of-life care among three options: home, nursing home, and medical facility. Eight hundred eighty-nine individuals participated in this study (effective response rate: 14.8%). The proportions of respondents choosing home, nursing home, and medical facility for the cancer scenario were 49.6%, 10.9%, and 39.5%, respectively; for the end-stage heart disease scenario, 30.5%, 18.9%, and 50.6%; and for the dementia scenario, 15.2%, 54.5%, and 30.3% (p < 0.0001, chi-square test). The preferred place of end-of-life care differed by the assumed clinical scenario. In clinical practice, concrete information about diseases and their status should be provided during discussions about preferred place for end-of-life care to reveal people's preferences more accurately.
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Mota-Romero E, Rodríguez-Landero O, Moya-Dieguez R, Cano-Garzón GM, Montoya-Juárez R, Puente-Fernández D. Information and Advance Care Directives for End-of-Life Residents with and without Dementia in Nursing Homes. Healthcare (Basel) 2023; 11:healthcare11030353. [PMID: 36766928 PMCID: PMC9914900 DOI: 10.3390/healthcare11030353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/10/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Communication and advance care directives may be affected by the presence of dementia. We sought to describe the information and end-of-life preferences provided to nursing homes residents and their families. METHODS Trained nurses collected information from 124 residents randomly selected with palliative care needs from eight nursing homes. RESULTS A total of 54.4% of the residents with dementia had been provided with information about their state of health, compared to 92.5% of the residents without dementia (p < 0.01); family members exhibited no differences regarding information (p = 0.658), regardless of whether the resident was cognitively impaired. Most advance care interventions remained unexplored, except for cases where a transfer to hospital (81.5%) or serotherapy (69.4%) was desired. Decisions regarding palliative sedation (p = 0.017) and blood transfusion (p = 0.019) were lower among residents with dementia. CONCLUSIONS Residents, especially residents with dementia, are provided with limited information and their preferences are inadequately explored.
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Affiliation(s)
- Emilio Mota-Romero
- Andalusian Health Service District Metropolitano Granada, Salvador Caballero Primary Care Centre, Institute for Biosanitary Research of Granada (IBS), University of Granada, 18014 Granada, Spain
| | | | | | | | - Rafael Montoya-Juárez
- Department of Nursing, Institute for Biosanitary Research of Granada (IBS), University of Granada, 18014 Granada, Spain
| | - Daniel Puente-Fernández
- Department of Nursing, Institute for Biosanitary Research of Granada (IBS), University of Granada, 18014 Granada, Spain
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Beck S, Lundblad L, Göras C, Eneslätt M. Implementing advance care planning in Swedish healthcare settings - a qualitative study of professionals' experiences. Scand J Prim Health Care 2022; 41:23-32. [PMID: 36519794 PMCID: PMC10088918 DOI: 10.1080/02813432.2022.2155456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is a process involving conversations about values and preferences regarding future care at the end-of-life. ACP has led to positive outcomes, both in relation to quality of life and with increased use of palliative care, less life-sustaining treatment and fewer hospital admissions. Sweden has yet to embrace the practice systematically, but scattered initiatives exist. AIM To study implementation of a routine for ACP in NH settings in Sweden by exploring healthcare professionals' experiences of engaging in ACP following this implementation. METHODS The study followed a qualitative inductive design with convenience and snowball sampling. Semi-structured group and individual interviews with registered healthcare professionals were analysed using qualitative content analysis. FINDINGS Organisational support for sustainable ACP implementation was found to be essential. This included sufficient training, facilitation, collaboration and uniform work routines across providers and professionals. Engaging in ACP conversations following the implemented routine was found to be a process of preparing, being, talking, deciding and sharing. CONCLUSIONS Successful implementation of ACP in NHs requires a carefully planned implementation strategy. ACP in NHs tend to be medically focused at the expense of residents' psychosocial care-planning needs. Widespread uptake of ACP in Sweden could be useful in the national effort to adopt more person-centred care in Swedish healthcare.KEY POINTS While advance care planning has been implemented in many other countries, Sweden lacks a national strategy on advance care planning and Swedish healthcare settings have yet to systematically implement this practice. • This study is the first to report on professionals' experiences of engaging in sustainable advance care planning, following top-down implementation of the practice in one Swedish region. • Successful implementation of advance care planning in nursing homes requires a system-level approach, and shortcomings of the implementation process are highlighted.
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Affiliation(s)
- Simon Beck
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Lina Lundblad
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Camilla Göras
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Malin Eneslätt
- Department of Health, Education, and Technology, Luleå University of Technology, Luleå, Sweden
- Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet, Stockholm, Sweden
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Ramirez-Valdez EA, Leong C, Wu F, Ball S, Maistrello G, Martin G, Fritz Z. Towards cataloguing and characterising advance care planning and end-of-life care resources. BMC Palliat Care 2022; 21:211. [PMID: 36447187 PMCID: PMC9706845 DOI: 10.1186/s12904-022-01102-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 11/11/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Resources for healthcare professionals, patients and those important to them relating to planning and coordinating treatment and care at the end of life are abundant, and can be difficult to navigate. However, they have not been systematically collated or catalogued in terms of their purpose, scope or intended audience. AIM To collate, categorise and characterise advance care planning and end-of-life treatment and care (EoLT + C) resources directed towards healthcare professionals, patients and their families. METHODS Rapid review and thematic synthesis of resources available in the United Kingdom. Google searches and reviews of websites belonging to selected organisations that develop and publish materials relating to EoLT + C, and advance care planning were used. Materials were included if they were intended for those over 18 living in the UK and pertained to five domains of EoLT + C: identifying those approaching end of life; accessing EoLT + C services; conducting important conversations about EoLT + C and preferences; advance care planning, including recording of preferences and plans; and ensuring that plans and preferences are accessed and used by health and social care services. RESULTS 246 resources directed at healthcare professionals, patients and their families were identified, collated, catalogued and made internationally available for clinicians, researchers, patients and the public. 61 were classified as interactive, providing decision support in EoLT + C that went beyond simply providing information. Of these, there was notable content overlap among tools for identifying patients in their last year of life. There was variation in the development of tools across all domains of end-of-life care by geography and patient group. Few interactive resources integrated seamlessly with a digital interface or healthcare provider workflows. Incentives for the adoption of best-practice appeared rare. CONCLUSIONS We present a repeatable and scalable approach to the cataloguing and characterisation of palliative care resources. The identified resources will be of benefit not only to those in the UK but to those in other countries, developing or evaluating their own resources for aiding professionals and patients to plan and deliver excellent treatment and care at the end of life.
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Affiliation(s)
- Edric Aram Ramirez-Valdez
- grid.120073.70000 0004 0622 5016School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Hills Rd, Cambridge, CB2 0SP UK
| | - Clare Leong
- grid.5335.00000000121885934The Healthcare Improvement Studies Institute, THIS Institute, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH UK
| | - Frances Wu
- grid.5335.00000000121885934The Healthcare Improvement Studies Institute, THIS Institute, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH UK
| | - Sarah Ball
- grid.425785.90000 0004 0623 2013RAND Europe, Cambridge, UK
| | | | - Graham Martin
- grid.5335.00000000121885934The Healthcare Improvement Studies Institute, THIS Institute, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH UK
| | - Zoë Fritz
- grid.5335.00000000121885934The Healthcare Improvement Studies Institute, THIS Institute, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH UK
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Ke X, Zhu H, Zhang Y, Yang L, Shi S, Zhu F, Luo H. Willingness of patients with cancer pain to participate in end-of-life decisions: a multi-center cross-sectional study from three coastal provinces in southern China. Palliat Care 2022; 21:207. [PMID: 36434622 PMCID: PMC9700943 DOI: 10.1186/s12904-022-01108-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/15/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Little is known about patients' intention for participation in end-of-life decisions (EOLD) in three coastal provinces in southern China. This study aimed to explore the willingness of patients with cancer pain to participate in EOLD and potential influencing factors. METHODS A multi-center cross-sectional study was performed in three coastal provinces in southern China. Two hundred and thirty patients with cancer pain were recruited and consented to fill out the questionnaires. The patients' willingness to participate in EOLD, demographic and disease-related data was surveyed. RESULTS In total, 223 patients completed and returned the survey (response rate = 96.95%). One hundred four cases (46.64%) were willing to participate in EOLD. 119 (54.36%) cases not willing to participate in EOLD, respectively. Multivariate logistic regression analysis shows that educational level (OR: 0.683, 95% CI: 0.482-0.966), history of alcoholism (OR: 8.353, 95%CI: 2.535-27.525), Eastern Cooperative Oncology Group (ECOG) score (OR: 0.645, 95% CI: 0.450-0.925) and experience of explosive pain (OR: 6.367, 95% CI: 3.103-13.062) and clinical rescue (OR: 3.844, 95% CI: 1.722-8.577) had significant effects on EOLD intention (P < 0.05). Finally, a predictive model combined above five factors was established, which showed a good discrimination (area under receiver operating characteristic curve: 0.849, 95% CI: 0.796-0.899, P < 0.001) and calibration (Hosmer-Lemeshow Test: Chi-square = 10.103, P = 0.258) for which patients more willing to participate in EOLD. CONCLUSIONS The willingness of patients with cancer pain to participate in EOLD is at a modest level in three coastal provinces in southern China. Patients with lower educational level, history of alcoholism, better health status and experience of explosive pain and clinical rescue may be more prone to participate in EOLD.
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Affiliation(s)
- Xi Ke
- grid.415110.00000 0004 0605 1140Department of Abdominal Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road 420#, Fuzhou, 350014 China
| | - Hongyu Zhu
- grid.415110.00000 0004 0605 1140Department of Abdominal Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road 420#, Fuzhou, 350014 China
| | - Yu Zhang
- Department of Internal Medicine-Oncology, Shaanxi Cancer Hospital, Xian, 710061 China
| | - Ling Yang
- grid.256607.00000 0004 1798 2653Department of Gastroenterology-Oncology, Cancer Hospital Affiliated to Guangxi Medical University, Nanning, 530000 China
| | - Simei Shi
- grid.488530.20000 0004 1803 6191Department of Gastroenterology-Oncology, Sun Yat-Sen University Cancer Prevention and Treatment Center, Sun Yat-sen University Cancer Center, Guangzhou, 510060 China
| | - Fang Zhu
- grid.415110.00000 0004 0605 1140Department of thoracic oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Huiyu Luo
- grid.415110.00000 0004 0605 1140Nursing management department, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road 420#, Fuzhou, 350014 China
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Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews. Age Ageing 2022; 51:6834152. [PMID: 36413591 PMCID: PMC9681131 DOI: 10.1093/ageing/afac257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND care home residents aged over 65 have disproportionate rates of emergency department (ED) attendance and hospitalisation. Around 40% attendances may be avoidable, and hospitalisation is associated with harms. We synthesised the evidence available in qualitative systematic reviews of different stakeholders' experiences of decisions to transfer residents to the ED. METHODS six electronic databases, references and citations of included reviews and relevant policy documents were searched. Reviews of qualitative studies exploring factors that influenced care home staff, medical practitioners, residents' family or residents' experiences and factors influencing decisions to transfer residents to the ED were included. Thematic analysis was used to synthesise findings. RESULTS six previous reviews were included, which synthesised the findings of 34 primary studies encompassing 152 care home residents, 283 resident family members or carers and 447 care home staff. Of the primary studies, 19 were conducted in the North America, seven in Australia, five were conducted in Scandinavia, two in the United Kingdom and one in Holland. Three themes were identified: (i) power dynamics between residents, family members, care home staff and health care professionals (external to the care home) influence decisions; (ii) admission can be necessary; however, (iii) some decisions may be driven by factors other than clinical need. CONCLUSION transfer decisions are complex and are determined not just by changes in health status interventions aimed at reducing avoidable transfers need to address the key role family members have in transfer decisions, the medical legal fears of care home staff and barriers to accessing community services.
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Affiliation(s)
- Carl Marincowitz
- Address correspondence to: Carl Marincowitz, Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
| | - Louise Preston
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Anna Cantrell
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Michael Tonkins
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Lisa Sabir
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Suzanne Mason
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
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Vilapakkam Nagarajan S, Poulos CJ, Clayton JM, Atee M, Morris T, Lovell MR. Australian residential aged care home staff experiences of implementing an intervention to improve palliative and end-of-life care for residents: A qualitative study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e5588-e5601. [PMID: 36068671 PMCID: PMC10087131 DOI: 10.1111/hsc.13984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/26/2022] [Accepted: 08/13/2022] [Indexed: 06/15/2023]
Abstract
Access to high-quality and safe evidence-based palliative care (PC) is important to ensure good end-of-life care for older people in residential aged care homes (RACHs). However, many barriers to providing PC in RACHs are frequently cited. The Quality End-of-Life Care (QEoLC) Project was a multicomponent intervention that included training, evidence-based tools and tele-mentoring, aiming to equip healthcare professionals and careworkers in RACHs with knowledge, skills and confidence in providing PC to residents. This study aims to understand: (1) the experiences of healthcare professionals, careworkers, care managers, planners/implementers who participated in the implementation of the QEoLC Project; and (2) the barriers and facilitators to the implementation. Staff from two RACHs in New South Wales, Australia were recruited between September to November 2021. Semi-structured interviews and thematic data analysis were used. Fifteen participants (seven health professionals [includes one nurse, two clinical educators, three workplace trainers, one clinical manager/nurse], three careworkers and five managers) were interviewed. Most RACH participants agreed that the QEoLC Project increased their awareness of PC and provided them with the skills/confidence to openly discuss death and dying. Participants perceived that the components of the QEoLC Project had the following benefits for residents: more appropriate use of medications, initiation of timely pain management and discussions with families regarding end-of-life care preferences. Key facilitators for implementation were the role of champions, the role of the steering committee, regular clinical meetings to discuss at-risk residents and mentoring. Implementation barriers included: high staff turnover, COVID-19 pandemic, time constraints, perceived absence of executive sponsorship, lack of practical support and systems-related barriers. The findings underline the need for strong leadership, supportive organisational culture and commitment to the implementation of processes for improving the quality of end-of-life care. Furthermore, the results highlight the need for codesigning the intervention with RACHs, provision of dedicated staff/resources to support implementation, and integration of project tools with existing systems for achieving effective implementation outcomes.
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Affiliation(s)
- Srivalli Vilapakkam Nagarajan
- The Palliative CentreHammondCare, Greenwich HospitalSydneyNew South WalesAustralia
- Sydney Medical School, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Christopher J. Poulos
- Centre for Positive AgeingHammondCareSydneyNew South WalesAustralia
- School of Population HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Josephine M. Clayton
- The Palliative CentreHammondCare, Greenwich HospitalSydneyNew South WalesAustralia
- Sydney Medical School, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Mustafa Atee
- The Dementia CentreHammondCareOsborne ParkWestern AustraliaAustralia
| | - Thomas Morris
- The Dementia CentreHammondCareSt LeonardsNew South WalesAustralia
| | - Melanie R. Lovell
- The Palliative CentreHammondCare, Greenwich HospitalSydneyNew South WalesAustralia
- Sydney Medical School, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
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Slezáčková A, Malatincová T, Rusinová K, Kopecký O, Kuře J. Evaluation of the Utility of the Advance Care Planning and Decision‑Making Supportive Tool. ANESTEZIOLOGIE A INTENZIVNÍ MEDICÍNA 2022. [DOI: 10.36290/aim.2022.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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Kesten JM, Redwood S, Pullyblank A, Tavare A, Pocock L, Brant H, Hill EM, Tutaev M, Shum RZ, Banks J. Using the recommended summary plan for emergency care and treatment (ReSPECT) in care homes: a qualitative interview study. Age Ageing 2022; 51:6770071. [PMID: 36273344 PMCID: PMC9588387 DOI: 10.1093/ageing/afac226] [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: 03/03/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an advance care planning process designed to facilitate discussion and documentation of preferences for care in a medical emergency. Advance care planning is important in residential and nursing homes. AIM To explore the views and experiences of GPs and care home staff of the role of ReSPECT in: (i) supporting, and documenting, conversations about care home residents' preferences for emergency care situations, and (ii) supporting decision-making in clinical emergencies. SETTING/PARTICIPANTS Sixteen GPs providing clinical care for care home residents and 11 care home staff in the West of England. METHODS A qualitative research design using semi-structured interviews. RESULTS Participants' accounts described the ReSPECT process as facilitating person-centred conversations about residents' preferences for care in emergency situations. The creation of personalised scenarios supported residents to consider their preferences. However, using ReSPECT was complex, requiring interactional work to identify and incorporate resident or relative preferences. Subsequent translation of preferences into action during emergency situations also proved difficult in some cases. Care staff played an important role in facilitating and supporting ReSPECT conversations and in translating it into action. CONCLUSIONS The ReSPECT process in care homes was positive for GPs and care home staff. We highlight challenges with the process, communication of preferences in emergency situations and the importance of balancing detail with clarity. This study highlights the potential for a multi-disciplinary approach engaging care staff more in the process.
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Affiliation(s)
- Joanna May Kesten
- Address correspondence to: Joanna May Kesten, NIHR ARC West at University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol BS1 2NT, UK.
| | - Sabi Redwood
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | - Anne Pullyblank
- West of England Academic Health Science Network (West of England AHSN), Bristol, UK,North Bristol NHS Trust, Bristol, UK
| | - Alison Tavare
- West of England Academic Health Science Network (West of England AHSN), Bristol, UK
| | - Lucy Pocock
- Population Health Sciences, Bristol Medical School, University of Bristol
| | - Heather Brant
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | - Elizabeth M Hill
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | | | - Rui Zhi Shum
- Population Health Sciences, Bristol Medical School, University of Bristol
| | - Jon Banks
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
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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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Götze K, Bausewein C, Feddersen B, Fuchs A, Hot A, Hummers E, Icks A, Kirchner Ä, Kleinert E, Klosterhalfen S, Kolbe H, Laag S, Langner H, Lezius S, Meyer G, Montalbo J, Nauck F, Reisinger C, Rieder N, Schildmann J, Schunk M, Stanze H, Vogel C, Wegscheider K, Zapf A, Marckmann G, in der Schmitten J, Albert A, Alheid C, Bausewein C, Bruene M, Calles C, Camci H, Daubmann A, Dahlke S, Enger S, Feddersen B, Felder G, Fluck C, Freienstein A, Freytag T, Fuchs A, Icks A, in der Schmitten J, Hensel L, Hummers E, Hot A, Kirchner Ä, Kleinert E, Klosterhalfen S, Kolbe H, Laag S, Langner H, Lezius S, Marckmann G, Meyer G, Montalbo J, Nauck F, Nguyen T, Nowak A, Ossenberg M, Reisinger C, Reuter S, Rieder N, Riester T, Rosu I, Rösgen H, Salanta K, Sassi Z, Schildmann J, Schulenberg T, Schunk M, Sommer D, Stanze H, Stöhr A, Theuerkauf A, Thilo N, Tönjann J, Partowinia-Peters M, Prommersberger S, Przybylla S, Vogel C, Vomhof M, Wilken J, Zapf A, Zimprich J. Effectiveness of a complex regional advance care planning intervention to improve care consistency with care preferences: study protocol for a multi-center, cluster-randomized controlled trial focusing on nursing home residents (BEVOR trial). Trials 2022; 23:770. [PMID: 36096948 PMCID: PMC9465132 DOI: 10.1186/s13063-022-06576-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background According to recent legislation, facilitated advance care planning (ACP) for nursing home (NH) residents is covered by German sickness funds. However, the effects of ACP on patient-relevant outcomes have not been studied in Germany yet. This study investigates whether implementing a complex regional ACP intervention improves care consistency with care preferences in NH residents. Methods This is a parallel-group cluster-randomized controlled trial (cRCT) with 48 NHs (≈ 3840 resident beds) between 09/2019 and 02/2023. The intervention group will receive a complex, regional ACP intervention aiming at sustainable systems redesign at all levels (individual, institutional, regional). The intervention comprises comprehensive training of ACP facilitators, implementation of reliable ACP processes, organizational development in the NH and other relevant institutions of the regional healthcare system, and education of health professionals caring for the residents. Control group NHs will deliver care as usual. Primary outcome is the hospitalization rate during the 12-months observation period. Secondary outcomes include the rate of residents whose preferences were known and honored in potentially life-threatening events, hospital days, index treatments like resuscitation and artificial ventilation, advance directives, quality of life, psychological burden on bereaved families, and costs of care. The NHs will provide anonymous, aggregated data of all their residents on the primary outcome and several secondary outcomes (data collection 1). For residents who have given informed consent, we will evaluate care consistency with care preferences and further secondary outcomes, based on chart reviews and short interviews with residents, surrogates, and carers (data collection 2). Process evaluation will aim to explain barriers and facilitators, economic evaluation the cost implications. Discussion This study has the potential for high-quality evidence on the effects of a complex regional ACP intervention on NH residents, their families and surrogates, NH staff, and health care utilization in Germany. It is the first cRCT investigating a comprehensive regional ACP intervention that aims at improving patient-relevant clinical outcomes, addressing and educating multiple institutions and health care providers, besides qualification of ACP facilitators. Thereby, it can generate evidence on the potential of ACP to effectively promote patient-centered care in the vulnerable population of frail and often chronically ill elderly. Trial registration ClinicalTrials.gov ID NCT04333303. Registered 30 March 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06576-3.
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Pimsen A, Kao CY, Hsu ST, Shu BC. The Effect of Advance Care Planning Intervention on Hospitalization Among Nursing Home Residents: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2022; 23:1448-1460.e1. [PMID: 35964662 DOI: 10.1016/j.jamda.2022.07.017] [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: 04/02/2022] [Revised: 07/11/2022] [Accepted: 07/16/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the effect of advance care planning (ACP) interventions on the hospitalization of nursing home residents. DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS Nursing homes and nursing home residents. METHODS A literature search was systematically conducted in 6 electronic databases (Embase, Ovid MEDLINE, Cochrane Library, CINAHL, AgeLine, and the Psychology & Behavioral Sciences Collection), in addition to hand searches and reference list checking; the articles retrieved were those published from 1990 to November 2021. The eligible studies were randomized controlled trials, controlled trials, and pre-post intervention studies describing original data on the effect of ACP on hospitalization of nursing home residents; these studies had to be written in English. Two independent reviewers appraised the quality of the studies and extracted the relevant data using the Joanna Briggs Institute abstraction form and critical appraisal tools. A study protocol was registered in PROSPERO (CRD42022301648). RESULTS The initial search yielded 744 studies. Nine studies involving a total of 57,180 residents were included in the review. The findings showed that the ACP reduced the likelihood of hospitalization [relative risk (RR) 0.54, 95% CI 0.47-0.63; I2 = 0%)], it had no effect on emergency department (ED) visits (RR 0.60, 95% CI 0.31-1.42; I2 = 99), hospice enrollment (RR 0.98, 95% CI 0.88-1.10; I2 = 0%), mortality (RR 0.83, 95% CI 0.68-1.00; I2 = 4%), and satisfaction with care (standardized mean difference: -0.04, 95% CI -0.14 to -0.06; I2 = 0%). CONCLUSION AND IMPLICATIONS ACP reduced hospitalizations but did not affect the secondary outcomes, namely, ED visits, hospice enrollment, mortality, and satisfaction with care. These findings suggest that policy makers should support the implementation of ACP programs in nursing homes. More robust studies are needed to determine the effects of ACP on ED visits, hospice enrollment, mortality, and satisfaction with care.
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Affiliation(s)
- Apiradee Pimsen
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC; Faculty of Nursing, Mahidol University, Bangkok, Thailand.
| | - Chi-Yin Kao
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC.
| | - Sheng-Tzu Hsu
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC; Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan, ROC
| | - Bih-Ching Shu
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC; Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC.
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Zúñiga F, Gaertner K, Weber-Schuh SK, Löw B, Simon M, Müller M. Inappropriate and potentially avoidable emergency department visits of Swiss nursing home residents and their resource use: a retrospective chart-review. BMC Geriatr 2022; 22:659. [PMID: 35948872 PMCID: PMC9367060 DOI: 10.1186/s12877-022-03308-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background Emergency department (ED) visits for nursing home residents lead to higher morbidity and mortality. Therefore, inappropriate visits (for conditions treatable elsewhere) or potentially avoidable visits (those avoidable through adequate chronic care management) must be minimized. This study aimed to investigate factors and resource consumption patterns associated with inappropriate and potentially avoidable visits in a Swiss tertiary hospital. Methods This is a single-center retrospective chart review in an urban Swiss university hospital ED. A consecutive sample of 1276 visits by nursing home residents (≥ 65 years old), recorded between January 1, 2015 and December 31, 2017 (three calendar years) were included. Case characteristics were extracted from ED electronic documentation. Appropriateness was assessed via a structured Appropriateness Evaluation Protocol; potentially avoidable visits—measured as ambulatory-care sensitive conditions (ACSCs)—were analyzed separately. Inter-group differences concerning ED resource use were tested respectively with chi-square or Wilcoxon rank sum tests. To identify predictors of inappropriate or potentially-avoidable visits, we used multivariable logistic regression analysis. Results Six percent of visits were rated as inappropriate: they had lower triage levels (OR 0.55 [95%-CI 0.33-0.92], p=0.024) and, compared to ambulance calls, they had higher odds of initiation via either patient-initiated walk-in (OR 3.42 [95%-CI 1.79-6.55], p≤0.001) or GP referrals (OR 2.13 [95%-CI 1.16-3.90], p=0.015). For inappropriate visits, overall ED resource use was significantly lower (median 568 vs. 1403 tax points, p≤0.001). Of all visits included, 29% were due to (often potentially-avoidable) ACSCs. In those cases, compared to ambulance initiation, odds of being potentially-avoidable were considerably lower for walk-in patients (OR 0.46 [95%-CI 0.27-0.77], p=0.004) but higher for GP referrals (OR 1.40 [95%-CI 1.00-1.94], p=0.048). Nurse work (93 tax points vs. 64, p≤0.001) and laboratory resource use (334 tax points vs. 214, p≤0.001) were higher for potentially-avoidable ED visits. Conclusions We revealed substantial differences between the investigated groups. While nearly one third of ED visits from nursing homes were potentially avoidable, inappropriate visits were lower in numbers and not resource-intensive. Further research is required to differentiate potentially avoidable visits from inappropriate ones and to determine these findings’ public health implications. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03308-9.
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Affiliation(s)
- Franziska Zúñiga
- Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland.
| | - Katharina Gaertner
- Institute of Integrative Medicine, Witten/Herdecke University, Witten, Germany
| | - Sabine K Weber-Schuh
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland.,GP practice, Praxis Weissenbühl, Bern, Switzerland
| | - Barbara Löw
- Department of Practice Development in Nursing, Solothurner Spitaler AG, Solothurn, Switzerland
| | - Michael Simon
- Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
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40
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Tyler DA, Kordomenos C, Ingber MJ. Reducing Hospitalizations Among Nursing Facility Residents: Policy Environment and Suggestions for the Future in Seven States. J Gerontol Nurs 2022; 48:10-16. [PMID: 35914083 DOI: 10.3928/00989134-20220629-03] [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: 11/20/2022]
Abstract
The current study examined the policy and market context existing in the seven states where the Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents took place. Stakeholder organizations with knowledge of the skilled nursing facility environment but who were not directly involved with the CMS Initiative were interviewed to assess the impact of policies and programs affecting transfers to the hospital from long-term care facilities. Focused interviews were used to identify areas of quality improvement as well as market forces that contributed to hospitalization rates. Interviews were qualitatively coded and emerging patterns and themes were identified. Market pressures were similar across states. Few policies were found that may have affected the Initiative, but most states had regional coalitions focused on improving some aspect of care. When asked what else could be done to reduce hospitalizations among nursing facility residents, participants across the stakeholder organizations suggested greater presence of physicians and nurse practitioners in nursing facilities, better training around behavioral health issues for frontline staff, and more advance care planning and education for families regarding end of life. [Journal of Gerontological Nursing, 48(8), 10-16.].
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41
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Nguyen PT, Liaw SY, Tan AJQ, Rusli KDB, Tan LLC, Goh HS, Chua WL. “Nurses caught in the middle”: A qualitative study of nurses’ perspectives on the decision to transfer deteriorating nursing home residents to emergency departments in Singapore. Collegian 2022. [DOI: 10.1016/j.colegn.2021.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lin H, Ko E, Wu B, Ni P. Hospice Care Preferences and Its Associated Factors among Community-Dwelling Residents in China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159197. [PMID: 35954548 PMCID: PMC9368034 DOI: 10.3390/ijerph19159197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 02/04/2023]
Abstract
Hospice care is a comprehensive approach addressing patients’ physical, psychosocial, and spiritual needs at the end of life (EoL). Despite the recognition of its effectiveness in improving the quality of EoL care, little is known about hospice care in mainland China. In this study, we aimed to examine the preferences for hospice care and its related factors among community-dwelling residents in mainland China. Participants were recruited using a convenience sampling method, and 992 community-dwelling residents responded to an online survey from June 2018 to August 2019. The majority (66.7%) of the participants were female, and the mean age was 48.4 years. Approximately 28% of the participants had heard of hospice care, and 91.2% preferred to receive hospice care if diagnosed with a terminal illness. Participants who had heard of hospice care, and with higher levels of education (bachelor’s degree or above) and health insurance coverage were more likely to accept hospice care than their counterparts. Community-based education on hospice care is imperative to improve public knowledge and the acceptance of hospice care. Meanwhile, there is a need to develop policies to integrate and expand hospice care into clinical settings.
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Affiliation(s)
- Huijing Lin
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Eunjeong Ko
- School of Social Work, San Diego State University, San Diego, CA 92182, USA;
| | - Bei Wu
- Rory Meyers College of Nursing, New York University, New York, NY 10010, USA;
- NYU Aging Incubator, New York University, New York, NY 10010, USA
| | - Ping Ni
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
- Correspondence: ; Tel.: +86-1387-1540-316
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Kirchner Ä, Langner H, Meyer G, Schnakenberg R, Silies K, Hoffmann F, Köpke S, Köberlein-Neu J, Berg A. Beratung zu Advance Care Planning in der ambulanten Pflege. Pflege 2022; 35:345-354. [DOI: 10.1024/1012-5302/a000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Zusammenfassung. Hintergrund: StAdPlan ist eine multizentrische, Cluster-randomisierte kontrollierte Studie mit der Zielstellung, eine Intervention zu Advance Care Planning (ACP) für den Anwendungskontext der ambulanten Pflege in Deutschland zu entwickeln und zu evaluieren. Fragestellung/Ziel: In diesem Beitrag wird die Interventionsentwicklung unter Einbezug bestehender ACP-Konzepte und deren Anpassung auf die zeitlichen und personellen Ressourcen im System der ambulanten Pflege in Deutschland dargestellt. Pflegefachpersonen kommt dabei die Rolle zu, ältere pflegebedürftige Menschen und deren Angehörige im Rahmen von strukturierten Gesprächen für das Thema ACP zu sensibilisieren und die Nutzung bestehender Beratungsangebote zu fördern. Methoden: Die Interventionskomponenten wurden unter Anwendung des Behaviour Change Wheel (BCW) entwickelt. Ergebnisse: Die komplexe Intervention in Form eines niedrigschwelligen Beratungsangebotes richtet sich an Pflegebedürftige über 65 Jahre und ihre Angehörigen. Ein zweitägiges Schulungsangebot qualifiziert Pflegefachpersonen ambulanter Pflegedienste für leitfadengestützte Beratungsgespräche, die im häuslichen Umfeld der pflegebedürftigen Person, möglichst unter Einbeziehung Angehöriger, im Rahmen von mindestens zwei Terminen durchgeführt werden. Eine Broschüre ergänzt das Informationsangebot. Schlussfolgerungen: Das Vorgehen entlang des BCW-Modells war für Analyse, Beschreibung und Definition der spezifischen Funktionen der Intervention gut geeignet. Die Intervention wird in der anschließenden Studie auf ihre Effektivität untersucht.
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Affiliation(s)
- Änne Kirchner
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Deutschland
| | - Henriette Langner
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Deutschland
| | - Gabriele Meyer
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Deutschland
| | - Rieke Schnakenberg
- Department für Versorgungsforschung, Fakultät für Medizin und Gesundheitswissenschaften, Carl von Ossietzky Universität Oldenburg, Deutschland
| | - Katharina Silies
- Institut für Sozialmedizin und Epidemiologie, Universität zu Lübeck, Deutschland
| | - Falk Hoffmann
- Department für Versorgungsforschung, Fakultät für Medizin und Gesundheitswissenschaften, Carl von Ossietzky Universität Oldenburg, Deutschland
| | - Sascha Köpke
- Institut für Pflegewissenschaft, Medizinische Fakultät, Universität zu Köln, Deutschland
| | - Juliane Köberlein-Neu
- Bergisches Kompetenzzentrum für Gesundheitsökonomik und Versorgungsforschung, Fakultät für Wirtschaftswissenschaft, Schumpeter School of Business and Economics, Bergische Universität Wuppertal, Deutschland
| | - Almuth Berg
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Deutschland
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Pivodic L, Wendrich-van Dael A, Gilissen J, De Buyser S, Deliens L, Gastmans C, Vander Stichele R, Van den Block L. Effects of a theory-based advance care planning intervention for nursing homes: A cluster randomized controlled trial. Palliat Med 2022; 36:1059-1071. [PMID: 35769038 DOI: 10.1177/02692163221102000] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Uptake of advance care planning in routine nursing home care is low. Through extensive literature review, theoretical development, and stakeholder involvement, we developed the ACP+ intervention. AIMS To evaluate the effects of ACP+ on the knowledge and self-efficacy (confidence in own skills) of nursing home care staff concerning advance care planning. DESIGN Cluster randomized controlled trial, conducted between February 2018 and January 2019 (NCT03521206, clinicaltrials.gov). ACP+ is a multicomponent intervention aimed at training and supporting nursing home staff and management in implementing advance care planning in nursing home practice through a train-the-trainer approach over 8 months. Fourteen nursing homes were randomized using a matched-pairing strategy, seven received ACP+, seven followed usual practice. Analyses (intention-to-treat) involved linear mixed models. SETTING/PARTICIPANTS Nursing homes in Flanders (Belgium). RESULTS 694 of 1017 care staff (68% response rate) at baseline and 491 of 989 care staff (50%) post-intervention (8 months) returned questionnaires. Post-intervention, care staff's self-efficacy concerning advance care planning was significantly higher in the intervention than in the control group (baseline-adjusted mean difference 0.57; 95% CI 0.20-0.94; p = 0.003; Cohen's d = 0.30). Advance care planning knowledge (95% CI 0.95-1.15; p = 0.339; ratio: 1.04) did not differ significantly between groups. CONCLUSIONS The ACP+ intervention for nursing homes improved care staff's self-efficacy but not their knowledge concerning advance care planning. Considering the comprehensive and multi-component approach used, these effects were smaller than expected. Reasons for this may be related to the chosen follow-up period, outcomes and measurements, or to the intervention itself and its implementation.
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Affiliation(s)
- Lara Pivodic
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Brussels, Belgium
| | - Annelien Wendrich-van Dael
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Brussels, Belgium
| | - Joni Gilissen
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Brussels, Belgium.,Atlantic Fellows for Equity in Brain Health, Global Brain Health Institute, University California San Francisco, San Francisco, CA, USA
| | - Stefanie De Buyser
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Luc Deliens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | | | - Lieve Van den Block
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Brussels, Belgium
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Walther W, Müller-Mundt G, Wiese B, Schneider N, Stiel S. Providing palliative care for residents in LTC facilities: an analysis of routine data of LTC facilities in Lower Saxony, Germany. Palliat Care 2022; 21:111. [PMID: 35739546 PMCID: PMC9218045 DOI: 10.1186/s12904-022-00998-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 06/13/2022] [Indexed: 11/22/2022] Open
Abstract
Background Demographic trends show an increasing number of elderly people and thus a growing need for palliative care (PC). Such care is increasingly being provided by long-term care (LTC) facilities. The present study aimed at exploring PC indicators of residents at LTC facilities belonging to a non-profit provider in Lower Saxony, Germany, in order to identify potential improvements. Methods A descriptive cross-sectional study was conducted, drawing on routine nursing chart data. Structural data from 16 participating LTC facilities and the care data of all residents who died in 2019 (N = 471) were collected anonymously between March and May 2020. Based on key literature on quality indicators of PC in LTC facilities in Germany, a structured survey was developed by a multidisciplinary research team. The descriptive, comparative and inferential data analysis was conducted using the SPSS software package. Results In total, the complete records of 363 (77%) residents who died in the participating LTC facilities in 2019 were retrieved. The records reflected that 45% of the residents had been hospitalized at least once during the last 6 months of their lives, and 19% had died in hospital. Advance care planning (ACP) consultation was offered to 168 (46%) residents, and 64 (38%) declined this offer. A written advance directive was available for 47% of the residents. A specialized PC team and hospice service volunteers were involved in caring for 6% and 14% of the residents, respectively. Cancer patients received support from external services significantly more frequently (p < .001) than did non-cancer patients. Differences emerged in the distribution of PC indicators between LTC facilities. Facilities that have more PC trained staff offered more ACP, supported by more specialized PC teams and hospice services, and had fewer hospitalizations. In addition, more volunteer hospice services were offered in urban facilities. Conclusions Overall, a rather positive picture of PC in participating LTC facilities in Germany emerged, although there were differences in the expression of certain indicators between facilities. ACP consultation, volunteer hospice services, and hospital admissions appeared to be superior in LTC facilities with more trained PC staff. Therefore, PC training for staff should be further promoted.
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Affiliation(s)
- Wenke Walther
- Institute for General Practice and Palliative Care, Medical School Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Gabriele Müller-Mundt
- Institute for General Practice and Palliative Care, Medical School Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Birgitt Wiese
- Institute for General Practice and Palliative Care, Medical School Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Nils Schneider
- Institute for General Practice and Palliative Care, Medical School Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Stephanie Stiel
- Institute for General Practice and Palliative Care, Medical School Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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46
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Bretschneider C, Poeck J, Freytag A, Günther A, Schneider N, Schwabe S, Bleidorn J. [Emergency situations and emergency department visits in nursing homes-a scoping review about circumstances and healthcare interventions]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2022; 65:688-696. [PMID: 35581404 PMCID: PMC9113071 DOI: 10.1007/s00103-022-03543-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Nursing home residents are more likely to be hospitalized as non-institutionalized peers. A large number of emergency medical services (EMS) and emergency department visits are classified as potentially avoidable. OBJECTIVES To identify circumstances that increase the number of emergency situations in nursing homes and approaches to reduce hospital admissions in order to illustrate the complexity and opportunities for action. MATERIALS AND METHODS Scoping review with analysis of current original and peer-reviewed papers (2015-2020) in PubMed, CINAHL, and hand-search databases. RESULTS From 2486 identified studies, 302 studies were included. Injuries, fractures, cardiovascular, respiratory, and infectious diseases are the most frequent diagnostic groups that have been retrospectively recorded. Different aspects could be identified as circumstances inducing emergency department visits: resident-related (e.g., multimorbidity, lack of volition, and advance directives), facility-related (e.g., staff turnover, uncertainties), physician-related (lack of accessibility, challenging access to specialists), and system-related circumstances (e.g., limited possibilities for diagnostics and treatment in facilities). Multiple approaches to reduce emergency department visits are being explored. CONCLUSIONS A variety of circumstances influence the course of action in emergency situations in nursing facilities. Therefore, interventions to reduce emergency department visits address, among other things, strengthening the competence of nursing staff, interprofessional communication, and systemic approaches. A comprehensive understanding of the complex processes of care is essential for developing and implementing effective interventions.
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Affiliation(s)
- Carsten Bretschneider
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland
| | - Juliane Poeck
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland.
| | - Antje Freytag
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland
| | | | - Nils Schneider
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Sven Schwabe
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Jutta Bleidorn
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland
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47
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Ninteau K, Bishop CE. Nursing Home Palliative Care during the Pandemic: Directions for the Future. Innov Aging 2022; 6:igac030. [PMID: 35832204 PMCID: PMC9273407 DOI: 10.1093/geroni/igac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Indexed: 11/15/2022] Open
Abstract
Background and Objectives Palliative care addresses physical, emotional, psychological, and spiritual suffering that accompanies serious illness. Emphasis on symptom management and goals of care is especially valuable for seriously ill nursing home residents. We investigated barriers to nursing home palliative care provision highlighted by the coronavirus disease 2019 (COVID-19) pandemic and the solutions nursing home staff used to provide care in the face of those barriers. Research Design and Methods For this descriptive qualitative study, seven Massachusetts nursing home directors of nursing were interviewed remotely about palliative care provision before and during the COVID-19 pandemic. Interview data were analyzed using thematic analysis. Results Before the pandemic, palliative care was delivered primarily by nursing home staff depending on formal and informal consultations from palliative care specialists affiliated with hospice providers. When COVID-19 lockdowns precluded these consultations, nursing staff did their best to provide palliative care, but were often overwhelmed by shortfalls in resources, resident decline brought on by isolation and COVID-19 itself, and a sense that their expertise was lacking. Advance care planning conversations focused on hospitalization decisions and options for care given resource constraints. Nevertheless, nursing staff discovered previously untapped capacity to provide palliative care on-site as part of standard care, building trust of residents and families. Discussion and Implications Nursing staff rose to the palliative care challenge during the COVID-19 pandemic, albeit with great effort. Consistent with prepandemic analysis, we conclude that nursing home payment and quality standards should support development of in-house staff capacity to deliver palliative care while expanding access to the formal consultations and family involvement that were restricted by the pandemic. Future research should be directed to evaluating initiatives that pursue these aims.
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Affiliation(s)
- Kacy Ninteau
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Christine E Bishop
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
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Slam Bam, Thank you, Ma’am: The Challenges of Advance Care Planning Engagement in Long-Term Care. Can J Aging 2022; 41:443-450. [DOI: 10.1017/s0714980821000738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract
This interpretative, qualitative study explored residents’ and families’ perspectives on advance care planning (ACP) in long-term care (LTC). Perspectives on when, how, and with whom ACP discussions should be introduced and barriers and solutions to improving ACP engagement were examined. Fifty-one residents and families participated in seven focus groups. The findings revealed that residents and families prioritized caring connections over professional rank when reflecting on staff involvement in ACP. The findings further revealed that the caring and compassionate environment considered to be a critical pre-condition for ACP engagement was more typically enacted at end of life when ACP was no longer an option. Our findings suggest that work practices and organizational structures within LTC play an important role in inhibiting ACP engagement.
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McCreedy EM, Yang X, Mitchell SL, Gutman R, Teno J, Loomer L, Moyo P, Volandes A, Gozalo PL, Belanger E, Ogarek J, Mor V. Effect of advance care planning video on do-not-hospitalize orders for nursing home residents with advanced illness. BMC Geriatr 2022; 22:298. [PMID: 35392827 PMCID: PMC8991654 DOI: 10.1186/s12877-022-02970-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of the study is to evaluate the effect of an Advance Care Planning (ACP) Video Program on documented Do-Not-Hospitalize (DNH) orders among nursing home (NH) residents with advanced illness. METHODS Secondary analysis on a subset of NHs enrolled in a cluster-randomized controlled trial (41 NHs in treatment arm implemented the ACP Video Program: 69 NHs in control arm employed usual ACP practices). Participants included long (> 100 days) and short (≤ 100 days) stay residents with advanced illness (advanced dementia or cardiopulmonary disease (chronic obstructive pulmonary disease or congestive heart failure)) in NHs from March 1, 2016 to May 31, 2018 without a documented Do-Not-Hospitalize (DNH) order at baseline. Logistic regression with covariate adjustments was used to estimate the impact of the resident being in a treatment versus control NH on: the proportion of residents with new DNH orders during follow-up; and the proportion of residents with any hospitalization during follow-up. Clustering at the facility-level was addressed using hierarchical models. RESULTS The cohort included 6,117 residents with advanced illness (mean age (SD) = 82.8 (8.4) years, 65% female). Among long-stay residents (n = 3,902), 9.3% (SE, 2.2; 95% CI 5.0-13.6) and 4.2% (SE, 1.1; 95% CI 2.1-6.3) acquired a new DNH order in the treatment and control arms, respectively (average marginal effect, (AME) 5.0; SE, 2.4; 95% CI, 0.3-9.8). Among short-stay residents with advanced illness (n = 2,215), 8.0% (SE, 1.6; 95% CI 4.6-11.3) and 3.5% (SE 1.0; 95% CI 1.5-5.5) acquired a new DNH order in the treatment and control arms, respectively (AME 4.4; SE, 2.0; 95% CI, 0.5-8.3). Proportion of residents with any hospitalizations did not differ between arms in either cohort. CONCLUSIONS Compared to usual care, an ACP Video Program intervention increased documented DNH orders among NH residents with advanced disease but did not significantly reduce hospitalizations. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02612688 .
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Affiliation(s)
- Ellen M McCreedy
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA. .,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.
| | - Xiaofei Yang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St, Boston, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Joan Teno
- Oregon Health Sciences University School of Medicine, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business and Economics, University of Minnesota Duluth, 1518 Kirby Dr, Duluth, MN, 55806, USA
| | - Patience Moyo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Angelo Volandes
- Section of General Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Emmanuelle Belanger
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Jessica Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
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50
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Johansson T, Tishelman C, Eriksson LE, Cohen J, Goliath I. Use, usability, and impact of a card-based conversation tool to support communication about end-of-life preferences in residential elder care – a qualitative study of staff experiences. BMC Geriatr 2022; 22:274. [PMID: 35366816 PMCID: PMC8976536 DOI: 10.1186/s12877-022-02915-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 03/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Proactive conversations about individual preferences between residents, relatives, and staff can support person-centred, value-concordant end-of-life (EOL) care. Nevertheless, prevalence of such conversations is still low in residential care homes (RCHs), often relating to staff’s perceived lack of skills and confidence. Using tools may help staff to facilitate EOL conversations. While many EOL-specific tools are script-based and focus on identifying and documenting treatment priorities, the DöBra card tool is developed to stimulate reflection and conversation about EOL care values and preferences. In this study, we explore staff’s experiences of use, usability, and perceived impact of the DöBra cards in supporting discussion about EOL care in RCH settings.
Methods
This qualitative study was based on data from two participatory action research processes in which RCH staff tested and evaluated use of DöBra cards in EOL conversations. Data comprise 6 interviews and 8 group meetings with a total of 13 participants from 7 facilities. Qualitative content analysis was performed to identify key concepts in relation to use, usability, and impact of the DöBra cards in RCH practice.
Results
Based on participants’ experiences of using the DöBra cards as an EOL conversation tool in RCHs, we identified three main categories in relation to its usefulness. Outcomes of using the cards (1) included the outlining of content of conversations and supporting connection and development of rapport. Perceived impact (2) related to enabling openings for future communication and aligning care goals between stakeholders. Use and usability of the cards (3) were influenced by supporting and limiting factors on the personal and contextual level.
Conclusions
This study demonstrates how the DöBra cards was found to be useful by staff for facilitating conversations about EOL values, influencing both the content of discussion and interactions between those present. The tool encouraged reflection and interaction, which staff perceived as potentially helpful in building preparedness for future care-decision making. The combination of providing a shared framework and being adaptable in use appeared to be key features for the DöBra cards usability in the RCH setting.
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