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Yip WKA, Chung PMB, Christensen M. End-of-life conversations for the older person: A concept analysis. Scand J Caring Sci 2024; 38:614-635. [PMID: 38778516 DOI: 10.1111/scs.13263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/29/2024] [Accepted: 04/07/2024] [Indexed: 05/25/2024]
Abstract
AIM The aim of this concept analysis is to seek clarity as to what end-of-life conversations involve by developing a clear working definition and using model cases to conceptualise the defining attributes of an end-of-life conversations with the older person. DESIGN Walker and Avant's eight step approach to Concept Analysis. DATA SOURCES Four databases were searched, including PubMed, CINAHL, PsycINFO, and Scopus. A total of 339 publications were identified with 30 papers meeting the inclusion criteria and put forward for the final conceptual analysis. RESULTS The defining attributes associated with end-of life conversations included (1) an ongoing process of older person empowerment, (2) discussion's concerning values and preferences concerning end-of-life issues, and (3) maintaining an open dialogue between all concerned individuals. Antecedents were associated with the older person is their readiness to talk openly about death and dying. Consequences were identified as having a better understanding of what death and dying may mean to the older person in a more specific manner. CONCLUSIONS End-of-life conversations are vital in understanding an individual's values and preferences at the end of life, and yet, the concept of the end-of-life conversation has not been well defined in the literature. End-of-life conversations with the older person encompass ongoing discussions and maintaining open dialogue around end-of-life care while developing strategies to promote individual empowerment in making informed choices. Using a conceptual model, aides in addressing aspects of end-of-life conversations and an acknowledgment of the dynamic process of end-of-life conversations.
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Affiliation(s)
- Wing Ki Agnes Yip
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong
- School of Nursing, Tung Wah College, Kowloon, Hong Kong
| | - Pui Man Betty Chung
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong
- Interdisciplinary Centre for Qualitative Research, Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Martin Christensen
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong
- Interdisciplinary Centre for Qualitative Research, Hong Kong Polytechnic University, Kowloon, Hong Kong
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2
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Haaksman M, Ham L, Brom L, Baars A, van Basten JP, van den Borne BEEM, Hendriks MP, de Jong WK, van Laarhoven HWM, van Lindert ASR, Mandigers CMPW, van der Padt-Pruijsten A, Smilde TJ, van Zuylen LC, van Vliet LM, Raijmakers NJH. Open communication between patients and relatives about illness & death in advanced cancer-results of the eQuiPe Study. Support Care Cancer 2024; 32:214. [PMID: 38446248 PMCID: PMC10917842 DOI: 10.1007/s00520-024-08379-5] [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: 12/19/2023] [Accepted: 02/12/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE To assess the degree of openness of communication about illness and death between patients with advanced cancer and their relatives during the last three months of the patient's life, and its association with relatives' characteristics and bereavement distress. METHODS We used data from bereaved relatives of patients with advanced cancer from the prospective, longitudinal, multicenter, observational eQuipe study. Univariate and multivariable linear regression analyses were used to assess the association between the degree of openness of communication (measured using the validated Caregivers' Communication with patients about Illness and Death scale), the a priori defined characteristics of the relatives, and the degree of bereavement distress (measured using the Impact of Event Scale). RESULTS A total of 160 bereaved relatives were included in the analysis. The average degree of open communication about illness and death between patients with advanced cancer and their relatives was 3.86 on a scale of 1 to 5 (SE=0.08). A higher degree of open communication was associated with a lower degree of bereavement distress (p=0.003). No associations were found between the degree of open communication and the relatives' age (p=0.745), gender (p=0.196), level of education (p>0.773), (religious) worldview (p=0.435), type of relationship with the patient (p>0.548), or level of emotional functioning before the patient's death (p=0.075). CONCLUSIONS Open communication about illness and death between patients and relatives seems to be important, as it is associated with a lower degree of bereavement distress. Healthcare professionals can play an important role in encouraging the dialogue. However, it is important to keep in mind that some people not feel comfortable talking about illness and death.
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Affiliation(s)
- Michelle Haaksman
- Department of Health, Medical and Neuropsychology, University of Leiden, Leiden, the Netherlands.
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, the Netherlands.
| | - Laurien Ham
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, the Netherlands
- Netherlands Association for Palliative Care (PZNL), Utrecht, the Netherlands
| | - Linda Brom
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, the Netherlands
| | - Arnold Baars
- Department of Internal Medicine, Hospital Gelderse Vallei, Ede, the Netherlands
| | | | | | - Mathijs P Hendriks
- Department of Medical Oncology, Northwest Clinics, Alkmaar, The Netherlands
| | - Wouter K de Jong
- Department of Pulmonology, Hospital Gelderse Vallei, Ede, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Amsterdam University Medical Center, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Anne S R van Lindert
- Department of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - Tineke J Smilde
- Department of Medical Oncology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Lia C van Zuylen
- Department of Medical Oncology, Amsterdam University Medical Center, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Liesbeth M van Vliet
- Department of Health, Medical and Neuropsychology, University of Leiden, Leiden, the Netherlands
| | - Natasja J H Raijmakers
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, the Netherlands
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Poelman SW, Ermers DJM, Schers HJ, Vissers KCP, Veldhoven CMM, Kuip EJM, Perry M. Are specialist-provided end-of-life scenarios key to initiation of advance care planning in primary care? A mixed-methods study. Palliat Support Care 2024:1-9. [PMID: 38362721 DOI: 10.1017/s1478951523002055] [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: 02/17/2024]
Abstract
OBJECTIVES Specialist-provided end-of-life scenarios (SP-EOLS) may improve advance care planning (ACP) implementation in primary care by helping overcome barriers such as uncertain prognosis and poor interprofessional collaboration. We aimed to explore the current use and potential impact of SP-EOLS on ACP in Dutch primary care. METHODS We performed a mixed-methods study. From patients discussed in a hospital-based academic palliative care multidisciplinary team meeting between 2016 and 2019 and died, we collected primary care electronic medical records data on SP-EOLS, actual EOLS, and ACP initiation and applied descriptive and comparative analyses. Subsequently, we interviewed general practitioners (GPs) and thematically analyzed the transcripts. RESULTS In 69.7% of 66 reviewed patient files, SP-EOLS were found. In patients whose GP had received SP-EOLS, ACP conversations were more often reported (92.0 vs. 61.0%, p = 0.006). From 11 GP interviews, we identified 4 themes: (1) SP-EOLS guide GPs, patients, and relatives when dealing with an uncertain future perspective; (2) SP-EOLS provide continuity of care between primary and secondary/tertiary care; (3) SP-EOLS should be tailored to the individual patient; and (4) SP-EOLS need to be personalized and uniformly transferred to GPs. SIGNIFICANCE OF RESULTS SP-EOLS may facilitate ACP conversations by GPs. They have the potential to help overcome existing barriers to ACP implementation by providing guidance and supporting interprofessional collaboration. Future research should focus on improving SP-EOLS and tailor them to the needs of all end users, focusing on improving their effect on ACP conversations.
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Affiliation(s)
- Sophie W Poelman
- Department of Primary and Community Care, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Daisy J M Ermers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Henk J Schers
- Department of Primary and Community Care, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Carel M M Veldhoven
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Evelien J M Kuip
- Department of Medical Oncology and Department of Anaesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Marieke Perry
- Department of Geriatrics, Radboudumc, Nijmegen, Gelderland, The Netherlands
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4
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Carter RZ, Ludwig M, Gao A, Tan A, Barwich D, Howard M. Primary care providers' perceptions on the integration of community-led advance care planning activities with primary care: a cross-sectional survey. BMC PRIMARY CARE 2023; 24:197. [PMID: 37743490 PMCID: PMC10519084 DOI: 10.1186/s12875-023-02144-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 08/30/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Advance care planning (ACP) is a process intended to help ensure people receive medical care that is consistent with their values, goals, and preferences during serious and chronic illness. Barriers to implementing ACP in primary care settings exist. Community-led ACP initiatives exist in British Columbia to engage the public directly. These initiatives may help prepare people for conversations with their primary care providers. The objectives of this study were to elicit primary care providers' perceptions of the utility and desired content of community-led ACP activities and suggestions for integrating community-led ACP activities with primary care. METHODS We conducted an online cross-sectional survey of primary care providers practicing in British Columbia, Canada in 2021. Both quantitative and qualitative survey questions addressed ACP engagement in practice, the perceived role and desired outcomes of community-led ACP activities, and ways to integrate community-led ACP activities with primary care. RESULTS Eighty-one providers responded. Over 80% perceived a moderate or greater potential impact of community-led ACP activities. The most common reasons for not referring a patient to a community-led ACP activity were lack of awareness of the option locally (62.1%) and in general (44.8%). Respondents wanted their patients to reflect on their values, wishes and preferences for care, to have at least thought about their goals of care and to have chosen a substitute decision maker in the community. They indicated a desire for a summary of their patient's participation and a follow-up discussion with them about their ACP. They suggested ways to integrate referral to programs into existing health care system structures. CONCLUSIONS Community-led ACP activities were perceived to be useful to engage and prepare patients to continue ACP discussions with clinicians. Efforts should be made to establish and integrate community-based ACP initiatives within existing primary care systems to ensure awareness and uptake.
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Affiliation(s)
- Rachel Z Carter
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada.
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada.
| | - Monika Ludwig
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada
| | - Angela Gao
- Michael G. DeGroote School of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Amy Tan
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Doris Barwich
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
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Devik SA, Lersveen GL. Specialist and Primary Physicians' Experiences and Perspectives of Collaboration While Caring for Palliative Patients-A Qualitative Study. Healthcare (Basel) 2023; 11:2188. [PMID: 37570428 PMCID: PMC10419283 DOI: 10.3390/healthcare11152188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
Increasing numbers of people living with chronic and life-limiting diseases are actualising a greater need for palliative care. Physicians are an important provider for identifying the need for palliation, and effective follow-up requires physician collaboration across different service levels. This study aimed to explore and describe how physicians in hospitals and municipalities experience their roles and interactions in the care of palliative patients. Pair interviews were performed with seven physicians working in hospitals, primary care and nursing homes in Mid-Norway. Systematic text condensation was used to analyse the data, resulting in three main themes: The boundaries of palliative care, Alternating understandings of roles and Absence of planning. The physicians' interactions with palliative patients appeared as a fragmented distribution of tasks rather than a real collaboration with shared responsibility. At both levels, the physicians seemed to assume withdrawn roles as a reaction to unclear and unspoken expectations and to avoid interfering with others' responsibilities. Moreover, their understanding of palliative care and which groups should be included varied. Realising a collaboration between physicians that is beneficial for both patients and physicians, greater openness and real arenas for discussion and decision-making support are required.
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Affiliation(s)
- Siri Andreassen Devik
- Centre for Care Research, Mid-Norway, Faculty of Nursing and Health Sciences, Nord University, 8026 Bodø, Norway
| | - Gunhild Lein Lersveen
- Centre for Development of Institutional and Home Care Services in Trøndelag, 7650 Verdal, Norway;
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Roberts A. Live Well, Die Well: The Development of an Online, Arts-Based Palliative Care Programme in the Shadow of the COVID-19 Pandemic. OMEGA-JOURNAL OF DEATH AND DYING 2023; 86:1349-1370. [PMID: 33840273 PMCID: PMC9902991 DOI: 10.1177/00302228211009753] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The Covid-19 crisis led to an increase in the 'total pain' of many terminally ill patients who faced a reduction in support, due to the temporary closure of front-line palliative day therapy services. A hospice volunteer, I instigated an online day therapy programme for patients previously attending face-to-face day therapy. Participant feedback revealed the importance of providing a space for ongoing peer support for participants' changing sense of identity, an issue for time-limited day therapy programmes. An exploration of key concepts associated with palliative care established the multiple connections between such changing identity and arts-based approaches to living well. This article charts how I used this understanding to develop an alternative, online arts-based support programme, Live well, die well. It explores the links between ongoing mutual support, arts-based activity and the reactions to a shifting identity in patients with a life-limiting illness.
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Affiliation(s)
- Amanda Roberts
- Visiting Lecturer,University of Hertfordshire, Hatfield, UK,Amanda Roberts, University of Hertfordshire, Hatfield, UK.
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Henderson AW, Turner AP, Leonard C, Sayre G, Suckow B, Williams SL, Norvell DC, Czerniecki JM. Mortality Conversations Between Male Veterans and Their Providers Prior to Dysvascular Lower Extremity Amputation. Ann Vasc Surg 2023; 92:313-322. [PMID: 36746270 PMCID: PMC10121889 DOI: 10.1016/j.avsg.2023.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND Among patients facing lower extremity amputation due to dysvascular disease, the mortality risk is very high. Given this, as well as the importance of a patient-centered approach to medical care, informing patients about their possible risk of dying may be important during preoperative shared decision-making. The goal of this investigation was to gain an understanding of patient and provider experiences discussing mortality within the context of amputation within the Veterans Health Administration. METHODS Semistructured interviews were performed with Veterans with peripheral arterial disease and/or diabetes, vascular and podiatric surgeons, and physical medicine and rehabilitation physicians. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions. RESULTS We interviewed 22 patients and 21 surgeons and physicians and identified 3 themes related to conversations around mortality: (1) both patients and providers report that mortality conversations are not common prior to amputation; (2) while most providers find value in mortality conversations, some express concerns around engaging in these discussions with patients; and (3) some patients perceive mortality conversations as unnecessary, but many are open to engaging in the conversation. CONCLUSIONS Providers may benefit from introducing the topic with patients, including providing the context for why mortality conversations may be valuable, with the understanding that patients can always decline to participate should they not be interested or comfortable discussing this issue.
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Affiliation(s)
- Alison W Henderson
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA.
| | - Aaron P Turner
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Chelsea Leonard
- VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Denver Seattle COIN, VA Eastern Colorado Healthcare System, Aurora, CO; Health Systems, Management and Policy, University of Colorado, School of Public Health, Aurora, CO
| | - George Sayre
- VA Puget Sound Health Care System, Seattle, WA; Qualitative Research Core, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA; VA Collaborative Evaluation Center (VACE), Seattle, WA; Department of Health Services, University of Washington, Seattle, WA
| | - Bjoern Suckow
- Department of Vascular Surgery, White River Junction VA Medical Center, White River Junction, VT; Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Sienna L Williams
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA
| | - Daniel C Norvell
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Joseph M Czerniecki
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
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8
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Tros W, van der Steen JT, Liefers J, Akkermans R, Schers H, Numans ME, van Peet PG, Groenewoud AS. Actual timing versus GPs' perceptions of optimal timing of advance care planning: a mixed-methods health record-based study. BMC PRIMARY CARE 2022; 23:321. [PMID: 36514002 DOI: 10.1186/s12875-022-01940-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Timely initiation of advance care planning (ACP) in general practice is challenging, especially in patients with non-malignant conditions. Our aim was to investigate how perceived optimal timing of ACP initiation and its triggers relate to recorded actual timing in patients with cancer, organ failure, or multimorbidity. METHODS In this mixed-methods study in the Netherlands, we analysed health records selected from a database with primary care routine data and with a recorded ACP conversation in the last two years before death of patients who died with cancer, organ failure, or multimorbidity. We compared actual timing of ACP initiation as recorded in health records of 51 patients with the perceived optimal timing as determined by 83 independent GPs who studied these records. Further, to identify and compare triggers for GPs to initiate ACP, we analysed the health record documentation around the moments of the recorded actual timing of ACP initiation and the perceived optimal timing of ACP initiation. We combined quantitative descriptive statistics with qualitative content analysis. RESULTS The recorded actual timing of ACP initiation was significantly closer to death than the perceived optimal timing in patients with cancer (median 88 vs. 111 days before death (p = 0.049)), organ failure (227 vs. 306 days before death (p = 0.02)) and multimorbidity (113 vs. 338 days before death (p = 0.006)). Triggers for recorded actual versus perceived optimal timing were similar across the three groups, the most frequent being 'expressions of patients' reflections or wishes' (14% and 14% respectively) and 'appropriate setting' (10% and 13% respectively). CONCLUSION ACP in general practice was initiated and recorded later in the illness trajectory than considered optimal, especially in patients with organ failure or multimorbidity. As triggers were similar for recorded actual and perceived optimal timing, we recommend that GPs initiate ACP shortly after a trigger is noticed the first time, rather than wait for additional or more evident triggers when the illness is in an advanced stage.
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Affiliation(s)
- Willemijn Tros
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, the Netherlands.
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, the Netherlands.,Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands
| | - Janine Liefers
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud university medical center, Nijmegen, the Netherlands
| | - Reinier Akkermans
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands.,Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud university medical center, Nijmegen, the Netherlands
| | - Henk Schers
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands
| | - Mattijs E Numans
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Petra G van Peet
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - A Stef Groenewoud
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud university medical center, Nijmegen, the Netherlands
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Bekker YAC, Suntjens AF, Engels Y, Schers H, Westert GP, Groenewoud AS. Advance care planning in primary care: a retrospective medical record study among patients with different illness trajectories. BMC Palliat Care 2022; 21:21. [PMID: 35152892 PMCID: PMC8842525 DOI: 10.1186/s12904-022-00907-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Advance Care Planning (ACP) enables physicians to align healthcare with patients’ wishes, reduces burdensome life-prolonging medical interventions, and potentially improves the quality of life of patients in the last phase of life. However, little objective information is available about the extent to which structured ACP conversations are held in general practice.
Our aim was to examine the documentation of ACP for patients with cancer, organ failure and multimorbidity in medical records (as a proxy for ACP application) in Dutch general practice.
Methods
We chose a retrospective medical record study design in seven primary care facilities. Medical records of 119 patients who died non-suddenly (55 cancer, 28 organ failure and 36 multimorbidity) were analysed. Other variables were: general characteristics, data on ACP documentation, correspondence between medical specialist and general practitioner (GP), and healthcare utilization in the last 2 years of life.
Results
In 65% of the records, one or more ACP items were registered by the GP. Most often documented were aspects regarding euthanasia (35%), the preferred place of care and death (29%) and concerns and hopes towards the future (29%). Median timing of the first ACP conversation was 126 days before death (inter-quartile range (IQR) 30–316). ACP was more often documented in patients with cancer (84%) than in those with organ failure (57%) or multimorbidity (42%) (p = 0.000). Patients with cancer had the most frequent (median 3 times, IQR 2–5) and extensive (median 5 items, IQR 2–7) ACP consultations.
Conclusion
Documentation of ACP items in medical records by GPs is present, however limited, especially in patients with multimorbidity or organ failure. We recommend more attention for – and documentation of – ACP in daily practice, in order to start anticipatory conversations in time and address the needs of all people living with advanced conditions in primary care.
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10
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de Joode K, Tol J, Hamberg P, Cloos M, Kastelijn EA, Borgers JSW, Nuij VJAA, Klaver Y, Herder GJM, Mutsaers PGNJ, Dumoulin DW, Oomen-de Hoop E, van Diemen NGJ, Libourel EJ, Geraedts EJ, Bootsma GP, van der Leest CH, Peerdeman AL, Herbschleb KH, Visser OJ, Bloemendal HJ, van Laarhoven HWM, de Vries EGE, Hendriks LEL, Beerepoot LV, Westgeest HM, van den Berkmortel FWPJ, Haanen JBAG, Dingemans AMC, van der Veldt AAM. Life-prolonging treatment restrictions and outcomes in patients with cancer and COVID-19: an update from the Dutch Oncology COVID-19 Consortium. Eur J Cancer 2021; 160:261-272. [PMID: 34799210 PMCID: PMC8542445 DOI: 10.1016/j.ejca.2021.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 01/08/2023]
Abstract
Aim of the study The coronavirus disease 2019 (COVID-19) pandemic significantly impacted cancer care. In this study, clinical patient characteristics related to COVID-19 outcomes and advanced care planning, in terms of non-oncological treatment restrictions (e.g. do-not-resuscitate codes), were studied in patients with cancer and COVID-19. Methods The Dutch Oncology COVID-19 Consortium registry was launched in March 2020 in 45 hospitals in the Netherlands, primarily to identify risk factors of a severe COVID-19 outcome in patients with cancer. Here, an updated analysis of the registry was performed, and treatment restrictions (e.g. do-not-intubate codes) were studied in relation to COVID-19 outcomes in patients with cancer. Oncological treatment restrictions were not taken into account. Results Between 27th March 2020 and 4th February 2021, 1360 patients with cancer and COVID-19 were registered. Follow-up data of 830 patients could be validated for this analysis. Overall, 230 of 830 (27.7%) patients died of COVID-19, and 60% of the remaining 600 patients with resolved COVID-19 were admitted to the hospital. Patients with haematological malignancies or lung cancer had a higher risk of a fatal outcome than other solid tumours. No correlation between anticancer therapies and the risk of a fatal COVID-19 outcome was found. In terms of end-of-life communication, 50% of all patients had restrictions regarding life-prolonging treatment (e.g. do-not-intubate codes). Most identified patients with treatment restrictions had risk factors associated with fatal COVID-19 outcome. Conclusion There was no evidence of a negative impact of anticancer therapies on COVID-19 outcomes. Timely end-of-life communication as part of advanced care planning could save patients from prolonged suffering and decrease burden in intensive care units. Early discussion of treatment restrictions should therefore be part of routine oncological care, especially during the COVID-19 pandemic.
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Affiliation(s)
- Karlijn de Joode
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Jolien Tol
- Department of Internal Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Paul Hamberg
- Department of Oncology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Marissa Cloos
- Department of Internal Medicine, Groene Hart Hospital, Gouda, the Netherlands
| | - Elisabeth A Kastelijn
- Department of Pulmonology, St. Antonius Hospital Utrecht/Nieuwegein, Utrecht, the Netherlands
| | - Jessica S W Borgers
- Department of Medical Oncology, Netherlands Cancer Institute (NKI), Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Veerle J A A Nuij
- Department of Internal Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Yarne Klaver
- Department of Internal Medicine, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Gerarda J M Herder
- Department of Pulmonary Medicine, Meander Medical Center, Amersfoort, the Netherlands
| | - Pim G N J Mutsaers
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Daphne W Dumoulin
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Esther Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | | | - Eduard J Libourel
- Department of Internal Medicine, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Erica J Geraedts
- Department of Pulmonology, Groene Hart Hospital, Gouda, the Netherlands
| | - Gerben P Bootsma
- Department of Pulmonology, Zuyderland Medical Center, Heerlen, the Netherlands
| | | | - Anne L Peerdeman
- Department of Internal Medicine, Bernhoven, Uden, the Netherlands
| | - Karin H Herbschleb
- Department of Internal Medicine, St. Antonius Hospital Utrecht/Nieuwegein, Utrecht, the Netherlands
| | - Otto J Visser
- Department of Hematology, Isala Hospital, Zwolle, the Netherlands
| | - Haiko J Bloemendal
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Lizza E L Hendriks
- Department of Pulmonary Diseases GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Laurens V Beerepoot
- Department of Internal Medicine, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Hans M Westgeest
- Department of Internal Medicine, Amphia Hospital, Breda, the Netherlands
| | | | - John B A G Haanen
- Department of Medical Oncology, Netherlands Cancer Institute (NKI), Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Anne-Marie C Dingemans
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Astrid A M van der Veldt
- Department of Medical Oncology and Department of Radiology & Nuclear Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.
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Viftrup DT, Prinds C, Nissen RD, Steenfeldt VØ, Søndergaard J, Hvidt NC. Older Adults' Experience of Meaning at the End of Life in Two Danish Hospices: A Qualitative Interview Study. Front Psychol 2021; 12:700285. [PMID: 34603128 PMCID: PMC8484531 DOI: 10.3389/fpsyg.2021.700285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
The aim of this study was to explore how older adults (aged > 65) confronted with imminent death express their thoughts and feelings about death and dying and verbalize meaning. Furthermore, the aim was to investigate how health professionals could better address the needs of this patient group to experience meaning at the end of life. The study applied a qualitative method, involving semi-structured interviews with 10 participants at two hospices. The method of analysis was interpretative phenomenological analysis. We found three chronological time-based themes: (1) Approaching Death, (2) The time before dying, and (3) The afterlife. The participants displayed scarce existential vernacular for pursuing meaning with approaching death. They primarily applied understanding and vocabulary from a medical paradigm. The participants' descriptions of how they experienced and pursued meaning in the time before dying were also predominantly characterized by medical vernacular, but these descriptions did include a few existential words and understandings. When expressing thoughts and meaning about the afterlife, participants initiated a two-way dialogue with the interviewer and primarily used existential vernacular. This indicates that the participants' scarce existential vernacular to talk about meaning might be because people are not used to talking with healthcare professionals about meaning or their thoughts and feelings about death. They are mostly "trained" in medical vernacular. We found that participants' use of, respectively, medical or existential vernacular affected how they experienced meaning and hope at the end of life. We encourage healthcare professionals to enter into existential dialogues with people to support and strengthen their experiences of meaning and hope at the end of life.
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Affiliation(s)
- Dorte Toudal Viftrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Christina Prinds
- Research Unit of Gynecology and Obstetrics, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department for Research and Development, University College South Denmark, Haderslev, Denmark
| | - Ricko Damberg Nissen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | | | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Niels Christian Hvidt
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
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Honinx E, Van den Block L, Piers R, Van Kuijk SMJ, Onwuteaka-Philipsen BD, Payne SA, Szczerbińska K, Gambassi GG, Finne-Soveri H, Deliens L, Smets T. Potentially Inappropriate Treatments at the End of Life in Nursing Home Residents: Findings From the PACE Cross-Sectional Study in Six European Countries. J Pain Symptom Manage 2021; 61:732-742.e1. [PMID: 32916262 DOI: 10.1016/j.jpainsymman.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/28/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Certain treatments are potentially inappropriate when administered to nursing homes residents at the end of life and should be carefully considered. An international comparison of potentially inappropriate treatments allows insight into common issues and country-specific challenges of end-of-life care in nursing homes and helps direct health-care policy in this area. OBJECTIVES To estimate the prevalence of potentially inappropriate treatments in the last week of life in nursing home residents and analyze the differences in prevalence between countries. METHODS A cross-sectional study of deceased residents in nursing homes (2015) in six European countries: Belgium (Flanders), England, Finland, Italy, The Netherlands, and Poland. Potentially inappropriate treatments included enteral administration of nutrition, parental administration of nutrition, artificial fluids, resuscitation, artificial ventilation, blood transfusion, chemotherapy/radiotherapy, dialysis, surgery, antibiotics, statins, antidiabetics, new oral anticoagulants. Nurses were questioned about whether these treatments were administered in the last week of life. RESULTS We included 1384 deceased residents from 322 nursing homes. In most countries, potentially inappropriate treatments were rarely used, with a maximum of 18.3% of residents receiving at least one treatment in Poland. Exceptions were antibiotics in all countries (between 11.3% in Belgium and 45% in Poland), artificial nutrition and hydration in Poland (54.3%) and Italy (41%) and antidiabetics in Poland (19.7%). CONCLUSION Although the prevalence of potentially inappropriate treatments in the last week of life was generally low, antibiotics were frequently prescribed in all countries. In Poland and Italy, the prevalence of artificial administration of food/fluids in the last week of life was high, possibly reflecting country differences in legislation, care organization and culture, and the palliative care competences of staff.
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Affiliation(s)
- Elisabeth Honinx
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Lieve Van den Block
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Ruth Piers
- Clinic of Geriatric Medicine, Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Sander M J Van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC, Maastricht, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Vrije Universiteit Amsterdam Medisch Centrum, Amsterdam, The Netherlands
| | - Sheila A Payne
- Faculty of Health And Medicine, Lancaster University, Lancaster, UK
| | - Katarzyna Szczerbińska
- Laboratory for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine, Medical Faculty, Jagiellonian University Medical College, Kraków, Poland
| | - Giovanni G Gambassi
- Department of Internal Medicine, Istituto di Medicina Interna e Geriatria, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Harriet Finne-Soveri
- Geriatric Medicine, Department of Welfare, Ageing Disability and Functioning Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Luc Deliens
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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Ermers DJM, van Beuningen-van Wijk MPH, Rit EP, Stalpers-Konijnenburg SC, Taekema DG, Bosch FH, Engels Y, van Mierlo PJWB. Life-sustaining treatment preferences in older patients when referred to the emergency department for acute geriatric assessment: a descriptive study in a Dutch hospital. BMC Geriatr 2021; 21:58. [PMID: 33446116 PMCID: PMC7807792 DOI: 10.1186/s12877-020-02002-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/29/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In many cases, life-sustaining treatment preferences are not timely discussed with older patients. Advance care planning (ACP) offers medical professionals an opportunity to discuss patients' preferences. We assessed how often these preferences were known when older patients were referred to the emergency department (ED) for an acute geriatric assessment. METHODS We conducted a descriptive study on patients referred to the ED for an acute geriatric assessment in a Dutch hospital. Patients were referred by general practitioners (GPs), or in the case of nursing home residents, by elderly care physicians. The referring physician was asked if preferences regarding life-sustaining treatments were known. The primary outcome was the number of patients for whom preferences were known. Secondary outcomes included which preferences, and which variables predict known preferences. RESULTS Between 2015 and 2017, 348 patients were included in our study. At least one preference regarding life-sustaining treatments was known at referral in 45.4% (158/348) cases. In these cases, cardiopulmonary resuscitation (CPR) policy was always included. Preferences regarding invasive ventilation policy and ICU admission were known in 17% (59/348) and 10.3% (36/348) of the cases respectively. Known preferences were more frequent in cases referred by the elderly care physician than the GP (P < 0.001). CONCLUSIONS In less than half the patients, at least one preference regarding life-sustaining treatments was known at the time of referral to the ED for an acute geriatric assessment; in most cases it concerned CPR policy. We recommend optimizing ACP conversations in a non-acute setting to provide more appropriate, desired, and personalized care to older patients referred to the ED.
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Affiliation(s)
- Daisy J M Ermers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, PO Box 9101, Nijmegen, HB, 6500, The Netherlands.
| | | | - Evi Peters Rit
- Department of Geriatrics, Meander medical center, Amersfoort, The Netherlands
| | | | - Diana G Taekema
- Department of Geriatrics, Rijnstate, Arnhem, The Netherlands
| | - Frank H Bosch
- Department of Intensive Care Medicine, Rijnstate, Arnhem, The Netherlands.,Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, PO Box 9101, Nijmegen, HB, 6500, The Netherlands
| | - Patricia J W B van Mierlo
- Department of Geriatrics, Rijnstate, Arnhem, The Netherlands.,Center of Supportive and Palliative Care, Rijnstate, Arnhem, The Netherlands
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Besseling J, Reitsma J, Van Erkelens JA, Schepens MHJ, Siroen MPC, Ziedses des Plantes CMP, van Berge Henegouwen MI, Beerepoot LV, Van Voorthuizen T, Van Zuylen L, Verhoeven RHA, van Laarhoven H. Use of Palliative Chemotherapy and ICU Admissions in Gastric and Esophageal Cancer Patients in the Last Phase of Life: A Nationwide Observational Study. Cancers (Basel) 2021; 13:cancers13010145. [PMID: 33466279 PMCID: PMC7794997 DOI: 10.3390/cancers13010145] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 12/18/2022] Open
Abstract
Simple Summary This is the first nationwide study on chemotherapy use and intensive care unit (ICU) admission in the last three months before death in patients with cancer of the stomach or esophagus. Chemotherapy use and ICU admission shortly before death were relatively infrequent in the Netherlands. Chemotherapy was used less often in hospitals that treat many patients compared to hospitals that treat fewer patients. In patients that received chemotherapy before their final three months before death, chemotherapy was prescribed four times more often in the last three months before death compared to patients without previous chemotherapy use. Abstract Since intensive care unit (ICU) admission and chemotherapy use near death impair the quality of life, we studied the prevalence of both and their correlation with hospital volume in incurable gastroesophageal cancer patients as both impair the quality of life. We analyzed all Dutch patients with incurable gastroesophageal cancer who died in 2017–2018. National insurance claims data were used to determine the prevalence of ICU admission and chemotherapy use (stratified on previous chemotherapy treatment) at three and one month(s) before death. We calculated correlations between hospital volume (i.e., the number of included patients per hospital) and both outcomes. We included 3748 patients (mean age: 71.4 years; 71.4% male). The prevalence of ICU admission and chemotherapy use were, respectively, 5.6% and 21.2% at three months and 4.2% and 8.0% at one month before death. Chemotherapy use at three and one months before death was, respectively, 4.3 times (48.0% vs. 11.2%) and 3.7 times higher (15.7% vs. 4.3%), comparing patients with previous chemotherapy treatment to those without. Hospital volume was negatively correlated with chemotherapy use in the final month (rweighted = −0.23, p = 0.04). ICU admission and chemotherapy use were relatively infrequent. Oncologists in high-volume hospitals may be better equipped in selecting patients most likely to benefit from chemotherapy.
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Affiliation(s)
- Joost Besseling
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.V.Z.); (R.H.A.V.)
- Correspondence: (J.B.); (H.v.L.); Tel.: +31-(0)-682046266 (J.B.); +31-(0)-20-44-44321 (H.v.L.); Fax: +31-(0)-20-44-44355 (H.v.L.)
| | - Jan Reitsma
- Zorgverzekeraars Nederland, 3708 JE Zeist, The Netherlands; (J.R.); (M.H.J.S.)
| | | | | | | | | | - Mark I. van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands;
| | | | | | - Lia Van Zuylen
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.V.Z.); (R.H.A.V.)
| | - Rob H. A. Verhoeven
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.V.Z.); (R.H.A.V.)
- Department of Research & Development, Netherlands Comprehensive Cancer Organisation, 3511 DT Utrecht, The Netherlands
| | - Hanneke van Laarhoven
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.V.Z.); (R.H.A.V.)
- Correspondence: (J.B.); (H.v.L.); Tel.: +31-(0)-682046266 (J.B.); +31-(0)-20-44-44321 (H.v.L.); Fax: +31-(0)-20-44-44355 (H.v.L.)
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Damarell RA, Morgan DD, Tieman JJ, Healey D. Bolstering General Practitioner Palliative Care: A Critical Review of Support Provided by Australian Guidelines for Life-Limiting Chronic Conditions. Healthcare (Basel) 2020; 8:healthcare8040553. [PMID: 33322394 PMCID: PMC7763828 DOI: 10.3390/healthcare8040553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023] Open
Abstract
General practitioners (GPs) are increasingly expected to provide palliative care as ageing populations put pressure on specialist services. Some GPs, however, cite barriers to providing this care including prognostication challenges and lack of confidence. Palliative care content within clinical practice guidelines might serve as an opportunistic source of informational support to GPs. This review analysed palliative care content within Australian guidelines for life-limiting conditions to determine the extent to which it might satisfy GPs’ stated information needs and support them to provide quality end-of-life care. Six databases and guideline repositories were searched (2011–2018). Eligible guidelines were those for a GP audience and explicitly based on an appraisal of all available evidence. Content was mapped against an established palliative care domain framework (PEPSI-COLA) and quality was assessed using AGREE-II. The nine guidelines meeting inclusion criteria were heterogenous in scope and depth of palliative care domain coverage. The ‘communication’ needs domain was best addressed while patient physical and emotional needs were variably covered. Spiritual, out-of-hours, terminal care and aftercare content was scant. Few guidelines addressed areas GPs are known to find challenging or acknowledged useful decision-support tools. A template covering important domains might reduce content variability across guidelines.
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Affiliation(s)
- Raechel A. Damarell
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Flinders University, Adelaide 5001, Australia; (D.D.M.); (J.J.T.)
- Correspondence: ; Tel.: +61-8-7221-8887
| | - Deidre D. Morgan
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Flinders University, Adelaide 5001, Australia; (D.D.M.); (J.J.T.)
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide 5001, Australia;
| | - Jennifer J. Tieman
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Flinders University, Adelaide 5001, Australia; (D.D.M.); (J.J.T.)
| | - David Healey
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide 5001, Australia;
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de Voogd X, Oosterveld-Vlug MG, Torensma M, Onwuteaka-Philipsen BD, Willems DL, Suurmond JL. A dignified last phase of life for patients with a migration background: A qualitative study. Palliat Med 2020; 34:1385-1392. [PMID: 32912088 PMCID: PMC7543003 DOI: 10.1177/0269216320948708] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preserving personal dignity is an important part of palliative care. Generally, autonomy, independency and not being a burden to others are emphasised for preserving dignity. Dignity has not been studied yet from the perspective of the growing group of patients with a migration background living in Western countries. AIM To gain insight into (1) what patients - and their relatives - with a Turkish, Moroccan or Surinamese background, living in the Netherlands, in their last phase of life find important aspects of dignity, and (2) how care professionals can preserve and strengthen the dignity of these patients. DESIGN Qualitative thematic analysis of semi-structured interviews. PARTICIPANTS A total of 23 patients and 21 relatives with a Turkish, Moroccan or Surinamese background were interviewed. RESULTS For respondents dignity encompassed surrender to God's or Allah's will and meaningful relationships with others, rather than preserving autonomy. Surrender to God or Allah meant accepting the illness, the situation and performing religious practice. A meaningful relationship meant being assisted or cared for by family members and maintaining a social role. Professionals could preserve dignity by showing respect and attention; guaranteeing physical integrity, hygiene and self-direction; and indirect communication about diagnoses and prognoses. CONCLUSIONS Religion and appropriate involvement of family members are important aspects of dignity in the last phase of life, in addition to autonomy and independency. Care professionals need to take these factors into account in order to provide person-centred care.
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Affiliation(s)
- X de Voogd
- Department of Public Health, Amsterdam UMC and Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - M G Oosterveld-Vlug
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, the Netherlands
| | - M Torensma
- Department of Public Health, Amsterdam UMC and Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - B D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam UMC Expertise center for Palliative Care and Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - D L Willems
- Department of General Practice, Amsterdam UMC Expertise center for Palliative Care and Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - J L Suurmond
- Department of Public Health, Amsterdam UMC and Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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de Voogd X, Willems DL, Onwuteaka-Philipsen B, Torensma M, Suurmond JL. Community Education for a Dignified Last Phase of Life for Migrants: A Community Engagement, Mixed Methods Study among Moroccan, Surinamese and Turkish Migrants. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17217797. [PMID: 33114464 PMCID: PMC7662901 DOI: 10.3390/ijerph17217797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 11/20/2022]
Abstract
Community engagement and -education are proposed to foster equity in access to care and to ensure dignity of migrant patients in the last phase of life, but evidence is lacking. We evaluated nine community educational interactive meetings about palliative care (136 participants totally)- co-created with educators from our target groups of Moroccan, Surinamese and Turkish migrants—with a mixed methods approach, including 114 questionnaires, nine observations, nine interviews with educators, and 18 pre- and post- group- and individual interviews with participants. Descriptive and thematic analysis was used. 88% of the participants experienced the meetings as good or excellent. Educators bridged an initial resistance toward talking about this sensitive topic with vivid real-life situations. The added value of the educational meetings were: (1) increased knowledge and awareness about palliative care and its services (2) increased comprehensiveness of participant’s wishes and needs regarding dignity in the last phase; (3) sharing experiences for relief and becoming aware of real-life situations. Community engagement and -education about palliative care for migrants effectively increases knowledge about palliative care and is a first step towards improved access to palliative care services, capacity building and a dignified last phase of life among migrants.
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Affiliation(s)
- Xanthe de Voogd
- Amsterdam UMC, Department of Public & Occupational Health, Amsterdam Public Health Research Institute, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1100 DD Amsterdam, The Netherlands; (M.T.); (J.L.S.)
- Correspondence: ; Tel.: +31-6136-34476
| | - Dick L. Willems
- Amsterdam UMC, Department of Ethics, Law and Humanities, Amsterdam UMC Expertise Center for Palliative Care and Amsterdam Public Health Research Institute, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands;
| | - Bregje Onwuteaka-Philipsen
- Amsterdam UMC, Department of Public & Occupational Health, Amsterdam UMC Expertise Center for Palliative Care and Amsterdam Public Health Research Institute, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands;
| | - Marieke Torensma
- Amsterdam UMC, Department of Public & Occupational Health, Amsterdam Public Health Research Institute, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1100 DD Amsterdam, The Netherlands; (M.T.); (J.L.S.)
| | - Jeanine L. Suurmond
- Amsterdam UMC, Department of Public & Occupational Health, Amsterdam Public Health Research Institute, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1100 DD Amsterdam, The Netherlands; (M.T.); (J.L.S.)
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Tilburgs B, Koopmans R, Schers H, Smits C, Vernooij-Dassen M, Perry M, Engels Y. Advance care planning with people with dementia: a process evaluation of an educational intervention for general practitioners. BMC FAMILY PRACTICE 2020; 21:199. [PMID: 32967619 PMCID: PMC7513545 DOI: 10.1186/s12875-020-01265-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 09/09/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND General practitioners (GPs) are advised to offer advance care planning (ACP) to people with dementia (PWD). In a randomized controlled trial, an educational intervention for GPs aimed at initiating and optimizing ACP proved to be effective. During the intervention most GPs were accompanied by their practice nurse (PN). To provide insights into the intervention's successful components and what could be improved, we conducted a process evaluation and explored implementation, mechanisms of impact and contextual factors. METHODS We used the Medical Research Council guidance for process evaluations. Implementation was explored identifying reach and acceptability. We performed descriptive analyses of participants' characteristics; selection, inclusion and intervention attendance; a GP post-intervention survey on initiating ACP; a post intervention focus group with trainers of the intervention. Mechanisms of impact were explored identifying adoption and appropriateness. We used: participants' intervention ratings; a GP post-intervention survey on conducting ACP; ACP documentation in PWD's medical files; post-intervention interviews with PWD/FC dyads. All data was used to identify contextual factors. RESULTS The intervention was implemented by a small percentage of the total Dutch GP population invited, who mostly included motivated PWD/FC dyads with relatively little burden, and PWD with limited cognitive decline. The mechanisms of impact for GPs were: interactively learning to initiate ACP with training actors with a heterogeneous group of GPs and PNs. For PWD/FCs dyads, discussing non-medical preferences was most essential regarding their SDM experience and QoL. Some dyads however found ACP stressful and not feasible. Younger female GPs more often initiated ACP. Male PWD and those with mild dementia more often had had ACP. These characteristics and the safe and intimate training setting, were important contextual facilitators. CONCLUSION We recommend Interventions aimed at improving ACP initiation with PWD by GPs to include interactive components and discussion of non-medical preferences. A safe environment and a heterogeneous group of participants facilitates such interventions. However, in practice not all FC/PWD dyads will be ready to start. Therefore, it is necessary to check their willingness when ACP is offered.
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Affiliation(s)
- Bram Tilburgs
- Department of IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
| | - Raymond Koopmans
- Department of primary and community care, Radboudumc, Nijmegen, The Netherlands
- Radboudumc Alzheimer Centre, Nijmegen, The Netherlands
- Joachim en Anna, Centre for specialized geriatric care, Nijmegen, The Netherlands
| | - Henk Schers
- Department of primary and community care, Radboudumc, Nijmegen, The Netherlands
| | - Carolien Smits
- Research Group Innovating with Older Adults, Windesheim University of Applied Sciences, Zwolle, The Netherlands
| | | | - Marieke Perry
- Department of primary and community care, Radboudumc, Nijmegen, The Netherlands
- Radboudumc Alzheimer Centre, Nijmegen, The Netherlands
- Department of geriatric medicine, Radboudumc, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of anesthesiology, pain and palliative medicine, Radboudumc, Nijmegen, The Netherlands
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Thomas HR, Deckx L, Sieben NA, Foster MM, Mitchell GK. General practitioners' considerations when deciding whether to initiate end-of-life conversations: a qualitative study. Fam Pract 2020; 37:554-560. [PMID: 31796956 DOI: 10.1093/fampra/cmz088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND End-of-life discussions often are not initiated until close to death, even in the presence of life-limiting illness or frailty. Previous research shows that doctors may not explicitly verbalize approaching end-of-life in the foreseeable future, despite shifting their focus to comfort care. This may limit patients' opportunity to receive information and plan for the future. General Practitioners (GPs) have a key role in caring for increasing numbers of patients approaching end-of-life. OBJECTIVE To explore GPs' thought processes when deciding whether to initiate end-of-life discussions. METHODS A qualitative approach was used. We purposively recruited 15 GPs or GP trainees from South-East Queensland, Australia, and each participated in a semi-structured interview. Transcripts were analyzed using inductive thematic analysis. RESULTS Australian GPs believe they have a responsibility to initiate end-of-life conversations, and identify several triggers to do so. Some also describe caution in raising this sensitive topic, related to patient, family, cultural and personal factors. CONCLUSIONS These findings enable the development of approaches to support GPs to initiate end-of-life discussions that are cognizant both of GPs' sense of responsibility for these discussions, and factors that may contribute to caution initiating them, such as anticipated patient response, cultural considerations, societal taboos, family dynamics and personal challenges to doctors.
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Affiliation(s)
- Hayley R Thomas
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Laura Deckx
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Nicolas A Sieben
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Michele M Foster
- The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Woolloongabba, Australia
| | - Geoffrey K Mitchell
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, Australia
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Deckx L, Thomas HR, Sieben NA, Foster MM, Mitchell GK. General practitioners' practical approach to initiating end-of-life conversations: a qualitative study. Fam Pract 2020; 37:401-405. [PMID: 31786593 PMCID: PMC7448298 DOI: 10.1093/fampra/cmz074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND As doctors who provide care across the life-course, general practitioners (GPs) play a key role in initiating timely end-of-life discussions. Nonetheless, these discussions are often not initiated until close to death. Given the ageing of the population, GPs will be confronted with end-of-life care more often, and this needs to become a core skill for all GPs. OBJECTIVE To describe GPs' approach to initiating end-of-life discussions. METHODS Fifteen GPs or GP trainees from South-East Queensland, Australia, were purposively recruited to participate in a semi-structured interview. We analysed transcripts using a thematic analysis. RESULTS GPs' approach to initiating end-of-life discussions was summarized by four themes: (1) Preparing the ground; (2) finding an entry point; (3) tailoring communication and (4) involving the family. CONCLUSIONS Emphasis on the doctor-patient relationship; assessing patient readiness for end-of-life discussions; and sensitive information delivery is consistent with factors previously reported to be important to both GPs and patients in this context. Our findings provide a framework for GPs initiating end-of-life discussions, which must be tailored to patient and GP personality factors. Further research is required to evaluate its outcomes.
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Affiliation(s)
- Laura Deckx
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Hayley R Thomas
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Nicolas A Sieben
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Michele M Foster
- The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Woolloongabba, Australia
| | - Geoffrey K Mitchell
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, Australia
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Mieras A, Pasman HRW, Klop HT, Onwuteaka-Philipsen BD, Tarasevych S, Tiemessen MA, Becker-Commissaris A. What Goals Do Patients and Oncologists Have When Starting Medical Treatment for Metastatic Lung Cancer? Clin Lung Cancer 2020; 22:242-251.e5. [PMID: 32698949 DOI: 10.1016/j.cllc.2020.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/27/2020] [Accepted: 06/11/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Metastatic lung cancer is an incurable disease that can be treated with systemic therapy. These treatments might prolong survival and reduce symptoms, but they may also cause serious adverse effects. We studied the treatment goals of patients with metastasized lung cancer and their oncologists before starting systemic therapy, concordance between patients' and oncologists' goals, and feasibility of these goals. PATIENTS AND METHODS This research was conducted between November 2016 and April 2018 in 1 academic and 5 nonacademic hospitals across the Netherlands. A total of 266 patients with metastatic lung cancer and their prescribing oncologists (n = 23) filled out a questionnaire about their treatment goals and the estimated feasibility of these goals before treatment was started. Additional interviews were conducted with patients and oncologists. RESULTS Patients and oncologists reported quality of life (respectively, 45% and 72%), life prolongation (45% and 55%), decrease in tumor size (39% and 66%), and cure (19% and 2%) as treatment goals. The interviews showed that the latter appeared to be often as motivation to stay alive. Concordances between patients' and oncologists' treatment goals were low (ranging from 24% to 33%). Patients had slightly higher feasibility scores than oncologists (6.8 vs. 5.8 on a 10-point scale). Educational level, age, religious views, and performance status of patients were associated with treatment goals. CONCLUSION Patients and oncologists set various goals for the treatment they receive/prescribe. Low concordance might exist because different goals are set or because the patient misunderstands something. Clear communication about treatment goals should be integrated into clinical care.
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Affiliation(s)
- Adinda Mieras
- Department of Pulmonary Diseases, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - H Roeline W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Hanna T Klop
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Svitlana Tarasevych
- Department of Pulmonary Diseases, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Marian A Tiemessen
- Department of Pulmonary Diseases, Dijklander Ziekenhuis Hoorn, Hoorn, The Netherlands
| | - Annemarie Becker-Commissaris
- Department of Pulmonary Diseases, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Howard M, Langevin J, Bernard C, Tan A, Klein D, Slaven M, Barwich D, Elston D, Arora N, Heyland DK. Primary care clinicians' confidence, willingness participation and perceptions of roles in advance care planning discussions with patients: a multi-site survey. Fam Pract 2020; 37:219-226. [PMID: 31536615 DOI: 10.1093/fampra/cmz050] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND People who engage in advance care planning (ACP) are more likely to receive health care that is concordant with their goals at the end of life. Little discussion of ACP occurs in primary care. OBJECTIVE The objective of this study was to describe primary care clinicians' perspectives on having ACP conversations with their patients. METHODS We conducted a survey of family physicians and non-physician clinicians in primary care in 2014-2015. We compared family physicians and non-physician clinicians on willingness, confidence, participation and acceptability for other clinicians to engage in six aspects of ACP (initiating, exchanging information, decision coaching, finalizing plans, helping communicate plans with family members and other health professionals) on scales from 0 = not at all/extremely unacceptable to 6 = very/all the time/extremely acceptable. RESULTS The response rate was 72% (n = 117) among family physicians and 69% (n = 64) among non-physician clinicians. Mean ratings (standard deviation [SD]) of willingness were high (4.5 [1.4] to 5.0 [1.2] for physicians; 3.4 [1.8] to 4.6 [1.6] non-physician clinicians). There was little participation (mean ratings 2.4 [1.7] to 2.7 [1.6] for physicians, 1.0 [1.5] to 1.4 [1.7] for non-physician clinicians). Non-physician clinicians rated confidence statistically significantly lower than physicians for all ACP aspects. Acceptability for non-physician clinician involvement was high in both groups (mean acceptability ratings greater than 4). CONCLUSION Current engagement of primary care clinicians in ACP is low. Given the high willingness and acceptability for non-physician clinician involvement, increasing the capacity of non-physician clinicians could enable uptake of ACP in primary care.
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Affiliation(s)
- Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton
| | | | - Carrie Bernard
- Department of Family Medicine, McMaster University, Hamilton.,Department of Family and Community Medicine, University of Toronto, Calgary
| | - Amy Tan
- Department of Family Medicine, University of Calgary, Calgary
| | - Doug Klein
- Department of Family Medicine, University of Alberta, Edmonton
| | - Marissa Slaven
- Department of Family Medicine, McMaster University, Hamilton.,Division of Palliative Care, McMaster University, Hamilton
| | - Doris Barwich
- Division of Palliative Care, Department of Medicine, University of British Columbia, Vancouver
| | - Dawn Elston
- Department of Family Medicine, McMaster University, Hamilton
| | - Neha Arora
- Department of Family Medicine, McMaster University, Hamilton
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston.,Department of Public Health, Queen's University, Kingston.,Department of Critical Care Medicine, Kingston General Hospital, Kingston, Canada
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24
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Hamano J, Oishi A, Morita T, Kizawa Y. Frequency of discussing and documenting advance care planning in primary care: secondary analysis of a multicenter cross-sectional observational study. BMC Palliat Care 2020; 19:32. [PMID: 32183800 PMCID: PMC7079526 DOI: 10.1186/s12904-020-00543-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 03/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To improve the quality of advance care planning (ACP) in primary care, it is important to understand the frequency of and topics involved in the ACP discussion between patients and their family physicians (FPs). METHODS A secondary analysis of a previous multicenter cross-sectional observational study was performed. The primary outcome of this analysis was the frequency of and topics involved in the ACP discussion between outpatients and FPs. In March 2017, 22 family physicians at 17 clinics scheduled a day to assess outpatients and enrolled patients older than 65 years who were recognized by FPs as having regular visits. We defined three ACP discussion topics: 1) future decline in activities of daily living (ADL), 2) future inability to eat, and 3) surrogate decision makers. FPs assessed whether they had ever discussed any ACP topics with each patient and their family members, and if they had documented the results of these discussions in medical records before patients were enrolled in the present study. We defined patients as being at risk of deteriorating and dying if they had at least 2 positive general indicators or at least 1 positive disease-specific indicator in the Japanese version of the Supportive and Palliative Care Indicators Tool. RESULTS In total, 382 patients with a mean age of 77.4 ± 7.9 years were enrolled, and 63.1% were female. Seventy-nine patients (20.7%) had discussed at least one ACP topic with their FPs. However, only 23 patients (6.0%) had discussed an ACP topic with family members and their FPs, with the results being documented in their medical records. The topic of future ADL decline was discussed and documented more often than the other two topics. Patients at risk of deteriorating and dying discussed ACP topics significantly more often than those not at risk of deteriorating and dying (39.4% vs. 16.8%, p < 0.001). CONCLUSION FPs may discuss ACP with some of their patients, but may not often document the results of this discussion in medical records. FPs need to be encouraged to discuss ACP with patients and family members and describe the decisions reached in medical records.
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Affiliation(s)
- Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Ai Oishi
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Medical School (Doorway 1), Teviot Place, Edinburgh, UK
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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25
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Perception of the Quality of Communication With Physicians Among Relatives of Dying Residents of Long-term Care Facilities in 6 European Countries: PACE Cross-Sectional Study. J Am Med Dir Assoc 2020; 21:331-337. [DOI: 10.1016/j.jamda.2019.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/24/2019] [Accepted: 05/04/2019] [Indexed: 02/07/2023]
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26
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Koper I, Pasman HRW, Schweitzer BPM, van der Zweep G, Uyttewaal G, Onwuteaka-Philipsen BD. Variation in the implementation of PaTz: a method to improve palliative care in general practice - a prospective observational study. BMC Palliat Care 2020; 19:10. [PMID: 31948417 PMCID: PMC6966787 DOI: 10.1186/s12904-020-0514-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/08/2020] [Indexed: 11/22/2022] Open
Abstract
Background PaTz (palliative care at home) is a method to improve palliative care in the primary care setting in the Netherlands. PaTz has three basic principles: (1) local GPs and DNs meet at least six times per year to identify and discuss their patients with a life-threatening illness; (2) these meetings are supervised by a specialist palliative care professional; (3) groups use a palliative care register on which all identified patients are listed. Since the start in 2010, the number of PaTz-groups in the Netherlands has been growing consistently. Although the theory of all PaTz-groups is the same, the practical functioning of PaTz-groups may vary substantially, which may complicate further implementation of PaTz as well as interpretation of effect studies. This study aims to describe the variation in practice of PaTz-groups in the Netherlands. Method In this prospective observational study, ten PaTz-groups logged and described the activities in their meetings as well as the registered and discussed patients and topics of discussions in registration forms for a 1 year follow-up period. In addition, non-participatory observations were performed in all participating groups. Meeting and patient characteristics were analysed using descriptive statistics. Conventional content analysis was performed in the analysis of topic discussions. Results While the basic principles of PaTz are found in almost every PaTz-group, there is considerable variation in the practice and content of the meetings of different PaTz-groups. Most groups spend little time on other topics than their patients, although the number of patients discussed in a single meeting varies considerably, as well as the time spent on an individual patient. Most registered patients were diagnosed with cancer and patient discussions mainly concerned current affairs and rarely concerned future issues. Conclusion The basic principles are the cornerstone of any PaTz-group. At the same time, the observed variation between PaTz-groups indicates that tailoring a PaTz-group to the needs of its participants is important and may enhance its sustainability. The flexibility of PaTz-groups may also provide opportunity to modify the content and tools used, and improve identification of palliative patients and advance care planning.
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Affiliation(s)
- Ian Koper
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - H Roeline W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bart P M Schweitzer
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | | | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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27
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Douplat M, Daoud K, Berthiller J, Schott AM, Potinet V, Le Coz P, Tazarourte K, Jacquin L. Poor Involvement of General Practitioners in Decisions of Withholding or Withdrawing Life-Sustaining Treatment in Emergency Departments. J Gen Intern Med 2020; 35:177-181. [PMID: 31686289 PMCID: PMC6957665 DOI: 10.1007/s11606-019-05464-y] [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: 11/13/2018] [Accepted: 09/30/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Decisions of withholding or withdrawing life-sustaining treatment are frequent in emergency departments (ED) and patients are often unable to communicate their wishes concerning end of life desires. OBJECTIVE To evaluate the participation of general practitioners (GPs) during the decision-making process of withholding or withdrawing life-sustaining treatments in ED. DESIGN Prospective observational multicenter study. PATIENTS We included patients for whom a decision of withdrawing or withholding life-sustaining treatments was made in ED. For each patient, we enrolled one general practitioner. MAIN MEASURES GPs were interviewed about their perception of end of life patient's management and the communication with ED and families. KEY RESULTS There were 109 potential patient participants. We obtained answers from 54 (49.5%) of the patient's associated GPs. Only 4 (7.4%) GPs were involved during the decision-making process of withholding or withdrawing life-sustaining treatments. Among GPs, 29 (53.7%) were contacted by family after the decision, most often to talk about their difficult experience with the decision. A majority (94%) believed their involvements in these decisions were important and 68% wished to "always" participate in end of life decisions despite the fact that they usually don't participate in these decisions. Finally, 66% of GPs believed that management of end of life in the emergency department was a failure and should be anticipated. CONCLUSIONS GPs would like to be more involved and barriers to GP involvement need to be overcome. We do not have any outcome data to suggest that routine involvement of GPs in all end of life patients improves their outcomes. Moreover, it requires major system and process-based changes to involve all primary care physicians in ED decision-making. NIH TRIAL REGISTRY NUMBER NCT02844972.
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Affiliation(s)
- Marion Douplat
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d’Accueil des urgences, 165 chemin du Grand Revoyet, F-69495 Pierre Bénite, France
- Aix-Marseille Université/EFS/CNRS, UMR 7268 ADéS, Faculté de Médecine, 27 Boulevard Jean Moulin, 13005 Marseille, France
| | - Khadidja Daoud
- Hôpital de Vienne, Service d’Accueil des urgences, Montée du Dr Chapuis, 38209 Vienne, France
| | - Julien Berthiller
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon/University Claude Bernard Lyon 1 /HESPER EA 7425, Lyon, France
| | - Anne-Marie Schott
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon/University Claude Bernard Lyon 1 /HESPER EA 7425, Lyon, France
| | - Véronique Potinet
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d’Accueil des urgences, 165 chemin du Grand Revoyet, F-69495 Pierre Bénite, France
| | - Pierre Le Coz
- Aix-Marseille Université/EFS/CNRS, UMR 7268 ADéS, Faculté de Médecine, 27 Boulevard Jean Moulin, 13005 Marseille, France
| | - Karim Tazarourte
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d’Accueil des urgences, 5 place d’Arsonval, F-69003 Lyon, France
| | - Laurent Jacquin
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d’Accueil des urgences, 5 place d’Arsonval, F-69003 Lyon, France
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Electronic care coordination systems for people with advanced progressive illness: a mixed-methods evaluation in Scottish primary care. Br J Gen Pract 2019; 70:e20-e28. [PMID: 31848198 PMCID: PMC6917358 DOI: 10.3399/bjgp19x707117] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/09/2019] [Indexed: 11/29/2022] Open
Abstract
Background Electronic care coordination systems, known as the Key Information Summary (KIS) in Scotland, enable the creation of shared electronic records available across healthcare settings. A KIS provides clinicians with essential information to guide decision making for people likely to need emergency or out-of-hours care. Aim To estimate the proportion of people with an advanced progressive illness with a KIS by the time of death, to examine when planning information is documented, and suggest improvements for electronic care coordination systems. Design and setting This was a mixed-methods study involving 18 diverse general practices in Scotland. Method Retrospective review of medical records of patients who died in 2017, and semi-structured interviews with healthcare professionals were conducted. Results Data on 1304 decedents were collected. Of those with an advanced progressive illness (79%, n = 1034), 69% (n = 712) had a KIS. These were started a median of 45 weeks before death. People with cancer were most likely to have a KIS (80%, n = 288), and those with organ failure least likely (47%, n = 125). Overall, 68% (n = 482) of KIS included resuscitation status and 55% (n = 390) preferred place of care. People with a KIS were more likely to die in the community compared to those without one (61% versus 30%). Most KIS were considered useful/highly useful. Up-to-date free-text information within the KIS was valued highly. Conclusion In Scotland, most people with an advanced progressive illness have an electronic care coordination record by the time of death. This is an achievement. To improve further, better informal carer information, regular updating, and a focus on generating a KIS for people with organ failure is warranted.
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The association between PaTz and improved palliative care in the primary care setting: a cross-sectional survey. BMC FAMILY PRACTICE 2019; 20:112. [PMID: 31376833 PMCID: PMC6679548 DOI: 10.1186/s12875-019-1002-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 07/24/2019] [Indexed: 12/04/2022]
Abstract
Background The PaTz-method (acronym for Palliatieve Thuiszorg, palliative care at home) is perceived to improve coordination, continuity and communication in palliative care in the Netherlands. Although important for further implementation, research showing a clear effect of PaTz on patient-related outcomes is scarce. This study aimed to examine perceived barriers and added value of PaTz and its association with improved care outcomes. Methods Ninety-eight Dutch general practitioners and 229 Dutch district nurses filled out an online questionnaire with structured questions on added value and barrier perception of PaTz-participation, and palliative care provided to their most recently deceased patient, distributed online by Dutch medical and nurses’ associations. Data from PaTz-participants and non-participants was compared using Chi-square tests, independent t-tests and logistic regression analyses. Results While both PaTz-participants and non-participants perceived PaTz to be beneficial for knowledge collaboration, coordination and continuity of care, time (or lack thereof) is considered the most important barrier for participation. PaTz-participation is associated with discussing five or more end-of-life topics with patients (OR = 3.16) and with another healthcare provider (OR = 2.55). PaTz-participation is also associated with discussing palliative sedation (OR = 3.85) and euthanasia (OR = 2.97) with another healthcare provider. Significant associations with other care outcomes were not found. Conclusions General practitioners and district nurses feel that participating in a PaTz-group has benefits, but perceive various barriers for participation. While participating in a PaTz-group is associated with improved communication between healthcare providers and with patients, the effect on patient outcomes remains unclear. To stimulate further implementation, future research should focus on the effect of PaTz on tangible care characteristics and how to facilitate participation and remove barriers.
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Lakin JR, Benotti E, Paladino J, Henrich N, Sanders J. Interprofessional Work in Serious Illness Communication in Primary Care: A Qualitative Study. J Palliat Med 2019; 22:751-763. [DOI: 10.1089/jpm.2018.0471] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Joshua R. Lakin
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Emily Benotti
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
| | - Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Natalie Henrich
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
| | - Justin Sanders
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
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Care staff's self-efficacy regarding end-of-life communication in the long-term care setting: Results of the PACE cross-sectional study in six European countries. Int J Nurs Stud 2019; 92:135-143. [PMID: 30822706 DOI: 10.1016/j.ijnurstu.2018.09.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/31/2018] [Accepted: 09/28/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND An important part of palliative care is discussing preferences at end of life, however such conversations may not often occur. Care staff with greater self-efficacy towards end-of-life communication are probably more likely to have such discussions, however, there is a lack of research on self-efficacy towards end-of-life discussions among long-term care staff in Europe and related factors. OBJECTIVES Firstly, to describe and compare the self-efficacy level of long-term care staff regarding end-of-life communication across six countries; secondly, to analyse characteristics of staff and facilities which are associated to self-efficacy towards end-of-life communication. DESIGN Cross-sectional survey. SETTINGS Long-term care facilities in Belgium, England, Finland, Italy, the Netherlands and Poland (n = 290). PARTICIPANTS Nurses and care assistants (n = 1680) completed a self-efficacy scale and were included in the analyses. METHODS Care staff rated their self-efficacy (confidence in their own ability) on a scale of 0 (cannot do at all) to 7 -(certain can do) of the 8-item communication subscale of the Self-efficacy in End-of-Life Care survey. Staff characteristics included age, gender, professional role, education level, training in palliative care and years working in direct care. Facility characteristics included facility type and availability of palliative care guidelines, palliative care team and palliative care advice. Analyses were conducted using Generalized Estimating Equations, to account for clustering of data at facility level. RESULTS Thde proportion of staff with a mean self-efficacy score >5 was highest in the Netherlands (76.4%), ranged between 55.9% and 60.0% in Belgium, Poland, England and Finland and was lowest in Italy (29.6%). Higher levels of self-efficacy (>5) were associated with: staff over 50 years of age (OR 1.86 95% CI[1.30-2.65]); nurses (compared to care assistants) (1.75 [1.20-2.54]); completion of higher secondary or tertiary education (respectively 2.22 [1.53-3.21] and 3.11 [2.05-4.71]; formal palliative care training (1.71 [1.32-2.21]); working in direct care for over 10 years (1.53 [1.14-2.05]); working in a facility with care provided by onsite nurses and care assistants and offsite physicians (1.86 [1.30-2.65]); and working in a facility where guidelines for palliative care were available (1.39 [1.03-1.88]). CONCLUSION Self-efficacy towards end-of-life communication was most often low in Italy and most often high in the Netherlands. In all countries, low self-efficacy was found relatively often for discussion of prognosis. Palliative care education and guidelines for palliative care could improve the self-efficacy of care staff.
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Wichmann AB, van Dam H, Thoonsen B, Boer TA, Engels Y, Groenewoud AS. Advance care planning conversations with palliative patients: looking through the GP's eyes. BMC FAMILY PRACTICE 2018; 19:184. [PMID: 30486774 PMCID: PMC6263059 DOI: 10.1186/s12875-018-0868-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/13/2018] [Indexed: 11/23/2022]
Abstract
Background Although it is often recommended that general practitioners (GPs) initiate advance care planning (ACP), little is known about their experiences with ACP. This study aimed to identify GP experiences when conducting ACP conversations with palliative patients, and what factors influence these experiences. Methods Dutch GPs (N = 17) who had participated in a training on timely ACP were interviewed. Data from these interviews were analysed using direct content analysis. Results Four themes were identified: ACP and society, the GP’s perceived role in ACP, initiating ACP and tailor-made ACP. ACP was regarded as a ‘hot topic’. At the same time, a tendency towards a society in which death is not a natural part of life was recognized, making it difficult to start ACP discussions. Interviewees perceived having ACP discussions as a typical GP task. They found initiating and timing ACP easier with proactive patients, e.g. who are anxious of losing capacity, and much more challenging when it concerned patients with COPD or heart failure. Patients still being treated in hospital posed another difficulty, because they often times are not open to discussion. Furthermore, interviewees emphasized that taking into account changing wishes and the fact that not everything can be anticipated, is of the utmost importance. Moreover, when patients are not open to ACP, at a certain point it should be granted that choosing not to know, for example about where things are going or what possible ways of care planning might be, is also a form of autonomy. Conclusions ACP currently is a hot topic, which has favourable as well as unfavourable effects. As GPs experience difficulties in initiating ACP if patients are being treated in the hospital, future research could focus on a multidisciplinary ACP approach and the role of medical specialists in ACP. Furthermore, when starting ACP with palliative patients, we recommend starting with current issues. In doing so, a start can be made with future issues kept in view. Although the tension between ACP’s focus on the patient’s direction and the right not to know can be difficult, ACP has to be tailored to each individual patient. Electronic supplementary material The online version of this article (10.1186/s12875-018-0868-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne B Wichmann
- Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical center, Nijmegen, The Netherlands.
| | - Hanna van Dam
- Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical center, Nijmegen, The Netherlands
| | - Bregje Thoonsen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Theo A Boer
- Section Ethics, University Kampen, Kampen, The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - A Stef Groenewoud
- Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical center, Nijmegen, The Netherlands
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Koper I, Pasman HRW, Onwuteaka-Philipsen BD. Experiences of Dutch general practitioners and district nurses with involving care services and facilities in palliative care: a mixed methods study. BMC Health Serv Res 2018; 18:841. [PMID: 30409204 PMCID: PMC6225713 DOI: 10.1186/s12913-018-3644-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/23/2018] [Indexed: 01/18/2023] Open
Abstract
Background Generals practitioners (GPs) and district nurses (DNs) play a leading role in providing palliative care at home. Many services and facilities are available to support them in providing this complex care. This study aimed to examine the extent to which GPs and DNs involve these services, what their experiences are, and how involvement of these services and facilities can be improved. Methods Sequential mixed methods consisting of an online questionnaire with structured and open questions completed by 108 GPs and 258 DNs, followed by three homogenous online focus groups with 8 GPs and 19 DNs, analyzed through open coding. Results Most GPs reported that they sometimes or often involved palliative home care teams (99%), hospices (94%), and palliative care consultation services (93%). Most DNs reported sometimes or often involving volunteers (90%), hospices (88%), and spiritual caregivers (80%). The least involved services and facilities were psychologists and psychiatrists (51% and 50%) and social welfare (44% and 57%). Main reason for not involving services and facilities was ‘not needing’ them. If they had used them, most GPs and DNs (68–93%) reported solely positive experiences. Hardly anyone (0–3%) reported solely negative experiences with any of the services and the facilities. GPs and DNs suggested improvements in three areas: (1) establishment of local centers giving information on available services and facilities, (2) presentation of services and facilities in local multidisciplinary meetings, and (3) support organizations to proactively offer their facilities and services. Conclusion Psychological, social, and spiritual services are involved less often, suggesting that the classic care model, which focuses strongly on somatic issues, is still well entrenched. More familiarity with services that can provide additional care in these areas, regarding their availability and their added value, could improve the quality of life for patients and relatives at the end of life.
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Affiliation(s)
- Ian Koper
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081, BT, Amsterdam, The Netherlands.
| | - H Roeline W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081, BT, Amsterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081, BT, Amsterdam, The Netherlands
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Liu JT, Kovar-Gough I, Farabi N, Animikwam F, Weers SB, Phillips J. The Role of Primary Care Physicians in Providing End-of-Life Care. Am J Hosp Palliat Care 2018; 36:249-254. [PMID: 30354178 DOI: 10.1177/1049909118808232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Primary care physicians (PCPs) frequently have long-term relationships with patients as well as their families. As such they are well positioned to care for their patients at the end of their lives. As the number of patients in need of end-of-life care continues to grow, it is critical to understand how PCPs can fulfill that need. The purpose of our study is to perform a narrative review of the literature and develop a theoretical model delineating the overarching roles played by PCPs in caring for patients at the end of life. METHODS For this narrative review, the authors searched Medline (PubMed), Embase, Cochrane Library, and Scopus up to March 22, 2017. Articles were not limited by geography. RESULTS Review of existing literature generally supports 4 broad categories as the primary roles for PCP involvement in end of life: pain and symptom management; information management, including transmitting and clarifying information, setting care priorities, and assisting patients with treatment decisions; coordinating care and collaborating with other providers; and addressing patients' social, emotional, and spiritual needs. CONCLUSIONS Based on the results of this review, PCPs provide a wide range of services to patients at the end of life. Promoting the provision of the full scope of services by PCPs will help ensure improved continuity of care while providing the highest quality of care for patients, both in the United States and around the world.
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Affiliation(s)
- Jan Tse Liu
- Sparrow-MSU Family Medicine Residency Program, MI, USA
| | | | - Nabila Farabi
- Michigan State University College of Human Medicine, East Lansing, MI, USA
| | | | | | - Julie Phillips
- Sparrow-MSU Family Medicine Residency Program, MI, USA.,Michigan State University College of Human Medicine, East Lansing, MI, USA
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Ding J, Johnson CE, Cook A. How We Should Assess the Delivery of End-Of-Life Care in General Practice? A Systematic Review. J Palliat Med 2018; 21:1790-1805. [PMID: 30129811 DOI: 10.1089/jpm.2018.0194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The majority of end-of-life (EOL) care occurs in general practice. However, we still have little knowledge about how this care is delivered or how it can be assessed and supported. AIM (i) To review the existing evaluation tools used for assessment of the delivery of EOL care from the perspective of general practice; (ii) To describe how EOL care is provided in general practice; (iii) To identify major areas of concern in providing EOL care in this context. DESIGN A systematic review. DATA SOURCES Systematic searches of major electronic databases (Medline, EMBASE, PsycINFO, and CINAHL) from inception to 2017 were used to identify evaluation tools focusing on organizational structures/systems and process of end-of-life care from a general practice perspective. RESULTS A total of 43 studies representing nine evaluation tools were included. A relatively restricted focus and lack of validation were common limitations. Key general practitioner (GP) activities assessed by the evaluation tools were summarized and the main issues in current GP EOL care practice were identified. CONCLUSIONS The review of evaluation tools revealed that GPs are highly involved in management of patients at the EOL, but there are a range of issues relating to the delivery of care. An EOL care registration system integrated with electronic health records could provide an optimal approach to address the concerns about recall bias and time demands in retrospective analyses. Such a system should ideally capture the core GP activities and any major issues in care provision on a case-by-case basis.
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Affiliation(s)
- Jinfeng Ding
- 1 School of Population and Global Health, University of Western Australia , Perth, Western Australia, Australia
| | - Claire E Johnson
- 2 Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), Medical School, University of Western Australia , Perth, Western Australia, Australia
- 3 School of Nursing and Midwifery, Monash University , Melbourne, Victoria, Australia
| | - Angus Cook
- 1 School of Population and Global Health, University of Western Australia , Perth, Western Australia, Australia
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Johnson CE, McVey P, Rhee JJO, Senior H, Monterosso L, Williams B, Fallon-Ferguson J, Grant M, Nwachukwu H, Aubin M, Yates P, Mitchell G. General practice palliative care: patient and carer expectations, advance care plans and place of death-a systematic review. BMJ Support Palliat Care 2018:bmjspcare-2018-001549. [PMID: 30045939 DOI: 10.1136/bmjspcare-2018-001549] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/20/2018] [Accepted: 07/04/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND With an increasing ageing population in most countries, the role of general practitioners (GPs) and general practice nurses (GPNs) in providing optimal end of life (EoL) care is increasingly important. OBJECTIVE To explore: (1) patient and carer expectations of the role of GPs and GPNs at EoL; (2) GPs' and GPNs' contribution to advance care planning (ACP) and (3) if primary care involvement allows people to die in the place of preference. METHOD Systematic literature review. DATA SOURCES Papers from 2000 to 2017 were sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases. RESULTS From 6209 journal articles, 51 papers were relevant. Patients and carers expect their GPs to be competent in all aspects of palliative care. They valued easy access to their GP, a multidisciplinary approach to care and well-coordinated and informed care. They also wanted their care team to communicate openly, honestly and empathically, particularly as the patient deteriorated. ACP and the involvement of GPs were important factors which contributed to patients being cared for and dying in their preferred place. There was no reference to GPNs in any paper identified. CONCLUSIONS Patients and carers prefer a holistic approach to care. This review shows that GPs have an important role in ACP and that their involvement facilitates dying in the place of preference. Proactive identification of people approaching EoL is likely to improve all aspects of care, including planning and communicating about EoL. More work outlining the role of GPNs in end of life care is required.
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Affiliation(s)
- Claire E Johnson
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- School of Nursing & Midwifery, Monash University, Melbourne, Victoria, Australia
- Eastern Health, Melbourne, Victoria, Australia
| | - Peta McVey
- Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
| | - Joel Jin-On Rhee
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Hugh Senior
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- College of Health, Massey University, Auckland, New Zealand
| | - Leanne Monterosso
- School of Nursing & Midwifery, Notre Dame University, Fremantle, Western Australia, Australia
- Centre for Nursing and Midwifery Research, St John of God Murdoch Hospital, Murdoch, Western Australia, Australia
- School of Nursing & Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Briony Williams
- School of General Practice and Rural Medicine, University of Western Australia, Perth, Western Australia, Australia
- Primary Care Collaborative Cancer Clinical Trials Group, University of Melbourne, Melbourne, Victoria, Australia
| | - Julia Fallon-Ferguson
- School of General Practice and Rural Medicine, University of Western Australia, Perth, Western Australia, Australia
- Primary Care Collaborative Cancer Clinical Trials Group, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew Grant
- Victoria Comprehensive Cancer Centre Palliative Care Research Group, University of Melbourne, Melbourne, Victoria, Australia
| | - Harriet Nwachukwu
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michèle Aubin
- Département de médecine familiale et de médecined\'urgence, Universite Laval, Faculte de medecine, Québec City, Canada
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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De Vleminck A, Batteauw D, Demeyere T, Pype P. Do non-terminally ill adults want to discuss the end of life with their family physician? An explorative mixed-method study on patients' preferences and family physicians' views in Belgium. Fam Pract 2018; 35:495-502. [PMID: 29272418 DOI: 10.1093/fampra/cmx125] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Research about advance care planning (ACP) has often targeted those with serious illness and limited prognosis, thereby not addressing the preferences of healthy adults or adults with a stable condition. AIMS (i) To describe to what extent patients aged 50 and older who are relatively stable or in good health are thinking about the end of life (EOL) and willing to discuss this with their family physician (FP) and (ii) to explore whether patients and FPs indicate the same topics as triggers for ACP discussions in family practice. METHODS A cross-sectional study was conducted in a diverse sample of 289 patients aged ≥50 years in family practice in Flanders, Belgium. Subsequently, semi-structured interviews were conducted with patients (n = 5) and FPs (n = 5) to explore their preferences and views on ACP in family practice. RESULTS The majority (69.8%) of patients had thought about the EOL and would appreciate it if their FP would initiate a conversation about this (75.9%). The qualitative interviews revealed that when thinking about the EOL, a number of themes captured the thoughts of people according to both patients and FPs: (i) becoming care dependent, (ii) physical and mental deterioration, (iii) dying alone and (iv) having paperwork in order. However, on the basis of patients' ideas and FPs' experiences in practice, a difference was noticed between them when it comes to identifying the themes as triggers for initiating ACP discussions. CONCLUSION Although patients are willing to discuss the EOL with their FPs, patients and FPs identified different themes as triggers to initiate discussions about the EOL. The variation in triggers could lead to missed opportunities to engage in ACP in a timely manner.
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Affiliation(s)
- Aline De Vleminck
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - David Batteauw
- Department of Family Medicine and Primary Health Care, Ghent University, Gent, Belgium
| | - Tijs Demeyere
- Department of Family Medicine and Primary Health Care, Ghent University, Gent, Belgium
| | - Peter Pype
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Family Medicine and Primary Health Care, Ghent University, Gent, Belgium
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ten Koppel M, Onwuteaka-Philipsen BD, Pasman HR, Bernabei R, Carpenter I, Denkinger MD, Onder G, van der Roest HG, Topinkova E, van Hout HPJ. Are older long term care residents accurately prognosticated and consequently informed about their prognosis? Results from SHELTER study data in 5 European countries. PLoS One 2018; 13:e0200590. [PMID: 30020976 PMCID: PMC6051611 DOI: 10.1371/journal.pone.0200590] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/01/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Informing residents in long term care facilities (LTCFs) about their prognosis can help them prepare for the end of life. This study aimed to examine which proportion of European LTCF residents, close to death, are accurately prognosticated and consequently informed about their prognosis; and to examine factors related to accurate prognostication and discussion of prognosis. METHODS A subsample of SHELTER study data was used, consisting of: 500 residents from 5 European countries, who died within 6 months after their last assessment, and had a valid answer on the item 'End stage disease, 6 or fewer months to live'. This item was used to indicate whether an accurate prognosis was established and discussed with residents. Generalized estimating equations were used to examine factors related to establishment and discussion of accurate prognosis. RESULTS 86.4% of residents close to death did not receive an accurate prognosis. Residents with cancer; fatigue; dehydration; and normal mode of nutritional intake were more likely to have an accurate prognosis established and discussed. Accurate prognostication and prognosis discussion was less likely for residents who: had a diagnosis under 'other'; initiated interactions; and residents from Germany, Italy and the Netherlands. CONCLUSIONS The great majority of residents close to death did not receive an accurate prognosis. Prognostication tools might help clinicians to increase their prognostic accuracy and communication training might help to discuss prognosis with residents.
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Affiliation(s)
- Maud ten Koppel
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - Bregje D. Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - H. Roeline Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Roberto Bernabei
- Centro Medicina dell’Invecchiamento, Università Cattolica Sacro Cuore, Rome, Italy
| | - Iain Carpenter
- Centre for Health Services Studies, University of Kent, Canterbury, United Kingdom
| | - Michael D. Denkinger
- Agaplesion Bethesda Clinic, Geriatric Centre Ulm/Alb-Donau, Ulm University, Ulm, Germany
| | - Graziano Onder
- Centro Medicina dell’Invecchiamento, Università Cattolica Sacro Cuore, Rome, Italy
| | - Henriëtte G. van der Roest
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Eva Topinkova
- Department of Geriatrics, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Hein P. J. van Hout
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
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Improving palliative care provision in primary care: a pre- and post-survey evaluation among PaTz groups. Br J Gen Pract 2018; 68:e351-e359. [PMID: 29581128 DOI: 10.3399/bjgp18x695753] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/20/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND In PaTz (PAlliatieve Thuis Zorg, palliative care at home), modelled after the Gold Standards Framework, GPs and community nurses meet on a regular basis to identify patients with palliative care needs (the PaTz register), and to discuss care for these patients. AIM To study the effects of the implementation of PaTz, and provide additional analyses on two important elements: the PaTz register and patient discussions. DESIGN AND SETTING A pre- and post-evaluation among Dutch GPs (n = 195 before the start of PaTz; n = 166, 1 year after the start of PaTz). The GPs also provided data on recently deceased patients (n = 460 before the start of PaTz; n = 305 14 months after the start of PaTz). METHOD GPs from all 37 PaTz groups filled in questionnaires. Pre- and post-test differences were analysed using multilevel analyses to adjust for PaTz group. RESULTS Identification of patients with palliative care needs was done systematically for more patients after implementation of PaTz compared with before (54.3% versus 17.6%). After implementation, 64.8% of deceased patients had been included on the PaTz register. For these patients, when compared with patients not included on the PaTz register, preferred place of death was more likely to be known (88.1% of patients not on the register and 97.3% of deceased patients included on the register), GPs were more likely to have considered a possible death sooner (>1 month before death: 53.0% and 80.2%), and conversations on life expectancy, physical complaints, existential issues, and possibilities of care occurred more often (60.8% and 81.3%; 68.6% and 86.1%; 22.5% and 34.2%; 60.8% and 84.0%, respectively). CONCLUSIONS Implementation of PaTz improved systematic identification of palliative care patients within the GP practice. Use of the PaTz register has added value.
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Wammes JJG, Tanke M, Jonkers W, Westert GP, Van der Wees P, Jeurissen PP. Characteristics and healthcare utilisation patterns of high-cost beneficiaries in the Netherlands: a cross-sectional claims database study. BMJ Open 2017; 7:e017775. [PMID: 29133323 PMCID: PMC5695517 DOI: 10.1136/bmjopen-2017-017775] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/29/2017] [Accepted: 09/25/2017] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To determine medical needs, demographic characteristics and healthcare utilisation patterns of the top 1% and top 2%-5% high-cost beneficiaries in the Netherlands. DESIGN Cross-sectional study using 1 year claims data. We broke down high-cost beneficiaries by demographics, the most cost-incurring condition per beneficiary and expensive treatment use. SETTING Dutch curative health system, a health system with universal coverage. PARTICIPANTS 4.5 million beneficiaries of one health insurer. MEASURES Annual total costs through hospital, intensive care unit use, expensive drugs, other pharmaceuticals, mental care and others; demographics; most cost-incurring and secondary conditions; inpatient stay; number of morbidities; costs per ICD10-chapter (International Statistical Classification of Diseases, 10th revision); and expensive treatment use (including dialysis, transplant surgery, expensive drugs, intensive care unit and diagnosis-related groups >€30 000). RESULTS The top 1% and top 2%-5% beneficiaries accounted for 23% and 26% of total expenditures, respectively. Among top 1% beneficiaries, hospital care represented 76% of spending, of which, respectively, 9.0% and 9.1% were spent on expensive drugs and ICU care. We found that 54% of top 1% beneficiaries were aged 65 years or younger and that average costs sharply decreased with higher age within the top 1% group. Expensive treatments contributed to high costs in one-third of top 1% beneficiaries and in less than 10% of top 2%-5% beneficiaries. The average number of conditions was 5.5 and 4.0 for top 1% and top 2%-5% beneficiaries, respectively. 53% of top 1% beneficiaries were treated for circulatory disorders but for only 22% of top 1% beneficiaries this was their most cost-incurring condition. CONCLUSIONS Expensive treatments, most cost-incurring condition and age proved to be informative variables for studying this heterogeneous population. Expensive treatments play a substantial role in high-costs beneficiaries. Interventions need to be aimed at beneficiaries of all ages; a sole focus on the elderly would leave many high-cost beneficiaries unaddressed. Tailored interventions are needed to meet the needs of high-cost beneficiaries and to avoid waste of scarce resources.
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Affiliation(s)
- Joost Johan Godert Wammes
- Scientific Institute for Quality of Healthcare, Celsus Academy for Sustainable Healthcare, Radboud university medical center, Nijmegen, The Netherlands
| | - Marit Tanke
- Scientific Institute for Quality of Healthcare, Celsus Academy for Sustainable Healthcare, Radboud university medical center, Nijmegen, The Netherlands
| | - Wilma Jonkers
- Kenniscentrum - Research Consultancy, Zilveren Kruis, Zwolle, The Netherlands
| | - Gert P Westert
- Scientific Institute for Quality of Healthcare, Radboud university medical center, Nijmegen, The Netherlands
| | - Philip Van der Wees
- Scientific Institute for Quality of Healthcare, Celsus Academy for Sustainable Healthcare, Radboud university medical center, Nijmegen, The Netherlands
| | - Patrick Pt Jeurissen
- Scientific Institute for Quality of Healthcare, Celsus Academy for Sustainable Healthcare, Radboud university medical center, Nijmegen, The Netherlands
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Abstract
Zusammenfassung. Dieser Artikel gibt einen Überblick über die aktuelle Diskussion zu Ansätzen ärztlicher Spiritual Care. Der ärztliche Beitrag zu einer interprofessionellen Spiritual Care ist aus drei Gründen wichtig: 1. Für manche Patienten stellen religiös-spirituelle Faktoren im Umgang mit Krankheit und Sterben entweder eine Ressource oder ein Problem dar. 2. Religiös-spirituelle Faktoren können medizinische Entscheidungen beeinflussen, insbesondere am Lebensende. 3. Aufgrund des besonderen Abhängigkeitsverhältnisses im stationären Bereich tragen Ärzte eine Mitverantwortung dafür, dass die Ausübung religiöser Lebensvollzüge unter den Bedingungen des klinischen Alltags gewährleistet bleibt. Eine spezifisch ärztliche Spiritual Care ist deshalb als integrales Moment des ärztlichen Behandlungsauftrags zu verstehen.
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How do treatment aims in the last phase of life relate to hospitalizations and hospital mortality? A mortality follow-back study of Dutch patients with five types of cancer. Support Care Cancer 2017; 26:777-786. [PMID: 28936558 PMCID: PMC5785603 DOI: 10.1007/s00520-017-3889-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 09/11/2017] [Indexed: 11/30/2022]
Abstract
Purpose The purpose of this study is to describe and compare the relation between treatment aims, hospitalizations, and hospital mortality for Dutch patients who died from lung, colorectal, breast, prostate, or pancreatic cancer. Methods A mortality follow-back study was conducted within a sentinel network of Dutch general practitioners (GPs), who recorded the end-of-life care of 691 patients who died from one of the abovementioned cancer types between 2009 and 2015. Differences in care by type of cancer were analyzed using multilevel analyses to control for clustering within general practices. Results Among all cancer types, patients with prostate cancer most often and patients with pancreatic cancer least often had a palliative treatment aim a month before death (95% resp. 84%). Prostate cancer patients were also least often admitted to hospital in the last month of life (18.5%) and least often died there (3.1%), whereas lung cancer patients were at the other end of the spectrum with 41.8% of them being admitted to hospital and 22.6% dying in hospital. Having a palliative treatment aim and being older were significantly associated with less hospital admissions, and having a palliative treatment aim, having prostate cancer, and dying in a more recent year were significantly associated with less hospital deaths. Conclusion There is large variation between patients with different cancer types with regard to treatment aims, hospital admissions, and hospital deaths. The results highlight the need for early initiation of GP palliative care to support patients from all cancer types to stay at the place they prefer as long as possible.
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Udo C, Lövgren M, Lundquist G, Axelsson B. Palliative care physicians' experiences of end-of-life communication: A focus group study. Eur J Cancer Care (Engl) 2017; 27. [PMID: 28727207 DOI: 10.1111/ecc.12728] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2017] [Indexed: 01/26/2023]
Abstract
The aim of this study was to explore palliative home care physicians' experiences regarding end-of-life breakpoint communication (BPC). This is a qualitative study where focus group interviews were conducted and analysed using qualitative content analysis. The results show that the participants saw themselves as being responsible for accomplishing BPC, and they were convinced that it should be regarded as a process of communication initiated at an early stage, i.e. proactively. However, BPC was often conducted as a reaction to the patient's sudden deterioration or sometimes not at all. The barriers to achieving proactive BPC included physicians' uncertainty regarding the timing of BPC, primarily due to difficulties in prognostication in terms of time of death, and uncertainty as to what BPC should include and how it should best be approached. Furthermore, there was insufficient documentation regarding previous BPC, which impeded proactive BPC. Although our study shows that physicians are ambitious when it comes to the communication of information to patients and families, there is a need for further training in how to conduct BPC and when to initiate the BPC process. Furthermore, there should be documentation that different professionals can access as this would appear to facilitate a proactive BPC process.
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Affiliation(s)
- C Udo
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.,CKF, Centre for Clinical Research Dalarna, County Council of Dalarna, Falun, Sweden
| | - M Lövgren
- The Department of Health Care Sciences, Ersta Sköndal University College, Stockholm, Sweden.,Paediatric Oncology and Haematology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Childhood Cancer Research Unit, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - G Lundquist
- CKF, Centre for Clinical Research Dalarna, County Council of Dalarna, Falun, Sweden
| | - B Axelsson
- Research Unit Östersund Hospital, Department of Radiation Sciences, Umeå University, Umeå, Sweden
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Lakin JR, Koritsanszky LA, Cunningham R, Maloney FL, Neal BJ, Paladino J, Palmor MC, Vogeli C, Ferris TG, Block SD, Gawande AA, Bernacki RE. A Systematic Intervention To Improve Serious Illness Communication In Primary Care. Health Aff (Millwood) 2017; 36:1258-1264. [DOI: 10.1377/hlthaff.2017.0219] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joshua R. Lakin
- Joshua R. Lakin ( ) is a palliative care physician at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital and an associate faculty member at Ariadne Labs, all in Boston, Massachusetts
| | | | - Rebecca Cunningham
- Rebecca Cunningham is medical director of the Integrated Care Management Program at Brigham and Women’s Hospital and an assisant professor of medicine at Harvard Medical School, both in Boston
| | | | | | - Joanna Paladino
- Joanna Paladino is a palliative care physician at Dana-Farber Cancer Institute and the assistant director of implementation for the Serious Illness Care Program at Ariadne Labs
| | | | - Christine Vogeli
- Christine Vogeli is an assistant professor of medicine at Massachusetts General Hospital and Harvard Medical School and director of evaluation and research at the Center for Population Health, Partners HealthCare, in Boston
| | - Timothy G. Ferris
- Timothy G. Ferris is senior vice president of population health at Massachusetts General Hospital and Partners Healthcare and an associate professor of medicine at Harvard Medical School
| | - Susan D. Block
- Susan D. Block is director of the Serious Illness Care Program at Ariadne Labs; founding chair of the Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women’s Hospital; and a professor of psychiatry and medicine, Harvard Medical School
| | - Atul A. Gawande
- Atul A. Gawande is executive director of Ariadne Labs; a surgeon at Brigham and Women’s Hospital; and a professor at the Harvard T. H. Chan School of Public Health and Harvard Medical School
| | - Rachelle E. Bernacki
- Rachelle E. Bernacki is director of quality initiatives for palliative care at the Dana-Farber Cancer Institute and associate director of the Serious Illness Care Program at Ariadne Labs
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Abstract
BACKGROUND Little population-level information exists about the delivery of palliative care across multiple health sectors, important in providing a complete picture of current care and gaps in care. AIM Provide a population perspective on end-of-life palliative care delivery across health sectors. DESIGN Retrospective population-level cohort study, describing palliative care in the last year of life using linked health administrative databases. SETTING/PARTICIPANTS All decedents in Ontario, Canada, from 1 April 2010 to 31 March 2012 ( n = 177,817). RESULTS Across all health sectors, about half (51.9%) of all decedents received at least one record of palliative care in the last year of life. Being female, middle-aged, living in wealthier and urban neighborhoods, having cancer, and less multi-morbidity were all associated with higher odds of palliative care receipt. Among 92,276 decedents receiving palliative care, 84.9% received care in acute care hospitals. Among recipients, 35 mean days of palliative care were delivered. About half (49.1%) of all palliative care days were delivered in the last 2 months of life, and half (50.1%) had palliative care initiated in this period. Only about one-fifth of all decedents (19.3%) received end-of-life care through publicly funded home care. Less than 10% of decedents had a record of a palliative care home visit from a physician. CONCLUSION We describe methods to capture palliative care using administrative data. Despite an estimate of overall reach (51.9%) that is higher than previous estimates, we have shown that palliative care is infrequently delivered particularly in community settings and to non-cancer patients and occurs close to death.
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Affiliation(s)
- Peter Tanuseputro
- Bruyère Centre for Learning, Research and Innovation in Long-Term Care, Bruyère Research Institute, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital—Civic Campus, Ottawa, ON, Canada
| | - Suman Budhwani
- Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Yu Qing Bai
- Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Walter P Wodchis
- Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
- Primary Care & Population Health, Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada
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Rak A, Raina R, Suh TT, Krishnappa V, Darusz J, Sidoti CW, Gupta M. Palliative care for patients with end-stage renal disease: approach to treatment that aims to improve quality of life and relieve suffering for patients (and families) with chronic illnesses. Clin Kidney J 2016. [PMID: 28638606 PMCID: PMC5469574 DOI: 10.1093/ckj/sfw105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Providing end-of-life care to patients suffering from chronic kidney disease (CKD) and/or end-stage renal disease often presents ethical challenges to families and health care providers. However, as the conditions these patients present with are multifaceted in nature, so should be the approach when determining prognosis and treatment strategies for this patient population. Having an interdisciplinary palliative team in place to address any concerns that may arise during conversations related to end-of-life care encourages effective communication between the patient, the family and the medical team. Through the use of a case study, the authors demonstrate how an interdisciplinary palliative team can be used to make decisions that satisfy the patient's and the medical team's desires for end-of-life care.
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Affiliation(s)
- Amy Rak
- Department of Internal Medicine and Research, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA
| | - Rupesh Raina
- Department of Internal Medicine and Research, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA.,Department of Nephrology, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA
| | - Theodore T Suh
- Division of Geriatric and Palliative Medicine, University of Michigan Health System, Geriatric Research Education and Clinical Center, Ann Arbor VA Hospital, Ann Arbor, MI, USA
| | - Vinod Krishnappa
- Department of Internal Medicine and Research, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA.,Department of Nephrology, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA
| | - Jessica Darusz
- Department of Internal Medicine and Research, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA.,Department of Nephrology, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA
| | | | - Mona Gupta
- Section of Palliative Medicine, Taussig Cancer Institute, Cleveland, OH, USA.,Center for Geriatric Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
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Evenblij K, Widdershoven GAM, Onwuteaka-Philipsen BD, de Kam H, Pasman HRW. Palliative care in mental health facilities from the perspective of nurses: a mixed-methods study. J Psychiatr Ment Health Nurs 2016; 23:409-18. [PMID: 27530547 DOI: 10.1111/jpm.12320] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2016] [Indexed: 11/28/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: Nurses play an important role in monitoring and supporting patients and their relatives at the end of life. To date, there is a lack of recent empirical research on the experiences of psychiatric nurses in providing palliative care to psychiatric patients who suffer from life-threatening physical co-morbidity. The limited literature available indicates that palliative care for psychiatric patients needs to be improved. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This explorative study is unique in offering an insight into current palliative care practice for psychiatric patients and showed that one in three nurses working in Dutch mental health facilities is involved in palliative care provision. Important elements of palliative care, i.e.: care domains, multidisciplinary approach, early recognition and family care are recognized by nurses. Moreover, in palliative care for psychiatric patients there is more attention for psychosocial and spiritual care compared to palliative care for patients without psychiatric disorders. Patient characteristics and little attention for palliative care within mental health facilities were found to hamper timely and adequate palliative care provision by nurses. WHAT ARE THE IMPLICATIONS FOR RESEARCH AND PRACTICE?: Educating psychiatric nurses about palliative care and close collaboration between physical and mental health care are crucial to address the palliative care needs of this vulnerable patient group. Since mental health care is increasingly provided ambulatory, the development of palliative care for psychiatric patients outside mental health facilities should be closely monitored. ABSTRACT Introduction Recent empirical research on palliative care for psychiatric patients is lacking. Aim The aim of this study was to explore nurses' experiences with and identify barriers to providing palliative care to psychiatric patients in Dutch mental health facilities. Methods Mixed-methods; 137 nurses working in Dutch mental health facilities completed a survey. Nine participated in in-depth interviews. Results Thirty-six percent of nurses had experience with providing palliative care to psychiatric patients with physical co-morbidity in the past 2 years. Of all patients, 63% received physical care before death, 46% psychosocial care and 33% spiritual care. In 91% of all cases, care was provided by multidisciplinary teams. Patient characteristics and little attention to palliative care were barriers for timely and adequate palliative care. Discussion In palliative care for psychiatric patients, there is more attention for psychosocial and spiritual care compared to palliative care for patients without psychiatric disorders. Yet there are barriers to adequate palliative care provision. Implications for practice Educating psychiatric nurses about palliative care and close collaboration between physical and mental health care are crucial to address the palliative care needs of psychiatric patients. Since mental health care is increasingly provided ambulatory, palliative care for psychiatric patients outside mental health facilities should be closely monitored.
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Affiliation(s)
- K Evenblij
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands.,Center of Expertise in Palliative Care, VU University Medical Center, Amsterdam, The Netherlands.,EMGO institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - G A M Widdershoven
- Center of Expertise in Palliative Care, VU University Medical Center, Amsterdam, The Netherlands.,EMGO institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of Medical Humanities, VU University Medical Center, Amsterdam, The Netherlands
| | - B D Onwuteaka-Philipsen
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands.,Center of Expertise in Palliative Care, VU University Medical Center, Amsterdam, The Netherlands.,EMGO institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - H de Kam
- GGz Centraal, Center for Mental Healthcare, Amersfoort, The Netherlands
| | - H R W Pasman
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands.,Center of Expertise in Palliative Care, VU University Medical Center, Amsterdam, The Netherlands.,EMGO institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Hoek PD, Schers HJ, Hendriks JCM, Vissers KCP, Hasselaar JGJ. Palliative care consultations in primary care: a cross-sectional survey among Dutch general practitioners. BMJ Support Palliat Care 2016; 9:e30. [PMID: 27316637 DOI: 10.1136/bmjspcare-2015-000967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 04/25/2016] [Accepted: 05/31/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Expert consultation supports general practitioners (GPs) in delivering adequate palliative homecare. Insight into consultation practices from a GP's perspective is needed in order to shape consultation services to their wishes and needs. AIM To explore palliative care consultation practices from a GP's perspective. DESIGN AND SETTING Cross-sectional web-based survey among all GPs (n=235) in the region of Nijmegen, the Netherlands. METHODS Our questionnaire contained questions about the delivery of palliative care by GPs, their consultation practices and satisfaction with current services. Questions consisted mainly of 5-point Likert scales. We transformed these scales into numerical values to calculate mean scores. Linear mixed models for repeated measurements were used to study differences in scores. RESULTS GPs most often consulted informal caregivers (mean score 3.6) or fellow GPs (mean score 3.3). Physical problems were discussed the most (mean score 3.5), while social and existential issues were discussed least (mean score 1.9 for both). In their choice of a particular consultation service, GPs considered the quality of the provided advice to be the most important factor. GPs were satisfied with current consultation services, with fellow GPs receiving the highest satisfaction scores (mean score 4.6). Finally, when recalling their last palliative patient, most GPs started requesting consultation during this patient's last month of life. CONCLUSIONS Next to informal caregivers, GPs preferably seek advice from fellow GPs. Physical issues receive much attention during consultations; however, other vital aspects of palliative care seem to remain relatively neglected, such as social and existential issues and a proactive care approach.
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Affiliation(s)
- Patrick D Hoek
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henk J Schers
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan C M Hendriks
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen G J Hasselaar
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Morin L, Johnell K, Van den Block L, Aubry R. Discussing end-of-life issues in nursing homes: a nationwide study in France. Age Ageing 2016; 45:395-402. [PMID: 27013503 DOI: 10.1093/ageing/afw046] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 12/23/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND discussing end-of-life issues with nursing home residents and their relatives is needed to ensure patient-centred care near the end of life. OBJECTIVES this study aimed to estimate the frequency of nursing home physicians discussing end-of-life issues with residents and their relatives and to investigate how discussing end-of-life issues was associated with care outcomes in the last month of life. METHODS post-mortem cohort study in a nationwide, representative sample of 78 nursing home facilities in France. Residents who died from non-sudden causes between 1 October 2013 and 31 May 2014 in these facilities were included (n = 674). RESULTS end-of-life issues were discussed with at most 21.7% of the residents who died during the study period. In one-third of the situations (32.8%), no discussion about end-of-life-related topics ever occurred, either with the resident or with the relatives. Older people with severe dementia were less likely to have discussed more than three of the six end-of-life topics we investigated, compared with residents without dementia (OR = 0.17, 95% CI = 0.08-0.22). In the last month of life, discussing more than three end-of-life issues with the residents or their relatives was significantly associated with reduced odds of dying in a hospital facility (adjusted OR = 0.51, 95% CI = 0.33-0.79) and with a higher likelihood of withdrawing potentially futile life-prolonging treatments (adjusted OR = 2.37, 95% CI = 1.72-3.29). CONCLUSION during the last months of life, discussions about end-of-life issues occurred with only a minority of nursing home decedents, although these discussions may improve end-of-life care outcomes.
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Affiliation(s)
- Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden French National Observatory on End-of-Life Care, Paris, France
| | - Kristina Johnell
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Lieve Van den Block
- VUB-UGent End-of-Life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Régis Aubry
- French National Observatory on End-of-Life Care, Paris, France Department of Palliative Care, University Hospital of Besancon, Besançon, France
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50
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Pivodic L, Pardon K, Miccinesi G, Vega Alonso T, Moreels S, Donker GA, Arrieta E, Onwuteaka-Philipsen BD, Deliens L, Van den Block L. Hospitalisations at the end of life in four European countries: a population-based study via epidemiological surveillance networks. J Epidemiol Community Health 2015; 70:430-6. [DOI: 10.1136/jech-2015-206073] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/30/2015] [Indexed: 11/04/2022]
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