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Hewitt J, Alsaba N, May K, Cartwright C, Willmott L, White BP, Marshall AP. The role of law in end-of-life decision-making in emergency departments and intensive care units: a retrospective review of current practice in a Queensland health service. AUST HEALTH REV 2024; 48:95-102. [PMID: 38081044 DOI: 10.1071/ah23160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/17/2023] [Indexed: 02/02/2024]
Abstract
Objective There is limited evidence about how legal frameworks that underpin end-of-life decisions are applied in practice. This study aimed to identify how end-of-life decisions are made and documented in emergency departments and intensive care units. The secondary aim was to explore the extent to which the legal processes featured in these decisions. Methods A retrospective chart audit of 85 adult patients who died in the emergency departments and intensive care units of a Queensland health service was undertaken. Quantitative data were analysed and reported using descriptive statistics. Qualitative textual data were analysed using inductive content analysis. Results Nearly all admissions were unplanned (97.6%), and most patients (74.1%) were admitted from home. Only one patient had an advance health directive, although all had an eligible substitute decision-maker. The qualitative analysis revealed two main concepts - 'healthcare professionals choreograph the end of life' and 'patients and families are carried on an unplanned journey'. Conclusions There was limited documentation related to the application of the legal framework in these decisions. Healthcare professionals relied on their clinical judgment about what was in the best interest of the patient. It was common for there to be a substantial effort to achieve consensus in decision-making which coincidently complied with the law.
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Affiliation(s)
- Jayne Hewitt
- School of Nursing and Midwifery, Griffith University, Gold Coast Campus, Parklands Drive, Southport, Qld 4222, Australia; and Griffith University, Law Futures Centre, Gold Coast Campus, Parklands Drive, Southport, Qld 4222, Australia; and Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia
| | - Nemat Alsaba
- Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia; and Faculty of Health Science and Medicine, Bond University, 14 University Drive, Robina, Qld 4226, Australia
| | - Katya May
- School of Nursing and Midwifery, Griffith University, Gold Coast Campus, Parklands Drive, Southport, Qld 4222, Australia; and Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia
| | - Colleen Cartwright
- Faculty of Health, Southern Cross University, Southern Cross Drive, Bilinga, Qld 4225, Australia
| | - Lindy Willmott
- Faculty of Business and Law, Queensland University of Technology, Gardens Point campus, 2 George Street, Brisbane, Qld 4000, Australia
| | - Ben P White
- Faculty of Business and Law, Queensland University of Technology, Gardens Point campus, 2 George Street, Brisbane, Qld 4000, Australia
| | - Andrea P Marshall
- School of Nursing and Midwifery, Griffith University, Gold Coast Campus, Parklands Drive, Southport, Qld 4222, Australia; and Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia
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Zacarias H, Marques JAL, Felizardo V, Pourvahab M, Garcia NM. ECG Forecasting System Based on Long Short-Term Memory. Bioengineering (Basel) 2024; 11:89. [PMID: 38247966 PMCID: PMC10813352 DOI: 10.3390/bioengineering11010089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/31/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024] Open
Abstract
Worldwide, cardiovascular diseases are some of the primary causes of death; yet the early detection and diagnosis of such diseases have the potential to save many lives. Technological means of detection are becoming increasingly essential and numerous techniques have been created for this purpose, such as forecasting. Of these techniques, the time series forecasting technique seeks to predict future events. The long-term time series forecasting of physiological data could assist medical professionals in predicting and treating patients based on very early diagnosis. This article presents a model that utilizes a deep learning technique to predict long-term ECG signals. The forecasting model can learn signals' nonlinearity, nonstationarity, and complexity based on a long short-term memory architecture. However, this is not a trivial task as the correct forecasting of a signal that closely resembles the original complex signal's structure and behavior while minimizing any differences in amplitude continues to pose challenges. To achieve this goal, we used a dataset available on the Physio net database, called MIT-BIH, with 48 ECG recordings of 30 min each. The developed model starts with pre-processing to reduce interference in the original signals, then applies a deep learning algorithm, based on a long short-term memory (LTSM) neural network with two hidden layers. Next, we applied the root mean square error (RMSE) and mean absolute error (MAE) metrics to evaluate the performance of the model and obtained an average RMSE of 0.0070±0.0028 and an average MAE of 0.0522±0.0098 across all simulations. The results indicate that the proposed LSTM model is a promising technique for ECG forecasting, considering the trends of the changes in the original data series, most notably in R-peak amplitude. Given the model's accuracy and the features of the physiological signals, the system could be used to improve existing predictive healthcare systems for cardiovascular monitoring.
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Affiliation(s)
- Henriques Zacarias
- Faculdade de Ciências de Saúde, Universidade da Beira Interior, 6201-001 Covilha, Portugal
- Instituto de Telecomunicacoes, 6201-001 Lisboa, Portugal; (V.F.); (N.M.G.)
- Instituto Politécnico da Huíla, Universidade Mandume Ya Ndemufayo, Lubango 1049-001, Angola
| | | | - Virginie Felizardo
- Instituto de Telecomunicacoes, 6201-001 Lisboa, Portugal; (V.F.); (N.M.G.)
- Departamento de Informática, Universidade da Beira Interior, 6201-001 Covilha, Portugal;
| | - Mehran Pourvahab
- Departamento de Informática, Universidade da Beira Interior, 6201-001 Covilha, Portugal;
| | - Nuno M. Garcia
- Instituto de Telecomunicacoes, 6201-001 Lisboa, Portugal; (V.F.); (N.M.G.)
- Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisboa, Portugal
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Quail P, Keller H, Vucea V, Heckman G, Sasan M, Boscart V, Ramsey C, Garland A. A Qualitative Study of Nursing Home Staff Lived Experience With Advance Care Planning. J Am Med Dir Assoc 2023; 24:1761-1766. [PMID: 37536660 DOI: 10.1016/j.jamda.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE Advance care planning (ACP) within nursing homes (NHs) is an integral component of resident-centered care yet remains an ongoing area for improvement. This study explored health care providers' experiences when facilitating ACP discussions with residents and their families. DESIGN Interpretive description was used to explore meanings and generate knowledge that is applicable for clinical contexts. SETTING AND PARTICIPANTS A purposive sample of 27 staff members (2 directors of care, 3 assistant directors of care, 1 nurse practitioner, 11 registered nurses, 3 registered practical nurses, and 7 social workers) from 29 NHs located across 3 Canadian provinces that participated in cluster-randomized intervention study to improve ACP. METHODS Semistructured interviews were conducted between January and July 2020. Interpretive description methods were used for analysis. RESULTS Three themes were identified. "Navigating Relational Tensions During ACP with Families" captures the relational tensions that participants experienced while navigating ACP processes with residents and their families. The second theme, "Where's the Doctor?" highlights the general lack of physician involvement in ACP discussions and the subsequent pressures faced by participants when supporting residents and families. The last theme, "Crises Change the Best Laid Plans," illustrates the challenges participants face when trying to adhere to existing care plans during residents' medical crises. CONCLUSION AND IMPLICATIONS Participants' experiences indicate that current ACP processes in NHs do not meet the needs of residents, families, or care teams. Additional support from physicians and changes to structural processes are needed to support resident-centered end-of-life planning within this care context.
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Affiliation(s)
- Patrick Quail
- Department of Family Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada.
| | - Heather Keller
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Vanessa Vucea
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - George Heckman
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Mehar Sasan
- McMaster University, Hamilton, Ontario, Canada
| | - Veronique Boscart
- Conestoga College, Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Clare Ramsey
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allan Garland
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Islam Z, Pollock K, Patterson A, Hanjari M, Wallace L, Mururajani I, Conroy S, Faull C. Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-135. [PMID: 37464868 DOI: 10.3310/jvfw4781] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background This study explored whether or not, and how, terminally ill patients from ethnically diverse backgrounds and their family caregivers think ahead about deterioration and dying, and explored their engagement with health-care professionals in end-of-life care planning. Objective The aim was to address the question, what are the barriers to and enablers of ethnically diverse patients, family caregivers and health-care professionals engaging in end-of-life care planning? Design This was a qualitative study comprising 18 longitudinal patient-centred case studies, interviews with 19 bereaved family caregivers and 50 public and professional stakeholder responses to the findings. Setting The study was set in Nottinghamshire and Leicestershire in the UK. Results Key barriers - the predominant stance of patients was to live with hope, considering the future only in terms of practical matters (wills and funerals), rather than the business of dying. For some, planning ahead was counter to their faith. Health-care professionals seemed to feature little in people's lives. Some participants indicated a lack of trust and experienced a disjointed system, devoid of due regard for them. However, religious and cultural mores were of great importance to many, and there were anxieties about how the system valued and enabled these. Family duty and community expectations were foregrounded in some accounts and concern about being in the (un)care of strangers was common. Key enablers - effective communication with trusted individuals, which enables patients to feel known and that their faith, family and community life are valued. Health-care professionals getting to 'know' the person is key. Stakeholder responses highlighted the need for development of Health-care professionals' confidence, skills and training, Using stories based on the study findings was seen as an effective way to support this. A number of behavioural change techniques were also identified. Limitations It was attempted to include a broad ethnic diversity in the sample, but the authors acknowledge that not all groups could be included. Conclusions What constitutes good end-of-life care is influenced by the intersectionality of diverse factors, including beliefs and culture. All people desire personalised, compassionate and holistic end-of-life care, and the current frameworks for good palliative care support this. However, health-care professionals need additional skills to navigate complex, sensitive communication and enquire about aspects of people's lives that may be unfamiliar. The challenge for health-care professionals and services is the delivery of holistic care and the range of skills that are required to do this. Future work Priorities for future research: How can health professionals identify if/when a patient is 'ready' for discussions about deterioration and dying? How can discussions about uncertain recovery and the need for decisions about treatment, especially resuscitation, be most effectively conducted in a crisis? How can professionals recognise and respond to the diversity of faith and cultural practices, and the heterogeneity between individuals of beliefs and preferences relating to the end of life? How can conversations be most effectively conducted when translation is required to enhance patient understanding? Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. X. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Zoebia Islam
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Anne Patterson
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Matilda Hanjari
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Louise Wallace
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
| | - Irfhan Mururajani
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Christina Faull
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
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van der Gaast K, Jansma JE, Wertheim-Heck S. Between ambitions and actions: how citizens navigate the entrepreneurial process of co-producing sustainable urban food futures. AGRICULTURE AND HUMAN VALUES 2023; 40:1-16. [PMID: 37359836 PMCID: PMC10088799 DOI: 10.1007/s10460-023-10425-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 06/28/2023]
Abstract
Cities increasingly envision sustainable future food systems. The realization of such futures is often understood from a planning perspective, leaving the role of entrepreneurship out of scope. The city of Almere in the Netherlands provides a telling example. In the neighborhood Almere Oosterwold, residents must use 50% of their plot for urban agriculture. The municipality formulated an ambition that over time, 10% off all food consumed in Almere must be produced in Oosterwold. In this study, we assume the development of urban agriculture in Oosterwold is an entrepreneurial process, i.e. a creative (re)organization that is ongoing and intervenes in daily life. To understand how this entrepreneurial process helps to realize sustainable food futures, this paper explores what futures for urban agriculture residents of Oosterwold prefer and deem possible and how these futures are organized in the present. We use futuring to explore possible and preferable images of the future, and to backcast those images to the present day. Our findings show residents have different perspectives of the future. Furthermore, they are capable in formulating specific actions to obtain the futures they prefer, but have trouble committing to the actions themselves. We argue this is the result of a temporal dissonance, a myopia where residents have trouble looking beyond their own situation. It shows imagined futures must fit with the lived experiences of citizens in order to be realized. We conclude that urban food futures need planning and entrepreneurship to be realized since they are complementary social processes.
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Affiliation(s)
- Koen van der Gaast
- Food and Healthy Living Group, Aeres University of Applied Sciences, Arboretum West 98, Almere, 1325 WB The Netherlands
- Urban Economics Group (UEC), Wageningen University and Research, Hollandseweg 1, Wageningen, 6706 KN The Netherlands
| | - Jan Eelco Jansma
- Food and Healthy Living Group, Aeres University of Applied Sciences, Arboretum West 98, Almere, 1325 WB The Netherlands
- Environmental Policy Group (ENP), Wageningen University and Research, Hollandseweg 1, Wageningen, 6706 KN The Netherlands
- Wageningen Plant Research, Wageningen University and Research, Edelhertweg 1, Lelystad, 8219 PH The Netherlands
| | - Sigrid Wertheim-Heck
- Food and Healthy Living Group, Aeres University of Applied Sciences, Arboretum West 98, Almere, 1325 WB The Netherlands
- Environmental Policy Group (ENP), Wageningen University and Research, Hollandseweg 1, Wageningen, 6706 KN The Netherlands
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Promoting advance care planning (ACP) in community health clinics in Israel: Perceptions of older adults with pro-ACP attitudes and their family physicians. Palliat Support Care 2023; 21:83-92. [PMID: 35109955 DOI: 10.1017/s1478951521001942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We examined barriers and facilitators to patient-family physician discussions in Israel about advance care planning, including preparation of an advance directive by adults over age 65, as part of a program in two community health clinics which afforded family physicians the opportunity to dedicate time to such discussions with patients. To the best of our knowledge, the program is the first of its kind in Israel. METHOD We used thematic analyses of qualitative data collected through 22 interviews with patients with pro-advanced care planning attitudes and three focus groups with eleven family physicians. RESULTS Overall, three themes in the interviews with patients and two themes in the focus groups with physicians emerged. The program gave people with pro-advanced care planning attitudes the opportunity to follow through with their ideas. We found that patients viewed their family physicians as facilitators and that the use of an information leaflet was an effective way to promote advance directives. Family physicians expressed positive attitudes toward assisting patients in the preparation of advance directives and welcomed an allotment of time for this endeavor as part of their schedule but expressed hesitation about assisting patients concerning legal and moral issues. SIGNIFICANCE OF RESULTS A pro-advanced care planning attitude is not enough for patients to complete the process of creating an advance directive; patients need active encouragement and intervention in order to turn their ideas into action. More patient and physician education are necessary to enable patients to protect their right to self-determination in end-of-life medical decision-making and to support physicians as facilitators of the process.
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Dube D, Sussman T, Brotman S, de Vries B, Gutman G. Advance Care Planning among Older Gay Men Living with HIV in Montreal, Canada: Challenges to Thinking and Talking about Future Care. JOURNAL OF HOMOSEXUALITY 2022; 69:756-772. [PMID: 33433307 DOI: 10.1080/00918369.2020.1855029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This qualitative study employed a cross sectional focus group design to explore how older gay men living with HIV, experience, perceive, and engage with advance care planning (ACP). Seven gay men 50+, residing in Montreal, Canada, participated in a focus group that was audio-recorded, transcribed, and thematically analyzed. Findings suggested that social isolation, preoccupations with day-to-day living, and managing disclosures related to sexual orientation and HIV status created barriers to these men's capacities to think about let alone talk about future care. These findings challenge current conceptualizations of ACP, which position reflection as an individual process that precedes allocating a decision-maker and communicating care preferences. Analyses further revealed that relational connections helped create a space where ACP could occur for participants. Hence, improving the uptake of ACP amongst older gay men with HIV may require interventions that embed such discussions into broader programs aimed at building support and community.
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Affiliation(s)
- Denis Dube
- School of Social Work, McGill University, Montreal, Quebec, Canada
| | - Tamara Sussman
- School of Social Work, McGill University, Montreal, Quebec, Canada
| | - Shari Brotman
- School of Social Work, McGill University, Montreal, Quebec, Canada
| | - Brian de Vries
- Department of Gerontology, San Francisco State University, San Francisco, California, USA
| | - Gloria Gutman
- Department of Gerontology, Simon Fraser University, Vancouver, British Columbia, Canada
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Sellen K, McGovern M, MacGregor E, Halleran L, Ly L. The Time Moving exhibit: Exploring perceptions of time in end-of-life experiences. Health Expect 2022; 25:558-566. [PMID: 35032410 PMCID: PMC8957742 DOI: 10.1111/hex.13379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 09/15/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Conversations about end of life rarely take place beyond healthcare spaces and in advance of imminent death. As the Canadian ageing population increases and new policies and options emerge for end-of-life choices, there will be an increasing need for supports for decision-making on end of life. Time Moving was a participatory art exhibit created to engage participants in reflections on end-of-life experiences and the ways in which their perception of time fluctuated within these moments. DESIGN A participatory and constructivist approach informed decisions on exhibit design and analysis. The Time Moving exhibit was installed in a downtown university hall for 10 days during the 2019 annual DesignTO festival, open to all members of the public. The exhibit was used as the primary method of data collection. There were three prompts informed by concepts from prior work on time perception. Participants were invited to respond by drawing, writing or constructing. OUTCOME There were over 120 contributions of participants over the duration of the Time Moving exhibit. These contributions revealed new insights related to temporal perception and end-of-life experiences. Participants shared their perception of time during end-of-life experiences in a variety of ways, revealing a diversity of perceptions of time beyond calendar and clock time, including time experienced as a spiral. CONCLUSIONS The insights on time perception highlight opportunities for approaching dialogue on end of life and in grief support, and for exhibit as a mechanism for research and education. PATIENT OR PUBLIC CONTRIBUTION As a public exhibit, over 120 people contributed ideas, personal stories, drawings and other creative outputs to the exhibit. An estimated 250 people visited the exhibit.
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Affiliation(s)
- Kate Sellen
- Health Design Studio, OCAD University, Toronto, Ontario, Canada
| | - Molly McGovern
- Health Design Studio, OCAD University, Toronto, Ontario, Canada
| | - Emma MacGregor
- Health Design Studio, OCAD University, Toronto, Ontario, Canada
| | - Laura Halleran
- Health Design Studio, OCAD University, Toronto, Ontario, Canada
| | - Lawrence Ly
- Health Design Studio, OCAD University, Toronto, Ontario, Canada
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Lemos Dekker N, Bolt SR. Relating to the end of life through advance care planning: Expectations and experiences of people with dementia and their family caregivers. DEMENTIA 2022; 21:918-933. [PMID: 34978465 PMCID: PMC8996290 DOI: 10.1177/14713012211066370] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Dementia is widely considered a progressive condition associated with changes in
cognitive capacities, which promotes the idea that people with dementia need to
anticipate end-of-life care preferences. There is a growing body of interventions meant
to support advance care planning (ACP) for people with dementia and their families.
However, a deeper understanding of their experiences and expectations regarding planning
the end of life is needed to inform ethically sound and person-centered ACP. This study
explores how end-of-life care planning for people with dementia is experienced and
perceived in practice. Methods We conducted a secondary analysis of qualitative data from in-depth interviews and
ethnographic fieldwork. Participants included people with dementia living in the
community or in nursing homes, family caregivers, and professional caregivers. During
reflective sessions, the researchers moved back and forth between their original data
and overarching topics related to ACP. Both performed deductive coding to filter
relevant information from their data. Ongoing discussions allowed for the fine-tuning of
themes. Results End-of-life care planning for people with dementia can encompass a paradox of control.
While it may foster a sense of being in control, it may also feel like relinquishing
control over future situations. It raises concerns regarding responsibility, as present,
former and future wishes may not align. Family caregivers are often responsible for
concrete end-of-life decision-making, prompting them to weigh previous wishes against
present situations. Further, people with dementia may wish to focus on the present and
distance themselves from the future. Discussion Advance decisions about end-of-life care are often decontextualized and people may find
it difficult to oversee their future conditions and preferences. The widely recognized
purpose of ACP to exert control over end-of-life care may need revision to match the
needs of people with dementia while they are coping with their condition and an
uncertain future.
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Affiliation(s)
- Natashe Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Leiden, the Netherlands
| | - Sascha R Bolt
- TRANZO Tilburg School of Social and Behavioral Sciences, Tilburg University;, Tilburg, the Netherlands Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Living Lab in Ageing and Long-Term Care, 5211Maastricht University, Maastricht, the Netherlands
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Jia Z, Yeh IM, Lee CH, Yeung AS, Tulsky JA, Leiter RE. Barriers and Facilitators to Advance Care Planning among Chinese Patients with Advanced Cancer and Their Caregivers. J Palliat Med 2021; 25:774-782. [PMID: 34847732 DOI: 10.1089/jpm.2021.0404] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: Chinese American adults experience health disparities at the end of life. Culturally tailored advance care planning (ACP) may promote goal-concordant care across the continuum of serious illness. However, seriously ill Chinese Americans' preferences for ACP remain unknown. Objective: To explore barriers and facilitators to ACP among Chinese patients with advanced cancer and their caregivers. Design: Informed by socioecological theory, we conducted an exploratory qualitative study using semistructured interviews that were thematically analyzed. Setting/Participants: We recruited participants at one U.S. comprehensive cancer center. Of 27 eligible patients approached, we recruited 20 patients (74.1%) and 8 accompanying caregivers. Overall, participants were middle aged (55.6 ± 13.5 years), 60.7% female, 85.7% partnered/married, 89.3% college educated, and had low acculturation (mean Suinn-Lew Asian Self-Identify Acculturation = 2.0 ± 1.6/5.0). More patients were privately insured (35%) than self-pay (30%), Medicare (25%), and Medicaid (10%). Caregivers were split between "spouse" and "child." Results: Findings highlight participants' trust in their clinicians and the study institution as primary supports for clinicians to lead ACP. However, participants' preconceptions of clinicians' professional responsibilities and participants' belief in an uncertain future may hinder an open discussion of goals and values for future medical care. A key moderating factor in how participants view ACP may be their level of acculturation to local care, behavioral, and communication norms. Conclusions: Chinese patients may prefer a routinized clinician-led ACP approach that supports their actionable priorities in the present by leveraging patient-clinician trust, gauging acculturation level, and using indirect communication strategies. Future studies should investigate preferred communication strategies to support in-the-moment care planning.
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Affiliation(s)
- Zhimeng Jia
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Irene M Yeh
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | | | - Albert S Yeung
- Harvard Medical School, Boston, Massachusetts, USA.,Depression Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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11
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Sinclair C, Sellars M, Buck K, Detering KM, White BP, Nolte L. Association Between Region of Birth and Advance Care Planning Documentation Among Older Australian Migrant Communities: A Multicenter Audit Study. J Gerontol B Psychol Sci Soc Sci 2021; 76:109-120. [PMID: 32803263 PMCID: PMC7756686 DOI: 10.1093/geronb/gbaa127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives This study explored associations between birth region, sociodemographic predictors, and advance care planning (ACP) uptake. Methods A prospective, multicenter, cross-sectional audit study of 100 sites across 8 Australian jurisdictions. ACP documentation was audited in the health records of people aged 65 years or older accessing general practice (GP), hospital, and long-term care facility (LTCF) settings. Advance care directives (ACDs) completed by the person (“person completed ACDs”) and ACP documents completed by a health professional or other person (“health professional or someone else ACP”) were counted. Hierarchical multilevel logistic regression assessed associations with birth region. Results From 4,187 audited records, 30.0% (1,152/3,839) were born outside Australia. “Person completed ACDs” were less common among those born outside Australia (21.9% vs 28.9%, X2 (1, N = 3,840) = 20.3, p < .001), while “health professional or someone else ACP” was more common among those born outside Australia (46.4% vs 34.8%, X2 (1, N = 3,840) = 45.5, p < .001). Strongest associations were found for those born in Southern Europe: “person completed ACD” (odds ratio [OR] = 0.56, 95% confidence interval [CI] = 0.36–0.88), and “health professional or someone else ACP” (OR = 1.41, 95% CI = 1.01–1.98). English-language proficiency and increased age significantly predicted both ACP outcomes. Discussion Region of birth is associated with the rate and type of ACP uptake for some older Australians. Approaches to ACP should facilitate access to interpreters and be sensitive to diverse preferences for individual and family involvement in ACP.
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Affiliation(s)
- Craig Sinclair
- School of Psychology, University of New South Wales, Sydney, Australia.,Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney, Australia.,Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Marcus Sellars
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.,Australian Centre for Health Research Law, Faculty of Law, Queensland University of Technology, Brisbane, Australia
| | - Kimberly Buck
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Karen M Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Ben P White
- Australian Centre for Health Research Law, Faculty of Law, Queensland University of Technology, Brisbane, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
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12
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Carter C, Mohammed S, Upshur R, Kontos P. Biomedicalization of end-of-life conversations with medically frail older adults - Malleable and senescent bodies. Soc Sci Med 2020; 291:113428. [PMID: 34756384 DOI: 10.1016/j.socscimed.2020.113428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 11/15/2022]
Abstract
The common practice of delaying and/or avoiding end-of-life conversations with medically frail older adults is an important clinical issue. Most research investigating this practice focuses on clinician training and developing conversation skills. Little is known about the socio-political factors shaping the phenomenon of end-of-life conversations between clinicians and medically frail older patients. Using the critical lens of biomedicalization we consider how two dominant discourses, successful aging and frailty, and subsequent constructions of bodies as malleable or senescent, shape patient subjectivities and influence normative expectations about appropriate healthcare conversations and the consumption of biomedicine for medically frail adults. We highlight the uneven ways medically frail older adults are clinically positioned as successful or frail agers and briefly discuss how gender, class, and race may impact this tension and ambiguity. We conclude by arguing that end-of-life conversations with medically frail older adults is constrained by the pervasiveness of the successful aging discourse and the tendency within medical institutions to construct older bodies as malleable and in need of medical intervention to promote health and longevity.
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Affiliation(s)
- Celina Carter
- Dalla Lana School of Public Health, University of Toronto, 550 College St, Toronto, ON, M6G 1B1, Canada.
| | - Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada
| | - Ross Upshur
- Dalla Lana School of Public Health, University of Toronto, Canada
| | - Pia Kontos
- Dalla Lana School of Public Health, University of Toronto, Canada; KITE-Toronto Rehabilitation Institute, University Health Network, Canada
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13
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Jia Z, Leiter RE, Yeh IM, Tulsky JA, Sanders JJ. Toward Culturally Tailored Advance Care Planning for the Chinese Diaspora: An Integrative Systematic Review. J Palliat Med 2020; 23:1662-1677. [PMID: 32991239 DOI: 10.1089/jpm.2020.0330] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: The Chinese diaspora experiences disparate end-of-life (EOL) care outcomes. Advance care planning (ACP) may be an effective intervention to improve EOL care, but its reception and uptake in the Chinese diaspora are unknown. Objective: Review and synthesize current literature to develop a culturally tailored ACP framework for the Chinese diaspora. Design: A systematic integrative review framed by Whittemore and Knafl's method was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Data Sources: PubMed, Embase, CINAHL, Web of Science, Cochrane Library, and University of York Center for Reviews and Dissemination were systematically searched for articles published before February 2020. All English, peer-reviewed quantitative, qualitative, and mixed-method literature studying ACP in Chinese adults living outside China and Taiwan were included. A mixed-method appraisal tool was utilized for quality assessment. Results: The search yielded 836 unique articles, from which we included 30. Integrative synthesis resulted in a novel framework to guide culturally tailored ACP among the Chinese diaspora. The framework highlights the importance of an authority-initiated, indirect approach to ACP that maximizes individual and collective harmony. Furthermore, due to evolving sociodemographic and acculturation factors, the perception of harmony may differ between individuals and generations. Conclusion: The Chinese diaspora population is willing to engage in ACP. An individualized, culturally sensitive approach that captures and maximizes harmony will be central to the success of ACP in this population. Further work is required to understand the influence of serious illness, spirituality, and family on ACP.
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Affiliation(s)
- Zhimeng Jia
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Irene M Yeh
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Justin J Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Ariadne Labs, Boston, Massachusetts, USA
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14
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Henke C, Mroz E, Le NA, Gregory HM, Ghiaseddin A, McFarland NR, Baron-Lee J. Introducing a Supportive Care Team for Advance Directive Education in a Neurological and Neurosurgical Patient Population. J Patient Exp 2020; 7:1286-1293. [PMID: 33457577 PMCID: PMC7786676 DOI: 10.1177/2374373520932449] [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] [Indexed: 12/12/2022] Open
Abstract
Background: Patient-centered care includes delineation of patient treatment values (ie, advance care planning [ACP]). Advance care planning often includes advance directive (AD) completion and is underutilized, particularly among neurology and neurosurgery patients. Implementation of a supportive care team (SCT) in outpatient clinic settings may offer opportunities for AD education and completion. Objective: This study assesses the effectiveness of an integrative SCT composed of hospice volunteers and undergraduate quality improvement interns in their efforts to provide ACP education in neurological and neurosurgical outpatient clinics. Assessment includes a description of different types of SCT-patient encounters, as well as patient interest in and completion of ADs after interacting with the SCT. Results: Across the data collection period, 2770 encounters were initiated. The majority of encounters resulted in patient ACP education. Some patients completed ADs during their SCT encounter (3.45%) or after their SCT encounter (10.18%). Conclusion: The SCT effectively enhances ACP education in this patient population. The utilization of trained interns to assist with ACP is beneficial and practical in clinic workflow.
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Affiliation(s)
- Charlotte Henke
- Department of Neurology, University of Florida, Gainesville, FL, USA.,These authors contributed equally to this work
| | - Emily Mroz
- Department of Neurology, University of Florida, Gainesville, FL, USA.,Department of Psychology, University of Florida, Gainesville, FL, USA.,These authors contributed equally to this work
| | - Ngoc Anh Le
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Hannah M Gregory
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Ashley Ghiaseddin
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Nikolaus R McFarland
- Department of Neurology, University of Florida, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
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15
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Mroz E, Bluck S, Smith K. Young adults' perspectives on advance care planning: Evaluating the Death over Dinner initiative. DEATH STUDIES 2020; 46:381-390. [PMID: 32098575 DOI: 10.1080/07481187.2020.1731015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We investigated how death attitudes and experience relate to perspectives on advance care planning (ACP) in young adulthood, and whether attending a Death over Dinner event affects perspectives on ACP. Participants (N = 109) were assigned to a Death over Dinner or waitlist control condition, completing pretest and post-test measures. Higher Death Rejection and having more Experience with Death predicted Reservations about ACP. Participation in a Death over Dinner decreased Reservations toward ACP compared to the control group. Death over Dinner appears to be useful in ameliorating reservations toward ACP without shortening individuals' sense of their time left to live.
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Affiliation(s)
- Emily Mroz
- Department of Psychology, Life Story Lab, University of Florida, Gainesville, Florida, USA
| | - Susan Bluck
- Department of Psychology, Life Story Lab, University of Florida, Gainesville, Florida, USA
| | - Krista Smith
- Department of Psychology, Life Story Lab, University of Florida, Gainesville, Florida, USA
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16
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Zivkovic T. About face: Relationalities of ageing and dying in Chinese migrant families. Soc Sci Med 2020; 291:112827. [DOI: 10.1016/j.socscimed.2020.112827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 01/20/2020] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
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17
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Zivkovic T. Lifelines and End-of-life Decision-making: An Anthropological Analysis of Advance Care Directives in Cross-cultural Contexts. ETHNOS 2019. [DOI: 10.1080/00141844.2019.1696857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Maffoni M, Argentero P, Giorgi I, Giardini A. Healthcare professionals' perceptions about the Italian law on advance directives. Nurs Ethics 2019; 27:796-808. [PMID: 31631774 DOI: 10.1177/0969733019878831] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the variegated legislative framework on advance directives, the first specific regulation in Italy on this issue came into force only in 2018. RESEARCH OBJECTIVE This qualitative study aimed to investigate the implications of the new Italian law on advance directives in clinical practice from the perspective of those who deal with this delicate ethical issue on an everyday basis, that is, Italian healthcare professionals. RESEARCH DESIGN A qualitative research design using semi-structured audio-recorded interviews was adopted. The data collection and analysis were performed according to the Grounded Theory approach. PARTICIPANTS Nineteen healthcare professionals (16 nurses, 3 physicians) working in a palliative care unit of a research and clinical institute in Italy. ETHICAL CONSIDERATIONS The study is part of the WeDistress HELL Project (WEllness and DISTRESS in HEalth care professionals dealing with end of Life and bioethicaL issues) approved by the Ethical Committee of ICS Maugeri - Institute of Pavia (Italy). FINDINGS The authors identified a main overall category, 'Pros and Cons of the Italian law on advance directives', composed of six constituent categories: Positive welcome, Self-determination and protection, Prompts for future betterment, Uncertainties, Lack of knowledge, and Neutrality and no suggestions. DISCUSSION The Italian law n. 219/2017 on advance directives was seen as a legal instrument possessing both strengths and weaknesses, but able to guarantee the patient's self-determination and support healthcare professionals in providing care according to patients' wishes. CONCLUSION An understanding of the healthcare providers' perspective may support the discussion on advance directives and bridge the gaps that currently persist in handling ethical issues.
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Affiliation(s)
- Marina Maffoni
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Ines Giorgi
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit - Institute of Pavia, Italy
| | - Anna Giardini
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit - Institute of Montescano, Italy
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