1
|
Hughes MC, Vernon E, Egwuonwu C, Afolabi O. Measuring decision aid effectiveness for end-of-life care: A systematic review. PEC INNOVATION 2024; 4:100273. [PMID: 38525314 PMCID: PMC10957449 DOI: 10.1016/j.pecinn.2024.100273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/26/2024] [Accepted: 03/11/2024] [Indexed: 03/26/2024]
Abstract
Objective To systematically review research analyzing the effectiveness of decision aids for end-of-life care, including how researchers specifically measure decision aid success. Methods We conducted a systematic review synthesizing quantitative, qualitative, and mixed-methods study results using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Four databases were searched through February 18, 2023. Inclusion criteria required articles to evaluate end-of-life care decision aids. The review is registered under PROSPERO (#CRD42023408449). Results A total of 715 articles were initially identified, with 43 meeting the inclusion criteria. Outcome measures identified included decisional conflict, less aggressive care desired, knowledge improvements, communication improvements, tool satisfaction, patient anxiety and well-being, and less aggressive care action completed. The majority of studies reported positive outcomes especially when the decision aid development included International Patient Decision Aid Standards. Conclusion Research examining end of life care decision aid use consistently reports positive outcomes. Innovation This review presents data that can guide the next generation of decision aids for end-of-life care, namely using the International Patient Decision Aid Standards in developing tools and showing which tools are effective for helping to prevent the unnecessary suffering that can result when patients' dying preferences are unknown.
Collapse
Affiliation(s)
- M. Courtney Hughes
- School of Health Studies, Northern Illinois University, Wirtz Hall 209, DeKalb, IL 60115, USA
| | - Erin Vernon
- Department of Economics, Seattle University, Pigott 522, Seattle, WA 98122, USA
| | - Chinenye Egwuonwu
- School of Health Studies, Northern Illinois University, Wirtz Hall 209, DeKalb, IL 60115, USA
| | - Oluwatoyosi Afolabi
- School of Health Studies, Northern Illinois University, Wirtz Hall 209, DeKalb, IL 60115, USA
| |
Collapse
|
2
|
Riley SR, Voisin C, Stevens EE, Bose-Brill S, Moss KO. Tools for tomorrow: a scoping review of patient-facing tools for advance care planning. Palliat Care Soc Pract 2024; 18:26323524241263108. [PMID: 39045292 PMCID: PMC11265253 DOI: 10.1177/26323524241263108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/03/2024] [Indexed: 07/25/2024] Open
Abstract
Advance care planning (ACP) supports individuals in aligning their medical care with personal values and preferences in the face of serious illness. The variety of ACP tools available reflects diverse strategies intended to facilitate these critical conversations, yet evaluations of their effectiveness often show mixed results. Following the Arskey and O'Malley framework, this scoping review aims to synthesize the range of ACP tools targeted at patients and families, highlighting their characteristics and delivery methods to better understand their impact and development over time. Studies included focused on patient-facing ACP tools across all settings and mediums. Exclusions were applied to studies solely targeting healthcare providers or those only aiming at completion of advance directives without broader ACP discussions. Searches were conducted across PubMed, Embase, CINAHL, The Cochrane Library, and Web of Science. Data were extracted using a predesigned spreadsheet, capturing study population, setting, intervention modality, and intervention theme. Tools were categorized by delivery method and further analyzed through a year-wise distribution to track trends and developments. We identified 99 unique patient-facing tools, with those focusing on counseling (31) and video technologies (21) being the most prevalent while others incorporated online platforms, print materials, games, or some combination of different delivery methods. Over half the tools were designed for specific patient groups, especially for various diseases and racial or ethnic communities. Recent years showed a surge in tool variety and innovation, including integrated patient portals and psychological techniques. The review demonstrates a broad array of innovative ACP tools that facilitate personalized and effective ACP. Our findings contribute to an enhanced understanding of their utilization and potential impacts, offering valuable insights for future tool development and policy making in ACP.
Collapse
Affiliation(s)
- Sean R. Riley
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus, OH 43215, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Christiane Voisin
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Erin E. Stevens
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- The James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Karen O. Moss
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Healthy Aging, Self-Management, and Complex Care, The Ohio State University College of Nursing, Columbus, OH, USA
| |
Collapse
|
3
|
Nouri S, Quinn M, Doyle BN, McKissack M, Johnson N, Wertz M, Tan C, Pantilat SZ, Lyles CR, Ritchie CS, Sudore RL. "We've Got to Bring Information to Where People Are Comfortable": Community-Based Advance Care Planning with the Black Community. J Gen Intern Med 2023; 38:2478-2485. [PMID: 36894819 PMCID: PMC9998020 DOI: 10.1007/s11606-023-08134-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/01/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND People identifying as Black/African American are less likely to engage in advance care planning (ACP) compared to their White peers, despite the association of ACP with improved patient and caregiver outcomes. OBJECTIVES Assess facilitators/barriers to ACP in the San Francisco (SF) Black community and co-design/implement/test community-based ACP pilot events. DESIGN Community-based participatory research, including qualitative research, intervention development, and implementation. PARTICIPANTS In partnership with the SF Palliative Care Workgroup (which includes health system, city, and community-based organizations), we formed an African American Advisory Committee (n = 13). We conducted 6 focus groups with Black older adults (age ≥ 55), caregivers, and community leaders (n = 29). The Advisory Committee then selected 5 community-based organizations through a widespread request for proposal. These community-based organizations designed and implemented community-based pilot events to support ACP engagement. MAIN MEASURES Two authors analyzed recorded focus group transcripts using thematic analysis. We assessed pre- vs post-event readiness to engage in ACP (validated ACP Engagement Survey; 1-4 scale, 4 = most ready) using Wilcoxon signed rank tests and assessed event acceptability with open-ended questions. KEY RESULTS Themes included the importance of ACP to the Black community (sub-themes: strengthens families; preserves dignity, particularly for sexual/gender minorities; is tied to financial planning) and facilitators for increasing ACP engagement (sub-themes: culturally relevant materials; events in trusted community spaces including Black-owned businesses). A total of 114 participants attended 5 events; 74% identified as Black, and 16% as sexual/gender minorities. Readiness to engage in ACP was similar pre- vs post-events; 98% would recommend the events to others. CONCLUSIONS Community-based ACP events designed and led by and for the Black community are highly acceptable. Novel insights underscored the importance of financial planning as part of ACP and the role of Black-owned businesses as trusted spaces for ACP-related discussions.
Collapse
Affiliation(s)
- Sarah Nouri
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Mara Quinn
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Natalya Johnson
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Molly Wertz
- Molly Wertz Consulting, San Francisco, CA, USA
| | - Charissa Tan
- John A. Burns School of Medicine, University of Hawai'I at Mānoa, Honolulu, HI, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Courtney R Lyles
- Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, USA
| |
Collapse
|
4
|
Diegelmann S, Bidmon S, Terlutter R. Promoting advance care planning via mediated health resources: A systematic mixed studies review. PATIENT EDUCATION AND COUNSELING 2022; 105:15-29. [PMID: 34144856 DOI: 10.1016/j.pec.2021.06.008] [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] [Received: 08/03/2020] [Revised: 05/05/2021] [Accepted: 06/07/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This systematic review aims (a) to analyze the message design of mediated advance care planning (ACP) interventions targeted at adults from a social marketing and health communication perspective, (b) to identify associations between message design and ACP outcomes, and (c) to illuminate gaps in the literature and highlight needs for future research. METHODS A systematic mixed studies review was conducted. Empirical articles on mediated ACP interventions were systematically searched by using nine scientific databases with keywords related to ACP and mediated health communication. Data were synthesized using a sequential explanatory approach. RESULTS A total of 11,824 titles were identified, of which 36 studies were included. Interventions disseminated ACP messages via video (36%), digital channels (22%), print (19%), a combination of channels (19%), and mass media (3%). The interventions used generic (42%), targeted (33%), and tailored (25%) communication. Overall, the evidence suggests that mediated ACP resources positively impact ACP Process and Action outcomes. CONCLUSION This study has shown that mediated ACP interventions use various contents, formats, and structures to influence patient-centered ACP outcomes. Most message design techniques were associated with positive ACP outcomes. PRACTICE IMPLICATIONS Mediated ACP resources are a promising approach to encourage ACP among adults.
Collapse
Affiliation(s)
- Svenja Diegelmann
- Alpen-Adria-Universität Klagenfurt, Department of Marketing and International Management, Universitätsstrasse 65-67, 9020 Klagenfurt, Austria.
| | - Sonja Bidmon
- Alpen-Adria-Universität Klagenfurt, Department of Marketing and International Management, Universitätsstrasse 65-67, 9020 Klagenfurt, Austria
| | - Ralf Terlutter
- Alpen-Adria-Universität Klagenfurt, Department of Marketing and International Management, Universitätsstrasse 65-67, 9020 Klagenfurt, Austria
| |
Collapse
|
5
|
Witteman HO, Vaisson G, Provencher T, Chipenda Dansokho S, Colquhoun H, Dugas M, Fagerlin A, Giguere AM, Haslett L, Hoffman A, Ivers NM, Légaré F, Trottier ME, Stacey D, Volk RJ, Renaud JS. An 11-Item Measure of User- and Human-Centered Design for Personal Health Tools (UCD-11): Development and Validation. J Med Internet Res 2021; 23:e15032. [PMID: 33724194 PMCID: PMC8074832 DOI: 10.2196/15032] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/27/2020] [Accepted: 10/03/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Researchers developing personal health tools employ a range of approaches to involve prospective users in design and development. OBJECTIVE The aim of this paper was to develop a validated measure of the human- or user-centeredness of design and development processes for personal health tools. METHODS We conducted a psychometric analysis of data from a previous systematic review of the design and development processes of 348 personal health tools. Using a conceptual framework of user-centered design, our team of patients, caregivers, health professionals, tool developers, and researchers analyzed how specific practices in tool design and development might be combined and used as a measure. We prioritized variables according to their importance within the conceptual framework and validated the resultant measure using principal component analysis with Varimax rotation, classical item analysis, and confirmatory factor analysis. RESULTS We retained 11 items in a 3-factor structure explaining 68% of the variance in the data. The Cronbach alpha was .72. Confirmatory factor analysis supported our hypothesis of a latent construct of user-centeredness. Items were whether or not: (1) patient, family, caregiver, or surrogate users were involved in the steps that help tool developers understand users or (2) develop a prototype, (3) asked their opinions, (4) observed using the tool or (5) involved in steps intended to evaluate the tool, (6) the process had 3 or more iterative cycles, (7) changes between cycles were explicitly reported, (8) health professionals were asked their opinion and (9) consulted before the first prototype was developed or (10) between initial and final prototypes, and (11) a panel of other experts was involved. CONCLUSIONS The User-Centered Design 11-item measure (UCD-11) may be used to quantitatively document the user/human-centeredness of design and development processes of patient-centered tools. By building an evidence base about such processes, we can help ensure that tools are adapted to people who will use them, rather than requiring people to adapt to tools.
Collapse
Affiliation(s)
- Holly O Witteman
- Université Laval, Quebec City, QC, Canada
- VITAM Research Centre for Sustainable Health, Quebec City, QC, Canada
- CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Gratianne Vaisson
- Université Laval, Quebec City, QC, Canada
- CHU de Québec-Université Laval, Quebec City, QC, Canada
| | | | | | | | - Michele Dugas
- Université Laval, Quebec City, QC, Canada
- VITAM Research Centre for Sustainable Health, Quebec City, QC, Canada
| | - Angela Fagerlin
- University of Utah, Salt Lake City, UT, United States
- Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance, Salt Lake City, UT, United States
| | - Anik Mc Giguere
- Université Laval, Quebec City, QC, Canada
- VITAM Research Centre for Sustainable Health, Quebec City, QC, Canada
| | - Lynne Haslett
- East End Community Health Centre, Toronto, ON, Canada
| | - Aubri Hoffman
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Noah M Ivers
- University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
| | - France Légaré
- Université Laval, Quebec City, QC, Canada
- VITAM Research Centre for Sustainable Health, Quebec City, QC, Canada
| | - Marie-Eve Trottier
- Université Laval, Quebec City, QC, Canada
- CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Dawn Stacey
- University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Robert J Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jean-Sébastien Renaud
- Université Laval, Quebec City, QC, Canada
- VITAM Research Centre for Sustainable Health, Quebec City, QC, Canada
| |
Collapse
|
6
|
Hart AS, Matthews AK. End-of-Life Interventions for African Americans With Serious Illness: A Scoping Review. J Hosp Palliat Nurs 2021; 23:9-19. [PMID: 33136802 DOI: 10.1097/njh.0000000000000706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Older African Americans (AAs) with serious illness experience disparities in advance care planning, access to palliative care and hospice, and decision-making at end of life. While culturally specific drivers of care outcomes have been identified, little has been done to standardize integration and application of targeted elements of end-of-life (EOL) interventions for AA populations. A scoping review was conducted to describe and evaluate the benefit of culturally targeted EOL interventions for AAs. A computerized search of empirical and gray literature was completed. Twelve full-text articles, 1 brief report, and 1 abstract describing a total of 14 EOL interventions for AAs with a range of serious illness were reviewed. Interventions were described relative to culturally targeted adaptations and resulting cognitive, emotional, and behavioral outcomes. Most interventions were theory-based and used psychoeducational approaches and interactive discussion and interviews. Significant improvements in psychological and behavioral outcomes were reported including knowledge and self-efficacy (n = 8); self-reported anxiety, depression, and/or well-being (n = 5); and advance care plan completion (n = 3). Few culturally tailored randomized controlled trials (n = 9) have been conducted. Preliminary results show promise for interventions using cultural adaptations. Culturally targeted intervention approaches are feasible to address EOL outcomes for AA patients and families experiencing serious illness.
Collapse
|
7
|
McDonnell J, Idler E. Promoting advance care planning in African American faith communities: literature review and assessment of church-based programs. Palliat Care Soc Pract 2020; 14:2632352420975780. [PMID: 33336189 PMCID: PMC7724408 DOI: 10.1177/2632352420975780] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 10/29/2020] [Indexed: 11/30/2022] Open
Abstract
Advance care planning is under-used among Black Americans, often because of
experiences of racism in the health care system, resulting in a lower quality of
care at the end of life. African American faith communities are trusted
institutions where such sensitive conversations may take place safely. Our
search of the literature identified five articles describing faith-based advance
care planning education initiatives for Black Americans that have been
implemented in local communities. We conducted a content analysis to identify
key themes related to the success of a program’s implementation and
sustainability. Our analysis showed that successful implementation of advance
care planning programs in Black American congregations reflected themes of
building capacity, using existing ministries, involving faith leadership,
exhibiting cultural competency, preserving a spiritual/Biblical context,
addressing health disparities, building trust, selectively using technology, and
fostering sustainability. We then evaluated five sets of well-known advance care
planning education program materials that are frequently used by pastors, family
caregivers, nurse’s aides, nurses, physicians, social workers, and chaplains
from a variety of religious traditions. We suggest ways these materials may be
tailored specifically for Black American faith communities, based on the key
themes identified in the literature on local faith-based advance care planning
initiatives for Black churches. Overall, the goal is to achieve better alignment
of advance care planning education materials with the African American faith
community and to increase implementation and success of advance care planning
education initiatives for all groups.
Collapse
|
8
|
van der Smissen D, Overbeek A, van Dulmen S, van Gemert-Pijnen L, van der Heide A, Rietjens JA, Korfage IJ. The Feasibility and Effectiveness of Web-Based Advance Care Planning Programs: Scoping Review. J Med Internet Res 2020; 22:e15578. [PMID: 32181750 PMCID: PMC7109619 DOI: 10.2196/15578] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/04/2019] [Accepted: 12/16/2019] [Indexed: 01/20/2023] Open
Abstract
Background Advance care planning (ACP) is a process with the overall aim to enhance care in concordance with patients’ preferences. Key elements of ACP are to enable persons to define goals and preferences for future medical treatment and care, to discuss these with family and health care professionals, and to document and review these if appropriate. ACP is usually conducted through personal conversations between a health care professional, a patient, and—if appropriate—family members. Although Web-based ACP programs have the potential to support patients in ACP, their effectiveness is unknown. Objective This study aimed to assess the feasibility and effectiveness of Web-based, interactive, and person-centered ACP programs. Methods We systematically searched for quantitative and qualitative studies evaluating Web-based, interactive, and person-centered ACP programs in seven databases including EMBASE, Web of Science, Cochrane Central and Google Scholar. Data on the characteristics of the ACP programs’ content (using a predefined list of 10 key elements of ACP), feasibility, and effectiveness were extracted using a predesigned form. Results Of 3434 titles and abstracts, 27 studies met the inclusion criteria, evaluating 11 Web-based ACP programs—10 were developed in the United States and one in Ireland. Studied populations ranged from healthy adults to patients with serious conditions. Programs typically contained the exploration of goals and values (8 programs), exploration of preferences for treatment and care (11 programs), guidance for communication about these preferences with health care professionals or relatives (10 programs), and the possibility to generate a document in which preferences can be recorded (8 programs). Reportedly, participants were satisfied with the ACP programs (11/11 studies), considering them as easy to use (8/8 studies) and not burdensome (7/8 studies). Designs of 13 studies allowed evaluating the effectiveness of five programs. They showed that ACP programs significantly increased ACP knowledge (8/8 studies), improved communication between patients and their relatives or health care professionals (6/6 studies), increased ACP documentation (6/6 studies), and improved concordance between care as preferred by the patients and the decisions of clinicians and health care representatives (2/3 studies). Conclusions Web-based, interactive, and person-centered ACP programs were mainly developed and evaluated in the United States. They contained the key elements of ACP, such as discussing and documenting goals and preferences for future care. As participants considered programs as easy to use and not burdensome, they appeared to be feasible. Among the 13 studies that measured the effectiveness of programs, improvement in ACP knowledge, communication, and documentation was reported. The concordance between preferred and received care is yet understudied. Studies with high-quality study designs in different health care settings are warranted to further establish the feasibility and effectiveness of Web-based ACP programs.
Collapse
Affiliation(s)
- Doris van der Smissen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Anouk Overbeek
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Criminal Law, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Sandra van Dulmen
- Nivel (Netherlands institute for health services research), Utrecht, Netherlands.,Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands.,Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Lisette van Gemert-Pijnen
- Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, Enschede, Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Judith Ac Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| |
Collapse
|
9
|
Green MJ, Van Scoy LJ, Foy AJ, Dimmock AEF, Lehman E, Levi BH. Patients With Advanced Cancer Choose Less Aggressive Medical Treatment on Vignettes After Using a Computer-Based Decision Aid. Am J Hosp Palliat Care 2019; 37:537-541. [PMID: 31830798 DOI: 10.1177/1049909119892596] [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: 12/13/2022] Open
Abstract
BACKGROUND Although patients often prefer less rather than more treatment at the end of life, in the absence of contrary instructions, the medical profession's de facto position is to treat aggressively. It is unknown whether a computer-based decision aid can affect treatment choices. METHODS Secondary analysis of a single-center, single-blind randomized controlled trial of an advance care planning (ACP) intervention among 200 patients with stage IV cancer. Participants were randomized to intervention (Making Your Wishes Known, a values-neutral, educational, computer-based decision aid) or control (standard living will + brochure). After reading a hypothetical clinical vignette, participants were asked whether they would want 11 medical/surgical treatments in that situation (dialysis, cardiopulmonary resuscitation [CPR], ventilator, feeding tube, etc). The median number of treatments wanted by participants was compared between groups, and logistic regression was used to compare between-group likelihood of not wanting each specific treatment. RESULTS The median number of treatments wanted was 1 in the intervention group versus 5 in the control (P < .001). For 6 of 11 treatments, the intervention group was significantly less likely than control to want aggressive treatment. Most notably, compared to control, intervention participants were less likely to want CPR (odds ratio [OR] = 0.31), short-term mechanical ventilation (OR = 0.34), short-term dialysis (OR = 0.38), surgery (OR = 0.37), and transfusion (OR = 0.21). CONCLUSIONS Individuals using an educational ACP decision aid were less likely to want aggressive medical treatment than those completing standard living wills. These findings have implications not only for how to respect patient's wishes but also potentially for reducing costs at the end of life.
Collapse
Affiliation(s)
- Michael J Green
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA.,Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA.,Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Andrew J Foy
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Anne E F Dimmock
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Erik Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| |
Collapse
|
10
|
Schubart JR, Levi BH, Bain MM, Farace E, Green MJ. Advance Care Planning Among Patients With Advanced Cancer. J Oncol Pract 2018; 15:e65-e73. [PMID: 30543761 DOI: 10.1200/jop.18.00044] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Advance directives (AD) have been heralded as vehicles to promote patient autonomy and have been decried as ineffective. Efforts to improve advance care planning (ACP) and AD documents are wide ranging but have not been prospectively studied. MATERIALS AND METHODS In an institutional review board-approved, single-blind, randomized, controlled trial, we compared an interactive, educational ACP decision aid to standard ACP among patients with advanced cancer. We hypothesized that use of the decision aid would increase physician awareness of patients' health care wishes and increase physician adherence to patients' end-of-life wishes compared with standard ACP. RESULTS A total of 200 patients were randomly assigned to two study arms. We analyzed data from medical records and interviews with physicians and family members for 121 patients who died by August 2016. No differences in physician awareness or adherence were found between the ACP decision aid and standard ACP groups. End-of-life treatment wishes and discussion of wishes were documented for 70% and 64% of the patients, respectively, but only 35% had an actual AD in the medical record. According to family members, end-of-life care was consistent with the patients' stated wishes 94% of the time. Similarly, according to physicians, it was consistent for 98%. However, according to AD documents, delivered care was consistent with desired care in only 65%. Considerably fewer patients than predicted died, and data from physicians were difficult to obtain. CONCLUSION ACP type did not influence documentation of patient wishes or end-of-life care received. Future prospective studies must account for challenges in prognostication and point-of-care data collection at the end of life.
Collapse
Affiliation(s)
- Jane R Schubart
- 1 The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Benjamin H Levi
- 1 The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Megan M Bain
- 1 The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Elana Farace
- 1 The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Michael J Green
- 1 The Pennsylvania State University, College of Medicine, Hershey, PA
| |
Collapse
|
11
|
Green MJ, Van Scoy LJ, Foy AJ, Stewart RR, Sampath R, Schubart JR, Lehman EB, Dimmock AEF, Bucher AM, Lehmann LS, Harlow AF, Yang C, Levi BH. A Randomized Controlled Trial of Strategies to Improve Family Members' Preparedness for Surrogate Decision-Making. Am J Hosp Palliat Care 2017; 35:866-874. [PMID: 29186982 DOI: 10.1177/1049909117744554] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate 2 strategies for preparing family members for surrogate decision-making. DESIGN A 2 × 2 factorial, randomized controlled trial testing whether: (1) comprehensive online advance care planning (ACP) is superior to basic ACP, and (2) having patients engage in ACP together with family members is superior to ACP done by patients alone. SETTING Tertiary care centers in Hershey, Pennsylvania, and Boston, Massachusetts. PARTICIPANTS Dyads of patients with advanced, severe illness (mean age 64; 46% female; 72% white) and family members who would be their surrogate decision-makers (mean age 56; 75% female; 75% white). INTERVENTIONS Basic ACP: state-approved online advance directive plus brochure. Making Your Wishes Known (MYWK): Comprehensive ACP decision aid including education and values clarification. MEASUREMENTS Pre-post changes in family member self-efficacy (100-point scale) and postintervention concordance between patients and family members using clinical vignettes. RESULTS A total 285 dyads enrolled; 267 patients and 267 family members completed measures. Baseline self-efficacy in both MYWK and basic ACP groups was high (90.2 and 90.1, respectively), and increased postintervention to 92.1 for MYWK ( P = .13) and 93.3 for basic ACP ( P = .004), with no between-group difference. Baseline self-efficacy in alone and together groups was also high (90.2 and 90.1, respectively), and increased to 92.6 for alone ( P = .03) and 92.8 for together ( P = .03), with no between-group difference. Overall adjusted concordance was higher in MYWK compared to basic ACP (85.2% vs 79.7%; P = .032), with no between-group difference. CONCLUSION The disconnect between confidence and performance raises questions about how to prepare family members to be surrogate decision-makers.
Collapse
Affiliation(s)
- Michael J Green
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Andrew J Foy
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,4 Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA, USA
| | - Renee R Stewart
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Ramya Sampath
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Jane R Schubart
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,6 Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Erik B Lehman
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Anne E F Dimmock
- 2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Ashley M Bucher
- 4 Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA, USA
| | - Lisa S Lehmann
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,7 National Center for Ethics in Health Care, Veterans Administration, Washington, DC, USA
| | - Alyssa F Harlow
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Chengwu Yang
- 8 Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York, NY, USA
| | - Benjamin H Levi
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,9 Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| |
Collapse
|
12
|
Levi BH, Simmons Z, Hanna C, Brothers A, Lehman E, Farace E, Bain M, Stewart R, Green MJ. Advance care planning for patients with amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2017. [PMID: 28631959 DOI: 10.1080/21678421.2017.1285317] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine whether an advance care planning (ACP) decision-aid could improve communication about end-of-life treatment wishes between patients with amyotrophic lateral sclerosis (ALS) and their clinicians. METHODS Forty-four patients with ALS (>21, English-speaking, without dementia) engaged in ACP using an interactive computer based decision-aid. Before participants completed the intervention, and again three months later, their clinicians reviewed three clinical vignettes, and made treatment decisions (n = 18) for patients. After patients indicated their agreement with the team's decisions, concordance was calculated. RESULTS The mean concordance between patient wishes and the clinical team decisions was significantly higher post-intervention (post = 91.9%, 95% CI = 87.8, 96.1, vs. pre = 52.4%, 95% CI = 41.9, 62.9; p <0.001). Clinical team members reported greater confidence that their decisions accurately represented each patient's wishes post-intervention (mean = 6.5) compared to pre-intervention (mean = 3.3, 1 = low, 10 = high, p <0.001). Patients reported high satisfaction (mean = 26.4, SD = 3.2; 6 = low, 30 = high) and low decisional conflict (mean = 28.8, SD = 8.2; 20 = low, 80 = high) with decisions about end-of-life care, and high satisfaction with the decision-aid (mean = 52.7, SD = 5.7, 20 = low, 60 = high). Patient knowledge regarding ACP increased post-intervention (pre = 47.8% correct responses vs. post = 66.3%; p <0.001) without adversely affecting patient anxiety or self-determination. CONCLUSION A computer based ACP decision-aid can significantly improve clinicians' understanding of ALS patients' wishes with regard to end-of-life medical care.
Collapse
Affiliation(s)
- Benjamin H Levi
- a Department of Humanities & Pediatrics , Penn State College of Medicine , Hershey , PA , USA
| | - Zachary Simmons
- b Department of Neurology , Penn State College of Medicine, ALS Clinic and Research Center , Hershey , PA , USA
| | | | - Allyson Brothers
- d Human Development and Family Studies , Colorado State University , Fort Collins , CO , USA
| | - Erik Lehman
- e Department of Public Health Sciences , Penn State College of Medicine , Hershey , PA , USA
| | - Elana Farace
- e Department of Public Health Sciences , Penn State College of Medicine , Hershey , PA , USA
| | - Megan Bain
- f Department of Humanities , Penn State College of Medicine , Hershey , PA , USA , and
| | - Renee Stewart
- f Department of Humanities , Penn State College of Medicine , Hershey , PA , USA , and
| | - Michael J Green
- g Department of Humanities & Medicine , Penn State College of Medicine , Hershey , PA , USA
| |
Collapse
|