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Ban JW, Perera R, Williams V. Influence of research evidence on the use of cardiovascular clinical prediction rules in primary care: an exploratory qualitative interview study. BMC PRIMARY CARE 2023; 24:194. [PMID: 37730553 PMCID: PMC10512575 DOI: 10.1186/s12875-023-02155-w] [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: 07/04/2022] [Accepted: 09/06/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Cardiovascular clinical prediction rules (CPRs) are widely used in primary care. They accumulate research evidence through derivation, external validation, and impact studies. However, existing knowledge about the influence of research evidence on the use of CPRs is limited. Therefore, we explored how primary care clinicians' perceptions of and experiences with research influence their use of cardiovascular CPRs. METHODS We conducted an exploratory qualitative interview study with thematic analysis. Primary care clinicians were recruited from the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region Practice and Research Network (WPRN). We used purposeful sampling to ensure maximum variation within the participant group. Data were collected by conducting semi-structured online interviews. We analyzed data using inductive thematic analysis to identify commonalities and differences within themes. RESULTS Of 29 primary care clinicians who completed the questionnaire, 15 participated in the interview. We identified two main themes relating to the influence of clinicians' perceptions of and experiences with cardiovascular CPR research on their decisions about using cardiovascular CPRs: "Seek and judge" and "be acquainted and assume." When clinicians are familiar with, trust, and feel confident in using research evidence, they might actively search and assess the evidence, which may then influence their decisions about using cardiovascular CPRs. However, clinicians, who are unfamiliar with, distrust, or find it challenging to use research evidence, might be passively acquainted with evidence but do not make their own judgment on the trustworthiness of such evidence. Therefore, these clinicians might not rely on research evidence when making decisions about using cardiovascular CPRs. CONCLUSIONS Clinicians' perceptions and experiences could influence how they use research evidence in decisions about using cardiovascular CPRs. This implies, when promoting evidence-based decisions, it might be useful to target clinicians' unfamiliarity, distrust, and challenges regarding the use of research evidence rather than focusing only on their knowledge and skills. Further, because clinicians often rely on evidence-unrelated factors, guideline developers and policymakers should recommend cardiovascular CPRs supported by high-quality evidence.
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Affiliation(s)
- Jong- Wook Ban
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK.
- Department for Continuing Education, University of Oxford, Oxford, UK.
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Pitman S, Mason N, Cardona M, Lewis E, O'Shea M, Flood J, Kirk M, Seymour J, Duncan A. Triggering palliative care referrals through the identification of poor prognosis in older patients presented to emergency departments in rural Australia. Int J Palliat Nurs 2023; 29:83-90. [PMID: 36822616 DOI: 10.12968/ijpn.2023.29.2.83] [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: 02/25/2023]
Abstract
Background: Without objective screening for risk of death, the palliative care needs of older patients near the end of life may be unrecognised and unmet. Aim: This study aimed to estimate the usefulness of the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) tool in determining older patients' risk of death within 3-months after initial hospital admission. Methods: A prospective cohort study of 235 patients aged 70+ years, who presented to two rural emergency departments in two adjacent Australian states, was utilised. The 'risk of death' of each patient was screened with the CriSTAL prognostic tool. Their 3-month follow-up outcomes were assessed through telephone interviews and a clinical record review. Findings: A CriSTAL cut-off score of more than 7 yielded a sensitivity of 80.7% and specificity of 70.81% for a 3-month risk of death. Palliative care services were only used by 31% of the deceased in their last trimester of life. Conclusion: Prognostic tools provide a viable means of identifying individuals with a poor prognosis. Identification can trigger an earlier referral to palliative care, which will benefit the patient's wellbeing and quality of life.
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Affiliation(s)
| | - Naomi Mason
- Social Worker, Wodonga Community Palliative Care; Albury Wodonga Health, Australia
| | | | - Ebony Lewis
- Associate Lecturer, University of New South Wales, Australia
| | - Michael O'Shea
- Clinical Nurse Consultant, Albury Wodonga Health, Australia
| | | | - Mindy Kirk
- Social Worker, Albury Wodonga Health, Australia
| | | | - Anne Duncan
- Nurse Practitioner, Albury Wodonga Health, Australia
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Timmons S, Fox S. Palliative care for people with dementia. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:81-105. [PMID: 36599517 DOI: 10.1016/b978-0-12-824535-4.00013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Dementia is the most common neurologic disease, affecting approximately 55 million people worldwide. Dementia is a terminal illness, although not always recognized as such. This chapter discusses the key issues in providing palliative care for people with living with dementia and their families. Common palliative care needs and symptoms are presented, including psychosocial, physical, emotional, and spiritual, and the need to actively anticipate and seek symptoms according to the dementia type and stage is emphasized. Families are hugely impacted by a dementia diagnosis, and throughout this chapter, they are considered in the unit of care, and also as a member of the care team. Multiple challenges particular to dementia palliative care are highlighted throughout, such as the lack of timely dementia diagnoses, difficulty with symptom prognostication, the person's inability to verbally express their symptoms and care preferences, and a low threshold for medication side effects. Finally, service models for dementia palliative care in community, residential, and acute hospital settings are discussed, along with the evidence for each. Overall, this chapter reinforces that the individual needs of the person living with dementia and their family must be considered to provide person-centered and comprehensive palliative care, enabling them to live well until death.
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Affiliation(s)
- Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland; Department of Geriatric Medicine, Mercy University Hospital & St. Finbarr's Hospital, Cork, Ireland.
| | - Siobhan Fox
- Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
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Green G, Halevi Hochwald I, Radomyslsky Z, Nissanholtz-Gannot R. Family Caregiver's Depression, Confidence, Satisfaction, and Burden Regarding End-of-Life Home Care for People With End-Stage Dementia. OMEGA-JOURNAL OF DEATH AND DYING 2022:302228221147961. [PMID: 36573833 DOI: 10.1177/00302228221147961] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
To detect differences between two care services units: regarding family-caregiver (FC) depression, perceived-burden and confidence in the provision of care to people with end-stage dementia (PWESD); examine predictors such as FC age, depression, confidence in the provision of care to PWESD and satisfaction with the community-home-care service to burden; and explore a mediation model.The participants were 139 FC, caring for PWESD living at home. The questionnaire was composed of FC background characteristics, perceived-burden, satisfaction with the community-home-care services, depression, and confidence in the provision of care to the PWESD. HCUs' FC felt significantly more burdened than HHUs' FC. Furthermore, satisfaction with the community-home-care services mediated the relationship between FC confidence in the provision of care to the PWESD and FC burden. The study results may affect the development of end-of-life care policies and services which meet the needs of PWESD and their FC.
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Affiliation(s)
- Gizell Green
- School of Nursing, Ariel University, Ariel, Israel
| | | | - Zorian Radomyslsky
- Maccabi Healthcare Services, Tel-Aviv, Israel
- School of Health Sciences, Ariel University, Ariel, Israel
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Halevi Hochwald I, Arieli D, Radomyslsky Z, Danon Y, Nissanholtz-Gannot R. Emotion work and feeling rules: Coping strategies of family caregivers of people with end stage dementia in Israel-A qualitative study. DEMENTIA 2022; 21:1154-1172. [PMID: 35130758 PMCID: PMC9189436 DOI: 10.1177/14713012211069732] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background End stage dementia is an inevitable phase following a prolonged deterioration. Family
caregivers for people with end stage dementia who live in their home can experience an
emotional burden. Emotion work and “feeling-rules” refers to socially shared norms and
self-management of feelings, as well as projecting emotions appropriate for the
situation, aiming at achieving a positive environment as a resource for supporting
others’ wellbeing. Objectives Exploring and describing the experience of family caregivers of people with end stage
dementia at home, in Israel, unpacking their emotional coping and the
emotional-strategies they use, and placing family caregivers' emotion work in a cultural
context. Method We conducted fifty qualitative interviews using semi structured interviews analyzed
through a thematic content analysis approach. Findings Four characteristics of emotion work were identified: (1) sliding between detachment
and engagement, (2) separating the person from their condition (3), adoption of
caregiving as a social role and a type of social reinforcement, and (4) using the
caregiving role in coping with loneliness and emptiness. The emotional coping strategies
are culturally contextualized, since they are influenced by the participants’ cultural
background. Discussion This article’s focus is transparent family caregivers' emotion work, a topic which has
rarely been discussed in the literature is the context of caring for a family member
with dementia at home. In our study, emotion work appears as a twofold concept: the
emotion work by itself contributed to the burden, since family caregivers' burden
experience can evolve from the dissonance between their “true” feelings of anger and
frustration and their expected “acceptable” feelings (“feeling-rules”) formed by
cultural norms. However, emotion work was also a major source of coping and finding
strength and self-meaning. Understanding and recognizing the emotion work and the
cultural and religious influence in this coping mechanism can help professionals who
treat people with end stage dementia to better support family-caregivers.
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Affiliation(s)
- Inbal Halevi Hochwald
- Department of health systems management, Ariel University, Ariel, Israel; School of Nursing, Max Stern Yezreel Valley College, Israel
| | - Daniella Arieli
- School of Nursing, Max Stern Yezreel Valley, Israel; Department of Sociology and Anthropology, Max Stern Yezreel Valley College, Israel
| | - Zorian Radomyslsky
- Department of health systems management, Ariel University, Ariel, Israel; Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Yehuda Danon
- Department of health systems management, 42732Ariel University, Ariel, Israel
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van Eenennaam RM, Koppenol LS, Kruithof WJ, Kruitwagen-van Reenen ET, Pieters S, van Es MA, van den Berg LH, Visser-Meily JMA, Beelen A. Discussing Personalized Prognosis Empowers Patients with Amyotrophic Lateral Sclerosis to Regain Control over Their Future: A Qualitative Study. Brain Sci 2021; 11:brainsci11121597. [PMID: 34942899 PMCID: PMC8699408 DOI: 10.3390/brainsci11121597] [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: 10/19/2021] [Revised: 11/22/2021] [Accepted: 11/26/2021] [Indexed: 11/26/2022] Open
Abstract
The ENCALS survival prediction model offers patients with amyotrophic lateral sclerosis (ALS) the opportunity to receive a personalized prognosis of survival at the time of diagnosis. We explored experiences of patients with ALS, caregivers, and physicians with discussing personalized prognosis through interviews with patients and their caregivers, and in a focus group of physicians. Thematic analysis revealed four themes with seven subthemes; these were recognized by the focus group. First, tailored communication: physician’s communication style and information provision mediated emotional impact and increased satisfaction with communication. Second, personal factors: coping style, illness experiences, and information needs affected patient and caregiver coping with the prognosis. Third, emotional impact ranged from happy and reassuring to regret. Fourth, regaining control over the future: participants found it helpful in looking towards the future, and emphasized the importance of quality over quantity of life. Personalized prognosis can be discussed with minimal adverse emotional impact. How it is communicated—i.e., tailored to individual needs—is as important as what is communicated—i.e., a good or poor prognosis. Discussing personalized prognosis may help patients with ALS and their caregivers regain control over the future and facilitate planning of the future (care). For many patients, quality of life matters more than quantity of time remaining.
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Affiliation(s)
- Remko M. van Eenennaam
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands; (R.M.v.E.); (L.S.K.); (W.J.K.); (E.T.K.-v.R.); (J.M.A.V.-M.)
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, 3508 GA Utrecht, The Netherlands
| | - Loulou S. Koppenol
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands; (R.M.v.E.); (L.S.K.); (W.J.K.); (E.T.K.-v.R.); (J.M.A.V.-M.)
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, 3508 GA Utrecht, The Netherlands
| | - Willeke J. Kruithof
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands; (R.M.v.E.); (L.S.K.); (W.J.K.); (E.T.K.-v.R.); (J.M.A.V.-M.)
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, 3508 GA Utrecht, The Netherlands
| | - Esther T. Kruitwagen-van Reenen
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands; (R.M.v.E.); (L.S.K.); (W.J.K.); (E.T.K.-v.R.); (J.M.A.V.-M.)
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, 3508 GA Utrecht, The Netherlands
| | - Sotice Pieters
- Basalt Rehabilitation, 2543 SW The Hague, The Netherlands;
| | - Michael A. van Es
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands; (M.A.v.E.); (L.H.v.d.B.)
| | - Leonard H. van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands; (M.A.v.E.); (L.H.v.d.B.)
| | - Johanna M. A. Visser-Meily
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands; (R.M.v.E.); (L.S.K.); (W.J.K.); (E.T.K.-v.R.); (J.M.A.V.-M.)
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, 3508 GA Utrecht, The Netherlands
| | - Anita Beelen
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands; (R.M.v.E.); (L.S.K.); (W.J.K.); (E.T.K.-v.R.); (J.M.A.V.-M.)
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, 3508 GA Utrecht, The Netherlands
- Correspondence: ; Tel.: +31-638-555-078
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Hochwald IH, Yakov G, Radomyslsky Z, Danon Y, Nissanholtz-Gannot R. Ethical challenges in end-stage dementia: Perspectives of professionals and family care-givers. Nurs Ethics 2021; 28:1228-1243. [PMID: 34112013 PMCID: PMC8637375 DOI: 10.1177/0969733021999748] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND In Israel, caring for people with end-stage dementia confined to home is mainly done by home care units, and in some cases by home hospice units, an alternative palliative-care service. Because life expectancy is relatively unknown, and the patient's decision-making ability is poor, caring for this unique population raises ethical dilemmas regarding when to define the disease as having reached a terminal stage, as well as choosing between palliative and life-prolonging-oriented care. OBJECTIVES Exploring and describing differences and similarities of professional staff members' (PSMs') and family caregivers' perceptions of caring for people with end-stage dementia in two different settings. DESIGN Qualitative research, using semi-structured interviews analyzed through a thematic content-analysis approach. PARTICIPANTS Sixty-four interviews were conducted (24 PSMs and 40 family caregivers) in two care-settings-home hospice unit and home care unit. ETHICAL CONSIDERATIONS The study was approved by the Ethics Committee (BBL00118-17). FINDINGS We found dilemmas regarding palliative care to be the main theme, including definition of the disease as terminal, choosing "comfort" over "life-prolonging," clarifying patients' wishes and deciding whether or not to use artificial feeding. DISCUSSION Both PSMs and family caregivers deal with ethical dilemmas and have reached different conclusions, both legitimate. Comprehending dementia as a terminal disease influenced participants' perceptions of the relevancy of palliative care for people with end-stage dementia. Discrepancies between PSMs and family caregivers in caring for people with end-stage dementia were found in both home hospice unit and home care unit environments, raising potential conflicts regarding decisions for end-of-life care. CONCLUSIONS Communication between PSMs and family caregivers is crucial for the discussion about the discrepancies regarding the unique dilemmas of caring for people with end-stage dementia and bridging the gap between them. Lack of communication and resources can hamper the provision of an acceptable solution for quality and equality of care in the best interest of people with end-stage dementia.
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Affiliation(s)
| | - Gila Yakov
- Max Stern Yezreel Valley College, Israel
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van Eenennaam RM, Kruithof WJ, van Es MA, Kruitwagen-van Reenen ET, Westeneng HJ, Visser-Meily JMA, van den Berg LH, Beelen A. Discussing personalized prognosis in amyotrophic lateral sclerosis: development of a communication guide. BMC Neurol 2020; 20:446. [PMID: 33308184 PMCID: PMC7734773 DOI: 10.1186/s12883-020-02004-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Personalized ENCALS survival prediction model reliably estimates the personalized prognosis of patients with amyotrophic lateral sclerosis. Concerns were raised on discussing personalized prognosis without causing anxiety and destroying hope. Tailoring communication to patient readiness and patient needs mediates the impact of prognostic disclosure. We developed a communication guide to support physicians in discussing personalized prognosis tailored to individual needs and preferences of people with ALS and their families. METHODS A multidisciplinary working group of neurologists, rehabilitation physicians, and healthcare researchers A) identified relevant topics for guidance, B) conducted a systematic review on needs of patients regarding prognostic discussion in life-limiting disease, C) drafted recommendations based on evidence and expert opinion, and refined and finalized these recommendations in consensus rounds, based on feedback of an expert advisory panel (patients, family member, ethicist, and spiritual counsellor). RESULTS A) Topics identified for guidance were 1) filling in the ENCALS survival model, and interpreting outcomes and uncertainty, and 2) tailoring discussion to individual needs and preferences of patients (information needs, role and needs of family, severe cognitive impairment or frontotemporal dementia, and non-western patients). B) 17 studies were included in the systematic review. C) Consensus procedures on drafted recommendations focused on selection of outcomes, uncertainty about estimated survival, culturally sensitive communication, and lack of decisional capacity. Recommendations for discussing the prognosis include the following: discuss prognosis based on the prognostic groups and their median survival, or, if more precise information is desired, on the interquartile range of the survival probability. Investigate needs and preferences of the patients and their families for prognostic disclosure, regardless of cultural background. If the patient does not want to know their prognosis, with patient permission discuss the prognosis with their family. If the patient is judged to lack decisional capacity, ask the family if they want to discuss the prognosis. Tailor prognostic disclosure step by step, discuss it in terms of time range, and emphasize uncertainty of individual survival time. CONCLUSION This communication guide supports physicians in tailoring discussion of personalized prognosis to the individual needs and preferences of people with ALS and their families.
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Affiliation(s)
- Remko M van Eenennaam
- Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.,Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, the Netherlands.,Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Willeke J Kruithof
- Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.,Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, the Netherlands
| | - Michael A van Es
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Esther T Kruitwagen-van Reenen
- Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.,Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, the Netherlands
| | - Henk-Jan Westeneng
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Johanna M A Visser-Meily
- Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.,Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, the Netherlands
| | - Leonard H van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Anita Beelen
- Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands. .,Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, the Netherlands.
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Fairweather J, Cooper L, Sneddon J, Seaton RA. Antimicrobial use at the end of life: a scoping review. BMJ Support Palliat Care 2020:bmjspcare-2020-002558. [PMID: 33257407 DOI: 10.1136/bmjspcare-2020-002558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine antibiotic use in patients approaching end of life, in terms of frequency of prescription, aim of treatment, beneficial and adverse effects and contribution to the development of antimicrobial resistance. DESIGN Scoping review DATA SOURCES: An information scientist searched Ovid MEDLINE, Ovid EMBASE, The Cochrane library, PubMed Clinical Queries, NHS Evidence, Epistemonikos, SIGN, NICE, Google Scholar from inception to February 2019 for any study design including, but not limited to, randomised clinical trials, prospective interventional or observational studies, retrospective studies and qualitative studies. The search of Ovid MEDLINE was updated on the 10 June 2020. STUDY SELECTION Studies reporting antibiotic use in patients approaching end of life in any setting and clinicians' attitudes and behaviour in relation to antibiotic prescribing in this population DATA EXTRACTION: Two reviewers screened studies for eligibility; two reviewers extracted data from included studies. Data were analysed to describe antibiotic prescribing patterns across different patient populations, the benefits and adverse effects (for individual patients and wider society), the rationale for decision making and clinicians behaviours and attitudes to treatment with antibiotics in this patient group. RESULTS Eighty-eight studies were included. Definition of the end of life is highly variable as is use of antibiotics in patients approaching end of life. Prescribing decisions are influenced by patient age, primary diagnosis, care setting and therapy goals, although patients' preferences are not always documented or adhered to. Urinary and lower respiratory tract infections are the most commonly reported indications with outcomes in terms of symptom control and survival variably reported. Small numbers of studies reported on adverse events and antimicrobial resistance. Clinicians sometimes feel uncomfortable discussing antibiotic treatment at end of life and would benefit from guidelines to direct care. CONCLUSIONS Use of antibiotics in patients approaching the end of life is common although there is significant variation in practice. There are a myriad of intertwined biological, ethical, social, medicolegal and clinical issues associated with the topic.
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Affiliation(s)
| | - Lesley Cooper
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland Glasgow, Glasgow, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland Glasgow, Glasgow, UK
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Kochovska S, Garcia MV, Bunn F, Goodman C, Luckett T, Parker D, Phillips JL, Sampson EL, van der Steen JT, Agar MR. Components of palliative care interventions addressing the needs of people with dementia living in long-term care: A systematic review. Palliat Med 2020; 34:454-492. [PMID: 32013780 DOI: 10.1177/0269216319900141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND People with dementia requiring palliative care have multiple needs, which are amplified in long-term care settings. The European Association for Palliative Care White Paper offers recommendations for optimal palliative care in dementia integral for this population, providing useful guidance to inform interventions addressing their specific needs. AIM The aim of this study is to describe the components of palliative care interventions for people with dementia in long-term care focusing on shared decision-making and examine their alignment to the European Association for Palliative Care domains of care. DESIGN Systematic review with narrative synthesis (PROSPERO ID: CRD42018095649). DATA SOURCES Four databases (MEDLINE, CINAHL, PsycINFO and CENTRAL) were searched (earliest records - July 2019) for peer-reviewed articles and protocols in English, reporting on palliative care interventions for people with dementia in long-term care, addressing European Association for Palliative Care Domains 2 (person-centred) or 3 (setting care goals) and ⩾1 other domain. RESULTS Fifty-one papers were included, reporting on 32 studies. For each domain (1-10), there were interventions found aiming to address its goal, although no single intervention addressed all domains. Domain 7 (symptom management; n = 19), 6 (avoiding overly aggressive treatment; n = 18) and 10 (education; n = 17) were the most commonly addressed; Domain 5 (prognostication; n = 7) and 4 (continuity of care; n = 2) were the least addressed. CONCLUSION Almost all domains were addressed across all interventions currently offered for this population to various degrees, but not within a singular intervention. Future research optimally needs to be theory driven when developing dementia-specific interventions at the end of life, with the European Association for Palliative Care domains serving as a foundation to inform the best care for this population.
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Affiliation(s)
- Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Maja V Garcia
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Frances Bunn
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hertfordshire, UK
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hertfordshire, UK
| | - Tim Luckett
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Deborah Parker
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Elizabeth L Sampson
- Centre for Dementia Palliative Care Research, Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Meera R Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
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Haaksma ML, Eriksdotter M, Rizzuto D, Leoutsakos JMS, Olde Rikkert MGM, Melis RJF, Garcia-Ptacek S. Survival time tool to guide care planning in people with dementia. Neurology 2020; 94:e538-e548. [PMID: 31843808 PMCID: PMC7080282 DOI: 10.1212/wnl.0000000000008745] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/25/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To develop survival prediction tables to inform physicians and patients about survival probabilities after the diagnosis of dementia and to determine whether survival after dementia diagnosis can be predicted with good accuracy. METHODS We conducted a nationwide registry-linkage study including 829 health centers, i.e., all memory clinics and ≈75% of primary care facilities, across Sweden. Data including cognitive function from 50,076 people with incident dementia diagnoses ≥65 years of age and registered with the Swedish Dementia Register in 2007 to 2015 were used, with a maximum follow-up of 9.7 years for survival until 2016. Sociodemographic factors, comorbidity burden, medication use, and dates of death were obtained from nationwide registries. Cox proportional hazards regression models were used to create tables depicting 3-year survival probabilities for different risk factor profiles. RESULTS By August 2016, 20,828 (41.6%) patients in our cohort had died. Median survival time from diagnosis of dementia was 5.1 (interquartile range 2.9-8.0) years for women and 4.3 (interquartile range 2.3-7.0) years for men. Predictors of mortality were higher age, male sex, increased comorbidity burden and lower cognitive function at diagnosis, a diagnosis of non-Alzheimer dementia, living alone, and using more medications. The developed prediction tables yielded c indexes of 0.70 (95% confidence interval [CI] 0.69-0.71) to 0.72 (95% CI 0.71-0.73) and showed good calibration. CONCLUSIONS Three-year survival after dementia diagnosis can be predicted with good accuracy. The survival prediction tables developed in this study may aid clinicians and patients in shared decision-making and advance care planning.
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Affiliation(s)
- Miriam L Haaksma
- From the Department of Geriatric Medicine (M.L.H., M.G.M.O.R., R.J.F.M.), Radboudumc Alzheimer Center, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Aging Research Center (M.L.H., D.R.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna; Division of Clinical Geriatrics (M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet; Theme Aging (M.E., S.G.-P.), Karolinska University Hospital, Huddinge, Sweden; Department of Psychiatry (J.-M.S.L.), Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins University School of Medicine, Baltimore, MD; Radboud University Medical Center (M.G.M.O.R.), Donders Institute for Brain, Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands; and Department of Internal Medicine (S.G.-P.), Section for Neurology, Södersjukhuset Stockholm, Sweden
| | - Maria Eriksdotter
- From the Department of Geriatric Medicine (M.L.H., M.G.M.O.R., R.J.F.M.), Radboudumc Alzheimer Center, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Aging Research Center (M.L.H., D.R.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna; Division of Clinical Geriatrics (M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet; Theme Aging (M.E., S.G.-P.), Karolinska University Hospital, Huddinge, Sweden; Department of Psychiatry (J.-M.S.L.), Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins University School of Medicine, Baltimore, MD; Radboud University Medical Center (M.G.M.O.R.), Donders Institute for Brain, Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands; and Department of Internal Medicine (S.G.-P.), Section for Neurology, Södersjukhuset Stockholm, Sweden
| | - Debora Rizzuto
- From the Department of Geriatric Medicine (M.L.H., M.G.M.O.R., R.J.F.M.), Radboudumc Alzheimer Center, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Aging Research Center (M.L.H., D.R.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna; Division of Clinical Geriatrics (M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet; Theme Aging (M.E., S.G.-P.), Karolinska University Hospital, Huddinge, Sweden; Department of Psychiatry (J.-M.S.L.), Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins University School of Medicine, Baltimore, MD; Radboud University Medical Center (M.G.M.O.R.), Donders Institute for Brain, Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands; and Department of Internal Medicine (S.G.-P.), Section for Neurology, Södersjukhuset Stockholm, Sweden
| | - Jeannie-Marie S Leoutsakos
- From the Department of Geriatric Medicine (M.L.H., M.G.M.O.R., R.J.F.M.), Radboudumc Alzheimer Center, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Aging Research Center (M.L.H., D.R.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna; Division of Clinical Geriatrics (M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet; Theme Aging (M.E., S.G.-P.), Karolinska University Hospital, Huddinge, Sweden; Department of Psychiatry (J.-M.S.L.), Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins University School of Medicine, Baltimore, MD; Radboud University Medical Center (M.G.M.O.R.), Donders Institute for Brain, Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands; and Department of Internal Medicine (S.G.-P.), Section for Neurology, Södersjukhuset Stockholm, Sweden
| | - Marcel G M Olde Rikkert
- From the Department of Geriatric Medicine (M.L.H., M.G.M.O.R., R.J.F.M.), Radboudumc Alzheimer Center, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Aging Research Center (M.L.H., D.R.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna; Division of Clinical Geriatrics (M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet; Theme Aging (M.E., S.G.-P.), Karolinska University Hospital, Huddinge, Sweden; Department of Psychiatry (J.-M.S.L.), Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins University School of Medicine, Baltimore, MD; Radboud University Medical Center (M.G.M.O.R.), Donders Institute for Brain, Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands; and Department of Internal Medicine (S.G.-P.), Section for Neurology, Södersjukhuset Stockholm, Sweden
| | - René J F Melis
- From the Department of Geriatric Medicine (M.L.H., M.G.M.O.R., R.J.F.M.), Radboudumc Alzheimer Center, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Aging Research Center (M.L.H., D.R.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna; Division of Clinical Geriatrics (M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet; Theme Aging (M.E., S.G.-P.), Karolinska University Hospital, Huddinge, Sweden; Department of Psychiatry (J.-M.S.L.), Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins University School of Medicine, Baltimore, MD; Radboud University Medical Center (M.G.M.O.R.), Donders Institute for Brain, Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands; and Department of Internal Medicine (S.G.-P.), Section for Neurology, Södersjukhuset Stockholm, Sweden
| | - Sara Garcia-Ptacek
- From the Department of Geriatric Medicine (M.L.H., M.G.M.O.R., R.J.F.M.), Radboudumc Alzheimer Center, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Aging Research Center (M.L.H., D.R.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna; Division of Clinical Geriatrics (M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Karolinska Institutet; Theme Aging (M.E., S.G.-P.), Karolinska University Hospital, Huddinge, Sweden; Department of Psychiatry (J.-M.S.L.), Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins University School of Medicine, Baltimore, MD; Radboud University Medical Center (M.G.M.O.R.), Donders Institute for Brain, Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands; and Department of Internal Medicine (S.G.-P.), Section for Neurology, Södersjukhuset Stockholm, Sweden.
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Cowley LE, Farewell DM, Maguire S, Kemp AM. Methodological standards for the development and evaluation of clinical prediction rules: a review of the literature. Diagn Progn Res 2019; 3:16. [PMID: 31463368 PMCID: PMC6704664 DOI: 10.1186/s41512-019-0060-y] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 05/12/2019] [Indexed: 12/20/2022] Open
Abstract
Clinical prediction rules (CPRs) that predict the absolute risk of a clinical condition or future outcome for individual patients are abundant in the medical literature; however, systematic reviews have demonstrated shortcomings in the methodological quality and reporting of prediction studies. To maximise the potential and clinical usefulness of CPRs, they must be rigorously developed and validated, and their impact on clinical practice and patient outcomes must be evaluated. This review aims to present a comprehensive overview of the stages involved in the development, validation and evaluation of CPRs, and to describe in detail the methodological standards required at each stage, illustrated with examples where appropriate. Important features of the study design, statistical analysis, modelling strategy, data collection, performance assessment, CPR presentation and reporting are discussed, in addition to other, often overlooked aspects such as the acceptability, cost-effectiveness and longer-term implementation of CPRs, and their comparison with clinical judgement. Although the development and evaluation of a robust, clinically useful CPR is anything but straightforward, adherence to the plethora of methodological standards, recommendations and frameworks at each stage will assist in the development of a rigorous CPR that has the potential to contribute usefully to clinical practice and decision-making and have a positive impact on patient care.
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Affiliation(s)
- Laura E. Cowley
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
| | - Daniel M. Farewell
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
| | - Sabine Maguire
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
| | - Alison M. Kemp
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
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13
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Cardona M, O'Sullivan M, Lewis ET, Turner RM, Garden F, Alkhouri H, Asha S, Mackenzie J, Perkins M, Suri S, Holdgate A, Winoto L, Chang DW, Gallego‐Luxan B, McCarthy S, Hillman K, Breen D. Prospective Validation of a Checklist to Predict Short-term Death in Older Patients After Emergency Department Admission in Australia and Ireland. Acad Emerg Med 2019; 26:610-620. [PMID: 30428145 PMCID: PMC6619350 DOI: 10.1111/acem.13664] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 11/03/2018] [Accepted: 11/07/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Emergency departments (EDs) are pressured environment where patients with supportive and palliative care needs may not be identified. We aimed to test the predictive ability of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist to flag patients at risk of death within 3 months who may benefit from timely end-of-life discussions. METHODS Prospective cohorts of >65-year-old patients admitted for at least one night via EDs in five Australian hospitals and one Irish hospital. Purpose-trained nurses and medical students screened for frailty using two instruments concurrently and completed the other risk factors on the CriSTAL tool at admission. Postdischarge telephone follow-up was used to determine survival status. Logistic regression and bootstrapping techniques were used to test the predictive accuracy of CriSTAL for death within 90 days of admission as primary outcome. Predictability of in-hospital death was the secondary outcome. RESULTS A total of 1,182 patients, with median age 76 to 80 years (IRE-AUS), were included. The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% confidence interval [CI] = 7.7-8.6) versus 5.7 (95% CI = 5.1-6.2) and Irish mean of 7.7 (95% CI = 6.9-8.5) versus 5.7 (95% CI = 5.1-6.2). The model with Fried frailty score was optimal for the derivation (Australian) cohort but prediction with the Clinical Frailty Scale (CFS) was also good (areas under the receiver-operating characteristic [AUROC] = 0.825 and 0.81, respectively). Values for the validation (Irish) cohort were AUROC = 0.70 with Fried and 0.77 using CFS. A minimum of five of 29 variables were sufficient for accurate prediction, and a cut point of 7+ or 6+ depending on the cohort was strongly indicative of risk of death. The most significant independent predictor of short-term death in both cohorts was frailty, carrying a twofold risk of death. CriSTAL's accuracy for in-hospital death prediction was also good (AUROC = 0.795 and 0.81 in Australia and Ireland, respectively), with high specificity and negative predictive values. CONCLUSIONS The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) had good discriminant power to improve certainty of short-term mortality prediction in both health systems. The predictive ability of models is anticipated to help clinicians gain confidence in initiating earlier end-of-life discussions. The practicalities of embedding screening for risk of death in routine practice warrant further investigation.
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Affiliation(s)
- Magnolia Cardona
- Centre for Research in Evidence‐Based PracticeFaculty of Health Sciences and MedicineBond UniversityRobinaQLDAustralia
- School of Public Health and Community MedicineThe University of New South WalesSydneyNSWAustralia
| | | | - Ebony T. Lewis
- School of Public Health and Community MedicineThe University of New South WalesSydneyNSWAustralia
| | - Robin M. Turner
- Dean's OfficeDunedin School of MedicineUniversity of OtagoDunedinNew Zealand
| | - Frances Garden
- Ingham Institute for Applied Medical ResearchLiverpoolNSWAustralia
| | - Hatem Alkhouri
- Emergency Care InstituteAgency for Clinical InnovationChatswoodNSWAustralia
| | - Stephen Asha
- Emergency DepartmentSt George HospitalKogarahNSWAustralia
| | - John Mackenzie
- Emergency DepartmentPrince of Wales Hospital RandwickNSWAustralia
| | - Margaret Perkins
- Emergency DepartmentCampbelltown HospitalCampbelltownNSWAustralia
| | - Sam Suri
- Intensive Care UnitCampbelltown HospitalCampbelltownNSWAustralia
| | - Anna Holdgate
- Emergency DepartmentLiverpool HospitalLiverpoolNSWAustralia
| | - Luis Winoto
- Emergency DepartmentSutherland Hospital SutherlandNSWAustralia
| | - David C. W. Chang
- Graduate School of Biomedical EngineeringThe University of New South WalesSydneyNSWAustralia
| | - Blanca Gallego‐Luxan
- Centre for Health InformaticsAustralian Institute of Health InnovationMacquarie UniversitySydneyNSWAustralia
| | - Sally McCarthy
- Emergency DepartmentPrince of Wales Hospital RandwickNSWAustralia
| | - Ken Hillman
- South Western Sydney Clinical SchoolThe University of New South WalesSydneyNSWAustralia
- Intensive Care UnitLiverpool HospitalLiverpoolNSWAustralia
| | - Dorothy Breen
- Intensive Care UnitCork University HospitalCorkIreland
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14
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Livingston G, Sommerlad A, Orgeta V, Costafreda SG, Huntley J, Ames D, Ballard C, Banerjee S, Burns A, Cohen-Mansfield J, Cooper C, Fox N, Gitlin LN, Howard R, Kales HC, Larson EB, Ritchie K, Rockwood K, Sampson EL, Samus Q, Schneider LS, Selbæk G, Teri L, Mukadam N. Dementia prevention, intervention, and care. Lancet 2017; 390:2673-2734. [PMID: 28735855 DOI: 10.1016/s0140-6736(17)31363-6] [Citation(s) in RCA: 3473] [Impact Index Per Article: 496.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 01/20/2017] [Accepted: 01/25/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Gill Livingston
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK.
| | | | - Vasiliki Orgeta
- Division of Psychiatry, University College London, London, UK
| | - Sergi G Costafreda
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Jonathan Huntley
- Division of Psychiatry, University College London, London, UK; Department of Old Age Psychiatry, King's College London, London, UK
| | - David Ames
- National Ageing Research Institute, Parkville, VIC, Australia; Academic Unit for Psychiatry of Old Age, University of Melbourne, Kew, VIC, Australia
| | | | - Sube Banerjee
- Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Alistair Burns
- Centre for Dementia Studies, University of Manchester, Manchester, UK
| | - Jiska Cohen-Mansfield
- Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Heczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel; Minerva Center for Interdisciplinary Study of End of Life, Tel Aviv University, Tel Aviv, Israel
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Nick Fox
- Dementia Research Centre, University College London, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Laura N Gitlin
- Center for Innovative Care in Aging, Johns Hopkins University, Baltimore, MD, USA
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Helen C Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Karen Ritchie
- Inserm, Unit 1061, Neuropsychiatry: Epidemiological and Clinical Research, La Colombière Hospital, University of Montpellier, Montpellier, France; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kenneth Rockwood
- Centre for the Health Care of Elderly People, Geriatric Medicine Dalhousie University, Halifax, NS, Canada
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Quincy Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, Johns Hopkins University, Baltimore, MD, USA
| | - Lon S Schneider
- Department of Neurology and Department of Psychiatry and the Behavioural Sciences, Keck School of Medicine, Leonard Davis School of Gerontology of the University of Southern California, Los Angeles, CA, USA
| | - Geir Selbæk
- Norwegian National Advisory Unit on Aging and Health, Vestfold Health Trust, Tønsberg, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway; Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
| | - Linda Teri
- Department Psychosocial and Community Health, School of Nursing, University of Washington, Seattle, WA, USA
| | - Naaheed Mukadam
- Division of Psychiatry, University College London, London, UK
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Rauh SP, Heymans MW, Mehr DR, Kruse RL, Lane P, Kowall NW, Volicer L, van der Steen JT. Predicting mortality in patients treated differently: updating and external validation of a prediction model for nursing home residents with dementia and lower respiratory infections. BMJ Open 2016; 6:e011380. [PMID: 27577584 PMCID: PMC5013486 DOI: 10.1136/bmjopen-2016-011380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To evaluate whether a model that was previously developed to predict 14-day mortality for nursing home residents with dementia and lower respiratory tract infection who received antibiotics could be applied to residents who were not treated with antibiotics. Specifically, in this same data set, to update the model using recalibration methods; and subsequently examine the historical, geographical, methodological and spectrum transportability through external validation of the updated model. DESIGN 1 cohort study was used to develop the prediction model, and 4 cohort studies from 2 countries were used for the external validation of the model. SETTING Nursing homes in the Netherlands and the USA. PARTICIPANTS 157 untreated residents were included in the development of the model; 239 untreated residents were included in the external validation cohorts. OUTCOME Model performance was evaluated by assessing discrimination: area under the receiver operating characteristic curves; and calibration: Hosmer and Lemeshow goodness-of-fit statistics and calibration graphs. Further, reclassification tables allowed for a comparison of patient classifications between models. RESULTS The original prediction model applied to the untreated residents, who were sicker, showed excellent discrimination but poor calibration, underestimating mortality. Adjusting the intercept improved calibration. Recalibrating the slope did not substantially improve the performance of the model. Applying the updated model to the other 4 data sets resulted in acceptable discrimination. Calibration was inadequate only in one data set that differed substantially from the other data sets in case-mix. Adjusting the intercept for this population again improved calibration. CONCLUSIONS The discriminative performance of the model seems robust for differences between settings. To improve calibration, we recommend adjusting the intercept when applying the model in settings where different mortality rates are expected. An impact study may evaluate the usefulness of the two prediction models for treated and untreated residents and whether it supports decision-making in clinical practice.
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Affiliation(s)
- Simone P Rauh
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
- EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
- EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
| | - David R Mehr
- Department of Family and Community Medicine, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Robin L Kruse
- Department of Family and Community Medicine, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Patricia Lane
- E.N. Rogers Memorial Veterans Hospital, Geriatric Research Education Clinical Center, Bedford, Massachusetts, USA
| | - Neil W Kowall
- VA Boston Healthcare System, Department of Veterans Affairs and Boston University Alzheimer Disease Center at BU School of Medicine, Boston, Massachusetts, USA
| | - Ladislav Volicer
- School of Aging Studies, University of South Florida, Tampa, Florida, USA
| | - Jenny T van der Steen
- Leiden University Medical Center, Department of Public Health and Primary Care, Leiden, The Netherlands
- Radboud University Medical Center, Department of Primary and Community Care, Nijmegen, The Netherlands
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Iliffe S, Wilcock J, Drennan V, Goodman C, Griffin M, Knapp M, Lowery D, Manthorpe J, Rait G, Warner J. Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM). PROGRAMME GRANTS FOR APPLIED RESEARCH 2015. [DOI: 10.3310/pgfar03030] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BackgroundThe needs of people with dementia and their carers are inadequately addressed at all key points in the illness trajectory, from diagnosis through to end-of-life care. The EVIDEM (Evidence-based Interventions in Dementia) research and development programme (2007–12) was designed to help change this situation within real-life settings.ObjectivesThe EVIDEM projects were (1) evaluation of an educational package designed to enhance general practitioners’ (GPs’) diagnostic and management skills; (2) evaluation of exercise as therapy for behavioural and psychological symptoms of dementia (BPSD); (3) development of a toolkit for managing incontinence in people with dementia living at home; (4) development of a toolkit for palliative care for people with dementia; and (5) development of practice guidance on the use of the Mental Capacity Act (MCA) 2005.DesignMixed quantitative and qualitative methods from case studies to large database analyses, including longitudinal surveys, randomised controlled trials and research register development, with patient and public involvement built into all projects.SettingGeneral practices, community services, third-sector organisations and care homes in the area of the North Thames Dementia and Neurodegenerative Diseases Research Network local research network.ParticipantsPeople with dementia, their family and professional carers, GPs and community mental health team members, staff in local authority social services and third-sector bodies, and care home staff.Main outcome measuresDementia management reviews and case identification in general practice; changes in behavioural and psychological symptoms measured with the Neuropsychiatric Inventory (NPI); extent and impact of incontinence in community-dwelling people with dementia; mapping of pathways to death of people with dementia in care homes, and testing of a model of collaborative working between primary care and care homes; and understandings of the MCA 2005 among practitioners working with people with dementia.ResultsAn educational intervention in general practice did not alter management or case identification. Exercise as a therapy for BPSD did not reduce NPI scores significantly, but had a significant positive effect on carer burden. Incontinence is twice as common in community-dwelling people with dementia than their peers, and is a hidden taboo within a stigma. Distinct trajectories of dying were identified (anticipated, unexpected and uncertain), and collaboration between NHS primary care and care homes was improved, with cost savings. The MCA 2005 legislation provided a useful working framework for practitioners working with people with dementia.ConclusionsA tailored educational intervention for general practice does not change practice, even when incentives, policy pressure and consumer demand create a favourable environment for change; exercise has potential as a therapy for BPSD and deserves further investigation; incontinence is a common but unrecognised problem for people with dementia in the community; changes in relationships between care homes and general practice can be achieved, with benefits for people with dementia at the end of life and for the UK NHS; application of the MCA 2005 will continue to improve but educational reinforcements will help this. Increased research capacity in dementia in the community was achieved. This study suggests that further work is required to enhance clinical practice around dementia in general practice; investigate the apparent beneficial effect of physical activity on BPSD and carer well-being; develop case-finding methods for incontinence in people with dementia; optimise working relationships between NHS staff and care homes; and reinforce practitioner understanding of the MCA 2005.Trial registrationEVIDEM: ED-NCT00866099; EVIDEM: E-ISRCTN01423159.FundingThis project was funded by the Programme Grants for Applied Research programme of the National Institute for Health Research.
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Affiliation(s)
- Steve Iliffe
- Research Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Jane Wilcock
- Research Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Vari Drennan
- Centre for Health and Social Care Research, The Faculty of Health, Social Care and Education at Kingston University London & St George’s University of London (previously at University College London), London, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, School of Health and Social Work, University of Hertfordshire, Hertfordshire, UK
| | - Mark Griffin
- Research Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Martin Knapp
- Personal Social Services Research Unit (PSSRU), Department of Social Policy, London School of Economics and Political Science, London, UK
| | - David Lowery
- Older Peoples Mental Health Services, Central and North West London NHS Foundation Trust (previously known as Central & NW London Mental Health NHS Trust), London, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, Policy Institute at King’s, King’s College London, London, UK
| | - Greta Rait
- Research Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - James Warner
- Older Peoples Mental Health Services, Central and North West London NHS Foundation Trust (previously known as Central & NW London Mental Health NHS Trust), London, UK, Department of Psychiatry, Faculty of Medicine, Imperial College London, London, UK
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Lewis LF. Caregivers' experiences seeking hospice care for loved ones with dementia. QUALITATIVE HEALTH RESEARCH 2014; 24:1221-1231. [PMID: 25079503 DOI: 10.1177/1049732314545888] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
As the prevalence of dementia continues to grow, informal caregivers face unique challenges as they approach the end of life, and access to support and palliative care is often limited. I used a phenomenological approach to explore the experiences of caregivers actively seeking formal end-of-life care, in particular hospice care, for a loved one with dementia. In-depth interviews with 11 caregivers about 14 patients revealed five themes, including: setting the stage for heartbreak, reaching the boiling point, getting through the front lines, settling for less, and welcoming death. Nurses must recognize the complex needs of caregivers, educate caregivers on the disease process, and adjust to palliative goals sooner to meet the needs of caregivers. Prevalence of these issues must be further examined through quantitative study to evaluate the need to reconsider current hospice eligibility criteria based on prognosis.
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van der Steen JT, de Graas T, Arcand M, Hertogh CMPM. [Evaluation of a family booklet on comfort care in dementia by professional and family caregivers]. Tijdschr Gerontol Geriatr 2012; 42:215-25. [PMID: 22470987 DOI: 10.1007/s12439-011-0037-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Families of nursing home residents with dementia are usually involved in care and treatment decisions. To this end, family needs to be informed on the course of the dementia and possible palliative care. Based on a Canadian booklet, we developed an adapted version for use in the Netherlands. Elderly care physicians (n = 30), nurses (n = 38), and bereaved families (n = 59) evaluated the booklet and possible implementation strategies. All respondents confirmed that in general, there is a need of an information brochure on comfort care and end-of-life issues for families. Most (93%) families believed they would have found the booklet useful when received earlier. Compared to the physicians, nurses more frequently found the booklet useful to most or all families (p = 0.04). Acceptance, as measured on an 8-item scale, was highest among families and lowest among physicians. Overall usefulness was often perceived as high (means 7.9 to 8.3; scale range 0-10; SD 0.9 to 1.4) and did not differ across groups of respondents (p = 0.29). All respondents agreed that professional caregivers should have a role in providing the booklet. Additionally, half (53%; no difference across groups) favoured availability of the booklet through families' own initiative; some already before admission. In conclusion, there is a high need for written information on palliative care. The booklet is highly appreciated. A further improved version may support professional and family caregivers in practice.
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Affiliation(s)
- J T van der Steen
- VUmc, EMGO Instituut, afdeling Verpleeghuisgeneeskunde en afdeling Sociale Geneeskunde, Amsterdam.
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van der Steen JT, Lane P, Kowall NW, Knol DL, Volicer L. Antibiotics and mortality in patients with lower respiratory infection and advanced dementia. J Am Med Dir Assoc 2012; 13:156-61. [PMID: 21450193 PMCID: PMC6290468 DOI: 10.1016/j.jamda.2010.07.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 06/30/2010] [Accepted: 07/01/2010] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To describe long-term mortality rate and to assess associations between mortality rate and antibiotic treatment of lower respiratory infection in patients with advanced dementia; antibiotic treatment allocation was independent of mortality risk-leaving less room for biased associations than in previous multicenter observational studies. DESIGN Prospective study (2004-2009). Multilevel Cox proportional hazard analyses with adjustment for mortality risk were used to assess associations between antibiotics and mortality using time-dependent covariates. SETTING A US Department of Veterans Affairs nursing home. PARTICIPANTS Ninety-four residents with advanced dementia who developed 109 episodes. MEASUREMENTS Survival, treatment, mortality risk, illness severity, fluid intake, and several other patient characteristics. RESULTS Ten-day mortality was 48%, and 6-month mortality was 74%. Antibiotics were used in 77% of episodes. Overall, antibiotics were not associated with mortality rate (Hazard Ratio [HR] 0.70, Confidence Interval [CI] 0.38-1.30); however, antibiotics were associated with reduced 10-day mortality rate (HR 0.51, CI, 0.30-0.87; rate after 10 days: 1.5, CI 0.42-5.2). Benefit from antibiotics was less likely with inadequate fluid intake, and when experiencing the first episode. CONCLUSION In our sample of male nursing home residents with advanced dementia and lower respiratory infection, mortality was substantial despite antibiotic treatment. Antibiotics prolonged life but in many cases only for several days. Treatment decisions should take into account that antibiotics may delay death but may also prolong the dying process, indicating a need for accurate prediction of mortality and study of characteristics that may alter effectiveness of antibiotics.
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Affiliation(s)
- Jenny T. van der Steen
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Department of Nursing Home Medicine, VU University Medical Center, Amsterdam, The Netherlands
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
| | - Patricia Lane
- E.N. Rogers Memorial Veterans Hospital, Geriatric Research Education Clinical Center, Bedford, MA
| | - Neil W. Kowall
- E.N. Rogers Memorial Veterans Hospital, Geriatric Research Education Clinical Center, Bedford, MA
- Boston University School of Medicine, Boston, MA
- Boston University Alzheimer’s Disease Center and Neurology Service, VA Boston Healthcare System, Boston, MA
| | - Dirk L. Knol
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Ladislav Volicer
- School of Aging Studies University of South Florida, Tampa, FL
- Charles University Medical School, Prague, Czech Republic (formerly: E.N. Rogers Memorial Veterans Hospital, Geriatric Research Education Clinical Center, Bedford, MA)
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Wallace E, Smith SM, Perera-Salazar R, Vaucher P, McCowan C, Collins G, Verbakel J, Lakhanpaul M, Fahey T. Framework for the impact analysis and implementation of Clinical Prediction Rules (CPRs). BMC Med Inform Decis Mak 2011; 11:62. [PMID: 21999201 PMCID: PMC3216240 DOI: 10.1186/1472-6947-11-62] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 10/14/2011] [Indexed: 11/18/2022] Open
Abstract
Clinical Prediction Rules (CPRs) are tools that quantify the contribution of symptoms, clinical signs and available diagnostic tests, and in doing so stratify patients according to the probability of having a target outcome or need for a specified treatment. Most focus on the derivation stage with only a minority progressing to validation and very few undergoing impact analysis. Impact analysis studies remain the most efficient way of assessing whether incorporating CPRs into a decision making process improves patient care. However there is a lack of clear methodology for the design of high quality impact analysis studies.We have developed a sequential four-phased framework based on the literature and the collective experience of our international working group to help researchers identify and overcome the specific challenges in designing and conducting an impact analysis of a CPR.There is a need to shift emphasis from deriving new CPRs to validating and implementing existing CPRs. The proposed framework provides a structured approach to this topical and complex area of research.
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Affiliation(s)
- Emma Wallace
- Department of General Practice, Royal College of Surgeons in Ireland, (123 Stephen's green) Dublin 2, Republic of Ireland
| | - Susan M Smith
- Department of General Practice, Royal College of Surgeons in Ireland, (123 Stephen's green) Dublin 2, Republic of Ireland
| | - Rafael Perera-Salazar
- Department of Primary Health Care, University of Oxford, (23-38 Hythe Bridge Street), Oxford, (OX1 2ET), UK
| | - Paul Vaucher
- Department of Community Medicine and Primary Care, University of Geneva, (Michel-Servet 1, CH-1211), Geneva, Switzerland
| | - Colin McCowan
- School of Medicine, University of Dundee, (Nethergate), Dundee, (DD1 4HN), UK
| | - Gary Collins
- Centre for Statistics in Medicine, University of Oxford, (Linton Road), Oxford, (OX2 6UD), UK
| | - Jan Verbakel
- Department of General Practice, Katholieke University, Leuven, Belgium
| | - Monica Lakhanpaul
- Department of Medical and Social Care Education, University of Leicester, (University road), Leicester, (LE1 7RH), UK
| | - Tom Fahey
- Department of General Practice, Royal College of Surgeons in Ireland, (123 Stephen's green) Dublin 2, Republic of Ireland
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van der Steen JT, Toscani F, de Graas T, Finetti S, Nakanishi M, Nakashima T, Brazil K, Hertogh CMPM, Arcand M. Physicians' and Nurses' Perceived Usefulness and Acceptability of a Family Information Booklet about Comfort Care in Advanced Dementia. J Palliat Med 2011; 14:614-22. [DOI: 10.1089/jpm.2010.0484] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jenny T. van der Steen
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Department of Nursing Home Medicine, VU University Medical Center, Amsterdam, The Netherlands
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
| | - Franco Toscani
- Lino Maestroni Foundation-Palliative Medicine Research Institute, Cremona, Italy
| | - Tjomme de Graas
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Department of Nursing Home Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Silvia Finetti
- Lino Maestroni Foundation-Palliative Medicine Research Institute, Cremona, Italy
| | | | | | - Kevin Brazil
- Department of Clinical Epidemiology and Biostatistics, Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- St. Joseph's Health System Research Network, Hamilton, Canada
| | - Cees M. P. M. Hertogh
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Department of Nursing Home Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Marcel Arcand
- Department of Family Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
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