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Stevens J, Elston D, Tan A, Barwich D, Carter RZ, Cochrane D, Frenette N, Howard M. Clinicians' experiences implementing an advance care planning pathway in two Canadian provinces: a qualitative study. BMC PRIMARY CARE 2024; 25:217. [PMID: 38879532 PMCID: PMC11179357 DOI: 10.1186/s12875-024-02468-4] [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: 08/01/2023] [Accepted: 06/04/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Advance care planning (ACP) is a process which enables patients to communicate wishes, values, fears, and preferences for future medical care. Despite patient interest in ACP, the frequency of discussions remains low. Barriers to ACP may be mitigated by involving non-physician clinic staff, preparing patients ahead of visits, and using tools to structure visits. An ACP care pathway incorporating these principles was implemented in longitudinal generalist outpatient care, including primary care/family medicine and general internal medicine, in two Canadian provinces. This study aims to understand clinician experiences implementing the pathway. METHODS The pathway was implemented in one family practice in Alberta, two family practices in British Columbia (BC), and one BC internal medicine outpatient clinic. Physicians and allied health professionals delivered structured pathway visits based on the Serious Illness Conversation Guide. Twelve physicians and one social worker participated in interviews or focus groups at the end of the study period. Qualitative data were coded inductively using an iterative approach, with regular meetings between coders. RESULTS Clinicians described experiences with the ACP care pathway, impact at the clinician level, and impact at the patient level. Within each domain, clinicians described barriers and facilitators experienced during implementation. Clinicians also reflected candidly about potential for future implementation and the sustainability of the pathway. CONCLUSIONS While the pathway was implemented slightly differently between provinces, core experiences were that implementation of the pathway, and integration with current practice, were feasible. Across settings, similar themes recurred regarding usefulness of the pathway structure and its tools, impact on clinician confidence and interactions with patients, teamwork and task delegation, compatibility with existing workflow, and patient preparation and readiness. Clinicians were supportive of ACP and of the pathway. TRIAL REGISTRATION The study was prospectively registered with clinicaltrials.gov (NCT03508557). Registered April 25, 2018. https://classic. CLINICALTRIALS gov/ct2/show/NCT03508557 .
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Affiliation(s)
- Julie Stevens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Laarkbeeklaan 103, Brussels, Belgium.
| | - Dawn Elston
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
| | - Amy Tan
- Department of Medicine, Faculty of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, Canada
| | - Doris Barwich
- Department of Medicine, Faculty of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, Canada
- BC Centre for Palliative Care, 300 - 601 Sixth St., New Westminster, BC, Canada
| | - Rachel Zoe Carter
- Department of Medicine, Faculty of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, Canada
- BC Centre for Palliative Care, 300 - 601 Sixth St., New Westminster, BC, Canada
| | - Diana Cochrane
- BC Centre for Palliative Care, 300 - 601 Sixth St., New Westminster, BC, Canada
| | - Nicole Frenette
- Department of Family Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
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Lee HTS, Yang CL, Leu SV, Hu WY. Barriers to initiate a discussion about advance care planning among older Taiwanese residents of nursing homes and their families: A qualitative study. Appl Nurs Res 2024; 75:151766. [PMID: 38490796 DOI: 10.1016/j.apnr.2024.151766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 08/24/2023] [Accepted: 02/18/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND In Taiwan, the Patients' Right to Autonomy Act was enacted in 2019. However, advance care planning (ACP) implementation rates remain low in long-term care facilities. AIM This study explored the barriers to initiate a discussion about ACP among older Taiwanese residents of nursing homes and their families. METHODS A descriptive qualitative design was used. Face-to-face interviews were individually conducted with 38 participants (residents: 18; family members: 20), and data were analyzed through content analysis. RESULTS Five themes were identified: (1) having cultural or spiritual concerns (both groups), (2) prioritizing the bigger picture (family) (both groups), (3) waiting for the right time (both groups), (4) feeling unsure (residents), and (5) following the pace of the residents (family members). CONCLUSION The results indicate that discussing ACP with Chinese people and their families clashes with traditional Chinese culture. To implement ACP in long-term care facilities based in regions with ethnically Chinese populations, medical professionals must ensure that the residents and their family members understand advance directives and their role in ensuring a good death and must act as a bridge between residents and their family members to assist them in making consensual end-of-life-care decisions with residents.
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Affiliation(s)
- Hsin-Tzu Sophie Lee
- Department of Nursing, Tzu Chi University of Science and Technology, Hualien City 97005, Taiwan.
| | - Chia-Ling Yang
- MacKay Junior College of Medicine, Nursing and Management, Taipei City 11260, Taiwan.
| | - Sei-Ven Leu
- Department of Computer Center, Tzu Chi University, Hualien City 97071, Hualien County, Taiwan
| | - Wen-Yu Hu
- Department of Nursing, National Taiwan University, Taipei City, Taiwan.
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Hormazábal-Salgado R, Osman AD, Poblete-Troncoso M, Whitehead D, Hills D. Advanced Care Directives in Residential Aged Care for Residents with Major Neuro-Cognitive Disorders (Dementia): A Scoping Review. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2024; 20:83-114. [PMID: 37382889 DOI: 10.1080/15524256.2023.2229041] [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: 06/30/2023]
Abstract
The aim of this review was to identify, assess, collate, and analyze existing research that has made a direct contribution to aiding understanding of the ethical and decision-making issues related to the use of advance care directives for people with dementia and/or other major neurocognitive disorders and/or their surrogate decision-makers on treatment. The Web of Science, Scopus, PubMed, CINAHL, Academic Search Ultimate, and MEDLINE databases were searched between August and September 2021 and July to November 2022 limited to primary studies written in English, Spanish, or Portuguese. Twenty-eight studies of varying quality that addressed related thematic areas were identified. These themes being support for autonomy in basic needs (16%), making decisions ahead/planning ahead and upholding these decisions (52%), and support in decision-making for carers (32%). Advance care directives are an important mechanism for documenting treatment preferences in patient care planning. However, the available literature on the topic is limited in both quantity and quality. Recommendations for practice include involving decision makers, promoting educational interventions, exploring how they are used and implemented, and promoting the active involvement of social workers within the healthcare team.
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Affiliation(s)
| | - Abdi D Osman
- College of Sports, Health and Engineering, Victoria University, Melbourne, Australia
| | | | - Dean Whitehead
- Institute of Health and Wellbeing, Federation University Australia, Berwick, Australia
| | - Danny Hills
- Institute of Health and Wellbeing, Federation University Australia, Berwick, Australia
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Wang X, Huang XL, Wang WJ, Liao L. Advance care planning for frail elderly: are we missing a golden opportunity? A mixed-method systematic review and meta-analysis. BMJ Open 2023; 13:e068130. [PMID: 37247960 DOI: 10.1136/bmjopen-2022-068130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVE The aim is to integrate quantitative and qualitative evidence to understand the effectiveness and experience of advance care planning (ACP) for frail elderly. DESIGN A mixed-methods systematic review and meta-analysis was conducted. Quality evaluation was conducted using critical appraisal tools from the Joanna Briggs Institute. Data were synthesised and pooled for meta-analysis or meta-aggregation as needed. DATA SOURCES An electronic search of MEDLINE, CINAHL, Embase, PubMed, PsycINFO, and Cochrane Library databases from January 2003 to April 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included experimental and mixed-methods studies. The quantitative component attempts to incorporate a broader study design. The qualitative component aids in comprehending the participant's experience with ACP and its efficacy. DATA EXTRACTION AND SYNTHESIS Two independent reviewers undertook screening, data extraction and quality assessment. The quantitative and qualitative data were synthesised and integrated using a convergent segregated approach. RESULTS There were 12 158 articles found, and 17 matched the inclusion criteria. The quality of the quantitative component of most included studies (6/10) was rated as low, and the qualitative component of half included studies (4/8) was rated as moderate. The meta-analysis showed that the intervention of ACP for frail elderly effectively increases readiness, knowledge and process of ACP behaviours. The meta-aggregation showed that the participants hold a positive attitude towards ACP and think it facilitates expressing their preferences for the medical decision. CONCLUSION ACP is an effective and feasible strategy to facilitate frail elderly to express their healthcare wishes timely and improve their outcomes. This study could provide proof for a better understanding of the subject and help direct future clinical practice. More well-designed randomised controlled trials evaluating the most effective ACP interventions and tools are needed for the frail elderly population. PROSPERO REGISTRATION NUMBER CRD42022329615.
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Affiliation(s)
- Xinying Wang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Xin-Lin Huang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Wei-Jia Wang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Li Liao
- University of South China School of Nursing, Hengyang, Hunan, China
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5
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Mechanisms and contextual influences on the implementation of advance care planning for older people in long-term care facilities: A realist review. Int J Nurs Stud 2022; 133:104277. [PMID: 35717924 DOI: 10.1016/j.ijnurstu.2022.104277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 01/10/2023]
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Combes S, Forbes G, Gillett K, Norton C, Nicholson CJ. Development of a theory-based intervention to increase cognitively able frail elders' engagement with advance care planning using the behaviour change wheel. BMC Health Serv Res 2021; 21:712. [PMID: 34284759 PMCID: PMC8290869 DOI: 10.1186/s12913-021-06548-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/17/2021] [Indexed: 11/22/2022] Open
Abstract
Background Advance care planning (ACP) conversations support people to think about, discuss and document their beliefs, values and preferences regarding future care. This process means that should the person loose capacity in the future, care can be provided, consistent with their personal values and beliefs. The ACP process is particularly relevant for older people living with frailty (frail elders) as they are vulnerable to sudden deterioration. However, ACP is rarely undertaken by frail elders. The aim of this study was to develop an intervention to increase multidisciplinary health and social care professionals’ (H&SCPs) engagement of cognitively able, domestic-dwelling frail elders with ACP. Methods Intervention development was guided by the Medical Research Council framework for complex interventions and the Behaviour Change Wheel. Multiple methods were used to understand ACP barriers and enablers: a systematic integrative review, a survey (n = 73 H&SCPs), and semi-structured interviews (n = 10 frail elders, n = 8 family members). A conceptual model, developed from the integrative review, underpinned data collection for the survey and interviews. Synthesis of this data, including patient and public involvement, was then used to identify H&SCPs behaviours that needed to change for ACP to be implemented and decide content and implementation for the intervention. Results Following the Behaviour Change Wheel system, and based on the findings of the review, survey and interviews, the prototype intervention, Conversations on Living and Dying (CLaD), was developed. The CLaD prototype consisted of one 3.5-hour educational skills session for H&SCPs supported by a toolkit. Content focussed on the relevance of ACP for frail elders, experience of ACP by frail elders, and strategies H&SCPs could adopt to encourage frail elders’ engagement with ACP. Strategies include recognising the importance of relationships and living well now, preparing frail elders for ACP conversations and starting ACP early. Participants who took part in initial prototype refinement reported that the intervention helped them think differently about ACP and encouraged them to engage with frail elders. Conclusions The use of behavioural theory enabled the development of CLaD, an evidence-based, theory-driven, person-centred intervention to support ACP engagement with frail elders. While feasibility testing is required, initial prototype refinement demonstrated that H&SCPs found the intervention to be acceptable, engaging, and clinically valuable in their practice with frail elders and their families. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06548-4.
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Affiliation(s)
- S Combes
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK. .,St Christopher's Hospice, London, UK.
| | - G Forbes
- Centre for Behaviour Change, University College London, London, UK
| | - K Gillett
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - C Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - C J Nicholson
- St Christopher's Hospice, London, UK.,Faculty of Health and Medical Sciences, Surrey University, Guildford, UK
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Rainsford S, Hall Dykgraaf S, Kasim R, Phillips C, Glasgow N. 'Traversing difficult terrain'. Advance care planning in residential aged care through multidisciplinary case conferences: A qualitative interview study exploring the experiences of families, staff and health professionals. Palliat Med 2021; 35:1148-1157. [PMID: 34015973 PMCID: PMC8189000 DOI: 10.1177/02692163211013250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Advance care planning improves the quality of end-of-life care for older persons in residential aged care; however, its uptake is low. Case conferencing facilitates advance care planning. AIM To explore the experience of participating in advance care planning discussions facilitated through multidisciplinary case conferences from the perspectives of families, staff and health professionals. DESIGN A qualitative study (February-July 2019) using semi-structured interviews. SETTING Two residential aged care facilities in one Australian rural town. PARTICIPANTS Fifteen informants [family (n = 4), staff (n = 5), health professionals (n = 6)] who had participated in advance care planning discussions facilitated through multidisciplinary case conferences. RESULTS Advance care planning was like navigating an emotional landscape while facing the looming loss of a loved one. This emotional burden was exacerbated for substitute decision-makers, but made easier if the resident had capacity to be involved or had previously made their wishes clearly known. The 'conversation' was not a simple task, and required preparation time. Multidisciplinary case conferences facilitated informed decision-making and shared responsibility. Opportunity to consider all care options provided families with clarity, control and a sense of comfort. This enabled multiple stakeholders to bond and connect around the resident. CONCLUSION While advance care planning is an important element of high quality care it involves significant emotional labour and burden for families, care staff and health professionals. It is not a simple administrative task to be completed, but a process that requires time and space for reflection and consensus-building to support well-considered decisions. Multidisciplinary case conferences support this process.
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Affiliation(s)
- Suzanne Rainsford
- Rural Clinical School, Medical School, Australian National University, Canberra, ACT, Australia.,Clare Holland House, Calvary Health Care Bruce, Canberra, ACT, Australia
| | - Sally Hall Dykgraaf
- Rural Clinical School, Medical School, Australian National University, Canberra, ACT, Australia
| | - Rosny Kasim
- Rural Clinical School, Medical School, Australian National University, Canberra, ACT, Australia
| | - Christine Phillips
- Medical School, Australian National University, Canberra, ACT, Australia
| | - Nicholas Glasgow
- Clare Holland House, Calvary Health Care Bruce, Canberra, ACT, Australia.,Medical School, Australian National University, Canberra, ACT, Australia
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8
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Phung LH, Barnes DE, Volow AM, Li BH, Shirsat NR, Sudore RL. English and Spanish-speaking vulnerable older adults report many barriers to advance care planning. J Am Geriatr Soc 2021; 69:2110-2121. [PMID: 34061370 DOI: 10.1111/jgs.17230] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 04/06/2021] [Accepted: 04/20/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND/OBJECTIVES Advance care planning (ACP) rates are low in diverse, vulnerable older adults, yet little is known about the unique barriers they face and how these barriers impact ACP documentation rates. DESIGN Validated questionnaires listing patient, family/friend, and clinician/system-level ACP barriers and an open-ended question on ACP barriers. SETTING Two San Francisco public/Department of Veterans Affairs hospitals. PARTICIPANTS One thousand two hundred and forty-one English and Spanish-speaking patients, aged 55 and older, with two or more chronic conditions. MEASUREMENTS The open-ended question on ACP barriers was analyzed using content analysis. We conducted chart review for prior ACP documentation. We used chi-square/Wilcoxon rank-sum tests and logistic regression to assess associations between ACP barriers and demographic characteristics/ACP documentation. RESULTS Participant mean age was 65 ± 7.4 years; they were 74% from racial/ethnic minority groups, 36% Spanish-speaking, and 36% with limited health literacy. A total of 26 barriers were identified (15 patient, 4 family/friend, 7 clinician/system-level), and 91% reported at least one ACP barrier (mean: 5.6 ± 4.0). The most common barriers were: (patient-level) discomfort thinking about ACP (60%), wanting to leave health decisions to "God" (44%); (family/friend-level) not wanting to burden friends/family (33%), assuming friends/family already knew their preferences (31%); (clinician/system-level) assuming doctors already knew their preferences (41%), and mistrust (37%). Compared with those with no barriers, participants with at least one reported barrier were more likely to be from a racial/ethnic minority group (76% vs 53%), Spanish-speaking (39% vs 6%), with fair-to-poor health (48% vs 34%), and limited health literacy (39% vs 9%) (p < 0.001 for all). Participants who reported barriers were less likely to have ACP documentation (adjusted odds ratio = 0.64, 95% confidence interval [0.42, 0.98]). CONCLUSION English- and Spanish-speaking older adults reported 26 unique barriers to ACP, with higher barriers among vulnerable populations, and barriers were associated with lower ACP documentation. Barriers must be considered when developing customized ACP interventions for diverse older adults.
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Affiliation(s)
- Linda H Phung
- School of Medicine, Duke University, Durham, North Carolina, USA.,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Deborah E Barnes
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA.,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California, USA.,Innovation and Implementation Center for Aging and Palliative Care (I-CAP), Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Research Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Aiesha M Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brookelle H Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Nikita R Shirsat
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Innovation and Implementation Center for Aging and Palliative Care (I-CAP), Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Research Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
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9
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Combes S, Gillett K, Norton C, Nicholson CJ. The importance of living well now and relationships: A qualitative study of the barriers and enablers to engaging frail elders with advance care planning. Palliat Med 2021; 35:1137-1147. [PMID: 33934669 PMCID: PMC8189003 DOI: 10.1177/02692163211013260] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The population of frail elders is growing, and due to their vulnerability to sudden deterioration, advance care planning is particularly important. However, advance care planning is uncommon for multiple reasons, some of which are linked to the perceptions of frail elders and their families. AIM To explore the barriers and enablers to advance care planning engagement with frail elders. DESIGN Qualitative in-depth interviews with thematic analysis. SETTING/PARTICIPANTS Purposive sample of 10 frail elders and 8 nominated family members using a community-based older persons' service run by a large urban UK hospice. Frail elders had capacity, were ⩾65 (median 85, range 71-95), scored 6 or 7 (median 6.5) on the Clinical Frailty Scale, and 70% were female. RESULTS Key barriers were: Advance care planning is unclear, in terms of meaning and the language used; Lack of relevance, with frail elders preferring to focus on living well now; and the Importance of family, relationships and home, and the influence of relationship on end of life decision-making. Engagement strategies included preparing the frail elder for advance care planning conversations and using a gentle, honest, individualised approach. CONCLUSIONS Essential enablers for frail elders are understanding what advance care planning is and why it may be relevant to them. For professionals, enablers include recognising the importance of living well now and relational decision-making. To further support advance care planning, recommendations include early engagement and re-conceptualising advance care planning as an ongoing process which encompasses current and future care. Further research is needed in different cultures and care contexts.
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Affiliation(s)
- Sarah Combes
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,St Christopher's Hospice, London, UK
| | - Karen Gillett
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Caroline Jane Nicholson
- St Christopher's Hospice, London, UK.,Faculty of Health and Medical Sciences, Surrey University, Guildford, UK
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West E, Moore K, Kupeli N, Sampson EL, Nair P, Aker N, Davies N. Rapid review of decision-making for place of care and death in older people: lessons for COVID-19. Age Ageing 2021; 50:294-306. [PMID: 33336701 PMCID: PMC7799338 DOI: 10.1093/ageing/afaa289] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction The coronavirus pandemic (COVID-19) has affected the functioning and capacity of healthcare systems worldwide. COVID-19 has also disproportionately affected older adults. In the context of COVID-19, decision-making surrounding place of care (PoC) and place of death (PoD) in older adults involves significant new challenges. Aims To explore key factors that influence PoC and PoD decisions in older adults. A secondary aim was to investigate key factors that influence the process and outcome of these decisions in older adults. To apply findings from current evidence to the context of COVID-19. Methods Rapid review of reviews, undertaken using WHO guidance for rapid reviews for the production of actionable evidence. Data extracted was synthesised using narrative synthesis, with thematic analysis and tabulation. Results 10 papers were included for full data extraction. These papers were published between 2005 and 2020. Papers included discussed actual PoD, as well as preferred. Results were divided into papers that explored the process of decision-making, and those that explored decision-making outcomes. Conclusions The process and outcomes of decision-making for older people are affected by many factors—all of which have the potential to influence both patients and caregivers experience of illness and dying. Within the context of COVID-19, such decisions may have to be made rapidly and be reflexive to changing needs of systems and of families and patients.
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Affiliation(s)
- Emily West
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Kirsten Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet, Enfield and Haringey Mental Health Liaison Service, North Middlesex University Hospital NHS Trust, London, UK
| | - Pushpa Nair
- Centre for ageing population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Narin Aker
- Centre for ageing population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Centre for ageing population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
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Redressing disparities in end-of-life care and serious mental illness through models of care and workforce development. Int Psychogeriatr 2021; 33:109-112. [PMID: 33750500 PMCID: PMC9063934 DOI: 10.1017/s1041610220001519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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12
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Residents' and family members' perceptions of care quality and self-determination in palliative phase in residential care. Palliat Support Care 2020; 18:69-81. [PMID: 31030693 DOI: 10.1017/s1478951519000178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Dependency on others can compromise self-determination for older persons in the palliative phase in residential care. Family members can support the residents' self-determination but may also jeopardize it. Quality of care (QoC) is linked to respecting the autonomy of the residents and providing opportunities to participate in decision-making. The aim of the study was to provide knowledge about residents' and family members' perceptions of QoC and self-determination and to detect possible differences between their experiences. METHOD This cross-sectional study used an abbreviated version of the questionnaire, Quality from the Patients' Perspective, with additional items about decision-making. Wilcoxon's signed rank test was used to analyze the perception of QoC and to detect differences between residents' and family members' perceptions. RESULT QoC was perceived as lower than preferred in the majority of items and there was a high level of agreement between residents and family members. Lowest mean values in QoC were found in: support when feeling lonely; support when feeling worry, anxiety or fear; and staff's time to talk to the residents. Decision-making in everyday life and in life-changing situations showed that neither residents nor family members trusted staff to know about the residents' preferences. SIGNIFICANCE OF RESULTS Broad improvements are needed, especially in psychosocial care. Several of the negative outcomes on QoC and self-determination seem to derive from a focus on practical tasks and the lack of trustful relationships between residents and staff. An early implementation of palliative care, with a focus on what brings quality to each resident's life, could facilitate QoC and self-determination, in both everyday life and at the end of life.
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13
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Lee L, Hillier LM, Lu SK, Ward D. Enabling Advance Care Planning in Dementia Care: A Primary Care Approach. J Palliat Care 2020; 36:224-233. [PMID: 33176583 DOI: 10.1177/0825859720973937] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Lack of tools to support advance care planning (ACP) has been identified as a significant barrier to implementing these discussions. AIM We pilot tested an ACP framework tool for use with persons living with dementia (PLWD) in primary care-based memory clinics and an Adult Day Program; this study describes user and recipient experiences with this framework. METHODS We used a mixed methods approach. Health professionals completed an online survey following pilot testing and PLWD and substitute decision makers (SDM) completed survey immediately following the ACP discussion assessing their satisfaction (5-point scale) with the framework and exploring potential outcomes. Interviews with health professionals, PLWD, and SDM were conducted to gather more in-depth information on their perceptions of the ACP framework/ discussion. RESULTS Surveys were completed by 12 health professionals, 13 PLWD, and 16 SDM. While PLWD and SDM were satisfied with the ACP discussion (M = 4.0/5), health professionals were minimally satisfied with the ease of use of the framework (M = 2.0/5), acceptability for patients (M = 2.4/5) and feasibility in practice (M = 1.9/5). Sixteen interviews were completed with 8 health professionals, 1 PLWD, and 7 SDM. While health professionals valued ACP, lack of time and training were identified barriers to framework use. SDM felt better prepared for future decisions and PLWD were put at ease, knowing that their wishes for care were understood. CONCLUSION PLWD and SDM value the opportunity for ACP, and although health professionals identified some concerns with framework administration, they acknowledge the value and importance of ACP. Continuing efforts to refine ACP processes are justified.
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Affiliation(s)
- Linda Lee
- The Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada.,Department of Family Medicine, Faculty of Health Sciences, 3710McMaster University, Hamilton, Ontario, Canada
| | - Loretta M Hillier
- GERAS Centre for Aging Research, Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | - Stephanie K Lu
- The Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada
| | - Donna Ward
- Department of Family Medicine, Faculty of Health Sciences, 3710McMaster University, Hamilton, Ontario, Canada.,Hospice Palliative Care Associates Kitchener Waterloo and Area, Kitchener, Ontario, Canada
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Goossens B, Sevenants A, Declercq A, Van Audenhove C. Improving shared decision-making in advance care planning: Implementation of a cluster randomized staff intervention in dementia care. PATIENT EDUCATION AND COUNSELING 2020; 103:839-847. [PMID: 31818522 DOI: 10.1016/j.pec.2019.11.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/04/2019] [Accepted: 11/23/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Increasing staff engagement level of shared decision-making in advance care planning for persons with dementia in nursing homes. Perceived importance, competence and frequency of staff members applying shared decision-making were measured. Additionally, facilitators and barriers in the implementation process were described. METHODS In this pretest-posttest cluster randomized trial, 311 staff members from 65 Belgian nursing home wards participated. Key components of the intervention were knowledge on shared decision-making, role-play exercises and internal policies on advance care planning. Audio recordings of advance care planning conversations between residents, families and staff were compared before and after the intervention. Participants filled in questionnaires and provided feedback. RESULTS Wards demonstrated a higher level of shared decision-making after the intervention (p < 0.001) while time spent on the conversations did not increase. This effect persisted at 6 months follow-up (p < 0.001). Participants perceived shared decision-making as more important (p = 0.031) and felt more competent (p = 0.010), though frequency of use did not change (p = 0.201). High staff turnover and difficult co-operation with GP's were barriers. CONCLUSION Nursing home staff benefits from this training in shared decision-making. PRACTICE IMPLICATIONS Learning shared decision-making in advance care planning for persons with dementia is possible and sustainable in the time-constricted context of nursing homes.
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Affiliation(s)
- Bart Goossens
- LUCAS - Centre for Care Research & Consultancy, KU Leuven, Minderbroedersstraat 8, Postal Box 5310, 3000, Leuven, Belgium.
| | - Aline Sevenants
- LUCAS - Centre for Care Research & Consultancy, KU Leuven, Minderbroedersstraat 8, Postal Box 5310, 3000, Leuven, Belgium; Academic Center for General Practice, KU Leuven, Kapucijnenvoer 33j, Postal Box 7001, 3000, Leuven, Belgium.
| | - Anja Declercq
- LUCAS - Centre for Care Research & Consultancy, KU Leuven, Minderbroedersstraat 8, Postal Box 5310, 3000, Leuven, Belgium; Centre for Sociological Research, KU Leuven, Parkstraat 45, Postal Box 3601, 3000, Leuven, Belgium.
| | - Chantal Van Audenhove
- LUCAS - Centre for Care Research & Consultancy, KU Leuven, Minderbroedersstraat 8, Postal Box 5310, 3000, Leuven, Belgium; Academic Center for General Practice, KU Leuven, Kapucijnenvoer 33j, Postal Box 7001, 3000, Leuven, Belgium.
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15
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Ottoboni G, Chattat R, Camedda C, Galletti M, Macripò S, Mariani E, Ingravallo F. Nursing home staff members' knowledge, experience and attitudes regarding advance care planning: a cross-sectional study involving 12 Italian nursing homes. Aging Clin Exp Res 2019; 31:1675-1683. [PMID: 30637596 DOI: 10.1007/s40520-018-01110-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 12/21/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Advance care planning may be beneficial for nursing home residents, but its implementation is suboptimal in several countries. AIMS To investigate knowledge of, attitudes towards, and experience with advance care planning of nursing home staff members in Italy. METHODS Cross-sectional survey involving all healthcare professionals working in 12 Italian nursing homes. Statistical analyses investigated interactions between participants' characteristics, knowledge, attitudes and frequency of advance care planning discussion with residents. RESULTS Of the 185 participants (80.5% female, mean age 43.6 ± 9.2 years), 29.7% reported that they had heard of advance care planning, but their actual knowledge was suboptimal. Participants had positive attitudes towards advance care planning, and most of them clearly recognized its benefits. Apprehension about upsetting the patient or their family, or that patients were not ready for these conversations were the main concerns. Only 16% of respondents discussed advance care planning at least sometimes, usually upon patient/family input. Greater knowledge was significantly correlated with more positive attitudes towards advance care planning. The issues of healthcare professionals' knowledge and training in advance care planning, and of knowledge and awareness of advance care planning in patients, their families, and the general population were considered either main barriers or facilitators. DISCUSSION Nursing home staff members' concerns towards advance care planning seemed to be related to a misconception about patient and family willingness to discuss it. CONCLUSIONS A multifaceted strategy including educational and training programmes and the increase of public awareness is needed to implement advance care planning in Italian nursing homes.
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Combes S, Nicholson CJ, Gillett K, Norton C. Implementing advance care planning with community-dwelling frail elders requires a system-wide approach: An integrative review applying a behaviour change model. Palliat Med 2019; 33:743-756. [PMID: 31057042 PMCID: PMC6620766 DOI: 10.1177/0269216319845804] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Facilitating advance care planning with community-dwelling frail elders can be challenging. Notably, frail elders' vulnerability to sudden deterioration leads to uncertainty in recognising the timing and focus of advance care planning conversations. AIM To understand how advance care planning can be better implemented for community-dwelling frail elders and to develop a conceptual model to underpin intervention development. DESIGN A structured integrative review of relevant literature. DATA SOURCES CINAHL, Embase, Ovid Medline, PsycINFO, Cochrane Library, and University of York Centre for Reviews and Dissemination. Further strategies included searching for policy and clinical documents, grey literature, and hand-searching reference lists. Literature was searched from 1990 until October 2018. RESULTS From 3043 potential papers, 42 were included. Twenty-nine were empirical, six expert commentaries, four service improvements, two guidelines and one theoretical. Analysis revealed nine themes: education and training, personal ability, models, recognising triggers, resources, conversations on death and dying, living day to day, personal beliefs and experience, and relationality. CONCLUSION Implementing advance care planning for frail elders requires a system-wide approach, including providing relevant resources and clarifying responsibilities. Early engagement is key for frail elders, as is a shift from the current advance care planning model focussed on future ceilings of care to one that promotes living well now alongside planning for the future. The proposed conceptual model can be used as a starting point for professionals, organisations and policymakers looking to improve advance care planning for frail elders.
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Affiliation(s)
- Sarah Combes
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
- St Christopher’s Hospice, London,
UK
| | - Caroline Jane Nicholson
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
- St Christopher’s Hospice, London,
UK
| | - Karen Gillett
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
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Hemsley B, Meredith J, Bryant L, Wilson NJ, Higgins I, Georgiou A, Hill S, Balandin S, McCarthy S. An integrative review of stakeholder views on Advance Care Directives (ACD): Barriers and facilitators to initiation, documentation, storage, and implementation. PATIENT EDUCATION AND COUNSELING 2019; 102:1067-1079. [PMID: 30799141 DOI: 10.1016/j.pec.2019.01.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To examine the views and experiences of patients and their health care providers on developing advance care planning (ACP) and advance care directives (ACD); and determine barriers and facilitators to ACD development, storage, and use, including implications for people with communication disability. METHOD An integrative review of 93 studies, analysed according to their content themes. RESULTS Content themes encapsulated the initiation, documentation, and implementation stages of ACP/ACD. Lack of guidance for initiating and supporting ACP/ACD impedes discussions, and both patients and healthcare providers avoid discussions owing to fear of dying and reluctance to think about end-of-life. CONCLUSIONS There are several barriers and facilitators to the initiation of ACP discussions, documentation and implementation of ACD, and little research exploring the views of legal professionals on the development, storage, or use of ACP documents. Further research is needed to explore the timing and responsibility of both legal and health professionals in initiating and supporting ACP discussions. PRACTICE IMPLICATIONS It is important for healthcare providers to raise ACP discussions regularly so that patients have time to make informed advance care decisions. Storage of the document in an electronic health record might facilitate better access to and implementation of patients' end-of-life care decisions.
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Affiliation(s)
- Bronwyn Hemsley
- The University of Technology Sydney, Building 7, Faculty of Science and Graduate School of Health Building, 67 Thomas Street, Ultimo, Australia @BronwynHemsley.
| | - Jacqueline Meredith
- The University of Newcastle, University Drive, Callaghan, 2308, NSW, Australia.
| | - Lucy Bryant
- The University of Technology Sydney, Building 7, Faculty of Science and Graduate School of Health Building, 67 Thomas Street, Ultimo, Australia @BronwynHemsley.
| | - Nathan J Wilson
- Western Sydney University, Building G10/Office 10, Hawkesbury Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia.
| | - Isabel Higgins
- The University of Newcastle, University Drive, Callaghan, 2308, NSW, Australia.
| | - Andrew Georgiou
- Macquarie University, Room L6 36, Level 6, 75 Talavera Road, NSW, 2109, Australia.
| | - Sophie Hill
- La Trobe University, School of Psychology and Public Health, College of Science, Health and Engineering, VIC, 3086, Australia.
| | - Susan Balandin
- Deakin University, Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC, 3125, Australia.
| | - Shaun McCarthy
- The University of Newcastle, University Drive, Callaghan, 2308, NSW, Australia.
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Sævareid TJL, Førde R, Thoresen L, Lillemoen L, Pedersen R. Significance of advance care planning in nursing homes: views from patients with cognitive impairment, their next of kin, health personnel, and managers. Clin Interv Aging 2019; 14:997-1005. [PMID: 31213786 PMCID: PMC6549780 DOI: 10.2147/cia.s203298] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/18/2019] [Indexed: 01/23/2023] Open
Abstract
Purpose: Advance care planning (ACP) performed by regular staff, which also includes patients with cognitive impairment and their next of kin, is scarcely studied. Thus, we planned an implementation study including key stakeholders (patients, next of kin, and health care personnel) using a whole-ward/system approach to ACP. We explored how they experienced ACP and its significance. Patients and methods: This qualitative study is part of a mixed-method implementation study of ACP. In four nursing homes, we did qualitative interviews and audio-recordings of meetings. We completed 20 individual semistructured interviews with participants soon after ACP conversations. The interviews included patients with cognitive impairment, their next of kin, and health care personnel. We also conducted four focus group interviews with staff and managers in the nursing homes and audio-recorded four network meetings with the project teams implementing ACP. Results: All participants appreciated taking part in ACP. Patients and next of kin focused more on the past and present than future treatment preferences. Still, ACP seemed to contribute to a stronger patient focus on end-of-life conversations. More generally, ACP seemed to contribute to valuable information for future decision-making, trusting relations, improved end-of-life communication, and saving time and resources. Conclusion: Safeguarding a strong patient focus on ACP and fostering a person-centered care culture in nursing home wards seem to be achievable through implementation of ACP that includes regular staff, patients with cognitive impairment, and their next of kin.
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Affiliation(s)
| | - Reidun Førde
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Lisbeth Thoresen
- Centre for Medical Ethics, University of Oslo, Oslo, Norway.,Department of Health Sciences, University of Oslo, Oslo, Norway
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