Rural health professionals' experiences in implementing advance care planning: a focus group study

Increasing the uptake of advance care directives through staff education and one-on-one support for people facing end-of-life

BACKGROUND

An advance care plan outlines a patient's wishes regarding medical treatment or goals of care in the case that they become unable to communicate or to make decisions. An advance care directive (ACD) is an advance care plan that has been formally recorded and has legal status. Despite ACDs playing an important role in person-centred end-of-life care, an earlier retrospective medical records audit demonstrated that only 11% (58/531) of people who died due to a terminal illness had an ACD.The aim of this project was to increase the proportion of patients with a terminal illness completing an ACD. A secondary outcome was to measure the impact of ACDs on hospital and intensive care unit (ICU) admissions in the last 6 months of life.This multifaceted project comprised (1) education for health professionals and the public; (2) individual support for patients on request; (3) development of online resources for health professionals and the general public; and (4) monthly team meetings.

METHOD

The proportion of ACDs completed and hospital and ICU admissions during the last 6 months of life, were extracted via medical record audits.Written consent was required for patients to participate, including being contacted by the project team and accessing their medical records.

RESULTS

112 patients consented to participate in the project and 109 (97%) completed an ACD. There was no reduction in the average number of hospital admissions, while ICU admissions reduced from 14% (n=74) to 0%.

CONCLUSION

The targeted, multifaceted approach to education and support for completion of ACDs, resulted in a significant increase in ACD completion and a major reduction in ICU admissions.

A cross-sectional study assessing concordance with advance care directives in a rural health district

OBJECTIVE

To measure compliance with Advance Care Directives (ACDs) for decedents in a rural setting.

DESIGN

Observational, cross-sectional medical records audit comparing requests in ACDs with actual outcomes.

SETTING

Rural Australian coastal district.

PARTICIPANTS

People who had an ACD, died during the study period (30 May 2020 to 15 December 2021) and participated in a local research project.

MAIN OUTCOME MEASURE(S)

Compliance was measured by comparing stated requests in the ACD with outcomes recorded in medical records. This included the place of death and a list of 'unacceptable interventions'.

RESULTS

Sixty-eight people met the inclusion criteria (age range of 46-92 [mean 67 years; median 74 years]; 42 [62%] male). The main cause of death was cancer (n = 48; 71%). Preferred place of death was not stated in 16 ACDs. Compliance with documented preferred place of death was 63% (33/52): 48% (16/33) when the preferred place of death was home; 78% (7/9) when sub-acute was preferred; and 100% (10/10) when hospital was preferred. Compliance was 100% with 'unacceptable interventions'.

CONCLUSION

These results demonstrate strong compliance with rural patients' requests in ACDs, particularly 'unacceptable interventions'. Home was the most common preferred place of death, but the compliance measure (48%) was the lowest in this study. This requires further exploration.

Exploring patients' advance care planning needs during the annual 75+ health assessment: survey of Australian GPs' views and current practice

BACKGROUND

The 75+ health assessment has been identified as a suitable trigger to introduce advance care planning (ACP) to general practice patients. Australian general practitioners (GPs) were surveyed to explore their perceptions, attitudes and practices in introducing ACP during 75+ health assessments.

METHODS

A cross-sectional postal survey of Australian GPs covering their personal, professional and workplace characteristics, their current practice regarding ACP within a 75+ health assessment, and their attitude towards ACP. Multivariate logistic regression was used to analyse the factors associated with routinely discussing ACP as part of the 75+ health assessment.

RESULTS

A total of 185 (19.2%) out of 964 eligible GPs returned a completed survey. Most GPs reported that patients interested in ACP were supported by the GPs or the practice nurse. Two factors, (1) attitude that ACP is an essential component of the 75+ health assessment, and (2) regional or rural location of the practice, had a statistically and clinically significant association with the GP's self-reported discussion of ACP during 75+ health assessments.

CONCLUSIONS

GPs showed a high level of support and involvement in discussing ACP during 75+ health assessments. ACP support during 75+ health assessments was often provided directly by the GP or via the practice nurse. Given the international evidence that ACP training programs improve skills and knowledge, and foster positive attitudes towards ACP, there is an important need to continue funding ACP training programs for GPs and practice nurses.

Palliative Care Within the Primary Health Care Setting in Australia: A Scoping Review

Objectives: This scoping review identifies and details the scope of practice of health professionals who provide palliative care within the primary health setting in Australia.

Methods: A scoping review approach was conducted on the Cinahl (Ebsco), Scopus, Medline (Ovid) and PubMed databases to extract articles from 1 December 2015 to 1 December 2020. Broad text words and MeSH headings were used with relevance to palliative care, general practice, primary health, and community setting. Extracted journal articles were limited to those based on the Australian population or Australian health system.

Results: Eighty-four papers met the inclusion criteria and were included in the review. The review identified the following health professional roles within the Primary Health Care setting undertaking palliative care: General Practitioner, Nurse, Pharmacist, Paramedics, Carers, and Allied Health professionals.

Conclusion: This review offers a first understanding of the individual health professional roles and multidisciplinary team approach to actively providing palliative care within the Primary Health Care setting in Australia.

Organisational and advance care planning program characteristics associated with advance care directive completion: a prospective multicentre cross-sectional audit among health and residential aged care services caring for older Australians

Background

Advance care planning (ACP) and advance care directive (ACD) completion improve outcomes for patients, family, clinicians and the healthcare system. However, uptake remains low. Despite increasing literature regarding organisational-level ACP characteristics leading to success, there is a lack of data measuring the impact of these factors on ACD prevalence.

Methods

A prospective multi-centre, cross-sectional audit of health records among older Australians accessing general practices (GP), hospitals and residential aged care facilities (RACF) was undertaken to describe organisational and ACP-program characteristics across services, document ACD prevalence, and assess organisation-level predictors of ACD prevalence. Organisational-level data included general and ACP-program characteristics. Patient/resident data included demographics and presence of ACDs.

Results

One hundred organisations (GP = 15, hospitals = 27, RACFs = 58) participated, contributing data from 4187 patient/resident health records. Median prevalence of ACDs across organisations was 19.4%, (range = 0–100%). In adjusted models, organisational sector type was the strongest predictor of ACD prevalence, with higher rates in RACFs (unadjusted 28.7%, adjusted 20.6%) than hospitals (unadjusted 6.4%, adjusted 5.8%) or GPs (unadjusted 2.5%, adjusted 6.6%). RACFs in regional and rural/remote areas had higher prevalence than metropolitan organisations. Organisations supported by government funding and those that were Not For Profit had higher prevalence than those that were privately funded, and organisations with an ACP program that had been implemented at least 3 years before data collection had higher prevalence than those with either no program or a more recent program.

Conclusions

The median ACD prevalence was low, with substantial variation across organisations. Sector type was the strongest predictor, being highest in RACFs. Low prevalence rates, overall and in particular sectors, have implications for improvements. Further research into organisational factors associated with ACP/ACD completion is required.

Adapting and Going the Extra Mile: A Qualitative Study of Palliative Care in Rural Northern Norway From the Perspective of Healthcare Providers

BACKGROUND

Despite significant developments in palliative care in recent decades, we still find important differences in access to and delivery of care in rural Norway.

OBJECTIVE

The aim of this study was to explore what healthcare professionals consider necessary to provide equality in care for palliative patients in rural areas.

METHODS

A qualitative approach with focus group discussions and individual interviews with 52 health professionals was used, starting with 5 uniprofessional focus groups of general practitioners and nurses/cancer nurses, followed by 5 interprofessional groups and 6 individual interviews. Interview transcripts were analyzed thematically.

RESULTS

We found local variations in organization, competence and access to palliative care, and challenging geographical conditions. It was essential to be proactive, flexible and willing to go the extra mile, but this may conceal the need for a stronger focus on competence and organization of palliative care. Access to written guidelines and practical tools was important, as was forming palliative teams for particular situations.

CONCLUSIONS

Palliative care needs strengthening in rural areas, and increased competence for all healthcare professionals is vital to increase equality in care. Geographical conditions require locally adapted solutions. Access to guidelines and interprofessional collaboration are essential.

IMPLICATIONS FOR PRACTICE

Rural palliative care needs in Norway are improving, as exemplified by at least 1 cancer nurse assigned to each local authority, and access to guidelines and palliative tools and interprofessional collaboration.

Feasibility of an Advance Care Planning Program (ACP) for Korean Community-Dwelling Older Adults and ACP Training of Advance Practice Nurses

This study aimed to develop a locally suitable advance care planning (ACP) program for older community-dwelling adults and a training program for nurse facilitators in Korea, and to evaluate their feasibility from the facilitators' experiences. This was a mixed methods pilot study that assessed the feasibility of an ACP program by analyzing survey, checklist, and focus group interview data. The ACP program was named CLOSE (Communicating and Listening to Our Seniors' voices about End-of-life care). Home health care nurses (N = 9) participated in this study. The participants reported that CLOSE was applicable to older community-dwelling adults and the training program was useful for increasing facilitator competency. We suggest some lessons from this pilot study that can be used to improve the ACP program and encourage community health nurses to participate in ACP as facilitators.

General practitioners' views of advance care planning: a questionnaire-based study

BACKGROUND

Planning for end of life (EOL) care has become an important consideration for doctors and patients in the context of longer life expectancy in most high-income countries. Advance care plans (ACPs) allow individuals to make plans for future healthcare practices for when they no longer have the capacity to make such decisions. It has been suggested that general practitioners (GPs) have the ideal relationship with patients to facilitate this process. However, the uptake of ACPs still remains low, prompting the need to understand the views of GPs regarding ACPs.

AIM

The aim of this study was to assess the knowledge and attitudes of GPs regarding ACPs and to identify barriers in implementing ACPs into practice.

DESIGN AND SETTING

A cross-sectional descriptive study was conducted with GPs in county Cork and Kerry.

METHODS

A questionnaire was adapted from two previously published studies, piloted and posted to GPs. Two hundred thirty-seven questionnaires were posted.

RESULTS

Seventy-five questionnaires were completed, representing a 31.7% response rate. Findings revealed that GPs have positive attitudes towards ACPS, although there is an inadequate understanding of ACPs. In particular, GPs are challenged by defining the right moment to initiate EOL discussions, their patients' unawareness of ACPs, and lack of time during consultations.

CONCLUSION

In order to improve their implementation, workshops and courses should be developed to increase GPs' knowledge and confidence. Additionally, the healthcare system should be adapted, supporting GPs to facilitate these important discussions to take place.

Rural health services' relationships with patients: An enabler and a barrier to advance care planning

OBJECTIVE

The barriers and enablers to the uptake of advance care plans has been well documented but more so in metropolitan health services. Rural and regional areas have their own challenges of higher rates of chronic illness and an aging population when considering end of life care. This study aimed to explore the creation of advance care plans in a regional location that has service links to smaller health services.

DESIGN

A qualitative study involving thematic analysis of interview data.

SETTING

A regional local government area in Victoria, Australia.

PARTICIPANTS

Twelve representatives from rural and regional health services, including hospital, private practice and community organisation staff.

MAIN OUTCOME MEASURES

Barriers and enablers to the creation of advance care planning documents.

RESULTS

The data analysis yielded two main identified themes around Plan creation and communication of patient wishes: system and societal challenges to the creation and communication in advance care planning; and rural communities' expectation of the health service-patient relationship and advance care planning.

CONCLUSION

Although barriers to advance care planning are well known, rural and regional practitioners need to be aware of the effect long-term continuity of care from health practitioners and connections with health services has on advance care plan creation, and whether the paucity of written Plans effects end-of-life care. A potential solution was seen in the pending linkages to the national electronic patient record.

Advance Care Planning in Home Health: A Review of the Literature

The purpose of this article is to synthesize the evidence on advance care planning (ACP), determine what is applicable to the home health (HH) setting, and find where gaps in knowledge may exist. An integrative review methodology was chosen. Although there is ample literature on the topic of ACP, most research has been conducted in the acute care, outpatient, and general community settings. There is limited literature regarding ACP with patients living with chronic cardiovascular and pulmonary illnesses, who comprise the majority of the HH population. Some literature has been published regarding the interprofessional team's role in ACP in the HH setting. A gap in knowledge exists regarding ACP in HH, and recommendations for future research are provided.

Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis

OBJECTIVES

How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice?

DESIGN

A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting.

SETTING

Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews.

RESULTS

The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging.

CONCLUSION

Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice.

PROSPERO REGISTRATION NUMBER

CRD42018088838.

Advance care planning uptake among patients with severe lung disease: a randomised patient preference trial of a nurse-led, facilitated advance care planning intervention

OBJECTIVE

Advance care planning (ACP) clarifies goals for future care if a patient becomes unable to communicate their own preferences. However, ACP uptake is low, with discussions often occurring late. This study assessed whether a systematic nurse-led ACP intervention increases ACP in patients with advanced respiratory disease.

DESIGN

A multicentre open-label randomised controlled trial with preference arm.

SETTING

Metropolitan teaching hospital and a rural healthcare network.

PARTICIPANTS

149 participants with respiratory malignancy, chronic obstructive pulmonary disease or interstitial lung disease.

INTERVENTION

Nurse facilitators offered facilitated ACP discussions, prompted further discussions with doctors and loved ones, and assisted participants to appoint a substitute medical decision-maker (SDM) and complete an advance directive (AD).

OUTCOME MEASURES

The primary measure was formal (AD or SDM) or informal (discussion with doctor) ACP uptake assessed by self-report (6 months) and medical notes audit. Secondary measures were the factors predicting baseline readiness to undertake ACP, and factors predicting postintervention ACP uptake in the intervention arm.

RESULTS

At 6 months, formal ACP uptake was significantly higher (p<0.001) in the intervention arm (54/106, 51%), compared with usual care (6/43, 14%). ACP discussions with doctors were also significantly higher (p<0.005) in the intervention arm (76/106, 72%) compared with usual care (20/43, 47%). Those with a strong preference for the intervention were more likely to complete formal ACP documents than those randomly allocated. Increased symptom burden and preference for the intervention predicted later ACP uptake. Social support was positively associated with ACP discussion with loved ones, but negatively associated with discussion with doctors.

CONCLUSIONS

Nurse-led facilitated ACP is acceptable to patients with advanced respiratory disease and effective in increasing ACP discussions and completion of formal documents. Awareness of symptom burden, readiness to engage in ACP and relevant psychosocial factors may facilitate effective tailoring of ACP interventions and achieve greater uptake.

TRIAL REGISTRATION NUMBER

ACTRN12614000255684.