Public attitudes to emergency care treatment plans: a population survey of Great Britain

OBJECTIVES

To measure community attitudes to emergency care and treatment plans (ECTPs).

DESIGN

Population survey.

SETTING

Great Britain.

PARTICIPANTS

As part of the British Social Attitudes Survey, sent to randomly selected addresses in Great Britain, 1135 adults completed a module on ECTPs. The sample was nationally representative in terms of age and location, 619 (55%) were female and 1005 (89%) were of white origin.

OUTCOME MEASURES

People's attitudes having an ECTP for themselves now, and in the future; how comfortable they might be having a discussion about an ECTP and how they thought such a plan might impact on their future care.

RESULTS

Predominantly, respondents were in favour of people being able to have an ECTP, with 908/1135 (80%) being at least somewhat in favour. People in good health were less likely than those with activity-limiting chronic disease to want a plan at present (52% vs 64%, OR 1.78 (95% CI 1.30 to 2.45) p<0.001). Developing a long-term condition or becoming disabled would lead 42% (467/1112) and 43% (481/1112) of individuals, respectively, to want an ECTP. More, 634/1112 (57%) would want an ECTP if they developed a life-threatening condition. Predominantly, 938/1135 (83%) respondents agreed that an ECTP would help avoid their family needing to make difficult decisions on their behalf, and 939/1135 (83%) that it would ensure doctors and nurses knew their wishes. Nevertheless, a small majority-628/1135 (55%)-agreed that there was a serious risk of the plan being out of date when needed. A substantial minority-330/1135 (29%)-agreed that an ECTP might result in them not receiving life-saving treatment.

CONCLUSIONS

There is general support for the use of ECTPs by people of all ages. Nevertheless, many respondents felt these might be out of date when needed and prevent people receiving life-saving treatment.

Perceptions and experiences of onco-haematology professionals in relation to advance care planning: a qualitative study

PURPOSE

The objective of this study is to identify the beliefs, values, perceptions, and experiences of medical oncology, radiation oncology, and clinical haematology professionals about the advance care planning process.

METHODS

Qualitative exploratory study. There were four focus groups with 14 nurses and 12 physicians (eight medical oncology, one radiation oncology, three haematology). A reflexive thematic analysis of the data obtained was performed.

RESULTS

We identified 20 thematic categories, which we grouped into four themes: lack of knowledge about advance care planning; perception of the advance care planning process: knowledge acquired from practice; barriers and facilitators for the implementation of advance care planning; and communication as a key aspect of advance care planning.

CONCLUSIONS

The participants valued advance care planning as an early intervention tool that promotes autonomy. They perceived difficulties in approaching planning due to lack of knowledge, training, and time. They identified the therapeutic relationship with the person, the participation of the person's loved ones, teamwork, and communication skills as essential to ensuring the quality of the process. Finally, they recognised that palliative care professionals provide added value in supporting planning processes.

Experiences and perspectives of healthcare professionals, patients and caregivers toward the serious illness conversation guide: protocol for a qualitative meta-synthesis

INTRODUCTION

Exploring the experiences and perspectives of healthcare professionals, patients and caregivers toward serious illness conversations based on the Serious Illness Care Program is vital for improving communication with patients who are seriously ill, as has been shown in previous studies. However, few studies have carried out a systematic review to examine common themes, strengthen conclusions and identify gaps in the literature, the findings of which could help steer further research, policies and practice to improve more timely and person-centred conversations about the values and priorities of patients with serious illnesses. The objective of this qualitative meta-synthesis is to explore how healthcare professionals, patients and caregivers described their own experiences of the processes of serious illness communication through a secondary analysis of published qualitative data.

METHODS AND ANALYSIS

Meta-aggregation will be used to conduct a systematic review of qualitative studies. We conducted an initial search on 10 October 2023; papers published in English will be searched using electronic databases, including PubMed (MEDLINE), Web of Science, Embase, Ovid and CINAHL. Studies that satisfy the eligibility criteria will be evaluated for methodological quality using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. The meta-aggregative review will consist of the following: (1) extraction of findings of all included studies; (2) categorisation of the findings, with at least two findings per category; and (3) synthesis of one or more findings from at least two categories. Study eligibility screening, data extraction, analysis and JBI Critical Appraisal Checklist and Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research assessments will be undertaken independently by two authors.

ETHICS AND DISSEMINATION

Secondary data analysis of published literature does not require ethical approval. The results will be disseminated in peer-reviewed journals and presented in conference papers and elsewhere.

PROSPERO REGISTRATION NUMBER

CRD42022330859.

Advance Care Planning in Australia: Progress in research and implementation

Advance Care Planning in Australia has its foundations in the Respecting Patient Choices model, which was initially implemented in one state. The Australian population is diverse, ageing and geographically dispersed, with health and aged care services provided by a range of different organisations and regulated at different levels. Key challenges in ACP implementation include discomfort with ACP discussion, inconsistent legislation and ACP documentation across jurisdictions, poor quality control of ACP documents and difficulties accessing ACP documents at the point of care. The COVID-19 pandemic exposed a range of issues but also led to some innovative practices which have continued after the relaxation of public health restrictions. Ongoing implementation work focuses on meeting the needs of diverse communities and sectors in ACP, while seeking an overall coherence in policy and standardisation of practice through high-level best-practice principles, quality standards and policy frameworks.

Intersectoral communication amongst healthcare providers regarding care plans: a scoping review

Palliative care has become an increasingly important public health issue due to the rising acceptance of implementing a health promoting palliative care approach. To explore communication pathways that would facilitate implementation of this approach, we conducted a scoping review examining communication and enactment of care plans for older adults with life-limiting illnesses across health, social and community sectors. We used a scoping review methodology to map the current literature on communication plans between primary care and other sectors (community, health, and social). Five databases were searched MEDLINE (ovid), CINAHL (EBSCO), EMBASE (Elsevier), PsychInfo (EBSCO), and Scopus. The database search identified 5,289 records, after screening and hand-searching a total of 28 articles were extracted. Three major themes were determined through the records: (1) the importance of professional relationships across sectors, (2) the importance of community navigators in sharing the care plan, and (3) and creating comprehensive and multidisciplinary care plans. Findings suggested that enacting quality care plans is important to healthcare providers; the use of an electronic health records system can be useful in ensuring that all healthcare and community systems are in place to aid patients for better community-based care. Community navigators were also key to ensure that plans are communicated properly and efficiently. Further research is needed to determine how having a clear and properly implemented communication system for a healthcare system could facilitate community sector involvement in implementing care plans.

Australian general practice experiences of implementing a structured approach to initiating advance care planning and palliative care: a qualitative study

OBJECTIVES

Initiation of advance care planning (ACP) and palliative care (PC) assessments in general practice is key to quality end-of-life care. The Advance Project promotes a team-based approach to initiating ACP and PC needs assessment in general practices through training, resources and practical support for implementation from local primary health networks (PHNs). This paper aims to understand: (1) general practice participants' experiences of undertaking Advance Project training and implementing the Advance Project resources in their practices; (2) barriers and facilitators to implementation of Advance Project resources; and (3) PHN staff experiences of supporting general practices through training and practical support for implementation of the Advance Project resources.

DESIGN

Qualitative study using semistructured interviews and thematic analysis.

SETTING

Twenty-one general practices and four PHNs from three Australian states were recruited between June 2019 and May 2020.

PARTICIPANTS

General practitioners (GPs), general practice nurses, practice managers (PMs) and PHN staff.

RESULTS

45 participants comprising 13 GPs, 13 general practice nurses, 9 PMs, 3 allied health staff and 7 PHN staff were interviewed. The general practice participants generally agreed that the Advance Project training/resources led to changes in their own behaviour and increased their awareness of the importance of ACP/PC discussion with their patients. Participants reported the following benefits for patients: increased awareness of ACP; engagement with families/carers and peace of mind. Key facilitators for successful implementation were a team-based approach, the role of the PHN, the role of practice champions, training facilitators' ability to influence peers and facilitate change, and mentoring support. Barriers to implementation included issues related to workplace culture, cost, time/workload, patients and health system.

CONCLUSION

Findings suggest that the Advance Project approach facilitated successful implementation of ACP and PC needs assessment into usual care in general practices that encouraged teamwork among GPs and general practice nurses. The ability of the practice to make the best use of practical support and guidance available to them through their local PHN both before and during implementation was a key factor in integration of Advance Project resources into routine practice.

Barriers and facilitators to nurse-led advance care planning and palliative care practice change in primary healthcare: a qualitative study

Primary care settings are ideal for initiating advance care planning (ACP) conversations and assessing palliative and supportive care needs. However, time constraints and a lack of confidence to sensitively and efficiently initiate such discussions are noted barriers. The Advance Project implemented a national multicomponent training package to support Australian general practice nurses (GPNs) to work with GPs to initiate ACP and palliative care conversations in their practice. This paper reports on semistructured interviews conducted with 20 GPNs to explore barriers and facilitators to implementing the Advance Project model. Participants identified a range of factors that affected implementation, including lack of time, limited support from colleagues, lack of knowledge about systems and funding processes in general practice and a need for better alignment of the Advance Project resources and practices with general practice information management platforms. Barriers related to professional roles, particularly the lack of clarity and/or limitations in the scope of practice of GPNs, highlighted the importance of defining and supporting the roles that different primary health practice staff could play to support implementation of the model. The findings underline the need for complementary training in the Advance Project model for GPs and practice managers to enable a team-based approach to implementation.

Perceived Barriers and Facilitators of Implementing a Multicomponent Intervention to Improve Communication With Older Adults With and Without Dementia (SHARING Choices) in Primary Care: A Qualitative Study

INTRODUCTION

Implementing patient- and family-centered communication strategies has proven challenging in primary care, particularly for persons with dementia. To address this, we designed SHARING Choices, a multicomponent intervention combining patient and family partnered agenda setting, electronic portal access, and supports for advance care planning (ACP). This qualitative descriptive study describes factors affecting SHARING Choices implementation within primary care.

METHODS

Semi-structured interviews or focus groups with patient/family dyads (family, friends, unpaid caregivers) and primary care stakeholders (clinicians, staff, administrators) elicited perceived barriers and facilitators of SHARING Choices implementation. Field notes and interview transcripts were coded using template analysis along the Consolidated Framework for Implementation Research (CFIR) constructs. Content analysis identified themes not readily categorized within CFIR.

RESULTS

About 22 dyads, including 14 with cognitive impairment, and 30 stakeholders participated in the study. Participants were receptive to the SHARING Choices components. Enablers of SHARING Choices included adaptability of the intervention, purposive engagement of family (particularly for patients with dementia), consistency with organizational priorities, and the relative advantage of SHARING Choices compared to current practices. Perceived barriers to implementation included intervention complexity, space constraints, workflow, and ACP hesitancy. The ACP facilitator was perceived as supportive in addressing individual and organizational implementation barriers including patient health and technology literacy and clinician time for ACP discussions.

CONCLUSIONS

Patients, family, and primary care clinicians endorsed the objectives and individual components of SHARING Choices. Strategies to enhance adoption were to simplify materials, streamline processes, leverage existing workflows, and embed ACP facilitators within the primary care team.

A scoping review of nurse-led advance care planning

BACKGROUND

Advance care planning (ACP) supports persons at any age or health status to determine their values, goals, and preferences regarding future medical care. The American Nurses Association endorses nurses to facilitate ACP to promote patient- and family-centered care.

PURPOSE

This project reviewed and synthesized literature on nurse-led ACP training models.

METHODS

A scoping review used the Arksey and O'Malley Framework to identify: (a) ACP training model type, (b) nurse-led ACP recipients, (c) ACP in special populations, (d) ACP outcomes.

FINDINGS

Of 33 articles reviewed, 19 included 11 established models; however, the primary finding was lack of a clearly identified evidence-based nurse-led ACP training model.

DISCUSSION

Nurses are integral team members, well positioned to be a bridge of communication between patients and care providers. This is a call to action for nurse leaders, researchers, educators to collaborate to identify and implement an evidence-based, effective nurse-led ACP training model.

Nurse-led normalised advance care planning service in hospital and community health settings: a qualitative study

BACKGROUND

Advance Care Planning (ACP) by Registered Nurses (RNs) has been emerging. However, there is limited understanding about what RNs experience as they incorporate ACP into their practice. This study aimed to elicit the experiences of ACP RNs with the implementation of a normalised ACP (NACP) service in hospital and community care settings.

METHODS

A qualitative descriptive study invited four ACP RNs who delivered a nurse-led NACP for a 6 months duration at two hospital and two community health care settings in New South Wales (NSW), Australia. The experiences of the ACP RNs were captured through a semi-structured interview and weekly debriefing meetings. The interview recordings were transcribed verbatim and the minutes of weekly debriefing meetings were utilized. Data were analysed by two independent researchers using thematic analysis with the Normalisation Process Theory (NPT) as a methodological framework.

FINDINGS

The ACP RNs were females with a mean age of 43 years old. Their nursing experiences ranged 2 to 25 years but they had minimal experiences with ACP and had not attended any education about ACP previously. The following four themes were identified in the experiences of the ACP RNs; 1) Embracing NACP service; 2) Enablers and barriers related to patients and health professionals; 3) Enablers and barriers related to ACP RNs; and 4) What it means to be an ACP RN.

CONCLUSION

The introduction of a NACP service into existing clinical systems is complex. The study demonstrated the capacity of RNs to engage in ACP processes, and their willingness to deliver an NACP service with a raft of locally specific enablers and barriers.

TRIAL REGISTRATION

The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record.

Advance care planning for older adults in community-based settings: An umbrella review

BACKGROUND

Advance care planning (ACP) is critical to ensure better quality end of life care, and older adults are often a target of ACP. However, ACP interventions and their outcomes are neither standardised nor conclusive.

OBJECTIVES

To synthesise existing ACP systematic reviews and identify the types and outcomes of ACP interventions for older adults in community-based settings.

METHODS

An umbrella review of systematic reviews. The Joanna Briggs Institute Reviewer's Manual was followed. Relevant systematic reviews were searched by utilising bibliographic databases, grey literature sources, and manual searches between April and July, 2019. Nine systematic reviews met the inclusion criteria. Critical appraisal on the selected reviews was conducted. Data were independently extracted using a data extraction tool by two researchers and synthesised based on consensus.

RESULTS

The systematic reviews suggest the critical features of ACP interventions for older adults in community-based settings including clinicians' face-to-face communication with patients and their family members, comprehensive and individualized decisional aids, a proper intensity of ACP interventions, and professional training. When categorising ACP outcomes according to Sudore et al.'s (Journal of Pain and Symptom Management, 55, 2018, 245) framework, action outcomes (e.g., documentation, discussion) were frequently measured with positive outcomes. Quality of care outcomes such as congruence with care preference and healthcare outcomes such as health status were not reported sufficiently.

CONCLUSIONS

The reviews suggested essential features of ACP interventions, which were often omitted in ACP interventions for older adults. Although the outcomes were generally positive, it is inconclusive as to whether ACP interventions eventually improved quality of end of life care or health status of older adults in community-based settings.

IMPLICATIONS FOR PRACTICE

For ACP interventions to be effective and comparable in their outcomes, we recommend adopting the key intervention components identified in this study. As the effects of ACP interventions are inconclusive, further investigations are warranted.

When do Physicians and Nurses Start Communication about Advance Care Planning? A Qualitative Study at an Acute Care Hospital in Japan

Although advance care planning (ACP) can lead to more patient-centered care, the communication around it can be challenging in acute care hospitals, where saving a life or shortening hospitalization is important priorities. Our qualitative study in an acute care hospital in Japan revealed when specifically physicians and nurses start communication to facilitate ACP. Seven physicians and 19 nurses responded to an interview request, explaining when ACP communication was initiated with 32 patients aged 65 or older. Our qualitative approach employed descriptive analysis to identify major themes, which included "initiation by patients" and "initiation by healthcare professionals." In the latter case, seven specific triggers were identified: (1) when the patients' medical condition changed in terms of symptom relief, (2) when the patients' medical condition changed in terms of prognostic prediction, (3) when serious events occurred, (4) when a choice of treatment was presented, (5) when the location for end-of-life care was chosen, (6) when the patients' cognitive function deteriorated, and (7) when serious events settled down. Within this group of healthcare professionals, physicians were more focused on changes in their patients' medical condition, whereas nurses focused more on their patients' desire for a long-term perspective. Nurses encouraged patients to consider ACP themselves, which developed into an approach to respect patients' autonomy. In acute care hospitals, it appeared to be desirable to have an early discussion where patients could understand the significance ACP, which would matter even after their discharge from the hospital.

Detering K. Advance care planning in Australia during the COVID-19 outbreak: now more important than ever

The novel Coronavirus disease 2019 (COVID-19) outbreak has led to rapid and profound changes in healthcare system delivery and society more broadly. Older adults, and those living with chronic or life-limiting conditions, are at increased risk of experiencing severe or critical symptoms associated with COVID-19 infection and are more likely to die. They may also experience non-COVID-19 related deterioration in their health status during this period. Advance care planning (ACP) is critical for this cohort, yet there is no coordinated strategy for increasing the low rates of ACP uptake in these groups, or more broadly. This paper outlines a number of key reasons why ACP is an urgent priority, and should form a part of the health system's COVID-19 response strategy. These include reducing the need for rationing, planning for surges in healthcare demand, respecting human rights, enabling proactive care coordination and leveraging societal change. We conclude with key recommendations for policy and practice in the system-wide implementation of ACP, to enable a more ethical, coordinated and person-centred response in the COVID-19 context.

Impact of a Nurse-Led Advance Care Planning Intervention on Satisfaction, Health-Related Quality of Life, and Health Care Utilization Among Patients With Severe Respiratory Disease: A Randomized Patient-Preference Trial

CONTEXT

Previous work has found that facilitated advance care planning (ACP) interventions are effective in increasing ACP uptake among patients with severe respiratory disease.

OBJECTIVES

The objective of this study was to investigate whether a nurse-led, facilitated ACP intervention among participants with severe respiratory disease impacts self-reported or clinical outcomes.

METHODS

A multicenter, open-label, patient-preference, randomized controlled trial of a nurse-led facilitated ACP intervention was performed. Outcome measures included self-report scales (health care satisfaction and EQ-5D-5L health-related quality of life at three- and six-month follow-up), 12-month mortality, and health care utilization during the final 90 days of life.

RESULTS

One hundred forty-nine participants were recruited across two study settings (metropolitan tertiary hospital respiratory department and rural sites) and 106 were allocated to receive the ACP intervention. There was no effect of the intervention on satisfaction with health care, health-related quality of life, or 12-month mortality rates. Among those participants who died during the follow-up period (N = 54), those allocated to the ACP intervention had significantly fewer outpatient consultations (7.51 vs. 13.6, P < 0.001). There were no changes in emergency department attendances, total hospital admissions or length of stay, or home nursing visits. Among those allocated to the ACP intervention, there was a reduced length of stay in acute hospital settings (7.76 vs. 11.5 nights, P < 0.001) and increased length of stay in palliative hospital settings (5.54 vs. 2.08, P < 0.001) during the final 90 days of life.

CONCLUSION

A facilitated ACP intervention among patients with severe respiratory disease did not have an impact on satisfaction, health-related quality of life, or 12-month mortality rate. Facilitated ACP may be associated with a different type of health care utilization during the end-of-life period.