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Spear S, Little E, Tapp A, Nancarrow C, Morey Y, Warren S, Verne J. Attitudes towards advance care planning amongst community-based older people in England. PLoS One 2024; 19:e0306810. [PMID: 39167589 PMCID: PMC11338439 DOI: 10.1371/journal.pone.0306810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 06/24/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Advance care planning has been advocated as a way for people to have their wishes recorded and respected in relation to types of treatment and place of care. However, uptake in England remains low. AIMS To examine the views of older, well, adults towards Advance Care Plans (ACPs) and planning for end-of-life care, in order to inform national policy decisions. METHODS A mixed methods approach was adopted, involving individual and mini-group qualitative interviews (n = 76, ages 45-85), followed by a quantitative survey (n = 2294, age 55+). The quantitative sample was based on quotas in age, gender, region, socio-economic grade, and ethnicity, combined with light weighting to ensure the findings were representative of England. RESULTS Knowledge and understanding of advance care planning was low, with only 1% of survey respondents reporting they had completed an ACP for themselves. Common reasons for not putting wishes into writing were not wanting/needing to think about it now, the unpredictability of the future, trusting family/friends to make decisions, and financial resources limiting real choice. CONCLUSION Whilst advance care planning is seen as a good idea in theory by older, well, adults living in the community, there is considerable reticence in practice. This raises questions over the current, national policy position in England, on the importance of written ACPs. We propose that policy should instead focus on encouraging ongoing conversations between individuals and all those (potentially) involved in their care, about what is important to them, and on ensuring there are adequate resources in community networks and health and social care systems, to be responsive to changing needs.
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Affiliation(s)
- Sara Spear
- Faculty of Business and Law, St Mary’s University, London, England
- Bristol Business School, University of the West of England, Bristol, England
| | - Ed Little
- Bristol Business School, University of the West of England, Bristol, England
| | - Alan Tapp
- Bristol Business School, University of the West of England, Bristol, England
| | - Clive Nancarrow
- Bristol Business School, University of the West of England, Bristol, England
| | - Yvette Morey
- Bristol Business School, University of the West of England, Bristol, England
| | - Stella Warren
- Bristol Business School, University of the West of England, Bristol, England
| | - Julia Verne
- OHID, Department for Health and Social Care, London, England
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Stevens J, Miranda R, Deliens L, Pype P, De Vleminck A, Pardon K. Advance care planning engagement in patients with chronic, life-limiting illness: baseline findings from a cluster-randomised controlled trial in primary care. Br J Gen Pract 2023; 73:e384-e391. [PMID: 37012079 PMCID: PMC10098835 DOI: 10.3399/bjgp.2022.0100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 10/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) has been characterised as a complex process of communication and decision making. For ACP behaviour change, underlying processes such as self-efficacy and readiness are needed. However, studies about which patient characteristics are associated with ACP have mainly focused on whether ACP actions are completed, leaving behaviour change processes unexplored. AIM To assess whether patients' characteristics and patient-perceived quality of GP ACP communication were associated with patients' ACP engagement. DESIGN AND SETTING Baseline data were used from the ACP-GP cluster-randomised controlled trial in patients with chronic, life-limiting illness (n = 95). METHOD Patients completed questionnaires detailing demographic and clinical characteristics, and their perception about their GPs' ACP information provision and listening. Engagement was measured using the 15-item ACP Engagement Survey, with self-efficacy and readiness subscales. Linear mixed models tested associations with engagement. RESULTS Demographic and clinical characteristics were not associated with engagement; nor was how much ACP information patients received from their GP or the extent to which the GP listened to what was important for the patient to live well or important to the patient regarding future care. Higher overall ACP engagement (P = 0.002) and self-efficacy (P<0.001) were observed in patients who gave a high rating for the extent to which their GP listened to their worries regarding future health. CONCLUSION This study suggests that GPs providing information about ACP alone is not associated with a patient's ACP engagement; an important element is to listen to patients' worries regarding their future health.
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Affiliation(s)
- Julie Stevens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Universiteit Gent; Department of Family Medicine and Chronic Care, VUB, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Rose Miranda
- End-of-Life Care Research Group, VUB and Universiteit Gent; Department of Family Medicine and Chronic Care, VUB, Brussels
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Universiteit Gent; Department of Family Medicine and Chronic Care, VUB, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Peter Pype
- End-of-Life Care Research Group, VUB, and Universiteit Gent; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Aline De Vleminck
- End-of-Life Care Research Group, VUB and Universiteit Gent; Department of Family Medicine and Chronic Care, VUB, Brussels
| | - Koen Pardon
- End-of-Life Care Research Group, VUB and Universiteit Gent; Department of Family Medicine and Chronic Care, VUB, Brussels
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Martina D, Angka RN, Putranto R, Shatri H, Sudoyo AW, van der Heide A, van der Rijt CCD, Rietjens JAC. Cancer Survivors' Experiences With and Preferences for Medical Information Disclosure and Advance Care Planning: An Online Survey Among Indonesian Cancer Support Groups. JCO Glob Oncol 2023; 9:e2300003. [PMID: 37043710 DOI: 10.1200/go.23.00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
PURPOSE To understand the experiences and preferences of Indonesian cancer survivors regarding medical information disclosure and advance care planning. METHODS On the basis of systematic reviews of the scientific literature, qualitative studies, and expert-panel input, we developed an online survey that was distributed to nine cancer survivor support groups in Indonesia. RESULTS A total of 1,030 valid responses were received. Most participants were younger than 60 years (92%), female (91%), married (78%), Muslim (75%), diagnosed with breast cancer (68%), highly educated (64%), and more than one year beyond diagnosis of their cancer. If diagnosed with a life-limiting illness, participants wished to be informed about their diagnosis (74%), disease severity (61%), estimated curability (81%), expected disease trajectory (66%), and estimated life expectancy (37%). Between 46%-69% of the participants wished to discuss four topics of advance care planning (end-of-life treatments, resuscitation, health care proxies, and what matters at the end of life); 21%-42% had done so. Of those who wished to discuss these topics, 36%-79% preferred to do so with their family members. The most important reasons for not being willing to engage in advance care planning were the desire to surrender to God's will and to focus on here and now. CONCLUSION In a group of cancer survivors, most of them were highly educated, young, female, and diagnosed with breast cancer. Their preferences for medical information and advance care planning varied, with the majority wishing for information and involvement in advance care planning. Culturally sensitive advance care planning involves health care professionals eliciting individuals' preferences for medical information disclosure and discussing different topics in advance care planning conversations.
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Affiliation(s)
- Diah Martina
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, the Netherlands
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, the Netherlands
- Division of Psychosomatic and Palliative Medicine, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
- Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | | | - Rudi Putranto
- Division of Psychosomatic and Palliative Medicine, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
- Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Hamzah Shatri
- Division of Psychosomatic and Palliative Medicine, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
- Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Aru Wisaksono Sudoyo
- Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Indonesia
- Indonesian Cancer Foundation, Jakarta, Indonesia
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, the Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, the Netherlands
| | - Judith A C Rietjens
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, the Netherlands
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van der Smissen D, Rietjens JAC, van Dulmen S, Drenthen T, Vrijaldenhoven-Haitsma FRMD, Wulp M, van der Heide A, Korfage IJ. The Web-Based Advance Care Planning Program "Explore Your Preferences for Treatment and Care": Development, Pilot Study, and Before-and-After Evaluation. J Med Internet Res 2022; 24:e38561. [PMID: 36459410 DOI: 10.2196/38561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/07/2022] [Accepted: 10/11/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Web-based advance care planning (ACP) programs may support patients in thinking about and discussing their preferences for future treatment and care. However, they are not widely available, and only a limited number of programs are evidence based. OBJECTIVE We aimed to develop and evaluate an evidence-based, interactive web-based ACP program that guides users through the process of thinking about, discussing, and recording of preferences for treatment and care. METHODS The program "Explore your preferences for treatment and care" was developed, pilot-tested on feasibility, and subsequently evaluated; engagement in ACP was assessed before program completion and 2 months after program completion using the ACP Engagement Survey (score 1-5) among 147 persons with chronic disease. Usability (score 0-100) and user satisfaction (score 1-5) were also assessed. RESULTS ACP engagement increased from 2.8 before program completion to 3.0 two months after program completion (P<.001); contemplation about ACP increased from 2.6 to 2.8 (P=.003), and readiness for ACP increased from 2.2 to 2.5 (P<.001). No changes were found for knowledge about ACP (3.0-3.2; P=.07) and self-efficacy for ACP (3.8-3.8; P=.25). The program was perceived as usable (mean 70, SD 13), attractive (mean 3.8, SD 0.7), and comprehensible (mean 4.2, SD 0.6). CONCLUSIONS We developed an evidence-based, interactive web-based ACP program in cocreation with patients, relatives, and health care professionals. Before-and-after evaluation showed that the program can support people in taking first steps in ACP and in reflecting on preferences for treatment and care, by guiding them through the process of ACP using a stepwise approach. Participants perceived the program as usable and understandable, and they were satisfied with the program and with the amount of information. Health care professionals may use the program as a tool to start ACP discussions with their patients. The program may increase awareness of ACP.
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Affiliation(s)
- Doris van der Smissen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Judith A C Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sandra van Dulmen
- Nivel (Netherlands institute for health services research), Utrecht, Netherlands.,Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands.,Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Ton Drenthen
- Dutch College of General Practitioners, Utrecht, Netherlands
| | | | | | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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van Lummel EVTJ, Savelkoul C, Stemerdink ELE, Tjan DHT, van Delden JJM. The development and feasibility study of Multidisciplinary Timely Undertaken Advance Care Planning conversations at the outpatient clinic: the MUTUAL intervention. BMC Palliat Care 2022; 21:119. [PMID: 35794617 PMCID: PMC9258045 DOI: 10.1186/s12904-022-01005-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patients still receive non-beneficial treatments when nearing the end of life. Advance care planning (ACP) interventions have shown to positively influence compliance with end of life wishes. Hospital physicians seem to miss opportunities to engage in ACP, whereas patients visiting the outpatient clinic usually have one or more chronic conditions and are at risk for medical emergencies. So far, implemented ACP interventions have had limited impact. Structural implementation of ACP may be beneficial. We hypothesize that having ACP conversations more towards the end of life and involving the treating physician in the ACP conversation may help patient wishes and goals to become more concrete and more often documented, thus facilitating goal-concordant care. Aim To facilitate timely shared decision making and increase patient autonomy we aim to develop an ACP intervention at the outpatient clinic for frail patients and determine the feasibility of the intervention. Methods The United Kingdom’s Medical Research Council framework was used to structure the development of the ACP intervention. Key elements of the ACP intervention were determined by reviewing existing literature and an iterative process with stakeholders. The feasibility of the developed intervention was evaluated by a feasibility study of 20 ACP conversations at the geriatrics and pulmonology department of a non-academic hospital. Feasibility was assessed by analysing evaluation forms by patients, nurses and physicians and by evaluating with stakeholders. A general inductive approach was used for analysing comments. The developed intervention was described using the template for intervention description and replication (TIDieR). Results We developed a multidisciplinary timely undertaken ACP intervention at the outpatient clinic. Key components of the developed intervention consist of 1) timely patient selection 2) preparation of patient and healthcare professional 3) a scripted ACP conversation in a multidisciplinary setting and 4) documentation. 94.7% of the patients, 60.0% of the nurses and 68.8% of the physicians agreed that the benefits of the ACP conversation outweighed the potential burdens. Conclusion This study showed that the developed ACP intervention is feasible and considered valuable by patients and healthcare professionals. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01005-3.
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Fleuren N, Depla MFIA, Pasman HRW, Janssen DJA, Onwuteaka-Philipsen BD, Hertogh CMPM, Huisman M. Association Between Subjective Remaining Life Expectancy and Advance Care Planning in Older Adults: A Cross-Sectional Study. J Pain Symptom Manage 2021; 62:757-767. [PMID: 33631323 DOI: 10.1016/j.jpainsymman.2021.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 01/06/2023]
Abstract
CONTEXT Advance care planning (ACP) becomes more relevant with deteriorating health or increasing age. People might be more inclined to engage in ACP as they feel that they are approaching end of life. The perception of approaching end of life could be quantified as subjective remaining life expectancy (SRLE). OBJECTIVES First, to describe the prevalence of ACP with health care providers or written directives ("formal engagement in ACP") and ACP with loved-ones ("informal engagement in ACP") among older persons in the general population in The Netherlands. Second, to assess the association between SRLE and engagement in ACP. METHODS Cross-sectional study using data from the Longitudinal Aging Study Amsterdam (LASA) measurement wave of 2015-2016. Participants (n = 1585) were aged ≥ 57 years. RESULTS Median age was 69.4 years (IQR: 64.1-76.7), and median SRLE 25.9 years (17.7-36.0). Formal engagement in ACP was present in 32.6%, informal without formal engagement in 45.8%, and 21.6% was not engaged in ACP. For respondents with SRLE < 25 years, there was a nonstatistically significant association between SRLE and engagement in ACP (aOR: 0.97; 95% CI: 0.93-1.01; P= .088), and a statistically significant, small association with formal vs. informal engagement in ACP (aOR: 0.96; 0.93-0.99; P= .009). For respondents with SRLE ≥ 25 years there was no association between SRLE and engagement in ACP. CONCLUSION The perception of approaching end of life is associated with higher prevalence of formal engagement in ACP, but only for those with SRLE < 25 years. For clinicians, asking patients after their SRLE might serve as a starting point to explore readiness for ACP.
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Affiliation(s)
- Nienke Fleuren
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Marja F I A Depla
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - H Roeline W Pasman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Daisy J A Janssen
- Maastricht University, Care and Public Health Research Institute, Health Services Research, Maastricht, The Netherlands; CIRO, Research and Development, Horn, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Martijn Huisman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Vrije Universiteit Amsterdam, Faculty of Sociology, Amsterdam, The Netherlands
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van der Smissen D, van der Heide A, Sudore RL, Rietjens JAC, Korfage IJ. Measuring advance care planning behavior in Dutch adults: translation, cultural adaptation and validation of the Advance Care Planning Engagement Survey. BMC Med Res Methodol 2021; 21:194. [PMID: 34563115 PMCID: PMC8467154 DOI: 10.1186/s12874-021-01389-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 08/21/2021] [Indexed: 11/28/2022] Open
Abstract
Background Advance care planning (ACP) enables people to define, discuss, and record preferences for treatment and care. Measures of ACP behavior are lacking in the Netherlands. We aimed to translate, culturally adapt and validate the 34-item ACP Engagement Survey into Dutch. Methods Following validation guidelines, we tested content validity, internal consistency, reproducibility, construct validity, interpretability and criterion validity among persons with and without chronic disease. Results Forward-backward translation indicated the need of only minor adaptations. Two hundred thirty-two persons completed baseline and retest surveys; 121 were aged ≥60 years. Persons with chronic disease (n = 151) considered the survey more valuable than those without (66 vs. 59, p < 0.001, scale of 20–100), indicating good content validity. Internal consistency (Cronbach’s alpha: 0.97) and reproducibility (intraclass correlation: 0.88) were good. Total ACP Engagement was higher among persons with chronic disease than those without (2.9 vs. 2.4, p < 0.01, scale of 1 to 5), indicating good psychometric support for construct validity and interpretability. Positive correlations of the ACP Engagement Survey and the General Self-Efficacy survey indicated good criterion validity (p < 0.05). Conclusions This study provided good psychometric support for the validity and reliability of the Dutch 34-item ACP Engagement Survey. This instrument can be used to assess involvement in ACP in adults with and without chronic disease. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01389-5.
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Affiliation(s)
- Doris van der Smissen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands.
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA.,Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - Judith A C Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
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Sævareid TJL, Pedersen R, Magelssen M. Positive attitudes to advance care planning - a Norwegian general population survey. BMC Health Serv Res 2021; 21:762. [PMID: 34334131 PMCID: PMC8327435 DOI: 10.1186/s12913-021-06773-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 07/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background Authorities recommend advance care planning and public acceptance of it is a prerequisite for widespread implementation. Therefore, we did the first study of the Norwegian public with an aim of getting knowledge on their attitudes to issues related to advance care planning. Methods An electronic survey to a nationally representative web panel of Norwegian adults. Results From 1035 complete responses (response rate 40.7%), we found that more than nine out of ten of the general public wanted to participate in advance care planning, believed it to be useful for many, and wanted to make important healthcare decisions themselves. Almost nine out of ten wanted to be accompanied by next of kin during advance care planning. Most (69%) wanted health care personnel to initiate advance care planning and preferred it to be timed to serious illness with limited lifetime (68%). Only about 9% stated that health care personnel should have the final say in healthcare decisions in serious illness. Conclusions Developing and implementing advance care planning as a public health initiative seems warranted based on the results of this study. Patient perspectives should be promoted in decision-making processes. Nevertheless, training of health care personnel should emphasise voluntariness and an individual approach to initiating, timing and conducting advance care planning because of individual variations.
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Affiliation(s)
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166, Frederik Holsts hus, 0450, Oslo, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166, Frederik Holsts hus, 0450, Oslo, Norway
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van der Smissen D, Rietjens JAC, van Gemert-Pijnen L, van Dulmen S, van der Heide A, Korfage IJ. Information needs of patients with chronic diseases and their relatives for web-based advance care planning: a qualitative interview study. BMC Palliat Care 2021; 20:77. [PMID: 34053435 PMCID: PMC8164830 DOI: 10.1186/s12904-021-00770-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) enables persons to identify preferences for future treatment and care, and to discuss, record and review these preferences. However, the uptake of ACP among patients with chronic diseases is relatively low. Web-based ACP programs can support patients and their relatives in ACP. However, information needs of patients and their relatives for ACP are unknown. The aim of this study is to explore information needs of patients with chronic disease and their relatives for web-based ACP. METHODS We conducted semi-structured interviews with patients with chronic diseases and relatives at their home or at the study center. In three cases, the patient and relative were paired since they preferred to be interviewed together. We asked about information they would search for when to start with ACP, where they would search for information, what search terms they would use on the Internet, and what content and information they would consider important on an ACP website. The interviewer asked participants to clarify their responses during the interview. We used thematic analysis to analyze the interviewees' responses. RESULTS We interviewed nine patients with different chronic diseases including amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD) and kidney diseases, and seven relatives, namely partners or (adult) children. The interviewees were aged 24 to 80 years, nine were female and seven were male. Both patients with a chronic disease and relatives mentioned comparable information needs. Many interviewees indicated they would use the Internet to search for information about ACP. Mentioned search terms were "advance care planning", "treatment plan", "disease trajectory" and names of patient associations. Information needs concerned their disease trajectory and quality of life, medical treatment decisions, practical support in arranging care, the concept of ACP and guidance in ACP, communication of treatment and care preferences, peer support of others with chronic diseases, and information for relatives. Many appreciated encouragement of their healthcare providers to take a pro-active role in ACP. CONCLUSIONS We conclude that information needs for ACP included guidance in ACP, support in making decisions about medical treatment, and practical support in arranging care. We recommend adapting web-based ACP information to the information needs of patients and their relatives to increase its findability, uptake and usefulness.
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Affiliation(s)
- Doris van der Smissen
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000 the Netherlands
| | - Judith A. C. Rietjens
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000 the Netherlands
| | - Lisette van Gemert-Pijnen
- grid.6214.10000 0004 0399 8953Department of Psychology, Health and Technology, University of Twente, Enschede, the Netherlands
| | - Sandra van Dulmen
- grid.10417.330000 0004 0444 9382Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands ,grid.416005.60000 0001 0681 4687Nivel (Netherlands institute for health services research), Utrecht, the Netherlands
| | - Agnes van der Heide
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000 the Netherlands
| | - Ida J. Korfage
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000 the Netherlands
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Hanari K, Sugiyama T, Inoue M, Mayers T, Tamiya N. Caregiving Experience and Other Factors Associated With Having End-Of-Life Discussions: A Cross-Sectional Study of a General Japanese Population. J Pain Symptom Manage 2021; 61:522-530.e5. [PMID: 32827656 DOI: 10.1016/j.jpainsymman.2020.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT The factors associated with end-of-life discussion (EOLD) are not well elucidated; an understanding of these factors may help facilitate EOLD. OBJECTIVES To investigate the associations between EOLD and experiences of the death of and/or care for a loved one and other factors. METHODS Data from a nationwide anonymous questionnaire survey of public attitudes toward end-of-life medical care, conducted in December 2017 in Japan, were used. Participants were randomly selected from the general population (age ≥ 20 years), and respondents who completed the questionnaire were analyzed (respondents: n = 836; effective response rate: 13.9%). Respondents were divided into two groups based on their experience of EOLD: those who had engaged in EOLD and those who had not. The main predictors were the experiences of the death of and care for a loved one. Multivariable logistic regression analyses were performed. RESULTS Of the 836 respondents (male: 55.6%, aged 65 and over: 43.5%), 43.7% reported their engagement in EOLD. In the analyses, "having experience of caring for a loved one" was associated with EOLD compared with never having experience (odds ratio 1.88, 95% confidence interval 1.35-2.64). However, having experience of the death of a loved one had no association. CONCLUSION For health-care providers, it may be worth recognizing that the care experience of their patient's caregiver might affect the caregiver's own EOLD in the future.
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Affiliation(s)
- Kyoko Hanari
- Doctoral Programs in Medical Sciences, Department of Health Services Research, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan; Health Services Research & Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takehiro Sugiyama
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan; Faculty of Medicine, Department of Health Services Research, University of Tsukuba, Tsukuba, Ibaraki, Japan; Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan; Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Megumi Inoue
- Department of Social Work, George Mason University, Fairfax, Virginia, USA
| | - Thomas Mayers
- Faculty of Medicine, Department of Health Services Research, University of Tsukuba, Tsukuba, Ibaraki, Japan; Faculty of Medicine, Medical English Communications Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Nanako Tamiya
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan; Faculty of Medicine, Department of Health Services Research, University of Tsukuba, Tsukuba, Ibaraki, Japan
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11
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Glaudemans JJ, Willems DL, Wind J, Onwuteaka Philipsen BD. Preventing unwanted situations and gaining trust: a qualitative study of older people and families' experiences with advance care planning in the daily practice of primary care. Fam Pract 2020; 37:519-524. [PMID: 31816034 PMCID: PMC7474529 DOI: 10.1093/fampra/cmz089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Using advance care planning (ACP) to anticipate future decisions can increase compliance with people's end-of-life wishes, decrease inappropriate life-sustaining treatment and reduce stress, anxiety and depression. Despite this, only a minority of older people engage in ACP, partly because care professionals lack knowledge of approaches towards ACP with older people and their families. OBJECTIVE To explore older people's and their families' experiences with ACP in primary care. METHODS We conducted qualitative, semi-structured, face-to-face interviews with 22 older people (aged >70 years, v/m: 11/11), with experience in ACP, and eight of their family members (aged 40-79 years, f/m: 7/1). Transcripts were inductively analysed using a grounded theory approach. RESULTS We distinguished three main themes. (i) Openness and trust: Respondents were more open to ACP if they wanted to prevent specific future situations and less open if they lacked trust or had negative thoughts regarding general practitioners' (GPs') time for and interest in ACP. Engaging in ACP appeared to increase trust. (ii) Timing and topics: ACP was not initiated too early. Quality of ACP seemed to improve if respondents' views on their current life and future, a few specific future care scenarios and expectations and responsibilities regarding ACP were discussed. (iii) Roles of family: Quality of ACP appeared to improve if family was involved in ACP. CONCLUSIONS Quality and accessibility of ACP may improve if GPs and nurses involve family, explain GPs' interest in ACP and discuss future situations older people may want to prevent, and views on their current life and future.
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Affiliation(s)
- Jolien J Glaudemans
- Section of Medical Ethics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Dick L Willems
- Section of Medical Ethics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jan Wind
- Department of General Practice, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bregje D Onwuteaka Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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12
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Reinink H, Konya B, Geurts M, Kappelle LJ, van der Worp HB. Treatment Restrictions and the Risk of Death in Patients With Ischemic Stroke or Intracerebral Hemorrhage. Stroke 2020; 51:2683-2689. [PMID: 32757755 DOI: 10.1161/strokeaha.120.029788] [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: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Do-not-resuscitate (DNR) orders in the first 24 hours after intracerebral hemorrhage have been associated with an increased risk of early death. This relationship is less certain for ischemic stroke. We assessed the relation between treatment restrictions and mortality in patients with ischemic stroke and in patients with intracerebral hemorrhage. We focused on the timing of treatment restrictions after admission and the type of treatment restriction (DNR order versus more restrictive care). METHODS We retrospectively assessed demographic and clinical data, timing and type of treatment restrictions, and vital status at 3 months for 622 consecutive stroke patients primarily admitted to a Dutch university hospital. We used a Cox regression model, with adjustment for age, sex, comorbidities, and stroke type and severity. RESULTS Treatment restrictions were installed in 226 (36%) patients, more frequently after intracerebral hemorrhage (51%) than after ischemic stroke (32%). In 187 patients (83%), these were installed in the first 24 hours. Treatment restrictions installed within the first 24 hours after hospital admission and those installed later were independently associated with death at 90 days (adjusted hazard ratios, 5.41 [95% CI, 3.17-9.22] and 5.36 [95% CI, 2.20-13.05], respectively). Statistically significant associations were also found in patients with ischemic stroke and in patients with just an early DNR order. In those who died, the median time between a DNR order and death was 520 hours (interquartile range, 53-737). CONCLUSIONS The strong relation between treatment restrictions (including DNR orders) and death and the long median time between a DNR order and death suggest that this relation may, in part, be causal, possibly due to an overall lack of aggressive care.
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Affiliation(s)
- Hendrik Reinink
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
| | - Burak Konya
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
| | - Marjolein Geurts
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.).,Department of Neurology, Erasmus Medical Center, University Medical Center Rotterdam, the Netherlands (M.G.)
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
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13
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Gallagher J, Bolt T, Tamiya N. Advance care planning in the community: factors of influence. BMJ Support Palliat Care 2020; 12:bmjspcare-2020-002221. [PMID: 32513679 DOI: 10.1136/bmjspcare-2020-002221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/08/2020] [Accepted: 05/04/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES This study aims to identify factors among British community-based adults associated with advance care planning engagement. Factors are then compared among six domains of wishes: medical care, spiritual and religious needs, privacy and peace, dignified care, place of death and pain relief. METHODS Cross-sectional data were analysed from a stratified random sample of adults across Great Britain (England, Scotland and Wales) who were interviewed on their attitudes towards death and dying. Weighted multivariable logistic regression tested for associations with expressing any end-of-life wishes and then for each separate domain. RESULTS Analysis of 2042 respondents (response rate: 53.5%) revealed those less likely to have discussed their wishes were: male, younger, born in the UK, owned their residence, had no experience working in health or social care, had no chronic conditions or disabilities, had not experienced the death of a close person in the last 5 years and feel neither comfortable nor uncomfortable or uncomfortable talking about death. Additional factors among the six domains associated with having not discussed wishes include: having less and more formal education, no religious beliefs, lower household income and living with at least one other person. CONCLUSIONS This study is the first to be conducted among a sample of community-dwelling British adults and the first of its kind to compare domains of end-of-life wishes. Our findings provide an understanding of social determinants which can inform a public health approach to end-of-life care that promotes advance care planning among compassionate communities.
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Affiliation(s)
- Joshua Gallagher
- School of Global and Area Studies, University of Oxford, Oxford, UK
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Japan
| | - Timothy Bolt
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Economics, Saitama University, Saitama, Japan
| | - Nanako Tamiya
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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14
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Mangino DR, Nicolini ME, De Vries RG, Kim SYH. Euthanasia and Assisted Suicide of Persons With Dementia in the Netherlands. Am J Geriatr Psychiatry 2020; 28:466-477. [PMID: 31537470 PMCID: PMC7035163 DOI: 10.1016/j.jagp.2019.08.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the characteristics of persons with dementia receiving euthanasia/assisted suicide (EAS) and how the practice is regulated in the Netherlands. DESIGNS Qualitative directed content analysis of dementia EAS reports published by the Dutch euthanasia review committees between 2011 and October 5, 2018. RESULTS Seventy-five cases were reviewed: 59 concurrent requests and 16 advance requests. Fifty-three percent (40/75) were women, and 48% (36/75) had Alzheimer disease. Advance request EAS patients were younger, had dementia longer, and more frequently had personal experience with dementia. Some concurrent request EAS patients were quite impaired: 15% (9/59) were deemed incompetent by at least one physician; in 24% (14/59), patients' previous statements or current body language were used to assess competence. In 39% (29/75), patients' own physicians declined to perform EAS; in 43% (32/75), the physician performing EAS was new to them. Physicians disagreed about patients' eligibility in 21% (16/75). All advance request and 14 (25%) concurrent request patients had an advance euthanasia directive but the conditions of applicability often lacked specificity. In 5 of 16 advance request EAS and 2 of 56 concurrent request EAS cases, EAS procedure was modified (e.g., premedication). Twenty-five percent (4/16) of advance request cases did not meet legal due care criteria, in particular the "unbearable suffering" criterion. CONCLUSIONS Advance and concurrent request EAS cases differ in age, duration of illness, and past experience. Advance request EAS cases were complicated by ambiguous directives, patients being unaware of the EAS procedure, and physicians' difficulty assessing "unbearable suffering." Notably, some concurrent request patients were quite impaired yet deemed competent by appeals to previous statements.
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Affiliation(s)
- Dominic R Mangino
- Department of Bioethics, Clinical Center, National Institutes of Health (DRM, MEN, SYHK), Bethesda, MD
| | - Marie E Nicolini
- Department of Bioethics, Clinical Center, National Institutes of Health (DRM, MEN, SYHK), Bethesda, MD; Interfaculty Center for Biomedical Ethics and Law, KU Leuven (MEN), Leuven, Belgium
| | - Raymond G De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School (RGD), Ann Arbor, MI; CAPHRI School for Public Health and Primary Care, Maastricht University (RGD), Maastricht, the Netherlands
| | - Scott Y H Kim
- Department of Bioethics, Clinical Center, National Institutes of Health (DRM, MEN, SYHK), Bethesda, MD.
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15
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White BP, Willmott L, Tilse C, Wilson J, Ferguson M, Aitken J, Dunn J, Lawson D, Pearce A, Feeney R. Prevalence of advance care directives in the community: a telephone survey of three Australian States. Intern Med J 2019; 49:1261-1267. [DOI: 10.1111/imj.14261] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/21/2019] [Accepted: 02/02/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Ben P. White
- Australian Centre for Health Law Research Queensland University of Technology Brisbane Queensland Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research Queensland University of Technology Brisbane Queensland Australia
| | - Cheryl Tilse
- School of Nursing, Midwifery and Social Work The University of Queensland Brisbane Queensland Australia
| | - Jill Wilson
- School of Nursing, Midwifery and Social Work The University of Queensland Brisbane Queensland Australia
| | - Michele Ferguson
- The University of Queensland, Queensland University of Technology Brisbane Queensland Australia
| | | | - Jeffrey Dunn
- University of Southern Queensland, Toowoomba Queensland Australia
| | | | - Angela Pearce
- Cancer Council New South Wales Sydney New South Wales Australia
| | - Rachel Feeney
- Australian Centre for Health Law Research Queensland University of Technology Brisbane Queensland Australia
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16
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Attitudes and completion of advance care planning: Assessing the contribution of health beliefs about Alzheimer's disease among Israeli laypersons. Palliat Support Care 2019; 17:655-661. [DOI: 10.1017/s1478951519000336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectivesThe purpose of this study was to assess laypersons’ attitudes and completion of advance care planning (ACP) and to examine associations with sociodemographic characteristics and health beliefs on Alzheimer's disease.MethodsA cross-sectional telephone survey was conducted during April and May 2017, with a sample of 514 Israeli adults, aged 18 years and above. A structured, pretested questionnaire assessing participants’ awareness, attitudes, and completion of ACP, as well as health beliefs on Alzheimer's disease (subjective knowledge, susceptibility, and worry), and sociodemographic factors, was used.ResultsTwo-fifths of the participants had heard of at least one of the terms: advance directives or durable power of attorney. Overall, participants expressed positive attitudes toward ACP. Results of regression models showed that gender, religiosity, and subjective knowledge of Alzheimer's disease were statistically significant correlates of attitudes toward ACP. Adding health beliefs on Alzheimer's disease doubled the amount of the variance explained, from 3% to 6%.Significance of resultsOur results support the use of cognitive models of health behavior by assessing intra-personal beliefs and knowledge to understand ACP attitudes and completion. Specifically, we demonstrated the importance of knowledge of Alzheimer's disease for ACP attitudes, suggesting the importance of including a module on the topic to ACP interventions.
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Glaudemans JJ, de Jong AE, Onwuteaka Philipsen BD, Wind J, Willems DL. How do Dutch primary care providers overcome barriers to advance care planning with older people? A qualitative study. Fam Pract 2019; 36:219-224. [PMID: 29893922 DOI: 10.1093/fampra/cmy055] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Few older people benefit from advance care planning (ACP), due to several barriers related to primary care professionals, such as insufficient knowledge, negative beliefs and a lack of time. Information on overcoming these barriers is limited. We assumed primary care professionals experienced in ACP with older patients are likely to have learned how to overcome these barriers. OBJECTIVE To investigate how Dutch primary care professionals experienced in ACP with older patients overcome these barriers. METHODS A qualitative study, based on semi-structured interviews, among a purposive sample of 14 Dutch primary care professionals experienced in ACP with older people. Transcripts were thematically analysed. RESULTS We interviewed eight general practitioners (GPs), three nurses and three elderly care physicians, experienced in ACP with older people. Respondents overcame their own insufficient knowledge and skills, as well as their negative attitudes and beliefs by gaining experience through practicing ACP in their daily practices, exchanging and reflecting on those experiences with peers, pursuing continuing education, teaching and participating in research. To overcome patients' and families' lack of initiative and openness to ACP, respondents prepared them for further steps in ACP. To overcome a lack of time, respondents used tools and information communication technology, delegated parts of ACP to other primary care professionals, acquired financing and systematized documentation of ACP. CONCLUSION Primary care professionals can overcome barriers to ACP with older patients by practicing, reflecting on experiences and pursuing continuing education, by preparing patients and involving family and by investing in support to approach ACP more efficiently.
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Affiliation(s)
- Jolien J Glaudemans
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, the Netherlands
| | - Anja E de Jong
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, the Netherlands
| | - Bregje D Onwuteaka Philipsen
- Department of public and occupational health, Amsterdam Public Health Research Institute Expertise Centre for Palliative Care, VU Medical Centre, the Netherlands
| | - Jan Wind
- Department of General Practice, Academic Medical Centre, University of Amsterdam, the Netherlands
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, the Netherlands
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18
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Overbeek A, Korfage IJ, Hammes BJ, van der Heide A, Rietjens JAC. Experiences with and outcomes of Advance Care Planning in bereaved relatives of frail older patients: a mixed methods study. Age Ageing 2019; 48:299-306. [PMID: 30615071 DOI: 10.1093/ageing/afy184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/06/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Advance Care Planning (ACP) may prepare relatives of frail older patients for future decision-making. OBJECTIVE to investigate (1) how bereaved relatives of frail older patients experience ACP conversations and (2) whether ACP has an effect on relatives' preparation for decision-making and on their levels of anxiety and depression. DESIGN cluster randomised controlled trial. SETTING residential care homes in the Netherlands and community setting. SUBJECTS bereaved relatives of care home residents and community-dwelling frail older patients. METHODS we randomised 16 residential care homes to either the intervention group, where patient-participants were offered facilitated ACP, or the control group (n = 201), where they received 'care as usual'. If patient-participants died, we approached relatives for an interview. We asked relatives who had attended ACP conversations for their experience with ACP (open-ended questions). Furthermore, we compared relatives' preparation levels for decision-making and levels of anxiety and depression (HADS) between groups. This trial was registered (NTR4454). RESULTS we conducted interviews with 39/51 (76%) bereaved relatives (intervention group: n = 20, control group: n = 19). Relatives appreciated the ACP conversations. A few considered ACP redundant since they were already aware of the patients' preferences. Nine of 10 relatives in the intervention group felt adequately prepared for decision-making as compared to 5 of 11 relatives in the control group (P = 0.03). Relatives' levels of anxiety and depression did not differ significantly between groups. CONCLUSIONS in our study, bereaved relatives of frail older patients appreciated ACP. ACP positively affected preparedness for decision-making. It did not significantly affect levels of anxiety or depression.
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Affiliation(s)
- Anouk Overbeek
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, CA Rotterdam, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, CA Rotterdam, The Netherlands
| | - Bernard J Hammes
- Respecting Choices, C-TAC Innovations, 600 Third Street North, Suite 101 La Crosse, WI, USA
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, CA Rotterdam, The Netherlands
| | - Judith A C Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, CA Rotterdam, The Netherlands
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19
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Overbeek A, Polinder S, Haagsma J, Billekens P, de Nooijer K, Hammes BJ, Muliaditan D, van der Heide A, Rietjens JA, Korfage IJ. Advance Care Planning for frail older adults: Findings on costs in a cluster randomised controlled trial. Palliat Med 2019; 33:291-300. [PMID: 30269650 DOI: 10.1177/0269216318801751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Advance Care Planning aims at improving alignment of care with patients’ preferences. This may affect costs of medical care. Aim: To determine the costs of an Advance Care Planning programme and its effects on the costs of medical care and on concordance of care with patients’ preferences. Design/settings/participants: In a cluster randomised trial, 16 residential care homes were randomly allocated to the intervention group, where frail, older participants were offered facilitated Advance Care Planning conversations or to the control group. We calculated variable costs of Advance Care Planning per participant including personnel and travel costs of facilitators. Furthermore, we assessed participants’ healthcare use during 12 months applying a broad perspective (including medical care, inpatient days in residential care homes, home care) and calculated costs of care per participant. Finally, we investigated whether treatment goals were in accordance with preferences. Analyses were conducted for 97 participants per group. Trial registration number: NTR4454. Results: Average variable Advance Care Planning costs were €76 per participant. The average costs of medical care were not significantly different between the intervention and control group (€2360 vs €2235, respectively, p = 0.36). Costs of inpatient days in residential care homes (€41,551 vs €46,533) and of home care (€14,091 vs €17,361) were not significantly different either. Concordance of care with preferences could not be assessed since treatment goals were often not recorded. Conclusion: The costs of an Advance Care Planning programme were limited. Advance Care Planning did not significantly affect the costs of medical care for frail older adults.
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Affiliation(s)
- Anouk Overbeek
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Suzanne Polinder
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Juanita Haagsma
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Kim de Nooijer
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Daniel Muliaditan
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Ida J Korfage
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
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20
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Glaudemans JJ, Moll van Charante E, Wind J, Oosterink JJ, Willems DL. Experiences with approaches to advance care planning with older people: a qualitative study among Dutch general practitioners. BMJ Open 2018; 8:e024762. [PMID: 30478126 PMCID: PMC6254415 DOI: 10.1136/bmjopen-2018-024762] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Advance care planning (ACP) with older people needs to be approached differently than ACP with patients with a terminal illness. ACP is still used with only a minority of older patients due to a lack of knowledge regarding appropriate approaches to ACP with older people. General practitioners (GPs) may play a key role in ACP with older people. Therefore, we explored their experiences with and views on approaches to ACP with older patients in daily practice. DESIGN, SETTING AND PARTICIPANTS A qualitative study among a purposive sample of 19 Dutch GPs based on semistructured interviews. RESULTS Approaches to ACP with older patients can be divided into two categories: systematic and ad hoc. Systematic approaches consisted of discussing a fixed combination of topics with community-dwelling older patients who are frail, cognitively impaired or are aged >75 years, and with older patients living in residential care homes during group information meetings, intakes, comprehensive geriatric assessments and periodic assessments. Meetings were aimed at making agreements in anticipation of future care, at providing information and encouraging older people to take further steps in ACP. With ad hoc approaches, respondents discussed only one or two topics related to the near future. Ad hoc ACP was mainly done with deteriorating patients or when patients or family initiated ACP. Systematic and ad hoc approaches were used simultaneously or sequentially and were both used for initiating and following up on ACP. Due to a lack of time and knowledge of other occasions and topics than the ones respondents used, respondents seemed to underuse many occasions and topics. CONCLUSIONS Awareness of appropriate systematic and ad hoc approaches for ACP, and the focus on providing information and encouraging older people to take further steps in ACP reported in this study can support GPs and improve older patients' access to ACP.
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Affiliation(s)
- Jolien Jeltje Glaudemans
- Section of Medical Ethics, Department of General Practice, Amsterdam Public Health research institute, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Eric Moll van Charante
- Department of General Practice, Academic Medical Centre-University of Amsterdam-Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Jan Wind
- Department of General Practice, Academic Medical Centre-University of Amsterdam-Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | | | - Dick Ludolf Willems
- Section of Medical Ethics, Department of General Practice, Amsterdam Public Health research institute, Amsterdam University Medical Centres, Amsterdam, The Netherlands
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21
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Overbeek A, Korfage IJ, Jabbarian LJ, Billekens P, Hammes BJ, Polinder S, Severijnen J, Swart SJ, Witkamp FE, van der Heide A, Rietjens JAC. Advance Care Planning in Frail Older Adults: A Cluster Randomized Controlled Trial. J Am Geriatr Soc 2018; 66:1089-1095. [PMID: 29608789 DOI: 10.1111/jgs.15333] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the effectiveness of advance care planning (ACP) in frail older adults. DESIGN Cluster randomized controlled trial. SETTING Residential care homes in the Netherlands (N=16). PARTICIPANTS Care home residents and community-dwelling adults receiving home care (N=201; n=101 intervention; n=100 control). Participants were 75 years and older, frail, and capable of consenting to participation. INTERVENTION Adjusted Respecting Choices ACP program. MEASUREMENTS The primary outcome was change in patient activation (Patient Activation Measure, PAM-13) between baseline and 12-month follow-up. Secondary outcomes included change in quality of life (SF-12), advance directive (AD) completion, and surrogate decision-maker appointment. Use of medical care in the 12 months after inclusion was also assessed. Multilevel analyses were performed, controlling for clustering effects and differences in demographics. RESULTS Seventy-seven intervention participants and 83 controls completed the follow-up assessment. There were no statistically significant differences between the intervention (-0.26±11.2) and control group (-1.43±10.6) in change scores of the PAM (p=.43) or the SF-12. Of intervention group participants, 93% completed an AD, and 94% appointed a decision-maker. Of control participants, 34% completed an AD, and 67% appointed a decision-maker (p<.001). No differences in the use of medical care were found. CONCLUSIONS ACP did not increase levels of patient activation or quality of life but did increase completion of ADs and appointment of surrogate decision-makers. It did not affect use of medical care.
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Affiliation(s)
- Anouk Overbeek
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Lea J Jabbarian
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | | | - Bernard J Hammes
- Respecting Choices, C-TAC Innovations, La Crosse, Wisconsin, USA
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | | | | | - Frederika E Witkamp
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands.,Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.,Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands
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de Kort FAS, Geurts M, de Kort PLM, van Tuijl JH, van Thiel GJMW, Kappelle LJ, van der Worp HB. Advance directives, proxy opinions, and treatment restrictions in patients with severe stroke. BMC Palliat Care 2017; 16:52. [PMID: 29137615 PMCID: PMC5686946 DOI: 10.1186/s12904-017-0234-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 11/09/2017] [Indexed: 11/15/2022] Open
Abstract
Background Patients with severe stroke often do not have the capacity to participate in discussions on treatment restrictions because of a reduced level of consciousness, aphasia, or another cognitive disorder. We assessed the role of advance directives and proxy opinions in the decision-making process of incapacitated patients. Methods Sixty patients with severe functional dependence (Barthel Index ≤6) at day four after ischemic stroke or intracerebral hemorrhage were included in a prospective two-center cohort study. The decision-making process with respect to treatment restrictions was assessed by means of a semi-structured questionnaire administered to the treating physician at the day of inclusion. Results Forty-nine patients (82%) did not have the capacity to participate in the decision-making process. In eight patients, there was no discussion on treatment restrictions and full care was installed. In 41 patients, the decision whether to install treatment restrictions was discussed with proxies. One patient had a written advance directive. In the remaining 40 patients, proxies based their opinion on previously expressed wishes of the patient (18 patients) or advised in the best interest of the patient (22 patients). In 36 of 41 patients, treatment restrictions were installed after agreement between physician and proxy. At six months, 23 of 49 patients had survived. In only three of them the decision on treatment restrictions was based on previously expressed wishes. Remarkably, two of these survivors could not recall any of their alleged previously expressed wishes. Conclusions Treatment restrictions were installed in the majority of incapacitated patients after stroke. Proxy opinions frequently served as the best way to respect the patients’ autonomy, but their accuracy remains unclear. Electronic supplementary material The online version of this article (10.1186/s12904-017-0234-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Floor A S de Kort
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marjolein Geurts
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Paul L M de Kort
- Department of Neurology, Elisabeth-Twee Steden ziekenhuis, Tilburg, the Netherlands
| | - Julia H van Tuijl
- Department of Neurology, Elisabeth-Twee Steden ziekenhuis, Tilburg, the Netherlands
| | - Ghislaine J M W van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
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23
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Ko E, Lee J, Hong Y. Willingness to complete advance directives among low-income older adults living in the USA. HEALTH & SOCIAL CARE IN THE COMMUNITY 2016; 24:708-716. [PMID: 25939688 DOI: 10.1111/hsc.12248] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 06/04/2023]
Abstract
This study explored low-income older adults' willingness to (i) complete advance directives, legal documents, whereby an individual designates decision-makers in the event that they cannot make their own decisions about end-of-life treatment preferences, and (ii) the role of social support and other predictors that impact their willingness. This study was conducted as part of a larger study exploring behaviours of advance care planning among low-income older adults. Out of a total of 255 participants from the original study, this study included 204 participants who did not complete an advance directive for data analysis. A cross-sectional study using probability random sampling stratified by ethnicity was used. Older adults residing in two supportive housing facilities or who were members of a senior centre in San Diego, California, USA, were interviewed in person between December 2010 and April 2011. Hierarchical logistic regression analysis revealed that the majority of participants (72.1%) were willing to complete advance directives and the factors significantly predicting willingness to complete included self-rated health, attitudes towards advance decision-making and social support. Participants with a poorer health status (OR = 1.43, 95% CI = 1.07-1.90) were more willing to complete advance directives. Conversely, participants with higher positive attitudes (OR = 1.18, 95% CI = 1.00-1.39) and greater social support (OR = 1.07, 95% CI = 1.00-1.15) were also more willing to complete advance directives. The findings suggest the importance of ongoing support from healthcare professionals in end-of-life care planning. Healthcare professionals can be a source of support assisting older adults in planning end-of-life care. Initiating ongoing communication regarding personal value and preference for end-of-life care, providing relevant information and evaluating willingness to complete as well as assisting in the actual completion of advance directives will be necessary.
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Affiliation(s)
- Eunjeong Ko
- School of Social Work, San Diego State University, San Diego, California, USA
| | - Jaehoon Lee
- Institute for Measurement, Methodology, Analysis and Policy, Texas Tech University, Lubbock, Texas, USA.
| | - Youngjoon Hong
- Department of Family Welfare, Sangmyung University, Seoul, Korea
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24
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De Vleminck A, Pardon K, Beernaert K, Houttekier D, Vander Stichele R, Deliens L. How Do General Practitioners Conceptualise Advance Care Planning in Their Practice? A Qualitative Study. PLoS One 2016; 11:e0153747. [PMID: 27096846 PMCID: PMC4838248 DOI: 10.1371/journal.pone.0153747] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 04/04/2016] [Indexed: 12/02/2022] Open
Abstract
Objectives To explore how GPs conceptualise advance care planning (ACP), based on their experiences with ACP in their practice. Methods Five focus groups were held with 36 GPs. Discussions were analysed using a constant comparative method. Results Four overarching themes in the conceptualisations of ACP were discerned: (1) the organisation of professional care required to meet patients’ needs, (2) the process of preparing for death and discussing palliative care options, (3) the discussion of care goals and treatment decisions, (4) the completion of advance directives. Within these themes, ACP was both conceptualised in terms of content of ACP and/or in terms of tasks for the GP. A specific task that was mentioned throughout the discussion of the four different themes was (5) the task of actively initiating ACP by the GP versus passively waiting for patients’ initiation. Conclusions This study illustrates that GPs have varying conceptualisations of ACP, of which some are more limited to specific aspects of ACP. A shared conceptualisation and agreement on the purpose and goals of ACP is needed to ensure successful implementation, as well as a systematic integration of ACP in routine practice that could lead to a better uptake of all the important elements of ACP.
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Affiliation(s)
- Aline De Vleminck
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- * E-mail:
| | - Koen Pardon
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kim Beernaert
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Dirk Houttekier
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Heymans Institute, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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25
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Simon JE, Ghosh S, Heyland D, Cooke T, Davison S, Holroyd-Leduc J, Wasylenko E, Howlett J, Fassbender K. Evidence of increasing public participation in advance care planning: a comparison of polls in Alberta between 2007 and 2013. BMJ Support Palliat Care 2016; 9:189-196. [PMID: 26817793 DOI: 10.1136/bmjspcare-2015-000919] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 10/14/2015] [Accepted: 01/05/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Advance care planning (ACP) encompasses both verbal and written communications expressing preferences for future health and personal care and helps prepare people for healthcare decision-making in times of medical crisis. Healthcare systems are increasingly promoting ACP as a way to inform medical decision-making, but it is not clear how public engagement in ACP activities is changing over time. METHODS Raw data from 3 independently conducted public polls on ACP engagement, in the same Canadian province, were analysed to assess whether participation in ACP activities changed over 6 years. RESULTS Statistically significant increases were observed between 2007 and 2013 in: recognising the definition of ACP (54.8% to 80.3%, OR 3.37 (95% CI 2.68 to 4.24)), discussions about healthcare preferences with family (48.4% to 59.8%, OR 1.41 (95% CI 1.17 to 1.69)) and with healthcare providers (9.1% to 17.4%, OR 1.98 (95% CI 1.51 to 2.59)), written ACP plans (21% to 34.6%, OR 1.77 (95% CI 1.45 to 2.17)) and legal documentation (23.4% to 42.7%, OR 2.13 (95% CI 1.75 to 2.59)). These remained significant after adjusting for age, education and self-rated health status. CONCLUSIONS ACP engagement increased over time, although the overall frequency remains low in certain elements such as discussing ACP with healthcare providers. We discuss factors that may be responsible for the increase and provide suggestions for healthcare systems or other public bodies seeking to stimulate engagement in ACP.
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Affiliation(s)
- J E Simon
- Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - S Ghosh
- Department of Medical Oncology, Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services-Cancer Control
| | - D Heyland
- Clinical Evaluation Research Unit, Department of Medicine, Kingston General Hospital, Kingston, Ontario, Canada.,Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario, Canada
| | - T Cooke
- Health Quality Council of Alberta, Calgary, Alberta, Canada
| | - S Davison
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - J Holroyd-Leduc
- Department of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - E Wasylenko
- Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,John Dossetor Health Ethics Centre, University of Alberta, Edmonton, Alberta, Canada
| | - J Howlett
- Department of Cardiac Sciences, University of Calgary, and Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - K Fassbender
- Covenant Health Palliative Institute, Edmonton, Alberta, Canada.,Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
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26
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De Vleminck A, Pardon K, Houttekier D, Van den Block L, Vander Stichele R, Deliens L. The prevalence in the general population of advance directives on euthanasia and discussion of end-of-life wishes: a nationwide survey. BMC Palliat Care 2015; 14:71. [PMID: 26643482 PMCID: PMC4671216 DOI: 10.1186/s12904-015-0068-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 11/27/2015] [Indexed: 11/26/2022] Open
Abstract
Background To determine the extent to which members of the general population have talked to their physician about their wishes regarding medical treatment at the end of life, to describe the prevalence of advance directives on euthanasia, and to identify associated factors. Method This study used data from the cross-sectional Health Interview Study (HIS) 2008 that collected data from a representative sample (N = 9651) of the Belgian population. Results Of all respondents, 4.4 % had spoken to their physician about their wishes regarding medical treatment at the end of life, while 1.8 % had an advance directive on euthanasia. Factors positively associated with discussions regarding wishes for medical treatment at the end of life were being female, being older in age, having poorer health status and having more GP contacts. People older than 55 years and living in Flanders or Brussels were more likely than the youngest age categories to have an advance directive on euthanasia. Conclusion Younger people, men, people living in the Walloon region of Belgium, people without a longstanding illness, chronic condition or disability and people with few GP contacts could represent a target group for education regarding advance care planning. Public information campaigns and education of physicians may help to enable the public and physicians to engage more in advance care planning.
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Affiliation(s)
- Aline De Vleminck
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium.
| | - Koen Pardon
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium.
| | - Dirk Houttekier
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium.
| | - Lieve Van den Block
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium. .,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Robert Vander Stichele
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium. .,Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.
| | - Luc Deliens
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium. .,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium.
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