Social Work Involvement in Advance Care Planning: Findings from a Large Survey of Social Workers in Hospice and Palliative Care Settings

What Clinicians and Researchers Should Know About the Evolving Field of Advance Care Planning: a Narrative Review

Advance care planning (ACP) has been recognized as crucial by patients, families, and clinicians; however, different definitions and measurements have led to inconsistencies in practice and mixed evidence in the literature. This narrative review explores ACP's evolution, innovations, and outcomes using thematic analysis to synthesize data from randomized controlled trials, reviews, and editorials. Key findings include (1) ACP has evolved over the past several decades from a sole focus on code status and advance directive (AD) forms to a continuum of care planning over the life course focused on tailored preparation for patients and surrogate decision-makers and (2) ACP measurement has evolved from traditional outcome metrics, such as AD completion, to a comprehensive outcomes framework that includes behavior change theory, systems, implementation science, and a focus on surrogate outcomes. Since the recent development of an ACP consensus definition and outcomes framework, high-quality trials have reported mainly positive outcomes for interventions, especially for surrogates, which aligns with the patient desire to relieve decision-making burden for loved ones. Additionally, measurement of "clinically meaningful" ACP information, including documented goals of care discussions, is increasingly being integrated into electronic health records (EHR), and emerging, real-time assessments and natural language processing are enhancing ACP evaluation. To make things easier for patients, families, and care teams, clinicians and researchers can use and disseminate these evolved definitions; provide patients validated, easy-to-use tools that prime patients for conversations and decrease health disparities; use easy-to-access clinician training and simple scripts for interdisciplinary team members; and document patients' values and preferences in the medical record to capture clinically meaningful ACP so this information is available at the point of care. Future efforts should focus on efficient implementation, expanded reimbursement options, and seamless integration of EHR documentation to ensure ACP's continued evolution to better serve patients and their care partners.

High-quality patient-centered palliative care: interprofessional team members' perceptions of social workers' roles and contribution

A core tenet of interprofessional collaborative practice (IPCP) is that efficient and effective teams are critical for the delivery of high-quality, patient-centered care. Although palliative care has a history of excellent care, increasing demands and larger patient loads are challenging teams to adapt and strengthen team functioning in hospital settings. The purpose of this qualitative study was to better understand the IPCP contributions of advanced palliative social workers (PSWs) through the eyes of their colleagues. Twenty-four interprofessional palliative care (IPPC) team members from other professions (i.e. nurse practitioners, physicians, physician assistants) from 16 hospitals across the U.S. participated in 20-minute semi-structured interviews. The Patient-Centered Clinical Method (PCCM) was used as a conceptual model to aid in the interpretation of the data. This model illuminated the centrality of PSWs' role in building and sustaining a therapeutic alliance between the patient and the IPPC team, through assessing and promoting care that centers the patient's experience with illness, creating space to initiate, process and revisit difficult healthcare conversations and helping to modulate the pace and intensity of emotionally laden discussions. PSWs also support the therapeutic relationship with the IPPC team by providing continuity and connection across and during the hospital experience and supporting the well-being of the IPPC team. This study offers novel insights into how PSWs contribute to patient-centered IPPC and furthers the articulation of the role of PSWs in hospital settings.

End-of-Life Discussions From the Perspective of Social Care and Healthcare Professionals in Palliative Care

This study describes the state of end-of-life discussions in Finland. A qualitative descriptive study with thematic interviews was conducted. Data were gathered from palliative care unit nurses, physicians and social workers. Inductive content analysis was used. According to interviewees (n = 33), the state of end-of-life discussion included three main categories. First, optimal end-of-life discussion time included early end-of-life discussion, end-of-life discussion at different phases of severe illness, and flexibility and challenges in scheduling end-of-life discussion. Second, end-of-life discussion initiators included both healthcare professionals and non-healthcare professionals. Third, social care and healthcare professionals' experiences of end-of-life discussion consisted of the importance and challenge of end-of-life discussion, end-of-life communication skills development in multiprofessional care context, and end-of-life communication in multi-cultural care context. The results can be used to justify the need of a national strategy and systematic implementation on Advance Care Planning (ACP), considering the multiprofessional, multicultural and internationalizing operating environment.

Social workers' perspectives about advance directives: A qualitative study

OBJECTIVES

The study explores medical social workers' perceptions on the importance of and purpose for documenting Advance Directives (ADs) in the United States and their views of the benefits for engaging patients and families in dialogue about ADs and Advance Care Planning (ACP).

METHODS

We conducted a qualitative study using free-text responses from a survey of 142 social workers who work in the medical field in various in-patient hospital and out-patient medical/healthcare settings. Participants were asked, "What is the purpose of documenting an advance directive?" and "Why do you think advance directives are important?" and "What benefits have you experienced in educating patients about advance directives?" Thematic analysis informed themes about the purpose, importance, and benefits of supporting patients in completing an AD.

RESULTS

Four themes emerged: 1) The purpose of documenting an AD, 2) Facilitating communication, 3) Creating a plan involves relationship building, and 4) Having an AD reduces suffering and uncertainty.

CONCLUSION

Social workers have expertise in relationship building which is an essential element of the partnering process with patients and their support systems towards AD completion.

PRACTICE IMPLICATIONS

Social workers who work in medical settings provide ACP education for patients and families and create interprofessional linkages to support patient care. It is clear that social workers add value to care provision to improve communication and provide assistance towards AD completion.

Social Work Staffing and Use of Palliative Care Among Recently Hospitalized Veterans

IMPORTANCE

Palliative care improves quality of life for patients and families but may be underused.

OBJECTIVE

To assess the association of an intervention to increase social work staffing in Veterans Health Administration primary care teams with use of palliative care among veterans with a recent hospitalization.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used differences-in-differences analyses of the change in palliative care use associated with implementation of the Social Work Patient Aligned Care Team (PACT) staffing program, conducted from October 1, 2016, to September 30, 2019. The study included 71 VA primary care sites serving rural veterans. Participants were adult veterans who received primary care services from a site enrolled in the program and who received inpatient hospital care. Data were analyzed from January 2020 to August 2022.

EXPOSURES

The PACT staffing program was a clinic-level intervention that provided 3-year seed funding to Veterans Health Administration medical centers to hire 1 or more additional social workers in primary care teams. Staggered timing of the intervention enabled comparison of mean outcomes across sites before and after the intervention.

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of individuals per 1000 veterans who had any palliative care use in 30 days after an inpatient hospital stay.

RESULTS

The analytic sample included 43 200 veterans (mean [SD] age, 65.34 [13.95] years; 37 259 [86.25%] men) and a total of 91 675 episodes of inpatient hospital care. Among the total cohort, 8611 veterans (9.39%) were Black, 77 069 veterans (84.07%) were White, and 2679 veterans (2.92%) were another race (including American Indian or Alaskan Native, Asian, and Native Hawaiian or other Pacific Islander). A mean of 14.5 individuals per 1000 veterans (1329 individuals in all) used palliative care after a hospital stay. After the intervention, there was an increase of 15.6 (95% CI, 9.2-22.3) individuals per 1000 veterans using palliative or hospice care after a hospital stay, controlling for national time trends and veteran characteristics-a 2-fold difference relative to the mean.

CONCLUSIONS AND RELEVANCE

This cohort study found significant increases in use of palliative care for recently hospitalized veterans whose primary care team had additional social work staffing. These findings suggest that social workers may increase access to and/or use of palliative care. Future work should assess the mechanism for this association and whether the increase in palliative care is associated with other health or health care outcomes.

Dialysis Access Considerations in Kidney Palliative Care

In this review, we discuss common challenges at the interface between dialysis access planning, prognostication, and patient-centered decision making. Particularly for patients whose survival benefit from dialysis is attenuated by advanced age or other serious illness, knowing the potential complications and anticipated frequency of access procedures is essential for patients and families to be able to conceptualize what life on dialysis will look like. Although starting dialysis with a functioning graft or fistula is associated with reduced infection rates, mortality, hospitalizations, and cost compared with a central venous catheter, these benefits must be weighed against the chance that early access placement in an elderly or seriously ill patient is an unnecessary surgery because the chronic kidney disease never progresses, the patient dies before developing an indication to start dialysis, or, the patient prefers conservative kidney management over dialysis. Kidney palliative care is a growing subspecialty of nephrology focused on helping seriously ill patients navigate complex medical decisions, and may be useful for intensive goals-of-care discussions about treatment and access options for patients with limited anticipated survival because of age or other serious illness.

Evaluation of a Routine Psychosocial Screening for Patients Receiving Inpatient Specialist Palliative Care: Feasibility and Outcomes

This prospective one-year cohort study aimed to assess the feasibility and outcomes of a routine psychosocial screening at patients' admittance to specialist inpatient palliative care. Patients admitted to an academic palliative care ward were routinely screened for self-reported distress and psychological morbidity, psychosocial stress factors, and subjective need for help from psychosocial professions. Cognitive impairments were the most common patient barrier to screening. Screenings were completed in 138 of 428 patients (32%). Based on established cutoffs, distress was indicated in 89%, depression in 51%, and anxiety in 50% of these patients. The burden on next-of-kin emerged as the most prevalent stress factor (73%). One-half of the patients disclosed a subjective need for help (53%). Possible depression (p = .023), anxiety (p < .001), and subjective need for help (p < .001) correlated positively with a higher amount of time spent by psychologists and creative arts-based therapists with small to moderate effects. Patients who completed the screening were attributed with a higher amount of time by social workers than patients who did not (p = .004), but there were no relationships between screening results and social work. Results suggest the potential of screenings for the allocation of specialist psychosocial care during specialist palliative care; however, barriers to screening do exist.

Assessing the impact of a health navigator on improving access to care and addressing the social needs of palliative care patients experiencing homelessness: A service evaluation

BACKGROUND

Health navigators are healthcare professionals who specialize in care coordination, case management, navigating transitions, and reducing barriers to care. There is limited literature on the impact of health navigators on community-based palliative care for people experiencing homelessness.

AIM

We devised key performance indicators in nine categories with the aim to quantify the impact of a health navigator on the delivery of palliative care to patients experiencing homelessness.

DESIGN

Data were collected prospectively for all patient encounters involving a health navigator from July 2020 to 2021 and reviewed to determine the distribution of the health navigator's role and the ways in which patient care was impacted.

SETTING AND PARTICIPANTS

This study was conducted in Toronto, Ontario with the Palliative Education and Care for the Homeless (PEACH) Program. At any one time, the PEACH health navigator served a total of 50 patients.

RESULTS

We identified five key areas of the health navigator role including (1) facilitating access (2) coordinating care (3) addressing social determinants of health (4) advocating for patients, and (5) counselling patients and loved ones. The health navigator role was split evenly between activities pertaining to palliative care for structurally vulnerable populations and community-based palliative care for the general population. To achieve high impact outcomes, a considerable investment of time and energy was required of the health navigator, speaking to the importance of adequate and sustainable funding.

CONCLUSIONS

These findings underscore the potential for health navigators to add value to community-based palliative care teams, especially those caring for structurally vulnerable populations.

Education, Policy, and Advocacy in Predicting Use of Do-Not-Hospitalize Orders in Skilled Nursing Facilities

Nurses and social workers are uniquely positioned to advocate for patients' wishes for do-not-hospitalize (DNH) directives. The purpose of the current study was to explore the impact of DNH education, policy, and advocacy on the use of DNH orders by nurses (RNs and licensed practical nurses [LPNs]) and social workers employed in skilled nursing facilities (SNFs). This multisite secondary analysis used cross-sectional survey data and analyzed responses of RNs, LPNs, and social workers (N = 354) from 29 urban SNFs. Mixed model regression was used to examine possible predictors of frequency of DNH orders within SNFs while adjusting for random effects. Results showed that having a DNH written policy, education on DNH orders, and having an advanced care planning advocate in the facility were strongly associated with a higher reported frequency of DNH discussions with residents and their families (p < 0.01 for each variable). [Journal of Gerontological Nursing, 48(11), 45-52.].

Development of an intervention (PICASO) to optimise the palliative care capacity of social workers in Flanders: a study protocol based on phase I of the Medical Research Council framework

INTRODUCTION

An important challenge for future palliative care delivery is the growing number of people with palliative care needs compared with the limited qualified professional workforce. Existing but underused professional potential can further be optimised. This is certainly the case for social work, a profession that fits well in multidisciplinary palliative care practice but whose capacities remain underused. This study aims to optimise the palliative care capacity of social workers in Flanders (Belgium) by the development of a Palliative Care Program for Social Work (PICASO).

METHODS AND ANALYSIS

This protocol paper covers the steps of the development of PICASO, which are based on phase I of the Medical Research Council framework. However, additional steps were added to the original framework to include more opportunities for stakeholder involvement. The development of PICASO follows an iterative approach. First, we will identify existing evidence by reviewing the international literature and describe the problem by conducting quantitative and qualitative research among Flemish social workers. Second, we will further examine practice and identify an appropriate intervention theory by means of expert panels. Third, the process and outcomes will be depicted in a logic model.

ETHICS AND DISSEMINATION

Ethical approval for this study was given by the KU Leuven Social and Societal Ethics Committee (SMEC) on 14 April 2021 (reference number: G-2020-2247-R2(MIN)). Findings will be disseminated through professional networks, conference presentations and publications in scientific journals.

"We Are All Just Walking Each Other Home": Exploring the Lived Experiences of Rural Hospice Social Workers in "Companioning" the Dying

Social workers play a critical role on the hospice team including assessing risk and safety, advocacy, grief counseling, referral and connection to resources and providing guidance through advance care planning and advance directives. However, the voice of the rural hospice social worker is often absent from research. To address this gap in the literature, this study aimed to explore lived experiences of rural hospice social workers to better understand their role and challenges. Non-experimental qualitative research design was used for this study. Data was collected through in-depth qualitative interviews. A total of 19 rural hospice social workers participated in the study. We used a phenomenological approach focusing on the common lived experiences of rural hospice social workers and thus interviews were unstructured. Field notes and data were collected until data saturation was achieved. Five main themes were identified: (1) meaning of hospice social work, (2) role of hospice social workers, (3) vulnerability and realness, (4) self-care, and (5) rural culture. Based on these findings, we identified recommendations for hospice social work practice, research and policy, in general, as well as for rural hospice social work specifically. Future research could explore lived experiences of hospice professionals or of the dying and could also explore social worker experience of resource barriers.

Role of Social Workers in Family Conferences for Critically Ill Infants

Background: Communication challenges in the neonatal intensive care unit include fragmented communication, challenges managing expectations amidst uncertainty, and navigating complex medical information. Social workers are well suited to mitigate these challenges. Objective: In this study, we aimed to characterize the extent and nature of social worker participation in family conferences for critically ill infants. Design: We used a longitudinal observational mixed-methods design, enrolling infants with a neurological condition, their parent(s), and their clinicians. All audio-recorded conferences were transcribed and de-identified. Emergent themes and subthemes were identified using conventional content analysis. Results: We enrolled 40 infants and 61 parents. Sixty-eight conferences were held and audio recorded for 24 infants. Social workers were present for 51 of these conferences (n = 51/68, 75%) across 18 cases (n = 18/24, 75%). We identified four themes, conceptualized as distinct roles played by social workers in family conferences: (1) Translator: social workers served as a communicative bridge between parents and the medical team; (2) Coordinator: social workers simplified logistics and connected parents to community resources, including home health agencies and financial assistance; (3) Expectation manager: social workers provided anticipatory guidance and helped parents conceptualize the remainder of the hospital stay, discharge, and life at home; and (4) Advocate: social workers validated parental values and concerns and provided immediate emotional support. Conclusions: Social workers participated in three-quarters of family conferences for critically ill infants. When they participated, they facilitated communication, coordinated care, managed expectations, and advocated for families. These findings underscore the important, varied, and concurrent roles social workers play in the care of critically ill infants. Future communication and family support interventions should leverage these distinct roles.

How can social workers be meaningfully involved in palliative care? A scoping review on the prerequisites and how they can be realised in practice

Palliative care is a holistic practice using a multidisciplinary approach in addressing multidimensional needs. Although the social aspects surrounding the end-of-life phase suggest a place for social work in it, the profession is often inadequately involved in daily practice. This contrasts strongly with the potential meaningful contributions of social workers in this field. To date, no comprehensive list of prerequisites for meaningful social work involvement in palliative care exists. This review aims to gain more insight on the prerequisites for meaningful social work involvement in palliative care and how to realise them in practice. It could therefore provide pathways for future intervention development in enhancing the involvement of social workers and maximising their contributions in palliative care. A scoping review methodology was used. A systematic selection of peer-reviewed articles ranged from 2000 to April 2021 - out of the electronic databases Web of Science, Scopus and Pubmed - was conducted. The 170 articles that met the eligibility criteria were analysed for relevant content using open and axial coding processes. The findings are reported according to the PRISMA-ScR checklist. The nine prerequisites listed in this review concern the level of individual social work capacities and the level of contextual factors structuring social work practices. A majority of articles have, however, focused on the level of individual social work capacities in a rather specialist view on palliative care. Future research should further address the contextual level of social work involvement in the broader practice of death, dying and bereavement.

Conducting an advance care planning group among older adults living in residential care homes: An initiative of social workers in Hong Kong

This study aimed to examine the effects of an advance care planning (ACP) group which was developed by social workers in Hong Kong for older adults. A quasi-experimental study was conducted. Participants were recruited from 14 residential care homes. The ACP intervention group included 59 participants for analyses, and the control group 58. Three major outcomes were measured at two time points: (a) Quality-of-life concerns, (b) End-of-life preference and (c) Advance directive (AD)-related outcomes (awareness of AD, AD completion, willingness to complete AD and communication with family members about AD). Findings indicate that the ACP group enhanced participants' awareness of AD compared with the control group. Participants were also more willing to complete AD, and more participants communicated with family members about AD after participating in the ACP group. No significant difference was found in other outcomes. This study demonstrates the efforts of social workers in promoting ACP in Hong Kong and the effectiveness of an ACP group for enhancing older adults' awareness of AD. Findings support the role of social workers in promoting ACP for deprived groups, like frail older adults. The ACP group could be considered a first step in enhancing older adults' awareness of and willingness to discuss end-of-life issues. Further follow-up is required to develop individualised ACP for older adults.

A Multiple Goals Approach to Exploring Social Worker Conversational Plans for Advance Care Treatment with Terminally Ill Patients

Social workers play an integral role in end-of-life planning and patient outcomes, and yet how social workers approach such conversations with patients is not well understood. The current study employed a cross-sectional design to examine social worker planned communication about end-of-life care using a multiple goals framework. Recruited from online listservs, a content analysis was conducted with social worker curated plans (n = 20) for end-of-life conversations. Plans were coded for topics and content alignment with instrumental, identity, and relational goal types. Topics found were related to eliciting patient goals and the utilization of written resources. A substantial percentage of social workers also noted the inclusion of other parties in the conversation. Findings suggested that content was predominately instrumental (i.e. task-oriented) with an overwhelming majority adhering to multiple conversational goals. Plan content affords insight to occupational orientation and prioritization during conversations with patients. Further, identifying how the majority of planned responses integrate multiple goals simultaneously gives credence to existing research regarding enhanced conversational effectiveness when social workers are present on the palliative care team.

An Interprofessional Approach to Advance Care Planning

CONTEXT

Advance care planning (ACP) can improve patients' outcomes at end of life, and interprofessional collaboration has been recommended to facilitate ACP. However, role confusion in ACP facilitation among team members from different disciplines exists, and health professional disciplines' expectations for interprofessional collaboration in ACP are unclear.

OBJECTIVE

To review expectations of major health professional organizations for ACP competencies, in order to identify gaps and opportunities for promoting interprofessional collaboration in ACP facilitation.

METHODS

Guidelines and recommendations for ACP across disciplines including chaplaincy, medicine, nursing, psychology, and social work were identified and analyzed using content analysis. Main themes were then reviewed against national consensus statements on 4 ACP outcomes (process outcomes, action outcomes, quality of care outcomes, and healthcare outcomes) and mapped into existing domains for interprofessional education competency: values/ethics, roles/responsibilities, interprofessional communication, and teams and teamwork.

RESULTS

Three major content themes were identified: professional commitment to advocating for patients' values and self-determination, professional responsibility to facilitate ACP, and specific tasks in ACP. These themes addressed mostly process and action outcomes of ACP but not quality of care outcomes or healthcare outcomes. Few disciplines included interprofessional collaboration as part of ACP competency.

CONCLUSION

There is a need for standardized competency guidelines for interprofessional collaboration in ACP as an important first step in reducing confusion among roles and other challenges in facilitating ACP. Further efforts in practice, research, and policy are needed to facilitate interprofessional ACP, achieve competencies, and improve patients' outcomes.

The Surprise Question and Serious Illness Conversations: A pilot study

BACKGROUND

Serious Illness Conversations aim to discuss patient goals. However, on acute medicine units, seriously ill patients may undergo distressing interventions until death.

OBJECTIVES

To investigate the feasibility of using the Surprise Question, "Would you be surprised if this patient died within the next year?" to identify patients who would benefit from early Serious Illness Conversations and study any changes in the interdisciplinary team's beliefs, confidence, and engagement as a result of asking the Surprise Question.

DESIGN

A prospective cohort pilot study with two Plan-Do-Study-Act cycles.

PARTICIPANTS/CONTEXT

Fifty-eight healthcare professionals working on Acute Medicine Units participated in pre- and post-intervention questionnaires. The intervention involved asking participants the Surprise Question for each patient. Patient charts were reviewed for Serious Illness Conversation documentation.

ETHICAL CONSIDERATIONS

Ethical approval was granted by the institutions involved.

FINDINGS

Equivocal overall changes in the beliefs, confidence, and engagement of healthcare professionals were observed. Six out of 23 patients were indicated as needing a Serious Illness Conversation; chart review provided some evidence that these patients had more Serious Illness Conversation documentation compared with the 17 patients not flagged for a Serious Illness Conversation. Issues were identified in equating the Surprise Question to a Serious Illness Conversation.

DISCUSSION

Appropriate support for seriously ill patients is both a nursing professional and ethical duty. Flagging patients for conversations may act as a filtering process, allowing healthcare professionals to focus on conversations with patients who need them most. There are ethical and practical issues as to what constitutes a "serious illness" and if answering "no" to the Surprise Question always equates to a conversation.

CONCLUSION

The barriers of time constraints and lack of training call for institutional change in order to prioritise the moral obligation of Serious Illness Conversations.

Occupational differences in advance care planning: Are medical professionals more likely to plan?

Advance care planning (ACP) helps ensure that treatment preferences are met at the end of life. Medical professionals typically are responsible for facilitating patients' ACP, and may be especially effective in doing so if they have first-hand insights from their own planning. However, no large-scale U.S. studies examine whether persons working on the front lines of health care are more likely than other workers to have done ACP. We contrast the use of three ACP components (living wills, durable power of attorney for health care, and informal discussions) among persons working in medical, legal, social/health support services, other professional, and other non-professional occupations. Data are from the Health and Retirement Study (n = 7668) and Wisconsin Longitudinal Study (n = 5464). Multivariable logistic regression analyses are adjusted for socioeconomic, demographic, health, and psychosocial factors that may confound associations between occupational group and ACP. Medical professionals in both samples are more likely than other professional workers to discuss their own treatment preferences, net of all controls. Medical professionals in the WLS are more likely to execute living wills and DPAHC designations, whereas legal professionals in the HRS are more likely to name a DPAHC. Non-professional workers are significantly less likely to do all three types of planning, although these differences are accounted for by socioeconomic factors. Social and health services professionals are no more likely than other professionals to do ACP. The on-the-job experiences and expertise of medical professionals may motivate them to discuss their own end-of-life preferences, which may render them more trustworthy sources of information for patients and clients. The Affordable Care Act provides reimbursement for medical professionals' end-of-life consultations with Medicare beneficiary patients, yet practitioners uncomfortable with such conversations may fail to initiate them. Programs to increase medical professionals' own ACP may have the secondary benefit of increasing ACP among their patients.

Advance Directives in the Nursing Home Setting: An Initiative to Increase Completion and Reduce Potentially Avoidable Hospitalizations

Advance directive (AD) completion can improve transitions between hospitals and skilled nursing facilities (SNF's). One Centers for Medicare and Medicaid Services (CMS) Innovations Demonstration Project, The Missouri Quality Initiative (MOQI), focused on improving AD documentation and use in sixteen SNF's. The intervention included education, training, consultation and improvements to discussion process, policy development, increased AD enactment, and increased community education and awareness activities. An analysis was conducted of data collected from annual chart inventories occurring over four years. Using a logistic mixed model, results indicated statistical significance (p < .001) for increased AD documentation. Greatest gains occurred at project mid-point. The relationship between having an AD and occurrence of transfer to a hospital was tested on a sample of 1,563 residents with length of stays more than 30 days. Residents who did not have an AD were 29% more likely to be transferred. A logistic regression was conducted, and the results were statistically significant (p < .02).

Social work involvement in palliative care heart failure research: a review of recent literature

PURPOSE OF REVIEW

The aim of the review is to examine the findings of empirical studies of palliative care interventions for patients with heart failure in which a social worker was identified as a key member of the interprofessional clinical team.

RECENT FINDINGS

Our systematic review of the empirical literature from January 2016 to August 2019 found five palliative care interventions with heart failure patients that cited involvement of a social worker as a key team member. The reviewed studies highlighted social workers' roles in the areas of psychosocial assessments and support, advance care planning, and patient-medical team communication.

SUMMARY

Palliative social workers possess the knowledge and skills to provide expertise in psychological, social, and cultural care within palliative care domains of practice. Given this primary and critical role, more studies that include the assessment of outcomes linked to the social worker's role should be pursued. Our review unearthed several important studies that highlight the role of the palliative social workers in heart failure models of care.

Enhancing POLST Completion in a Hospital Setting: An Interdisciplinary Approach

EXECUTIVE SUMMARY

With increased therapeutic capabilities in healthcare today, many patients with multiple progressive comorbidities are living longer. They experience recurrent hospitalizations and often undergo procedures that are not aligned with their personal goals. That is why it is essential to discuss and document healthcare preferences prior to an acute event when significant interventions could occur, especially for patients with serious and progressive illness. Completion of an advance directive and a physician order for life-sustaining treatment (POLST) supports provision of goal-concordant care. Further, for patients who have do not attempt resuscitation (DNAR) orders or are diagnosed with advanced dementia, having a POLST is essential. This may be best accomplished with hospitalization discharge plans. Our 896-bed academic medical center, Cedars-Sinai Medical Center, launched a quality initiative in 2015 to complete POLSTs for patients being discharged with DNAR status or with dementia returning to a skilled nursing facility. As part of interdisciplinary progression of care rounds, emphasis was placed on those patients for whom POLST completion was indicated. Proactive, facilitated discussions with patients, family members, and attending physicians were initiated to support POLST completion. The completed forms were then uploaded to the electronic health record. Individual units and physicians received regular feedback on POLST completion rates, and the data were later shared at medical staff quality improvement meetings.During the initiative, POLST completion rates for DNAR patients discharged alive rose from 41% in fiscal year (FY) 2014 to 75% in FY 2019. Similar improvement was seen for patients with dementia discharged to skilled nursing facilities, regardless of code status (rising from 14% in FY 2014 to 54% in FY 2019). Subsequently, we have expanded our efforts to include early discussion and completion of these advanced care planning documents for patients recently diagnosed with high mortality cancers (ovarian, pancreatic, lung, glioblastoma), focusing on the completion of advanced care planning documentation and palliative care referrals.

An interprofessional training to improve advance care planning skills among medicine, nursing, and social work students

Suboptimal training for healthcare students is a recognized barrier to successful completion of advance care planning (ACP) with patients and families. Our study sought to enhance ACP knowledge and communication skills for interprofessional healthcare students. During academic year 2017-2018, 46 students (19-medicine, 16-nursing, and 11-social work), received three training modules delivered by interprofessional faculty. Students subsequently observed a clinical ACP encounter attended by a patient and their family, a clinical social worker, and an internal medicine resident. Three surveys (pre-training T1, post-training T2, and post-clinical encounter T3) evaluated change in student knowledge, communication self-efficacy, ACP self-efficacy, and interprofessional teamwork (using SPICE-R). A randomized waitlist approach was used to test the effects of the clinical ACP training. Student attendance and engagement were high. Relative to baseline, all outcomes differed at all data collection intervals (p < 0.05), except for the SPICE-R from T2 to T3 (p > 0.05). ACP self-efficacy scores declined at T2 before improving at T3. Communication self-efficacy was lower at T2 but improved at T3. Teamwork improved with a medium-large effect (ES = 0.75) at T2 and a large effect (ES = 1.00) at T3. Participant knowledge of ACP improved overall (p < 0.001) as well as for each discipline (p < 0.05). Preliminary findings indicate the interprofessional training experience enhanced student communication skills, ACP knowledge, and appreciation for team-based care. T2 findings demonstrate decrease in communication and ACP self-efficacy, perhaps suggesting students initially underestimated ACP complexity and overestimated their ability to communicate about ACP. T3 findings further suggest that students ultimately benefited from the training experience with meaningful improvements on all key outcomes.

Perceptions of Patient Portal Use for Advance Directive Documentation among Older Adults with Multiple Chronic Conditions

Patient portals can play an innovative role in facilitating advanced care planning (ACP) and documenting advance directives (ADs) among older adults with multiple chronic conditions. The objective of this qualitative sub-study was to (1) understand older adults' use of an ACP patient portal section and (2) obtain user-design input on AD documentation features. Although some older adults may be reluctant, participants reported likely to use a portal for ADs with proper portal design and support.

Top Ten Tips Palliative Care Clinicians Should Know About Psychosocial and Family Support

Palliative care (PC) is perhaps the most inherently interdisciplinary specialty within health care. Comprehensive PC is delivered by a core team of physicians, nurses, social workers, spiritual care providers, pharmacists, and others who address the broad range of medical, psychosocial, and spiritual needs of those living with serious illness. While PC clinicians are typically skilled in screening for distress, the best path to follow when patients screen positive for psychosocial distress or exhibit mental health challenges may not always be clear. This article brings together the perspectives of experienced social workers practicing across PC and hospice settings. It seeks to identify opportunities and rationale for the integration of palliative social work (PSW) in the provision of quality, person-centered, family-focused, and culturally congruent care for the seriously ill. Increasing recognition of the impact of social determinants of health highlights the critical importance of including PSW if we are to better understand and ultimately address the broad range of factors that influence people's quality of life.

Optimizing the role of social workers in advance care planning within an academic hospital: an educational intervention program

Advance Care Planning (ACP) promotes communication to help patients express future health-care preferences and goals for their medical care. Social workers (SWs) are trained to facilitate complex conversations and assist in various ACP tasks across clinical settings. This three-part mixed-method interventional study implemented a comprehensive education and training program for SWs of a large academic hospital, which used pre- and post-training evaluations, chart review, and qualitative data from debrief sessions to examine ACP skills and confidence, and assess the number of ACP conversations initiated with patients. Self-reported level of preparation to facilitate ACP conversations improved significantly (n = 26; pre 36% versus post 82%; p < .05). A 4-month post-intervention chart audit showed an 8.69 fold increase in the number of initiated ACP conversations. Qualitative analysis identified key themes regarding barriers and enablers of initiating ACP conversations during standard care from the perspective of SWs.

Cognitive and emotional representations of pain in cancer patients at an inpatient unit and home palliative care

PURPOSE

To compare symptomatic treatment at inpatient palliative care unit and at home in terms of: pain intensity; negative impact of pain on functioning in different areas of life; and beliefs about pain (cognitive and emotional aspects according to Leventhal's theory).

PATIENTS

The sample consisted of 74 cancer patients qualified for palliative care at an inpatient unit (N = 53) and at home (N = 21).

METHODS

Brief Pain Inventory--Short Form (measurement of pain intensity and pain interference with daily activities), Karnofsky Scale (performance status), Illness Perception Questionnaire for cognitive and emotional representations and beliefs about pain, and Hospital Anxiety and Depression Scale.

RESULTS

Patients treated at inpatient unit and patients treated at home did not differ in terms of pain intensity, depression, and anxiety. The only significant differences between groups were the beliefs about pain. Patients with cancer in home care were more convinced of pain treatment effectiveness but expressed higher level of distress related to pain. Patients convinced that pain can be treated more effectively were younger, the pain they experienced was less severe, and they were treated at home.

CONCLUSIONS

Effectiveness of symptomatic treatment is comparable in patients with cancer at inpatient unit and at home. Treatment at home is associated with stronger patient convictions that pain can be effectively treated and higher level of distress. In future studies, the source of higher distress intensity in patients treated at home may be further explored.

Involvement of Japanese Care Managers and Social Workers in Advance Care Planning

Successful advance care planning relies heavily on effective communication between the elderly and their families, care managers, and social workers. However, care managers and social workers are often not adequately prepared to conduct such discussion. The aim of the present study was to identify the specific challenges facing Japanese care managers and social workers when involvement in advance care planning. Two focus group discussions were held between August and November 2017, involving eleven care managers and three social workers employed at two long-term care facilities actively pursuing advance care planning initiatives. Four main themes were identified, through content analysis, as barriers and facilitators: client readiness, communication, variation-rich client individuality, and difficult-to-explain end-of-life options. This study revealed the importance of building rapport with the residents and their families in order to assess their readiness to discuss care options and preferences. Obstacles included lack of medical knowledge of care managers and social workers. Study findings suggested that a multi-disciplinary team, facilitated by care managers and social workers, was fundamental to achieving the goals of advance care planning.

Social workers' involvement in advance care planning: a systematic narrative review

BACKGROUND

Advance care planning is a process of discussion that enables competent adults to express their wishes about end-of-life care through periods of decisional incapacity. Although a number of studies have documented social workers' attitudes toward, knowledge about, and involvement in advance care planning, the information is fragmented. The purpose of this review was to provide a narrative synthesis of evidence on social workers' perspectives and experiences regarding implementation of advance care planning.

METHODS

Six databases were searched for peer-reviewed research papers from their respective inception through December 2016. All of the resulting studies relevant to both advance care planning and social worker were examined. The findings of relevant studies were synthesized thematically.

RESULTS

Thirty-one articles met the eligibility criteria. Six research themes were identified: social workers' attitudes toward advance care planning; social workers' knowledge, education and training regarding advance care planning; social workers' involvement in advance care planning; social workers' perceptions of their roles; ethical issues relevant to advance care planning; and the effect of social work intervention on advance care planning engagement. The findings suggest that there is a consensus among social workers that advance care planning is their duty and responsibility and that social workers play an important role in promoting and implementing advance care planning through an array of activities.

CONCLUSIONS

This study provides useful knowledge for implementing advance care planning through illustrating social workers' perspectives and experiences. Further studies are warranted to understand the complexity inherent in social workers' involvement in advance care planning for different life-limiting illnesses or within different socio-cultural contexts.