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Kistler CE, Inoue M, Matsui T, Abe M, Le Donne M, Kiyota A, Lin FC, Yang Y, Hanson LC. Pre-post-evaluation of a dementia-specific advance care planning toolkit for Japanese primary care clinicians. J Am Geriatr Soc 2024. [PMID: 38895937 DOI: 10.1111/jgs.19040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND The population of people living with dementia (PLwD) continues to grow in Japan where advance care planning (ACP) for PLwD is relatively new. Our aim was to evaluate the feasibility and cultural acceptability of a dementia-specific ACP communication skills toolkit for Japanese primary care clinicians. METHODS We delivered 13 training sessions in primary care clinics across central Japan and conducted a post-training survey to assess whether the toolkit increased confidence in dementia-specific ACP communication skills and the acceptability of the toolkit with the following four statements: (1) The language in the sessions was clear, (2) The sessions took an appropriate amount of time to complete, (3) The design of the sessions was an effective educational method, and (4) The sessions were culturally appropriate for communication with Japanese patients with dementia and their family members. We asked participants to respond using a 5-point Likert scale from strongly agree to strongly disagree. RESULTS All participants were Japanese and included 80 physicians (mean age 39.8 years), 33 nurses (mean age 45.7 years), and 58 other participants (mean age 42.9 years), who were 30.0%, 87.9%, and 55.2% female, respectively. Most participants practiced in rural settings. In pre- post-comparisons, participant confidence increased in determining capacity, understanding dementia prognosis, goals of care, eliciting surrogates, recommending self-care practices to families, and leading family meetings (all p < 0.001). Most participants strongly agreed or agreed that the toolkit was an effective method (96.9%), took an appropriate amount of time (94.5%), contained clear language (89.8%), and was culturally appropriate (73.6%). CONCLUSIONS Dementia-specific ACP communication skills toolkit can be delivered in Japan. Japanese primary care clinicians generally felt the dementia-specific ACP toolkit increased their confidence in ACP communication skills and was acceptable. The language, time, and design were well received, though further work is needed to improve the cultural appropriateness of the toolkit.
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Affiliation(s)
- Christine E Kistler
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Geriatric Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, USA
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Machiko Inoue
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomoko Matsui
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Michiko Abe
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Monique Le Donne
- Lake Erie College of Osteopathic Medicine, Bradenton, Florida, USA
| | - Ayano Kiyota
- Department of Family Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Feng-Chang Lin
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yumei Yang
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Geriatric Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Van Dinther K, Javanparast S. Voices of unpaid carers: problems and prospects in accessing palliative care and self-care information, resources and services. Palliat Care Soc Pract 2024; 18:26323524241255386. [PMID: 38827124 PMCID: PMC11141225 DOI: 10.1177/26323524241255386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
Background Unpaid carers make a substantial contribution to the health economy and carers of palliative patients are particularly vulnerable due to special patient needs and excessive carer burden. The Australian Government recently implemented the Integrated Carer Support Service Model to provide a range of free services to carers in the community. However, it is unclear whether such initiatives are effective and, more importantly, how carers of palliative patients gain access to information, support and services for the patient and themselves. Objectives We sought to investigate unpaid carers' experiences in accessing information and resources for support with patient care with a specific focus on palliative care resources and to determine carers' access to information and support for self-care. We also aimed to identify what opportunities and challenges remain for these particular carers according to their experiences. Methods We conducted 18 semi-structured interviews and 3 focus groups with unpaid family or friend carers of palliative patients in South Australia from metropolitan, regional and rural communities. Grounded in a descriptive phenomenological paradigm, we conducted a hybrid approach to thematic analysis combining deductive and inductive coding following Fereday and Muir-Cochrane's method. Results The government's web-based initiative provided little impact in supporting carers from our cohort. There remains a substantial gap between the formal recognition of the importance of carers and their lived reality. This recognition by health professionals is vital, as carer self-identification is not common and affects help-seeking behaviour. Carers seek and respond to more grassroots, personalized forms of support and sharing of information. Conclusion The lack of self-identification affects carers' help-seeking behaviours. Carer identification and recognition need to be initiated by health professionals in a proactive manner to ensure carers are prepared for their role and are emotionally supported to sustain it. Carers seek face-to-face guidance and sources of information.
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Affiliation(s)
- Kristine Van Dinther
- Research Centre for Palliative Care, Death and Dying, Flinders University, Bedford Park, GPO Box 2100, Adelaide, SA 5001, Australia
| | - Sara Javanparast
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, SA, Australia
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Miyatake H, Ozaki A, Kotera Y, Sakamoto R, Bhandari D, Uneno Y, Beniya H. Case report on the legal assurance of Advance Care Planning in collective culture. Clin Case Rep 2022; 10:e05759. [PMID: 35474992 PMCID: PMC9019877 DOI: 10.1002/ccr3.5759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 03/05/2022] [Accepted: 03/28/2022] [Indexed: 11/08/2022] Open
Abstract
This case report shows that there is a lack of a legal framework in Japan to protect patients' right during the end‐of‐life period, which hinders the implementation of ACP in medical practice. This report suggests that legal support can contribute to the advancement of ACP while addressing cultural differences. Advance Care Planning has been widely advocated in Japan, but it has not yet taken root. The collective decision making culture in Japan may unconsciously overpower or ignore the patients' wishes, hence legal support can mitigate its negative impacts on ACP.
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Affiliation(s)
| | - Akihiko Ozaki
- Orange Home‐Care Clinic Fukui Japan
- Department of Breast Surgery Jyoban Hospital of Tokiwa Foundation Iwaki Japan
| | - Yasuhiro Kotera
- School of Health Sciences University of Nottingham Nottingham UK
| | | | | | - Yu Uneno
- Department of Therapeutic Oncology Graduate School of Medicine Kyoto University Kyoto Japan
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Liu X, Chen H, Zhang L, Zhang Q, Feng T, Liu D. Advance Care Planning Engagement Among Family Members of Community-Dwelling Elderly Patients With Chronic Diseases in China: A Mixed-Methods Study. J Hosp Palliat Nurs 2022; 24:E26-E34. [PMID: 35045050 DOI: 10.1097/njh.0000000000000829] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In China, traditional culture advocates family consensus, and the advance care planning (ACP) engagement of family members is crucial to the implementation of ACP. However, there is still a lack of research on family members' engagement in ACP in mainland China. This study investigated the ACP engagement of family members of community-dwelling elderly patients with chronic diseases and provided evidence for further ACP intervention research. We conducted a mixed-methods sequential explanatory study, 273 family members were surveyed, and semistructured interviews were conducted. Following that, 12 family members were selected after statistical analysis to supplement the quantitative results. The results showed that the ACP engagement of family members of elderly patients with chronic diseases in the community was low, but the self-efficacy was higher. The age of family members, severity, and duration of patients' diseases were the main influencing factors for family members' ACP engagement. Traditional cultural, clinical decision-making mode, lack of understanding of ACP, and factors within the family may impede family members' engagement. This study showed that family-centered ACP practice has significant advantages in China and that future research should focus on the Chinese culture and medical system and highlight the role of families.
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Hung CH, Lee YH, Lee DC, Chang YP, Chow CC. The mediating and moderating effects of shared decision making and medical autonomy on improving medical service satisfaction in emergency observation units. Int Emerg Nurs 2021; 60:101101. [PMID: 34864441 DOI: 10.1016/j.ienj.2021.101101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 09/15/2021] [Accepted: 09/29/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Distinct from other medical settings, the emergency setting is unique and requires flexible and adaptive decision making to provide quality medical services. This study was designed to investigate the mediating and moderating effects of shared decision making (SDM) and patient attitude toward medical autonomy (AMA) on improving medical service satisfaction (MSS) in emergency observation units. METHODS In this cross-sectional study, we collected data via a verified structured questionnaire. A total of 165 participants met the inclusion criteria, and 100% of the questionnaires recovered were valid. RESULTS The results show that SDM had a partial mediating effect (p < 0.01) and that it significantly improved MSS. AMA had a moderating effect on some domains (p < 0.01). Meeting patient needs and increasing their participation in decision making can effectively improve MSS. However, excessive patient participation might not be productive, which is an important finding of this study. CONCLUSION In emergency observation units, SDM-based doctor-patient interactions and cooperation, effective patient-centered communication, and respect for patients' medical autonomy improve the doctor-patient relationship and patients' health literacy. Patients can thus participate in selecting the best treatment plan to achieve expected health outcomes, and ultimately improve MSS.
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Affiliation(s)
- Chun-Hua Hung
- Emergency Department, Changhua Christian Medical Foundation, Erlin Christian Hospital, 558, Sec. 1, Da-Chen Rd., Erlin, Changhua 52665, Taiwan ROC
| | - Yi-Hua Lee
- Department of Administration, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County 35053, Taiwan ROC
| | - De-Chi Lee
- Department of Information Management, Da-Yeh University, 168 University Road, Dacun, Changhua 51591, Taiwan ROC
| | - Yuan-Ping Chang
- Department of Nursing, Fooyin University, 151 Jinxue Rd., Daliao Dist., Kaohsiung City 83102, Taiwan ROC.
| | - Chih-Chung Chow
- Office of the Deputy Superintendent, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 500, Taiwan ROC
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Tanaka M, Bito S, Enzo A, Okita T, Atsushi A. Cross-sectional survey of surrogate decision-making in Japanese medical practice. BMC Med Ethics 2021; 22:128. [PMID: 34560873 PMCID: PMC8464150 DOI: 10.1186/s12910-021-00698-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Instances of surrogate decision-making are expected to increase with the rise in hospitalised older adults in Japan. Few large-scale studies have comprehensively examined the entire surrogate decision-making process. This study aimed to gather information to assess the current state of surrogate decision-making in Japan. METHODS A cross-sectional survey was conducted using online questionnaires. A total of 1000 surrogate decision-makers responded to the questionnaire. We examined the characteristics of surrogate decision-makers and patients, content of surrogate decision-making meeting regarding life-sustaining treatment between the doctors and surrogate decision-makers, extent of involvement of the various parties in the surrogate decision-making process, judgement grounds for surrogate decision-making, and frequency of involvement in the surrogate decision-making process. RESULTS Of the participants, 70.5% were male and 48.3% were eldest sons. Only 7.6% of the patients had left a written record of their preferences and 48.8% of the surrogates reported no knowledge of the patient having expressed their prior intentions regarding medical care in any form. Respondents indicated that their family meetings with healthcare professionals mostly included the information recommended by guidelines in a surrogate decision-making meeting in Japan. Most participants reported a good understanding of the meeting content. Although many participants based their decisions on multiple grounds, surrogates' considerations may not adequately reflect respect for patient autonomy in Japan. Specifically, the eldest son considered his own preference more frequently than that of the other surrogate decision-makers. In 26.1% of the cases, either zero or one family meeting with healthcare professionals was held. In these cases, significantly fewer decisions involved the participation of healthcare professionals other than the doctor compared to cases with multiple meetings. CONCLUSIONS Surrogate decisions in Japan are most commonly made by eldest sons and may not frequently consider the perspectives of other surrogates. The finding that patient preferences were rarely known suggests a role for increased advance care planning.
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Affiliation(s)
- Masashi Tanaka
- Department of Clinical Epidemiology, National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan. .,Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan. .,KARADA Internal Medicine Clinic Shibuya, 1-23-13 Jinnan, Shibuya-ku, Tokyo, 150-0041, Japan.
| | - Seiji Bito
- Department of Clinical Epidemiology, National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Aya Enzo
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Takethoshi Okita
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Asai Atsushi
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
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Kistler CE, Beeber AS, Winzelberg GS, Gabriel SL, Wretman CJ, Hanson LC. Evaluation of a Training Toolkit to Improve Clinicians' Skills for Dementia Advance Care Planning. J Palliat Med 2021; 24:1183-1190. [PMID: 33400605 DOI: 10.1089/jpm.2020.0638] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Primary care clinicians care for most persons with Alzheimer's disease and related dementias (ADRDs), yet lack dementia-specific skills in advance care planning (ACP). Objectives: To develop and evaluate a training toolkit for primary care clinicians to improve ACP communication for people with ADRD and their families. Design: Clinical practice outcomes assessment and pre-post-training evaluation. Intervention training toolkit addressed ACP skills by dementia stage: (1) advance directives in early dementia, (2) decision-making capacity in moderate dementia, (3) Physician Orders for Life-Sustaining Treatment (POLST) in late-stage dementia, and (4) hospice and hospitalization in advanced dementia. Setting/Subjects: Nonhospitalized clinical care sites, 51 clinicians in North Carolina, USA. Measurements: Data collection utilized structured chart abstractions and pre- and post-training surveys. Results: Of 51 participants trained, 33 had encounters with patients with ADRD in study period. Most participants were women (n = 42), white (n = 37), and physicians (n = 31). Participants increased documentation of surrogates (22.7% vs. 35.5%, p = 0.03), decision-making capacity (13.5% vs.23.2%, p = 0.04), and POLST completion (9.2% vs. 18.8%, p = 0.03). Training increased ACP documentation (6.4% vs. 14.5%, p = 0.031) and goals of care (GOC) decision-making discussions (17.0% vs. 31.9%, p = 0.005). In pre-post-comparisons, participant confidence increased in determining capacity, exploring dementia prognosis, GOC, eliciting surrogates, and leading family meetings (all p < 0.001). Most participants strongly agreed that the training addressed skills used in practice (n = 34), contained clear language (n = 40), took an appropriate amount of time (n = 32), and was designed effectively (n = 35). Conclusion: This video-based training resource increased the use of dementia-specific ACP communication skills and clinician confidence.
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Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Geriatric Medicine and Palliative Care Program, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anna S Beeber
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gary S Winzelberg
- Division of Geriatric Medicine and Palliative Care Program, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Stacey L Gabriel
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura C Hanson
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Geriatric Medicine and Palliative Care Program, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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Preferences on the Timing of Initiating Advance Care Planning and Withdrawing Life-Sustaining Treatment between Terminally-Ill Cancer Patients and Their Main Family Caregivers: A Prospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17217954. [PMID: 33138212 PMCID: PMC7662916 DOI: 10.3390/ijerph17217954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 12/29/2022]
Abstract
Background: The Western individualistic understanding of autonomy for advance care planning is considered not to reflect the Asian family-centered approach in medical decision-making. The study aim is to compare preferences on timing for advance care planning initiatives and life-sustaining treatment withdrawal between terminally-ill cancer patients and their family caregivers in Taiwan. Methods: A prospective study using questionnaire survey was conducted with both terminally-ill cancer patient and their family caregiver dyads independently in inpatient and outpatient palliative care settings in a tertiary hospital in Northern Taiwan. Self-reported questionnaire using clinical scenario of incurable lung cancer was employed. Descriptive analysis was used for data analysis. Results: Fifty-four patients and family dyads were recruited from 1 August 2019 to 15 January 2020. Nearly 80% of patients and caregivers agreed that advance care planning should be conducted when the patient was at a non-frail stage of disease. Patients’ frail stage of disease was considered the indicator for life-sustaining treatments withdrawal except for nutrition and fluid supplements, antibiotics or blood transfusions. Patient dyads considered that advance care planning discussions were meaningful without arousing emotional distress. Conclusion: Patient dyads’ preferences on the timing of initiating advance care planning and life-sustaining treatments withdrawal were found to be consistent. Taiwanese people’s medical decision-making is heavily influenced by cultural characteristics including relational autonomy and filial piety. The findings could inform the clinical practice and policy in the wider Asia–Pacific region.
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