1
|
Hill L, Baruah R, Beattie JM, Bistola V, Castiello T, Celutkienė J, Di Stolfo G, Geller TP, Lambrinou E, Mindham R, McIlfatrick S, Strömberg A, Jaarsma T. Culture, ethnicity, and socio-economic status as determinants of the management of patients with advanced heart failure who need palliative care: A clinical consensus statement from the Heart Failure Association (HFA) of the ESC, the ESC Patient Forum, and the European Association of Palliative Care. Eur J Heart Fail 2023; 25:1481-1492. [PMID: 37477052 DOI: 10.1002/ejhf.2973] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/29/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
The delivery of effective healthcare entails the configuration and resourcing of health economies to address the burden of disease, including acute and chronic heart failure, that affects local populations. Increasing migration is leading to more multicultural and ethnically diverse societies worldwide, with migration research suggesting that minority populations are often subject to discrimination, socio-economic disadvantage, and inequity of access to optimal clinical support. Within these contexts, the provision of person-centred care requires medical and nursing staff to be aware of and become adept in navigating the nuances of cultural diversity, and how that can impact some individuals and families entrusted to their care. This paper will examine current evidence, provide practical guidance, and signpost professionals on developing cultural competence within the setting of patients with advanced heart failure who may benefit from palliative care.
Collapse
Affiliation(s)
- Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
- College of Nursing and Midwifery, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Resham Baruah
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | - James M Beattie
- Cicely Saunders Institute, King's College London, London, UK
| | - Vasiliki Bistola
- National and Kapodistrian University of Athens, Department of Cardiology, Heart Failure Unit, Attikon University Hospital, Athens, Greece
| | - Teresa Castiello
- Department of Cardiovascular Imaging, King's College London, Croydon Health Service London, London, UK
| | - Jelena Celutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Giuseppe Di Stolfo
- Cardiovascular Department, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Tal Prager Geller
- Palliative care centre DOROT medical centre Netanya, Netanya, Israel
| | | | - Richard Mindham
- United Kingdom European Society of Cardiology Patient Forum, Sophia Antipolis, France
| | - Sonja McIlfatrick
- Institute of Nursing and Health Research, Ulster University, Belfast, UK
| | - Anna Strömberg
- Department of Health, Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Department of Cardiology, Linköping University, Linköping, Sweden
| | - Tiny Jaarsma
- Department of Health, Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
2
|
Vanderhaeghen B, Bossuyt I, Menten J, Rober P. What Is Good Advance Care Planning According to Hospitalized Palliative Patients and Their Families? An Explorative Study. J Palliat Care 2020; 35:236-242. [PMID: 32635800 DOI: 10.1177/0825859720938583] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advance care planning is not well implemented in Belgian hospital practice. In order to obtain successful implementation, implementation theory states that the adopters should be involved in the implementation process. This information can serve as a basis for creating better implementation strategies. AIM For this study, we asked hospitalized palliative patients and their families what they experienced as good advance care planning. METHODS Twenty-nine interviews were taken from patients and families, following the Tape Assisted Recall procedure of Elliot. These interviews were analyzed using content analysis based on grounded theory. To improve reliability, 3 independent external auditors audited the analysis. RESULTS Results show that hospitalized palliative patients and families want to have advance care planning communication about treatment and care throughout their disease and about different aspects: social, psychological, physical, practical, and medical. They prefer to have these conversations with their supervising physician. They report 4 important goals of advance care planning communication: establishing a trustful relationship with the physician, in which they feel the involvement of the physician; giving and receiving relevant information for the decision process, making a personal decision about which treatment and care are preferred; and finding consensus between the preferred decision of the physician, the patient and the family concerning the treatment and care policy. CONCLUSION This study can contribute to advance care planning implementation in hospital practice because it gives in insight into which elements in advance care planning patients and families experience as necessary and when advance care planning is necessary to them.
Collapse
Affiliation(s)
| | - Inge Bossuyt
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
| | - Johan Menten
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium.,Department of Radiation-Oncology and Palliative Care, University Hospitals Leuven, Leuven, Belgium
| | - Peter Rober
- Context, University Psychiatric Centre and Katholieke Universiteit (KU) Leuven, Leuven, Belgium.,Department of Neurosciences, Institute for Family and Sexuality Studies, 26657KU Leuven Medical School, Leuven, Belgium
| |
Collapse
|
3
|
Gilissen J, Pivodic L, Wendrich-van Dael A, Gastmans C, Vander Stichele R, Engels Y, Vernooij-Dassen M, Deliens L, Van den Block L. Implementing the theory-based advance care planning ACP+ programme for nursing homes: study protocol for a cluster randomised controlled trial and process evaluation. BMC Palliat Care 2020; 19:5. [PMID: 31915000 PMCID: PMC6950862 DOI: 10.1186/s12904-019-0505-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 12/10/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Research has highlighted the need for improving the implementation of advance care planning (ACP) in nursing homes. We developed a theory-based multicomponent ACP intervention (the ACP+ programme) aimed at supporting nursing home staff with the implementation of ACP into routine nursing home care. We describe here the protocol of a cluster randomised controlled trial (RCT) that aims to evaluate the effects of ACP+ on nursing home staff and volunteer level outcomes and its underlying processes of change. METHODS We will conduct a cluster RCT in Flanders, Belgium. Fourteen eligible nursing homes will be pair-matched and one from each pair will be randomised to either continue care and education as usual or to receive the ACP+ programme (a multicomponent programme which is delivered stepwise over an eight-month period with the help of an external trainer). Primary outcomes are: nursing home care staff's knowledge of, and self-efficacy regarding ACP. Secondary outcomes are: 1) nursing home care staff's attitudes towards ACP and ACP practices; 2) support staff's and volunteer's ACP practices and 3) support staff's and volunteers' self-efficacy. Measurements will be performed at baseline and eight months post-measurement, using structured self-reported questionnaires. A process evaluation will accompany the outcome evaluation in the intervention group, with measurements throughout and post-intervention to assess implementation, mechanisms of impact and context and will be carried out using a mixed-methods design. DISCUSSION There is little high-quality evidence regarding the effectiveness and underlying processes of change of ACP in nursing homes. This combined outcome and process evaluation of the ACP+ programme aims to contribute to building the necessary evidence to improve ACP and its uptake for nursing home residents and their family. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov (no. NCT03521206). Registration date: May 10, 2018. Inclusion of nursing homes started March, 2018. Hence, the trial was retrospectively registered but before end of data collection and analyses.
Collapse
Affiliation(s)
- Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Atlantic Fellow for Equity in Brain Health, Global Brain Health Institute (GBHI), UCSF & Trinity College Dublin, San Francisco, CA, USA. .,Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Jette, Belgium.
| | - Lara Pivodic
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Annelien Wendrich-van Dael
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 Box 7001, 3000, Leuven, Belgium
| | | | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Myrra Vernooij-Dassen
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Brussels, Belgium
| |
Collapse
|
4
|
Gilissen J, Pivodic L, Wendrich-van Dael A, Gastmans C, Vander Stichele R, Van Humbeeck L, Deliens L, Van den Block L. Implementing advance care planning in routine nursing home care: The development of the theory-based ACP+ program. PLoS One 2019; 14:e0223586. [PMID: 31622389 PMCID: PMC6797173 DOI: 10.1371/journal.pone.0223586] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 09/24/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND While various initiatives have been taken to improve advance care planning in nursing homes, it is difficult to find enough details about interventions to allow comparison, replication and translation into practice. OBJECTIVES We report on the development and description of the ACP+ program, a multi-component theory-based program that aims to implement advance care planning into routine nursing home care. We aimed to 1) specify how intervention components can be delivered; 2) evaluate the feasibility and acceptability of the program; 3) describe the final program in a standardized manner. DESIGN To develop and model the intervention, we applied multiple study methods including a literature review, expert discussions and individual and group interviews with nursing home staff and management. We recruited participants through convenience sampling. SETTING AND PARTICIPANTS Management and staff (n = 17) from five nursing homes in Flanders (Belgium), a multidisciplinary expert group and a palliative care nurse-trainer. METHODS The work was carried out by means of 1) operationalization of key intervention components-identified as part of a previously developed theory on how advance care planning is expected to lead to its desired outcomes in nursing homes-into specific activities and materials, through expert discussions and review of existing advance care planning programs; 2) evaluation of feasibility and acceptability of the program through interviews with nursing home management and staff and expert revisions; and 3) standardized description of the final program according to the TIDieR checklist. During step 2, we used thematic analysis. RESULTS The original program with nine key components was expanded to include ten intervention components, 22 activities and 17 materials to support delivery into routine nursing home care. The final ACP+ program includes ongoing training and coaching, management engagement, different roles and responsibilities in organizing advance care planning, conversations, documentation and information transfer, integration of advance care planning into multidisciplinary meetings, auditing, and tailoring to the specific setting. These components are to be implemented stepwise throughout an intervention period. The program involves the entire nursing home workforce. The support of an external trainer decreases as nursing home staff become more autonomous in organizing advance care planning. CONCLUSIONS The multicomponent ACP+ program involves residents, family, and the different groups of people working in the nursing home. It is deemed feasible and acceptable by nursing home staff and management. The findings presented in this paper, alongside results of the subsequent randomized controlled cluster trial, can facilitate comparison, replicability and translation of the intervention into practice.
Collapse
Affiliation(s)
- Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lara Pivodic
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | | | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven (KUL), Brussels, Belgium
| | | | | | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, and Department of Clinical Sciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| |
Collapse
|
5
|
Piers R, Albers G, Gilissen J, De Lepeleire J, Steyaert J, Van Mechelen W, Steeman E, Dillen L, Vanden Berghe P, Van den Block L. Advance care planning in dementia: recommendations for healthcare professionals. BMC Palliat Care 2018; 17:88. [PMID: 29933758 PMCID: PMC6014017 DOI: 10.1186/s12904-018-0332-2] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/10/2018] [Indexed: 01/08/2023] Open
Abstract
Background Advance care planning (ACP) is a continuous, dynamic process of reflection and dialogue between an individual, those close to them and their healthcare professionals, concerning the individual’s preferences and values concerning future treatment and care, including end-of-life care. Despite universal recognition of the importance of ACP for people with dementia, who gradually lose their ability to make informed decisions themselves, ACP still only happens infrequently, and evidence-based recommendations on when and how to perform this complex process are lacking. We aimed to develop evidence-based clinical recommendations to guide professionals across settings in the practical application of ACP in dementia care. Methods Following the Belgian Centre for Evidence-Based Medicine’s procedures, we 1) performed an extensive literature search to identify international guidelines, articles reporting heterogeneous study designs and grey literature, 2) developed recommendations based on the available evidence and expert opinion of the author group, and 3) performed a validation process using written feedback from experts, a survey for end users (healthcare professionals across settings), and two peer-review groups (with geriatricians and general practitioners). Results Based on 67 publications and validation from ten experts, 51 end users and two peer-review groups (24 participants) we developed 32 recommendations covering eight domains: initiation of ACP, evaluation of mental capacity, holding ACP conversations, the role and importance of those close to the person with dementia, ACP with people who find it difficult or impossible to communicate verbally, documentation of wishes and preferences, including information transfer, end-of-life decision-making, and preconditions for optimal implementation of ACP. Almost all recommendations received a grading representing low to very low-quality evidence. Conclusion No high-quality guidelines are available for ACP in dementia care. By combining evidence with expert and user opinions, we have defined a unique set of recommendations for ACP in people living with dementia. These recommendations form a valuable tool for educating healthcare professionals on how to perform ACP across settings.
Collapse
Affiliation(s)
- Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium.,End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Gwenda Albers
- Flanders Federation for Palliative Care, Vilvoorde, Belgium
| | - Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, ACHG, KU Leuven, Leuven, Belgium
| | - Jan Steyaert
- Department of Sociology, University of Antwerp, Antwerp, Belgium.,Flemish Expertise Centre on Dementia Care, Antwerp, Belgium
| | - Wouter Van Mechelen
- Department of Public Health and Primary Care, ACHG, KU Leuven, Leuven, Belgium
| | - Els Steeman
- Academic Centre for Nursing and Midwifery, KULeuven, Leuven, Belgium
| | - Let Dillen
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Brussels, Belgium.
| |
Collapse
|
6
|
Gilissen J, Pivodic L, Gastmans C, Vander Stichele R, Deliens L, Breuer E, Van den Block L. How to achieve the desired outcomes of advance care planning in nursing homes: a theory of change. BMC Geriatr 2018; 18:47. [PMID: 29444645 PMCID: PMC5813418 DOI: 10.1186/s12877-018-0723-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 01/23/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) has been identified as particularly relevant for nursing home residents, but it remains unclear how or under what circumstances ACP works and can best be implemented in such settings. We aimed to develop a theory that outlines the hypothetical causal pathway of ACP in nursing homes, i.e. what changes are expected, by means of which processes and under what circumstances. METHODS The Theory of Change approach is a participatory method of programme design and evaluation whose underlying intention is to improve understanding of how and why a programme works. It results in a Theory of Change map that visually represents how, why and under what circumstances ACP is expected to work in nursing home settings in Belgium. Using this approach, we integrated the results of two workshops with stakeholders (n = 27) with the results of a contextual analysis and a systematic literature review. RESULTS We identified two long-term outcomes that ACP can achieve: to improve the correspondence between residents’ wishes and the care/treatment they receive and to make sure residents and their family feel involved in planning their future care and are confident their care will be according to their wishes. Besides willingness on the part of nursing home management to implement ACP and act accordingly, other necessary preconditions are identified and put in chronological order. These preconditions serve as precursors to, or requirements for, accomplishing successful ACP. Nine original key intervention components with specific rationales are identified at several levels (resident/family, staff or nursing home) to target the preconditions: selection of a trainer, ensuring engagement by management, training ACP reference persons, in-service education for healthcare staff, information for staff, general practitioners, residents and their family, ACP conversations and documentation, regular reflection sessions, multidisciplinary meetings, and formal monitoring. ONCLUSIONS The Theory of Change map presented here illustrates a theory of how ACP is expected to work in order to achieve its desired long-term outcomes while highlighting organisational factors that potentially facilitate the implementation and sustainability of ACP. We provide the first comprehensive rationale of how ACP is expected to work in nursing homes, something that has been called for repeatedly.
Collapse
Affiliation(s)
- J. Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - L. Pivodic
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - C. Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35, Box 7001, 3000 Leuven, Belgium
| | - R. Vander Stichele
- Department of Pharmacology, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - L. Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - E. Breuer
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - L. Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| |
Collapse
|
7
|
Gilissen J, Pivodic L, Smets T, Gastmans C, Vander Stichele R, Deliens L, Van den Block L. Preconditions for successful advance care planning in nursing homes: A systematic review. Int J Nurs Stud 2016; 66:47-59. [PMID: 27987411 DOI: 10.1016/j.ijnurstu.2016.12.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/06/2016] [Accepted: 12/06/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES There is growing evidence of the potential effectiveness of advance care planning. Yet important knowledge gaps remain regarding the preconditions for successful implementation of advance care planning in the nursing home setting. We aim to identify the preconditions related to successful advance care planning in the nursing home setting. By specifying those, we would be able to make well-founded choices for the future design and planning of advance care planning intervention programs. DESIGN A systematic review. DATA SOURCES PubMed, PsycINFO, EMBASE and CINAHL. REVIEW METHODS Two authors independently screened publications. One author assessed methodological quality and extracted textual data, which was double-checked for a random sample. We extracted textual data and used thematic synthesis to identify "preconditions", defined as requirements, conditions and elements necessary to achieve the desired outcome of advance care planning, i.e. attaining concordance between residents' preferences and actual care or treatment received at the end of life. MAIN FINDINGS Based on 38 publications, we identified 17 preconditions at five different levels: resident, family, health-care professional, facility and community. Most preconditions were situated on multiple levels but the majority addressed professionals and the nursing home itself. We summarized preconditions in five domains: to have sufficient knowledge and skills, to be willing and able to participate in advance care planning, to have good relationships, to have an administrative system in place, and contextual factors supporting advance care planning within the nursing home. CONCLUSION There are multiple preconditions related to successfully implementing advance care planning in the complex nursing home setting that operate at micro, meso and macro level. Future interventions need to address these multiple domains and levels in a whole-system approach in order to be better implementable and more sustainable, while simultaneously target the important role of the health-care professional and the facility itself.
Collapse
Affiliation(s)
- Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium.
| | - Lara Pivodic
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium.
| | - Tinne Smets
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 Box 7001, 3000 Leuven, Belgium
| | | | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium; Department of Medical Oncology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Comparing Palliative Care in Care Homes Across Europe (PACE): Protocol of a Cross-sectional Study of Deceased Residents in 6 EU Countries. J Am Med Dir Assoc 2016; 17:566.e1-7. [DOI: 10.1016/j.jamda.2016.03.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/15/2016] [Indexed: 11/22/2022]
|
10
|
Luijendijk HJ, de Bruin NC, Hulshof TA, Koolman X. Terminal illness and the increased mortality risk of conventional antipsychotics in observational studies: a systematic review. Pharmacoepidemiol Drug Saf 2015; 25:113-22. [PMID: 26601922 DOI: 10.1002/pds.3912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 09/10/2015] [Accepted: 10/15/2015] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Numerous large observational studies have shown an increased risk of mortality in elderly users of conventional antipsychotics. Health authorities have warned against use of these drugs. However, terminal illness is a potentially strong confounder of the observational findings. So, the objective of this study was to systematically assess whether terminal illness may have biased the observational association between conventional antipsychotics and risk of mortality in elderly patients. METHODS Studies were searched in PubMed, CINAHL, Embase, the references of selected studies and articles referring to selected studies (Web of Science). Inclusion criteria were (i) observational studies that estimated (ii) the risk of all-cause mortality in (iii) new elderly users of (iv) conventional antipsychotics compared with atypical antipsychotics or no use. Two investigators assessed the characteristics of the exposure and reference groups, main results, measured confounders and methods used to adjust for unmeasured confounders. RESULTS We identified 21 studies. All studies were based on administrative medical and pharmaceutical databases. Sicker and older patients received conventional antipsychotics more often than new antipsychotics. The risk of dying was especially high in the first month of use, and when haloperidol was administered per injection or in high doses. Terminal illness was not measured in any study. Instrumental variables that were used were also confounded by terminal illness. CONCLUSIONS We conclude that terminal illness has not been adjusted for in observational studies that reported an increased risk of mortality risk in elderly users of conventional antipsychotics. As the validity of the evidence is questionable, so is the warning based on it.
Collapse
Affiliation(s)
- Hendrika J Luijendijk
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands.,Department of Geriatric Psychiatry, BAVO Europoort, Rotterdam, The Netherlands
| | - Niels C de Bruin
- Laurens Alzheimer's Care Research Center, Rotterdam, The Netherlands.,Novicare Geriatric Care Inc, Best, The Netherlands
| | - Tessa A Hulshof
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands.,Department of Health Sciences, VU University, Amsterdam, The Netherlands
| | - Xander Koolman
- Department of Health Sciences, VU University, Amsterdam, The Netherlands
| |
Collapse
|
11
|
Ampe S, Sevenants A, Smets T, Declercq A, Van Audenhove C. Advance care planning for nursing home residents with dementia: policy vs. practice. J Adv Nurs 2015; 72:569-81. [DOI: 10.1111/jan.12854] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Sophie Ampe
- KU Leuven; LUCAS; Centre for Care Research and Consultancy; Belgium
| | - Aline Sevenants
- KU Leuven; LUCAS; Centre for Care Research and Consultancy; Belgium
| | - Tinne Smets
- Vrije Universiteit Brussel; End-of-Life Care Research Group; Belgium
| | - Anja Declercq
- KU Leuven; LUCAS; Centre for Care Research and Consultancy; Belgium
| | | |
Collapse
|
12
|
Wils M, Devriendt E, Milisen K, Flamaing J. [The development and validation of a standardised transfer sheet for care transitions between residential and acute care settings in Leuven, Belgium]. Tijdschr Gerontol Geriatr 2015. [PMID: 26215171 DOI: 10.1007/s12439-015-0145-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND When elderly patients are transferred from a residential to an acute care setting, important information regarding their health care can be lost. Over the past years, the concept of advance care planning has also been given a more prominent place in the care for the elderly. However it remains a challenge to communicate the results achieved by this process when patients are referred to another health care setting. Developing a sound method for transferring information is a key element in the transitional care for the elderly patient. OBJECTIVES In collaboration with the residential and acute care settings in Leuven, Flemish Brabant, Belgium this study aimed to develop a validated, standardized transfer-sheet. METHODS After a literature search a topic list was generated to be used as the basis for a Delphi-procedure in which 16 experts from both the acute and the residential care settings participated. The transfer-sheet was then evaluated for content validity by an expert-panel (n = 9) from the acute and residential care settings. Face validity was assessed by two nurses and two doctors, randomly selected from the above settings. RESULTS All 44 subthemes in the transfer-sheet showed excellent content validity. The scale content validity universal agreement (S CVIUA) for the entire transfer-sheet was 0.68. The average scale content validity (S CVIAve) was 0.96. After a second and final Delphi-round a final transfer-sheet was constructed consisting of 8 themes and 50 sub-themes. CONCLUSIONS Based on these results standardized transfer-sheet was developed and validated.
Collapse
Affiliation(s)
- Maartje Wils
- Dienst Geriatrie, UZ Leuven campus Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium.
| | - Els Devriendt
- Dienst Geriatrie, UZ Leuven en Centrum voor Ziekenhuis- en Verplegingswetenschap, Departement Maatschappelijke Gezondheidszorg en Eerstelijnszorg, KU Leuven, Leuven, Belgium
| | - Koen Milisen
- Dienst Geriatrie, UZ Leuven en Centrum voor Ziekenhuis- en Verplegingswetenschap, Departement Maatschappelijke Gezondheidszorg en Eerstelijnszorg, KU Leuven, Leuven, Belgium
| | - Johan Flamaing
- Dienst Geriatrie, UZ Leuven en Departement Klinische en Experimentele Geneeskunde, KU Leuven, Leuven, Belgium
| |
Collapse
|
13
|
Hill L, McIlfatrick S, Taylor B, Dixon L, Harbinson M, Fitzsimons D. Patients' perception of implantable cardioverter defibrillator deactivation at the end of life. Palliat Med 2015; 29:310-23. [PMID: 25239128 DOI: 10.1177/0269216314550374] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Individualised care at the end of life requires professional understanding of the patient's perception of implantable cardioverter defibrillator deactivation. AIM The aim was to evaluate the evidence on patients' perception of implantable cardioverter defibrillator deactivation at end of life. DESIGN Systematic narrative review of empirical studies was published during 2008-2014. DATA SOURCES Data were collected from six databases, citations from relevant articles and expert recommendations. RESULTS In all, 18 studies included with collective population of n = 5810. Concept mapping highlighted three themes: (1) Diverse preferences regarding discussion and deactivation. Deactivation was rarely discussed pre-implantation, with some studies demonstrating patients' reluctance to discuss implantable cardioverter defibrillator deactivation at any stage. Two studies found the majority of patients valued such discussions. Diversity was reflected in patients' willingness to deactivate, ranging from 12% (n = 9) in Irish cohort to 79% (n = 195) in Dutch study. (2) Ethical and legal considerations were predominant in Canadian and American literature as patients wanted to contribute but felt the decision should be a doctor's responsibility. Advance directives were uncommon in Europe, and where they existed the implantable cardioverter defibrillator was not mentioned. (3) 'Living in the now' was evident as despite deteriorating symptoms many patients maintained a positive outlook and anticipated surviving more than 10 years. Several studies asserted living longer was more important than quality of life. CONCLUSION Patients regard the implantable cardioverter defibrillator as a complex and solely beneficial device, with little insight regarding its potential impact on a peaceful death. This review confirms the need for professionals to discuss with patients and families implantable cardioverter defibrillator functionality and deactivation at appropriate opportunities.
Collapse
Affiliation(s)
- Loreena Hill
- Institute of Nursing Research, University of Ulster, Jordanstown Campus, Newtownabbey, UK Belfast Health and Social Care Trust, Belfast, UK
| | - Sonja McIlfatrick
- Institute of Nursing Research, University of Ulster, Jordanstown Campus, Newtownabbey, UK All Ireland Institute of Hospice & Palliative Care, Dublin, Ireland
| | - Brian Taylor
- Institute of Nursing Research, University of Ulster, Jordanstown Campus, Newtownabbey, UK
| | - Lana Dixon
- Belfast Health and Social Care Trust, Belfast, UK
| | | | - Donna Fitzsimons
- Institute of Nursing Research, University of Ulster, Jordanstown Campus, Newtownabbey, UK Belfast Health and Social Care Trust, Belfast, UK All Ireland Institute of Hospice & Palliative Care, Dublin, Ireland
| |
Collapse
|
14
|
A review of advance care planning programs in long-term care homes: are they dementia friendly? Nurs Res Pract 2014; 2014:875897. [PMID: 24757563 PMCID: PMC3976775 DOI: 10.1155/2014/875897] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 01/07/2014] [Accepted: 01/17/2014] [Indexed: 11/18/2022] Open
Abstract
Background. Persons living with dementia in the long-term care home (LTCH) setting have a number of unique needs, including those related to planning for their futures. It is therefore important to understand the advance care planning (ACP) programs that have been developed and their impact in order for LTCH settings to select a program that best suits residents' needs. Methods. Four electronic databases were searched from 1990 to 2013, for studies that evaluated the impact of advance care planning programs implemented in the LTCH setting. Studies were critically reviewed according to rigour, impact, and the consideration of the values of residents with dementia and their family members according to the Dementia Policy Lens Toolkit. Results and Conclusion. Six ACP programs were included in the review, five of which could be considered more “dementia friendly.” The programs indicated a variety of positive impacts in the planning and provision of end-of-life care for residents and their family members, most notably, increased ACP discussion and documentation. In moving forward, it will be important to evaluate the incorporation of residents with dementia's values when designing or implementing ACP interventions in the LTCH settings.
Collapse
|
15
|
De Gendt C, Bilsen J, Stichele RV, Deliens L. Advance care planning and dying in nursing homes in Flanders, Belgium: a nationwide survey. J Pain Symptom Manage 2013; 45:223-34. [PMID: 22917717 DOI: 10.1016/j.jpainsymman.2012.02.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 02/06/2012] [Accepted: 02/14/2012] [Indexed: 11/28/2022]
Abstract
CONTEXT In Belgium, data on actual advance care planning (ACP) in nursing homes (NHs) are scarce. OBJECTIVES To investigate the prevalence and characteristics of documented advance directives and physicians' orders for end-of-life care in NHs, and the authorization of a legal representative in relation to the residents' demographic and clinical characteristics and care received. METHODS This was a retrospective cross-sectional study, including all NH residents deceased during September and October 2006 in all 594 NHs in Flanders, Belgium. Structured mail questionnaires about the resident's characteristics, hospital transfers, palliative care delivery, ACPs, and authorization of legal representatives were completed via the NH administrators and nurses involved in the care of the resident. RESULTS Administrators of 318 NHs (53.5%) reported 1303 deaths. Nurses provided information about 1240 (95.2%) of these deaths. At the end of life, NH residents often had dementia (65.2%) and were severely dependent (76.1%). Almost half (43.1%) had at least one hospital transfer during the last three months of life and two-thirds received palliative care. Half had an ACP, predominantly a physician's order and less often an advance directive. Having advance directives or physician's orders was associated with receiving palliative care. Residents with a physician's order more often died in the NH. Nine percent had an authorized legal representative. CONCLUSION Prevalence of ACPs and formal authorization of a legal representative was low among the deceased NH residents in Flanders, Belgium. There was a higher prevalence of physicians' orders, often established after the resident had lost capacity. Initiatives should be developed to stimulate more advance discussion on care options and making end-of-life decision with the residents while they retain capacity.
Collapse
Affiliation(s)
- Cindy De Gendt
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | |
Collapse
|
16
|
Abstract
BACKGROUND Large-scale nationwide data describing the end-of-life characteristics of older people with dementia are lacking. This paper describes the dying process and end-of-life care provided to elderly people with mild or severe dementia in Belgium. It compares with elderly people dying without dementia. METHODS A nationwide retrospective mortality study was conducted, via representative network of general practitioners (GPs) in 2008 in Belgium, with weekly registration of all deaths (aged ≥ 65) using a standardized form. GPs reported on diagnosis and severity of dementia, aspects of end-of-life care and communication, and on the last week of life in terms of symptoms that caused distress as judged by the GP, and the patients' physical and cognitive abilities. RESULTS Thirty-one percent of our sample (1,108 deaths) had dementia (43% mildly, 57% severely). Of those, 26% died suddenly, 59% in care home, and 74% received palliative treatment, versus 37%, 19%, and 55% in people without dementia. GP-patient conversations were less frequent among those with (45%) than those without (73%) dementia, and 11% of both groups had a proxy decision-maker. During the last week of life, physical and psychological distress was common in both groups. Of older people with dementia, 83% were incapable of decision-making and 83% were bedridden; both significantly higher percentages than found in the group without dementia (24% and 52%). CONCLUSIONS Several areas of end-of-life care provision could be improved. Early communication and exploration of wishes and appointment of proxy decision-makers are important components of an early palliative care approach which appears to be initiated too infrequently.
Collapse
|
17
|
Advance directives and physicians' orders in nursing home residents with dementia in Flanders, Belgium: prevalence and associated outcomes. Int Psychogeriatr 2012; 24:1133-43. [PMID: 22364648 DOI: 10.1017/s1041610212000142] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Advance care planning (ACP) is an important element of high-quality care in nursing homes, especially for residents having dementia who are often incompetent in decision-making toward the end of life. The aim of this study was describe the prevalence of documented ACP among nursing home residents with dementia in Flanders, Belgium, and associated clinical characteristics and outcomes. METHODS All 594 nursing homes in Flanders were asked to participate in a retrospective cross-sectional postmortem survey in 2006. Participating homes identified all residents who had died over the last two months. A structured questionnaire was mailed to the nurses closely involved in the deceased resident's care regarding the diagnosis of dementia and documented care planning, i.e. advance patient directives, authorization of a legal representative, and general practitioners' treatment orders (GP orders). RESULTS In 345 nursing homes (58% response rate), nurses identified 764 deceased residents with dementia of whom 62% had some type of documented care plan, i.e. advance patient directives in 3%, a legal representative in 8%, and GP orders in 59%. Multivariate logistic regression showed that the presence of GP orders was positively associated with receiving specialist palliative care in the nursing home (OR 3.10; CI, 2.07-4.65). Chances of dying in a hospital were lower if there was a GP order (OR 0.38; CI, 0.21-0.70). CONCLUSIONS Whereas GP orders are relatively common among residents with dementia, advance patient directives and a legal representative are relatively uncommon. Nursing home residents receiving palliative care are more likely to have a GP order. GP orders may affect place of death.
Collapse
|
18
|
Pepersack T. Comment on Monod et al: "Ethical issues in nutrition support of severely disabled elderly persons". JPEN J Parenter Enteral Nutr 2011; 35:437-9; author reply 440-2. [PMID: 21700964 DOI: 10.1177/0148607110394867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|
19
|
Houttekier D, Cohen J, Surkyn J, Deliens L. Study of recent and future trends in place of death in Belgium using death certificate data: a shift from hospitals to care homes. BMC Public Health 2011; 11:228. [PMID: 21489273 PMCID: PMC3094244 DOI: 10.1186/1471-2458-11-228] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 04/13/2011] [Indexed: 11/10/2022] Open
Abstract
Background Since most patients prefer out-of-hospital death, place of death can be considered an indicator of end-of-life care quality. The study of trends in place of death is necessary to examine causes of shifts, to evaluate efforts to alter place of death and develop future policies. This study aims to examine past trends and future projections of place of death. Methods Analysis of death certificates (decedents aged ≥ 1 year) in Belgium (Flanders and Brussels Capital region) 1998-2007. Trends in place of death were adjusted for cause of death, sociodemographic characteristics, environmental factors, numbers of hospital beds, and residential and skilled nursing beds in care homes. Future trends were based on age- and sex-specific mortality prognoses. Results Hospital deaths decreased from 55.1% to 51.7% and care home deaths rose from 18.3% to 22.6%. The percentage of home deaths remained stable. The odds of dying in a care home versus hospital increased steadily and was 1.65 (95%CI:1.53-1.78) in 2007 compared to 1998. This increase could be attributed to the replacement of residential beds by skilled nursing beds. Continuation of these trends would result in the more than doubling of deaths in care homes and a decrease in deaths at home and in hospital by 2040. Conclusions Additional end-of-life care resources in care homes largely explain the decrease in hospital deaths. Care homes will become the main locus of end-of-life care in the future. Governments should provide sufficient skilled nursing resources in care homes to fulfil the end-of-life care preferences and needs of patients.
Collapse
Affiliation(s)
- Dirk Houttekier
- Vrije Universiteit Brussel, End-of-Life Care Research Group Ghent University & Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium.
| | | | | | | |
Collapse
|