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Kang JA, Tark A, Estrada LV, Dhingra L, Stone PW. Timing of Goals of Care Discussions in Nursing Homes: A Systematic Review. J Am Med Dir Assoc 2023; 24:1820-1830. [PMID: 37918815 PMCID: PMC10757828 DOI: 10.1016/j.jamda.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVES Discussions between health professionals and nursing home (NH) residents or their families about the current or future goals of health care may be associated with better outcomes at the end of life (EOL), such as avoidance of unwanted interventions or death in hospital. The timing of these discussions varies, and it is possible that their influence on EOL outcomes depends on their timing. This study synthesized current evidence concerning the timing of goals of care (GOC) discussions in NHs and its impact on EOL outcomes. DESIGN Systematic review. SETTING AND PARTICIPANTS Adult populations in NH settings. METHODS This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. We searched PubMed, Embase, and Cumulative Index of Nursing and Allied Health from January 2000 to September 2022. We included studies that examined timing of GOC discussions in NHs, were peer-reviewed, and published in English. Quality of the studies was assessed using the Newcastle-Ottawa Scale. RESULTS Screening of 1930 abstracts yielded 149 papers that were evaluated for eligibility. Of the 18 articles, representing 16 distinct studies that met review criteria, 12 evaluated the timing of advance directives. There was variation in the timing of GOC discussions and compared with discussions that occurred within a month of death, earlier discussions (eg, at the time of facility admission) were associated with lower rates of hospitalization at the EOL and lower health care costs. CONCLUSIONS AND IMPLICATIONS The timing of GOC discussions in NHs varies and evidence suggests that late discussions are associated with poorer EOL outcomes. The benefits of goal-concordant care may be enhanced by earlier and more frequent discussions. Future studies should examine the optimal timing for GOC discussions in the NH population.
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Affiliation(s)
- Jung A Kang
- Columbia University School of Nursing, New York, NY, USA.
| | - Aluem Tark
- Helene Fuld College of Nursing, New York, NY, USA
| | - Leah V Estrada
- Icahn School of Medicine at Mount Sinai, Brookdale Department of Geriatrics and Palliative Medicine, New York, NY, USA
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, NY, USA; Albert Einstein College of Medicine, Bronx, NY, USA
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Detering KM, Sinclair C, Buck K, Sellars M, White BP, Kelly H, Nolte L. Organisational and advance care planning program characteristics associated with advance care directive completion: a prospective multicentre cross-sectional audit among health and residential aged care services caring for older Australians. BMC Health Serv Res 2021; 21:700. [PMID: 34271934 PMCID: PMC8283952 DOI: 10.1186/s12913-021-06523-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/12/2021] [Indexed: 11/18/2022] Open
Abstract
Background Advance care planning (ACP) and advance care directive (ACD) completion improve outcomes for patients, family, clinicians and the healthcare system. However, uptake remains low. Despite increasing literature regarding organisational-level ACP characteristics leading to success, there is a lack of data measuring the impact of these factors on ACD prevalence. Methods A prospective multi-centre, cross-sectional audit of health records among older Australians accessing general practices (GP), hospitals and residential aged care facilities (RACF) was undertaken to describe organisational and ACP-program characteristics across services, document ACD prevalence, and assess organisation-level predictors of ACD prevalence. Organisational-level data included general and ACP-program characteristics. Patient/resident data included demographics and presence of ACDs. Results One hundred organisations (GP = 15, hospitals = 27, RACFs = 58) participated, contributing data from 4187 patient/resident health records. Median prevalence of ACDs across organisations was 19.4%, (range = 0–100%). In adjusted models, organisational sector type was the strongest predictor of ACD prevalence, with higher rates in RACFs (unadjusted 28.7%, adjusted 20.6%) than hospitals (unadjusted 6.4%, adjusted 5.8%) or GPs (unadjusted 2.5%, adjusted 6.6%). RACFs in regional and rural/remote areas had higher prevalence than metropolitan organisations. Organisations supported by government funding and those that were Not For Profit had higher prevalence than those that were privately funded, and organisations with an ACP program that had been implemented at least 3 years before data collection had higher prevalence than those with either no program or a more recent program. Conclusions The median ACD prevalence was low, with substantial variation across organisations. Sector type was the strongest predictor, being highest in RACFs. Low prevalence rates, overall and in particular sectors, have implications for improvements. Further research into organisational factors associated with ACP/ACD completion is required.
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Affiliation(s)
- Karen M Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.,Faculty of Health, Arts and Innovation, Swinburne University of Technology, Hawthorn, Australia
| | - Craig Sinclair
- Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney, Australia.,School of Psychology, University of New South Wales, Sydney, Australia
| | - Kimberly Buck
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Marcus Sellars
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.,Department of Health Services Research & Policy, Research School of Population Health, College of Health & Medicine, The Australian National University, Canberra, Australia
| | - Ben P White
- Australian Centre for Health Research Law, Faculty of Law, Queensland University of Technology, Brisbane, Australia
| | - Helana Kelly
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.,Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.
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Detering KM, Buck K, Ruseckaite R, Kelly H, Sellars M, Sinclair C, Clayton JM, Nolte L. Prevalence and correlates of advance care directives among older Australians accessing health and residential aged care services: multicentre audit study. BMJ Open 2019; 9:e025255. [PMID: 30647047 PMCID: PMC6340468 DOI: 10.1136/bmjopen-2018-025255] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES It is important that the outcomes of advance care planning (ACP) conversations are documented and available at the point of care. Advance care directives (ACDs) are a subset of ACP documentation and refer to structured documents that are completed and signed by competent adults. Other ACP documentation includes informal documentation by the person or on behalf of the person by someone else (eg, clinician, family). The primary objectives were to describe the prevalence and correlates of ACDs among Australians aged 65 and over accessing health and residential aged care services. The secondary aim was to describe the prevalence of other ACP documentation. DESIGN AND SETTING A prospective multicentre health record audit in general practices (n=13), hospitals (n=12) and residential aged care facilities (RACFs; n=26). PARTICIPANTS 503 people attending general practice, 574 people admitted to hospitals and 1208 people in RACFs. PRIMARY AND SECONDARY OUTCOME MEASURES Prevalence of one or more ACDs; prevalence of other ACP documentation. RESULTS 29.8% of people had at least one ACD on file. The majority were non-statutory documents (20.9%). ACD prevalence was significantly higher in RACFs (47.7%) than hospitals (15.7%) and general practices (3.2%) (p<0.001), and varied across jurisdictions. Multivariate logistic regression showed that the odds of having an ACD were positively associated with greater functional impairment and being in an RACF or hospital compared with general practice. 21.6% of people had other ACP documentation. CONCLUSIONS In this study, 30% of people had ACDs accessible and a further 20% had other ACP documentation, suggesting that approximately half of participants had some form of ACP. Correlates of ACD completion were greater impairment and being in an RACF or hospital. Greater efforts to promote and standardise ACDs across jurisdictions may help to assist older people to navigate and complete ACDs and to receive care consistent with their preferences. TRIAL REGISTRATION NUMBER ACTRN12617000743369.
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Affiliation(s)
- Karen M Detering
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Kimberly Buck
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Rasa Ruseckaite
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Helana Kelly
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Marcus Sellars
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Craig Sinclair
- Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia
| | - Josephine M Clayton
- Centre for Learning and Research in Palliative Care, Hammond Care, Greenwich Hospital and Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
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Tjia J, Dharmawardene M, Givens JL. Advance Directives among Nursing Home Residents with Mild, Moderate, and Advanced Dementia. J Palliat Med 2017; 21:16-21. [PMID: 28772095 DOI: 10.1089/jpm.2016.0473] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe prevalence and content of AD documentation among NH residents by dementia stage. BACKGROUND The prevalence of advance directives (ADs) among nursing home (NH) residents with mild, moderate, and advanced dementia remains unclear. METHODS Population-based, cross-sectional study of all licensed NHs in five U.S. states. Subjects included all long-stay (>90 day) NH residents with dementia, aged ≥65 years, and a Cognitive Performance Scale (CPS) score ≥1 from the 2007 to 2008 Minimum Data Set 2.0 (n = 180,621). Dementia severity was classified as follows: mild (CPS 1-2), moderate (CPS 3-4), and advanced (CPS 5-6). MEASUREMENTS ADs were defined as the presence of a living will, do-not-resuscitate order, do-not-hospitalize order, medication restriction, or feeding restriction). RESULTS Overall, 59% of residents had any AD and 17% had a living will. Prevalence of any AD increased by dementia severity: mild (51.2%), moderate (58.2%), and advanced (61.5%) (p < 0.001). In adjusted analysis, resident characteristics associated with any AD documentation included older age, female gender, being white, and having more severe dementia. Having a living will was associated with higher education (≥high school graduate vs. some high school or less) and being married. DISCUSSION While dementia severity was associated with greater likelihood of having documented any AD, almost 4 in 10 residents with dementia lacked any AD. Effective outreach may focus efforts on subgroups with lower odds of any AD or living wills, including non-white, less educated, and unmarried NH residents. A greater understanding of how such factors impact care planning will help to address barriers to patient-centered care for this population.
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Affiliation(s)
- Jennifer Tjia
- 1 Quantitative Health Sciences, University of Massachusetts Medical School , Worcester, Massachusetts
| | | | - Jane L Givens
- 3 Department of Medicine, Hebrew SeniorLife , Boston, Massachusetts
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Kurella Tamura M, Liu S, Montez-Rath ME, O'Hare AM, Hall YN, Lorenz KA. Persistent Gaps in Use of Advance Directives Among Nursing Home Residents Receiving Maintenance Dialysis. JAMA Intern Med 2017; 177:1204-1205. [PMID: 28520863 PMCID: PMC5796530 DOI: 10.1001/jamainternmed.2017.1618] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This data analysis seeks to determine whether changes in the use of advance directives between 2000 and 2010 are related to changing patterns of end-of-life care among nursing home residents receiving dialysis.
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Affiliation(s)
- Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Palo Alto VA Health Care System, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Sai Liu
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Ann M O'Hare
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle.,Hospital and Specialty Medicine, Veteran Affairs Puget Sound Health Care System, Seattle, Washington
| | - Yoshio N Hall
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle.,Hospital and Specialty Medicine, Veteran Affairs Puget Sound Health Care System, Seattle, Washington
| | - Karl A Lorenz
- Division of Palliative Care, Palo Alto VA Health Care System, Stanford University School of Medicine, Palo Alto, California
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Measuring Family Members' Satisfaction with End-of-Life Care in Long-Term Care: Adaptation of the CANHELP Lite Questionnaire. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4621592. [PMID: 28706945 PMCID: PMC5494554 DOI: 10.1155/2017/4621592] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/28/2017] [Accepted: 04/20/2017] [Indexed: 11/17/2022]
Abstract
RATIONALE Improving end-of-life care (EOLC) in long-term care (LTC) homes requires quality measurement tools that assess families' satisfaction with care. This research adapted and pilot-tested an EOLC satisfaction measure (Canadian Health Care Evaluation Project (CANHELP) Lite Questionnaire) for use in LTC to measure families' perceptions of the EOLC experience and to be self-administered. METHODS AND RESULTS Phase 1. A literature review identified key domains of satisfaction with EOLC in LTC, and original survey items were assessed for inclusiveness and relevance. Items were modified, and one item was added. PHASE 2 The revised questionnaire was administered to 118 LTC family members and cognitive interviews were conducted. Further modifications were made including reformatting to be self-administered. PHASE 3 The new instrument was pilot-tested with 134 family members. Importance ratings indicated good content and face validity. Cronbach's alpha coefficients (range: .88-.94) indicated internal consistency. CONCLUSION This research adapted and pilot-tested the CANHELP for use in LTC. This paper introduces the new, valid, internally consistent, self-administered tool (CANHELP Lite Family Caregiver LTC) that can be used to measure families' perceptions of and satisfaction with EOLC. Future research should further validate the instrument and test its usefulness for quality improvement and care planning.
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Are Hospital/ED Transfers Less Likely Among Nursing Home Residents With Do-Not-Hospitalize Orders? J Am Med Dir Assoc 2017; 18:438-441. [DOI: 10.1016/j.jamda.2016.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/02/2016] [Accepted: 12/02/2016] [Indexed: 11/21/2022]
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8
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Levi BH, Simmons Z, Hanna C, Brothers A, Lehman E, Farace E, Bain M, Stewart R, Green MJ. Advance care planning for patients with amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2017. [PMID: 28631959 DOI: 10.1080/21678421.2017.1285317] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine whether an advance care planning (ACP) decision-aid could improve communication about end-of-life treatment wishes between patients with amyotrophic lateral sclerosis (ALS) and their clinicians. METHODS Forty-four patients with ALS (>21, English-speaking, without dementia) engaged in ACP using an interactive computer based decision-aid. Before participants completed the intervention, and again three months later, their clinicians reviewed three clinical vignettes, and made treatment decisions (n = 18) for patients. After patients indicated their agreement with the team's decisions, concordance was calculated. RESULTS The mean concordance between patient wishes and the clinical team decisions was significantly higher post-intervention (post = 91.9%, 95% CI = 87.8, 96.1, vs. pre = 52.4%, 95% CI = 41.9, 62.9; p <0.001). Clinical team members reported greater confidence that their decisions accurately represented each patient's wishes post-intervention (mean = 6.5) compared to pre-intervention (mean = 3.3, 1 = low, 10 = high, p <0.001). Patients reported high satisfaction (mean = 26.4, SD = 3.2; 6 = low, 30 = high) and low decisional conflict (mean = 28.8, SD = 8.2; 20 = low, 80 = high) with decisions about end-of-life care, and high satisfaction with the decision-aid (mean = 52.7, SD = 5.7, 20 = low, 60 = high). Patient knowledge regarding ACP increased post-intervention (pre = 47.8% correct responses vs. post = 66.3%; p <0.001) without adversely affecting patient anxiety or self-determination. CONCLUSION A computer based ACP decision-aid can significantly improve clinicians' understanding of ALS patients' wishes with regard to end-of-life medical care.
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Affiliation(s)
- Benjamin H Levi
- a Department of Humanities & Pediatrics , Penn State College of Medicine , Hershey , PA , USA
| | - Zachary Simmons
- b Department of Neurology , Penn State College of Medicine, ALS Clinic and Research Center , Hershey , PA , USA
| | | | - Allyson Brothers
- d Human Development and Family Studies , Colorado State University , Fort Collins , CO , USA
| | - Erik Lehman
- e Department of Public Health Sciences , Penn State College of Medicine , Hershey , PA , USA
| | - Elana Farace
- e Department of Public Health Sciences , Penn State College of Medicine , Hershey , PA , USA
| | - Megan Bain
- f Department of Humanities , Penn State College of Medicine , Hershey , PA , USA , and
| | - Renee Stewart
- f Department of Humanities , Penn State College of Medicine , Hershey , PA , USA , and
| | - Michael J Green
- g Department of Humanities & Medicine , Penn State College of Medicine , Hershey , PA , USA
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Developing Strategies to Improve Advance Care Planning in Long Term Care Homes: Giving Voice to Residents and Their Family Members. ACTA ACUST UNITED AC 2014. [DOI: 10.1155/2014/358457] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Long term care (LTC) homes, also known as residential care homes, commonly care for residents until death, making palliative care and advance care planning (ACP) important elements of care. However, limited research exists on ACP in LTC. In particular, research giving voice to family members and substitute decision makers is lacking. The objective of this research was to understand experiences, perspectives, and preferences to guide quality improvement of ACP in LTC. This qualitative descriptive study conducted 34 individual semistructured interviews in two LTC homes, located in Canada. The participants were 31 family members and three staff, consisting of a front line care worker, a registered nurse, and a nurse practitioner. All participants perceived ACP conversations as valuable to provide “resident-centred care”; however, none of the participants had a good understanding of ACP, limiting its effectiveness. Strategies generated through the research to improve ACP were as follows: educating families and staff on ACP and end-of-life care options; better preparing staff for ACP conversations; providing staff skills training and guidelines; and LTC staff initiating systematic, proactive conversations using careful timing. These strategies can guide quality improvement of palliative care and development of ACP tools and resources specific to the LTC home sector.
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10
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Zhang W. Older Adults Making End of Life Decisions: An Application of Roy's Adaptation Model. J Aging Res 2013; 2013:470812. [PMID: 24455259 PMCID: PMC3888737 DOI: 10.1155/2013/470812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 10/15/2013] [Indexed: 11/24/2022] Open
Abstract
Purpose. The purpose of this study was to identify variables that influenced completion of advanced directives in the context of adaptation from national data in older adults. Knowledge gained from this study would help us identify factors that might influence end of life discussions and shed light on strategies on effective communication on advance care planning. Design and Method. A model-testing design and path analysis were used to examine secondary data from 938 participants. Items were extracted from the data set to correspond to variables for this study. Scales were constructed and reliabilities were tested. Results. The final path model showed that physical impairment, self-rated health, continuing to work, and family structure had direct and indirect effects on completion of advanced directives. Five percent of the variance was accounted for by the path analysis. Conclusion. The variance accounted for by the model was small. This could have been due to the use of secondary data and limitations imposed for measurement. However, health care providers and families should explore patient's perception of self-health as well as their family and work situation in order to strategize a motivational discussion on advance directive or end of life care planning.
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Affiliation(s)
- Weihua Zhang
- Nell Hodgson Woodruff School of Nursing Emory University, 1520 Clifton Road, Atlanta, GA 30322-4207, USA
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11
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Schubart JR, Levi BH, Dellasega C, Whitehead M, Green MJ. Factors that affect decisions to receive (or not receive) life-sustaining treatment in advance care planning. J Psychosoc Nurs Ment Health Serv 2013; 52:38-44. [PMID: 24200911 DOI: 10.3928/02793695-20131028-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 08/07/2013] [Indexed: 11/20/2022]
Abstract
This study identifies factors that affect decisions people make regarding whether they want to receive life-sustaining treatment. It is an interpretive-descriptive study based on qualitative data from three focus groups (N = 23), representing a diverse population in central Pennsylvania. Study sites included a suburban senior center serving a primarily White, middle-class population; an urban senior center serving a frail, underserved, African American population; and a breast cancer support group. The most important factors affecting whether participants wished to receive life-sustaining medical treatment were prognosis, expected quality of life, burden to others, burden to oneself in terms of the medical condition and treatment, and effect on mental functioning and independence. Our findings contribute to the knowledge of the complex factors that influence how people make decisions about advance care planning and life-sustaining treatments. This understanding is critical if nurses are to translate the patient's goals, values, and preferences into an actionable medical plan.
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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.
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13
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Waldrop DP, Meeker MA. Hospice decision making: diagnosis makes a difference. THE GERONTOLOGIST 2012; 52:686-97. [PMID: 22387234 DOI: 10.1093/geront/gnr160] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE This study explored the process of decision making about hospice enrollment and identified factors that influence the timing of that decision. METHODS This study employed an exploratory, descriptive, cross-sectional design and was conducted using qualitative methods. In-depth in-person semistructured interviews were conducted with 36 hospice patients and 55 caregivers after 2 weeks of hospice care. The study was guided by Janis and Mann's conflict theory model (CTM) of decision making. Qualitative data analysis involved a directed content analysis using concepts from the CTM. RESULTS A model of hospice enrollment decision making is presented. Concepts from the CTM (appraisal, surveying and weighing the alternatives, deliberations, adherence) were used as an organizing framework to illustrate the dynamics. Distinct differences were found by diagnosis (cancer vs. other chronic illness, e.g., heart and lung diseases) during the pre-encounter phase or before the hospice referral but no differences emerged during the post-encounter phase. IMPLICATIONS Differences in decision making by diagnosis suggest the need for research about effective means for tailored communication in end-of-life decision making by type of illness. Recognition that decision making about hospice admission varies is important for clinicians who aim to provide person-centered and family-focused care.
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Affiliation(s)
- Deborah P Waldrop
- University at Buffalo School of Social Work, 685 Baldy Hall, Buffalo, NY 14260, USA.
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14
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Jeong SYS, Higgins I, tMcMillan M. Experiences with advance care planning: older people and family members' perspective. Int J Older People Nurs 2012; 6:176-86. [PMID: 21998863 DOI: 10.1111/j.1748-3743.2009.00201.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES The aim of this study is to report the findings of a case study that explored the phenomenon of advance care planning and advanced care directives in residential care settings in Australia. In particular, this study focuses on the experiences of residents' and family members'. BACKGROUND Understanding the phenomenon of advance care planning and advanced care directives is vital to end of life decision making. There are few studies that report the experiences of older people and family members in relation to advance care planning and advanced care directives. METHODS A case-study research was conducted and data was collected over 7 months involving participant observation, field notes, semi-structured interviews and document analysis. FINDINGS The participants' early experiences with advance care planning were expressed in unpleasant, hostile and negative ways. However, those emotions and concerns were transformed to more stable, amenable and positive attitudes and feelings as issues were resolved. The factors that enhanced or inhibited the transition were described. CONCLUSION Older people and families view the end of life with broader psychosocial and spiritual meanings shaped by a lifetime of experiences. Advance care planning led to a different level of appreciation of personal entity and transcendence. However, advance care planning demands concerted action and support by everyone involved.
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Affiliation(s)
- Sarah Yeun-Sim Jeong
- School of Nursing & Midwifery, University of Newcastle, Ourimbah, NSW, Australia.
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15
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Krok J, Dobbs D, Hyer K, Polivka-West L. Nurse managers' perspectives of structural and process characteristics related to residents' advance directives in nursing homes. Appl Nurs Res 2011; 24:e45-50. [PMID: 21439787 DOI: 10.1016/j.apnr.2010.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 11/17/2010] [Accepted: 11/30/2010] [Indexed: 10/18/2022]
Abstract
This article examines associations between nursing home structural and process characteristics and presence of advance directives and trends over 5 years of advance directives in Florida nursing homes. Our results underscore the importance of nursing homes' processes in facilitating discussions of nursing home residents' end-of-life care preferences.
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Affiliation(s)
- Jessica Krok
- University of South Florida, School of Aging Studies and Florida Policy Exchange Center on Aging, Tampa, 33612, USA.
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Green MJ, Levi BH. Teaching advance care planning to medical students with a computer-based decision aid. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2011; 26:82-91. [PMID: 20632222 PMCID: PMC3737727 DOI: 10.1007/s13187-010-0146-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Discussing end-of-life decisions with cancer patients is a crucial skill for physicians. This article reports findings from a pilot study evaluating the effectiveness of a computer-based decision aid for teaching medical students about advance care planning. Second-year medical students at a single medical school were randomized to use a standard advance directive or a computer-based decision aid to help patients with advance care planning. Students' knowledge, skills, and satisfaction were measured by self-report; their performance was rated by patients. 121/133 (91%) of students participated. The Decision-Aid Group (n = 60) outperformed the Standard Group (n = 61) in terms of students' knowledge (p < 0.01), confidence in helping patients with advance care planning (p < 0.01), knowledge of what matters to patients (p = 0.05), and satisfaction with their learning experience (p < 0.01). Likewise, patients in the Decision Aid Group were more satisfied with the advance care planning method (p < 0.01) and with several aspects of student performance. Use of a computer-based decision aid may be an effective way to teach medical students how to discuss advance care planning with cancer patients.
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Affiliation(s)
- Michael J Green
- Departments of Humanities and Internal Medicine, Penn State College of Medicine, C1743, 500 University Drive, Hershey, PA 17033, USA.
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Burgess M, Cha S, Tung EE. Advance care planning in the skilled nursing facility: what do we need for success? Hosp Pract (1995) 2011; 39:85-90. [PMID: 21441763 DOI: 10.3810/hp.2011.02.378] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Despite the established benefits of advance care planning (ACP) in the geriatric population, documentation of ACP counseling in the skilled nursing facility (SNF) setting remains poor. The primary aim of this study was to identify key barriers to ACP completion among SNF providers. A secondary aim was to identify ACP practice-based differences between SNF physicians and midlevel providers. METHODS As part of a divisional quality improvement project, 43 SNF providers from the area's 9 facilities were asked to complete an optional 14-item electronic survey. The survey was designed to explore and contrast SNF physicians' and midlevel providers' experiences with ACP counseling and documentation. RESULTS We obtained a 91% completion rate. Systems-based factors, such as lack of a centralized document location, inconsistent documentation habits, dispersion of responsibility, lack of time, and under-recognition of team members' efforts, were cited as key barriers to ACP documentation. Perceived patient characteristics contributing to a low completion rate included cognitive impairment and lack of family involvement. Key differences between the 2 provider groups included the location of their ACP documentation (electronic medical record vs paper chart), frequency of documentation, and recognition of who is documenting the ACP. CONCLUSION The survey demonstrated that systems-based barriers contribute to poor ACP documentation in the SNF setting. Key differences in attitudes about the impact of ACP on loved ones were identified between provider groups. Strategies aimed at mitigating practice-level barriers, such as standardizing a location for ACP documentation and formalizing workflow, are needed for increased ACP completion rates in SNFs.
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Affiliation(s)
- Mary Burgess
- Mayo Clinic, Internal Medicine Residency Program, Rochester, MN 55902, USA.
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Aparanji KP, Dharmarajan TS. Pause before a PEG: A feeding tube may not be necessary in every candidate! J Am Med Dir Assoc 2010; 11:453-6. [PMID: 20627188 DOI: 10.1016/j.jamda.2009.11.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 11/29/2009] [Accepted: 11/30/2009] [Indexed: 01/02/2023]
Abstract
Percutaneous endoscopic gastrostomies (PEGs) are a means to provide nutrition in older adults incapable of normal adequate nutrient intake. Often decisions to insert a PEG in patients with illness and dementia are made hastily, before exhausting every means of feeding and full evaluation for the potential to regain capacity to feed normally. Further, ethical aspects often cloud such decisions, with data not supporting meaningful long-term improvement in outcomes or quality of life for the recipient of a PEG. Our case illustrates the story of a nursing home resident in whom an organized approach determined a reversible basis for his inability to feed and the potential to avoid tube insertion.
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Hossler C, Levi BH, Simmons Z, Green MJ. Advance care planning for patients with ALS: feasibility of an interactive computer program. ACTA ACUST UNITED AC 2010; 12:172-7. [PMID: 20812887 DOI: 10.3109/17482968.2010.509865] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This pilot study examined whether an interactive, computer based decision aid can help patients with amyotrophic lateral sclerosis (ALS) engage in effective advance care planning. Individuals being treated for ALS (>18 years old, English speaking, and without dementia) were recruited to use a decision aid and complete pre-/post-intervention measures. Seventeen individuals completed the pre-intervention questionnaires and decision aid; 16/17 (94%) completed the post-intervention measures, and none reported any burden from the intervention. 'Overall satisfaction' with the decision aid was very high (mean = 8.5 ± 0.27: 1 = not at all satisfied, 10 = extremely satisfied), as was 'perceived accuracy' of the computer generated advance directive in reflecting patients' wishes (mean = 8.6 ± 0.27: 1 = not at all accurate, 10 = extremely accurate). Participants judged the 'amount of information' provided by the intervention appropriate (mean = 6.8 ± 0.38: 1 = too little, 5 = about right, 10 = too much), and on a detailed, 12-item assessment judged the decision aid very positively (mean = 4.16 ± 0.16: 1 = very dissatisfied, 5 = very satisfied). The intervention prompted many participants to discuss advance care planning with loved ones and to share their computer generated advance directive with their physician. This study demonstrates that individuals with ALS can successfully complete a computer based decision aid for advance care planning, and suggests that this intervention can help promote effective advance care planning.
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Affiliation(s)
- Carrie Hossler
- Department of Ob/Gyn, Penn State College of Medicine, Hershey, Pennsylvania, USA
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Kelly A, Conell-Price J, Covinsky K, Cenzer IS, Chang A, Boscardin WJ, Smith AK. Length of stay for older adults residing in nursing homes at the end of life. J Am Geriatr Soc 2010; 58:1701-6. [PMID: 20738438 DOI: 10.1111/j.1532-5415.2010.03005.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe lengths of stay of nursing home decedents. DESIGN Retrospective cohort study. SETTING The Health and Retirement Study (HRS), a nationally representative survey of U.S. adults aged 50 and older. PARTICIPANTS One thousand eight hundred seventeen nursing home residents who died between 1992 and 2006. MEASUREMENTS The primary outcome was length of stay, defined as the number of months between nursing home admission and date of death. Covariates were demographic, social, and clinical factors drawn from the HRS interview conducted closest to the date of nursing home admission. RESULTS The mean age of decedents was 83.3 ± 9.0; 59.1% were female, and 81.5% were white. Median and mean length of stay before death were 5 months (interquartile range 1-20) and 13.7 ± 18.4 months, respectively. Fifty-three percent died within 6 months of placement. Large differences in median length of stay were observed according to sex (men, 3 months vs women, 8 months) and net worth (highest quartile, 3 months vs lowest quartile, 9 months) (all P <.001). These differences persisted after adjustment for age, sex, marital status, net worth, geographic region, and diagnosed chronic conditions (cancer, hypertension, diabetes mellitus, lung disease, heart disease, and stroke). CONCLUSION Nursing home lengths of stay are brief for the majority of decedents. Lengths of stay varied markedly according to factors related to social support.
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Affiliation(s)
- Anne Kelly
- Veterans Affairs Medical Center, San Francisco, California, USA
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Shanley C, Whitmore E, Khoo A, Cartwright C, Walker A, Cumming RG. Understanding how advance care planning is approached in the residential aged care setting: a continuum model of practice as an explanatory device. Australas J Ageing 2010; 28:211-5. [PMID: 19951344 DOI: 10.1111/j.1741-6612.2009.00383.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To gain an understanding of how advance care planning (ACP) is understood and approached by managers of residential aged care facilities. METHODS Qualitative interviews with managers from 41 residential aged care facilities from South Western Sydney, Australia. Content and thematic analysis of interview transcripts. RESULTS The majority of facilities do not have a systematic approach to ACP, but tend to initiate discussions about end-of-life treatments late in a resident's illness. There are varying degrees to which these discussions are used in ongoing care planning or made explicit if the resident is transferred to hospital. A number of factors are identified that support the implementation of ACP. CONCLUSION A continuum model of practice is proposed that describes four broad approaches to practice under the domains of initiation, scope, follow-up and documentation of ACP as well as the organisational leadership adopted around ACP.
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Affiliation(s)
- Christopher Shanley
- Aged Care Research Unit, Liverpool Hospital, University of New South Wales, Sydney, New South Wales, Australia.
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Levi BH, Dellasega C, Whitehead M, Green MJ. What influences individuals to engage in advance care planning? Am J Hosp Palliat Care 2010; 27:306-12. [PMID: 20103783 DOI: 10.1177/1049909109355280] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is an underutilized process that involves thinking about what kind of life-prolonging medical care one would want should the need arise, identifying a spokesperson, and then communicating these wishes. OBJECTIVE To better understand what influences individuals to engage in ACP. DESIGN Three focus groups using semistructured interactive interviews were conducted with 23 older individuals from 3 diverse populations in central Pennsylvania. RESULTS Four categories of influences for engaging in ACP were identified: (1) concern for self; (2) concern for others; (3) expectations about the impact of ACP; and (4) anecdotes, stories, and experiences. CONCLUSIONS The motivations for undertaking ACP that we have identified offer health care providers insight into effective strategies for facilitating the process of ACP with their patients.
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Affiliation(s)
- Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania 17033, USA.
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Temkin-Greener H, Zheng NT, Norton SA, Quill T, Ladwig S, Veazie P. Measuring end-of-life care processes in nursing homes. THE GERONTOLOGIST 2009; 49:803-15. [PMID: 19574538 DOI: 10.1093/geront/gnp092] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE The objectives of this study were to develop measures of end-of-life (EOL) care processes in nursing homes and to validate the instrument for measuring them. DESIGN AND METHODS A survey of directors of nursing was conducted in 608 eligible nursing homes in New York State. Responses were obtained from 313 (51.5% response rate) facilities. Secondary data on structural characteristics of the nursing homes were obtained from the Online Survey Certification and Reporting System. Exploratory factor analyses and internal consistency reliability analyses were performed. Multivariate regression models with fixed and random effects were estimated. RESULTS Four EOL process domains were identified-assessment, delivery, communication and coordination of care among providers, and communication with residents and families. The scales measuring these EOL process domains demonstrated acceptable to high internal consistency reliability and face, content, and construct validity. Facilities with more EOL quality assurance or monitoring mechanisms in place and greater emphasis on EOL staff education had better scores on EOL care processes of assessment, communication and coordination among providers, and care delivery. Facilities with better registered nurse and certified nurse aide staffing ratios and those with religious affiliation also scored higher on selected care process measures. IMPLICATIONS This study offers a new validated tool for measuring EOL care processes in nursing homes. Our findings suggest wide variations in care processes across facilities, which in part may stem from lack of gold standards for EOL practice in nursing homes.
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Affiliation(s)
- Helena Temkin-Greener
- Department of Community and Preventive Medicine, Center for Ethics, Humanities and Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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Resnick HE, Schuur JD, Heineman J, Stone R, Weissman JS. Advance Directives in Nursing Home Residents Aged ≥65 Years: United States 2004. Am J Hosp Palliat Care 2008; 25:476-82. [DOI: 10.1177/1049909108322295] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In 1996, 53% of US nursing home residents had advance directives. This report defines documentation of advance directives in a nationally representative survey of US nursing home residents aged !65 years in 2004, as well as advance directive use in relation to demographic factors and receipt of specialty services including hospice/palliative care. In 2004, advance directives were documented in 69.9% of US nursing home residents aged !65 years and in 93.6% of residents receiving hospice/palliative care. Documentation of advance directives increased substantially between 1996 and 2004 and is nearly universal among residents receiving hospice/palliative care services. However in 2004, 3 of every 10 US nursing home residents did not have documentation of advance care plans. Continued efforts are needed to promote the importance of advance care planning among US nursing home residents.
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Affiliation(s)
- Helaine E. Resnick
- Institute for the Future of Aging Services, American Association of Homes and Services for the Aging, Department of Medicine, Georgetown University Washington, DC,
| | - Jeremiah D. Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School Boston
| | - Janice Heineman
- Institute for the Future of Aging Services, American Association of Homes and Services for the Aging
| | - Robyn Stone
- Institute for the Future of Aging Services, American Association of Homes and Services for the Aging
| | - Joel S. Weissman
- Department of Health Care Policy, Harvard Medical School and the Department of Health Policy and Management, Harvard School of Public Health, Institute for Health Policy, Massachusetts General Hospital Boston, Massachusetts
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Levy C, Morris M, Kramer A. Improving end-of-life outcomes in nursing homes by targeting residents at high-risk of mortality for palliative care: program description and evaluation. J Palliat Med 2008; 11:217-25. [PMID: 18333736 DOI: 10.1089/jpm.2007.0147] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The objectives were (1) to describe the Making Advance Planning a Priority (MAPP) program, a program designed to identify nursing home (NH) residents at high risk of death and (2) to evaluate end-of-life care outcomes for NH residents at high risk of death. DESIGN PROGRAM DESCRIPTION and evaluation using a retrospective chart review before and after implementation of the MAPP program. PARTICIPANTS NH residents who died 1 year before program implementation compared to NH residents who died 1 year after program implementation (n = 72). PROGRAM DESCRIPTION The MAPP program was designed to: (1) identify residents at high risk of death, (2) inform the attending physician of the residents' mortality risk, (3) obtain palliative care or, if the prognosis was 6 months of less, a hospice consultation, and (4) improve advance care planning documentation. PROGRAM EVALUATION Site of death (hospital versus nursing home), presence of an advance directive, presence of an order for cardiopulmonary resuscitation, proportion of NH residents with palliative care and/or hospice consultation prior to death, length of palliative care and/or hospice services before death. Following implementation of the MAPP program, we hypothesized that there would be a reduction in hospitalizations, an increase in hospice/palliative care referrals, an increase hospice/palliative care length of service, an increase the utilization of advance directives, but no difference in days in the hospital before death. RESULTS Following implementation of the MAPP program intervention, residents were less likely to die in the hospital (48.2% preintervention versus 8.9% postintervention, p < 0.0001). Every resident who died after implementation of the MAPP program had an advanced directive (p = 0.03). Residents were more also more likely to get palliative care referrals (7.4% preintervention versus 31.1% postintervention, p = 0.02). CONCLUSION An intervention designed to address the end-of-life needs of NH residents at high risk of death improves end-of-life outcomes with a reduction in terminal hospitalizations, an increase in palliative care referrals and improvement of advance directive completion.
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Affiliation(s)
- Cari Levy
- Department of Medicine, University of Colorado, Aurora, Colorado, USA.
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Laje RP, Wilks GB, Marx M, Cohen-Mansfield J. The Maryland patient plan of care form: perceptions of physicians and social workers. J Am Med Dir Assoc 2007; 8:575-81. [PMID: 17998113 DOI: 10.1016/j.jamda.2007.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Revised: 06/04/2007] [Accepted: 06/08/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess nursing home physicians' and social workers' perceptions of the new Maryland Patient Plan of Care Form (PPOC). DESIGN Mailed survey. SETTING Nursing homes in Maryland. PARTICIPANTS Thirty-seven physicians and 60 social workers. MEASUREMENTS Views of physicians and social workers were assessed through quantitative questions about the use of the PPOC form and qualitative questions about barriers in completing the form and recommendations to improve the form. RESULTS The majority (79.2%) of physicians and social workers reported that completing the PPOC is somewhat of a major burden. An overwhelming majority (85.6%) reported that social workers are completing the form, while close to half of the physicians and a quarter of the social work respondents say that physicians are involved in completing the form. Moreover, significantly more social workers (63.3%) than physicians (36.7%) believe the form would be more useful as a physician's order (X(2) = 5.287; d f = 1; P = .021). Both physicians and social workers identify barriers to completing the form and offer recommendations to improve the form. CONCLUSIONS Despite legislation requiring physicians to sign the PPOC, it is not a physician's order, thus shifting the burden of completing the PPOC to social workers. We conclude that most physicians and social workers view the PPOC as burdensome and do not feel that it is useful, but whether it is having an effect on patient care preferences merits further investigation.
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Affiliation(s)
- Rene P Laje
- Hebrew Home of Greater Washington, Research Institute on Aging, Rockville, MD 20852, USA.
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