Advance care planning for older people in Australia presenting to the emergency department from the community or residential aged care facilities

Advance directives in the emergency department-a systematic review of the status quo

BACKGROUND

Providing individualised healthcare in line with patient wishes is a particular challenge for emergency healthcare professionals. Documentation of patient wishes (DPW), e.g. as advance directives, can guide clinicians in making end-of-life decisions that respect the patient's wishes and autonomy. However, patient centered decisions are hindered by limited availability of DPWs in emergency settings.

OBJECTIVE

This systematic review aims to congregate present data on recorded rates for DPW existence and availability in the emergency department (ED) as well as contributing factors for these rates.

METHODS

We searched MEDLINE, Google Scholar, Embase and Web of Science databases in September 2023. Publications providing primary quantitative data on DPW in the ED were assessed. Publications referring only to a subset of ED patients (other than geriatric) and investigating DPW issued after admission were excluded.

RESULTS

A total of 22 studies from 1996 to 2021 were included in the analysis. Most were from the US (n = 12), followed by Australia (n = 4), Canada (n = 2), South Korea, Germany, the United Kingdom and Switzerland (n = 1 each). In the general adult population presenting to the ED, 19.9-27.8% of patients reported having some form of DPW, but only in 6.8% or less it was available on presentation. In the geriatric population, DPW rates (2.6-79%) as well as their availability (1.1-48.8%) varied widely. The following variables were identified as positive predictors of having DPW, among others: higher age, poorer overall health, as well as sociodemographic factors, such as female gender, having children, being in a relationship, higher level of education or a recent previous presentation to hospital.

CONCLUSIONS

Existence and availability of a recorded DPW among ED patients was low in general and even in geriatric populations mostly well below 50%. While we were able to gather data on prevalence and predictors, this was limited by heterogeneous data. We believe further research is needed to explore the quality of DPW and measures to increase both rates of existence and availability of DPW in the ED.

Experiences of Australian emergency doctors and nurses using advance care directives in the provision of care at the end of life

OBJECTIVE

An advance care directive is a legal document outlining the wishes made by a person about treatment options. However, there is increasing evidence that an advance care directive that has previously been documented may not always benefit the current prognosis of the patient. Therefore, the aim of the present study was to explore the experiences of Australian emergency doctors and nurses concerning the use of previously documented advance care directives at the point of care for patients and their families.

METHODS

A qualitative study guided by a phenomenological interpretive approach was employed. Semi-structured interviews were conducted with ED doctors and nurses across Australia. Data were thematically analysed using a seven-stage data analysis framework.

RESULTS

An analysis of the interview data resulted in four major themes: (i) Benefits of Advance Care Directives; (ii) Knowledge and Awareness; (iii) Communication; and (iv) Availability of Advance Care Directive Information.

CONCLUSIONS

From the findings, advance care directives were believed to be beneficial in decision making when patients, families, and ED staff agreed with the decisions made. Advance care directives were often made a long time ago but were useful to start conversations around goals of care and end-of-life care relevant to the patient's current situation. Findings in the present study further reinforced that an advance care directive was beneficial when used alongside goals of care at the point of care in EDs.

Impact of family involvement and an advance directive to not hospitalize on hospital transfers of residents in long-term care facilities

OBJECTIVE

With the rapidly aging population, the number of residents transferred to hospitals from long-term care facilities (LTCFs) is increasing globally. The objective of this study was to investigate the association between family involvement and an advance directive (AD) for not hospitalizing and hospital transfers among LTCF residents with dementia.

METHOD

Using the InterRAI assessment database from September 2014 to June 2019, we included 874 residents from 16 LTCFs in Japan.

RESULTS

Of the 874 participants, 19.0% had an AD for not hospitalizing, and 20.5% were transferred to hospitals. An AD for not hospitalizing decreased the likelihood of hospital transfers (p = 0.005). Multilevel logistic regression analysis showed that family involvement was not associated with hospital transfers (odds ratio [OR]: 1.18; 95% confidence interval [CI]: 0.77-1.80), while an AD for not hospitalizing was significantly associated with decreased hospital transfers (OR: 0.50; 95% CI: 0.28-0.89) among the LTCF residents.

CONCLUSIONS

Although ADs are not legally defined in Japan, we found that an AD for not hospitalizing decreased hospital transfers. Given that many older people tend to hesitate to express their wishes in clinical decision-making situations in Japan, regular discussions are necessary to help them express their care preferences while also documenting the discussions to ensure the residents receive high-quality care.

Advanced Care Directives in Residential Aged Care for Residents with Major Neuro-Cognitive Disorders (Dementia): A Scoping Review

The aim of this review was to identify, assess, collate, and analyze existing research that has made a direct contribution to aiding understanding of the ethical and decision-making issues related to the use of advance care directives for people with dementia and/or other major neurocognitive disorders and/or their surrogate decision-makers on treatment. The Web of Science, Scopus, PubMed, CINAHL, Academic Search Ultimate, and MEDLINE databases were searched between August and September 2021 and July to November 2022 limited to primary studies written in English, Spanish, or Portuguese. Twenty-eight studies of varying quality that addressed related thematic areas were identified. These themes being support for autonomy in basic needs (16%), making decisions ahead/planning ahead and upholding these decisions (52%), and support in decision-making for carers (32%). Advance care directives are an important mechanism for documenting treatment preferences in patient care planning. However, the available literature on the topic is limited in both quantity and quality. Recommendations for practice include involving decision makers, promoting educational interventions, exploring how they are used and implemented, and promoting the active involvement of social workers within the healthcare team.

Understanding the Clinical Profile and Hospitalisation Patterns of Residents From Aged Care Facilities: A Regional Victorian Hospital Study

Introduction Residents of residential aged care facilities (RACFs) are typically frailer than their community-dwelling counterparts. They often present to the emergency department (ED) with varied health issues, frequently leading to hospital admissions. These admissions can exacerbate patient frailty and strain the healthcare system. Despite global efforts to reduce ED presentations from RACFs, effective strategies still need to be discovered. This study examines the clinical profile and hospitalisation patterns of RACF residents in a regional Victorian town. Aims The study aimed to assess the prevalence of ED presentations and representations from RACFs, investigate the causes and outcomes of hospital admissions stemming from these presentations, and evaluate the prevalence of documented (advanced care directives) ACDs within this patient cohort. Methods Following ethical approval, we conducted a retrospective analysis of 467 ED presentations from 310 RACF patients admitted to Goulburn Valley Health's (GVH) ED from January to June 2022. We collected and examined data on demographics, ACD existence, ED presentation characteristics, and hospital admissions, classifying admission reasons into eleven groups. Statistical analysis was performed with GraphPad Prism and IBM SPSS, using inferential tests and logistic regression to assess readmission odds at a significance threshold of p<0.05. Results Our study encompassed 310 patients from multiple RACFs, yielding 467 ED presentations. These constituted 2.28% of total ED visits and 9.85% of those aged 65 and above. Most of the cohort were females (59.4%), aged between 79 and 91. About 98 patients presented multiple times, and 48.2% of presentations led to hospital admissions, with 6.2% of admitted patients succumbing during the hospital stay. A documented ACD was absent in 42.9% of the cohort. Statistically significant results include a correlation between male sex and an increased frequency of ED representations (p=0.0422) and a longer ED stay duration for admitted patients (p<0.0001). No significant associations were found between ACD presence and ED representations, ACD and sex, or between age and duration of stay in the ED. Age did not differ significantly among patients with single or multiple presentations or between patients with or without ACD. Regarding fall-related presentations, no significant sex-based difference in admission rates was found. The duration of stay between surgical and medical admissions was also statistically indifferent. Conclusion Our study highlights the significant utilisation of ED services by RACF residents, mainly males. The substantial percentage of these presentations resulting in hospital admissions underlines the critical nature of these visits. The absence of ACD in a significant portion of the cohort and the lack of its influence on the frequency of representations signal the need for further exploration. The results underline the ongoing challenge of meeting the complex healthcare needs of RACF residents and emphasise the importance of gender-specific interventions and efficient hospital utilisation strategies to optimise healthcare delivery in this population. Future studies should further investigate the underlying reasons for these findings to inform targeted strategies for reducing unnecessary ED visits and hospital admissions. Furthermore, fall-related presentations necessitate comprehensive ED assessments and integrated management approaches.

Emergency department transfers from residential aged care: what can we learn from secondary qualitative analysis of Australian Royal Commission data?

OBJECTIVES

To use publicly available submissions and evidence from the Australian Royal Commission into Aged Care Quality and Safety as data for secondary qualitative analysis. By investigating the topic of emergency department transfer from the perspective of residents, family members and healthcare professionals, we aimed to identify modifiable factors to reduce transfer rates and improve quality of care.

DESIGN

The Australian Royal Commission into Aged Care Quality and Safety has made over 7000 documents publicly available. We used the documents as a large data corpus from which we extracted a data set specific to our topic using keywords. The analysis focused on submissions and hearing transcripts (including exhibits). Qualitative thematic analysis was used to interrogate the text to determine what could be learnt about transfer events from a scholarly perspective.

RESULTS

Three overarching themes were identified: shortfalls and failings, reluctance and misunderstanding, and discovery and exposure.

CONCLUSIONS

The results speak to workforce inadequacies that have been central to problems in the Australian aged care sector to date. We identified issues around clinical and pain assessment, lack of consideration to advance care directives and poor communication among all parties. We also highlighted the role that emergency departments play in identifying unmet clinical needs, substandard care and neglect. Given the inadequate clinical care available in some residential aged care facilities, transferring residents to a hospital emergency department may be making the best of a bad situation. If the objective of reducing unnecessary transfers to emergency departments is to be achieved, then access to appropriate clinical care is the first step.

What factors are associated with advance care planning in community-dwelling older people? Data from TILDA

PURPOSE

To assess advance care planning (ACP) in a large population-representative sample of older people.

METHODS

At Wave 4 of the Irish Longitudinal Study on Ageing, participants were asked: Have you made your wishes/preferences known about the kind of care that you would like to receive in the event of serious illness?

RESULTS

One quarter (1153/4831) had discussed ACP. Of those, 90% had discussed with family/friends, 10% documented ACP in writing, while 2% had discussed with a healthcare professional. Age ≥ 80 years [OR 1.63 (1.31-2.02)], female sex [OR 1.58 (1.37-1.83)], higher educational attainment [OR 1.42 (1.18-1.71)], poorer self-rated health [OR 1.67 (1.06-2.62)] and lower levels of religiosity [OR 1.50 (1.02-2.19)] were independently associated with ACP.

CONCLUSION

Only one in four older people had discussed ACP informally, while less than 3% have ACP documented in writing. Further work is required to educate the public and healthcare professionals regarding treatment choices at end-of-life.

Advance care directive prevalence among older Australians and associations with person-level predictors and quality indicators

BACKGROUND

Advance care planning (ACP) conversations may result in preferences for medical care being documented.

OBJECTIVE

To explore the uptake and quality of advance care directives (ACDs) among older Australians accessing health and aged care services, by overall ACP documentation prevalence, person-level predictors and ACD quality indicators.

DESIGN AND SETTING

National multi-centre health record audit in general practices (GP), hospitals and residential aged care facilities (RACF).

PARTICIPANTS

A total of 4187 people aged ≥65 years attending their GP (n = 676), admitted to hospital (n = 1122) or residing in a RACF (n = 2389).

MAIN OUTCOME MEASURES

ACP documentation prevalence by setting and type including person-completed ACDs and non-ACD documents (completed by a health professional or someone else); person-level predictors and quality indicators of ACDs.

RESULTS

Overall ACP documentation prevalence was 46.5% (29.2% weighted). ACD prevalence was 25.3% (14.2% weighted). Unweighted ACD prevalence was higher in RACFs (37.7%) than in hospitals (11.1%) and GPs (5.5%). 35.8% of ACP documentation was completed by a health professional (9.7% weighted), and 18.1% was completed by someone else (10.6% weighted). Having an ACD was positively associated with being female, older, having two or more medical conditions, receiving palliative care, being divorced/separated and being in a RACF. Only 73% of ACDs included full name, signature, document date and witnessing.

CONCLUSIONS AND CONTRIBUTION

Low ACP documentation prevalence and a lack of accessible, person-completed and quality ACDs represent an important ACP implementation issue. Low prevalence is complicated by poor document quality and a higher prevalence of documents being completed by someone other than the person.

Facilitators and barriers to stakeholder engagement in advance care planning for older adults in community settings: a hybrid systematic review protocol

Background: Poor stakeholder engagement in advance care planning (ACP) poses national and international challenges, preventing maximisation of its potential benefits. Conceptualisation of advance care planning as a health behaviour highlights the need to design innovative, evidence-based strategies that will facilitate meaningful end-of-life care decision-making. Aim: To review systematically and synthesise quantitative and qualitative evidence on barriers and facilitators to stakeholders` engagement in ACP for older adults (≥ 50 years old) in a community setting. Methods: A hybrid systematic review will be conducted, identifying studies for consideration in two phases. First, databases will be searched from inception to identify relevant prior systematic reviews, and assess all studies included in those reviews against eligibility criteria (Phase 1). Second, databases will be searched systematically for individual studies falling outside the timeframe of those reviews (Phase 2). A modified SPIDER framework informed eligibility criteria. A study will be considered if it (a) included relevant adult stakeholders; (b) explored engagement in ACP among older adults (≥50 years old); (c) employed any type of design; (d) identified enablers and/or barriers to events specified in the Organising Framework of ACP Outcomes; (e) used either quantitative, qualitative, or mixed methods methodology; and (f) evaluated phenomena of interest in a community setting (e.g., primary care or community healthcare centres). Screening, selection, bias assessment, and data extraction will be completed independently by two reviewers. Integrated methodologies will be employed and quantitative and qualitative data will be combined into a single mixed method synthesis. The Behaviour Change Wheel will be used as an overarching analytical framework and to facilitate interpretation of findings. The Joanna Briggs Institute (JBI) Reviewers` Manual and PRISMA-P guidelines have been used to inform this protocol development. Registration: This protocol has been submitted for registration on PROSPERO, registration number CRD42020189568 and is awaiting review.

Gamification for promoting advance care planning: A mixed-method systematic review and meta-analysis

BACKGROUND

Gamification has been adopted in the health care field for broaching sensitive topics and increasing motivation for behavior changes. Games developed to stimulate discussion surrounding end-of-life issues, and thereby promoting advance care planning also emerged.

AIM

The aim is to integrate the quantitative evidence and qualitative evidence to understand the effectiveness of and experience with games for advance care planning.

DESIGN

A mixed-methods systematic review and meta-analysis (PROSPERO ID: CRD42020163312) was undertaken. Joanna Briggs Institute Critical Appraisal tools were used for quality appraisal. Data were synthesized and pooled for meta-analysis or meta-aggregation when appropriate.

DATA SOURCES

We searched MEDLINE, CINAHL, EMBASE, PsycINFO, Cochrane Library, WanFang, China Knowledge Resource Integrated Database, and Chinese Biomedical Literature Database from the inception of the databases for qualitative, quantitative, and mixed-method studies.

RESULTS

Eleven articles of ten studies were included, six of which were feasibility studies. The quality of the quantitative component of most included studies (7/8) was rated as low, and the qualitative component of most included studies (7/8) was rated as moderate. The meta-analysis showed that games for advance care planning are effective to increase self-efficacy, readiness, knowledge, and process of advance care planning behaviors. The meta-aggregation showed that games for advance care planning are highly acceptable and the participants perceived the game experience as fun and enjoyable.

CONCLUSIONS

Advance care planning games seem to be a promising intervention for increasing the uptake of advance care planning behaviors. Well-designed randomized controlled trials evaluating the effectiveness of games for advance care planning are needed in the future.

Oncology nurses' perceptions of advance directives for patients with cancer

This study examined oncology nurses' perceptions of the impact of advance directives on oncology patients' end-of-life care. Nurses (n = 104), who were members of an oncology nursing society or worked in a large metropolitan cancer center, completed a cross-sectional survey assessing perceptions of advance directives. There was high agreement that advance directives (i) make decisions easier for family (87%) and providers (82%); (ii) are doctors' responsibility to implement (80%); (iii) reduce unwanted aggressive treatment in the last weeks of life (80%); (iv) protect patient autonomy (77%); and (v) increase the likelihood of dying in a preferred location (76%). There was moderate or low agreement that advance directives (i) are accessible when needed (60%); (ii) are oncology nurses' responsibility to implement (46%); (iii) are always followed (41%); (iv) reduce the likelihood of pain in the last weeks of life (31%); (v) contain difficult to follow statements (30%); and (vi) have no impact on comfort in the last weeks of life (15%). Most nurses perceive benefits for advance directives, however, there remains uncertainty around accessibility and implementation. Guidelines and education about advance directive processes in oncology could improve person-centered end-of-life care.

Assessment of advance care planning documentation for residents of residential aged care facilities presenting to the emergency department

Objective This study assessed the availability and quality of advance care planning (ACP) documentation among older residential aged care facility (RACF) residents who presented to the emergency department (ED). Methods A prospective review of the medical records of RACF residents aged ≥75 years who presented to the ED from May to June 2018 was conducted. Availability of ACP was determined based on the presence of an ACP document inclusive of an advance care directive (ACD) in the medical record. The quality of ACP documentation was determined based on the presence of nine key components. Results In all, 48.8% of patients presented to the ED with either ACP or an ACD. However, only a mean total of 3.8 (out of 9) ACP components were documented in these documents. Conclusions Just under half (48.8%) of RACF residents presented to the ED with ACP documentation. There was limited coverage of core ACP components needed to guide clinical decision making. What is known about the topic? RACF residents are in the last years of their life and commonly lack capacity to make decisions regarding health care. Residents are at high risk of dying when acutely unwell in hospital. ACP documentation, when readily available, helps provide appropriate end-of-life care and improves both patient and family satisfaction. What does this paper add? Less than half the residents reporting to the ED from an RACF had ACP documentation available for clinicians. For those who presented to the ED with ACP documentation, most lacked sufficient information needed to provide care in full accordance with the patient's preferences. What are the implications for practitioners? There is a need to encourage, initiate, actively engage and develop systems for ACP conversations, documentation and availability when acutely unwell for people living in RACFs to provide sufficient information to guide clinical decision making. Without quality ACP, the provision of patient-centred health care may be compromised.

Care to the end: a retrospective observational study of aged care facility residents transferred to hospital in the last day of life

BACKGROUND

While transfer of aged care facility (ACF) residents to an acute hospital is sometimes necessary, for those at end of life this can cause fragmented care and disruption.

AIM

To explore the characteristics of ACF residents transferred to hospital in the last 24 h of life and factors that might influence this decision, including access to medical review, advance care planning (ACP) and pre-emptive symptom management prescribing, an area not previously researched.

METHODS

A retrospective observational audit of ACF residents transferred to a metropolitan hospital between 2012 and 2017 who died within 24 h of transfer.

RESULTS

A total of 149 patients met the criteria. The median age was 87 years, and 63 (42%) were male. Eighty-three (56%) were transferred 'out-of-hours', the majority (71%) having no medical review in the 24 h prior, and 43 (29%) died within 4 h of arrival. The most common reasons for transfer were dyspnoea (46%) and altered conscious state (32%), and the most common cause of death was pneumonia (37%). Some form of ACP documentation was available in 48%. Of the 86 (58%) patients who required injectable opioid for symptom management in hospital, only 7 (8%) had this pre-emptively prescribed on their ACF medication chart.

CONCLUSIONS

Appropriate decision-making around hospital transfers and end-of-life care for ACF residents may be influenced by access to professionals able to diagnose dying and access to appropriate symptom management medications. ACP is important, but often requires the aforementioned to be enacted. Further research is needed to better inform how we can identify and meet the end-of-life care needs of this cohort.

Feasibility of Using a Risk Assessment Tool to Predict Hospital Transfers or Death for Older People in Australian Residential Aged Care. A Retrospective Cohort Study

Residents of Aged Care Facilities (RACF) experience burdensome hospital transfers in the last year of life, which may lead to aggressive and potentially inappropriate hospital treatments. Anticipating these transfers by identifying risk factors could encourage end-of-life discussions that may change decisions to transfer. The aim was to examine the feasibility of identifying an end-of-life risk profile among RACF residents using a predictive tool to better anticipate predictors of hospital transfers, death or poor composite outcome of hospitalisation and/or death after initial assessment. A retrospective cohort study of 373 permanent residents aged 65+ years was conducted using objective clinical factors from records in nine RACFs in metropolitan Sydney, Australia. In total, 26.8% died and 34.3% experienced a composite outcome. Cox proportional hazard regression models confirmed the feasibility of estimating the level of risk for death or a poor composite outcome. Knowing this should provide opportunities to initiate advance care planning in RACFs, facilitating decision making near the end of life. We conclude that the current structure of electronic RACF databases could be enhanced to enable comprehensive assessment of the risk of hospital re-attendance without admission. Automation tools to facilitate the risk score calculation may encourage the adoption of prediction checklists and evaluation of their association with hospital transfers.

Prevalence of Geriatric Syndromes and the Need for Hospice Care in Older Patients of the Emergency Department: A Study in an Asian Medical Center

Background

The prevalence of geriatric syndromes and the need for hospice care in the emergency department (ED) in Asian populations remain unclear. This study was conducted to fill the data gap.

Methods

Using a newly developed emergency geriatric assessment (EGA), we investigated the prevalence of geriatric syndromes and the need for hospice care in older ED patients of a tertiary medical center between September 1, 2016, and January 31, 2017.

Results

We recruited a total of 693 patients with a mean age of 78.0 years (standard deviation 8.2 years), comprising 46.6% of females. According to age subgroups, 37.4% of patients were aged 65-74 years, 37.4% were aged 75-84 years, and 25.2% were aged ≥85 years. The prevalence rates of geriatric syndromes were as follows: delirium (11.4%), depression (23.4%), dementia (43.1%), deterioration of activities of daily living (ADL) for <1 year (29.4%), vision impairment (22.2%), hearing impairment (23.8%), sleep disturbance (13.1%), any fall in <1 year (21.8%), polypharmacy (28.7%), pain (35.1%), pressure ulcer (5.6%), incontinence or retention (29.6%), indwelling device or physical restrain (21.6%), nutrition problem (35.7%), frequent use of medical resources (50.1%), lack of advance care planning (84.0%), caregiver problem (4.6%), socioeconomic problem (5.5%), and need for family meeting (6.2%). The need for hospice care was 11.9%. Most geriatric syndromes increased with advancing age except depression, sleep disturbance, polypharmacy, pain, nutrition problem, lack of advance care planning, caregiver problem, and socioeconomic problem.

Conclusion

Geriatric syndromes and the need for hospice care were common in the older ED patients. Further studies about subsequent intervention for improving geriatric care are needed.

Associations between Cognitive Function, Hospitalizations and Costs in Nursing Homes: A Cross-sectional Study

In an Australian nursing home population, associations between cognitive function and 12-month hospitalizations and costs were examined. Participants with dementia had 57% fewer hospitalizations compared to those without dementia, with 41% lower mean hospitalization costs; poorer cognition scores were also associated with fewer hospitalizations. The cost per admission for those with dementia was 33% greater due to longer hospital stays (5.5 days versus 3.1 days for no dementia, p = .05). People with dementia were most frequently hospitalized for fractures. These findings have policy implications for increasing investment in accurate and timely diagnosis of dementia and fall and fracture prevention strategies to further reduce associated hospitalization costs.

Facilitators and barriers to stakeholder engagement in advance care planning for older adults in community settings: a hybrid systematic review protocol

Background: Poor stakeholder engagement in advance care planning (ACP) poses national and international challenges, preventing maximisation of its potential benefits. Conceptualisation of advance care planning as a health behaviour highlights the need to design innovative, evidence-based strategies that will facilitate meaningful end-of-life care decision-making. Aim: To review systematically and synthesise quantitative and qualitative evidence on barriers and facilitators to stakeholders` engagement in ACP for older adults (≥ 50 years old) in a community setting. Methods: A hybrid systematic review will be conducted, identifying studies for consideration in two phases. First, databases will be searched from inception to identify relevant prior systematic reviews, and assess all studies included in those reviews against eligibility criteria (Phase 1). Second, databases will be searched systematically for individual studies falling outside the timeframe of those reviews (Phase 2). A modified SPIDER framework informed eligibility criteria. A study will be considered if it (a) included relevant adult stakeholders; (b) explored engagement in ACP among older adults (≥50 years old); (c) employed any type of design; (d) identified enablers and/or barriers to events specified in the Organising Framework of ACP Outcomes; (e) used either quantitative, qualitative, or mixed methods methodology; and (f) evaluated phenomena of interest in a community setting (e.g., primary care or community healthcare centres). Screening, selection, bias assessment, and data extraction will be completed independently by two reviewers. Integrated methodologies will be employed and quantitative and qualitative data will be combined into a single mixed method synthesis. The Behaviour Change Wheel will be used as an overarching analytical framework and to facilitate interpretation of findings. The Joanna Briggs Institute (JBI) Reviewers` Manual and PRISMA-P guidelines have been used to inform this protocol development. Registration: This protocol has been submitted for registration on PROSPERO and is awaiting review.

Cardiopulmonary resuscitation and endotracheal intubation decisions for adults with advance care directive and resuscitation plans in the emergency department

BACKGROUND

Emergency departments routinely offer cardiopulmonary resuscitation and endotracheal intubation to patients in resuscitative states. With increasing longevity and prevalence of chronic conditions in Australia, there has been growing need to uptake and implement advance care directives and resuscitation plans. This study investigates the frequency of the presence of advance care directives and resuscitation plans and its utilisation in cardiopulmonary and endotracheal intubation decision making.

METHODS

Retrospective audit of electronic patients' medical records aged ≥65 years presenting over a 3-month period. Data collected included demographics, triage categories, advance care directive and/or resuscitation plans/orders status.

RESULTS

A total of 6439 patients were included representing 29% of the total patient population during the study period. Participants were randomly selected (N = 300); mean age was 78.7 (±8.1) years. An advance care directive was present in only 8% and one in three patients (37%) had a previous resuscitation plan/order. Senior consultant was present at the department for consultation by junior doctors for most of the patients (82%). Acknowledgment of either advance care directive or resuscitation plans/orders in clinical notes was only 9.5% (n = 116).

CONCLUSION

Advance care directive prevalence was low with resuscitation plans/orders being more common. However, clinician acknowledgement was infrequent for both.

Nurses' perceptions and experiences of caring for patients who die in the emergency department setting

INTRODUCTION

The number of people dying in emergency departments (EDs) is increasing. However, EDs are not well designed or resourced for safe and effective End-Of-Life (EOL) care encounters, and there is little evidence regarding clinicians' perceptions and experiences of providing such care when the death is sudden and unexpected.

AIM

This study explored nurses' perceptions and experiences of caring for patients who die suddenly and unexpectedly in the ED.

METHODS

Open-end responses were collected as part of a larger descriptive survey design. The qualitative data were analysed thematically.

RESULTS

211 ED nurse completed the online survey. Within the qualitative data, five themes were identified during analysis: 1) key elements of EOL care, 2) systemic and environmental barriers, 3) educational deficits, 4) role ambiguity, and 5) emotional impact. Participants identified communication, a standardised approach, and better educational preparedness as the most important elements of EOL care when the death was sudden and unexpected.

CONCLUSIONS

ED nurses want to provide high quality care to dying patients and their families. However, their efforts are hampered by systemic and environmental barriers outside their control. There is a need for a culture shift to overcome the barriers that currently obstruct ED nurses from providing meaningful and effective EOL care in the ED.

Advance directives and intensity of care delivered to hospitalized older adults at the end-of-life

BACKGROUND

Older adults prefer comfort over life-sustaining care. Decreased intensity of care is associated with improved quality of life at the end-of-life (EOL).

OBJECTIVES

This study explored the association between advance directives (ADs) and intensity of care in the acute care setting at the EOL for older adults.

METHODS

A retrospective, correlational study of older adult decedents (N = 496) was conducted at an academic medical center. Regression analyses explored the association between ADs and intensity of care.

RESULTS

Advance directives were not independently predictive of aggressive care but were independently associated with referrals to palliative care and hospice; however, effect sizes were small, and the timing of referrals was late.

CONCLUSION

The ineffectiveness of ADs to reduce aggressive care or promote timely referrals to palliative and hospice services, emphasizes persistent inadequacies related to EOL care. Research is needed to understand if this failure is provider-driven or a flaw in the documents themselves.

Nonstandard Advance Health Care Directives in Emergency Departments: Ethical and Legal Dilemma or Reality: A Narrative Review

People have tattooed themselves for thousands of years, and it remains popular with various groups across mainstream society. Although many people choose tattoos that express their life philosophy, epic events in their life, or their personal mantra, the use of tattooing in medicine such as a "do not resuscitate" tattoo is increasingly becoming more common (; ). As these tattoos do not meet the legal requirements for an advance health directive, they are at best a guide to the person's wishes and at worst a useless, painful exercise. New technology such as "talking tattoos" or implantable microchips could conceivably be used to record either an audible advance health directive or directions for emergency responders to access an individual's advance health directive. This article discusses the ethical and legal implications of nonstandard advance health directive tattoos in emergency treatment situations.

Integrated Palliative Care for Nursing Home Residents: Exploring the Challenges in the Collaboration between Nursing Homes, Home Care and Hospitals

INTRODUCTION

Nursing home residents are a vulnerable and frail segment of the population, characterised by their complex and palliative care needs. To ensure an integrated approach to palliative care for this target group, working on a collaborative basis with multiple providers across organisational boundaries is necessary. Considering that coordinators of palliative networks support and coordinate collaboration, the research question is: 'how do network coordinators perceive the process of collaboration between organisations in Flemish palliative networks?'

METHODS

A dual-phase sequential mixed-methods design was applied. First, the coordinators of each of the fifteen palliative networks in Flanders completed a survey in which they evaluated ten aspects of collaboration for two types of cooperation: between nursing homes and home care, and between nursing homes and hospitals. Next, the survey results thus obtained were discussed to improve understanding in a focus group composed of the above coordinators, and which was analysed on the basis of content analysis.

RESULTS

In both forms of cooperation, the 'formalisation' and 'governance' were the aspects that yielded the lowest mean scores. The coordinators in the focus group expressed a need for more formalised interaction among organisations with regard to palliative care, the establishment of formal channels of communication and the exchange of information, as well as the development of shared leadership.

CONCLUSIONS

The perspectives of the coordinators on inter-organisational collaboration are a valuable starting point for interventions directed at the stronger integration of palliative care for residents of long term-care facilities.

Facilitators and barriers to advance care planning implementation in Australian aged care settings: A systematic review and thematic analysis

OBJECTIVES

There are many studies investigating implementation of advance care planning (ACP) in aged care around the world, but few studies have investigated Australian settings. The objective of this study was to determine facilitators and barriers to implementation of ACP in Australian residential and community aged care.

METHODS

Evidence from Australian studies published between 2007 and September 2017 of ACP in residential and community aged care was sourced from electronic databases using predetermined search strategies. Data were extracted and synthesised using thematic analysis, and summarised according to themes.

RESULTS

Nine studies described facilitators and barriers of ACP implementation. Six themes were identified: "Education and Knowledge," "Skills and Training," "Procedures and Resources," "Perceptions and Culture," "Legislation" and "Systems."

CONCLUSIONS

A whole of systems approach is necessary to facilitate uptake of ACP in residential aged care settings. More research is needed to understand facilitators and barriers to ACP in community aged care.

Prevalence and correlates of advance care directives among older Australians accessing health and residential aged care services: multicentre audit study

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.

Substitute decision makers' experiences of making decisions at end of life for older persons with dementia: A systematic review and qualitative meta-synthesis

BACKGROUND

Substitute decision makers are important for people with advanced dementia, particularly at the end of life. Substitute decision makers report issues in providing support, and physical and psychological consequences from the role. However, there is no synthesised evidence about how substitute decision makers are affected by and experience making decisions for older persons diagnosed with dementia at end of life. Methodology: A protocol for a qualitative systematic review was developed. Seven articles met both inclusion and research quality criteria following a comprehensive search for published and unpublished studies (January 2007-2017, English language). Meta-synthesis was achieved through meta-aggregation of the results from included studies.

RESULTS

Meta-aggregation of 20 themes into eight categories resulted in five synthesised findings. The findings were: 'trust'; 'guilt, mistrust and confusion'; 'translating quality of life'; 'negotiating families'; and 'uncertainty and reactivity'. Trust in healthcare personnel positively affected substitute decision makers and supported their adaptability. Substitute decision makers experienced guilt, mistrust, and confusion as they encountered increased complexity in care and health interventions as social needs changed. Substitute decision makers experienced complexities and struggles as they interpreted quality of life and negotiated end of life treatment decisions. Substitute decision makers experienced practical needs to negotiate family as they fulfilled their support roles. Ambiguity in advance care plans, limited knowledge of dementia, end of life uncertainties, and communication issues reduced substitute decision makers' proactivity. Implications: Being a substitute decision maker for people with advanced dementia at end of life is stressful. Health professionals need to be cognizant of substitute decision makers experiences and needs, and identify mechanisms to achieve support and education. The findings generate need for further investigation of interventions to meet the needs of substitute decision makers.

Protocol for a national prevalence study of advance care planning documentation and self-reported uptake in Australia

INTRODUCTION

Advance care planning (ACP) is a process between a person, their family/carer(s) and healthcare providers that supports adults at any age or stage of health in understanding and sharing their personal values, life goals and preferences regarding future medical care. The Australian government funds a number of national initiatives aimed at increasing ACP uptake; however, there is currently no standardised Australian data on formal ACP documentation or self-reported uptake. This makes it difficult to evaluate the impact of ACP initiatives. This study aims to determine the Australian national prevalence of ACP and completion of Advance Care Directives (ACDs) in hospitals, aged care facilities and general practices. It will also explore people's self-reported use of ACP and views about the process.

METHODS AND ANALYSIS

Researchers will conduct a national multicentre cross-sectional prevalence study, consisting of a record audit and surveys of people aged 65 years or more in three sectors. From 49 participating Australian organisations, 50 records will be audited (total of 2450 records). People whose records were audited, who speak English and have a decision-making capacity will also be invited to complete a survey. The primary outcome measure will be the number of people who have formal or informal ACP documentation that can be located in records within 15 min. Other outcomes will include demographics, measure of illness and functional capacity, details of ACP documentation (including type of document), location of documentation in the person's records and whether current clinical care plans are consistent with ACP documentation. People will be surveyed, to measure self-reported interest, uptake and use of ACP/ACDs, and self-reported quality of life.

ETHICS AND DISSEMINATION

This protocol has been approved by the Austin Health Human Research Ethics Committee (reference HREC/17/Austin/83). Results will be submitted to international peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12617000743369.

Quantifying the Mortality Impact of Do-Not-Resuscitate Orders in the ICU

OBJECTIVES

We quantified the 28-day mortality effect of preexisting do-not-resuscitate orders in ICUs.

DESIGN

Longitudinal, retrospective study of patients admitted to five ICUs at a tertiary university medical center (Beth Israel Deaconess Medical Center, BIDMC, Boston, MA) between 2001 and 2008.

INTERVENTION

None.

PATIENTS

Two cohorts were defined: patients with do not resuscitate advance directives on day 1 of ICU admission and a control group comprising patients with no limitations of level of care on ICU day 1 (full code).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was mortality at 28 days after ICU admission. Of 19,007 ICU patients, 1,239 patients (6.5%) had a do-not-resuscitate order on the first day of ICU admission and survived 48 hours in the ICU. We matched those do-not-resuscitate patients with 2,402 patients with full-code status. Twenty-eight day and 1-year mortality were both significantly higher in the do-not-resuscitate group (33.9% vs 18.4% and 60.7% vs 40.2%; p < 0.001, respectively).

CONCLUSION

Do-not-resuscitate status is an independent risk factor for ICU mortality. This may reflect severity of illness not captured by other clinical factors, but the perceptions of the treating team related to do-not-resuscitate status could also be causally responsible for increased mortality in patients with do-not-resuscitate status.

Managing 'shades of grey': a focus group study exploring community-dwellers' views on advance care planning in older people

BACKGROUND

Community-dwelling consumers of healthcare are increasing, many aging with life-limiting conditions and deteriorating cognition. However, few have had advance care planning discussions or completed documentation to ensure future care preferences are acted upon. This study examines the awareness, attitudes, and experiences of advance care planning amongst older people and unrelated offspring/caregivers of older people residing in the community.

METHODS

Qualitative descriptive research, which included focus groups with older people (55+ years) and older people's offspring/caregivers living in an Australian city and surrounding rural region. Data was analysed using an inductive and comparative approach. Sampling was both convenience and purposive. Participants responded to web-based, newsletter or email invitations from an agency, which aims to support healthcare consumers, a dementia support group, or community health centres in areas with high proportions of culturally and linguistically diverse community-dwellers.

RESULTS

Eight focus groups were attended by a homogenous sample of 15 older people and 27 offspring/caregivers, with 43% born overseas. The overarching theme, 'shades of grey': struggles in transition, reflects challenges faced by older people and their offspring/caregivers as older people often erratically transition from independence and capacity to dependence and/or incapacity. Offspring/caregivers regularly struggled with older people's fluctuating autonomy and dependency as older people endeavoured to remain at home, and with conceptualising "best times" to actualise advance care planning with substitute decision maker involvement. Advance care planning was supported and welcomed, x advance care planning literacy was evident. Difficulties planning for hypothetical health events and socio-cultural attitudes thwarting death-related discussions were emphasised. Occasional offspring/caregivers with previous substitute decision maker experience reported distress related to their decisions.

CONCLUSIONS

Advance care planning programs traditionally assume participants are 'planning ready' to legally appoint a substitute decision maker (power of attorney) and record end-of-life treatment preferences in short time frames. This contrasts with how community dwelling older people and offspring/caregivers conceive future care decisions over time. Advance care planning programs need to include provision of information, which supports older people's advance care planning understanding and management, and also supports offspring/caregivers' development of strategies for broaching advance care planning with older people, and preparing for potential substitute decision maker roles. Development and integration of strategies to support older people's decision-making when in the 'grey zone', with fluctuating cognitive capacities, needs further consideration. Findings support an advance care planning model with conversations occurring at key points across a person's lifespan.

Quality gaps identified through mortality review

BACKGROUND

Hospital mortality rate is a common measure of healthcare quality. Morbidity and mortality meetings are common but there are few reports of hospital-wide mortality-review processes to provide understanding of quality-of-care problems associated with patient deaths.

OBJECTIVE

To describe the implementation and results from an institution-wide mortality-review process.

DESIGN

A nurse and a physician independently reviewed every death that occurred at our multisite teaching institution over a 3-month period. Deaths judged by either reviewer to be unanticipated or to have any opportunity for improvement were reviewed by a multidisciplinary committee. We report characteristics of patients with unanticipated death or opportunity for improved care and summarise the opportunities for improved care.

RESULTS

Over a 3-month period, we reviewed all 427 deaths in our hospital in detail; 33 deaths (7.7%) were deemed unanticipated and 100 (23.4%) were deemed to be associated with an opportunity for improvement. We identified 97 opportunities to improve care. The most common gap in care was: 'goals of care not discussed or the discussion was inadequate' (n=25 (25.8%)) and 'delay or failure to achieve a timely diagnosis' (n=8 (8.3%)). Patients who had opportunities for improvement had longer length of stay and a lower baseline predicted risk of death in hospital. Nurse and physician reviewers spent approximately 142 h reviewing cases outside of committee meetings.

CONCLUSIONS

Our institution-wide mortality review found many quality gaps among decedents, in particular inadequate discussion of goals of care.