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Omoya O, De Bellis A, Breaden K. Experiences of Australian emergency doctors and nurses using advance care directives in the provision of care at the end of life. Emerg Med Australas 2024; 36:231-242. [PMID: 37940110 DOI: 10.1111/1742-6723.14343] [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: 03/07/2023] [Revised: 10/03/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023]
Abstract
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.
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Affiliation(s)
- Oluwatomilayo Omoya
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Anita De Bellis
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Katrina Breaden
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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Vivekananda K, Jayawardene JS, O’Connor M, Watts KJ, Leonard AD, Keesing S, Halkett G, Shaw J, Colgan V, Yuen K, Jolly R, Towler SC, Chauhan A, Nicoletti M, Johnson CE. Family Carers' Experiences of Goals of Care Conversations in Acute Hospital Settings. J Appl Gerontol 2023; 42:2304-2312. [PMID: 37728282 PMCID: PMC10666475 DOI: 10.1177/07334648231198973] [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: 12/15/2022] [Revised: 08/09/2023] [Accepted: 08/08/2023] [Indexed: 09/21/2023] Open
Abstract
End-of-life Goals of Care (GoC) discussions aim to support care that is consistent with patients' preferences and values. This study uses an exploratory qualitative design drawing upon a social constructivist epistemology to examine family carers' perspectives on GoC within acute Australian hospital settings. Twenty-five family carers of aging inpatients were recruited from six Australian hospitals to participate in recorded, semi-structured interviews. Data were transcribed and analyzed using reflexive thematic analysis. Three main themes were developed. Theme 1 explored carers' experiences of GoC discussions-identifying varying levels of preparedness and carers' hopes for open, two-way discussions initiated by empathic Health Care Professionals (HCPs). Theme 2 examined carers' unmet needs for time, space, consistency, and support to make careful decisions. Theme 3 identified carers advocating for patients' needs when they could not do it themselves. Preparing carers and normalizing GoC discussions relating to end-of-life care maximizes benefits for patients, carers, and HCPs involved.
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Affiliation(s)
- Kitty Vivekananda
- School of Educational Psychology and Counselling, Faculty of Education, Monash University, Melbourne, VIC, Australia
| | - Jayamini S. Jayawardene
- School of Educational Psychology and Counselling, Faculty of Education, Monash University, Melbourne, VIC, Australia
| | - Moira O’Connor
- WA Cancer Prevention Research Unit, School of Population Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Kaaren J. Watts
- WA Cancer Prevention Research Unit, School of Population Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Anton D. Leonard
- Critical Care and Intensive Care, Royal Perth Bentley Group, East Metropolitan Health Service, Perth, WA, Australia
| | - Sharon Keesing
- School of Occupational Therapy, Speech Pathology and Social Work, Curtin University, Perth, WA, Australia
| | - Georgia Halkett
- Curtin School of Nursing, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Josephine Shaw
- Cancer Prevention Research Unit, School of Psychology, Curtin University, Perth, WA, Australia
| | - Valerie Colgan
- WA Cancer and Palliative Care Network, WA Department of Health, Perth, WA, Australia
| | - Kevin Yuen
- Palliative Care Department, Royal Perth Bentley Group, East Metropolitan Health Service, Perth, WA, Australia
| | - Renate Jolly
- Respiratory Medicine, Royal Perth Bentley Group, East Metropolitan Health Service, Perth, WA, Australia
| | - Simon C. Towler
- Staff Specialist, Intensive Care Unit, Fiona Stanley Hospital, South Metropolitan Health Service, Perth, WA, Australia
- Acting State Medical Director, DonateLife, WA, MHPHDS Division, North Metropolitan Health Service, Perth, WA, Australia
- Clinical Lead, End-of-Life Care, WA Department of Health, Perth, WA, Australia
| | - Anupam Chauhan
- Department of Intensive Care Medicine, Rockingham Hospital, South Metropolitan Health Service, Perth, WA, Australia
| | - Margherita Nicoletti
- Palliative Care, Rockingham Hospital, South Metropolitan Health Service, Perth, WA, Australia
| | - Claire E. Johnson
- Monash Nursing and Midwifery, Monash University, Melbourne, Australia
- Eastern Health, Melbourne, VIC, Australia
- Australian Health Services Research Institute, University of Wollongong, Wollongong, Australia
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Brown J, Myers H, Eng D, Kilshaw L, Abraham J, Buchanan G, Eggimann L, Kelly M. Evaluation of the 'Talking Together' simulation communication training for 'goals of patient care' conversations: a mixed-methods study in five metropolitan public hospitals in Western Australia. BMJ Open 2022; 12:e060226. [PMID: 35922109 PMCID: PMC9353005 DOI: 10.1136/bmjopen-2021-060226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In partnership with Cancer Council Western Australia (WA), the East Metropolitan Health Service in Perth, WA has developed a clinical simulation training programme 'Talking Together' using role play scenarios with trained actors as patients/carers. The aim of the training is to improve clinicians' communication skills when having challenging conversations with patients, or their carers, in relation to goals of care in the event of clinical deterioration. METHODS AND ANALYSIS A multisite, longitudinal mixed-methods study will be conducted to evaluate the impact of the communication skills training programme on patient, family/carer and clinician outcomes. Methods include online surveys and interviews. The study will assess outcomes in three areas: evaluation of the 'Talking Together' workshops and their effect on satisfaction, confidence and integration of best practice communication skills; quality of goals of patient care conversations from the point of view of clinicians, carers and family/carers; and investigation of the nursing/allied role in goals of patient care. ETHICS AND DISSEMINATION This study has received ethical approval from the Royal Perth Hospital, St John of God and Curtin University Human Research Ethics Committees. The outputs from this project will be a series of research papers and conference presentations.
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Affiliation(s)
- Janie Brown
- Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
| | - Helen Myers
- Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
| | - Derek Eng
- Palliative Care, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Lucy Kilshaw
- Aged Care, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Jillian Abraham
- East Metropolitan Health Service Executive, East Metropolitan Health Service, Perth, Western Australia, Australia
| | - Grace Buchanan
- Cancer Council Western Australia, Subiaco, Western Australia, Australia
| | - Liz Eggimann
- Cancer Council Western Australia, Subiaco, Western Australia, Australia
| | - Michelle Kelly
- Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
- Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Harris E, Eng D, Ang Q, Clarke E, Sinha A. Goals of care discussions in acute hospital admissions - Qualitative description of perspectives from patients, family and their doctors. PATIENT EDUCATION AND COUNSELING 2021; 104:2877-2887. [PMID: 34598803 DOI: 10.1016/j.pec.2021.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/03/2021] [Accepted: 09/06/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Goals of care discussions guide care for hospital inpatients at risk of deterioration. We aimed to explore patient and family experience of goals of care during the first 72 h of admission along with their doctor's perspective. METHODS A qualitative descriptive study. Patients, family and doctors who participated in a goals of care discussion during an acute hospital admission at an Australian tertiary teaching hospital were interviewed in 2019. RESULTS Many participants found goals of care discussions appropriate and reported understanding. However, communication was commonly procedure-focused, with questioning about preferences for cardiopulmonary resuscitation and intubation. Some considered the discussion as inapplicable to their state of health, and occasionally surprising. Participants commonly related goals of care with death, and without context, this led to fear of abandonment. Previous experience with end of life care influenced decision-making. Preference for family presence was clear. CONCLUSIONS This study identifies deficiencies in goals of care communication in the acute hospital setting. Discussions are life-saving-procedure focused, leading to poor understanding and potentially distress, and jeopardising patient-centred care. PRACTICE IMPLICATIONS Assessment of patient values and clear communication on the aims of goals of care discussions is essential to optimise patient and institutional outcomes. Clinicians should consider environment and invite family participation.
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Affiliation(s)
| | - Derek Eng
- Royal Perth Hospital, Perth, Australia; School of Medicine, Division of Internal Medicine, University of Western Australia, Crawley, Australia; St John of God Subiaco Hospital, Subiaco, Australia; School of Medicine, University of Notre Dame, Fremantle, Australia.
| | - QiKai Ang
- Royal Perth Hospital, Perth, Australia.
| | | | - Atul Sinha
- Royal Perth Hospital, Perth, Australia; School of Medicine, Division of Internal Medicine, University of Western Australia, Crawley, Australia; Fiona Stanley Hospital, Murdoch, Australia.
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Zhou S, Zhang R, Chen D, Zhu X. A novel framework for bringing smart big data to proactive decision making in healthcare. Health Informatics J 2021; 27:14604582211024698. [PMID: 34159834 DOI: 10.1177/14604582211024698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Big data have shown their great potential value to serve many aspects of human life. Due to complexity of the medical and healthcare big data in real life, traditional big data analysis methods are difficult to be dealt with. Therefore, a single method is unable to analyze and manage heterogeneous big data sources. To utilize data fully from the perspective of decision-making, we propose a novel framework which guides the healthcare big data to be smartly and proactively processed for decision-making without user interventions. The framework contains five stages, which are intelligent data cleaning, customized data fusion, analysis mapping, exploratory visualization analysis, and generation of decision-making reports. It also enables learning from the data and correlating them with the existing human knowledge. Subsequently, a smart big data-driven application exhibits innovative management in intelligent healthcare. The proposed framework provides the guidelines of the best practices of big data-driven analysis for intelligent healthcare according to our practical applications. The platform provides the appropriate reference for the big data-driven innovation of management in intelligent healthcare.
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Affiliation(s)
| | | | - Donghua Chen
- University of International Business and Economics, China
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A Cross-Sectional Analysis of Ambulatory Oncology Experience by Treatment Intent. ACTA ACUST UNITED AC 2020; 28:98-106. [PMID: 33704180 PMCID: PMC7816180 DOI: 10.3390/curroncol28010013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/20/2020] [Accepted: 12/15/2020] [Indexed: 12/28/2022]
Abstract
The Ambulatory Oncology Patient Satisfaction Survey (AOPSS) is a standardized instrument to assess the overall cancer patient experience. This study retrospectively investigated differences in care experiences and satisfaction among ambulatory oncology patients who self-identified as receiving outpatient therapies for curative intent or for symptom or disease control. This cross-sectional study analyzed data from the AOPSS collected between February and April 2019 within the provincial cancer program in Alberta, Canada. There were 2104 participants who returned the survey, representing a 52.7% response rate. This nationally validated survey gathers patient care experiences and satisfaction across six domains of person-centred care. Treatment intent was characterized by adding a new “goal of treatment” question. Statistical analysis was performed using Mann–Whitney U tests and analysis of covariance (ANCOVAs). Cancer patients’ treatment goals were found to be significantly associated with key patient characteristics like age, sex, tumour group, and the locations where they received care. Patients whose self-identified goal of treatment was to cure their cancer reported significantly higher levels of satisfaction and a more positive experience in five out of the six person-centred care domains. Results identify marked differences in satisfaction and experience between these two patient groups even though they both received care in the same ambulatory environments. A better understanding of the experience and satisfaction of non-curative cancer patients could allow for a more holistic and supportive approach to patient care. In addition, an early palliative approach to care is recommended for improved patient outcomes.
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Frechman E, Dietrich MS, Walden RL, Maxwell CA. Exploring the Uptake of Advance Care Planning in Older Adults: An Integrative Review. J Pain Symptom Manage 2020; 60:1208-1222.e59. [PMID: 32645455 PMCID: PMC7342022 DOI: 10.1016/j.jpainsymman.2020.06.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Advance care planning (ACP) is essential to elicit goals, values, and preferences of care in older adults with serious illness and on trajectories of frailty. An exploration of ACP uptake in older adults may identify barriers and facilitators. OBJECTIVE To conduct an integrative review of research on the uptake of ACP in older adults and create a conceptual model of the findings. METHODS Using Whittemore and Knafl's methodology, we systematically searched four electronic databases of ACP literature in older adults from 1996 through December 2019. Critical appraisal tools were used to assess study quality, and articles were categorized according to level of evidence. Statistical and thematic analysis was then undertaken. RESULTS Among 1081 studies, 78 met inclusion criteria. Statistical analysis evaluated ACP and variables within the domains of demographics, psychosocial, disability and functioning, and miscellaneous. Thematic analysis identified a central category of enhanced communication, followed by categories of 1) provider role and preparation; 2) patient/family relationship patterns; 3) standardized processes and structured approaches; 4) contextual influences; and 5) missed opportunities. A conceptual model depicted categories and relationships. CONCLUSIONS Enhanced communication and ACP facilitators improve uptake of ACP. Clinicians should be cognizant of these factors. This review provides a guide for clinicians who are considering implementation strategies to facilitate ACP in real-world settings.
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Affiliation(s)
- Erica Frechman
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA.
| | - Mary S Dietrich
- Vanderbilt University Schools of Medicine and Nursing, Nashville, Tennessee, USA
| | - Rachel Lane Walden
- Vanderbilt University Eskind Biomedical Library, Nashville, Tennessee, USA
| | - Cathy A Maxwell
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA
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Conduit C, Thompson M, Thomas R, Nott L, Wuttke M. Implementing 'Goals of Care' discussion and palliative care referral for patients with advanced lung cancer: an outpatient-based pilot project. Intern Med J 2020; 51:540-547. [PMID: 32202060 DOI: 10.1111/imj.14817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early involvement of palliative care and advance care planning improves quality-of-life outcomes and survival for patients with advanced lung cancer; however, there are barriers to implementation. AIMS A single-centre prospective audit reviewing 'Goals of Care' (GOC) form completion and palliative care referrals in an oncology clinic was undertaken with the aim of increasing GOC completion and palliative care referrals for patients with advanced lung cancer. METHODS Involved physicians attended a communication skills course and then received a communication-priming intervention. Clinicopathological factors associated with GOC completion and palliative care referral were explored. RESULTS A total of 84 patients receiving palliative treatment for advanced lung cancer was enrolled. Clinicopathological factors, such as poorer performance status, were associated with higher likelihood of GOC completion (P = 0.018) prior to the intervention. Male sex (P = 0.023), absence of sensitising epidermal growth factor receptor mutation or anaplastic lymphoma kinase rearrangement (P = 0.017), type of systemic therapy (P = 0.031) and poorer performance status (P < 0.001) were associated with higher likelihood of palliative care referral. The intervention improved GOC completion (relative risk (RR) 1.29, P = 0.004); however, this was not sustained in a follow-up audit (RR 0.98, P = 0.92) and there was no change in palliative care referral rate (RR 2.5, P = 0.16). Predictors of palliative referral following clinical review included age (RR 1.16, P = 0.001), male sex (RR 14.2, P = 0.02) and poorer performance status (RR 1.76, P < 0.001). CONCLUSIONS Communication-priming interventions can improve GOC completion for patients with advanced lung cancer. Further investigation is needed to pursue sustainable options for managing this complex patient group and improve guideline-adherence and patient care.
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Affiliation(s)
| | | | - Robyn Thomas
- Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Louise Nott
- Royal Hobart Hospital, Hobart, Tasmania, Australia
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Davies C, Fattori F, O'Donnell D, Donnelly S, Ní Shé É, O Shea M, Prihodova L, Gleeson C, Flynn Á, Rock B, Grogan J, O'Brien M, O'Hanlon S, Cooney MT, Tighe M, Kroll T. What are the mechanisms that support healthcare professionals to adopt assisted decision-making practice? A rapid realist review. BMC Health Serv Res 2019; 19:960. [PMID: 31831003 PMCID: PMC6909502 DOI: 10.1186/s12913-019-4802-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 12/02/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) establishes a right to legal capacity for all people, including those with support needs. People with disabilities have a legal right to be given the appropriate supports to make informed decisions in all aspects of their lives, including health. In Ireland, the Assisted Decision-Making (Capacity) Act (2015) ratifies the Convention and has established a legal framework for Assisted Decision Making (ADM). The main provisions of the Act are not yet implemented. Codes of Practice to guide health and social care professionals are currently being developed. Internationally, concerns are expressed that ADM implementation is poorly understood. Using realist synthesis, this study aims to identify Programme Theory (PT) that will inform ADM implementation in healthcare. METHODS A Rapid Realist Review using collaborative methods was chosen to appraise relevant literature and engage knowledge users from Irish health and social care. The review was led by an expert panel of relevant stakeholders that developed the research question which asks, 'what mechanisms enable healthcare professionals to adopt ADM into practice?' To ensure the PT was inclusive of local contextual influences, five reference panels were conducted with healthcare professionals, family carers and people with dementia. PT was refined and tested iteratively through knowledge synthesis informed by forty-seven primary studies, reference panel discussions and expert panel refinement and consensus. RESULTS The review has developed an explanatory PT on ADM implementation in healthcare practice. The review identified four implementation domains as significant. These are Personalisation of Health & ADM Service Provision, Culture & Leadership, Environmental & Social Re-structuring and Education, Training & Enablement. Each domain is presented as an explanatory PT statement using realist convention that identifies context, mechanism and outcome configurations. CONCLUSIONS This realist review makes a unique contribution to this field. The PT can be applied by policymakers to inform intervention development and implementation strategy. It informs the imminent policy and practice developments in Ireland and has relevance for other worldwide healthcare systems dealing with similar legislative changes in line with UNCRPD.
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Affiliation(s)
- Carmel Davies
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland.
| | - Francesco Fattori
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Deirdre O'Donnell
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Sarah Donnelly
- School of Social Policy, Social Work and Social Justice, University College Dublin, Dublin, Ireland
| | - Éidín Ní Shé
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Marie O Shea
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | | | | | - Áine Flynn
- Decision Support Service, Mental Health Commission, Dublin, Ireland
| | | | | | - Michelle O'Brien
- Medicine for the Elderly, St. Vincent's University Hospital, Dublin, Ireland
| | - Shane O'Hanlon
- Medicine for the Elderly, St. Vincent's University Hospital, Dublin, Ireland
| | | | | | - Thilo Kroll
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
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Flynn R, Rotter T, Hartfield D, Newton AS, Scott SD. A realist evaluation to identify contexts and mechanisms that enabled and hindered implementation and had an effect on sustainability of a lean intervention in pediatric healthcare. BMC Health Serv Res 2019; 19:912. [PMID: 31783853 PMCID: PMC6884784 DOI: 10.1186/s12913-019-4744-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 11/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2012, the Saskatchewan Ministry for Health mandated a system-wide Lean transformation. Research has been conducted on the implementation processes of this system-wide Lean implementation. However, no research has been done on the sustainability of these Lean efforts. We conducted a realist evaluation on the sustainability of Lean in pediatric healthcare. We used the context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic to explain under what contexts, for whom, how and why Lean efforts are sustained or not sustained in pediatric healthcare. METHODS We employed a case study research design. Guided by a realist evaluation framework, we conducted qualitative realist interviews with various stakeholder groups across four pediatric hospital units 'cases' at one acute hospital. Interview data was analyzed using an integrated approach of CMOc categorization coding, CMOc connecting and pattern matching. RESULTS We conducted thirty-two interviews across the four cases. Five CMOcs emerged from our realist interview data. These configurations illustrated a 'ripple-effect' from implementation outcomes to contexts for sustainability. Sense-making and staff engagement were prominent mechanisms to the sustainment of Lean efforts. Failure to trigger these mechanisms resulted in resistance. The implementation approach used influenced mechanisms and outcomes for sustainability, more so than Lean itself. Specifically, the language, messaging and training approaches used triggered mechanisms of innovation fatigue, poor 'sense-making' and a lack of engagement for frontline staff. The mandated, top-down, externally led nature of implementation and lack of customization to context served as potential pitfalls. Overall, there was variation between leadership and frontline staff's perceptions on how embedded Lean was in their contexts, and the degree to which participants supported Lean sustainability. CONCLUSIONS This research illuminates important contextual factors and mechanisms to the process of Lean sustainment that can be applicable to those implementing systems changes. Future work is needed to continue to develop the science on the sustainability of interventions for healthcare improvement.
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Affiliation(s)
- Rachel Flynn
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| | - Thomas Rotter
- Healthcare Quality Programs, Queen's University School of Nursing, Kingston, Ontario, K7L 3N6, Canada
| | - Dawn Hartfield
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue, Edmonton, AB, T6G 1C9, Canada
| | - Amanda S Newton
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue, Edmonton, AB, T6G 1C9, Canada
| | - Shannon D Scott
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
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Morgan DJR, Eng D, Higgs D, Beilin M, Bulsara C, Wong M, Angus L, Waldron N. Advance care planning documentation strategies; goals-of-care as an alternative to not-for-resuscitation in medical and oncology patients. A pre-post controlled study on quantifiable outcomes. Intern Med J 2019; 48:1472-1480. [PMID: 30043464 DOI: 10.1111/imj.14048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/09/2018] [Accepted: 07/11/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Health services in Tasmania, Victoria and now Western Australia are changing to goals-of-care (GOC) advance care planning (ACP) documentation strategies. AIM To compare the clinical impact of two different health department-sanctioned ACP documentation strategies. METHODS A non-blinded, pre-post, controlled study over two corresponding 6-month periods in 2016 and 2017 comparing the current discretional not-for-resuscitation (NFR) with a new, inclusive GOC strategy in two medical/oncology wards at a large private hospital. Main outcomes were the uptake of ACP forms per hospitalisation and the timing between hospital admission, ACP form completion and in-patient death. Secondary outcomes included utilisation of the rapid response team (RRT), palliative and critical care services. RESULTS In total, 650 NFR and 653 GOC patients underwent 1885 admissions (mean Charlson Comorbidity Index = 3.7). GOC patients had a higher uptake of ACP documentation (346 vs 150 ACP forms per 1000 admissions, P < 0.0001) and a higher proportion of ACP forms completed within the first 48 h of admission (58 vs 39%, P = 0.0002) but a higher incidence of altering the initial ACP level of care (P = 0.003). All other measures, including ACP documentation within 48 h of death (P = 0.50), activation of RRT (P = 0.73) and admission to critical (P = 0.62) or palliative (P = 0.81) care services, remained similar. GOC documentation was often incomplete, with most sub-sections left blank between 74 and 87% of occasions. CONCLUSION Despite an increased uptake of the GOC form, overall use remained low, written completion was poor, and most quantitative outcomes remained statistically unchanged. Further research is required before a wider GOC implementation can be supported in Australia's healthcare systems.
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Affiliation(s)
- David J R Morgan
- Department of Intensive Care Medicine, St John of God Subiaco Hospital, Western Australia, Australia
| | - Derek Eng
- Department of Palliative Care Medicine, St John of God Subiaco Hospital, Western Australia, Australia
| | - Dominic Higgs
- Department of Palliative Care Medicine, St John of God Subiaco Hospital, Western Australia, Australia.,Department of Oncology, St John of God Subiaco Hospital, Western Australia, Australia
| | - Maria Beilin
- Department of Research, St John of God Subiaco Hospital, Western Australia, Australia
| | - Caroline Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Milly Wong
- Internal Medicine, St John of God Subiaco Hospital, Western Australia, Australia
| | - Louise Angus
- Department of Palliative Care Medicine, St John of God Subiaco Hospital, Western Australia, Australia
| | - Nicholas Waldron
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Australia.,Health Strategy and Networks, System Policy and Planning, Department of Health, Government of Western Australia, Perth, Australia.,School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
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Levinson M, Walker KJ, Hanning J, Dunlop W, Cheong E, Mills A. Medical perspectives regarding goals-of-care consultations in Emergency Departments. PSYCHOL HEALTH MED 2019; 24:1137-1147. [PMID: 30924364 DOI: 10.1080/13548506.2019.1595683] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Goals-of-care discussions aim to establish patient values for shared medical decision-making. These discussions are relevant towards end-of-life as patients may receive non-beneficial treatments if they have never discussed preferences for care. End-of-life care is provided in Emergency Departments (EDs) but little is known regarding ED-led goals-of-care discussions. We aimed to explore practitioner perspectives on goals-of-care discussions for adult ED patients nearing end-of-life. We report the qualitative component of a mixed methods study regarding a 'Goals-of-Care' form in an Australian ED. Eighteen out of 34 doctors who completed the form were interviewed. We characterised ED-led goals-of-care consultations for the first time. Emergency doctors perceive goals-of-care discussions to be relevant to their practice and occurring frequently. They aim to ensure appropriate care is provided prior to review by the admitting team, focusing on limitations of treatment and clarity in the care process. ED doctors felt they could recognise end-of-life and that ED visits often prompt consideration of end-of-life care planning. They wanted long-term practitioners to initiate discussions prior to patient deterioration. There were numerous interpretations of palliative care concepts. Standardisation of language, education, collaboration and further research is required to ensure Emergency practitioners are equipped to facilitate these challenging conversations.
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Affiliation(s)
- Michele Levinson
- a Department of Medicine , Monash University , Melbourne , Australia
| | - Katherine J Walker
- b Emergency Department , Cabrini , Melbourne , Australia.,c Department of Epidemiology and Preventive Medicine , Monash University , Melbourne , Australia
| | - Jennifer Hanning
- b Emergency Department , Cabrini , Melbourne , Australia.,d Melbourne Medical School , University of Melbourne , Melbourne , Australia
| | - William Dunlop
- b Emergency Department , Cabrini , Melbourne , Australia
| | - Edward Cheong
- b Emergency Department , Cabrini , Melbourne , Australia
| | - Amber Mills
- a Department of Medicine , Monash University , Melbourne , Australia.,e Bolton Clarke
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13
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Pearse W, Oprescu F, Endacott J, Goodman S, Hyde M, O'Neill M. Advance care planning in the context of clinical deterioration: a systematic review of the literature. Palliat Care 2019; 12:1178224218823509. [PMID: 30718959 PMCID: PMC6348551 DOI: 10.1177/1178224218823509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/29/2018] [Indexed: 11/16/2022] Open
Abstract
Background: A Rapid Response Team can respond to critically ill patients in hospital to prevent further deterioration and unexpected deaths. However, approximately one-third of reviews involve a patient approaching the end-of-life. It is not well understood whether patients have pre-existing advance care plans at the time of significant clinical deterioration requiring Rapid Response Team review. Nor is it understood whether such critical events prompt patients, their families and treating teams to discuss advance care planning and consider referral to specialist palliative care services. Aim and design: This systematic review examined advance care planning with patients who experience significant clinical deterioration in hospital and require Rapid Response Team review. The prevalence of pre-existing advance directives, whether this event prompts end-of-life discussions, the provision of broader advance care planning and referral to specialist palliative care services was examined. Data sources: Three electronic databases up to August 2017 were searched, and a manual review of article reference lists conducted. Quality of studies was appraised by the first and fourth authors. Results: Of the 324 articles identified through database searching, 31 met the inclusion criteria, generating data from 47,850 patients. There was a low prevalence of resuscitation orders and formal advance directives prior to Rapid Response Team review, with subsequent increases in resuscitation and limitations of medical treatment orders, but not advance directives. There was high short- and long-term mortality following review, and low rates of palliative care referral. Conclusions: The failure of patients, their families and medical teams to engage in advance care planning may result in inappropriate Rapid Response Team review that is not in line with patient and family priorities and preferences. Earlier engagement in advance care planning may result in improved person-centred care and referral to specialist palliative care services for ongoing management.
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Affiliation(s)
- Wendy Pearse
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia School of Health and Sports Sciences, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - Florin Oprescu
- School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - John Endacott
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia
| | - Sarah Goodman
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia
| | - Mervyn Hyde
- School of Education, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - Maureen O'Neill
- School of Law, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
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14
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Bloomer MJ, Botti M, Runacres F, Poon P, Barnfield J, Hutchinson AM. Communicating end-of-life care goals and decision-making among a multidisciplinary geriatric inpatient rehabilitation team: A qualitative descriptive study. Palliat Med 2018; 32:1615-1623. [PMID: 30074431 PMCID: PMC6238176 DOI: 10.1177/0269216318790353] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND In geriatric inpatient rehabilitation settings, where the goal is to optimise function, providing end-of-life care can be challenging. AIM The aim of this study is to explore how end-of-life care goals and decision-making are communicated in a geriatric inpatient rehabilitation setting. DESIGN The design is a qualitative descriptive design using semi-structured individual and group interviews. SETTING/PARTICIPANTS This study was conducted in a 154-bed facility in metropolitan Melbourne, Australia, providing geriatric inpatient rehabilitation for older patients; medical, nursing and allied health clinicians, who had cared for an inpatient who died, were recruited. DATA COLLECTION Participants were interviewed using a conversational approach, guided by an 'aide memoire'. RESULTS A total of 19 clinicians participated in this study, with 12 interviewed individually and the remaining 7 clinicians participating in group interviews. The typical patient was described as older, frail and with complex needs. Clinicians described the challenge of identifying patients who were deteriorating towards death, with some relying on others to inform them. How patient deterioration and decision-making was communicated among the team varied. Communication with the patient/family about dying was expected but did not always occur, nor was it always documented. Some clinicians relied on documentation, such as commencement of a dying care pathway to indicate when a patient was dying. CONCLUSION Clinicians reported difficulties recognising patient deterioration towards death. Uncertainty and inconsistent communication among clinicians about patient deterioration negatively impacted team understanding, decision-making, and patient and family communication. Further education for all members of the multidisciplinary team focusing on how to recognise and communicate impending death will aid multidisciplinary teams to provide quality end-of-life care when required.
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Affiliation(s)
- Melissa J Bloomer
- 1 Deakin University, Burwood, VIC, Australia.,2 Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,3 Epworth/Deakin Centre for Clinical Nursing Research, Richmond, VIC, Australia.,4 Centre for Nursing Research, Deakin University and Monash Health Partnership, Monash Health, Clayton, VIC, Australia
| | - Mari Botti
- 1 Deakin University, Burwood, VIC, Australia.,2 Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,3 Epworth/Deakin Centre for Clinical Nursing Research, Richmond, VIC, Australia
| | - Fiona Runacres
- 5 Supportive and Palliative Care Unit, Monash Health, Clayton, VIC, Australia.,6 School of Medicine, Monash University, Clayton, VIC, Australia.,7 Department of Palliative Care, Calvary Health Care Bethlehem, South Caulfield, VIC, Australia.,8 The University of Notre Dame, Darlinghurst, NSW, Australia
| | - Peter Poon
- 5 Supportive and Palliative Care Unit, Monash Health, Clayton, VIC, Australia.,6 School of Medicine, Monash University, Clayton, VIC, Australia.,9 Eastern Palliative Care Association, Melbourne, VIC, Australia
| | - Jakqui Barnfield
- 10 Rehabilitation, Aged Persons Mental Health and Residential Services, Clayton, VIC, Australia.,11 School of Nursing and Midwifery, Monash University, Clayton, VIC, Australia
| | - Alison M Hutchinson
- 1 Deakin University, Burwood, VIC, Australia.,2 Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,4 Centre for Nursing Research, Deakin University and Monash Health Partnership, Monash Health, Clayton, VIC, Australia
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15
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Campling N, Cummings A, Myall M, Lund S, May CR, Pearce NW, Richardson A. Escalation-related decision making in acute deterioration: a retrospective case note review. BMJ Open 2018; 8:e022021. [PMID: 30121604 PMCID: PMC6104759 DOI: 10.1136/bmjopen-2018-022021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/02/2018] [Accepted: 07/06/2018] [Indexed: 11/03/2022] Open
Abstract
AIM To describe how decision making inter-relates with the sequence of events in individuals who die during admission and identify situations where formal treatment escalation plans (TEPs) may have utility. DESIGN AND METHODS A retrospective case note review using stratified sampling. Two data analysis methods were applied concurrently: directed content analysis and care management process mapping via annotated timelines for each case. Analysis was followed by expert clinician review (n=7), contributing to data interpretation. SAMPLE 45 cases, age range 38-96 years, 23 females and 22 males. Length of admission ranged from <24 hours to 97 days. RESULTS Process mapping led to a typology of care management, encompassing four trajectories: early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until significant point; and early treatment limits set. Directed content analysis revealed a number of contextual issues influencing decision making. Three categories were identified: multiple clinician involvement, family involvement and lack of planning clarity; all framed by clinical complexity and uncertainty. CONCLUSIONS The review highlighted the complex care management and related decision-making processes for individuals who face acute deterioration. These processes involved multiple clinicians, from numerous specialities, often within hierarchical teams. The review identified the need for visible and clear management plans, in spite of the frame of clinical uncertainty. Formal TEPs can be used to convey such a set of plans. Opportunities need to be created for patients and their families to request TEPs, in consultation with the clinicians who know them best, outside of the traumatic circumstances of acute deterioration.
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Affiliation(s)
- Natasha Campling
- School of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Amanda Cummings
- School of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Michelle Myall
- School of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Susi Lund
- School of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Carl R May
- School of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Neil W Pearce
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alison Richardson
- School of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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16
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Mills AC, Levinson M, Dunlop WA, Cheong E, Cowan T, Hanning J, O'Callaghan E, Walker KJ. Testing a new form to document 'Goals-of-Care' discussions regarding plans for end-of-life care for patients in an Australian emergency department. Emerg Med Australas 2018; 30:777-784. [PMID: 29663697 DOI: 10.1111/1742-6723.12986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 02/14/2018] [Accepted: 03/06/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE There is limited literature to inform the content and format of Goals-of-Care forms, for use by doctors when they are undertaking these important conversations. METHODS This was a prospective, qualitative and quantitative study evaluating the utility of a new 'Goals-of-Care' form to doctors in a private, tertiary ED, used from December 2016 to February 2017 at Cabrini, Melbourne. A Goals-of-Care form was designed, incorporating medical aims of therapy and patient values and preferences. Doctors wishing to complete a Not-for-CPR form were also supplied with the trial Goals-of-Care form. Form use, content and patient progress were followed. Doctors completing a form were invited to interview. RESULTS Forms were used in 3% of attendances, 120 forms were taken for use and 108 were analysed. The median patient age was 91, 81% were Supportive and Palliative Care Indicators Tool (SPICT) positive and patients had a 48% 6-month mortality. A total of 34 doctors completed the forms, 16 were interviewed (two ED trainees, 11 senior ED doctors and three others). Theme saturation was only achieved for the senior doctors interviewed. Having a Goals-of-Care form was valued by 88% of doctors. The frequency of section use was: Aims-of-Care 91%; Quality-of-Life 75% (the term was polarising); Functional Impairments 35%; and Outcomes of Value 29%. Opinions regarding the ideal content and format varied. Some doctors liked free-text space and others tick-boxes. The median duration of the conversation and documentation was 10 min (interquartile range 6-20 min). CONCLUSIONS Having a Goals-of-Care form in emergency medicine is supported; the ideal contents of the form was not determined.
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Affiliation(s)
- Amber C Mills
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michele Levinson
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - William A Dunlop
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Edward Cheong
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Timothy Cowan
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Jennifer Hanning
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Erin O'Callaghan
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Katherine J Walker
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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17
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Smith RJ, Santamaria JD, Holmes JA, Faraone EE, Hurune PN, Reid DA. Use of resuscitation plans at a tertiary Australian hospital: room for improvement. Intern Med J 2018; 47:767-774. [PMID: 28422404 DOI: 10.1111/imj.13460] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/23/2017] [Accepted: 04/08/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The 'Acute Resuscitation Plan' (ARP) is a document for recording the resuscitation plans of patients at a tertiary hospital for adult patients. The ARP was introduced at the hospital in September 2014, superseding the 'Not for Cardiopulmonary Resuscitation (CPR)' form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits. AIM To evaluate the introduction of the ARP. METHODS This study is a retrospective audit of the records of all admissions to the hospital from January to June 2014 (Not for CPR period) and January to June 2015 (ARP period). The main outcomes are the incidence of resuscitation plans, the proportion of ARP specifying consultation with the patient (or representative) and with senior medical staff, and the proportion of ARP among older patients and those with significant comorbidity. RESULTS Resuscitation plans were present for 453 of 23 325 (1.9%) admissions in the Not for CPR period versus 1801 of 24 037 (7.5%) in the ARP period (odds ratio (OR) 4.1, 95% confidence interval (CI) 3.7-4.5, P < 0.001). A total of 42% of ARP specified 'care of the dying' in the event of arrest. Acknowledgement of the views of the patient (or representative) was indicated on 37% of ARP and of a senior physician on 28%. An ARP was not present for 67% of patients aged ≥90 years, 59% from aged care, 90% with metastatic cancer and 64% aged ≥80 years and with a Charlson comorbidity index ≥3. CONCLUSIONS More patients had resuscitation plans after introducing the ARP. However, patients and senior physicians were often remote from the consultation process, and an ARP was not present for many patients likely to have a poor outcome from cardiopulmonary arrest.
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Affiliation(s)
- Roger J Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Jennifer A Holmes
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Espedito E Faraone
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Patricia N Hurune
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - David A Reid
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
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18
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Johnson CE, Chong JC, Wilkinson A, Hayes B, Tait S, Waldron N. Goals of patient care system change with video-based education increases rates of advance cardiopulmonary resuscitation decision-making and discussions in hospitalised rehabilitation patients. Intern Med J 2018; 47:798-806. [PMID: 28401688 DOI: 10.1111/imj.13454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/23/2017] [Accepted: 04/02/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Advance cardiopulmonary resuscitation (CPR) discussions and decision-making are not routine clinical practice in the hospital setting. Frail older patients may be at risk of non-beneficial CPR. AIM To assess the utility and safety of two interventions to increase CPR decision-making, documentation and communication for hospitalised older patients. METHODS A pre-post study tested two interventions: (i) standard ward-based education forums with CPR content; and (ii) a combined, two-pronged strategy with 'Goals of Patient Care' (GoPC) system change and a structured video-based workshop; against usual practice (i.e. no formal training). Participants were a random sample of patients in a hospital rehabilitation unit. The outcomes were the proportion of patients documented as: (i) not for resuscitation (NFR); and (ii) eligible for rapid response team (RRT) calls, and rates of documented discussions with the patient, family and carer. RESULTS When compared with usual practice, patients were more likely to be documented as NFR following the two-pronged intervention (adjusted odds ratio (aOR): 6.4, 95% confidence interval (CI): 3.0; 13.6). Documentation of discussions with patients was also more likely (aOR: 3.3, 95% CI:1.8; 6.2). Characteristics of patients documented NFR were similar between the phases, but were more likely for RRT calls following Phase 3 (P 0.03). CONCLUSION An increase in advance CPR decisions occurred following GoPC system change with education. This appears safe as NFR patients had the same level of frailty between phases but were more likely to be eligible for RRT review. Increased documentation of discussions suggests routine use of the GoPC form may improve communication with patients about their care.
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Affiliation(s)
- Claire E Johnson
- School of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - Jeffrey C Chong
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia
| | - Anne Wilkinson
- School of Nursing and Midwifery, Edith Cowan University, Perth, Western Australia, Australia
| | - Barbara Hayes
- Advance Care Planning Program, Northern Health, Melbourne, Victoria, Australia.,Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sonia Tait
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia
| | - Nicholas Waldron
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia.,Health Strategy and Networks, System Policy and Planning, Department of Health, Government of Western Australia, Perth, Western Australia, Australia.,School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
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19
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Abstract
BACKGROUND To provide preference-sensitive care, we propose that clinicians might routinely inquire about their patients' bucket-lists and discuss the impact (if any) of their medical treatments on their life goals. METHODS This cross-sectional, mixed methods online study explores the concept of the bucket list and seeks to identify common bucket list themes. Data were collected in 2015-2016 through an online survey, which was completed by a total of 3056 participants across the United States. Forty participants who had a bucket list were identified randomly and used as the development cohort: their responses were analyzed qualitatively using grounded theory methods to identify the six key bucket list themes. The responses of the remaining 3016 participants were used for the validation study. The codes identified from the development cohort were validated by analyses of responses from 50 randomly drawn subjects from the validation cohort. All the 3016 validation cohort transcripts were coded for presence or absence of each of the six bucket list themes. RESULTS Around 91.2% participants had a bucket list. Age and spirituality influence the patient's bucket-list. Participants who reported that faith/religion/spirituality was important to them were most likely (95%) to have a bucket list compared with those who reported it to be unimportant (68.2%), χ2 = 37.67. Six primary themes identified were the desire to travel (78.5%), desire to accomplish a personal goal (78.3%), desire to achieve specific life milestones (51%), desire to spend quality time with friends and family (16.7%), desire to achieve financial stability (24.3%), and desire to do a daring activity (15%). CONCLUSIONS The bucket list is a simple framework that can be used to engage patients about their healthcare decision making. Knowing a patient's bucket list can aid clinicians in relating each treatment option to its potential impact (if any) on the patient's life and life goals to promote informed decision making.
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Affiliation(s)
- Vyjeyanthi S Periyakoil
- 1 Division of Primary Care and Population Health, Center of Population Health Sciences, Stanford University School of Medicine , Stanford, California.,2 VA Palo Alto Health Care System , Palo Alto, California
| | - Eric Neri
- 1 Division of Primary Care and Population Health, Center of Population Health Sciences, Stanford University School of Medicine , Stanford, California
| | - Helena Kraemer
- 1 Division of Primary Care and Population Health, Center of Population Health Sciences, Stanford University School of Medicine , Stanford, California
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20
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Cummings A, Lund S, Campling N, May C, Richardson A, Myall M. Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review. BMJ Open 2017; 7:e017056. [PMID: 28988176 PMCID: PMC5640076 DOI: 10.1136/bmjopen-2017-017056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To identify the factors that promote and inhibit the implementation of interventions that improve communication and decision-making directed at goals of care in the event of acute clinical deterioration. DESIGN AND METHODS A scoping review was undertaken based on the methodological framework of Arksey and O'Malley for conducting this type of review. Searches were carried out in Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) to identify peer-reviewed papers and in Google to identify grey literature. Searches were limited to those published in the English language from 2000 onwards. Inclusion and exclusion criteria were applied, and only papers that had a specific focus on implementation in practice were selected. Data extracted were treated as qualitative and subjected to directed content analysis. A theory-informed coding framework using Normalisation Process Theory (NPT) was applied to characterise and explain implementation processes. RESULTS Searches identified 2619 citations, 43 of which met the inclusion criteria. Analysis generated six themes fundamental to successful implementation of goals of care interventions: (1) input into development; (2) key clinical proponents; (3) training and education; (4) intervention workability and functionality; (5) setting and context; and (6) perceived value and appraisal. CONCLUSIONS A broad and diverse literature focusing on implementation of goals of care interventions was identified. Our review recognised these interventions as both complex and contentious in nature, making their incorporation into routine clinical practice dependent on a number of factors. Implementing such interventions presents challenges at individual, organisational and systems levels, which make them difficult to introduce and embed. We have identified a series of factors that influence successful implementation and our analysis has distilled key learning points, conceptualised as a set of propositions, we consider relevant to implementing other complex and contentious interventions.
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Affiliation(s)
- Amanda Cummings
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Susi Lund
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Natasha Campling
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Carl May
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
- University Hospital Southampton, NHS Foundation Trust, Southampton, UK
| | - Alison Richardson
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
- University Hospital Southampton, NHS Foundation Trust, Southampton, UK
| | - Michelle Myall
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
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21
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Martin RS, Hayes BJ, Hutchinson A, Yates P, Lim WK. Implementation of 'Goals of Patient Care' medical treatment orders in residential aged care facilities: protocol for a randomised controlled trial. BMJ Open 2017; 7:e013909. [PMID: 28283490 PMCID: PMC5353337 DOI: 10.1136/bmjopen-2016-013909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Systematic reviews demonstrate that advance care planning (ACP) has many positive effects for residents of aged care facilities, including decreased hospitalisation. The proposed Residential Aged Care Facility (RACF) 'Goals of Patient Care' (GOPC) form incorporates a resident's prior advance care plan into medical treatment orders. Where none exists, it captures residents' preferences. This documentation helps guide healthcare decisions made at times of acute clinical deterioration. METHODS AND ANALYSIS This is a mixed methods study. An unblinded cluster randomised controlled trial is proposed in three pairs of RACFs. In the intervention arm, GOPC forms will be completed by a doctor incorporating advance care plans or wishes. In the control arm, residents will have usual care which may include an advance care plan. The primary hypothesis is that the GOPC form is superior to standard ACP alone and will lead to decreased hospitalisation due to clearer documentation of residents' medical treatment plans. The primary outcome will be an analysis of the effect of the GOPC medical treatment orders on emergency department attendances and hospital admissions at 6 months. Secondary outcome measurements will include change in hospitalisation rates at 3 and 12 months, length of stay and external mortality rates among others. Qualitative interviews, 12 months post GOPC implementation, will be used for process evaluation of the GOPC and to evaluate staff perceptions of the form's usefulness for improving communication and medical decision-making at a time of deterioration. DISSEMINATION The results will be disseminated in peer review journals and research conferences. This robust randomised controlled trial will provide high-quality data about the influence of medical treatment orders that incorporate ACP or preferences adding to the current gap in knowledge and evidence in this area. TRIAL REGISTRATION NUMBER ACTRN12615000298516, Results.
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Affiliation(s)
- Ruth S Martin
- Northern Health, Epping, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | | | - Anastasia Hutchinson
- Northern Health, Epping, Victoria, Australia
- Deakin University, Geelong, Victoria, Australia
| | - Paul Yates
- University of Melbourne, Melbourne, Victoria, Australia
- Austin Health, Heidelberg, Victoria, Australia
| | - Wen Kwang Lim
- Northern Health, Epping, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Health, Melbourne, Victoria, Australia
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22
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Waldron N, Johnson CE, Saul P, Waldron H, Chong JC, Hill AM, Hayes B. Development of a video-based education and process change intervention to improve advance cardiopulmonary resuscitation decision-making. BMC Health Serv Res 2016; 16:555. [PMID: 27716183 PMCID: PMC5053041 DOI: 10.1186/s12913-016-1803-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 09/28/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Advance cardiopulmonary resuscitation (CPR) decision-making and escalation of care discussions are variable in routine clinical practice. We aimed to explore physician barriers to advance CPR decision-making in an inpatient hospital setting and develop a pragmatic intervention to support clinicians to undertake and document routine advance care planning discussions. METHODS Two focus groups, which involved eight consultants and ten junior doctors, were conducted following a review of the current literature. A subsequent iterative consensus process developed two intervention elements: (i) an updated 'Goals of Patient Care' (GOPC) form and process; (ii) an education video and resources for teaching advance CPR decision-making and communication. A multidisciplinary group of health professionals and policy-makers with experience in systems development, education and research provided critical feedback. RESULTS Three key themes emerged from the focus groups and the literature, which identified a structure for the intervention: (i) knowing what to say; (ii) knowing how to say it; (iii) wanting to say it. The themes informed the development of a video to provide education about advance CPR decision-making framework, improving communication and contextualising relevant clinical issues. Critical feedback assisted in refining the video and further guided development and evolution of a medical GOPC approach to discussing and recording medical treatment and advance care plans. CONCLUSION Through an iterative process of consultation and review, video-based education and an expanded GOPC form and approach were developed to address physician and systemic barriers to advance CPR decision-making and documentation. Implementation and evaluation across hospital settings is required to examine utility and determine effect on quality of care.
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Affiliation(s)
- Nicholas Waldron
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, 3056 Albany Highway, Armadale, 6112, Western Australia, Australia.,Health Strategy and Networks, System Policy and Planning, Department of Health, Government of Western Australia, 189 Royal Street, East Perth, 6004, Western Australia, Australia.,School of Medicine, University of Notre Dame, 32 Mouat St, Fremantle, 6959, Western Australia, Australia
| | - Claire E Johnson
- Cancer and Palliative Care Research and Evaluation Unit, School of Surgery, The University of Western Australia, 35 Stirling Hwy, Nedlands, 6009, Western Australia, Australia.
| | - Peter Saul
- John Hunter Hospital, Lookout Rd, New Lambton Heights, Newcastle, NSW, 2305, Australia.,Intensive Care, Newcastle Private Hospital, 14 Lookout Rd, New Lambton Heights, Newcastle, NSW, 2305, Australia
| | - Heidi Waldron
- Clinical Teaching - Public Hospitals and Curriculum Development Communication and Clinical Practice Domain, School of Medicine, University of Notre Dame, 32 Mouat St, Fremantle, 6959, Western Australia, Australia
| | - Jeffrey C Chong
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, 3056 Albany Highway, Armadale, 6112, Western Australia, Australia
| | - Anne-Marie Hill
- School of Physiotherapy and Exercise Science, Curtin University, Kent St, Bentley, 6102, Western Australia, Australia
| | - Barbara Hayes
- Advance Care Planning Program, Northern Health, 85 Cooper St., Epping, VIC, 3076, Australia.,Medical School, University of Melbourne, Parkville, VIC, 3010, Australia
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23
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Yoong J. ‘Formalising the form?’: safety and quality concerns with not for resuscitation documentation. Intern Med J 2015; 45:120-1. [DOI: 10.1111/imj.12641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 09/11/2014] [Indexed: 11/28/2022]
Affiliation(s)
- J. Yoong
- Department of Palliative Care and Medical Oncology; The Northern Hospital; Melbourne Victoria Australia
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24
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Thomas RL, Zubair MY, Hayes B, Ashby MA. Goals of care: a clinical framework for limitation of medical treatment. Med J Aust 2014; 201:452-5. [DOI: 10.5694/mja14.00623] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 08/01/2014] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Barbara Hayes
- Advance Care Planning Program, Northern Health, Melbourne, VIC
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25
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Scott I. Physicians need to take the lead in advance care planning. Intern Med J 2014; 44:937-9. [DOI: 10.1111/imj.12557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 07/17/2014] [Indexed: 12/25/2022]
Affiliation(s)
- I. Scott
- Internal Medicine and Clinical Epidemiology; Princess Alexandra Hospital; Brisbane Queensland Australia
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