The Australian experience of advance directives and possible future directions

Factors associated with preferred place of death among older adults: a qualitative interview study in Tama City, Tokyo, Japan

OBJECTIVES

To analyse the cognitive processes involved in the decision-making of older adults who are not in the end-of-life stage regarding the selection of a preferred place of death.

DESIGN

A qualitative cross-sectional study based on semistructured in-depth interviews. The interview scripts were sectioned by context, then summarised, conceptualised and categorised. Post-categorisation, the relationships between the conceptual factors were examined.

SETTING

Tama City, Tokyo, Japan, from November 2015 to March 2016.

PARTICIPANTS

20 long-term care users and their families or care providers were interviewed about their preferred places of death and the factors behind their decisions.

RESULTS

Three categories based on the preferred place of end-of-life care and death were extracted from the interview transcripts: (A) discouraging the decision of a preferred place of death, (B) enhancing the desire for home death and (C) enhancing the desire for a hospital/long-term care facility death. Category A consists of concerns about the caregiver's health, anxiety about solitary death, and constraints of and concerns about the household budget. Both categories B and C consist of subcategories of reinforcing and inhibiting factors of whether to desire a home death or a hospital/long-term care facility death. If their previous experiences with care at home, a hospital or a care facility were positive, they preferred the death in the same setting. If those experiences were negative, they tend to avoid the death in the same setting.

CONCLUSIONS

One's mindset and decision regarding a preferred place of death include the consideration of economic factors, concerns for caregivers, and experiences of care at home or in a hospital/long-term care facility. Furthermore, health professionals need to be aware of the ambivalence of senior citizens to support their end-of-life decisions.

Advance care planning for older people in mainland China: An integrative literature review

BACKGROUND

Recently, the attempts to promote advance care planning (ACP) and advance directives (ADs) have appeared in mainland China. However, anecdotal evidence suggests that the concept of ACP and ADs is not widely known to the public and healthcare professionals.

AIM

To examine and synthesise currently available research about ACP and ADs for older people in mainland China, and to discuss implications for future nursing practice and research.

DESIGN

An integrative literature review.

METHODS

A systematic search was conducted in seven English electronic databases (CINAHL, MEDLINE, ProQuest, Cochrane, JBI, Scopus and Wiley) and four Chinese electronic databases (CNKI, Wanfang, VIP and CBM). Eligible articles were critically appraised using the Mixed Methods Appraisal Tool (MMAT).

FINDINGS

From various groups including older people, families and healthcare professionals, low levels of knowledge and awareness about ACP and ADs are reported. Demographic characteristics such as age, gender, education and clinical conditions were related to positive or negative attitude towards ACP. The main reason people cited for being 'reluctant/fairly reluctant' to make an AD was that they were 'Not familiar with it'.

CONCLUSIONS

Given that older people showed positive attitudes towards ACP, policy support and practice guidelines about ADs and ACP are necessary to respect their wishes and to guide healthcare professionals in mainland China.

Advance Care Planning: Contemporary Issues and Future Directions

Advance care planning (ACP) is widely considered an essential step toward achieving end-of-life care that is consistent with the preferences of dying patients and their families. ACP comprises a living will and a durable power of attorney for health care (DPAHC); these tools enable patients to articulate and convey their treatment preferences when they are still cognitively intact. In this article, we describe the strengths, weaknesses, and correlates of ACP in the United States, with attention to race and socioeconomic disparities therein. We then discuss other public policies and community programs designed to increase both the number of older adults who articulate their preferences for end-of-life care, and efficacy of ACP for ensuring that patients' end-of-life treatment preferences are met. We describe the characteristics, strengths, and limitations of Physician Orders for Life Sustaining Treatment (POLSTs), and describe community programs, educational interventions, and public policies aimed toward increasing the prevalence and efficacy of end-of-life preparations. A key policy advance in the early 2010s has been Medicare coverage of one doctor-patient consultation session regarding end-of-life issues; we highlight the potentials and possible pitfalls of this policy. We conclude by identifying areas for future research, and highlighting practices from other nations that may help improve quality of end-of-life care in the United States.

Advance directives in the provision of care for incarcerated adults: a scoping review protocol

SCOPING REVIEW QUESTION/OBJECTIVE

The objective of this review is to map the available evidence around advance directives in the care of incarcerated adults in terms of what has been undertaken, what outcomes have been reported, and what research gaps exist.The specific areas of investigation will include:Practices, policies or interventions used with incarcerated adults concerning advanced directives.Prisoners' experiences with advanced directives when receiving care.Barriers to establishing and implementing advanced directives.Healthcare providers' experiences with implementing advanced directives while providing care.The specific questions for this scoping review are:What types of research related to advanced directives in the provision of care for incarcerated adults have been conducted and reported?What research gaps exist in this area?

CENTER CONDUCTING THE REVIEW

The Indiana Centre for Evidence-Based Nursing Practice: a Collaborating Centre of the Joanna Briggs Institute.

It’s just too hard! Australian health care practitioner perspectives on barriers to advance care planning

This article presents findings from six focus groups with health care practitioners in an Australian hospital during 2010, which sought to elicit their perspectives on the barriers for people to plan their future health care should they become unwell. Such knowledge is invaluable in overcoming the barriers associated with advance care planning and enhancing the uptake of advance directives and the appointment of an enduring power of attorney for people of all ages. A person’s rights to self-determination in health care, including decision making about their wishes for future care in the event they lose cognitive capacity, should not be overlooked against the backdrop of increasing pressure on health care systems. Findings suggest that multiple barriers exist, from practitioners’ perspectives, which can be divided into three major categories, namely: patient-centred, practitioner-centred and system-centred barriers. Specifically, patient-centred barriers include lack of knowledge, accessibility concerns, the small ‘window of opportunity’ to discuss advance care planning, emotional reactions and avoidance when considering one’s mortality, and demographic influences. At the practitioner level, barriers relate to a lack of knowledge and uncertainty around advance care planning processes. Systemically, legislative barriers (including a lack of a central registry and conflicting state legislation), procedural issues (particularly in relation to assessing cognitive capacity and making decisions ad hoc) and questions about delegation, roles and responsibilities further compound the barriers to advance care planning.

Experiences with advance care planning: older people and family members' perspective

AIMS AND OBJECTIVES

The aim of this study is to report the findings of a case study that explored the phenomenon of advance care planning and advanced care directives in residential care settings in Australia. In particular, this study focuses on the experiences of residents' and family members'.

BACKGROUND

Understanding the phenomenon of advance care planning and advanced care directives is vital to end of life decision making. There are few studies that report the experiences of older people and family members in relation to advance care planning and advanced care directives.

METHODS

A case-study research was conducted and data was collected over 7 months involving participant observation, field notes, semi-structured interviews and document analysis.

FINDINGS

The participants' early experiences with advance care planning were expressed in unpleasant, hostile and negative ways. However, those emotions and concerns were transformed to more stable, amenable and positive attitudes and feelings as issues were resolved. The factors that enhanced or inhibited the transition were described.

CONCLUSION

Older people and families view the end of life with broader psychosocial and spiritual meanings shaped by a lifetime of experiences. Advance care planning led to a different level of appreciation of personal entity and transcendence. However, advance care planning demands concerted action and support by everyone involved.

Experiences with advance care planning: nurses' perspective

AIMS AND OBJECTIVES

The aim of this paper is to report the findings of a case study that explored the phenomenon of advanced care planning and advance care directives in residential care settings in Australia. In particular, this paper focuses on the experiences of Registered Nurses with advanced care planning and advance care directives.

BACKGROUND

Nurses need to know how to engage with residents and families when they invest time and effort on advanced care planning and documentation of advance care directives.

METHODS

A case-study design involving participant observation, field note recording, semi structured interviews and document analysis was used. Data were collected over 7 months. Data analysis involved thematic content analysis.

FINDINGS

The factors that enhanced and inhibited the experiences of the Registered Nurses with advanced care planning were identified. The enhancing factors include; 'it is their essence of who they are', and 'back-up from family members and other nursing staff’. The inhibiting factors are 'lack of time', 'a culture of do everything and don't go there', and 'lack of family involvement'.

CONCLUSION

The findings of the current study provided nurses with evidence of the positive nature of experiences of older people, family members, and nurses themselves with advanced care planning in an attempt to better implement and practise advanced care planning.

Uptake and implementation of Advance Care Planning in Australia: findings of key informant interviews

Objective. Advance Care Planning (ACP) has an important role in enhancing patient autonomy and guiding end-of-life care. However, there is low uptake of ACP and evidence that advance care plans are often not implemented. We explored these issues in interviews with expert clinicians and representatives of key stakeholder organisations with interest in end-of-life care. Method. Qualitative descriptive study of semi-structured telephone interviews with 23 participants. Results. Participants thought that the low uptake of ACP in Australia is a result of inadequate awareness, societal reluctance to discuss end-of-life issues, and lack of health professionals’ involvement in ACP. Problems in implementation of advance care plans were thought to be a result of problems in accessing ACP documents; interpreting written documents; making binding decisions for future unpredictable situations; and paternalistic attitudes of health professionals and families. Participants had different perspectives on how advance care plans should be implemented, with some believing in strict implementation, whereas others believed in a more flexible approach. Implications. Low uptake and poor implementation of advance care plans may be addressed by (1) increasing community awareness; (2) encouraging health professional involvement; and (3) system-wide implementation of multi-faceted interventions. A patient-centred approach to ACP is required to resolve the differences in views on how advance care plans should be implemented. What is known about the topic? Advance Care Planning (ACP) has been gaining prominence in Australia for its role in enhancing a patient’s autonomy and as an important component of good end-of-life care. Evidence from overseas and a limited number of Australian studies have identified several problems with ACP. First, the uptake of ACP seems to be low. Second, even when ACP process takes place, the resultant plans are often not implemented and make little effect on delivery of end-of-life care. What does this paper add? This paper confirms that the uptake of ACP is limited in Australia and is a result of inadequate awareness, societal reluctance to discuss end-of-life issues, and lack of health professionals’ involvement in ACP. Problems in implementation of advance care plans may be because of problems in: accessing ACP documents, interpreting written documents, making binding decisions for future unpredictable situations, and paternalistic attitudes of health professionals and families. This paper also shows that there are different perspectives in how advance care plans should be implemented, with some believing in strict implementation, whereas others believed in a more flexible approach. What are the implications for practitioners? This paper outlines several ways in which problems in the uptake and implementation of advance care plans may be addressed. This involves (1) increasing community awareness; (2) encouraging health professional involvement in ACP; and (3) system-wide implementation of multi-faceted interventions in ACP. Our findings also suggest that there needs to be a shift from a one-size-fits-all approach to implementing advance care plans to a more flexible patient-centred approach. This approach could ensure that a patient’s autonomy and right to self-determination are adequately protected, while also catering to the needs of those requiring more flexible approaches to end-of-life decision-making.

Equipping patients for a time of helplessness: an educational intervention

OBJECTIVES

Quantify rates of awareness about, and ownership of, End-of-Life Planning (ELP) instruments. Examine whether this rate is increased by brief education during routine team care. Measure the time required by this exercise.

DESIGN

Quality Improvement Activity.

SETTING

General Practice on Mid-North Coast, New South Wales.

PARTICIPANTS

Forty-two consecutive, consenting elderly patients undertaking a Home Health Assessment.

MAIN OUTCOME MEASURES

This study assessed rates of ELP instruments at baseline, at 2 weeks, at 2 months and at 2 years following the provision and discussion of a fact sheet while measuring the clinicians' time required.

RESULTS

This education exercise increased the number of patients with ELP instruments from one to ten (24%). On average it took 5.6 min of nursing time and 3.9 min for the GP.

CONCLUSIONS

Brief education during Home Health Assessments may empower patients to prepare for a scenario where they lost competency to make fully informed decisions. This may alleviate patient's fears about causing problems between those close to them and having treatments against their wishes.