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Edmonds DM, Zayts-Spence O, Au INY, Yuen JKY. "They are not taking it seriously": Constructing family dynamics in end-of-life care interactions in Hong Kong. DEATH STUDIES 2024:1-13. [PMID: 39096312 DOI: 10.1080/07481187.2024.2385383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/05/2024]
Abstract
In Chinese culture, the family is central to the decision-making around care provided to terminally-ill patients. Previous research examined the preferences that patients and relatives have in regard to the family's role in end-of-life care. Our article takes a discourse analytic perspective and focuses on how familial dynamics are interactionally constructed by patients in audio-recorded end-of-life care consultations in Hong Kong hospitals. We document three ways that patients construct family dynamics. First, patients expressed a reluctance to talk to their family members about their condition. Second, patients talked about their families as being reluctant in accepting and "believing" the reality of their condition. Third, patients reported an epistemic divide between themselves and their family regarding knowledge and understanding of their illness. Our findings provide insights into how to conceptualize family dynamics in interactional terms. We also reflect on how our findings can complement existing research on end-of-life care in Chinese contexts.
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Affiliation(s)
| | - Olga Zayts-Spence
- School of English, The University of Hong Kong, Hong Kong, Hong Kong
| | - Irene Nga Yu Au
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Jacqueline Kwan Yuk Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong
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Caine AM, Gustafsson L, Molineux M, Aplin T. Seeking residents' views regarding Australian residential aged care: A scoping review. Australas J Ageing 2024. [PMID: 38881513 DOI: 10.1111/ajag.13344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE This scoping review aimed to explore topics on which the views of residents of Australian residential aged care facilities (RACFs) have been sought. METHODS Scoping review methodology as outlined by Arksey and O'Malley was used to identify, explore and report on the range of literature regarding views of RACF residents. Seven electronic databases were searched using broad search terms relevant to the RACF context. Descriptive numerical analysis was completed for publication year, journal name and target profession, research methods and participant types. Thematic analysis then focussed on the aims of the included studies. RESULTS Four thousand two hundred and ninety studies were screened, and 104 publications met the inclusion criteria. A broad range of topics were explored by researchers, with the largest number of papers focused on residents' views of systems within RACFs (n = 24) and new programs and interventions (n = 21). Smaller topic areas included health conditions and health-care services (n = 13), socialisation (n = 13), physical activity (n = 3), self-care (n = 4), leisure (n = 4), general everyday life (n = 20) and aspects of the residential aged care environment (n = 15). There was limited exploration of meaningful activity (n = 13). The inclusion of residents with cognitive impairment was inconsistent, and the voices of other stakeholders were often privileged. CONCLUSION Voices of residents must be heard in order to prioritise the health and well-being of this population. More research which focuses on what is important to residents is needed and must include residents with cognitive impairment more effectively. Identification of optimal research methods with this population would make an important contribution in this area.
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Affiliation(s)
- Anne-Maree Caine
- School of Health Sciences and Social Work, Griffith University, Brisbane, Queensland, Australia
| | - Louise Gustafsson
- School of Health Sciences and Social Work, Griffith University, Brisbane, Queensland, Australia
| | - Matthew Molineux
- School of Health Sciences and Social Work, Griffith University, Brisbane, Queensland, Australia
| | - Tammy Aplin
- School of Health Sciences and Social Work, Griffith University, Brisbane, Queensland, Australia
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Yeoh LH, Tan B, Rhee J, Sinclair C. Attitudes and Perceptions on Advance Care Planning Among Chinese-Speaking Older Australians. Am J Hosp Palliat Care 2024; 41:814-823. [PMID: 37658638 PMCID: PMC11070119 DOI: 10.1177/10499091231200366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Current literature indicates low uptake of advance care planning (ACP) among the Chinese-speaking community in Australia. To increase the uptake of ACP among the Chinese-speaking community, a better understanding of their attitudes and perceptions on end-of-life (EOL) matters, and ACP is required. OBJECTIVE This study aimed to identify significant events and social and cultural factors that influence participants' values and characterize the attitudes and perceptions towards ACP among older Chinese-speaking Australians. METHODS A qualitative study explored participants' experiences through semi-structured one-to-one interviews. The interviews were conducted in Mandarin, Cantonese or English, then translated and transcribed into English. The transcripts were coded and analysed thematically. RESULTS Twenty participants were recruited (14 female, six male). Participants typically reported a preference to make health-related decisions autonomously. Their perspectives were grounded in past experiences of illnesses and EOL decision-making of loved ones, personal values, and perceived needs. Family dynamics and intimacy of relationships appeared to influence the role and responsibility of family members in EOL decision-making and ACP. Most participants perceived the need to engage in ACP only when encountering significant health changes or higher care needs. CONCLUSION Healthcare professionals should initiate ACP discussion using culturally appropriate communication with consideration of personal values, past experiences and family dynamics. Efforts should be invested in raising public awareness of ACP within the Chinese-Australian community.
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Affiliation(s)
- Ling H. Yeoh
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Benjamin Tan
- School of Nursing, Faculty of Health, Charles Darwin University, Darwin, NT, Australia
| | - Joel Rhee
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Craig Sinclair
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
- Neuroscience Research Australia, Sydney, NSW, Australia
- UNSW Ageing Futures Institute, Sydney, NSW, Australia
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Marshall KH, Riddiford-Harland DL, Meller AE, Caplan GA, Naganathan V, Cullen J, Gonski P, Zwar NA, O’Keeffe JA, Krysinska K, Rhee JJ. Feasibility and Acceptability of Facilitated Advance Care Planning in Outpatient Clinics: A Qualitative Study of Patient and Caregivers Experiences. J Appl Gerontol 2024; 43:339-348. [PMID: 37949095 PMCID: PMC10875901 DOI: 10.1177/07334648231206742] [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: 05/10/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023] Open
Abstract
Guidelines recommend advance care planning (ACP) for people with advanced illness; however, evidence supporting ACP as a component of outpatient care is lacking. We sought to establish the feasibility and acceptability of a facilitated ACP intervention for people attending tertiary outpatient clinics. Data from 20 semi-structured interviews with patient (M = 79.3 ± 7.7, 60% male) and caregiver (M = 68.1 ± 11.0, 60% female) participants recruited as part of a pragmatic, randomized controlled trial (RCT) were analyzed using qualitative descriptive methodology. Patients were randomized to intervention (e.g., facilitated support) or control (e.g., standard care). Intervention patients expressed high satisfaction, reporting the facilitated ACP session was clear, straightforward, and suited to their needs. Intervention caregivers did not report any significant concerns with the facilitated ACP process. Control participants reported greater difficulty completing ACP compared to intervention participants. Embedding facilitated ACP into tertiary outpatient care appears feasible and acceptable for people with advanced illnesses.
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Affiliation(s)
- Kate H. Marshall
- UNSW Academic General Practice Network, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Anne E. Meller
- Advance Care Planning Services, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Gideon A. Caplan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - John Cullen
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Peter Gonski
- Southcare Aged and Extended Community Care, Sutherland Hospital, Sydney, NSW, Australia
| | - Nicholas A. Zwar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Julie-Ann O’Keeffe
- Aged, Chronic Care and Rehabilitation, Sydney Local Health District, Sydney, NSW, Australia
| | - Karolina Krysinska
- Centre for Primary Health Care and Equity, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Joel J. Rhee
- UNSW Academic General Practice Network, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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Scott IA, Reymond L, Sansome X, Miller L. A whole-of-community program of advance care planning for end-of-life care. AUST HEALTH REV 2022; 46:442-449. [PMID: 35817410 DOI: 10.1071/ah22099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/15/2022] [Indexed: 11/23/2022]
Abstract
Since 2015 a whole-of-community program to promote advance care planning (ACP) within one Queensland Hospital and Health Service (HHS) catchment has spread statewide, financed by Queensland Health (QH) agencies and led by the Statewide Office of Advance Care Planning (SOACP). The program aims to identify ACP-eligible patients, invite and finalise ACP discussions, and ensure documented care preferences are easily retrievable by clinicians to guide future care if a person loses capacity. The SOACP established a digital infrastructure whereby quality-audited ACP documents are uploaded to a software platform accessible to all QH clinicians, private medical specialists, ambulance paramedics, general practitioners (GPs), and registered nurses, including those in residential aged care facilities (RACFs). The SOACP also hosts a website providing resources for clinicians and patients, delivers educational events and mentorship to GPs and hospital and RACF staff, and employs ACP facilitators working across all QH HHSs. The program has seen yearly increases in the numbers of ACP documents uploaded from around the state, with up to 79% of eligible patients in some hospitals receiving ACP, significant ACP uptake in RACFs, and acceptance by GPs to engage in ACP. Audits reveal high concordance between stated preferences and hospital care received, and ACP patients, compared to matched non-ACP controls, more frequently die out of hospital, have fewer inpatient days during their last 6 months of life, and receive less invasive care, with similar results seen among same-patient cohorts post-ACP. Barriers and enablers to ACP have been identified which will inform program evolution.
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Affiliation(s)
- Ian A Scott
- Princess Alexandra Hospital, 199 Ipswich Road, Brisbane, Qld 4102, Australia; and School of Clincial Medicine, University of Queensland, Qld, Australia
| | - Liz Reymond
- Eight Mile Plains Community Health, 51 McKechnie Drive, Eight Mile Plains, Qld 4113, Australia; and School of Public Health, Griffith School of Medicine, Qld, Australia
| | - Xanthe Sansome
- Eight Mile Plains Community Health, 51 McKechnie Drive, Eight Mile Plains, Qld 4113, Australia
| | - Leyton Miller
- Eight Mile Plains Community Health, 51 McKechnie Drive, Eight Mile Plains, Qld 4113, Australia
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Mechanisms and contextual influences on the implementation of advance care planning for older people in long-term care facilities: A realist review. Int J Nurs Stud 2022; 133:104277. [PMID: 35717924 DOI: 10.1016/j.ijnurstu.2022.104277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 01/10/2023]
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Jeong S, Cleasby P, Ohr SO, Barrett T, Davey R, Oldmeadow C. Efficacy of Normalisation of Advance Care Planning (NACP) for people with chronic diseases in hospital and community settings: a quasi-experimental study. BMC Health Serv Res 2021; 21:901. [PMID: 34470636 PMCID: PMC8408987 DOI: 10.1186/s12913-021-06928-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/18/2021] [Indexed: 01/21/2023] Open
Abstract
Background Advance Care Planning (ACP) has emerged to improve end-of-life processes and experiences. However, the available evidence presents the gloomy picture of increasing number of older people living with chronic diseases and the mismatch between their preferences for and the actual place of death. The study aimed to investigate the efficacy of normalisation of an Advance Care Planning (NACP) service delivered by specially trained Registered Nurses (RNs) in hospital and community settings. Methods A quasi-experimental study was conducted involving 16 sites (eight hospital and eight community sites) in Australia. Patients who were aged ≥18 years, who had at least one of nine chronic conditions, and who did not have an Advance Care Directive (ACD) were offered the NACP service. ACP was normalised as part of routine service on admission. The intervention, NACP, was a series of facilitated conversations about the components of ACP. The primary outcomes which included the completion of ACDs, and/or appointment of an Enduring Guardian (EG), were assessed in both intervention and control sites at pre and post intervention stages. Numbers of patients who completed an ACD or appointed an EG were described by count (percentage). ACD completion was compared between intervention and control sites using a logistic mixed effects regression model. The model includes fixed effects for treatment group, period, and their interaction, as well as random site level intercepts. Secondary model included potentially confounding variables as covariates, including age, sex and chronic diseases. Results The prevalence of legally binding ACDs in intervention sites has increased from five to 85 (from 0.85% in pre to 17.6% in post), whereas it has slightly decreased from five to 2 (from 1.2% in pre and to 0.49% in post) in control sites (the difference in these changes being statistically significant p < 0.001). ACD completion rate was 3.6% (n = 4) in LHD1 and 1.2% (n = 3) in LHD2 in hospital whereas it was 53% (n = 26) in LHD1 and 80% (n = 52) in LHD2 in community. Conclusions The study demonstrated that NACP service delivered by ACP RNs was effective in increasing completion of ACDs (interaction odds ratio = 50) and was more effective in community than hospital settings. Involvement of various healthcare professionals are warranted to ensure concordance of care. Trial registration The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246) on 03/10/2018. The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06928-w.
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Affiliation(s)
- Sarah Jeong
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia.
| | - Peter Cleasby
- Division of Aged, Subacute and Complex Care, PO Box 6088, Central Coast Local Health District, Long Jetty, NSW, 2261, Australia
| | - Se Ok Ohr
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia.,Hunter New England Nursing and Midwifery Research Centre, Hunter New England Local Health District, James Fletcher Campus, Gate Cottage, 72 Watt St, Newcastle, NSW, 2300, Australia
| | - Tomiko Barrett
- Department of Aged Care Services, Wyong Hospital, PO Box 4200, Central Coast Local Health District, Lakehaven, NSW, 2263, Australia
| | - Ryan Davey
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, Lot 1, Kookaburra Circuit, New Lambton Heights, Newcastle, NSW, 2305, Australia
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Jeong S, Ohr SO, Cleasby P, Barrett T, Davey R, Deeming S. A cost-consequence analysis of normalised advance care planning practices among people with chronic diseases in hospital and community settings. BMC Health Serv Res 2021; 21:729. [PMID: 34301254 PMCID: PMC8305493 DOI: 10.1186/s12913-021-06749-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A growing body of international literature concurs that comprehensive and complex Advance Care Planning (ACP) programs involving specially qualified or trained healthcare professionals are effective in increasing documentation of Advance Care Directives (ACDs), improving compliance with patients' wishes and satisfaction with care, and quality of care for patients and their families. Economic analyses of ACDs and ACP have been more sporadic and inconclusive. This study aimed to contribute to the evidence on resource use associated with implementation of ACP and to inform key decision-makers of the resource implications through the conduct of a cost-consequence analysis of the Normalised Advance Care Planning (NACP) trial. METHODS The outcomes for the economic evaluation included the number of completed "legally binding" ACDs and the number of completed Conversation Cards (CC). The cost analysis assessed the incremental difference in resource utilisation between Usual Practice and the Intervention. Costs have been categorised into: 1) Contract staff costs; 2) Costs associated with the development of the intervention; 3) Implementation costs; 4) Intervention (delivery) costs; and 5) Research costs. RESULTS The cost incurred for each completed ACD was A$13,980 in the hospital setting and A$1248 in the community setting. The cost incurred for each completed Conversation Card was A$7528 in the hospital setting and A$910 in the community setting. CONCLUSIONS The cost-consequence analysis does not support generalisation of the specified intervention within the hospital setting. The trial realised an estimated incremental cost per completed ACD of $1248, within the community setting. This estimate provides an additional benchmark against which decision-makers can assess the value of either 1) this approach towards the realisation of additional completed ACDs; and/or 2) the value of ACP and ACDs more broadly, when this estimate is positioned within the potential health outcomes and downstream health service implications that may arise for people with or without a completed ACD. TRIAL REGISTRATION The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record.
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Affiliation(s)
- Sarah Jeong
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW 2258 Australia
| | - Se Ok Ohr
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW 2258 Australia
- Hunter New England Nursing and Midwifery Research Centre, Hunter New England Local Health District, James Fletcher Campus, Gate Cottage, 72 Watt St, Newcastle, NSW 2300 Australia
| | - Peter Cleasby
- Division of Aged, Subacute and Complex Care, PO Box 6088 Long Jetty, Central Coast Local Health District, NSW 2261 Gosford, Australia
| | - Tomiko Barrett
- Department of Aged Care Services, Wyong Hospital, PO Box 4200, Lakehaven, Central Coast Local Health District, Wyong, NSW 2263 Australia
| | - Ryan Davey
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW 2258 Australia
| | - Simon Deeming
- Hunter Medical Research Institute, Lot 1, Kookaburra Circuit, New Lambton Heights, Newcastle, NSW 2305 Australia
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Silies KT, Köpke S, Schnakenberg R. Informal caregivers and advance care planning: systematic review with qualitative meta-synthesis. BMJ Support Palliat Care 2021; 12:bmjspcare-2021-003095. [PMID: 33952583 DOI: 10.1136/bmjspcare-2021-003095] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/23/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Advance care planning (ACP) is a communication process about a person's values, life goals and preferences for current and future treatment and care. It can improve end-of-life care experiences for care recipients as well as for family caregivers. Knowledge about caregivers' needs might support implementation of ACP interventions suitable to both care recipients and their caregivers. OBJECTIVE To explore the experiences and attitudes of informal family caregivers, and their knowledge, regarding ACP. METHODS A systematic literature search was conducted (participants: family caregivers; intervention: advance care planning; databases: MEDLINE, PsycINFO, CINAHL, Cochrane Library). Thematic synthesis was applied to qualitative and mixed methods studies; quantitative studies were described in relation to the themes of the meta-synthesis. RESULTS 57 studies were included, of these 51 in the meta-synthesis. Three themes emerged: (1) caregiver's individual conceptualisation of ACP, (2) caregiver's relationships and (3) ACP process. These themes were incorporated into a longitudinal perspective on the caregiver's ACP trajectory, encompassing the phases (A) life before, (B) ACP process, (C) utilisation of ACP and (D) life after. The implications for ACP activities are described according to each phase. CONCLUSION For the benefit of care recipients, healthcare professionals should carefully consider caregivers' conceptualisations of ACP as well as the relationships within the family. They need to be skilled communicators, sensitive to individual needs and equipped with sufficient time resources to tailor ACP interventions to their clients' unique situation. Thus, they will support decision-making according to care recipients' wishes, caregivers' end-of-life experience and their life after bereavement. PROSPERO REGISTRATION NUMBER CRD42018082492.
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Affiliation(s)
| | - Sascha Köpke
- Institute of Nursing Science, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Rieke Schnakenberg
- Department for Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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Jeong S, Barrett T, Ohr SO, Cleasby P, Davey R, David M. Prevalence of advance care planning practices among people with chronic diseases in hospital and community settings: a retrospective medical record audit. BMC Health Serv Res 2021; 21:303. [PMID: 33820535 PMCID: PMC8022421 DOI: 10.1186/s12913-021-06265-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance Care Planning (ACP) enables healthcare professionals to embrace the important process where patients think about their values in life and goals for health care, and discuss their future health care preferences with family members for a time when they are not able to make health care decisions. Despite the promotion of ACP last two decades, and well-known benefits of ACP and a written Advance Care Directive (ACD), they are still underutilised in Australia and across the world. Previous studies have provided some insights, however, an uptake of ACP and prevalence of ACDs in community settings is rarely reported. METHODS The aim of this study was to determine the uptake of ACP and prevalence of ACDs among people with chronic diseases in hospital and community settings. A retrospective medical record audit of eligible patients looking for evidence of ACP was conducted in 16 research sites in eight hospital and eight community care settings. Participants included those who were admitted to one of the research sites, and who were aged 18 years and over with at least one of nine nominated chronic diseases. The primary outcome measures included the number of patients with evidence of ACP through the following practices: completion of an ACD, appointment of an Enduring Guardian (EG), or completion of a resuscitation plan. RESULTS The overall prevalence of ACD was 2.8% (n = 28) out of 1006 audited records, and only 10 (1%) of them were legally binding. The number of EGs appointed was 39 (3.9%) across the sites. A total of 151 (15.4%) resuscitation plans were found across the eight hospital sites. 95% (n = 144) of the resuscitation plans indicated 'Not-for-resuscitation'. CONCLUSIONS The uptake of ACP is very low. Current medical recording system reveals the challenges in ACP lie in the process of storage, access and execution of the ACDs. Given that having an ACD or Enduring Guardian in place is only useful if the treating physician knows how and where to access the information, it has implications for policy, information system, and healthcare professionals' education. TRIAL REGISTRATION The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx.
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Affiliation(s)
- Sarah Jeong
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia.
| | - Tomiko Barrett
- Department of Aged Care Services, Wyong Hospital, Central Coast Local Health District, PO Box 4200, Lakehaven, NSW, 2263, Australia
| | - Se Ok Ohr
- Hunter New England Nursing and Midwifery Research Centre, Hunter New England Local Health District, James Fletcher Campus, Gate Cottage, 72 Watt St, Newcastle, NSW, 2300, Australia
| | - Peter Cleasby
- Division of Aged, Subacute and Complex Care, Central Coast Local Health District, PO Box 6088, Long Jetty, NSW, 2261, Australia
| | - Ryan Davey
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia
| | - Michael David
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
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Abstract
OBJECTIVE To explore family members' experiences of advance care planning in nursing homes. DESIGN Individual interviews. Thematic analysis. SETTING Four nursing homes in Sweden. SUBJECTS Eighteen family members of deceased nursing home patients. MAIN OUTCOME MEASURES Family members' experiences of advance care planning in nursing homes. RESULTS Family members' experiences of advance care planning in a nursing home context involved five themes: Elephant in the room, comprising end-of-life issues being difficult to talk about; Also silent understanding, e.g. patient's preferences explicitly communicated, but also implicitly conveyed. In some cases family members had a sense of the patient's wishes although preferences had not been communicated openly; Significance of small details, e.g. family members perceive everyday details as symbols of staff commitment; Invisible physician, supporting nurse, e.g. nurse being a gatekeeper, providing a first line assessment in the physician's absence; and Feeling of guilt, e.g. family members wish to participate in decisions regarding direction of care and treatment limits, and need guidance in the decisions. CONCLUSION Our study stresses the significance of staff involving the patient and family members in the advance care planning process in nursing homes, thereby adapting the care in line with patient's wishes, and for the patient to share these preferences with family members. Education in communication related to the subject may be important to shape advance care planning. Key points Knowledge on advance care planning (ACP) in a nursing home (NH) context from the perspective of family members is limited. Role of the nurse in ACP is seen as central, whereas physician involvement is often perceived to be lacking. Significance of small details, perceive to symbolize staff competence and respect for patient autonomy. To limit family members' feeling of guilt, communicating end-of-life issues is important in order to align ACP with patient preferences.
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Affiliation(s)
- Lisa Kastbom
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Primary Health Care Center in Ljungsbro, Linköping University, Linköping, Sweden
- CONTACT Lisa Kastbom Department of Health, Medicine and Caring Sciences, Linköping University, pl 14, Linköping, S-581 83, Sweden
| | - Marit Karlsson
- Department of Advanced Home Care in Linköping, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Magnus Falk
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Primary Health Care Center in Kärna, Linköping University, Linköping, Sweden
| | - Anna Milberg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Advanced Home Care in Norrköping, Linköping University, Linköping, Sweden
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Mc Kenna D, O'Shea J, Tanner L. The Heart of Living and Dying: Upstreaming Advance Care Planning into Community Conversations in the Public Domain in Northern Ireland. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2020; 16:346-363. [PMID: 33308045 DOI: 10.1080/15524256.2020.1858471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This paper provides an evaluation of the Heart of Living and Dying (HLD) Initiative. This initiative is a group process that attempts to bring Advance Care Planning (ACP) into the public domain. It encourages participants to consider what matters to them in their living along with their hopes, preferences, and wishes for their final years and end-of-life care. An inductive, interpretive, and naturalistic approach allowed the researcher to study these phenomena in their natural setting i.e., the community. This qualitative study used 5 focus groups with 17 people and employed thematic data analysis to identify key themes. All participants in the HLD speak from a personal perspective irrespective of any professional background. It transpired that 16 respondents worked in health and social care, which subsequently became noteworthy in the findings. Three key themes were identified: (a) feeling emotionally safe enough to have such sensitive conversations is vital; (b) participating in the HLD process increases the confidence of those participants who worked in health and social care, to undertake ACP conversations and (c) planning ahead is a complex, staged process rather than a single record-making event. The Covid-19 pandemic crisis reinforced the need to upstream ACP initiatives such as the HLD, as the norm for everyone, since all of us will one day die. It is recommended that the HLD be incorporated within ACP training given that the experiential nature of it and the use of groups was reported to build confidence in facilitating ACP conversations. A virtual HLD process needs to be developed to adapt to restrictions on gatherings due to Covid 19.
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Affiliation(s)
- Deirdre Mc Kenna
- Southern Health and Social Care Trust, Craigavon, Northern Ireland
| | - Johanna O'Shea
- Applied Social Sciences, Social Work Department, Maynooth University, Co. Kildare, Ireland
| | - Liz Tanner
- Social Work Training Unit, Southern Health and Social Care Trust, Armagh, Northern Ireland
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Dodd SR, Payne SA, Preston NJ, Walshe CE. Understanding the Outcomes of Supplementary Support Services in Palliative Care for Older People. A Scoping Review and Mapping Exercise. J Pain Symptom Manage 2020; 60:449-459.e21. [PMID: 32201310 DOI: 10.1016/j.jpainsymman.2020.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Supplementary support services in palliative care for older people are increasingly common, but with neither recommended tools to measure outcomes nor reviews synthesizing anticipated outcomes. Common clinically focused tools may be less appropriate. OBJECTIVES To identify stakeholder perceptions of key outcomes from supplementary palliative care support services, then map these onto outcome measurement tools to assess relevance and item redundancy. METHODS A scoping review using the design by Arksey and O'Malley. EMBASE, CINAHL, MEDLINE, and PSYCHinfo searched using terms relating to palliative care, qualitative research, and supplementary support interventions. Articles were imported into Endnote™, and Covidence™ was used by two reviewers to assess against inclusion criteria. Included articles were imported into NVivo™ and thematically coded to identify key concepts underpinning outcomes. Each item within contender outcome measurement tools was assessed against each concept. RESULTS Sixty included articles focused on advance care planning, guided conversations, and volunteer befriending services. Four concepts were identified: enriching relationships; greater autonomy and perceived control; knowing more; and improved mental health. Mapping concepts to contender tool items revealed issues of relevance and redundancy. Some tools had no redundant items but mapped only to two of four outcome themes; others mapped to all concepts, but with many redundant questions. Tools such as ICECAP-Supportive Care Measure and McGill Quality of Life had high relevance and low redundancy. CONCLUSION Pertinent outcome concepts for these services and population are not well represented in commonly used outcome measurement tools, and this may have implications in appropriately measuring outcomes. This review and mapping method may have utility in fields where selecting appropriate outcome tools can be challenging.
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Affiliation(s)
- Steven R Dodd
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Sheila A Payne
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Nancy J Preston
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Catherine E Walshe
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK.
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Klemmt M, Henking T, Heizmann E, Best L, van Oorschot B, Neuderth S. Wishes and needs of nursing home residents and their relatives regarding end-of-life decision-making and care planning-A qualitative study. J Clin Nurs 2020; 29:2663-2674. [PMID: 32301187 DOI: 10.1111/jocn.15291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/04/2020] [Accepted: 03/29/2020] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To explore wishes and needs, such as existing and preferred communication processes, of residents and relatives regarding medical and nursing planning at the end of life. BACKGROUND Nursing home residents are a relevant target group for advance care planning (ACP) due to their high age and multimorbidity. Their relatives seem to be important partners in terms of communication and their documentation of wishes and needs. DESIGN A qualitative descriptive design was used. METHODS Thirty-two guideline-based interviews with nursing home residents (n = 24) and relatives (n = 8) were conducted in nursing homes in Germany (n = 7). All interviews were analysed by content-structured content analysis. The COREQ checklist was used to document reporting of the study. RESULTS Residents particularly express wishes and needs regarding their health, like the desire to maintain or improve one's current state of health and to be active and mobile and also regarding their social situation, for example the well-being of relatives and beloved ones. A limited group of people was identified with whom residents spoke about issues such as preparedness and self-determination. These were mainly their relatives. Relatives themselves have a need for more communication. Various communication barriers could be identified. CONCLUSION Residents express diverse and partly explicit wishes and needs. Although many of the respondents had already drafted advanced directives, the demand for offers of communication to plan ahead for the end of life remains clear. The results indicate the unconditional participation of relatives and people close to the residents, if they are available. RELEVANCE TO CLINICAL PRACTICE Derivations for a target group-related ACP concept in the study region are identified. Besides the involvement of relatives, nurses could also be involved in the communication and decision-making process of residents in nursing homes under certain conditions.
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Affiliation(s)
- Malte Klemmt
- Fakultät Angewandte Sozialwissenschaften, Hochschule für Angewandte Wissenschaften Würzburg-Schweinfurt, Wurzburg, Germany
| | - Tanja Henking
- Fakultät Angewandte Sozialwissenschaften, Hochschule für Angewandte Wissenschaften Würzburg-Schweinfurt, Wurzburg, Germany
| | - Esther Heizmann
- Fakultät Angewandte Sozialwissenschaften, Hochschule für Angewandte Wissenschaften Würzburg-Schweinfurt, Wurzburg, Germany
| | - Lukas Best
- Fakultät Angewandte Sozialwissenschaften, Hochschule für Angewandte Wissenschaften Würzburg-Schweinfurt, Wurzburg, Germany
| | - Birgitt van Oorschot
- Interdisziplinäres Zentrum Palliativmedizin, Universitätsklinkum Würzburg, Würzburg, Germany
| | - Silke Neuderth
- Fakultät Angewandte Sozialwissenschaften, Hochschule für Angewandte Wissenschaften Würzburg-Schweinfurt, Wurzburg, Germany
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Jeong SYS, Moon KJ, Lee WS, David M. Experience of gerotranscendence among community-dwelling older people: A cross-sectional study. Int J Older People Nurs 2019; 15:e12296. [PMID: 31885195 DOI: 10.1111/opn.12296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 10/26/2019] [Accepted: 11/29/2019] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To investigate the experience of gerotranscendence among older people in community in Korea and the factors that influence their experience. BACKGROUND While the literature provides estimates of how many older people are affected by negative aspects of ageing, it is not known to what extent and why some older people experience gerotranscendence, despite the challenges they encounter throughout their lifetime. DESIGN A cross-sectional survey. METHODS A 55-item questionnaire was distributed to 109 older people between March and June 2017. Univariable and multivariable linear regressions were conducted on the four question group sum scores to identify factors associated with gerotranscendence. RESULTS Older people aged 65-93 who live in a community in Korea reported the experience of gerotranscendence. Age and religion showed a statistically significant association with gerotranscendence. Religiosity showed a statistically significant association with beliefs about death and dying. Age and beliefs about death and dying have significant relationship with the experience of gerotranscendence. CONCLUSIONS Older people who have more positive views about death and dying are more likely to experience gerotranscendence. The study results provide nurses and other healthcare professionals with new understandings and insights about the factors potentially related to positive ageing process. IMPLICATIONS FOR PRACTICE It is essential for nurses to investigate their own beliefs about death and dying, and their understanding of gerotranscendence which will contribute to developing education programs and practice guidelines as an essential part of promoting gerotranscendence and positive ageing.
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Affiliation(s)
- Sarah Yeun-Sim Jeong
- The School of Nursing and Midwifery, The University of Newcastle, Ourimbah, NSW, Australia
| | | | - Woo Suck Lee
- College of Nursing, Teagu Science University, Daegu, Korea
| | - Michael David
- The School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
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Risk J, Mohammadi L, Rhee J, Walters L, Ward PR. Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis. BMJ Open 2019; 9:e030275. [PMID: 31537570 PMCID: PMC6756326 DOI: 10.1136/bmjopen-2019-030275] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice? DESIGN A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting. SETTING Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews. RESULTS The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging. CONCLUSION Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice. PROSPERO REGISTRATION NUMBER CRD42018088838.
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Affiliation(s)
- Jo Risk
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Leila Mohammadi
- Library, Flinders University, Adelaide, South Australia, Australia
| | - Joel Rhee
- General Practice Academic Unit, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Lucie Walters
- Rural Health, Flinders University, Adelaide, South Australia, Australia
| | - Paul R Ward
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Nonstandard Advance Health Care Directives in Emergency Departments: Ethical and Legal Dilemma or Reality: A Narrative Review. Adv Emerg Nurs J 2019; 40:324-327. [PMID: 30365447 DOI: 10.1097/tme.0000000000000214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Jeong S, Barrett T, Ohr SO, Cleasby P, David M, Chan S, Fairlamb H, Davey R, Saul P. Study protocol to investigate the efficacy of normalisation of Advance Care Planning (ACP) for people with chronic diseases in acute and community settings: a quasi-experimental design. BMC Health Serv Res 2019; 19:286. [PMID: 31054578 PMCID: PMC6500579 DOI: 10.1186/s12913-019-4118-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advanced care planning (ACP) is a process that involves thinking about what medical care one would like should individuals be seriously ill and cannot communicate decisions about treatment for themselves. The literature indicates that ACP leads to increased satisfaction from both patients and healthcare professionals. Despite the well-known benefits of ACP, it is still underutilised in Australia. METHODS The aim of this study is to investigate the effects of normalising ACP in acute and community settings with the use of specially trained normalisation agents. This is a quasi-experimental study, involving 16 sites (8 intervention and 8 control) in two health districts in Australia. A minimum of total 288 participants will be recruited (144 intervention, 144 control). We will train four registered nurses as normalisation agents in the intervention sites, who will promote and facilitate ACP discussions with adult patients with chronic conditions in hospital and community settings. An audit of the prevalence of ACP and Advanced Care Directives (ACDs) will be conducted before and after the 6-month intervention period at the 16 sites to assess the effects of the ACP service delivered by these agents. We will also collect interview and survey data from patients and families who participate, and healthcare professionals who are involved in this service to capture their experiences with ACP. DISCUSSION This study will potentially contribute to better patient outcomes with their health care services. Completion of ACDs will allow patients to express their wishes for care and receive the care that they wish for, as well as ease their family from the burden of making difficult decisions. The study will contribute to development of a new best practice model to normalise ACP that is sustainable and transferable in the processes of: 1) initiation of conversation; 2) discussion of important issues; 3) documentation of the wishes; 4) storage of the documented wishes; and 5) access and execution of the documented wishes. The study will generate new evidence on the challenges, strategies and benefits of normalising ACP into practice in acute and community settings. TRIAL REGISTRATION This project has been approved by the Hunter New England Human Research Ethics Committee (Approval No. 17/12/13/4.16). It has also been retrospectively registered on 3 October 2018 with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). This study will operate in accordance with the National Health and Medical Research Council's National Statement on Ethical Conduct in Human Research (2007) and the CPMP/ICH Note for Guidance on Good Clinical Practice.
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Affiliation(s)
- Sarah Jeong
- School of Nursing and Midwifery, University of Newcastle, PO Box 127, Ourimbah, NSW, 2258, Australia.
| | - Tomiko Barrett
- Department of Aged Care Services, Wyong Hospital, PO Box 4200, Lakehaven, NSW, 2263, Australia
| | - Se Ok Ohr
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, Gate Cottage, 72 Watt St, Newcastle, NSW, 2300, Australia
| | - Peter Cleasby
- Division of Aged, Subacute and Complex Care, PO Box 6088, Long Jetty, NSW, 2261, Australia
| | - Michael David
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Sally Chan
- School of Nursing and Midwifery, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Helen Fairlamb
- Cumbria Partnership National Health Service Foundation Trust. E27 Ruskin Corridor, The Carleton Clinic, Cumwhinton Drive, Carlisle, CA1 3SX, UK
| | - Ryan Davey
- School of Nursing and Midwifery, University of Newcastle, PO Box 127, Ourimbah, NSW, 2258, Australia
| | - Peter Saul
- Calvary Mater Hospital & Newcastle Private Hospital ICU, Organ and Tissue donation for the Hunter New England Local Health District , New Lambton Heights, Australia
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Batchelor F, Hwang K, Haralambous B, Fearn M, Mackell P, Nolte L, Detering K. Facilitators and barriers to advance care planning implementation in Australian aged care settings: A systematic review and thematic analysis. Australas J Ageing 2019; 38:173-181. [PMID: 30873713 DOI: 10.1111/ajag.12639] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 02/07/2019] [Accepted: 02/17/2019] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | - Kerry Hwang
- National Ageing Research Institute, Parkville, Victoria, Australia
| | | | - Marcia Fearn
- National Ageing Research Institute, Parkville, Victoria, Australia
| | - Paulene Mackell
- National Ageing Research Institute, Parkville, Victoria, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Karen Detering
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Parkville, Victoria, Australia
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Andrade SRD, Ruoff AB, Piccoli T, Schmitt MD, Ferreira A, Xavier ACA. O ESTUDO DE CASO COMO MÉTODO DE PESQUISA EM ENFERMAGEM: UMA REVISÃO INTEGRATIVA. TEXTO & CONTEXTO ENFERMAGEM 2017. [DOI: 10.1590/0104-07072017005360016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
RESUMO Objetivo: analisar a aplicação do estudo de caso como método de pesquisa pela enfermagem nas publicações científicas nacionais e internacionais. Método: revisão integrativa de literatura realizada nas bases bibliográficas eletrônicas PubMed, CINAHL, LILACS e SciELO, utilizando os descritores estudo de caso, pesquisa e enfermagem. Foram incluídos artigos originais disponíveis na íntegra no formato on-line, nos idiomas português, inglês ou espanhol, no recorte temporal de 2010 a 2015. Resultados: foram encontrados 624 estudos, dos quais 50 atenderam ao objetivo. Os autores Yin e Stake foram os pesquisadores cujos referenciais metodológicos de estudo de caso se destacaram no contexto da pesquisa na área da enfermagem. A aplicação do método abrangeu os diferentes campos de atuação da profissão: educação, assistência/cuidado e gestão/administração. Conclusão: o estudo de caso como método de pesquisa mostrou-se uma importante metodologia que pode ser amplamente utilizada pela enfermagem nos seus diversos campos de atuação ao buscar compreender fenômenos relacionados a indivíduos, grupos ou organizações.
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Ke LS, Huang X, Hu WY, O'Connor M, Lee S. Experiences and perspectives of older people regarding advance care planning: A meta-synthesis of qualitative studies. Palliat Med 2017; 31:394-405. [PMID: 27515975 DOI: 10.1177/0269216316663507] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Studies have indicated that family members or health professionals may not know or predict their older relatives' or patients' health preferences. Although advance care planning is encouraged for older people to prepare end-of-life care, it is still challenging. AIM To understand the experiences and perspectives of older people regarding advance care planning. DESIGN A systematic review of qualitative studies and meta-synthesis was conducted. DATA SOURCES CINAHL, MEDLINE, EMBASE, and PsycINFO databases were searched. RESULTS A total of 50 articles were critically appraised and a thematic synthesis was undertaken. Four themes were identified: life versus death, internal versus external, benefits versus burdens, and controlling versus being controlled. The view of life and death influenced older people's willingness to discuss their future. The characteristics, experiences, health status, family relationship, and available resources also affected their plans of advance care planning. Older people needed to balance the benefits and burdens of advance care planning, and then judge their own ability to make decisions about end-of-life care. CONCLUSION Older people's perspectives and experiences of advance care planning were varied and often conflicted; cultural differences amplified variances among older people. Truthful information, available resources, and family support are needed to enable older people to maintain dignity at the end of life. The views of life and death for older people from different cultures should be compared to assist health professionals to understand older people's attitudes toward advance care planning, and thus to develop appropriate strategies to promote advance care planning in different cultures.
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Affiliation(s)
- Li-Shan Ke
- 1 Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan.,2 School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Xiaoyan Huang
- 3 School of Nursing, Fudan University, Shanghai, China.,4 Palliative Care Research Team, School of Nursing and Midwifery, Monash University, Frankston, VIC, Australia
| | - Wen-Yu Hu
- 2 School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Margaret O'Connor
- 4 Palliative Care Research Team, School of Nursing and Midwifery, Monash University, Frankston, VIC, Australia.,5 Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Susan Lee
- 4 Palliative Care Research Team, School of Nursing and Midwifery, Monash University, Frankston, VIC, Australia
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Mignani V, Ingravallo F, Mariani E, Chattat R. Perspectives of older people living in long-term care facilities and of their family members toward advance care planning discussions: a systematic review and thematic synthesis. Clin Interv Aging 2017; 12:475-484. [PMID: 28424546 PMCID: PMC5344428 DOI: 10.2147/cia.s128937] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective We aimed to search and synthesize qualitative studies exploring the perspectives of older people living in long-term care facilities and of their family members about advance care planning (ACP) discussions. Methods The enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) framework was used to guide the review and report its results. PubMed, CINAHL, and PsycINFO were searched for studies published between January 2000 and November 2015. All included studies were assessed for comprehensiveness of reporting, and a thematic synthesis of their results was performed. Results The nine included studies differed in terms of qualitative method used, comprehensiveness of reporting, and geographical origin. The thematic synthesis led to the identification of four main themes: 1) plans already made; 2) end-of-life care and decision-making; 3) opinions and attitudes toward ACP; and 4) how, when, about what, and with whom to do ACP. Conclusion Despite their willingness to be involved in a shared decision-making process, older residents and their families still have little experience with ACP. Practical implications In view of implementing ACP for elders living in long-term care facilities, it would be important to rethink ACP and also to incorporate their nonmedical preferences, according to their own priorities.
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Affiliation(s)
- Veronica Mignani
- Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio, Bologna, Italy
| | - Francesca Ingravallo
- Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio, Bologna, Italy
| | - Elena Mariani
- Department of Psychology, University of Bologna, Viale Berti Pichat, Bologna, Italy
| | - Rabih Chattat
- Department of Psychology, University of Bologna, Viale Berti Pichat, Bologna, Italy
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McLennan VEJ, Boddy JHM, Daly MG, Chenoweth LM. Relinquishing or taking control? Community perspectives on barriers and opportunities in advance care planning. AUST HEALTH REV 2016; 39:528-532. [PMID: 26027685 DOI: 10.1071/ah14152] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 03/26/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This paper reports on the experiences and perspectives of community members in relation to advance healthcare directives and enduring power of attorney, including the factors that encourage or discourage engagement in advance care planning (ACP). METHODS; A qualitative methodology was used involving 26 in-depth telephone interviews with community members (mean age 66 years). The aims of the interview question were to gain an understanding of: (1) motivations for engaging in ACP; (2) barriers that prevent people from engaging in ACP; and (3) suggestions for promoting ACP. RESULTS The findings suggest that: (1) community members lack knowledge about ACP; (2) forms appear inaccessible and complex; (3) community members avoid ACP due to fear, mistrust and concerns over control; and (4) there are misperceptions regarding the relevance of ACP based on age and health. CONCLUSIONS There is unnecessary fear, avoidance and mistrust around ACP activities, largely resulting from misinformation. There is an undoubted need for greater education and support to be offered to individuals and their families regarding ACP, its benefits and its limitations.
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Affiliation(s)
- Vanette E J McLennan
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, Qld 4222, Australia. Email
| | - Jennifer H M Boddy
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, Qld 4222, Australia. Email
| | - Michelle G Daly
- School of Human Services and Social Work, Griffith University, Gold Coast Campus, Parklands Drive, Southport, Qld 4222, Australia. Email
| | - Lesley M Chenoweth
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, Qld 4222, Australia. Email
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Parker D, Clifton K, Tuckett A, Walker H, Reymond E, Prior T, McAnelly K, Jenkin P, Israel F, Greeve K, Glaetzer K. Palliative care case conferences in long-term care: views of family members. Int J Older People Nurs 2015; 11:140-8. [DOI: 10.1111/opn.12105] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 07/13/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Deborah Parker
- School of Nursing and Midwifery; The University of Queensland; Milton BC Qld Australia
- Blue Care Research and Practice Development Centre; The University of Queensland; Milton BC Qld Australia
| | - Karen Clifton
- School of Nursing and Midwifery; The University of Queensland; Milton BC Qld Australia
- Blue Care Research and Practice Development Centre; The University of Queensland; Milton BC Qld Australia
| | - Anthony Tuckett
- School of Nursing and Midwifery; The University of Queensland; Milton BC Qld Australia
- Blue Care Research and Practice Development Centre; The University of Queensland; Milton BC Qld Australia
| | - Helen Walker
- Western Australia Department of Health; WA Cancer and Palliative Care Network; East Perth WA Australia
| | - Elizabeth Reymond
- Brisbane South Palliative Care Collaborative; Queensland Health; Griffith University School of Medicine; Eight Mile Plains; Qld Australia
| | - Teresa Prior
- Western Australia Department of Health; WA Cancer and Palliative Care Network; East Perth WA Australia
| | - Kristien McAnelly
- Brisbane South Palliative Care Collaborative; Queensland Health; Griffith University School of Medicine; Eight Mile Plains; Qld Australia
| | - Peter Jenkin
- Southern Adelaide Palliative Services; Repatriation General Hospital; Daw Park SA Australia
| | - Fiona Israel
- Brisbane South Palliative Care Collaborative; Queensland Health; Griffith University School of Medicine; Eight Mile Plains; Qld Australia
| | - Kim Greeve
- Western Australia Department of Health; WA Cancer and Palliative Care Network; East Perth WA Australia
| | - Karen Glaetzer
- Southern Adelaide Palliative Services; Repatriation General Hospital; Flinders University; Daw Park SA Australia
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Rietze L, Stajduhar K. Registered nurses' involvement in advance care planning: an integrative review. Int J Palliat Nurs 2015; 21:495-503. [DOI: 10.12968/ijpn.2015.21.10.495] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Lori Rietze
- Assistant Professor, School of Nursing, Laurentian University
| | - Kelli Stajduhar
- Professor, Centre on Ageing, School of Nursing, University of Victoria
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Lee MC, Hinderer KA, Friedmann E. Engaging Chinese American Adults in Advance Care Planning: A Community-Based, Culturally Sensitive Seminar. J Gerontol Nurs 2015; 41:17-21. [PMID: 25912237 DOI: 10.3928/00989134-20150406-01] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 01/26/2015] [Indexed: 11/20/2022]
Abstract
Ethnic minority groups are less engaged than Caucasian American adults in advance care planning (ACP). Knowledge deficits, language, and culture are barriers to ACP. Limited research exists on ACP and advance directives in the Chinese American adult population. Using a pre-posttest, repeated measures design, the current study explored the effectiveness of a nurseled, culturally sensitive ACP seminar for Chinese American adults on (a) knowledge, completion, and discussion of advance directives; and (b) the relationship between demographic variables, advance directive completion, and ACP discussions. A convenience sample of 72 urban, community-dwelling Chinese American adults (mean age=61 years) was included. Knowledge, advance directive completion, and ACP discussions increased significantly after attending the nurse-led seminar (p<0.01). Increased age correlated with advance directive completion and ACP discussions; female gender correlated with ACP discussions. Nursing education in a community setting increased advance directive knowledge and ACP engagement in Chinese American adults.
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Hoping for the best, preparing for the worst: strategies to promote honesty and prevent medical futility at end-of-life. Dimens Crit Care Nurs 2015; 33:22-7. [PMID: 24310712 DOI: 10.1097/dcc.0000000000000013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Critical care nurses frequently care for patients nearing end of life. Associated advance care planning is often not introduced as early as it needs to be, and nurses can help to stimulate a culture change by initiating honest discussions about end-of-life treatment options. The Physician Orders for Life-Sustaining Treatment form can provide a framework for honesty and information sharing at end of life. This article discusses the use of the Physician Orders for Life-Sustaining Treatment form as an end-of-life care planning tool as well as evidence-based communication strategies that promote honest, effective end-of-life conversations.
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28
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Fosse A, Schaufel MA, Ruths S, Malterud K. End-of-life expectations and experiences among nursing home patients and their relatives--a synthesis of qualitative studies. PATIENT EDUCATION AND COUNSELING 2014; 97:3-9. [PMID: 24976628 DOI: 10.1016/j.pec.2014.05.025] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 05/20/2014] [Accepted: 05/30/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Synthesize research about patients' and relatives' expectations and experiences on how doctors can improve end-of-life care in nursing homes. METHODS We systematically searched qualitative studies in English in seven databases (Medline, Embase, PsycINFO, CINAHL, Ageline, Cochrane Systematic Reviews and Cochrane Trials). We included 14 publications in the analysis with meta-ethnography. RESULTS Patients and families emphasized the importance of health personnel anticipating illness trajectories and recognizing the information and palliation needed. Family members who became proxy decision-makers reported uncertainty and distress when guidance from health personnel was lacking. They worried about staff shortage and emphasized doctor availability. Relatives and health personnel seldom recognized patients' ability to consent, and patients' preferences were not always recognized. CONCLUSION Nursing home patients and their relatives wanted doctors more involved in end-of-life care. They expected doctors to acknowledge their preferences and provide guidance and symptom relief. PRACTICE IMPLICATIONS High-quality end-of-life care in nursing homes relies on organization, funding and skilled staff, including available doctors who are able to recognize illness trajectories and perform individualized Advance Care Planning.
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Affiliation(s)
- Anette Fosse
- Research Unit for General Practice, Uni Health Research, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | | | - Sabine Ruths
- Research Unit for General Practice, Uni Health Research, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Health Research, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Research Unit for General Practice, Copenhagen, Denmark
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29
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Jeong S, Ohr S, Pich J, Saul P, Ho A. 'Planning ahead' among community-dwelling older people from culturally and linguistically diverse background: a cross-sectional survey. J Clin Nurs 2014; 24:244-55. [PMID: 25041247 DOI: 10.1111/jocn.12649] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2014] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To explore preparedness of end-of-life care planning among community-dwelling older persons of culturally and linguistically diverse background. BACKGROUND To improve end-of-life care through advance care planning, the key concept 'Planning ahead' has been promoted in Australia. However, since the introduction of the model in 2008, it is not known whether 'Planning Ahead' practice by older people from culturally and linguistically diverse backgrounds has improved. DESIGN A cross-sectional survey. METHODS A total of 453 community older adults (65+) who attended 17 day care centres in a region were invited to participate in the study. A total of 229 people completed the survey with a response rate of 50·5%. The questions relevant to this study include: (1) awareness of enduring guardian, advance care directive and advance care planning, (2) the preference for substitute decision-makers and (3) the challenges experienced with advance care planning. RESULTS Awareness of advance care planning was low, and completion of advance care directive was very low. 37·5% of Anglo Celtic group had an enduring guardian, compared with 15·5, 24·1 and 13·3% from Mediterranean, Eastern European and Asia/Pacific group, respectively. Children were the most preferred substitute decision-makers more for Asia/Pacific group than Anglo Celtic, Mediterranean and Eastern Europeans. The various difficulties experienced included being time-consuming, difficult to understand terms and forms, and do not know how to do it. CONCLUSION Regardless of cultural and ethnic backgrounds, a low level of 'Planning ahead' practices was apparent because of a lack of understanding of the concept, the forms and the processes involved. The gap identified between the existing legal/ethical frameworks and the preferences of older people as substitute decision-makers adds new knowledge for further discussion. RELEVANCE TO CLINICAL PRACTICE Nursing professionals are provided with an opportunity to improve their practice to meet the needs of older persons and their families in planning ahead for future treatment options.
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Affiliation(s)
- Sarah Jeong
- The School of Nursing & Midwifery, The University of Newcastle, Ourimbah, NSW, Australia
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30
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Jeong S. The majority of hospitalised elderly people at high risk of dying have thought about end-of-life care, though documentation of preferences in medical records may be lacking. Evid Based Nurs 2014; 17:96. [PMID: 24052579 DOI: 10.1136/eb-2013-101503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Sarah Jeong
- School of Nursing and Midwifery, University of Newcastle, Ourimbah, New South Wales, Australia
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31
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Michael N, O'Callaghan C, Baird A, Hiscock N, Clayton J. Cancer caregivers advocate a patient- and family-centered approach to advance care planning. J Pain Symptom Manage 2014; 47:1064-77. [PMID: 24144996 DOI: 10.1016/j.jpainsymman.2013.07.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/19/2013] [Accepted: 07/23/2013] [Indexed: 11/29/2022]
Abstract
CONTEXT Cancer caregivers have important roles in delivering practical, emotional, and end-of-life support to patients; however, they express multiple unmet needs, particularly information on future care planning. Early regular communication and decision making may improve access to timely information, alleviate anxiety, reduce uncertainty, and improve coping strategies. OBJECTIVES This study examines how cancer caregivers view advance care planning (ACP) to inform an ACP program in an Australian cancer center. METHODS This study used a qualitative descriptive design with grounded theory overtones. Eighteen caregivers of patients from lung and gastrointestinal tumor streams participated in focus groups or semistructured interviews, which incorporated the vignette technique. RESULTS Caregivers believe that, although confronting, ACP discussions can be helpful. Conversations are sometimes patient initiated, although caregivers may intend to sensitively broach conversations over time. Findings highlight the impact of caregiver hierarchies, adaptive family decision-making styles, and complex cultural influences on decision making. Some caregivers may develop subsidiary care intentions, based on "knowing" or overriding patients' desires. Hindrances on caregivers supporting patients' ACPs include limited information access, patient or caregiver resistance to engage in conversations, and ACPs association in oncology with losing hope. Many caregivers wanted professional support and further opportunities to obtain information, develop subsidiary plans, and help patients engage in ACP discussions. CONCLUSION Findings highlight the influence of cancer caregivers and family dynamics over ACP decisions and actualization of future care plans. A patient- and family-centered care approach to ACP, promoting shared decision making and caregiver support, is recommended. Given that caregivers may override and, plausibly, misinterpret patients' desires, caregivers' subsidiary planning warrants further investigation.
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Affiliation(s)
- Natasha Michael
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
| | - Clare O'Callaghan
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Departments of Oncology and Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Angela Baird
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Nathaniel Hiscock
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Josephine Clayton
- Hammond Care Palliative and Supportive Care Service, Greenwich Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Séchaud L, Goulet C, Morin D, Mazzocato C. Advance care planning for institutionalised older people: an integrative review of the literature. Int J Older People Nurs 2013; 9:159-68. [DOI: 10.1111/opn.12033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 04/05/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Laurence Séchaud
- University Institute of Graduate Studies and Research in Care - IUFRS; University Hospital Center; University of Lausanne; Lausanne Switzerland
- University of Applied Sciences and Arts Western Switzerland; Nursing Department; School of Health Sciences; Geneva Switzerland
| | - Céline Goulet
- University of Montreal; Montreal QC Canada
- University Institute of Graduate Studies and Research in Care - IUFRS; Vaud University Hospital Center; University of Lausanne; Lausanne Switzerland
| | - Diane Morin
- University Institute of Graduate Studies and Research in Care - IUFRS; Vaud University Hospital Center; University of Lausanne; Lausanne Switzerland
| | - Claudia Mazzocato
- Service of Palliative Care; Ethic Unit; Vaud University Hospital Center; University of Lausanne; Lausanne Switzerland
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Zampieron A, Saraiva M, Corso M, Buja A. AN INTERNATIONAL SURVEY ON ATTITUDES OF RENAL NURSES TOWARDS OLDER PEOPLE. J Ren Care 2012; 38:213-21. [DOI: 10.1111/j.1755-6686.2012.00314.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Jeong SY, McMillan M, Higgins I. Gerotranscendence: The Phenomenon of Advance Care Planning. JOURNAL OF RELIGION SPIRITUALITY & AGING 2012. [DOI: 10.1080/15528030.2012.632712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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