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Bischoff KE, Liera D, Tang J, Madugala N, Cohen E, Galea MD, Lindenberger E, Pantilat SZ, Lomen-Hoerth C. Development and Piloting of a Bereaved Care Partner Survey to Inform Quality Improvement in ALS Supportive Care. J Pain Symptom Manage 2024; 68:467-476.e2. [PMID: 39111585 DOI: 10.1016/j.jpainsymman.2024.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/16/2024] [Accepted: 07/29/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVES Bereaved care partner surveys typically focus on the experience with care in the final days of life. We sought to develop and pilot a novel bereaved care partner survey to understand experiences with ALS supportive care provided throughout the illness and identify opportunities for quality improvement. METHODS We developed the survey using a multisite, interdisciplinary consensus process involving ALS and palliative care clinicians as well as patient advocates. We then piloted the survey at a single site via video interviews with care partners of patients who died from ALS between three and 15 months prior. Qualitative findings were analyzed using Rapid Qualitative Analysis. RESULTS The survey includes 17 core questions and nine demographic items. Questions inquire about whether the patient and care partner received adequate help with physical symptoms, emotional and practical needs, education about the illness and how to provide hands-on care, preparing for what was to come, and bereavement. They also query whether care was person-centered and consistent with the patient's values and preferences. During the pilot with 18 bereaved care partners, the tool generated detailed feedback about aspects of care to preserve as well as how to improve ALS supportive care. DISCUSSION We developed and piloted a bereaved care partner survey to understand and improve the quality of ALS supportive care, which was found to be feasible and acceptable. Next steps include testing it at additional centers in order to generate learnings that can advance ALS supportive care in ways that are meaningful to patients and care partners.
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Affiliation(s)
- Kara E Bischoff
- Division of Palliative Medicine, Department of Medicine (K.E.B., E.C., S.Z.P.), University of California, San Francisco, California, USA.
| | - Daniela Liera
- School of Medicine (D.L., J.T.), University of California, San Francisco, California, USA
| | - Janette Tang
- School of Medicine (D.L., J.T.), University of California, San Francisco, California, USA
| | - Neha Madugala
- Department of Neurology (N.M., C.L.-H.), University of California, San Francisco, California, USA
| | - Eve Cohen
- Division of Palliative Medicine, Department of Medicine (K.E.B., E.C., S.Z.P.), University of California, San Francisco, California, USA
| | - Marinella D Galea
- Department of Medicine (M.D.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elizabeth Lindenberger
- Division of Palliative Care and Geriatric Medicine (E.L.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine (K.E.B., E.C., S.Z.P.), University of California, San Francisco, California, USA
| | - Catherine Lomen-Hoerth
- Department of Neurology (N.M., C.L.-H.), University of California, San Francisco, California, USA
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Paladino J, Fromme EK, Kilpatrick L, Dingfield L, Teuteberg W, Bernacki R, Jackson V, Sanders JJ, Jacobsen J, Ritchie C, Mitchell S. Lessons Learned About System-Level Improvement in Serious Illness Communication: A Qualitative Study of Serious Illness Care Program Implementation in Five Health Systems. Jt Comm J Qual Patient Saf 2023; 49:620-633. [PMID: 37537096 DOI: 10.1016/j.jcjq.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Serious illness communication is a key element of high-quality care, but it is difficult to implement in practice. The Serious Illness Care Program (SICP) is a multifaceted intervention that contributes to more, earlier, and better serious illness conversations and improved patient outcomes. This qualitative study examined the organizational and implementation factors that influenced improvement in real-world contexts. METHODS The authors performed semistructured interviews of 30 health professionals at five health systems that adopted SICP as quality improvement initiatives to investigate the organizational and implementation factors that appeared to influence improvement. RESULTS After SICP implementation across the organizations studied, approximately 4,661 clinicians have been trained in serious illness communication and 56,712 patients had had an electronic health record (EHR)-documented serious illness conversation. Facilitators included (1) visible support from leaders, who financially invested in an implementation team and champions, expressed the importance of serious illness communication as an institutional priority, and created incentives for training and documenting serious illness conversations; (2) EHR and data infrastructure to foster performance improvement and accountability, including an accessible documentation template, a reporting system, and customized data feedback for clinicians; and (3) communication skills training and sustained support for clinicians to problem-solve communication challenges, reflect on communication experiences, and adapt the intervention. Inhibitors included leadership inaction, competing priorities and incentives, variable clinician acceptance of EHR and data tools, and inadequate support for clinicians after training. CONCLUSION Successful implementation appeared to rely on multilevel organizational strategies to prioritize, reward, and reinforce serious illness communication. The insights derived from this research may function as an organizational road map to guide implementation of SICP or related quality initiatives.
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Wolff JL, Cagle J, Echavarria D, Dy SM, Giovannetti ER, Boyd CM, Hanna V, Hussain N, Reiff JS, Scerpella D, Zhang T, Roth DL. Sharing Health Care Wishes in Primary Care (SHARE) among older adults with possible cognitive impairment in primary care: Study protocol for a randomized controlled trial. Contemp Clin Trials 2023; 129:107208. [PMID: 37116645 PMCID: PMC10258688 DOI: 10.1016/j.cct.2023.107208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Little is known about effective strategies to improve advance care planning (ACP) for persons with cognitive impairment in primary care, the most common setting of care. We describe a randomized controlled trial to test the efficacy of a multicomponent communication intervention, "Sharing Healthcare Wishes in Primary Care" (SHARE). PARTICIPANTS Planned enrollment of 248 dyads of adults 80 years and older with possible cognitive impairment and their care partner, from primary care clinics at 2 Mid-Atlantic health systems. METHODS The treatment protocol encompasses an introductory letter from the clinic; access to a designated facilitator trained in ACP; person-family agenda-setting to align perspectives about the family's role; and print education. The control protocol encompasses minimally enhanced usual care, which includes print education and a blank advance directive. Randomization occurs at the individual dyad-level. Patient and care partner surveys are fielded at baseline, 6-, 12-, and 24- months. Fidelity of interventionist delivery of the protocol is measured through audio-recordings of ACP conversations and post-meeting reports, and by ongoing monitoring and support of interventionists. OUTCOMES The primary outcome is quality of end-of-life care communication at 6 months; secondary outcomes include ACP process measures. An exploratory aim examines end-of-life care quality and bereaved care partner experiences for patients who die by 24 months. CONCLUSIONS Caregiver burden, clinician barriers, and impaired decisional capacity amplify the difficulty and importance of ACP discussions in the context of cognitive impairment: this intervention will comprehensively examine communication processes for this special subpopulation in a key setting of primary care. REGISTRATION ClinicalTrials.gov: NCT04593472.
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Affiliation(s)
- Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
| | - John Cagle
- School of Social Work, University of Maryland, Baltimore, Baltimore, MD, United States of America.
| | - Diane Echavarria
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, United States of America.
| | - Sydney M Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, United States of America.
| | - Erin R Giovannetti
- Health Economics and Aging Research Institute, MedStar Health, 10980 Grantchester Way Columbia, MD 21044, United States of America.
| | - Cynthia M Boyd
- Division of Geriatric Medicine & Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building, Center Tower, Room 317, Baltimore, MD 21224, United States of America.
| | - Valecia Hanna
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, United States of America.
| | - Naaz Hussain
- Johns Hopkins Community Physicians, 45 TJ Drive, Suite 109, Frederick, MD 21702, United States of America.
| | - Jenni S Reiff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
| | - Danny Scerpella
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, United States of America.
| | - Talan Zhang
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD, United States of America.
| | - David L Roth
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD, United States of America.
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Medendorp NM, Stiggelbout AM, Aalfs CM, Han PKJ, Smets EMA, Hillen MA. A scoping review of practice recommendations for clinicians' communication of uncertainty. Health Expect 2021; 24:1025-1043. [PMID: 34101951 PMCID: PMC8369117 DOI: 10.1111/hex.13255] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/21/2021] [Accepted: 03/23/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Health-care providers increasingly have to discuss uncertainty with patients. Awareness of uncertainty can affect patients variably, depending on how it is communicated. To date, no overview existed for health-care professionals on how to discuss uncertainty. OBJECTIVE To generate an overview of available recommendations on how to communicate uncertainty with patients during clinical encounters. SEARCH STRATEGY A scoping review was conducted. Four databases were searched following the PRISMA-ScR statement. Independent screening by two researchers was performed of titles and abstracts, and subsequently full texts. INCLUSION CRITERIA Any (non-)empirical papers were included describing recommendations for any health-care provider on how to orally communicate uncertainty to patients. DATA EXTRACTION Data on provided recommendations and their characteristics (eg, target group and strength of evidence base) were extracted. Recommendations were narratively synthesized into a comprehensible overview for clinical practice. RESULTS Forty-seven publications were included. Recommendations were based on empirical findings in 23 publications. After narrative synthesis, 13 recommendations emerged pertaining to three overarching goals: (a) preparing for the discussion of uncertainty, (b) informing patients about uncertainty and (c) helping patients deal with uncertainty. DISCUSSION AND CONCLUSIONS A variety of recommendations on how to orally communicate uncertainty are available, but most lack an evidence base. More substantial research is needed to assess the effects of the suggested communicative approaches. Until then, health-care providers may use our overview of communication strategies as a toolbox to optimize communication about uncertainty with patients. PATIENT OR PUBLIC CONTRIBUTION Results were presented to stakeholders (physicians) to check and improve their practical applicability.
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Affiliation(s)
- Niki M. Medendorp
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
| | - Anne M. Stiggelbout
- Medical Decision MakingDepartment of Biomedical Data SciencesLeiden University Medical CenterLeidenThe Netherlands
| | - Cora M. Aalfs
- Division of Biomedical GeneticsDepartment of GeneticsUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Paul K. J. Han
- Center for Outcomes Research and EvaluationMaine Medical Center Research InstitutePortlandMEUSA
| | - Ellen M. A. Smets
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
| | - Marij A. Hillen
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
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5
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van Someren JL, Lehmann V, Stouthard JM, Stiggelbout AM, Smets EMA, Hillen MA. Oncologists' Communication About Uncertain Information in Second Opinion Consultations: A Focused Qualitative Analysis. Front Psychol 2021; 12:635422. [PMID: 34135806 PMCID: PMC8201772 DOI: 10.3389/fpsyg.2021.635422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Uncertainty is omnipresent in cancer care, including the ambiguity of diagnostic tests, efficacy and side effects of treatments, and/or patients' long-term prognosis. During second opinion consultations, uncertainty may be particularly tangible: doubts and uncertainty may drive patients to seek more information and request a second opinion, whereas the second opinion in turn may also affect patients' level of uncertainty. Providers are tasked to clearly discuss all of these uncertainties with patients who may feel overwhelmed by it. The aim of this study was to explore how oncologists communicate about uncertainty during second opinion consultations in medical oncology. Methods: We performed a secondary qualitative analysis of audio-recorded consultations collected in a prospective study among cancer patients (N = 69) who sought a second opinion in medical oncology. We purposively selected 12 audio-recorded second opinion consultations. Any communication about uncertainty by the oncologist was double coded by two researchers and an inductive analytic approach was chosen to allow for novel insights to arise. Results: Seven approaches in which oncologists conveyed or addressed uncertainty were identified: (1) specifying the degree of uncertainty, (2) explaining reasons of uncertainty, (3) providing personalized estimates of uncertainty to patients, (4) downplaying or magnifying uncertainty, (5) reducing or counterbalancing uncertainty, and (6) providing support to facilitate patients in coping with uncertainty. Moreover, oncologists varied in their (7) choice of words/language to convey uncertainty (i.e., "I" vs. "we"; level of explicitness). Discussion: This study identified various approaches of how oncologists communicated uncertain issues during second opinion consultations. These different approaches could affect patients' perception of uncertainty, emotions provoked by it, and possibly even patients' behavior. For example, by minimizing uncertainty, oncologists may (un)consciously steer patients toward specific medical decisions). Future research is needed to examine how these different ways of communicating about uncertainty affect patients. This could also facilitate a discussion about the desirability of certain communication strategies. Eventually, practical and evidence-based guidance needs to be developed for clinicians to optimally inform patients about uncertain issues and support patients in dealing with these.
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Affiliation(s)
- Jamie L van Someren
- Department of Medical Psychology, Amsterdam Public Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Vicky Lehmann
- Department of Medical Psychology, Amsterdam Public Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | | | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam Public Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam Public Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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Wolff JL, Aufill J, Echavarria D, Blackford AL, Connolly RM, Fetting JH, Jelovac D, Papathakis K, Riley C, Stearns V, Zafman N, Thorner E, Levy HP, Guo A, Dy SM, Wolff AC. A randomized intervention involving family to improve communication in breast cancer care. NPJ Breast Cancer 2021; 7:14. [PMID: 33579966 PMCID: PMC7881185 DOI: 10.1038/s41523-021-00217-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 12/02/2020] [Indexed: 01/01/2023] Open
Abstract
We examined the effects of a communication intervention to engage family care partners on patient portal (MyChart) use, illness understanding, satisfaction with cancer care, and symptoms of anxiety in a single-blind randomized trial of patients in treatment for breast cancer. Patient-family dyads were recruited and randomly assigned a self-administered checklist to clarify the care partner role, establish a shared visit agenda, and facilitate MyChart access (n = 63) or usual care (n = 55). Interviews administered at baseline, 3, 9 (primary endpoint), and 12 months assessed anxiety (GAD-2), mean FAMCARE satisfaction, and complete illness understanding (4 of 4 items correct). Time-stamped electronic interactions measured MyChart use. By 9 months, more intervention than control care partners registered for MyChart (77.8 % vs 1.8%; p < 0.001) and logged into the patient’s account (61.2% vs 0% of those registered; p < 0.001), but few sent messages to clinicians (6.1% vs 0%; p = 0.247). More intervention than control patients viewed clinical notes (60.3% vs 32.7%; p = 0.003). No pre-post group differences in patient or care partner symptoms of anxiety, satisfaction, or complete illness understanding were found. Intervention patients whose care partners logged into MyChart were more likely to have complete illness understanding at 9 months (changed 70.0% to 80.0% vs 69.7% to 54.6%; p = 0.03); symptoms of anxiety were numerically lower (16.7% to 6.7% vs 15.2% to 15.2%; p = 0.24) and satisfaction numerically higher (15.8–16.2 vs 18.0–17.4; p = 0.25). A brief, scalable communication intervention led to greater care partner MyChart use and increased illness understanding among patients with more engaged care partners (NCT03283553).
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Affiliation(s)
- Jennifer L Wolff
- Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Jennifer Aufill
- Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Diane Echavarria
- Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Amanda L Blackford
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Roisin M Connolly
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - John H Fetting
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Danijela Jelovac
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Katie Papathakis
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carol Riley
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vered Stearns
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Nelli Zafman
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elissa Thorner
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Howard P Levy
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy Guo
- Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Sydney M Dy
- Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA.
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7
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Wolff JL, Scerpella D, Cockey K, Hussain N, Funkhouser T, Echavarria D, Aufill J, Guo A, Sloan DH, Dy SM, Smith KM. SHARING Choices: A Pilot Study to Engage Family in Advance Care Planning of Older Adults With and Without Cognitive Impairment in the Primary Care Context. Am J Hosp Palliat Care 2020; 38:1314-1321. [PMID: 33325729 DOI: 10.1177/1049909120978771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Few advance care planning (ACP) interventions proactively engage family or address the needs of older adults with and without cognitive impairment in the primary care context. OBJECTIVES To pilot a multicomponent intervention involving: an introductory letter describing a new clinic initiative and inviting patients to complete a patient-family pre-visit agenda-setting checklist, share their electronic health information with family, and talk about their wishes for future care with a trained ACP facilitator (SHARING Choices). METHODS SHARING Choices was delivered to 40 patient-family dyads from 3 primary care clinics. Facilitators completed post-ACP reports. Patient and family participants completed baseline and 6-week surveys. RESULTS Patients were on average 75 years (range 65-90). Family were spouses (85.0%) or adult children (15.0%). At 6 weeks, nearly half of dyads participated in ACP conversations (n = 19) or used the agenda-setting checklist (n = 17), one-third (n = 13) registered family to access the patient's portal account, and most (n = 28) provided the primary care team with a new or previously completed advance directive. Of 12 patients who screened positive for cognitive impairment, 9 completed ACP conversations and 10 provided the clinic with an advance directive. ACP engagement, measured on a 4-point scale, was comparatively lower at baseline and 6 weeks among family (3.05 and 3.19) than patients (3.56 and 3.54). Patients remarked that SHARING Choices clarified communication and preferences while family reported a better understanding of their role in ACP and communication. CONCLUSION SHARING Choices was acceptable among older adults with and without cognitive impairment and may increase advance directive completion.
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Affiliation(s)
- Jennifer L Wolff
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Danny Scerpella
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kimberly Cockey
- 121577MedStar Health Institute for Quality and Safety, MedStar Health System, Columbia, MD, USA
| | - Naaz Hussain
- 527470Johns Hopkins Community Physicians, Baltimore, MD, USA
| | - Tara Funkhouser
- 527470Johns Hopkins Community Physicians, Baltimore, MD, USA
| | - Diane Echavarria
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer Aufill
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amy Guo
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Danetta H Sloan
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Health, Behavior, and Society, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sydney M Dy
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kelly M Smith
- 121577MedStar Health Institute for Quality and Safety, MedStar Health System, Columbia, MD, USA
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Communication Tools to Support Advance Care Planning and Hospital Care During the COVID-19 Pandemic: A Design Process. Jt Comm J Qual Patient Saf 2020; 47:127-136. [PMID: 33191165 PMCID: PMC7584878 DOI: 10.1016/j.jcjq.2020.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022]
Abstract
The COVID-19 pandemic has exposed the medical and social vulnerability of an unprecedented number of people. Consequently, there has never been a more important time for clinicians to engage patients in advance care planning (ACP) discussions about their goals, values, and preferences in the event of critical illness. An evidence-based communication tool-the Serious Illness Conversation Guide-was adapted to address COVID-related ACP challenges using a user-centered design process: convening relevant experts to propose initial guide adaptations; soliciting feedback from key clinical stakeholders from multiple disciplines and geographic regions; and iteratively testing language with patient actors. With feedback focused on sharing risk about COVID-19-related critical illness, recommendations for treatment decisions, and use of person-centered language, the team also developed conversation guides for inpatient and outpatient use. These tools consist of open-ended questions to elicit perception of risk, goals, and care preferences in the event of critical illness, and language to convey prognostic uncertainty. To support use of these tools, publicly available implementation materials were also developed for clinicians to effectively engage high-risk patients and overcome challenges related to the changed communication context, including video demonstrations, telehealth communication tips, and step-by-step approaches to identifying high-risk patients and documenting conversation findings in the electronic health record. Well-designed communication tools and implementation strategies can equip clinicians to foster connection with patients and promote shared decision making. Although not an antidote to this crisis, such high-quality ACP may be one of the most powerful tools we have to prevent or ameliorate suffering due to COVID-19.
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9
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Paladino J, Brannen E, Benotti E, Henrich N, Ritchie C, Sanders J, Lakin JR. Implementing Serious Illness Communication Processes in Primary Care: A Qualitative Study. Am J Hosp Palliat Care 2020; 38:459-466. [PMID: 32794412 DOI: 10.1177/1049909120951095] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Primary care clinicians face barriers to engaging patients in conversations about prognosis, values, and goals ("serious illness conversations"). We introduced a structured, multi-component intervention, the Serious Illness Care Program (SICP), to facilitate conversations in the primary care setting. We present findings of a qualitative study to explore practical aspects of program implementation. METHODS We conducted semi-structured interviews of participating primary care physicians, nurse care coordinators, and social workers and coded transcripts to assess the activities used to integrate SICP into the workflow. RESULTS We conducted interviews with 14 of 46 clinicians from 6 primary care clinics, stopping with thematic saturation. Qualitative analysis revealed major themes around activities in the timing of the conversation (before, during, and after) and overarching insights about the program. Clinicians used a variety of strategies to adapt program components while preserving key program goals, including processes to generate accountability to ensure that conversations happen in busy clinical workflows. The interviews revealed changes to clinicians' mindset and norms, such as the recognition of the need to start conversations earlier in the illness course and the use of more expansive models of prognostic communication that address function and quality of life. Data also revealed indicators of sustainable behavior change and the spread of communication practices to patients outside the intended program scope. CONCLUSION SICP served as a framework for primary care clinicians to integrate serious illness communication into routine care. The shifts in processes employed by inter-professional clinicians revealed comprehensive models for prognostic communication and creative workflows to ensure that patients with complex illnesses had proactive, longitudinal, and patient-centered serious illness conversations and care planning.
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Affiliation(s)
- Joanna Paladino
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Elise Brannen
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily Benotti
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA
| | - Natalie Henrich
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA
| | - Christine Ritchie
- Harvard Medical School, Boston, MA, USA.,Division of Palliative Medicine, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Justin Sanders
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Psychosocial Oncology and Palliative Care, 1855Dana-Farber Cancer Institute, Boston, MA, USA
| | - Joshua R Lakin
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Psychosocial Oncology and Palliative Care, 1855Dana-Farber Cancer Institute, Boston, MA, USA
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10
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Liu Y, Zhang CW, Zhao XD. Long-term survival of femoral neck fracture patients aged over ninety years: Arthroplasty compared with nonoperative treatment. BMC Musculoskelet Disord 2020; 21:217. [PMID: 32268893 PMCID: PMC7140318 DOI: 10.1186/s12891-020-03249-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/27/2020] [Indexed: 02/08/2023] Open
Abstract
Background The aging of the Chinese population is expected to lead to an increase in nonagenarians and centenarians. The mortality rate in nonagenarian hip fracture patients is equivalent to the mortality rate in the average population at 5 years after injury. It is imperative to evaluate 5-year mortality in this small but very challenging subgroup of patients to optimize patient management. The primary purpose of the current retrospective study was to compare five-year survival in patients aged over 90 years who received arthroplasty or nonoperative treatment for femoral neck fracture during a 16-year period. Methods From January 1998 to December 2014, all consecutive nonagenarian and centenarian patients with femoral neck fracture admitted to our hospital were included in the evaluation. The primary outcome was defined as thirty-day, 1-year, 3-year, and 5-year mortality after injury. Survival analysis was performed with the Kaplan-Meier method. Using the log-rank test, stratified analyses were performed to compare differences in the overall cumulative mortality and mortality at three time points (1 year, 3 years, and 5 years) after injury and differences in survival distributions. Results Over the 16-year study period, the arthroplasty group and the nonoperative treatment group included 33 and 53 patients, respectively. The long-term survival probability of the arthroplasty group was significantly higher than that of the nonoperative treatment group (p = 0.002). The survival time of the arthroplasty group was significantly higher than that of the nonoperative treatment group (median (P75-P25) = 53 (59) versus median (P75-P25) = 22 (52), p = 0.001). The mortality differences, except for 30-day mortality, at five time points (1, 2, 3, 4, and 5 years) between the nonoperative group and arthroplasty group were significant. The stratified analyses of overall cumulative mortality and mortality at three time points (1, 3, and 5 years) after injury demonstrated that the nonoperative treatment group had significantly higher cumulative mortality than the arthroplasty group. Conclusions Our study demonstrates that arthroplasty is more likely to improve long-term survival in femoral neck fracture patients aged over 90 years than nonoperative treatment. It can be expected that nearly half of patients will survive more than 5 years after surgery.
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Affiliation(s)
- Yang Liu
- Department of Orthopedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Wai Nan Guo Xue Lane No. 37, Wuhou District, Chengdu, Sichuan Province, P.R. China, 610041.
| | - Chong-Wei Zhang
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Wai Nan Guo Xue Lane No. 37, Wuhou District, Chengdu, Sichuan Province, P.R. China, 610041
| | - Xiao-Dan Zhao
- Department of Orthopedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Wai Nan Guo Xue Lane No. 37, Wuhou District, Chengdu, Sichuan Province, P.R. China, 610041
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11
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Wolff JL, Aufill J, Echavarria D, Heughan JA, Lee KT, Connolly RM, Fetting JH, Jelovac D, Papathakis K, Riley C, Stearns V, Thorner E, Zafman N, Levy HP, Dy SM, Wolff AC. Sharing in care: engaging care partners in the care and communication of breast cancer patients. Breast Cancer Res Treat 2019; 177:127-136. [PMID: 31165374 PMCID: PMC6640103 DOI: 10.1007/s10549-019-05306-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Family is often overlooked in cancer care. We developed a patient-family agenda setting intervention to engage family in cancer care communication. METHODS We conducted a pilot randomized controlled trial (NCT03283553) of patients on active treatment for breast cancer and their family "care partner." Intervention dyads (n = 69) completed a self-administered checklist to clarify care partner roles, establish a shared visit agenda, and facilitate MyChart patient portal access. Control dyads (n = 63) received usual care. We assessed intervention acceptability and initial effects from post-visit surveys and MyChart utilization at 6 weeks. RESULTS At baseline, most patients (89.4%) but few care partners (1.5%) were registered for MyChart. Most patients (79.4%) wanted their care partner to have access to their records and 39.4% of care partners reported accessing MyChart. In completing the checklist, patients and care partners endorsed active communication roles for the care partner and identified a similar visit agenda: most (> 90%) reported the checklist was easy, useful, and recommended it to others. At 6 weeks, intervention (vs control) care partners were more likely to be registered for MyChart (75.4% vs 1.6%; p < 0.001), to have logged in (43.5% vs 0%; p < 0.001) and viewed clinical notes (30.4% vs 0%; p < 0.001), but were no more likely to exchange direct messages with clinicians (1.5% vs 0%; p = 0.175). No differences in patients' MyChart use were observed, but intervention patients more often viewed clinical notes (50.7% vs 9.5%; p < 0.001). CONCLUSIONS A patient-family agenda setting intervention was acceptable and affected online practices of cancer patients and care partners.
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Affiliation(s)
- Jennifer L Wolff
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 692, Baltimore, MD, 21205, USA.
| | - Jennifer Aufill
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 692, Baltimore, MD, 21205, USA
| | - Diane Echavarria
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 692, Baltimore, MD, 21205, USA
| | - JaAlah-Ai Heughan
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 692, Baltimore, MD, 21205, USA
| | - Kimberley T Lee
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, 201 N. Broadway, Viragh 10-289, Baltimore, MD, 21287, USA
| | - Roisin M Connolly
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, 201 N. Broadway, Viragh 10-289, Baltimore, MD, 21287, USA
| | - John H Fetting
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, 201 N. Broadway, Viragh 10-289, Baltimore, MD, 21287, USA
| | - Danijela Jelovac
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, 201 N. Broadway, Viragh 10-289, Baltimore, MD, 21287, USA
| | - Katie Papathakis
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, 201 N. Broadway, Viragh 10-289, Baltimore, MD, 21287, USA
| | - Carol Riley
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, 201 N. Broadway, Viragh 10-289, Baltimore, MD, 21287, USA
| | - Vered Stearns
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, 201 N. Broadway, Viragh 10-289, Baltimore, MD, 21287, USA
| | - Elissa Thorner
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, 201 N. Broadway, Viragh 10-289, Baltimore, MD, 21287, USA
| | - Nelli Zafman
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, 201 N. Broadway, Viragh 10-289, Baltimore, MD, 21287, USA
| | - Howard P Levy
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sydney M Dy
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 692, Baltimore, MD, 21205, USA
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA.
- Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, 201 N. Broadway, Viragh 10-289, Baltimore, MD, 21287, USA.
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Abstract
PURPOSE OF REVIEW A patient's prognosis and risk of adverse drug effects are important considerations for individualizing care of older patients with diabetes. This review summarizes the evidence for risk assessment and proposes approaches for clinicians in the context of current clinical guidelines. RECENT FINDINGS Diabetes guidelines vary in their recommendations for how life expectancy should be estimated and used to inform the selection of glycemic targets. Readily available prognostic tools may improve estimation of life expectancy but require validation among patients with diabetes. Treatment decisions based on prognosis are difficult for clinicians to communicate and for patients to understand. Determining hypoglycemia risk involves assessing major risk factors; models to synthesize these factors have been developed. Applying risk assessment to individualize diabetes care is complex and currently relies heavily on clinician judgment. More research is need to validate structured approaches to risk assessment and determine how to incorporate them into patient-centered diabetes care.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA.
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elbert S Huang
- Division of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
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13
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Moré JM, Lang-Brown S, Romo RD, Lee SJ, Sudore R, Smith AK. "Planting the Seed": Perceived Benefits of and Strategies for Discussing Long-Term Prognosis with Older Adults. J Am Geriatr Soc 2018; 66:2367-2371. [PMID: 30347432 PMCID: PMC6365284 DOI: 10.1111/jgs.15524] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/01/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To characterize the goals and approaches of clinicians with experience discussing long-term prognostic information with older adults. DESIGN We used a semistructured interview guide containing 2 domains of perceived benefits and strategies to explore why and how clinicians choose to discuss long-term prognosis, defined as life expectancy on the scale of years, with patients. SETTING Clinicians from home-based primary care practices, community-based clinics, and academic medical centers across San Francisco. PARTICIPANTS Fourteen physicians, including 11 geriatricians and 1 geriatric nurse practitioner, with a mean age of 40 and a mean 9 years in practice. MEASUREMENTS Clinician responses were analyzed qualitatively using the constant comparisons approach. RESULTS Perceived benefits of discussing long-term prognosis included establishing realistic expectations for patients, encouraging conversations about future planning, and promoting shared decision-making through understanding of patient goals of care. Communication strategies included adapting discussions to individual patient preferences and engaging in multiple conversations over time. Clinicians preferred to communicate prognosis in words and with a visual aid, although most did not know of a suitable visual aid. CONCLUSION Engaging in customized longitudinal discussions of long-term prognosis aids clinicians in anchoring conversations about future planning and preparing patients for the end of life. J Am Geriatr Soc 66:2367-2371, 2018.
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Affiliation(s)
| | - Sean Lang-Brown
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Rafael D Romo
- School of Nursing, University of Virginia, Charlottesville, VA
| | - Sei J Lee
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
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