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Tessaro I, Hooper SM, Watt D, Menestres D, Farrell D. Development of an online tool to support financial and legal planning in dementia. PEC INNOVATION 2024; 5:100312. [PMID: 39035235 PMCID: PMC11259804 DOI: 10.1016/j.pecinn.2024.100312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 05/16/2024] [Accepted: 06/20/2024] [Indexed: 07/23/2024]
Abstract
Objective To develop, assess, and refine an online educational tool, Plan for Clarity, to support financial and legal planning in dementia. Methods A Delphi mixed-method study with three rounds of anonymous review by lay and professional stakeholders was designed to reach consensus about the content of the online tool and explore the socio-cultural and behavioral factors that could affect access and use. Results Consensus showed that the online tool covered key information, knowledge, and communication skills for financial and legal planning. Study themes: 1) the online tool had to be easy to navigate with relevant, easily understood information; 2) people with early signs of memory difficulties would be able to use the tool; 3) a referral from a trusted source is a primary way to facilitate access and use of the tool; and 4) discussions about financial and legal issues should be held early, ahead of barriers that can block discussion. Conclusion These data suggest this online tool is relevant and feasible for dementia care and support as well as aging more generally. Innovation Plan for Clarity is innovative as an evidence and theory-driven online education tool to address financial and legal planning for dementia care, particularly among underserved older adults.
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Affiliation(s)
- Irene Tessaro
- People Designs, Inc, 1304 Broad St., Durham, NC 27705, USA
| | - Sarah M. Hooper
- UC College of the Law San Francisco, 200 McAllister St., San Francisco, CA 94102, USA
| | - Denise Watt
- UC College of the Law San Francisco, 200 McAllister St., San Francisco, CA 94102, USA
| | | | - David Farrell
- People Designs, Inc, 1304 Broad St., Durham, NC 27705, USA
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2
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Brown C, Khan S, Parekh TM, Muir AJ, Sudore RL. Barriers and Strategies to Effective Serious Illness Communication for Patients with End-Stage Liver Disease in the Intensive Care Setting. J Intensive Care Med 2024:8850666241280892. [PMID: 39247992 DOI: 10.1177/08850666241280892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
Background: Patients with end-stage liver disease (ESLD) often require Intensive Care Unit (ICU) admission during the disease trajectory, but aggressive medical treatment has not resulted in increased quality of life for patients or caregivers. Methods: This narrative review synthesizes relevant data thematically exploring the current state of serious illness communication in the ICU with identification of barriers and potential strategies to improve performance. We provide a conceptual model underscoring the importance of providing comprehensible disease and prognosis knowledge, eliciting patient values and aligning these values with available goals of care options through a series of discussions. Achieving effective serious illness communication supports the delivery of goal concordant care (care aligned with the patient's stated values) and improved quality of life. Results: General barriers to effective serious illness communication include lack of outpatient serious illness communication discussions; formalized provider training, literacy and culturally appropriate patient-directed serious illness communication tools; and unoptimized electronic health records. ESLD-specific barriers to effective serious illness communication include stigma, discussing the uncertainty of prognosis and provider discomfort with serious illness communication. Evidence-based strategies to address general barriers include using the Ask-Tell-Ask communication framework; clinician training to discuss patients' goals and expectations; PREPARE for Your Care literacy and culturally appropriate written and online tools for patients, caregivers, and clinicians; and standardization of documentation in the electronic health record. Evidence-based strategies to address ESLD-specific barriers include practicing with empathy; using the "Best-Case, Worst Case" prognostic framework; and developing interdisciplinary solutions in the ICU. Conclusion: Improving clinician training, providing patients and caregivers easy-to-understand communication tools, standardizing EHR documentation, and improving interdisciplinary communication, including palliative care, may increase goal concordant care and quality of life for critically ill patients with ESLD.
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Affiliation(s)
- Cristal Brown
- Department of Medicine, University of Texas at Austin, Dell Medical School, Austin, TX, USA
- Department of Medicine, Ascension Seton and Seton Family of Doctors, Austin, TX, USA
| | - Saif Khan
- Department of Medicine, University of Texas at Austin, Austin, TX, USA
| | - Trisha M Parekh
- Department of Medicine, University of Texas at Austin, Dell Medical School, Austin, TX, USA
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
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Yamarik RL, Cacciata M, Chen JLT, Ballard-Hernandez J, Gupta P, Pirverdian A, Tonthat S, Fernandez J, Sudore RL. Feasibility of Nurse-Facilitated Advance Care Planning Among Older Veterans in a Dialysis Unit and an Oncology Infusion Center. Mil Med 2024:usae388. [PMID: 39212935 DOI: 10.1093/milmed/usae388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/19/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Many veterans with serious illnesses, such as end-stage kidney disease requiring dialysis and advanced cancer requiring treatment infusions, must make complex decisions about their current and future medical care. Advance care planning (ACP) is a process where individuals identify, express, and communicate their personal values, life goals, and preferences for care. ACP may be feasible in chemotherapy infusion centers or chronic dialysis centers during patient treatment. MATERIALS AND METHODS We assessed the feasibility of a licensed vocational nurse (LVN) facilitator to help veterans review the PREPARE for Your Care program (www.prepareforyourcare.org) and complete an advance directive (AD) in an outpatient hemodialysis unit or a chemotherapy infusion center. PREPARE For Your Care is an evidence-based online program with written pamphlets and ADs that prepares patients to participate with clinicians in making medical decisions. We measured the time to complete a session and the level of assistance required from LVNs via LVN self-report. Self-reported ease-of-use, comfort, and helpfulness were assessed on a 10-point Likert scale from 1 (not at all) to 10 (very). RESULTS Twenty-eight patients were enrolled (mean age ± SD: 67 ± 11 years); all (100%) completed PREPARE and the AD within 1 session. The mean completion time was 100 (±40) minutes. Most of the patients required considerable assistance from the LVN. The mean scores were 8.0 of 10 for ease-of-use (±2.3), 7.7 of 10 (±2.8) for comfort, and 8.2 of 10 (±2.3) for helpfulness. CONCLUSIONS This pilot study demonstrates that using PREPARE as an ACP tool for veterans may be feasible for patients during hemodialysis and chemotherapy infusion. Patients required considerable assistance from the LVN to complete PREPARE. Hemodialysis and chemotherapy infusion are opportunities when patients have time and space to consider ACP.
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Affiliation(s)
- Rebecca Liddicoat Yamarik
- Department of Medicine, Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA
- Department of Medicine, University of California, Irvine, Orange, CA 92868, USA
| | - Marysol Cacciata
- Department of Medicine, Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA
| | - Joline L T Chen
- Department of Medicine, Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA
- Department of Medicine, University of California, Irvine, Orange, CA 92868, USA
| | - Jennifer Ballard-Hernandez
- Department of Medicine, Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA
- Department of Medicine, University of California, Irvine, Orange, CA 92868, USA
| | - Pankaj Gupta
- Department of Medicine, Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA
| | - Ateena Pirverdian
- Department of Medicine, Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA
- Department of Medicine, University of California, Irvine, Orange, CA 92868, USA
| | - Sam Tonthat
- Department of Medicine, Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA
- Department of Medicine, University of California, Irvine, Orange, CA 92868, USA
| | - Jocell Fernandez
- Department of Medicine, Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA
| | - Rebecca L Sudore
- Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, CA 94121, USA
- Department of Medicine, University of California, San Francisco, CA 94143, USA
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Ferguson CM, Gilissen J, Scheerens C, Volow A, Powell J, Shi Y, McMahan R, Barnes D, Sudore RL. Action plans increase advance care planning documentation and engagement among English and Spanish-speaking older adults. J Am Geriatr Soc 2024. [PMID: 39126153 DOI: 10.1111/jgs.19127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Advance care planning (ACP) has been reconceptualized as a health behavior. Action plans (APs), or patient-directed mini contracts, improve behavior change. However, no prior studies have assessed whether APs can increase ACP documentation and engagement. METHODS We included English and Spanish-speaking primary care patients from San Francisco, ≥55 years of age, with ≥2 serious or chronic illnesses. Participants were in the intervention arm of the PREPAREforYOURcare.org trial and asked at baseline to choose 1 of 5 actions (e.g., choose a surrogate). At 6 months, we assessed whether participants completed their AP and if completion was associated with demographics, electronic health record (EHR) ACP documentation, and five-point ACP Engagement Survey scores. We used t-tests, chi-squared, multivariate analysis adjusted for baseline ACP and clustering by physician, and qualitative thematic analysis to explore reasons for non-completion. RESULTS The mean age of 586 participants was 65 ± 10 years; 44.0% women, 45.9% Spanish-speaking, 31.4% had limited health literacy, and 43% completed an AP at 6 months; surrogate-related (47.4%), tell others about medical wishes (33.7%), ask clinicians questions (13.7%), and decide what matters most in life (5.2%). Participants with limited versus adequate health literacy were less likely to complete an AP (25.4% vs 35.9%, p = 0.01). Completing an AP was associated with greater ACP EMR documentation 49.8% vs 35.6%, p < 0.001 (adjusted odds ratio: 2.06; 95% CI [1.43-2.97]) and engagement (adjusted five-point scores [3.69; 95% CI 3.57-3.81 vs 3.10; 95% CI: 2.98-3.21], p < 0.001). Themes for non-completion included not being ready and logistical issues (e.g., surrogate deceased). CONCLUSIONS Among English and Spanish-speaking older adults, creating an ACP AP resulted in greater documentation and engagement. APs may help facilitate ACP behavior change as part of effective ACP interventions. Additional support may be needed for patients with limited health literacy and those facing logistical barriers.
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Affiliation(s)
- Clarissa M Ferguson
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Joni Gilissen
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Charlotte Scheerens
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Aiesha Volow
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco VA Medical Center, San Francisco, California, USA
| | - Jana Powell
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Ying Shi
- San Francisco VA Medical Center, San Francisco, California, USA
| | - Ryan McMahan
- San Francisco VA Medical Center, San Francisco, California, USA
| | - Deborah Barnes
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco VA Medical Center, San Francisco, California, USA
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Riley SR, Voisin C, Stevens EE, Bose-Brill S, Moss KO. Tools for tomorrow: a scoping review of patient-facing tools for advance care planning. Palliat Care Soc Pract 2024; 18:26323524241263108. [PMID: 39045292 PMCID: PMC11265253 DOI: 10.1177/26323524241263108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/03/2024] [Indexed: 07/25/2024] Open
Abstract
Advance care planning (ACP) supports individuals in aligning their medical care with personal values and preferences in the face of serious illness. The variety of ACP tools available reflects diverse strategies intended to facilitate these critical conversations, yet evaluations of their effectiveness often show mixed results. Following the Arskey and O'Malley framework, this scoping review aims to synthesize the range of ACP tools targeted at patients and families, highlighting their characteristics and delivery methods to better understand their impact and development over time. Studies included focused on patient-facing ACP tools across all settings and mediums. Exclusions were applied to studies solely targeting healthcare providers or those only aiming at completion of advance directives without broader ACP discussions. Searches were conducted across PubMed, Embase, CINAHL, The Cochrane Library, and Web of Science. Data were extracted using a predesigned spreadsheet, capturing study population, setting, intervention modality, and intervention theme. Tools were categorized by delivery method and further analyzed through a year-wise distribution to track trends and developments. We identified 99 unique patient-facing tools, with those focusing on counseling (31) and video technologies (21) being the most prevalent while others incorporated online platforms, print materials, games, or some combination of different delivery methods. Over half the tools were designed for specific patient groups, especially for various diseases and racial or ethnic communities. Recent years showed a surge in tool variety and innovation, including integrated patient portals and psychological techniques. The review demonstrates a broad array of innovative ACP tools that facilitate personalized and effective ACP. Our findings contribute to an enhanced understanding of their utilization and potential impacts, offering valuable insights for future tool development and policy making in ACP.
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Affiliation(s)
- Sean R. Riley
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus, OH 43215, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Christiane Voisin
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Erin E. Stevens
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- The James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Karen O. Moss
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Healthy Aging, Self-Management, and Complex Care, The Ohio State University College of Nursing, Columbus, OH, USA
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Meyer S, Yoo-Jeong M. A systematic review on advance care planning for people living with HIV: insights from the studies of persons without HIV. AIDS Care 2024:1-14. [PMID: 38838033 DOI: 10.1080/09540121.2024.2361822] [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: 08/31/2023] [Accepted: 05/24/2024] [Indexed: 06/07/2024]
Abstract
With advances in medicine, HIV has evolved into a chronic condition for people living with HIV (PLWH). However, many PLWH do not engage in advance care planning (ACP), and it occurs primarily in acute situations. ACP may improve preparedness for end-of-life care and increase advance directive (AD) documentation. Searches of PubMed, PsycInfo, and CINHAL were conducted to synthesize current ACP-related randomized controlled trials on two separate populations: (1) PLWH and (2) older adults without HIV. Two articles met inclusion criteria for PLWH, and the intervention had a significant improvement in ACP engagement. For the latter population, thirteen of fourteen articles had interventions that led to statistically significant increases in ACP engagement. This review underscores the need to further investigate the best strategies to improve ACP among PLWH and provides insights from existing ACP interventions for the general population to be adapted to the needs of PLWH.
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Affiliation(s)
- Sabrina Meyer
- School of Nursing, Northeastern University, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Moka Yoo-Jeong
- School of Nursing, Northeastern University, Boston, MA, USA
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Fischer SM, Min SJ, Kline DM, Lester K, Gozansky W, Schifeling C, Himberger J, Lopez J, Fink RM. Patient Navigator Intervention to Improve Palliative Care Outcomes for Hispanic Patients With Serious Noncancer Illness: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:384-393. [PMID: 38345793 PMCID: PMC10862271 DOI: 10.1001/jamainternmed.2023.8145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/08/2023] [Indexed: 02/15/2024]
Abstract
Importance Disparities persist across the trajectory of serious illness, including at the end of life. Patient navigation has been shown to reduce disparities and improve outcomes for underserved populations. Objective To determine the effectiveness of a lay patient navigator intervention, Apoyo con Cariño, in improving palliative care outcomes among Hispanic patients. Design, Setting, and Participants This was a multicenter randomized clinical trial that took place across academic, nonprofit, safety-net, and community health care systems in urban, rural, and mountain/frontier regions of Colorado from January 2017 to January 2021. Self-identifying Hispanic adults with serious noncancer medical illness and limited prognosis were recruited. Data were collected and analyzed from July 2022 to July 2023. Interventions Participants randomized to the intervention group received 5 home visits from a bilingual, bicultural lay patient navigator; participants randomized to control received care as usual. Both groups received culturally tailored educational materials. Investigators/outcome accessors remained blinded to participant assignment. Main Outcomes and Measures Change in score from baseline to 3 months on the Functional Assessment of Chronic Illness Therapy (FACIT) General quality of life (QOL) scale (primary outcome), Advance Care Planning (ACP) Engagement Survey, Brief Pain Inventory, Edmonton Symptom Assessment Scale, and FACIT Spiritual Well-Being subscale; at 6 months, advance directive (AD) documentation; and at 46 months or death, hospice utilization and length of stay, as well as aggressiveness of care at end of life. Results Of 209 patients enrolled (mean [SD] age, 63.6 [14.3] years; 108 [51.7%] male), 105 patients were randomized to control and 104 patients to the intervention. There were no statistically significant differences in the change in mean (SD) QOL score between the intervention and control groups (5.0 [16.5] vs 4.3 [15.5]; P = .75). Participants in the intervention group, compared with the control group, had statistically significant greater increases in mean (SD) ACP engagement (0.8 [1.3] vs 0.1 [1.4]; P < .001) and were more likely to have a documented AD (62 of 104 [59.6%] vs 28 of 105 [26.9%]; P < .001). There were no statistically significant differences in mean (SD) change in pain intensity score (0-10) between patients in the intervention group compared with control (-0.4 [2.6] vs -0.5 [2.8]; P = .79), nor pain interference (-0.2 [3.7] vs -0.4 [3.7]; P = .71). Patients receiving the intervention were more likely to be referred to hospice compared with patients receiving control (19 of 43 patients [44.2%] vs 7 of 33 patients [21.2%]; P = .04) and less likely to receive aggressive care at end of life (27 of 42 patients [64.3%] vs 28 of 33 patients [84.8%]; P = .046). Conclusion and Relevance In this randomized clinical trial, a culturally tailored patient navigator intervention did not improve QOL for patients. However, the intervention did increase ACP engagement, AD documentation, and hospice utilization in Hispanic persons with serious medical illness. Trial Registration ClinicalTrials.gov Identifier: NCT03181750.
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Affiliation(s)
- Stacy M. Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | | | | | | | | | | | | | - Joseph Lopez
- University of Colorado Health North, Fort Collins
| | - Regina M. Fink
- University of Colorado School of Medicine, Aurora
- University of Colorado College of Nursing, Aurora
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Murray SA, Boyd K, Moine S, Kendall M, Macpherson S, Mitchell G, Amblàs-Novellas J. Using illness trajectories to inform person centred, advance care planning. BMJ 2024; 384:e067896. [PMID: 38428953 DOI: 10.1136/bmj-2021-067896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Affiliation(s)
- Scott A Murray
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Kirsty Boyd
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Sebastien Moine
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
- Health Education and Practices Laboratory, University of Paris 13, Bobigny, France
| | - Marilyn Kendall
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Stella Macpherson
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
- patient author, UK
| | | | - Jordi Amblàs-Novellas
- Central Catalonia Chronicity Research Group, Faculty of Medicine, University of Vic-Central University of Catalonia, 08500 Vic, Spain
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McMahan RD, Hickman SE, Sudore RL. What Clinicians and Researchers Should Know About the Evolving Field of Advance Care Planning: a Narrative Review. J Gen Intern Med 2024; 39:652-660. [PMID: 38169025 PMCID: PMC10973287 DOI: 10.1007/s11606-023-08579-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
Advance care planning (ACP) has been recognized as crucial by patients, families, and clinicians; however, different definitions and measurements have led to inconsistencies in practice and mixed evidence in the literature. This narrative review explores ACP's evolution, innovations, and outcomes using thematic analysis to synthesize data from randomized controlled trials, reviews, and editorials. Key findings include (1) ACP has evolved over the past several decades from a sole focus on code status and advance directive (AD) forms to a continuum of care planning over the life course focused on tailored preparation for patients and surrogate decision-makers and (2) ACP measurement has evolved from traditional outcome metrics, such as AD completion, to a comprehensive outcomes framework that includes behavior change theory, systems, implementation science, and a focus on surrogate outcomes. Since the recent development of an ACP consensus definition and outcomes framework, high-quality trials have reported mainly positive outcomes for interventions, especially for surrogates, which aligns with the patient desire to relieve decision-making burden for loved ones. Additionally, measurement of "clinically meaningful" ACP information, including documented goals of care discussions, is increasingly being integrated into electronic health records (EHR), and emerging, real-time assessments and natural language processing are enhancing ACP evaluation. To make things easier for patients, families, and care teams, clinicians and researchers can use and disseminate these evolved definitions; provide patients validated, easy-to-use tools that prime patients for conversations and decrease health disparities; use easy-to-access clinician training and simple scripts for interdisciplinary team members; and document patients' values and preferences in the medical record to capture clinically meaningful ACP so this information is available at the point of care. Future efforts should focus on efficient implementation, expanded reimbursement options, and seamless integration of EHR documentation to ensure ACP's continued evolution to better serve patients and their care partners.
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Affiliation(s)
- Ryan D McMahan
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Veterans Administration Medical Center, San Francisco, CA, USA.
| | - Susan E Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
- Indiana University Center for Aging Research, Regenstrief Institute Inc, Indianapolis, IN, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Veterans Administration Medical Center, San Francisco, CA, USA
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Baumeister A, Aldin A, Chakraverty D, Hübner C, Adams A, Monsef I, Skoetz N, Kalbe E, Woopen C. Interventions for improving health literacy in migrants. Cochrane Database Syst Rev 2023; 11:CD013303. [PMID: 37963101 PMCID: PMC10645402 DOI: 10.1002/14651858.cd013303.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
BACKGROUND Health literacy (HL) is a determinant of health and important for autonomous decision-making. Migrants are at high risk for limited HL. Improving HL is important for equitable promotion of migrants' health. OBJECTIVES To assess the effectiveness of interventions for improving HL in migrants. To assess whether female or male migrants respond differently to the identified interventions. SEARCH METHODS We ran electronic searches to 2 February 2022 in CENTRAL, MEDLINE, Embase, PsycInfo and CINAHL. We also searched trial registries. We used a study filter for randomised controlled trials (RCTs) (RCT classifier). SELECTION CRITERIA We included RCTs and cluster-RCTs addressing HL either as a concept or its components (access, understand, appraise, apply health information). DATA COLLECTION AND ANALYSIS We used the methodological procedures recommended by Cochrane and followed the PRISMA-E guidelines. Outcome categories were: a) HL, b) quality of life (QoL), c) knowledge, d) health outcomes, e) health behaviour, f) self-efficacy, g) health service use and h) adverse events. We conducted meta-analysis where possible, and reported the remaining results as a narrative synthesis. MAIN RESULTS We included 28 RCTs and six cluster-RCTs (8249 participants), all conducted in high-income countries. Participants were migrants with a wide range of conditions. All interventions were adapted to culture, language and literacy. We did not find evidence that HL interventions cause harm, but only two studies assessed adverse events (e.g. anxiety). Many studies reported results for short-term assessments (less than six weeks after total programme completion), reported here. For several comparisons, there were also findings at later time points, which are presented in the review text. Compared with no HL intervention (standard care/no intervention) or an unrelated HL intervention (similar intervention but different information topic) Self-management programmes (SMP) probably improve self-efficacy slightly (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.50; 2 studies, 333 participants; moderate certainty). SMP may improve HIV-related HL (understanding (mean difference (MD) 4.25, 95% CI 1.32 to 7.18); recognition of HIV terms (MD 3.32, 95% CI 1.28 to 5.36)) (1 study, 69 participants). SMP may slightly improve health behaviours (3 studies, 514 participants), but may have little or no effect on knowledge (2 studies, 321 participants) or subjective health status (MD 0.38, 95% CI -0.13 to 0.89; 1 study, 69 participants) (low certainty). We are uncertain of the effects of SMP on QoL, health service use or adverse events due to a lack of evidence. HL skills building courses (HLSBC) may improve knowledge (MD 10.87, 95% CI 5.69 to 16.06; 2 studies, 111 participants) and any generic HL (SMD 0.48, 95% CI 0.20 to 0.75; 2 studies, 229 participants), but may have little or no effect on depression literacy (MD 0.17, 95% CI -1.28 to 1.62) or any health behaviour (2 studies, 229 participants) (low certainty). We are uncertain if HLSBC improve QoL, health outcomes, health service use, self-efficacy or adverse events, due to very low-certainty or a lack of evidence. Audio-/visual education without personal feedback (AVE) probably improves depression literacy (MD 8.62, 95% CI 7.51 to 9.73; 1 study, 202 participants) and health service use (MD -0.59, 95% CI -1.11 to -0.07; 1 study, 157 participants), but probably has little or no effect on health behaviour (risk ratio (RR) 1.07, 95% CI 0.91 to 1.25; 1 study, 135 participants) (moderate certainty). AVE may improve self-efficacy (MD 3.51, 95% CI 2.53 to 4.49; 1 study, 133 participants) and may slightly improve knowledge (MD 8.44, 95% CI -2.56 to 19.44; 2 studies, 293 participants) and intention to seek depression treatment (MD 1.8, 95% CI 0.43 to 3.17), with little or no effect on depression (SMD -0.15, 95% CI -0.40 to 0.10) (low certainty). No evidence was found for QoL and adverse events. Adapted medical instruction may improve understanding of health information (3 studies, 478 participants), with little or no effect on medication adherence (MD 0.5, 95% CI -0.1 to 1.1; 1 study, 200 participants) (low certainty). No evidence was found for QoL, health outcomes, knowledge, health service use, self-efficacy or adverse events. Compared with written information on the same topic SMP probably improves health numeracy slightly (MD 0.7, 95% CI 0.15 to 1.25) and probably improves print literacy (MD 9, 95% CI 2.9 to 15.1; 1 study, 209 participants) and self-efficacy (SMD 0.47, 95% CI 0.3 to 0.64; 4 studies, 552 participants) (moderate certainty). SMP may improve any disease-specific HL (SMD 0.67, 95% CI 0.27 to 1.07; 4 studies, 955 participants), knowledge (MD 11.45, 95% CI 4.75 to 18.15; 6 studies, 1101 participants) and some health behaviours (4 studies, 797 participants), with little or no effect on health information appraisal (MD 1.15, 95% CI -0.23 to 2.53; 1 study, 329 participants) (low certainty). We are uncertain whether SMP improves QoL, health outcomes, health service use or adverse events, due to a lack of evidence or low/very low-certainty evidence. AVE probably has little or no effect on diabetes HL (MD 2, 95% CI -0.15 to 4.15; 1 study, 240 participants), but probably improves information appraisal (MD -9.88, 95% CI -12.87 to -6.89) and application (RR 1.51, 95% CI 1.29 to 1.77) (1 study, 608 participants; moderate certainty). AVE may slightly improve knowledge (MD 8.35, 95% CI -0.32 to 17.02; low certainty). No short-term evidence was found for QoL, depression, health behaviour, self-efficacy, health service use or adverse events. AVE compared with another AVE We are uncertain whether narrative videos are superior to factual knowledge videos as the evidence is of very low certainty. Gender differences Female migrants' diabetes HL may improve slightly more than that of males, when receiving AVE (MD 5.00, 95% CI 0.62 to 9.38; 1 study, 118 participants), but we do not know whether female or male migrants benefit differently from other interventions due to very low-certainty or a lack of evidence. AUTHORS' CONCLUSIONS Adequately powered studies measuring long-term effects (more than six months) of HL interventions in female and male migrants are needed, using well-validated tools and representing various healthcare systems.
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Affiliation(s)
- Annika Baumeister
- Center for Life Ethics/Hertz Chair TRA 4, University of Bonn, Bonn, Germany
| | - Angela Aldin
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Digo Chakraverty
- Medical Psychology, Neuropsychology and Gender Studies and Center for Neuropsychological Diagnostics and Intervention (CeNDI), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Constanze Hübner
- Center for Life Ethics/Hertz Chair TRA 4, University of Bonn, Bonn, Germany
| | - Anne Adams
- Institute of Medical Statistics and Computational Biology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nicole Skoetz
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Elke Kalbe
- Medical Psychology, Neuropsychology and Gender Studies and Center for Neuropsychological Diagnostics and Intervention (CeNDI), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Christiane Woopen
- Center for Life Ethics/Hertz Chair TRA 4, University of Bonn, Bonn, Germany
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11
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Gelfman LP, Barnes DE, Goldstein N, Volow AM, Shi Y, Li B, Sudore RL. Quality and Satisfaction With Advance Care Planning Conversations Among English- and Spanish-Speaking Older Adults. J Palliat Med 2023; 26:1380-1385. [PMID: 37335910 PMCID: PMC10551762 DOI: 10.1089/jpm.2022.0565] [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] [Accepted: 04/17/2023] [Indexed: 06/21/2023] Open
Abstract
Background: Little is known about the patient-reported quality of and satisfaction with advance care planning (ACP) conversations with surrogates and clinicians among English- and Spanish-speaking older adults, or the potential disparities associated with ACP communication satisfaction. Objectives: To determine patients' perceived quality of and satisfaction with ACP surrogate/clinician conversations and associated patient characteristics. Design: Cross-sectional baseline data were used from two ACP trials, 2013-2017. Outcomes included self-reported ACP conversation quality ("general" vs. "detailed") and communication satisfaction (5-point Likert scale). Associations were determined by chi-squared and t-tests. Setting/Subjects: Subjects were primary care patients ≥55 years with chronic/serious illness in the United States. Results: Of 1398 patients, mean age was 65.6 years (±7.7), 46% women, 32% Spanish speaking, 34% had limited health literacy, and 589 (42%) reported conversations with surrogates and 216 (15%) with clinicians. Of these, less than half rated the conversations as detailed high quality (clinician: 43%; surrogate: 37%). Five-point communication satisfaction scores were higher with detailed versus general conversations (e.g., surrogates: 4.4 vs. 4.1, p = 0.001; clinicians: 4.4 vs. 4.2, p = 0.18) and more often reported by men versus women [(4.4 (0.8) vs. 4.0 (1.0), p = 0.003]; those with adequate versus limited health literacy [4.4 (0.8) vs. 4.0 (0.9), p = 0.002]; and English versus Spanish speakers [4.5 (0.7) vs. 3.5 (0.9), p < 0.001]. Conclusions: Among English- and Spanish-speaking older adults, ACP conversations were infrequent and most were general in quality. Higher quality detailed conversations resulted in greater communication satisfaction. Interventions are needed to improve conversation quality, particularly for Spanish-speaking patients and those with limited health literacy. Trial Registrations: ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941.
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Affiliation(s)
- Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Deborah E. Barnes
- Department of Psychiatry and University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Nathan Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aiesha M. Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ying Shi
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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12
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Carter RZ, Ludwig M, Gao A, Tan A, Barwich D, Howard M. Primary care providers' perceptions on the integration of community-led advance care planning activities with primary care: a cross-sectional survey. BMC PRIMARY CARE 2023; 24:197. [PMID: 37743490 PMCID: PMC10519084 DOI: 10.1186/s12875-023-02144-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 08/30/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Advance care planning (ACP) is a process intended to help ensure people receive medical care that is consistent with their values, goals, and preferences during serious and chronic illness. Barriers to implementing ACP in primary care settings exist. Community-led ACP initiatives exist in British Columbia to engage the public directly. These initiatives may help prepare people for conversations with their primary care providers. The objectives of this study were to elicit primary care providers' perceptions of the utility and desired content of community-led ACP activities and suggestions for integrating community-led ACP activities with primary care. METHODS We conducted an online cross-sectional survey of primary care providers practicing in British Columbia, Canada in 2021. Both quantitative and qualitative survey questions addressed ACP engagement in practice, the perceived role and desired outcomes of community-led ACP activities, and ways to integrate community-led ACP activities with primary care. RESULTS Eighty-one providers responded. Over 80% perceived a moderate or greater potential impact of community-led ACP activities. The most common reasons for not referring a patient to a community-led ACP activity were lack of awareness of the option locally (62.1%) and in general (44.8%). Respondents wanted their patients to reflect on their values, wishes and preferences for care, to have at least thought about their goals of care and to have chosen a substitute decision maker in the community. They indicated a desire for a summary of their patient's participation and a follow-up discussion with them about their ACP. They suggested ways to integrate referral to programs into existing health care system structures. CONCLUSIONS Community-led ACP activities were perceived to be useful to engage and prepare patients to continue ACP discussions with clinicians. Efforts should be made to establish and integrate community-based ACP initiatives within existing primary care systems to ensure awareness and uptake.
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Affiliation(s)
- Rachel Z Carter
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada.
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada.
| | - Monika Ludwig
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada
| | - Angela Gao
- Michael G. DeGroote School of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Amy Tan
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Doris Barwich
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
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13
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Ben-Moshe S, Curseen KA. Advance Care Planning in the Geriatrics Clinic. Clin Geriatr Med 2023; 39:407-416. [PMID: 37385692 DOI: 10.1016/j.cger.2023.05.003] [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: 07/01/2023]
Abstract
Advance care planning (ACP) is a process that allows individuals to express their health-care preferences and make decisions about their future medical care. Clinicians practicing in a Geriatrics clinic or with many patients who are aged 65 years or older have a unique opportunity to discuss patients' goals of care. ACP is particularly important for older adults, who may be facing serious health issues and/or end-of-life decisions. This review article will provide an overview of the importance of ACP in the geriatrics clinic, discuss the barriers to implementation, and explore strategies for successful integration..
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Affiliation(s)
- Sivan Ben-Moshe
- Department of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine, Geriatrics Clinic, Emory Healthcare, 1525 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Kimberly A Curseen
- Division of Palliative Medicine, Emory Palliative Care Center, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30322, USA.
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14
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Borenko C, Simon J, Myers J, Diedrich K, Stajduhar K, Cash C, Wikjord N, Cory S, Schock B. Evolution and current state of Advance Care Planning in Canada. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:36-42. [PMID: 37537087 DOI: 10.1016/j.zefq.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/18/2023] [Indexed: 08/05/2023]
Abstract
Canada is one of the early pioneers of Advance Care Planning concepts, processes, programs and initiatives. The evolution of national messages, models and frameworks is shaped by our publicly funded healthcare system and culturally diverse populations. Our Pan-Canadian Community Framework highlights the importance of individuals, those that matter to them, communities, organizations, and healthcare professionals collaborating, integrating, sharing, and building upon each other's strengths and successes. This framework describes Canada's priority actions at national, provincial and local levels. Our collective vision is for Advance Care Planning to be a part of the life journey.
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Affiliation(s)
- Cari Borenko
- Fraser Health Authority, Surrey, British Columbia, Canada.
| | - Jessica Simon
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Jeff Myers
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karine Diedrich
- Canadian Hospice Palliative Care Association, Ottawa, Ontario, Canada
| | - Kelli Stajduhar
- School of Nursing and Institute on Aging & Lifelong Health, University of Victoria, Victoria, British Columbia, Canada
| | - Colleen Cash
- Nova Scotia Hospice Palliative Care Association, Nova Scotia, Canada
| | - Nicole Wikjord
- First Nations Health Authority, Vancouver, British Columbia, Canada
| | - Shelly Cory
- Canadian Virtual Hospice, Winnipeg, Manitoba, Canada
| | - Bren Schock
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
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15
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Gonçalves do Nascimento N, Venâncio Paes L, Ferreira Raiol Sousa I, Onceição de Lima FC, Conceição Dias Garcez J, Teixeira E, Sousa Ferreira D, Mariany Rêgo Lopes Ueno T. Validação de tecnologia educacional para familiares/cuidadores de pacientes oncológicos elegíveis aos cuidados paliativos no domicílio. REME: REVISTA MINEIRA DE ENFERMAGEM 2023. [DOI: 10.35699/2316-9389.2023.40756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Objetivo: validar o conteúdo de uma cartilha para melhorar a qualidade de vida no cotidiano de familiares/cuidadores de pacientes oncológicos em cuidados paliativos domiciliares. Métodos: estudo de caráter metodológico. Dados coletados de setembro de 2021 a maio de 2022. Os participantes foram 17 juízes especialistas, sendo 14 da área da saúde e 3 de outras áreas. Estudo mediado por um questionário estruturado de acordo com a escala Likert, possui itens dispostos em objetivos, estrutura, apresentação e relevância. Resultados: dos 21 itens do questionário dos juízes da área da saúde somente três resultaram em escore I (inadequado). Revela-se a tecnologia validada, pois conforme a literatura é necessário obter um índice de validação de conteúdo em pelo menos 70%, e o índice alcançado foi de 88%. Conforme as sugestões dos juízes produziu-se a versão adequação da tecnologia. Conclusão: considera-se que a cartilha está validada e com os ajustes poderá a promover o autocuidado, podendo reduzir desconhecimentos e dar mais qualidade de vida aos familiares/cuidadores de pacientes oncológicos em fim de vida.
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16
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Rennels CF, Barnes DE, Volow A, Shi Y, Li B, Sudore RL. PREPARE for your care and easy-to-read advance directives increase real-time goal concordant care. J Am Geriatr Soc 2023; 71:668-670. [PMID: 36214201 PMCID: PMC9957783 DOI: 10.1111/jgs.18074] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/05/2022] [Accepted: 09/10/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Carolyn F Rennels
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Deborah E Barnes
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Aiesha Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Department of Geriatrics, Palliative and Extended Care, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Ying Shi
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Department of Geriatrics, Palliative and Extended Care, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Brookelle Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Department of Geriatrics, Palliative and Extended Care, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Department of Geriatrics, Palliative and Extended Care, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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17
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Malhotra C, Shafiq M, Batcagan-Abueg APM. What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials. BMJ Open 2022. [PMCID: PMC9301802 DOI: 10.1136/bmjopen-2021-060201] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives To conduct an up-to-date systematic review of all randomised controlled trials assessing efficacy of advance care planning (ACP) in improving patient outcomes, healthcare use/costs and documentation. Design Narrative synthesis conducted for randomised controlled trials. We searched electronic databases (MEDLINE/PubMed, Embase and Cochrane databases) for English-language randomised or cluster randomised controlled trials on 11 May 2020 and updated it on 12 May 2021 using the same search strategy. Two reviewers independently extracted data and assessed methodological quality. Disagreements were resolved by consensus or a third reviewer. Results We reviewed 132 eligible trials published between 1992 and May 2021; 64% were high-quality. We categorised study outcomes as patient (distal and proximal), healthcare use and process outcomes. There was mixed evidence that ACP interventions improved distal patient outcomes including end-of-life care consistent with preferences (25%; 3/12 with improvement), quality of life (0/14 studies), mental health (21%; 4/19) and home deaths (25%; 1/4), or that it reduced healthcare use/costs (18%; 4/22 studies). However, we found more consistent evidence that ACP interventions improve proximal patient outcomes including quality of patient–physician communication (68%; 13/19), preference for comfort care (70%; 16/23), decisional conflict (64%; 9/14) and patient-caregiver congruence in preference (82%; 18/22) and that it improved ACP documentation (a process outcome; 63%; 34/54). Conclusion This review provides the most comprehensive evidence to date regarding the efficacy of ACP on key patient outcomes and healthcare use/costs. Findings suggest a need to rethink the main purpose and outcomes of ACP. PROSPERO registration number CRD42020184080.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Mahham Shafiq
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
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18
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Dupont C, Smets T, Monnet F, Pivodic L, De Vleminck A, Van Audenhove C, Van den Block L. Publicly Available, Interactive Web-Based Tools to Support Advance Care Planning: Systematic Review. J Med Internet Res 2022; 24:e33320. [PMID: 35442207 PMCID: PMC9069298 DOI: 10.2196/33320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 02/01/2022] [Accepted: 02/23/2022] [Indexed: 01/28/2023] Open
Abstract
Background There is an increasing number of interactive web-based advance care planning (ACP) support tools, which are web-based aids in any format encouraging reflection, communication, and processing of publicly available information, most of which cannot be found in the peer-reviewed literature. Objective This study aims to conduct a systematic review of web-based ACP support tools to describe the characteristics, readability, and quality of content and investigate whether and how they are evaluated. Methods We systematically searched the web-based gray literature databases OpenGrey, ClinicalTrials.gov, ProQuest, British Library, Grey Literature in the Netherlands, and Health Services Research Projects in Progress, as well as Google and app stores, and consulted experts using the following eligibility criteria: web-based, designed for the general population, accessible to everyone, interactive (encouraging reflection, communication, and processing of information), and in English or Dutch. The quality of content was evaluated using the Quality Evaluation Scoring Tool (score 0-28—a higher score indicates better quality). To synthesize the characteristics of the ACP tools, readability and quality of content, and whether and how they were evaluated, we used 4 data extraction tables. Results A total of 30 tools met the eligibility criteria, including 15 (50%) websites, 10 (33%) web-based portals, 3 (10%) apps, and 2 (7%) with a combination of formats. Of the 30 tools, 24 (80%) mentioned a clear aim, including 7 (23%) that supported reflection or communication, 8 (27%) that supported people in making decisions, 7 (23%) that provided support to document decisions, and 2 (7%) that aimed to achieve all these aims. Of the 30 tools, 7 (23%) provided information on the development, all of which were developed in collaboration with health care professionals, and 3 (10%) with end users. Quality scores ranged between 11 and 28, with most of the lower-scoring tools not referring to information sources. Conclusions A variety of ACP support tools are available on the web, varying in the quality of content. In the future, users should be involved in the development process of ACP support tools, and the content should be substantiated by scientific evidence. Trial Registration PROSPERO CRD42020184112; https://tinyurl.com/mruf8b43
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Affiliation(s)
- Charlèss Dupont
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Fanny Monnet
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Lara Pivodic
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Aline De Vleminck
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | | | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
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19
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Dalgord RE, Stein A, Franczek M. Improving advance care planning and shared decision-making for veterans. Nursing 2022; 52:54-59. [PMID: 35196287 DOI: 10.1097/01.nurse.0000820052.63068.fc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Rhian E Dalgord
- Rhian E. Dalgord is a nurse practitioner at OSF Healthcare St. Francis Hospital and Medical Group in Gladstone, Mich. Anne Stein is a nurse practitioner at Northern Michigan University's (NMU) Health Center and an associate professor at NMU's School of Nursing, where Mary Franczek is an associate professor
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20
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Nouri S, Street RL, Barnes DE, Shi Y, Volow AM, Li B, Alexander SC, Sudore RL. Empowering patients with the PREPARE advance care planning program results in reciprocal clinician communication. J Am Geriatr Soc 2022; 70:585-591. [PMID: 34758115 PMCID: PMC8821241 DOI: 10.1111/jgs.17540] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/07/2021] [Accepted: 10/10/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The patient-directed PREPAREforYourCare.org program empowers patients to participate in advance care planning (ACP) discussions with clinicians. Our goal was to determine whether PREPARE could reciprocally increase clinician ACP communication. METHODS In a secondary analysis of two trials evaluating the efficacy of PREPARE plus an easy-to-read advance directive (AD) versus an AD alone, patients were included if they were ≥55 years old, English- or Spanish-speaking, and had ≥2 chronic conditions. We audio-recorded postintervention primary care visits and used the validated clinician-patient participation coding scheme to calculate the number of clinician ACP utterances concerning information-giving, recommendations, or supportive talk. We examined differences by study arm using mixed effects negative binomial models, stratifying by language. To assess possible mediation, we adjusted for active patient participation (e.g., asking questions or stating preferences). RESULTS Three hundred ninety-three visits were audio-recorded (177 in PREPARE arm and 216 in AD-only arm). Recordings included 179 clinicians (mean 2.2 [SD 1.9] patients each). Patients' mean age was 66 ± 8 years, 31% had limited health literacy, and 25% were Spanish-speaking. Exactly 67% of recordings included information-giving, 85% recommendations, and 62% supportive talk. PREPARE resulted in 51% more clinician supportive talk versus the AD alone (mean 4.5 [8.9] vs. 2.9 [6.0] utterances; incidence rate ratio 1.51 [95% CI 1.02-2.24]). Effects were most pronounced among Spanish speakers. There were no differences in information-giving or recommendations. After adjusting for active patient participation, no differences in supportive talk remained. CONCLUSIONS The patient-directed PREPARE program was associated with greater clinician supportive ACP communication with older adults compared with an AD alone; the effect was most pronounced among Spanish speakers and was mediated by active patient participation. Thus, PREPARE helps patients be more engaged communicators, which in turn encourages clinicians to be more supportive of patients. Enhanced patient-clinician communication represents an important mechanism by which PREPARE may decrease disparities in ACP.
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Affiliation(s)
- Sarah Nouri
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Richard L. Street
- Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas,Texas A&M University, College Station, Texas
| | - Deborah E. Barnes
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Ying Shi
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, United States,San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Aiesha M. Volow
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Brookelle Li
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | | | - Rebecca L. Sudore
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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21
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Lindvall C, Deng CY, Moseley E, Agaronnik N, El-Jawahri A, Paasche-Orlow MK, Lakin JR, Volandes A, Tulsky TAPIJA. Natural Language Processing to Identify Advance Care Planning Documentation in a Multisite Pragmatic Clinical Trial. J Pain Symptom Manage 2022; 63:e29-e36. [PMID: 34271146 PMCID: PMC9124370 DOI: 10.1016/j.jpainsymman.2021.06.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 01/03/2023]
Abstract
CONTEXT Large multisite clinical trials studying decision-making when facing serious illness require an efficient method for abstraction of advance care planning (ACP) documentation from clinical text documents. However, the current gold standard method of manual chart review is time-consuming and unreliable. OBJECTIVES To evaluate the ability to use natural language processing (NLP) to identify ACP documention in clinical notes from patients participating in a multisite trial. METHODS Patients with advanced cancer followed in three disease-focused oncology clinics at Duke Health, Mayo Clinic, and Northwell Health were identified using administrative data. All outpatient and inpatient notes from patients meeting inclusion criteria were extracted from electronic health records (EHRs) between March 2018 and March 2019. NLP text identification software with semi-automated chart review was applied to identify documentation of four ACP domains: (1) conversations about goals of care, (2) limitation of life-sustaining treatment, (3) involvement of palliative care, and (4) discussion of hospice. The performance of NLP was compared to gold standard manual chart review. RESULTS 435 unique patients with 79,797 notes were included in the study. In our validation data set, NLP achieved F1 scores ranging from 0.84 to 0.97 across domains compared to gold standard manual chart review. NLP identified ACP documentation in a fraction of the time required by manual chart review of EHRs (1-5 minutes per patient for NLP, vs. 30-120 minutes for manual abstraction). CONCLUSION NLP is more efficient and as accurate as manual chart review for identifying ACP documentation in studies with large patient cohorts.
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Affiliation(s)
- Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital (C.L., JR.L., JA.T.), Boston, Massachusetts; Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts.
| | - Chih-Ying Deng
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts
| | - Edward Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts
| | - Nicole Agaronnik
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts; Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts
| | - Areej El-Jawahri
- Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts; Department of Medicine, Massachusetts General Hospital (A.EJ., A.V.), Boston, Massachusetts
| | - Michael K Paasche-Orlow
- Department of Medicine, Boston University School of Medicine, Boston Medical Center (MK.PO.), Boston, Massachusetts; ACP Decisions (MK.PO., A.V.), Boston, Massachusetts
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital (C.L., JR.L., JA.T.), Boston, Massachusetts; Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts
| | - Angelo Volandes
- Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts; Department of Medicine, Massachusetts General Hospital (A.EJ., A.V.), Boston, Massachusetts; ACP Decisions (MK.PO., A.V.), Boston, Massachusetts
| | - The Acp-Peace Investigators James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital (C.L., JR.L., JA.T.), Boston, Massachusetts; Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts
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22
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Feasibility and acceptability of a web-based advance care plan for dementia. Geriatr Nurs 2022; 44:251-258. [PMID: 35259603 PMCID: PMC9190025 DOI: 10.1016/j.gerinurse.2022.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 11/23/2022]
Abstract
While advance care planning (ACP) can help elicit preferences and is associated with improved end-of-life outcomes, persons living with dementia (PLWD) in nursing homes are rarely included in ACP. Web-based decision aids are a readily available tool to engage PLWD in ACP, but none are designed for the unique needs of PLWD, particularly those residing in nursing homes. Our Memory Care Wishes (OMCW) was adapted from a publicly available web-based ACP tool in collaboration with dementia care experts. This study aimed to explore the acceptability of OMCW. We used a convergent, mixed methods design to describe PLWD and surrogates' experiences using the OMCW website. Participants described ease of use, comfort with viewing, helpfulness for planning, and likelihood to recommend. Overall, OMCW is acceptable, however, PLWD continue to have difficulties understanding and engaging with some website content. Modifications were incorporated based on these findings, setting the stage for implementation and effectiveness testing.
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23
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Biller-Andorno N, Biller A. The Advance Care Compass- A New Mechanics for Digitally Transforming Advance Directives. Front Digit Health 2021; 3:753747. [PMID: 34723244 PMCID: PMC8554048 DOI: 10.3389/fdgth.2021.753747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Advance directives allow people to declare their treatment preferences for a potential future state of incompetency. Covid-19, with its high numbers of quickly deteriorating patients requiring intensive care, has acutely demonstrated how helpful it would be for clinicians to have reliable, readily available, up-to-date information at hand to be able to act in accordance with what the individual patient would have wanted. Yet for the past few decades advance directives have fallen short of their potential, for various reasons. At worst, advance directives are perceived as unwieldy legal documents that put excessive demands on patients without providing useful guidance for better care. Recent efforts such as advance care planning have tried to remedy some of these shortcomings but have so far met with limited success. We suggest a new concept-the Advance Care Compass-that harnesses the potential of digitalization in healthcare to overcome many of difficulties encountered so far.
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Affiliation(s)
- Nikola Biller-Andorno
- Faculty of Medicine, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
| | - Armin Biller
- Multi-Dimensional Medical Information Lab, Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
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24
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Scheerens C, Gilissen J, Volow AM, Powell JL, Ferguson CM, Farrell D, Li B, Berry C, Sudore RL. Developing eHealth tools for diverse older adults: Lessons learned from the PREPARE for Your Care Program. J Am Geriatr Soc 2021; 69:2939-2949. [PMID: 34081773 PMCID: PMC8497394 DOI: 10.1111/jgs.17284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Electronic Health (eHealth) tools offer opportunities for people to access health information online; yet, most tools are not designed to meet the unique needs of diverse older adults, leading to health disparities. Our goal was to provide guidance for the development of eHealth tools for diverse older populations for use in geriatric care models. DESIGN Guidance for eHealth tools was compiled from user design resources and eHealth design literature. Pragmatic examples were provided from an evidenced-based eHealth tool called PREPAREforYourCare.org (PREPARE). We used quantitative feasibility data from PREPARE research studies and qualitative analysis of PREPARE focus groups, cognitive interviews, and feedback from randomized trials to further inform our recommendations. RESULTS Guidance and lessons learned include: (1) define clear objectives and a conceptual framework; (2) co-create with the target population; (3) optimize the design and layout for accessibility and ease of use, such as text at the 5th grade reading level, closed captioning, etc.; (4) use simple, standardized navigation design; (5) use actionable information to enhance behavior change, such as modeling of behaviors; (6) align accompanying written materials with the eHealth tool; and (7) create tracking mechanisms for ongoing user feedback. PREPARE is used as a case example to provide pragmatic illustrations for how the guidance may be operationalized. CONCLUSION eHealth tools can be tailored to the unique characteristics, preferences, and needs of diverse older populations. Following the "lessons learned" may help decrease health disparities among diverse older adults and ensure eHealth tools are readily accessible and culturally appropriate.
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Affiliation(s)
- Charlotte Scheerens
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
- Department of Public Health and Primary Health Care, Ghent University, Ghent, Belgium
| | - Joni Gilissen
- Department of Public Health and Primary Health Care, Ghent University, Ghent, Belgium
- Atlantic Fellow for Equity in Brain Health, Global Brain Health Institute (GBHI), University of California, San Francisco, California, USA
| | - Aiesha M Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Jana L Powell
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Clarissa M Ferguson
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | | | - Brookelle Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | | | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Innovation and Implementation Center on Aging and Palliative Care, Division of Geriatrics, University of California, San Francisco, California, USA
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25
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Kobewka D, Heyland DK, Dodek P, Nijjar A, Bansback N, Howard M, Munene P, Kunkel E, Forster A, Brehaut J, You JJ. Randomized Controlled Trial of a Decision Support Intervention About Cardiopulmonary Resuscitation for Hospitalized Patients Who Have a High Risk of Death. J Gen Intern Med 2021; 36:2593-2600. [PMID: 33528779 PMCID: PMC8390722 DOI: 10.1007/s11606-021-06605-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many seriously ill hospitalized patients have cardiopulmonary resuscitation (CPR) as part of their care plan, but CPR is unlikely to achieve the goals of many seriously ill hospitalized patients. OBJECTIVE To determine if a multicomponent decision support intervention changes documented orders for CPR in the medical record, compared to usual care. DESIGN Open-label randomized controlled trial. PATIENTS Patients on internal medicine and neurology wards at two tertiary care teaching hospitals who had a 1-year mortality greater than 10% as predicted with a validated model and whose care plan included CPR, if needed. INTERVENTION Both the control and intervention groups received usual communication about CPR at the discretion of their care team. The intervention group participated in a values clarification exercise and watched a CPR video decision aid. MAIN MEASURE The primary outcome was the proportion of patients who had a no-CPR order at 14 days after enrollment. KEY RESULTS We recruited 200 patients between October 2017 and October 2018. Mean age was 77 years. There was no difference between the groups in no-CPR orders 14 days after enrollment (17/100 (17%) intervention vs 17/99 (17%) control, risk difference, - 0.2%) (95% confidence interval - 11 to 10%; p = 0.98). In addition, there were no differences between groups in decisional conflict summary score or satisfaction with decision-making. Patients in the intervention group had less conflict about understanding treatment options (decisional conflict knowledge subscale score mean (SD), 17.5 (26.5) intervention arm vs 40.4 (38.1) control; scale range 0-100 with lower scores reflecting less conflict). CONCLUSIONS Among seriously ill hospitalized patients who had CPR as part of their care plan, this decision support intervention did not increase the likelihood of no-CPR orders compared to usual care. PRIMARY FUNDING SOURCE Canadian Frailty Network, The Ottawa Hospital Academic Medical Organization.
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Affiliation(s)
- Daniel Kobewka
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. .,Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada. .,School of Epidemiology & Public Health, University of Ottawa, Ottawa, Ontario, Canada.
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Peter Dodek
- Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Aman Nijjar
- General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nick Bansback
- Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada.,David Braley Health Sciences Centre, Hamilton, ON, Canada
| | - Peter Munene
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elizabeth Kunkel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,School of Epidemiology & Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Department of National Defence, Ottawa, ON, Canada
| | - Alan Forster
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,School of Epidemiology & Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology & Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - John J You
- Division of General Internal and Hospitalist Medicine, Department of Medicine, Credit Valley Hospital, Trillium Health Partners, Mississauga, Ontario, Canada
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26
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McIlfatrick S, Slater P, Bamidele O, Muldrew D, Beck E, Hasson F. ' It's almost superstition: If I don't think about it, it won't happen'. Public knowledge and attitudes towards advance care planning: A sequential mixed methods study. Palliat Med 2021; 35:1356-1365. [PMID: 34000901 PMCID: PMC8267083 DOI: 10.1177/02692163211015838] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Internationally, participation in advance care planning is low. Whilst a community action approach is advocated, what the public know and understand about advance care planning is unknown. AIM To assess public awareness, knowledge and attitudes towards advance care planning and identify strategies to raise awareness within a public health framework. DESIGN Sequential mixed methods comprising a cross-sectional survey and focus group/interviews. SETTING/PARTICIPANTS A random representative sample of adults from one region of the United Kingdom (n = 1201; response rate 56%) completed a face-to-face survey. Twenty-five participants consented to an additional focus group/interview held in a secure accessible location or via telephone. RESULTS Most participants (78.7%) acknowledged the benefits of advance care planning conversations, however, two thirds did not want to think about advance care planning or find out more at present. Respondents were reluctant to broach advance care planning as it was linked to end of life care and funeral plans, and they did not wish to cause distress to their loved one. Respondents trusted their family to respect their wishes and they considered having an advance care plan in place would be of assistance in the future. Top-down leadership, normalisation, and increased education were identified as potential approaches to overcome barriers. CONCLUSIONS Advance care planning was recognised as important despite limited awareness, lack of knowledge and misperceptions. Whilst a community action approach to enhance understanding and engagement was supported, a 'one size fits all' approach will not work; rather bespoke targeting is required with educational and media messaging aligned.
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Affiliation(s)
- Sonja McIlfatrick
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Northern Ireland
| | - Paul Slater
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Northern Ireland
| | - Olufikayo Bamidele
- Institute of Clinical and Applied Health Research, Hull York Medical School, University of Hull, Hull, UK
| | - Deborah Muldrew
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Northern Ireland
| | - Esther Beck
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Northern Ireland
| | - Felicity Hasson
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Northern Ireland
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27
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Nouri SS, Barnes DE, Shi Y, Volow AM, Shirsat N, Kinderman AL, Harris HA, Sudore RL. The PREPARE for Your Care program increases advance care planning engagement among diverse older adults with cancer. Cancer 2021; 127:3631-3639. [PMID: 34076892 DOI: 10.1002/cncr.33676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 04/15/2021] [Accepted: 05/03/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Advance care planning (ACP) is low among older adults with cancer. In a secondary analysis of randomized trial data, the authors compared the efficacy of the PREPARE for Your Care (PREPARE) website plus an easy-to-read advance directive (AD) with an AD only among older adults with and without cancer. METHODS Safety net, primary care patients in San Francisco were included if they were 55 years old or older, were English- or Spanish-speaking, and had 2 or more chronic conditions. The authors determined cancer diagnoses by using International Classification of Diseases, Ninth Revision/Tenth Revision codes. The primary outcome was new ACP documentation in the medical record at 15 months; the secondary outcomes were self-reported ACP engagement, ease of use, satisfaction, and depression/anxiety. The authors used mixed effects logistic and linear regression adjusted for prior ACP, health literacy, and clinician, including a cancer interaction term. RESULTS Of 986 participants, 220 (22%) had cancer. The mean age was 63 years (SD, 6 years), 61% were women, 81% were of a minority race/ethnicity, 45% were Spanish-speaking, 39% had limited health literacy, and 27% had prior ACP. New ACP documentation was higher in the PREPARE arm versus the AD-only arm among participants with cancer (62% vs 43%; P = .01) and without cancer (38% vs 28%; P = .01), as was ACP engagement in both arms (P < .001), with no interactions by cancer. Ease of use and satisfaction were high, and depression/anxiety was low, with no differences by study arm or by cancer/no cancer. CONCLUSIONS PREPARE plus an easy-to-read AD increased ACP documentation and engagement among diverse older adults with cancer more than an AD alone, with no increase in depression or anxiety between study arms or by cancer. PREPARE may help to decrease ACP disparities among patients with cancer. LAY SUMMARY Advance care planning (ACP) is the process of sharing values, goals, and preferences for medical care, but engagement in ACP is low among older adults with cancer. Among 986 English- and Spanish-speaking older adults from a safety net hospital, an interactive, multimedia, web-based ACP program (PREPARE for Your Care at https://prepareforyourcare.org/) plus an easy-to-read advance directive increased ACP documentation and engagement more than an advance directive alone. There were no differences in this increase in ACP between older adults with cancer and older adults without cancer. Also, engaging in ACP did not result in increased depression or anxiety.
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Affiliation(s)
- Sarah S Nouri
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Deborah E Barnes
- Department of Psychiatry, University of California San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Ying Shi
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Aiesha M Volow
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Nikita Shirsat
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Anne L Kinderman
- San Francisco General Hospital and Trauma Center, San Francisco, California.,Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Heather A Harris
- San Francisco General Hospital and Trauma Center, San Francisco, California.,Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Rebecca L Sudore
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
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28
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Hickman SE, Torke AM, Sachs GA, Sudore RL, Tang Q, Bakoyannis G, Heim Smith N, Myers AL, Hammes BJ. Factors associated with concordance between POLST orders and current treatment preferences. J Am Geriatr Soc 2021; 69:1865-1876. [PMID: 33760241 DOI: 10.1111/jgs.17095] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/04/2021] [Accepted: 02/16/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND POLST is widely used to document the treatment preferences of nursing facility residents as orders, but it is unknown how well previously completed POLST orders reflect current preferences (concordance) and what factors are associated with concordance. OBJECTIVES To describe POLST preference concordance and identify factors associated with concordance. DESIGN Chart reviews to document existing POLST orders and interviews to elicit current treatment preferences. SETTING POLST-using nursing facilities (n = 29) in Indiana. PARTICIPANTS Nursing facility residents (n = 123) and surrogates of residents without decisional capacity (n = 152). MEASUREMENTS Concordance was determined by comparing existing POLST orders for resuscitation, medical interventions, and artificial nutrition with current treatment preferences. Comfort-focused POLSTs contained orders for do not resuscitate, comfort measures, and no artificial nutrition. RESULTS Overall, 55.7% (123/221) of residents and 44.7% (152/340) of surrogates participated (total n = 275). POLST concordance was 44%, but concordance was higher for comfort-focused POLSTs (68%) than for non-comfort-focused POLSTs (27%) (p < 0.001). In the unadjusted analysis, increasing resident age (OR 1.04, 95% CI 1.01-1.07, p < 0.01), better cognitive functioning (OR 1.07, 95% CI 1.02-1.13, p < 0.01), surrogate as the decision-maker (OR 2.87, OR 1.73-4.75, p < 0.001), and comfort-focused POLSTs (OR 6.01, 95% CI 3.29-11.00, p < 0.01) were associated with concordance. In the adjusted multivariable model, only having an existing comfort-focused POLST was associated with higher odds of POLST concordance (OR 5.28, 95% CI 2.59-10.73, p < 0.01). CONCLUSIONS Less than half of all POLST forms were concordant with current preferences, but POLST was over five times as likely to be concordant when orders reflected preferences for comfort-focused care. Findings suggest a clear need to improve the quality of POLST use in nursing facilities and focus its use among residents with stable, comfort-focused preferences.
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Affiliation(s)
- Susan E Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA.,Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Alexia M Torke
- Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Greg A Sachs
- Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Qing Tang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Giorgos Bakoyannis
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Nicholette Heim Smith
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Anne L Myers
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Bernard J Hammes
- A Division of C-TAC Innovations, Respecting Choices, La Crosse, Wisconsin, USA
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29
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Catlin CC, Connors HL, Teaster PB, Wood E, Sager ZS, Moye J. Unrepresented Adults Face Adverse Healthcare Consequences: The Role of Guardians, Public Guardianship Reform, and Alternative Policy Solutions. J Aging Soc Policy 2021; 34:418-437. [PMID: 33461436 PMCID: PMC8286275 DOI: 10.1080/08959420.2020.1851433] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Persons without family or friends to serve as healthcare agents may become "unrepresented" in healthcare, with no one to serve as healthcare agents when decisional support is needed. Surveys of clinicians (N = 81) and attorneys/guardians (N = 23) in Massachusetts reveal that unrepresented adults experience prolonged hospital stays (66%), delays in receiving palliative care (52%), delays in treatment (49%), and other negative consequences. Clinicians say guardianship is most helpful in resolving issues related to care transitions, medical treatment, quality of life, housing, finances, and safety. However, experiences with guardianship are varied, with delays often/always in court appointments (43%) and actions after appointments (24%). Policy solutions include legal reform, education, and alternate models.
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Affiliation(s)
- Casey C Catlin
- Boston VA Research Institute and VA Boston Healthcare System, Boston, MA, USA
| | | | - Pamela B Teaster
- Virginia Tech University, Department of Human Development and Faculty Science, Blacksburg, VA, USA
| | - Erica Wood
- American Bar Association Commission on Law and Aging, Washington DC, USA
| | - Zachary S Sager
- New England GRECC and Harvard Medical School, Department of Psychiatry, Boston, MA, USA
| | - Jennifer Moye
- New England GRECC and Harvard Medical School, Department of Psychiatry, Boston, MA, USA
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