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Yourman L, Pollner A, Khatibi J, Ramos V, Melkote V, O'Gorman A, Begler E, Lum HD. Feasibility and Effectiveness of Virtual Group Advance Care Planning Visits During the COVID-19 Pandemic. Am J Hosp Palliat Care 2024; 41:1238-1245. [PMID: 38896819 DOI: 10.1177/10499091241233687] [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: 06/21/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic necessitated the transition from in person to virtual advance care planning (ACP) engagement efforts. This pilot initiative evaluated virtual group visits (GVs) and in-person GVs for ACP to determine their feasibility and effectiveness. METHODS Participants included patients in a Geriatric Medicine clinic who were referred by their primary care physician to an ACP GVs intervention. The ACP GVs had 2 sessions, led by clinicians with ACP expertise who facilitated a discussion on patients' values, goals, and preferences. Participants were provided with technical assistance to support use of the virtual platform. Evaluation included an ACP readiness survey, post-session feedback, GV observations, and electronic health record review at baseline and a 6 month follow-up for goals of care documentation and advance directives. RESULTS Seventy patients attended 46 ACP GVs from August 2019 to February 2022, including 16 in-person GVs and 54 virtual GVs. At a 6 month follow-up, for virtual GVs participants (n = 54), goals of care documentation increased from 31% to 93%, and advance directives increased from 22% to 30%. For in-person GVs participants (n = 16), goals of care documentation increased from 25% to 100%, and advance directives increased from 69% to 75%. All surveyed patients in both formats would recommend ACP GVs. CONCLUSION ACP GVs are feasible and effective for supporting ACP, demonstrating an increase in both goals of care conversations and advance directives completion.
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Affiliation(s)
- Lindsey Yourman
- Division of Geriatrics, Gerontology, and Palliative Care, Department of Internal Medicine, University of California at San Diego School of Medicine, La Jolla, San Diego, CA, USA
| | | | | | - Vanessa Ramos
- Health Sciences, University of California, San Diego, San Diego, CA, USA
| | | | | | - Erika Begler
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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2
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Tan M, Tang S, Feder S, Xiao J, Huang C, Cook A, Johnson CE, Ding J. Interventions to promote readiness for advance care planning: A systematic review and meta-analysis. Int J Nurs Stud 2024; 156:104778. [PMID: 38761437 DOI: 10.1016/j.ijnurstu.2024.104778] [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] [Received: 11/29/2023] [Revised: 04/16/2024] [Accepted: 04/18/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Advance care planning is recommended as part of standard medical services. Readiness, denoting stages of behavior change, exerts a substantial influence on its uptake. However, the characteristics and impacts of advance care planning interventions on readiness are not well-established. METHOD We systematically reviewed and conducted a meta-analysis of randomized controlled trials assessing the effects of advance care planning interventions on readiness. Studies were appraised using Joanna Briggs Institute Critical Appraisal tools. Meta-analyses were performed using mean difference of continuous variables or risk ratios of binary variables and their 95 % confidence interval as the pooled effect sizes. RESULTS Eight studies were included in this review and were all rated low quality. Meta-analysis showed that interventions resulted in slight improvement in overall readiness (mean difference = 0.19, 95 % confidence interval: 0.02-0.36) for advance care planning. However, statistically significant effects of interventions were not identified for readiness in relation to specific behaviors (appointment of a healthcare proxy, talking to a healthcare proxy, talking to a medical practitioner about living wills, and signing a living will). CONCLUSION Our meta-analyses demonstrated that interventions can improve the overall readiness for advance care planning, suggesting the necessity to integrate readiness into future health policies and clinical practices. Nevertheless, the absence of significant effects on specific behavioral readiness underscores the requirement for additional refinement in intervention design, advanced technologies, and theoretical foundations. REGISTRATION Not registered.
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Affiliation(s)
- Minghui Tan
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Siyuan Tang
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Shelli Feder
- Yale School of Nursing, West Haven, CT, United States
| | - Jinnan Xiao
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Chongmei Huang
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Angus Cook
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Claire E Johnson
- Palliative Aged Care Outcomes Program, University of Wollongong, Wollongong, Australia
| | - Jinfeng Ding
- Xiangya School of Nursing, Central South University, Changsha, China.
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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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5
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Kato H, Iwasaki T, Ko A, Nishina Y, Tanigaki S, Norikoshi C, Sakai M, Ito M, Harasawa N, Tamura K, Nagae H. Experiences of dialogue in advance care planning educational programs. Nurs Ethics 2024; 31:493-507. [PMID: 37496291 DOI: 10.1177/09697330231166086] [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: 07/28/2023]
Abstract
BACKGROUND Advance care planning (ACP) is a process in which adults engage in an ongoing dialogue about future medical treatment and care. Though ACP is recommended to improve the quality of end-of-life care, the details of the dialogue experience in ACP are unknown. OBJECTIVE To explore participants' experiences of dialogue in an ACP educational program that encouraged them to discuss the value of a way of life. RESEARCH DESIGN This qualitative descriptive study used the focus group interview method. Data were analyzed using qualitative content analysis. PARTICIPANTS AND RESEARCH CONTEXT A dialogue-based ACP educational program was conducted in four regions in Japan for local citizens to discuss the value of their way of life. A total of 66 individuals (mean age = 55.5 ± 17.2 years; 50 women and 16 men) participated in focus group interviews. ETHICAL CONSIDERATIONS This study was approved by the Ethical Review Committee of Tokyo Women's Medical University (no. 4723) and Kyoto University (no. R2099). FINDINGS Five main themes were extracted: discussing one's thoughts with others in a considerate manner, reflecting on one's way of life through others, feeling a sense of connection with others through storytelling, realizing the difficulties of talking about "what if" topics, and turning one's eyes toward the future through the dialogue. These themes were interrelated and illustrated the complexity of the experience of discussing values. CONCLUSIONS The results suggest that dialogue in ACP is useful in clarifying values. They also indicated the need for dealing with the ethical challenges of discussing value and the importance of caring for the interlocutor to have a safe dialogue. In the ACP process, safety in dialogue may improve readiness in ACP, and health practitioners who support ACP need to address the ethical challenges entailing dialogue about values.
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Affiliation(s)
| | | | | | | | | | | | | | - Mari Ito
- Kawasaki Medical School General Medical Center, Japan
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6
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Tan M, Ding J, Johnson CE, Cook A, Huang C, Xiao L, Tang S. Stages of readiness for advance care planning: Systematic review and meta-analysis of prevalence rates and associated factors. Int J Nurs Stud 2024; 151:104678. [PMID: 38262171 DOI: 10.1016/j.ijnurstu.2023.104678] [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] [Received: 07/25/2023] [Revised: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Advance care planning has been widely recommended to respect the medical care preferences of patients in the final stages of life. However, uptake of advance care planning in healthcare settings remains suboptimal. It may be beneficial to take into account individuals' readiness for advance care planning based on the stages to change identified in the Transtheoretical Model. OBJECTIVE To identify the measurements used to assess readiness of advance care planning based on the Transtheoretical Model, to pool the prevalence of readiness stages, and to summarize the factors affecting people's readiness for advance care planning. DESIGN Systematic review and meta-analysis. METHODS We systematically searched the databases of PubMed, EMBASE, The Cochrane Library, CINAHL, and Web of Science for relevant studies from inception to February 2023. A random effects model was used to estimate the pooled prevalence. And a narrative review on the factors associated with stages of readiness was conducted. RESULTS This meta-analysis included 25 studies involving a total of 4237 individuals. The precontemplation stage was the most commonly identified stage of readiness among advance care planning behaviors (26-72 %). The prevalence of readiness stages for advance care planning varied among different types of behavior. The behavior of "talking to health care proxy/family/loved ones about thoughts on quality versus quantity of life" had the highest level of readiness among all listed behaviors, followed by "talking to health care proxy/family/loved ones about living will", "signing a health care proxy form" and "signing a living will", "signing an advance directive", as well as "talking to doctors about living will". Regarding to influencing factors, a majority of sociodemographic and clinical factors did not show consistent associations with readiness, but some studies did suggest potential links with age, health status, countries, type of assessment, core structures of the Transtheoretical Model, and intervention modalities. CONCLUSIONS A majority of individuals were unaware of advance care planning. There is an urgent need to promote readiness for such planning. Starting with preliminary activities such as "talking to health care proxy/family/loved ones about thoughts on quality versus quantity of life" can help initiate advance care planning. Better integration of the Transtheoretical Model and interventions into the research of advance care planning readiness are needed. REGISTRATION Not registered.
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Affiliation(s)
- Minghui Tan
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Jinfeng Ding
- Xiangya School of Nursing, Central South University, Changsha, China.
| | - Claire E Johnson
- Palliative Aged Care Outcomes Program, University of Wollongong, Wollongong, Australia
| | - Angus Cook
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Chongmei Huang
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Lin Xiao
- School of Nursing, Southern Medical University, Guangzhou, China
| | - Siyuan Tang
- Xiangya School of Nursing, Central South University, Changsha, China.
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7
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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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8
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Carter RZ, Siden E, Husband A, Barwich D, Soheilipour S, Kryworuchko J, Sawatzky R, Kazanjian A, Stajduhar K, Hassan E. Community-led, peer-facilitated Advance Care Planning workshops prompt increased Advance Care Planning behaviors among public attendees. PEC INNOVATION 2023; 3:100199. [PMID: 37662691 PMCID: PMC10474229 DOI: 10.1016/j.pecinn.2023.100199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/31/2023] [Accepted: 08/20/2023] [Indexed: 09/05/2023]
Abstract
Objective Despite recognized benefits, engagement in Advance Care Planning (ACP) remains low. Research into peer-facilitated, group ACP interventions is limited. This study investigated the acceptability of community-led peer-facilitated ACP workshops for the public and whether these workshops are associated with increased knowledge, motivation and engagement in ACP behaviors. Methods Peer-facilitators from 9 community organizations were recruited and trained to deliver free ACP workshops to members of the public with an emphasis on conversation. Using a cohort design, workshop acceptability and engagement in ACP behaviors was assessed by surveying public participants at the end of the workshop and 4-6 weeks later. Results 217 participants returned post-workshop questionnaires, and 69 returned follow-up questionnaires. Over 90% of participants felt they gained knowledge across all 6 learning goals. Every ACP behavior saw a statistically significant increase in participant completion after 4-6 weeks. Almost all participants were glad they attended (94%) and would recommend the workshop to others (95%). Conclusion This study revealed an association of peer-facilitated ACP workshops and completion of ACP behaviors in public participants. Innovation This innovative approach supports investment in the spread of community-based, peer-facilitated ACP workshops for the public as important ACP promotion strategies.
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Affiliation(s)
- Rachel Z. Carter
- British Columbia Centre for Palliative Care, New Westminster, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Ellie Siden
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Amber Husband
- British Columbia Centre for Palliative Care, New Westminster, Canada
| | - Doris Barwich
- British Columbia Centre for Palliative Care, New Westminster, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Shimae Soheilipour
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | | | - Richard Sawatzky
- School of Nursing, Trinity Western University, Langley, Canada
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, Canada
| | - Arminee Kazanjian
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | | | - Eman Hassan
- British Columbia Centre for Palliative Care, New Westminster, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
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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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10
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Pajka SE, Kushel M, Handley MA, Olsen P, Li B, Enriquez C, Kaplan L, Sudore RL. Using behavioral theory to adapt advance care planning for homeless-experienced older adults in permanent supportive housing. J Am Geriatr Soc 2023; 71:2615-2626. [PMID: 36928791 PMCID: PMC10440262 DOI: 10.1111/jgs.18314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 01/31/2023] [Accepted: 02/18/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Older adults experiencing chronic homelessness (i.e., prolonged homelessness and a disabling condition) have low rates of advance care planning (ACP) despite high rates of morbidity and mortality. Rehousing of homeless-experienced individuals into permanent supportive housing (PSH) may present an opportunity to introduce ACP; but this is unknown. Therefore, we explored staff and resident perceptions of conducting ACP in PSH. METHODS We conducted semi-structured interviews with PSH staff (n = 13) and tenants (PSH residents) (n = 26) in San Francisco. We used the capability (C), opportunity (O), motivation (M), behavior (COM-B) framework within the Behavior Change Wheel model and the Theoretical Domains Framework (TDF) to inform interviews, categorize themes, and guide qualitative thematic analysis. RESULTS The mean age of PSH residents was 67 (SD = 6.1) years and 52% were women. Of staff, 69% were women. Important COM-B barriers included ACP complexity (C), complicated relationship dynamics (O), resource limitations (O), pessimism (M), variable staff confidence (M), and competing priorities (M). Facilitators included easy-to-use documents/videos, including the PREPARE for Your Care program (C), stability with housing (O), exposure to health crises (O), potential for strong relationships (O), and belief that ACP is impactful (M). Recommendations included adapting materials to the PSH setting, providing staff trainings/scripts, and using optional one-on-one or group sessions. CONCLUSIONS We identified behavioral determinants related to ACP for formerly chronically homeless older adults in PSH. Future interventions should include using easy-to-use ACP materials and developing resources to educate PSH residents, train staff, and model ACP in groups or one-on-one sessions.
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Affiliation(s)
- Sarah E Pajka
- Medical Student, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Margot Kushel
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, The University of California San Francisco, San Francisco, California, USA
| | - Margaret A Handley
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Pamela Olsen
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Celeste Enriquez
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Lauren Kaplan
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
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11
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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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12
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Wang X, Huang XL, Wang WJ, Liao L. Advance care planning for frail elderly: are we missing a golden opportunity? A mixed-method systematic review and meta-analysis. BMJ Open 2023; 13:e068130. [PMID: 37247960 DOI: 10.1136/bmjopen-2022-068130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVE The aim is to integrate quantitative and qualitative evidence to understand the effectiveness and experience of advance care planning (ACP) for frail elderly. DESIGN A mixed-methods systematic review and meta-analysis was conducted. Quality evaluation was conducted using critical appraisal tools from the Joanna Briggs Institute. Data were synthesised and pooled for meta-analysis or meta-aggregation as needed. DATA SOURCES An electronic search of MEDLINE, CINAHL, Embase, PubMed, PsycINFO, and Cochrane Library databases from January 2003 to April 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included experimental and mixed-methods studies. The quantitative component attempts to incorporate a broader study design. The qualitative component aids in comprehending the participant's experience with ACP and its efficacy. DATA EXTRACTION AND SYNTHESIS Two independent reviewers undertook screening, data extraction and quality assessment. The quantitative and qualitative data were synthesised and integrated using a convergent segregated approach. RESULTS There were 12 158 articles found, and 17 matched the inclusion criteria. The quality of the quantitative component of most included studies (6/10) was rated as low, and the qualitative component of half included studies (4/8) was rated as moderate. The meta-analysis showed that the intervention of ACP for frail elderly effectively increases readiness, knowledge and process of ACP behaviours. The meta-aggregation showed that the participants hold a positive attitude towards ACP and think it facilitates expressing their preferences for the medical decision. CONCLUSION ACP is an effective and feasible strategy to facilitate frail elderly to express their healthcare wishes timely and improve their outcomes. This study could provide proof for a better understanding of the subject and help direct future clinical practice. More well-designed randomised controlled trials evaluating the most effective ACP interventions and tools are needed for the frail elderly population. PROSPERO REGISTRATION NUMBER CRD42022329615.
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Affiliation(s)
- Xinying Wang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Xin-Lin Huang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Wei-Jia Wang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Li Liao
- University of South China School of Nursing, Hengyang, Hunan, China
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13
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Betz M, Polzer E, Knoepke C, Prater L, Simonetti J, Lee T, Meador L, Nearing K. Cars, Guns, Aging, and "Giving Up the Keys". THE GERONTOLOGIST 2023; 63:717-730. [PMID: 36383376 PMCID: PMC10167763 DOI: 10.1093/geront/gnac142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Age-associated changes can impair abilities for safe driving and the use of firearms. We sought to examine multiple perspectives on reducing access to firearms, including similarities and differences compared to reducing driving. RESEARCH DESIGN AND METHODS Online focus groups and 1-on-1 interviews were conducted (November 2020 to May 2021) in the United States with: older adults who drove and owned firearms; family members of older adult firearm owners/drivers; professionals in aging-related agencies; and firearm retailers/instructors. Recorded sessions were transcribed, coded, and analyzed following a mixed inductive-deductive thematic analysis process. RESULTS Among 104 participants (81 in focus groups, 23 in interviews), 50 (48%) were female, and 92 (88%) White. Key similarities: decisions are emotional and challenging; needs change over time; safety concerns are heightened by new impairments; prior experiences prompt future planning; tension between autonomy and reliance on trusted others; and strategies like reframing may ease transitions and avoid confrontations. Key differences: "retirement" was not an acceptable term for firearms; reducing driving may affect daily independence more, but there are few alternatives for the psychological safety conferred by firearms; and there are specific firearm-related legal concerns but more driving-related regulations, policies, and resources. DISCUSSION AND IMPLICATIONS The similarities and differences in the processes and preferences related to reducing driving or firearm access have implications for the development of resources to support planning and action. Such resources for the public and providers might empower older adults and their families to make voluntary, shared decisions, and reduce injuries and deaths.
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Affiliation(s)
- Marian E Betz
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Evan R Polzer
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado, USA
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Veterans Health Administration, Aurora, Colorado, USA
| | - Christopher E Knoepke
- Division of Cardiology, School of Medicine, University of Colorado, Aurora, Colorado, USA
- Adult and Child Consortium for Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Laura C Prater
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington,USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, Washington,USA
| | - Joseph A Simonetti
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Veterans Health Administration, Aurora, Colorado, USA
- Division of Hospital Medicine, University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA
| | - Teresa M Lee
- Department of Neurology, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Lauren E Meador
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado, USA
- Department of Pathology, Stanford Medicine, Palo Alto, California, USA
| | - Kathryn A Nearing
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Geriatrics and Multidisciplinary Center on Aging, School of Medicine, University of Colorado, Aurora, Colorado, USA
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14
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Nagarkatti N, Miller SM, Ahuja V, Schneider EB, Mohanty S, Kodadek LM. An Evaluation of Sex-Based Differences in Surrogate Consent for Older Adults Undergoing Surgical Intervention. J Surg Res 2023; 288:246-251. [PMID: 37030182 DOI: 10.1016/j.jss.2023.02.041] [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: 07/15/2022] [Revised: 01/23/2023] [Accepted: 02/19/2023] [Indexed: 04/10/2023]
Abstract
INTRODUCTION Differences between female and male patients have been identified in many facets of medicine. We sought to understand whether differences in frequency of surrogate consent for operation exist between older female and male patients. MATERIALS AND METHODS A descriptive study was designed using data from the hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients age 65 y and older who underwent operation between 2014 and 2018 were included. RESULTS Of 51,618 patients identified, 3405 (6.6%) had surrogate consent for surgery. Overall, 7.7% of females had surrogate consent compared to 5.3% of males (P < 0.001). Stratified analysis based on age categories showed no difference in surrogate consent between female and male patients aged 65-74 yy (2.3% versus 2.6%, P = 0.16), but higher rates of surrogate consent in females than males among patients aged 75-84 y old (7.3% versus 5.6%, P < 0.001) and age ≥85 y (29.7% versus 20.8%, P < 0.001). A similar relationship was seen between sex and preoperative cognitive status. There was no difference in preoperative cognitive impairment in female and male patients age 65-74 y (4.4% versus 4.6%, P = 0.58), but higher rates of preoperative cognitive impairment were seen in females than males for those age 75-84 (9.5% versus 7.4%, P < 0.001) and aged ≥85 y (29.4% versus 21.3%, P < 0.001). Matching for age and cognitive impairment, there was no significant difference between rate of surrogate consent in males and females. CONCLUSIONS Female patients are more likely than males to undergo surgery with surrogate consent. This difference is not based on patient sex alone - females undergoing operation are older than their male counterparts and more likely to be cognitively impaired.
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Affiliation(s)
| | - Samuel M Miller
- Yale School of Medicine, New Haven, Connecticut; National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut
| | - Vanita Ahuja
- Yale School of Medicine, New Haven, Connecticut; West Haven Veterans Affairs Medical Center, West Haven, Connecticut
| | - Eric B Schneider
- Department of Surgery, Center for Health Services and Outcomes Research, Yale School of Medicine, New Haven, Connecticut
| | - Sanjay Mohanty
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lisa M Kodadek
- Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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15
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Dassel KB, Iacob E, Utz RL, Supiano KP, Fuhrmann H. Promoting Advance Care Planning for Persons with Dementia: Study Protocol for the LEAD (Life-Planning in Early Alzheimer's and Other Dementias) Clinical Trial. OBM INTEGRATIVE AND COMPLIMENTARY MEDICINE 2023; 8:26. [PMID: 37859668 PMCID: PMC10586385 DOI: 10.21926/obm.icm.2301004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Due to the insidious progression of Alzheimer's disease and related dementias (ADRD), surrogate decision-makers typically make medical and long-term-care decisions for a care recipient, most often a family care partner. Unfortunately, many care recipient/care partner dyads have failed to engage in advance care planning or have lost the opportunity to do so due to the cognitive decline of the care recipient. To address this need, our team created a validated dementia-focused advance care planning tool known as the LEAD Guide (Life-Planning in Early Alzheimer's and Other Dementias). With funding from the National Alzheimer's Association and in consultation with our community advisory board, we developed a preliminary web-based intervention. This intervention integrates the LEAD Guide with self-paced educational modules that lead dyads through conversations and dementia-focused advance care planning processes. In this concept paper, we describe the aims of our funded R01 clinical trial (National Institute on Aging), where we aim to refine our preliminary web-based platform for use in a 5-month mixed-method NIH Stage-1 behavioral intervention. Using a sample of diverse community-based ADRD dyads (n = 60), we aim to: 1) describe the acceptability, usability, and feasibility of the intervention, 2) assess the initial efficacy of the intervention on the primary outcome (decision-making self-efficacy), and secondary outcomes (relationship quality, subjective well-being, anxiety) as perceived by both the care recipient and the care partner, and 3) examine advance care planning congruence as a mechanism of action. The LEAD clinical trial addresses public health challenges by guiding and supporting families through challenging advance care planning conversations, facilitating the transfer of knowledge regarding care preferences and values from the care recipient to the care partner, with the ultimate goal of improving the quality of life for both individuals with ADRD and their care partners.
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Affiliation(s)
- Kara B. Dassel
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
| | - Eli Iacob
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
| | - Rebecca L. Utz
- University of Utah, College of Social and Behavioral Sciences, 260 South Central Campus Drive, Salt Lake City, UT, USA
| | | | - Hollie Fuhrmann
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
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16
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Sussman T, Lawrence J, Pimienta R. "This is how I want it": Exploring the use of a workbook with persons with dementia to support advance care planning engagement. DEMENTIA 2022; 21:2601-2618. [PMID: 36151606 PMCID: PMC9583280 DOI: 10.1177/14713012221127358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This mixed method sequential study reports focus group and pilot intervention findings that (1) explore the views of persons with dementia and their caregivers on using a self-directed advance care planning engagement workbook (Your Conversation Starter Kit) and (2) uncover the conditions that encouraged and hindered workbook use. In Phase 1, we conducted five focus groups consisting of 10 persons with dementia and eight family members/caregivers from two urban Canadian cities to explore overall impressions of the workbook and factors that might affect its use. In Phase 2, we empirically explored the factors identified in Phase 1 by distributing the workbook to 24 persons with dementia. The combined findings suggest that the workbook offers promise in supporting advance care planning engagement for persons with dementia in the early stages of their condition. Involving family/caregivers and clarifying some of the ranked questions might improve the workbook's use. Persons with dementia without familial support or those who have never contemplated advance care planning may require additional guidance prior to workbook distribution.
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Affiliation(s)
- Tamara Sussman
- School of Social Work, McGill University, Montreal, Canada
| | - Jack Lawrence
- School of Social Work, McGill University, Montreal, Canada
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17
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Abedini NC, Downey L, Engelberg RA, Curtis JR, Sharma RK. End-of-life healthcare utilization and palliative care use among older adults with limited English proficiency. J Am Geriatr Soc 2022; 70:2847-2857. [PMID: 35670104 DOI: 10.1111/jgs.17913] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known about end-of-life healthcare utilization and palliative care use among older adults with serious illness and limited English proficiency (LEP). METHODS We conducted a retrospective analysis of seriously-ill older adults (65+) with and without LEP, from a large health system, who died between 2010 and 2018. Primary outcomes were measures of healthcare utilization in the last 30 and 180 days of life: hospitalization, emergency department (ED) visits, intensive care unit (ICU) admission, and 30-day readmission. Secondary outcomes were palliative care consultation and advance care planning documents. We used multivariate analyses adjusted for sociodemographic factors including race and ethnicity. RESULTS Among 18,490 decedents, 1363 had LEP. Patients with LEP were older at time of death (median age 80 vs 77 years), more likely to be female (48% vs 44%), of Asian descent (64% vs 4%), of Hispanic ethnicity (10% vs 2%), with <12th grade education (38% vs 9%), and Medicaid (36% vs 6%). In the last 30 days of life, patients with LEP had higher odds of ED visits (33% vs 20%; aOR 1.41, 95% CI 1.26-1.72; p < 0.001), readmission (12% vs 8%; aOR 1.64, 95% CI 1.30-2.07; p < 0.001), and in-hospital death (45% vs 37%; aOR 1.24, 95% CI 1.07-1.44; p = 0.005) compared to patients without LEP. Findings were similar in the last 180-days of life. Only 14% of patients with LEP and 10% of those without LEP received palliative care consultation in the last month of life. Patients with LEP were less likely to have advance care planning documents than patients without LEP (36% vs 40%; aOR 0.68, 95% CI 0.50-0.80; p < 0.001). CONCLUSIONS Older adults with serious illness and LEP have higher rates of end-of-life healthcare utilization. Additional research is needed to identify drivers of these differences and inform linguistically- and culturally-appropriate interventions to improve end-of-life care in this population.
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Affiliation(s)
- Nauzley C Abedini
- Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
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18
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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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19
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Daddato AE, Staton EW, Bettcher BM, Shanbhag P, Lum HD. Human-Centered Design of an Advance Care Planning Group Visit for Mild Cognitive Impairment. THE GERONTOLOGIST 2021; 62:1226-1237. [PMID: 34940855 PMCID: PMC9451012 DOI: 10.1093/geront/gnab181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES While advance care planning (ACP) is critical for ensuring optimal end-of-life outcomes among individuals with mild cognitive impairment (MCI), many individuals who may benefit from ACP have not initiated this process. This article aims to describe the iterative design of an MCI group visit-based intervention and evaluate the feasibility and acceptability of the intervention. RESEARCH DESIGN AND METHODS We used human-centered design, rapid-cycle prototyping, and multiple methods to adapt an ENgaging in Advance Care planning Talks (ENACT) Group Visits intervention. We convened an advisory panel of persons with MCI and care partners (n = 6 dyads) to refine the intervention and conducted a single-arm pilot of 4 MCI ENACT intervention prototypes (n = 13 dyads). We used surveys and interviews to assess outcomes from multiple perspectives. RESULTS The advisory panel affirmed that ACP is a priority for individuals with MCI, described the need for ACP in a group setting, and suggested refinements to ACP resources for the MCI ENACT intervention. Feasibility of recruitment was limited. MCI ENACT intervention participants strongly agreed that group discussions provided useful information and recommended the intervention. Themes supporting acceptability included (a) feedback on acceptability of the intervention, (b) previous experiences with ACP, and (c) reasons for participation, including desire for discussions about MCI and how it relates to ACP. DISCUSSION AND IMPLICATIONS Despite stakeholders' positive ratings of acceptability of the MCI ENACT intervention, future work is needed to enhance the feasibility of recruitment to support implementation into clinical settings.
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Affiliation(s)
- Andrea E Daddato
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Elizabeth W Staton
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Brianne M Bettcher
- Alzheimer’s and Cognition Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Prajakta Shanbhag
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hillary D Lum
- Address correspondence to: Hillary D. Lum, MD, PhD, Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 E. 17th Ave., Mail Stop B179, Aurora, CO 80045, USA. E-mail: ; Twitter handle: @hdaylum
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20
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Motamedi M, Brandenburg C, Bakhit M, Michaleff ZA, Albarqouni L, Clark J, Ooi M, Bahudin D, Chróinín DN, Cardona M. Concerns and potential improvements in end-of-life care from the perspectives of older patients and informal caregivers: a scoping review. BMC Geriatr 2021; 21:729. [PMID: 34930177 PMCID: PMC8690959 DOI: 10.1186/s12877-021-02680-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/29/2021] [Indexed: 12/19/2022] Open
Abstract
Background Overtreatment in advanced age i.e. aggressive interventions that do not improve survival and are potentially harmful, can impair quality of care near the end of life (EOL). As healthcare provider perspectives on care quality may differ from that of service users, the aim of this study was to explore the views of older patients near EOL or their caregivers about the quality of health care at the EOL based on their lived experience, and to identify healthcare service improvements. Methods Medline and backward citation searches were conducted for qualitative or quantitative studies reported on the views of patients and/or informal caregivers about EOL care quality. Thematic analysis was used to summarise qualitative data (primary analysis); narrative and tabulations were used to summarise quantitative data (secondary analysis). Results Thirty articles met the inclusion criteria. Five main qualitative themes regarding quality care emerged: (1) Effective communication between clinicians and patients/caregivers; (2) Healthcare that values patient preferences and shared decision making; (3) Models of care that support quality of life and death with dignity; (4) Healthcare services that meet patient expectations; and (5) Support for informal caregivers in dealing with EOL challenges. The quantitative articles supported various aspects of the thematic framework. Conclusion The findings of this study show that many of the issues highlighted by patients or bereaved relatives have persisted over the past two decades. There is an urgent need for comprehensive evaluation of care across the healthcare system and targeted redesign of existing EOL care pathways to ensure that care aligns with what patients and informal caregivers consider high-quality patient-centred care at the EOL. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02680-2.
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Affiliation(s)
- Mina Motamedi
- Australian Centre for Health Engagement Evidence and Values (ACHEEV), University of Wollongong, Wollongong, NSW, Australia
| | - Caitlin Brandenburg
- Allied Health Services, Gold Coast University Hospital, Southport, QLD, Australia.,Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Mina Bakhit
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD, Australia
| | - Zoe A Michaleff
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD, Australia
| | - Loai Albarqouni
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD, Australia
| | - Justin Clark
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD, Australia
| | - Meidelynn Ooi
- Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Danial Bahudin
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Danielle Ní Chróinín
- Department of Geriatric Medicine, Liverpool Hospital, Liverpool, NSW, Australia.,South Western Sydney Clinical School, UNSW Sydney, Sydney, NSW, Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD, Australia. .,Bond EBP Professorial Unit, Gold Coast University Hospital, QLD, Southport, Australia.
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21
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Ahluwalia SC, Bandini JI, Kogan AC, Bekelman DB, Olsen B, Phillips J, Sudore RL. Impact of group visits for older patients with heart failure on advance care planning outcomes: Preliminary data. J Am Geriatr Soc 2021; 69:2908-2915. [PMID: 34077563 PMCID: PMC8497395 DOI: 10.1111/jgs.17283] [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: 02/23/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Advance care planning (ACP) is critically important for heart failure patients, yet important challenges exist. Group visits can be a helpful way to engage patients and caregivers in identifying values and preferences for future care in a resource-efficient way. We sought to evaluate the impact of group visits for ACP among older adults with heart failure and their caregivers on ACP-related outcomes. METHODS We conducted a mixed-methods pilot study evaluating the impact of an ACP group visit for older adults with heart failure and their caregivers on ACP-related outcomes including readiness and self-efficacy. The evidence-based PREPARE for Your Care video-based intervention was used to guide the group visits. Twenty patients and 10 caregivers attended one of the five 90-min group visits led by a trained facilitator. Group visit participants completed pre-, post-, and 1-month follow-up surveys using validated 5-point ACP readiness and self-efficacy scales. Qualitative feedback obtained within 3 days of a group visit was analyzed using a directed content analysis. RESULTS Patient participants had a median age of 78 years. Approximately half were female while caregiver participants were mostly female. Participants were predominantly white. Patient readiness scores improved significantly pre-to-post (+0.53; p = 0.002) but was not sustained at 1-month follow-up. Patient and caregiver self-efficacy showed some improvement pre-to-post but was also not sustained at follow-up. Interviews revealed positive impacts of group visits across the three themes: encouraging reviewing or revisiting prior ACP activities, motivating patients to take direct steps towards ACP, and serving as a "wake-up" call to action. CONCLUSIONS Disease-focused group visits may have a short-term effect on ACP outcomes but ongoing touchpoints are likely necessary to sustain ACP over time. The results highlight a need for follow-up ACP conversations after a single group visit. Timing for follow-ups and the ideal person to follow-up ACP conversations needs to be explored.
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Affiliation(s)
- Sangeeta C. Ahluwalia
- RAND Corporation, Santa Monica, CA
- UCLA Fielding School of Public Health, Los Angeles, CA
| | | | - Alexis Coulourides Kogan
- Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra, CA
| | - David B. Bekelman
- Department of Medicine, Eastern Colorado VA HCS and Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus
| | - Bonnie Olsen
- Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra, CA
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22
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Schickedanz HB, Polzin R, Vassar SD, Brown AF, Kim KJ. Primary care provider-led group visits for advance care planning in the safety net. J Am Geriatr Soc 2021; 69:1404-1406. [PMID: 33797751 DOI: 10.1111/jgs.17098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Heather B Schickedanz
- Department of Family Medicine, Harbor-UCLA Medical Center, Los Angeles, California, USA.,Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rhonda Polzin
- Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA
| | - Stefanie D Vassar
- Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Arleen F Brown
- Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Karen J Kim
- Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Kistler CE, Beeber AS, Winzelberg GS, Gabriel SL, Wretman CJ, Hanson LC. Evaluation of a Training Toolkit to Improve Clinicians' Skills for Dementia Advance Care Planning. J Palliat Med 2021; 24:1183-1190. [PMID: 33400605 DOI: 10.1089/jpm.2020.0638] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Primary care clinicians care for most persons with Alzheimer's disease and related dementias (ADRDs), yet lack dementia-specific skills in advance care planning (ACP). Objectives: To develop and evaluate a training toolkit for primary care clinicians to improve ACP communication for people with ADRD and their families. Design: Clinical practice outcomes assessment and pre-post-training evaluation. Intervention training toolkit addressed ACP skills by dementia stage: (1) advance directives in early dementia, (2) decision-making capacity in moderate dementia, (3) Physician Orders for Life-Sustaining Treatment (POLST) in late-stage dementia, and (4) hospice and hospitalization in advanced dementia. Setting/Subjects: Nonhospitalized clinical care sites, 51 clinicians in North Carolina, USA. Measurements: Data collection utilized structured chart abstractions and pre- and post-training surveys. Results: Of 51 participants trained, 33 had encounters with patients with ADRD in study period. Most participants were women (n = 42), white (n = 37), and physicians (n = 31). Participants increased documentation of surrogates (22.7% vs. 35.5%, p = 0.03), decision-making capacity (13.5% vs.23.2%, p = 0.04), and POLST completion (9.2% vs. 18.8%, p = 0.03). Training increased ACP documentation (6.4% vs. 14.5%, p = 0.031) and goals of care (GOC) decision-making discussions (17.0% vs. 31.9%, p = 0.005). In pre-post-comparisons, participant confidence increased in determining capacity, exploring dementia prognosis, GOC, eliciting surrogates, and leading family meetings (all p < 0.001). Most participants strongly agreed that the training addressed skills used in practice (n = 34), contained clear language (n = 40), took an appropriate amount of time (n = 32), and was designed effectively (n = 35). Conclusion: This video-based training resource increased the use of dementia-specific ACP communication skills and clinician confidence.
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Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Geriatric Medicine and Palliative Care Program, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anna S Beeber
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gary S Winzelberg
- Division of Geriatric Medicine and Palliative Care Program, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Stacey L Gabriel
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura C Hanson
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Geriatric Medicine and Palliative Care Program, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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