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Ernecoff NC, Kurtz EC, Pearson EM, Grimes TH, Aldous A, Lupu DE, Schell JO. Advanced Care Planning in Chronic Kidney Disease: Qualitative Impact of the MY WAY Intervention. J Pain Symptom Manage 2024; 68:e167-e173. [PMID: 38848793 DOI: 10.1016/j.jpainsymman.2024.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/23/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024]
Abstract
CONTEXT Despite recommendations for shared decision-making and advanced care planning (ACP) for people with chronic kidney disease (CKD), such conversations are infrequent. The MY WAY educational and patient coaching intervention aimed to promote high-quality ACP. OBJECTIVES This qualitative substudy sought to gain participant feedback on the MY WAY ACP coaching intervention, and how it impacted their wishes, perceptions of kidney care, and factors that helped them reflect on ACP. METHODS We conducted semi-structured interviews with participants from the intervention arm of the MY WAY study about their prior experience with ACPs in the context of CKD, impressions of the MY WAY intervention, and outcomes of the MY WAY intervention. We conducted a qualitative thematic analysis of transcribed interviews. RESULTS Among 15 intervention participants, the following major themes emerged: 1) Patients with CKD approach ACP with varied experiences; 2) Patients felt the MY WAY coaching intervention supported ACP by reinforcing values; and 3) Patients found the coaching intervention focused on end of life, but not necessarily on decision making regarding CKD. CONCLUSION Participants perceived the coaching intervention to have high utility in facilitating ACP, but had a limited impact on CKD-specific decision-making. These findings suggest that the coach plays a crucial role in comfort with ACP conversations and that ACP readiness and engagement may not correlate with treatment preferences or understanding of CKD treatment decisions.
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Affiliation(s)
| | - Elizabeth Chen Kurtz
- University of Pittsburgh (E.C.K., E.M.P., T.H.G., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Elise Mandel Pearson
- University of Pittsburgh (E.C.K., E.M.P., T.H.G., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Tinsley H Grimes
- University of Pittsburgh (E.C.K., E.M.P., T.H.G., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Annette Aldous
- George Washington University (A.A., D.E.L.), Washington, District of Columbia, USA
| | - Dale E Lupu
- George Washington University (A.A., D.E.L.), Washington, District of Columbia, USA
| | - Jane O Schell
- University of Pittsburgh (E.C.K., E.M.P., T.H.G., J.O.S.), Pittsburgh, Pennsylvania, USA
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Cushman T, Hays E, Nagengast AK. Perioperative Care of the Patient with Directives Limiting Life-Sustaining Treatments. Anesthesiol Clin 2024; 42:393-406. [PMID: 39054015 DOI: 10.1016/j.anclin.2023.12.005] [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: 07/27/2024]
Abstract
Like most complex aspects of procedural care, sound perioperative management of limits to life-sustaining medical therapy requires a multidisciplinary team-based approach bolstered by appropriate care management strategies. This article discusses the implications of care for the patient for whom limitations of life-sustaining care are in place and the roles and responsibilities of each provider in supporting quality procedural care compatible with patients' right to self-determination. The authors focus on the roles of the surgeon, preoperative clinic provider, anesthesiologist, and postoperative care consultants and discuss how the health care system and care pathways can support and improve adherence to best practices.
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Affiliation(s)
- Tera Cushman
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Elizabeth Hays
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Andrea K Nagengast
- Portland VA Medical Center, 3710 Southwest US Veterans Hospital Road, Portland, OR 97239, USA
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McMahan RD, Sudore RL. Making advance care planning easier for adults with kidney disease and their clinicians. Nat Rev Nephrol 2024; 20:564-565. [PMID: 39090389 DOI: 10.1038/s41581-024-00871-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Affiliation(s)
- Ryan D McMahan
- University of California, San Francisco School of Medicine, San Francisco, CA, USA.
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
| | - Rebecca L Sudore
- University of California, San Francisco School of Medicine, San Francisco, CA, USA.
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
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Zupanc SN, Quintiliani LM, LeClair AM, Paasche-Orlow MK, Volandes A, Penumarthy A, Henault L, Itty JE, Davis AD, Lakin JR. The Sowers of Seeds: A Qualitative Analysis of the Role of Palliative Care Educators in Facilitating Goals-of-Care Conversations and Palliative Care Referrals. Am J Hosp Palliat Care 2024:10499091241267917. [PMID: 39196855 DOI: 10.1177/10499091241267917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2024] Open
Abstract
BACKGROUND Optimal care for seriously ill and older patients often involves advance care planning (ACP), goals-of-care (GOC) conversations, and specialty palliative care consultation, three sometimes overlapping, yet distinct practices. Insufficient staffing and investment in these areas have limited their availability. OBJECTIVES We explored the facilitators and barriers to successful implementation of the VIDEO-PCE trial. The intervention aimed to increase patient engagement in ACP, GOC, and by establishing Palliative Care Educators, a new clinical role integrated into existing hospital wards. DESIGN This qualitative interview study employed a semi-structured interview guide tailored to the interviewee's clinical role. The interviews elicited perceptions of the facilitators and barriers to integration of palliative care educators (PCEs) into existing workflows. We developed deductive codes a priori and inductive codes as we coded interview transcripts. SETTING/SUBJECTS Medical/surgical floor clinical colleagues, palliative care team members, and PCEs from both participating sites were interviewed. RESULTS Twenty-four individuals were interviewed (12 clinical staff of medical and surgical wards, seven palliative care team members, and five PCEs). Four themes were identified: (1) The work completed by the PCEs provided a foundation for future palliative care involvement; (2) Constituting the new role in practice required revision and creativity; (3) Communication was important to providing continuity of care; and (4) Establishing trust catalyzed the acceptance of the role. CONCLUSION The creation and implementation of a new role within existing clinical workflows posed some challenges but were felt to relieve staff from some work burden and allow more patients to engage in ACP and GOC conversations. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04857060.
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Affiliation(s)
- Seth N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Lisa M Quintiliani
- Division of General Internal Medicine, Department of Medicine, Tufts University School of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Amy M LeClair
- Division of General Internal Medicine, Department of Medicine, Tufts University School of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Division of General Internal Medicine, Department of Medicine, Tufts University School of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, MA, USA
- Section of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- ACP Decisions, Newton, MA, USA
| | - Akhila Penumarthy
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Lori Henault
- Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Jennifer E Itty
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | | | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, 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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Ma JE, Schlichte L, Haverfield M, Gambino J, Lange A, Blanchard K, Morgan B, Bekelman DB. Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy. J Am Geriatr Soc 2024; 72:2500-2507. [PMID: 38593240 PMCID: PMC11323159 DOI: 10.1111/jgs.18913] [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: 09/05/2023] [Revised: 03/07/2024] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Documenting goals of care in the electronic health record is meant to relay patient preferences to other clinicians. Evaluating the content and documentation of nurse and social worker led goals of care conversations can inform future goals of care initiative efforts. METHODS As part of the ADvancing symptom Alleviation with Palliative Treatment trial, this study analyzed goals of care conversations led by nurses and social workers and documented in the electronic health record. Informed by a goals of care communication guide, we identified five goals of care components: illness understanding, goals and values, end of life planning, surrogate, and advance directives. Forty conversation transcripts underwent content analysis. Through an iterative team process, we defined documentation accuracy as four categories: (1) Complete-comprehensive accurate documentation of the conversation, (2) Incomplete-partial documentation of the conversation, (3) Missing-discussed and not documented, and (4) Incorrect-misrepresented in documentation. We also defined-Not Discussed-for communication guide questions that were not discussed nor documented. A constant comparative approach was used to determine the presence or absence of conversation content in the documentation. RESULTS All five goals of care components were discussed in 67% (27/40) of conversation transcripts. Compared to the transcripts, surrogate (37/40, 93%) and advance directives (36/40, 90%) were often documented completely. Almost 40% of goals and values (15/40, 38%) and half of end of life planning (19/40, 48%) were incomplete. Illness understanding was missing (13/40, 33%), not discussed (13/40, 33%), or incorrect (2/40, 5%). CONCLUSION Nurse and social worker led goals of care conversations discussed and documented most components of the goals of care communication guide. Further research may guide how best to determine the relative importance of accuracy, especially in the broad setting of incomplete, missing, and incorrect EHR documentation.
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Affiliation(s)
- Jessica E Ma
- Geriatric Research Education and Clinical Center, Durham VA Health System, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Marie Haverfield
- Department of Communication Studies, San José State University, San Jose, California, USA
| | | | - Allison Lange
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kelly Blanchard
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Brianne Morgan
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - David B Bekelman
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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Shepherd V, Hood K, Wood F. 'It's not making a decision, it's prompting the discussions': a qualitative study exploring stakeholders' views on the acceptability and feasibility of advance research planning (CONSULT-ADVANCE). BMC Med Ethics 2024; 25:80. [PMID: 39039465 PMCID: PMC11265470 DOI: 10.1186/s12910-024-01081-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/08/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Health and care research involving people who lack capacity to consent requires an alternative decision maker to decide whether they participate or not based on their 'presumed will'. However, this is often unknown. Advance research planning (ARP) is a process for people who anticipate periods of impaired capacity to prospectively express their preferences about research participation and identify who they wish to be involved in future decisions. This may help to extend individuals' autonomy by ensuring that proxy decisions are based on their actual wishes. This qualitative study aimed to explore stakeholders' views about the acceptability and feasibility of ARP and identify barriers and facilitators to its implementation in the UK. METHODS We conducted semi-structured interviews with 27 researchers, practitioners, and members of the public who had participated in a preceding survey. Interviews were conducted remotely between April and November 2023. Data were analysed thematically. RESULTS Participants were supportive of the concept of ARP, with differing amounts of support for the range of possible ARP activities depending on the context. Six main themes were identified: (1) Planting a seed - creating opportunities to initiate/engage with ARP; (2) A missing part of the puzzle - how preferences expressed through ARP could help inform decisions; (3) Finding the sweet spot - optimising the timing of ARP; (4) More than a piece of paper - finding the best mode for recording preferences; (5) Keeping the door open to future opportunities - minimising the risk of unintended consequences; and (6) Navigating with a compass - principles underpinning ARP to ensure safeguarding and help address inequalities. Participants also identified a number of implementation challenges, and proposed facilitative strategies that might overcome them which included embedding advance research planning in existing future planning processes and research-focused activities. CONCLUSIONS This study provides a routemap to implementing ARP in the UK to enable people anticipating impaired capacity to express their preferences about research, thus ensuring greater opportunities for inclusion of this under-served group, and addressing the decisional burden experienced by some family members acting as proxies. Development of interventions and guidance to support ARP is needed, with a focus on ensuring accessibility.
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Affiliation(s)
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Fiona Wood
- PRIME Centre Wales, Cardiff, UK
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Stevens J, Scherrens AL, Pype P, Deliens L, De Vleminck A, Pardon K. Experiences with implementing advance care planning (ACP-GP) in Belgian general practice in the context of a cluster RCT: a process evaluation using the RE-AIM framework. BMC PRIMARY CARE 2024; 25:247. [PMID: 38971761 PMCID: PMC11227713 DOI: 10.1186/s12875-024-02510-5] [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: 11/07/2023] [Accepted: 07/01/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND General practice is often recommended as an ideal setting to initiate advance care planning (ACP), but uptake of ACP in this setting is low. ACP-GP is a complex intervention to facilitate ACP for patients with chronic, life-limiting illness in Belgian general practice. It aims to increase patient ACP engagement and general practitioner (GP) ACP self-efficacy. In a cluster-randomized controlled trial, the intervention was not superior to control in increasing these outcomes. A parallel process evaluation aimed to enhance understanding of how the intervention was implemented, and which factors might have influenced trial results. METHODS We conducted a mixed-methods process evaluation following the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data sources include recruitment and implementation monitoring, questionnaires for patients and GPs, and semi-structured (focus group) interviews with patients and GPs. Questionnaire data were analyzed descriptively. Qualitative data were first analyzed inductively; themes were then assigned deductively to RE-AIM dimensions. RESULTS Thirty-five GPs and 95 patients were recruited to the trial; GP reach was low. Sixteen GPs and 46 patients provided questionnaire data at 3 months post-baseline; qualitative data were transcribed for 14 GPs and 11 patients. Adoption of intervention components was moderate to good, with the exception of the documentation template for GPs. Interviews revealed varying patient attitudes towards ACP, but patients nonetheless emphasized that conversations made them feel reassured. GPs especially valued a positive framing of ACP. When adopted, the intervention was well-implemented and participant satisfaction was high. However, intention for maintenance was moderate, with GPs raising questions of how to sustainably implement ACP conversations in the future. CONCLUSIONS Implementing the complex ACP-GP intervention in general practice is feasible, and can be successful. However, the implementation process is challenging and the sustainability is suboptimal. Our findings will guide future research and recommendations for facilitating and implementing ACP in general practice. TRIAL REGISTRATION ISRCTN12995230; prospectively registered on 19/06/2020.
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Affiliation(s)
- Julie Stevens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium.
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels, 1090, Belgium.
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, Gent, 9000, Belgium.
| | - Anne-Lore Scherrens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, Gent, 9000, Belgium
| | - Peter Pype
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, Gent, 9000, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, Gent, 9000, Belgium
| | - Aline De Vleminck
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels, 1090, Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels, 1090, Belgium
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Nomura S, Nishio M, Abe SK, Eguchi A, Inoue M, Suzuki M, Hashizume M. Impact of the COVID-19 Pandemic on Cancer Death Locations in Japan: An Analysis of Excess Mortality Through February 2023. J Epidemiol 2024; 34:349-355. [PMID: 37866926 PMCID: PMC11167266 DOI: 10.2188/jea.je20230235] [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: 08/25/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND The novel coronavirus disease 2019 (COVID-19) pandemic has significantly impacted end-of-life decisions for cancer patients in Japan, with disparities existing between preferred and actual care settings. Our study investigates the potential shifts in cancer death locations during the pandemic and if there were excess cancer deaths. METHODS Utilizing national mortality data from the Ministry of Health, Labour and Welfare from January 2012 to February 2023, we identified cancer deaths using International Classification of Disease, 10th revision codes. We assessed death locations, including medical institutions, nursing facilities, and homes. The Farrington algorithm was employed to estimate expected death counts, and the differences between observed and expected counts were denoted as excess deaths. RESULTS From January 2018 to February 2023, there was consistently increase in the weekly observed cancer deaths. The presence of a definitive excess during the pandemic period remains uncertain. The percentage of deaths in medical institutions declined from 83.3% to 70.1%, while home deaths increased from 12.1% to 22.9%. Between April 2020 and February 2023, deaths in medical institutions frequently fell below the 95% prediction lower limit. Home deaths consistently exceeded the 95% prediction upper limit, with significant excess deaths reported annually. CONCLUSION Our study found a shift in cancer death locations from medical institutions to homes in Japan during the COVID-19 pandemic. Our study did not confirm an overall increase in cancer deaths during this period. As with global trends, the profound shift from hospitals to homes in Japan calls for a comprehensive exploration to grasp the pandemic's multifaceted impact on end-of-life cancer care decisions.
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Affiliation(s)
- Shuhei Nomura
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
- Division of Prevention, National Cancer Center Institute for Cancer Control, Tokyo, Japan
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Tokyo Foundation for Policy Research, Tokyo, Japan
| | - Marisa Nishio
- Division of Prevention, National Cancer Center Institute for Cancer Control, Tokyo, Japan
- Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | - Sarah Krull Abe
- Division of Prevention, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Akifumi Eguchi
- Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Manami Inoue
- Division of Prevention, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Motoi Suzuki
- Infectious Disease Surveillance Center at the National Institute of Infectious Diseases, Tokyo, Japan
| | - Masahiro Hashizume
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Magoon C, Jackson V, Shalev D. Serious illness communication: A gap in psychiatric care. Gen Hosp Psychiatry 2024; 89:106-107. [PMID: 38658245 DOI: 10.1016/j.genhosppsych.2024.04.004] [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] [Received: 02/14/2024] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Christopher Magoon
- Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, United States of America.
| | - Vicki Jackson
- Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, United States of America
| | - Daniel Shalev
- Weill Cornell Medical College, 1300 York Ave, New York, NY 10065, United States of America
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11
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Komiya K, Yamatani I, Kadota JI. Treatment strategy for older patients with pneumonia independent of the risk of drug resistance in the world's top country for longevity. Respir Investig 2024; 62:710-716. [PMID: 38823190 DOI: 10.1016/j.resinv.2024.05.016] [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: 03/21/2024] [Revised: 05/05/2024] [Accepted: 05/26/2024] [Indexed: 06/03/2024]
Abstract
The number of older people with impaired swallowing function increases with aging population. Aspiration pneumonia is one of the most cases of pneumonia developing among older people. As aspiration pneumonia may develop as a result of age-related deterioration, it is crucial to consider it as an unavoidable event with aging. While pneumonia is diagnosed based on respiratory symptoms and radiological features, the lung involvement of aspiration pneumonia may be undetectable via a frontal chest radiograph in some cases. Bacterial profiles show the predominance of drug-resistant bacteria, such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA), but isolated bacteria from respiratory samples do not necessarily indicate causative pathogens. Furthermore, there is no evidence regarding treatment superiority using broad-spectrum antibiotics compared with narrow-spectrum antibiotics. Even if isolated pathogens are a causative factor for pneumonia among older patients, the use of broad-spectrum antibiotics covering the bacteria may not improve their outcomes. Therefore, we propose a treatment strategy independent of the risk of drug resistance focusing on the discrimination of patients who are unlikely to respond to broad-spectrum antibiotics. An aspiration risk is associated with increased in-hospital mortality in patients with pneumonia, which could also lead to a greater risk of poor long-term outcomes with increased 1-year mortality. Advance care planning is now recognized as a process for communication and medical decision-making across the life course. This approach would be widely recommended for older people with aspiration risk.
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Affiliation(s)
- Kosaku Komiya
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan; Research Center for Global and Local Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan.
| | - Izumi Yamatani
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan; Department of Mycobacterium Reference and Research, the Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Kiyose, Tokyo, Japan.
| | - Jun-Ichi Kadota
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan.
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Manning ME, Fricker Z. Cardiopulmonary Resuscitation Outcomes and Trainee Perception of Code Status Discussions in Patients with Cirrhosis. Dig Dis Sci 2024; 69:2390-2400. [PMID: 38652391 DOI: 10.1007/s10620-024-08443-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) outcomes among patients with cirrhosis are poor, but factors associated with outcomes and provider awareness remain under-evaluated. AIMS We retrospectively investigated in-hospital CPR mortality among patients with cirrhosis, and, using these results, undertook an educational study among providers to improve knowledge of CPR outcomes and code status in patients with cirrhosis. METHODS We identified patients with cirrhosis admitted from 2012 to 2022 who underwent CPR at our center; the primary outcome was survival-to-discharge. A brief video based on these results was presented online to Internal Medicine residents, along with paired pre/post-surveys assessing attitudes toward holding code status conversations and knowledge of CPR outcomes in patients with cirrhosis. RESULTS 97 cases of CPR were identified. 27 patients (28%) survived to discharge post-CPR. A history of liver decompensation was significantly associated with lower survival (OR 0.21, p < 0.05). 22 residents participated in the educational intervention; afterward, their estimation of survival after CPR for patients with cirrhosis significantly improved (p < 0.05). Mean confidence in answering patient questions about prognosis, measured from 1 to 5, also significantly improved (2.4-"a little confident" vs. 3.8-"confident", p < 0.05). 59% of surveyed residents identified impact on liver transplant candidacy as at least a "somewhat significant" barrier to code status conversations. CONCLUSIONS We identified significant trainee uncertainty about outcomes in patients with cirrhosis. These deficits improved after an educational intervention and gave providers more confidence in holding informed code status conversations with patients with cirrhosis, a population that faces barriers to adequate code discussions.
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Affiliation(s)
- Margot E Manning
- Harvard Medical School, Boston, MA, USA.
- Internal Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Zachary Fricker
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Hepatology, & Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
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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 2024:10499091241233687. [PMID: 38896819 DOI: 10.1177/10499091241233687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [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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Stevens J, Elston D, Tan A, Barwich D, Carter RZ, Cochrane D, Frenette N, Howard M. Clinicians' experiences implementing an advance care planning pathway in two Canadian provinces: a qualitative study. BMC PRIMARY CARE 2024; 25:217. [PMID: 38879532 PMCID: PMC11179357 DOI: 10.1186/s12875-024-02468-4] [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: 08/01/2023] [Accepted: 06/04/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Advance care planning (ACP) is a process which enables patients to communicate wishes, values, fears, and preferences for future medical care. Despite patient interest in ACP, the frequency of discussions remains low. Barriers to ACP may be mitigated by involving non-physician clinic staff, preparing patients ahead of visits, and using tools to structure visits. An ACP care pathway incorporating these principles was implemented in longitudinal generalist outpatient care, including primary care/family medicine and general internal medicine, in two Canadian provinces. This study aims to understand clinician experiences implementing the pathway. METHODS The pathway was implemented in one family practice in Alberta, two family practices in British Columbia (BC), and one BC internal medicine outpatient clinic. Physicians and allied health professionals delivered structured pathway visits based on the Serious Illness Conversation Guide. Twelve physicians and one social worker participated in interviews or focus groups at the end of the study period. Qualitative data were coded inductively using an iterative approach, with regular meetings between coders. RESULTS Clinicians described experiences with the ACP care pathway, impact at the clinician level, and impact at the patient level. Within each domain, clinicians described barriers and facilitators experienced during implementation. Clinicians also reflected candidly about potential for future implementation and the sustainability of the pathway. CONCLUSIONS While the pathway was implemented slightly differently between provinces, core experiences were that implementation of the pathway, and integration with current practice, were feasible. Across settings, similar themes recurred regarding usefulness of the pathway structure and its tools, impact on clinician confidence and interactions with patients, teamwork and task delegation, compatibility with existing workflow, and patient preparation and readiness. Clinicians were supportive of ACP and of the pathway. TRIAL REGISTRATION The study was prospectively registered with clinicaltrials.gov (NCT03508557). Registered April 25, 2018. https://classic. CLINICALTRIALS gov/ct2/show/NCT03508557 .
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Affiliation(s)
- Julie Stevens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Laarkbeeklaan 103, Brussels, Belgium.
| | - Dawn Elston
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
| | - Amy Tan
- Department of Medicine, Faculty of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, Canada
| | - Doris Barwich
- Department of Medicine, Faculty of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, Canada
- BC Centre for Palliative Care, 300 - 601 Sixth St., New Westminster, BC, Canada
| | - Rachel Zoe Carter
- Department of Medicine, Faculty of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, Canada
- BC Centre for Palliative Care, 300 - 601 Sixth St., New Westminster, BC, Canada
| | - Diana Cochrane
- BC Centre for Palliative Care, 300 - 601 Sixth St., New Westminster, BC, Canada
| | - Nicole Frenette
- Department of Family Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
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15
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Wittenberg E, Sullivan SS, Rios M. Improving Dementia Caregiver Activation With a Brief Communication Module. Am J Hosp Palliat Care 2024; 41:805-813. [PMID: 37703530 DOI: 10.1177/10499091231200639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
Objective: Palliative care often plays a pivotal role in supporting informal caregivers of persons living with dementia who experience a lack of continuity in care. Dementia caregiver activation, the caregiver's willingness and ability to navigate care needs, requires communication skills for developing relationships with healthcare providers. Communication activation is important because caregivers facilitate physician and patient information exchange. This study aimed to explore changes in communication outcomes (attitude, knowledge, and skills) and impact on caregiver communication activation (confidence, self-report) following completion of a brief communication module. Methods: A 15-minute asynchronous online module was developed to provide caregivers with communication skills for working with doctors and nurses. Caregivers completed pre/post module measures of communication outcomes, a vignette for applying communication strategies and were interviewed within a week of module completion to assess self-reported communication activation. Module acceptability was also evaluated. Results: Communication knowledge (P < .01) significantly increased and nearly all participants (99%) demonstrated use of module-specific communication skills after completing the module. While not statistically significant, caregiver attitudes were in the expected direction. Caregiver self-reported communication confidence (P < .001) significantly increased and 84% of caregivers described communication activation at post-module. Caregivers (83%) were likely to recommend the module. Conclusions: The brief communication module for dementia caregivers in this project offers an online resource with low time-burden that results in caregiver communication activation. Future testing in the clinical setting will increase understanding of its efficacy and integration and could be a viable resource for palliative care providers.
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Affiliation(s)
- Elaine Wittenberg
- Department of Communication Studies, California State University Los Angeles, Los Angeles, CA, USA
| | - Suzanne S Sullivan
- School of Nursing, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Melissa Rios
- Department of Psychology, California State University Los Angeles, Los Angeles, CA, USA
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Roberts RL, Cherry KD, Mohan DP, Statler T, Kirkendall E, Moses A, McCraw J, Brown III AE, Fofanova TY, Gabbard J. A Personalized and Interactive Web-Based Advance Care Planning Intervention for Older Adults (Koda Health): Pilot Feasibility Study. JMIR Aging 2024; 7:e54128. [PMID: 38845403 PMCID: PMC11089888 DOI: 10.2196/54128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/28/2024] [Accepted: 03/14/2024] [Indexed: 06/10/2024] Open
Abstract
Background Advance care planning (ACP) is a process that involves patients expressing their personal goals, values, and future medical care preferences. Digital applications may help facilitate this process, though their use in older adults has not been adequately studied. Objective This pilot study aimed to evaluate the reach, adoption, and usability of Koda Health, a web-based patient-facing ACP platform, among older adults. Methods Older adults (aged 50 years and older) who had an active Epic MyChart account at an academic health care system in North Carolina were recruited to participate. A total of 2850 electronic invitations were sent through MyChart accounts with an embedded hyperlink to the Koda platform. Participants who agreed to participate were asked to complete pre- and posttest surveys before and after navigating through the Koda Health platform. Primary outcomes were reach, adoption, and System Usability Scale (SUS) scores. Exploratory outcomes included ACP knowledge and readiness. Results A total of 161 participants enrolled in the study and created an account on the platform (age: mean 63, SD 9.3 years), with 80% (129/161) of these participants going on to complete all steps of the intervention, thereby generating an advance directive. Participants reported minimal difficulty in using the Koda platform, with an overall SUS score of 76.2. Additionally, knowledge of ACP (eg, mean increase from 3.2 to 4.2 on 5-point scale; P<.001) and readiness (eg, mean increase from 2.6 to 3.2 on readiness to discuss ACP with health care provider; P<.001) significantly increased from before to after the intervention. Conclusions This study demonstrated that the Koda Health platform is feasible, had above-average usability, and improved ACP documentation of preferences in older adults. Our findings indicate that web-based health tools like Koda may help older individuals learn about and feel more comfortable with ACP while potentially facilitating greater engagement in care planning.
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Affiliation(s)
| | | | | | - Tiffany Statler
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Eric Kirkendall
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | - Adam Moses
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | - Jennifer McCraw
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | - Andrew E Brown III
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | | | - Jennifer Gabbard
- Section of Gerontology and Geriatric Medicine, School of Medicine, Wake Forest University, Winston-Salem, NC, United States
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Song MK, Higgins MK, Ward SE, Lee H, Noorani N, Happ MB. Measures of Patient and Surrogate Preparedness for End-of-Life Decision-Making. J Pain Symptom Manage 2024; 67:429-440.e2. [PMID: 38355069 PMCID: PMC11032227 DOI: 10.1016/j.jpainsymman.2024.02.005] [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: 12/12/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/16/2024]
Abstract
CONTEXT Reliable and valid measures are critical in accurately assessing outcomes of advance care planning interventions (ACP) for end-of-life (EOL) decision-making. OBJECTIVES To develop measures of preparedness for EOL decision-making for patients with end-stage renal disease and their surrogates (an exemplar population). METHODS In this 3-phase study, Phases 1 and 2 included a cross-discipline concept analysis of the preparedness construct, item generation for patient and surrogate scales (82 items), evaluation of content validity and readability, cognitive interviewing, and item reduction. In phase 3, the retained 26 patient and 25 surrogate items were administered to 426 patients and 426 surrogates during a multisite trial of an ACP intervention versus care-as-usual and evaluated internal consistency, 2-week test-retest reliability, and construct validity. RESULTS Scales were reduced to 20 patient and 19 surrogate items during phase 3. Cronbach's alphas were 0.86 (patient) and 0.90 (surrogate). There was a strong correlation between preparedness at baseline and two weeks for both scales (r = 0.66-0.69, P < 0.001). Confirmatory factor analysis and item-response analyses suggested unidimensionality. A significant correlation was shown between patient preparedness and patient decisional conflict (r = -0.53, P < 0.001), and surrogate preparedness and surrogate decision-making confidence (r = 0.44, P < 0.001). Among those who received the ACP intervention, the effect size of change was medium: Cohen's d = 0.54, P < 0.001 for patients and d = 0.57, P < 0.001 for surrogates. CONCLUSIONS The preparedness scales demonstrated strong psychometric properties. Future studies should examine scale performance in other populations.
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Affiliation(s)
- Mi-Kyung Song
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA.
| | - Melinda K Higgins
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA
| | - Sandra E Ward
- School of Nursing (S.E.W.), University of Wisconsin-Madison, Signe Skott Cooper Hall, 701 Highland Avenue, Madison, WI 53705, USA
| | - Haerim Lee
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA
| | - Naziya Noorani
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA
| | - Mary Beth Happ
- College of Nursing (M.B.H.), The Ohio State University, 1577 Neil Ave, Columbus, OH 43210, USA
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Colley A, Broering J, Lee K, Lin JA, Pierce L, Finlayson E, Sudore RL, Wick EC. "It Gives Me Peace of Mind So I Can Focus on Healing": Views on Advance Care Planning for Older Surgical Patients. J Palliat Med 2024; 27:667-674. [PMID: 38386513 PMCID: PMC11238830 DOI: 10.1089/jpm.2023.0589] [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: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction: The period of time before an elective operation may be an opportune time to engage older adults in advance care planning (ACP). Past interventions have not been readily incorporated into surgical workflows leaving a need for ACP tools that are generalizable, easy to implement, and effective. Design: This is a qualitative study. Setting and Subjects: Older adults with a history of cancer and a recent major operation were recruited through their surgical oncologist at a tertiary medical center in the United States. Interviews were conducted to determine how to adapt the validated PrepareForYourCare.org ACP program with electronic health record prompts for the perioperative setting and openness to introducing ACP during a presurgical visit. We used qualitative content analysis to determine themes. Results: Eight themes were identified: (1) ACP as static and private, (2) people expected a prompt, (3) family trusted to do the "right" thing, (4) lack of relationship or comfort with providers, (5) a team-based approach can be helpful, (6) surgeon's expertise (e.g., prognosis and surgical risk), (7) ACP belongs on the surgical checklist, and (8) patients would welcome a conversation starter. Discussion: Older surgical patients are interested in engaging with ACP, particularly if prompted, and believe it has a place on the preoperative "checklist." Conclusions: To effectively engage patients with ACP, a combination of routine prompts by the health care team and patient-centered follow-up may be required.
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Affiliation(s)
- Alexis Colley
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jeannette Broering
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Katherine Lee
- Division of Palliative Medicine, University of California, San Francisco, California, USA
| | - Joseph A. Lin
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Logan Pierce
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Elizabeth C. Wick
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
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Nakanishi M, Martins Pereira S, Van den Block L, Parker D, Harrison-Dening K, Di Giulio P, In der Schmitten J, Larkin PJ, Mimica N, Sudore RL, Holmerová I, Korfage IJ, van der Steen JT. Future policy and research for advance care planning in dementia: consensus recommendations from an international Delphi panel of the European Association for Palliative Care. THE LANCET. HEALTHY LONGEVITY 2024; 5:e370-e378. [PMID: 38608695 PMCID: PMC11262782 DOI: 10.1016/s2666-7568(24)00043-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 04/14/2024] Open
Abstract
Advance care planning (ACP) is increasingly recognised in the global agenda for dementia care. The European Association for Palliative Care (EAPC) Taskforce on ACP in Dementia aimed to provide recommendations for policy initiatives and future research. We conducted a four-round Delphi study with a 33-country panel of 107 experts between September, 2021, and June, 2022, that was approved by the EAPC Board. Consensus was achieved on 11 recommendations concerning the regulation of advance directives, equity of access, and dementia-inclusive approaches and conversations to express patients' values. Identified research gaps included the need for an evidence-based dementia-specific practice model that optimises engagement and communication with people with fluctuating and impaired capacity and their families to support decision making, while also empowering people to adjust their decisions if their goals or preferences change over time. Policy gaps included insufficient health services frameworks for dementia-inclusive practice. The results highlight the need for more evidence and policy development that support inclusive ACP practice models.
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Affiliation(s)
- Miharu Nakanishi
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands; Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, Sendai-shi, Japan; Mental Health Promotion Unit, Research Center for Social Science and Medicine, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan.
| | - Sandra Martins Pereira
- CEGE: Research Center in Management and Economics - Ethics and Sustainability Research Area, Católica Porto Business School, Universidade Católica Portuguesa, Porto, Portugal
| | - Lieve Van den Block
- Vrije Universiteit Brussel-UGent End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Deborah Parker
- School of Nursing and Midwifery, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Karen Harrison-Dening
- Department of Research and Publications, Dementia UK, London, UK; Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Jürgen In der Schmitten
- Institute of General Practice/Family Practice, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Philip J Larkin
- Institute of Higher Education and Research in Healthcare, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ninoslav Mimica
- School of Medicine, University of Zagreb, Zagreb, Croatia; Department for Biological Psychiatry and Psychogeriatrics, University Psychiatric Hospital Vrapče, Zagreb, Croatia
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Iva Holmerová
- Centre of Expertise in Longevity and Long-Term Care, Faculty of Humanities, Charles University, Prague, Czech Republic
| | - Ida J Korfage
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands; Radboudumc Alzheimer Center and Department of Primary and Community Care, Radboud university medical center, Nijmegen, Netherlands; Cicely Saunders Institute, Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Kaplan A, Ladin K, Junna S, Lindenberger E, Ufere NN. Serious Illness Communication in Cirrhosis Care: Tools to Improve Illness Understanding, Prognostic Understanding, and Care Planning. GASTRO HEP ADVANCES 2024; 3:634-645. [PMID: 38873184 PMCID: PMC11175167 DOI: 10.1016/j.gastha.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Patients with cirrhosis frequently experience an unpredictable illness trajectory, with frequent hospitalizations and complications. Along with the uncertain nature of the disease, the possibility of a lifesaving and curative transplant often makes prognostic discussions and future care decisions challenging. Serious illness communication (SIC) refers to supportive communication whereby clinicians assess patients' illness understanding, share prognostic information according to patients' preferences, explore patients' goals, and make recommendations for care that align with these goals. SIC includes 3 key components: (1) illness understanding; (2) prognostic understanding; and (3) care planning. In this piece, we explore current barriers to early implementation of SIC in cirrhosis care and share possible solutions, including adopting a multidisciplinary approach, delivering culturally competent care, and training clinicians in SIC core skills. By use of a case example, we aim to demonstrate SIC in action and to provide clinicians with tools and skills that can be used in practice.
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Affiliation(s)
- Alyson Kaplan
- Department of Gastroenterology, Department of Surgery, Transplant Institute, Tufts University Medical Center, Boston, Massachusetts
| | - Keren Ladin
- Department of Community Health, Tufts University, Boston, Massachusetts
| | - Shilpa Junna
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Elizabeth Lindenberger
- Department of Geriatrics and Palliative Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Nneka N. Ufere
- Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
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Umberfield EE, Fields MC, Lenko R, Morgan TP, Adair ES, Fromme EK, Lum HD, Moss AH, Wenger NS, Sudore RL, Hickman SE. An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go? J Am Med Dir Assoc 2024; 25:557-564.e8. [PMID: 38395413 PMCID: PMC10996838 DOI: 10.1016/j.jamda.2024.01.009] [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: 11/16/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research. DESIGN Integrative review. SETTING AND PARTICIPANTS Not applicable. METHODS We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization. RESULTS Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified. CONCLUSIONS AND IMPLICATIONS Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.
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Affiliation(s)
- Elizabeth E Umberfield
- Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN, USA; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA.
| | - Matthew C Fields
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
| | - Rachel Lenko
- Department of Nursing, School of Health, Calvin University, Grand Rapids, MI, USA
| | - Teryn P Morgan
- Center for Biomedical Informatics, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of BioHealth Informatics, School of Informatics and Computing, Indiana University, Indianapolis, IN, USA
| | | | - Erik K Fromme
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA; Divisions of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
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Zupanc SN, Durieux BN, Walling AM, Lindvall C. Bolstering Advance Care Planning Measurement Using Natural Language Processing. J Palliat Med 2024; 27:447-450. [PMID: 38324042 DOI: 10.1089/jpm.2023.0528] [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: 02/08/2024] Open
Abstract
Despite its growth as a clinical activity and research topic, the complex dynamic nature of advance care planning (ACP) has posed serious challenges for researchers hoping to quantitatively measure it. Methods for measurement have traditionally depended on lengthy manual chart abstractions or static documents (e.g., advance directive forms) even though completion of such documents is only one aspect of ACP. Natural language processing (NLP), in the form of an assisted electronic health record (EHR) review, is a technological advancement that may help researchers better measure ACP activity. In this article, we aim to show how NLP-assisted EHR review supports more accurate and robust measurement of ACP. We do so by presenting three example applications that illustrate how using NLP for this purpose supports (1) measurement in research, (2) detailed insights into ACP in quality improvement, and (3) identification of current limitations of ACP in clinical settings.
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Affiliation(s)
- Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- UCSF School of Medicine, San Francisco, California, USA
| | - Brigitte N Durieux
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anne M Walling
- Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
- VDepartment of Medicine, A Greater Los Angeles Health System, Los Angeles, California, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
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Giordano A, De Panfilis L, Veronese S, Bruzzone M, Cascioli M, Farinotti M, Giovannetti AM, Grasso MG, Kruger P, Lugaresi A, Manson L, Perin M, Pucci E, Solaro C, Ghirotto L, Solari A. User appraisal of a booklet for advance care planning in multiple sclerosis: a multicenter, qualitative Italian study. Neurol Sci 2024; 45:1145-1154. [PMID: 37816932 PMCID: PMC10858142 DOI: 10.1007/s10072-023-07087-y] [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: 08/04/2023] [Accepted: 09/25/2023] [Indexed: 10/12/2023]
Abstract
OBJECTIVES Implementation of advance care planning (ACP) in people with progressive multiple sclerosis (PwPMS) is limited. We aimed to involve users (PwPMS, significant others, and healthcare professionals involved in PwPMS care) in the evaluation and refinement of a booklet to be used during the ACP conversations. METHODS This qualitative study consisted of cognitive interviews with PwPMS and significant others and a focus group with healthcare professionals from three Italian centers. We analyzed the interviews using the framework method and the focus group using thematic analysis. RESULTS We interviewed 10 PwPMS (3 women; median age 54 years; median Expanded Disability Status Scale score 6.0) and three significant others (2 women; 2 spouses and one daughter). The analysis yielded three themes: booklet comprehensibility and clarity, content acceptability and emotional impact, and suggestions for improvement. Twelve healthcare professionals (7 neurologists, 3 psychologists, one nurse, and one physiotherapist) participated in the focus group, whose analysis identified two themes: booklet's content importance and clarity and challenges to ACP implementation. Based on analysis results, we revised the booklet (text, layout, and pictures) and held a second-round interviews with two PwPMS and one significant other. The interviewees agreed on the revisions but reaffirmed their difficulty in dealing with the topic and the need for a physician when using the booklet. CONCLUSIONS Appraisal of the booklet was instrumental in improving its acceptability and understandability before using it in the ConCure-SM feasibility trial. Furthermore, our data reveal a lack of familiarity with ACP practice in the Italian context.
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Affiliation(s)
- Andrea Giordano
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy.
| | - Ludovica De Panfilis
- Bioethics Unit - Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, 42100, Reggio Emilia, Italy
| | | | | | - Marta Cascioli
- Hospice 'La Torre Sul Colle, Azienda USL Umbria 2, 06049, Spoleto, Italy
| | - Mariangela Farinotti
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | - Ambra Mara Giovannetti
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | | | - Paola Kruger
- The European Patients' Academy (EUPATI), 00165, Rome, Italy
| | - Alessandra Lugaresi
- UOSI Riabilitazione Sclerosi Multipla, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40121, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, 40121, Bologna, Italy
| | - Leigh Manson
- Health Quality & Safety Commission New Zealand, 7045, Nelson, New Zealand
| | - Marta Perin
- Bioethics Unit - Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, 42100, Reggio Emilia, Italy
- Doctoral Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41100, Modena, Italy
| | - Eugenio Pucci
- UOC Neurologia AV4, ASUR Marche, 63900, Fermo, Italy
| | - Claudio Solaro
- Department of Rehabilitation, CRRF "Mons. L. Novarese", Loc. Trompone, 13040, Moncrivello, Italy
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL-IRCCS di Reggio Emilia, 42100, Reggio Emilia, Italy
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
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24
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Tietbohl CK, Ritger C, Jordan S, Shanbhag P, Sudore RL, Lum HD. A Mixed-Methods Comparison of Interventions to Increase Advance Care Planning. J Am Board Fam Med 2024; 37:215-227. [PMID: 38740474 PMCID: PMC11262783 DOI: 10.3122/jabfm.2023.230187r2] [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: 05/16/2023] [Revised: 09/12/2023] [Accepted: 10/09/2023] [Indexed: 05/16/2024] Open
Abstract
PURPOSE Although interventions can increase advance care planning (ACP) engagement, it remains unclear which interventions to choose in primary care settings. This study compares a passive intervention (mailed materials) to an interactive intervention (group visits) on participant ACP engagement and experiences. METHODS We used mixed methods to examine ACP engagement at baseline and six months following two ACP interventions. Eligible patients were randomized to receive mailed materials or participate in two ACP group visits. We administered the 4-item ACP Engagement survey (n = 110) and conducted interviews (n = 23). We compared mean scores and percent change in ACP engagement, analyzed interviews with directed content analysis to understand participants' ACP experiences, and integrated the findings based on mailed materials or group visits intervention. RESULTS All participants demonstrated increased ACP engagement scores. At six months, group visit participants reported higher percent change in mean overall score compared with mailed materials participants (+8% vs +3%, P < .0001). Group visits participants reported that being prompted to think about end-of-life preferences, gaining knowledge about ACP, and understanding the value of completing ACP documentation influenced their ACP readiness. While both interventions encouraged patients to start considering and refining their end-of-life preferences, group visits made patients feel more knowledgeable about ACP, highlighted the importance of completing ACP documentation early, and sparked further ACP discussions with others. CONCLUSIONS While primary care patients may benefit from mailed ACP materials, patients reported increased readiness after ACP group visits. Group visits emphasized the value of upstream preparation, ongoing conversations, and increased knowledge about ACP.
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Affiliation(s)
- Caroline K Tietbohl
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO (CKT); Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO (CKT, CR); Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (SJ,PS,HDL); Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA (RSL).
| | - Carly Ritger
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO (CKT); Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO (CKT, CR); Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (SJ,PS,HDL); Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA (RSL)
| | - Sarah Jordan
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO (CKT); Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO (CKT, CR); Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (SJ,PS,HDL); Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA (RSL)
| | - Prajakta Shanbhag
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO (CKT); Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO (CKT, CR); Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (SJ,PS,HDL); Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA (RSL)
| | - Rebecca L Sudore
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO (CKT); Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO (CKT, CR); Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (SJ,PS,HDL); Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA (RSL)
| | - Hillary D Lum
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO (CKT); Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO (CKT, CR); Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (SJ,PS,HDL); Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA (RSL)
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25
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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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26
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Hickman SE, Fromme EK. Realizing the Promise of Advance Care Planning Will Require Health System Accountability to Quality Standards. Jt Comm J Qual Patient Saf 2024; 50:93-94. [PMID: 38171950 DOI: 10.1016/j.jcjq.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 11/20/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024]
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Monnet F, Diaz A, Gove D, Dupont C, Pivodic L, Van den Block L. The perspectives of people with dementia and their supporters on advance care planning: A qualitative study with the European Working Group of People with Dementia. Palliat Med 2024; 38:251-263. [PMID: 38293945 PMCID: PMC10938474 DOI: 10.1177/02692163231219915] [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] [Indexed: 02/01/2024]
Abstract
BACKGROUND Advance care planning has been defined in an international consensus paper, supported by the European Association for Palliative Care. There are concerns that this definition may not apply to dementia. Moreover, it is not informed by input from people with dementia. AIM To gather the perspective of the European Working Group of People with Dementia and their supporters on how advance care planning is defined and develop recommendations for changes to the definition. DESIGN An in-depth qualitative study was conducted, analysing online focus groups and interviews using thematic analysis. SETTING/PARTICIPANTS We included 12 people with dementia and 9 supporters. RESULTS Participants suggested several changes to the current advance care planning definition: mentioning people with decreasing decisional capacity; better reflecting the role of family and/or trust-based relationships; reducing focus on end-of-life/medical decisions; strengthening focus on social aspects of care. Elements of the current definition that participants suggested keeping and highlighting include the framing of advance care planning as a continuous process, that is also optional; mention of communication next to documentation of decisions; and the importance of proxy decision makers. Based on this input, we developed three overarching and 16 specific recommendations for a modified definition of advance care planning that is inclusive of people with dementia. CONCLUSIONS The perspectives of the European Working Group of People with Dementia and their supporters highlighted the need for a person-centred and dementia-inclusive advance care planning definition. We provide tangible recommendations for future adaptations of the definition that reflect these perspectives.
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Affiliation(s)
- Fanny Monnet
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Ana Diaz
- Alzheimer Europe, Luxembourg, Luxembourg
| | | | - Charlèss Dupont
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Lara Pivodic
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Li L, Barnes DE, Nouri S, Shi Y, Volow AM, Feuz M, Li BH, Sudore RL. Surrogate decision-makers from historically marginalized populations have lower levels of preparedness for care planning. J Am Geriatr Soc 2024; 72:559-566. [PMID: 38193805 PMCID: PMC10922733 DOI: 10.1111/jgs.18732] [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: 05/31/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Surrogate preparedness for medical decision-making is an important part of care planning. This study examined preparedness and engagement among historically marginalized surrogates. METHODS Surrogates were included if they were named medical decision-makers by patients ≥55 years at a San Francisco safety-net and Veterans Affairs hospital. We assessed preparedness for medical decision-making by asking if surrogates had been formally asked to be the medical decision-maker, if patients had discussed medical wishes with surrogates, and if the surrogate role and these medical wishes had been documented. We assessed surrogate confidence and readiness using a modified Surrogate ACP Engagement Survey. We used Wilcoxon rank-sum tests to measure the association of engagement scores with surrogate characteristics. RESULTS Of 422 surrogates, their mean age was 53 years (SD ±14.5), 73% were from minoritized groups, 38% were Spanish-speaking, and 15% had limited health literacy. For preparedness outcomes, 13% of surrogates were not formally asked to play this role, 46% reported the patient had not discussed end-of-life medical wishes, and 51% reported there had been no formal documentation of the surrogate role. Surrogates reported higher confidence 4.43/5 (SD ± 0.64) than readiness 3.70 (1.22) for decision-making (p < 0.001). Confidence and readiness scores were lower among historically marginalized participants. CONCLUSION More resources are needed to prepare surrogate decision-makers from historically marginalized communities for discussing patient's goals of care and treatment preferences.
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Affiliation(s)
- Lingsheng Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Deborah E. Barnes
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
| | - Sarah Nouri
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Ying Shi
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Aiesha M. Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Mariko Feuz
- University of Iowa-Des Moines Internal Medicine Residency Program, Des Moines, IA, USA
| | - Brookelle H. Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
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29
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Jackson VA, Emanuel L. Navigating and Communicating about Serious Illness and End of Life. N Engl J Med 2024; 390:63-69. [PMID: 38118003 DOI: 10.1056/nejmcp2304436] [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: 12/22/2023]
Affiliation(s)
- Vicki A Jackson
- From the Department of Medicine, Division of Palliative Care and Geriatric Medicine (V.A.J.), and the Center for Aging and Serious Illness Research (V.A.J., L.E.) and Cancer Outcomes Research and Education Program (V.A.J.), the Mongan Institute, Massachusetts General Hospital, and the Harvard Medical School Center for Palliative Care (V.A.J.) - both in Boston; and the Department of Supportive Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Medical Group, Feinberg School of Medicine, Chicago (L.E.)
| | - Linda Emanuel
- From the Department of Medicine, Division of Palliative Care and Geriatric Medicine (V.A.J.), and the Center for Aging and Serious Illness Research (V.A.J., L.E.) and Cancer Outcomes Research and Education Program (V.A.J.), the Mongan Institute, Massachusetts General Hospital, and the Harvard Medical School Center for Palliative Care (V.A.J.) - both in Boston; and the Department of Supportive Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Medical Group, Feinberg School of Medicine, Chicago (L.E.)
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30
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Arnold RM, Levoy K, Hickman SE, Jawahri AE, Jackson V, Tulsky JA. JPSM Controversies in Palliative Care: "What is the Most Important, Measurable Goal of Serious Illness Conversations in the Ambulatory Setting?". J Pain Symptom Manage 2024; 67:e105-e110. [PMID: 37591321 DOI: 10.1016/j.jpainsymman.2023.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023]
Abstract
There is widespread agreement that clinicians should talk to seriously ill patients and their families about their illnesses. However, advance directives as a quality metric have been called into question because of the lack of data that these conversations lead to goal-concordant care. The controversy has led many to reexamine the purpose of conversations with seriously ill patients and what should be discussed in ambulatory visits. In this Controversies in Palliative care, experts in palliative care review the literature and suggest both how it influences their clinical practice and what research needs to be done to clarify the controversy. While there is not a single outcome that the experts agree on, they posit a variety of different ways to assess these conversations.
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Affiliation(s)
- Robert M Arnold
- Department of Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (R.M.A.), UPMC Health System, Palliative and Supportive Care Institute, Pittsburgh, PA, USA.
| | - Kristin Levoy
- Department of Community and Health Systems (K.L., S.E.H.), Indiana University School of Nursing, Indianapolis, IN, USA; Indiana University Center for Aging Research (K.L., S.E.H.), Regenstrief Institute, Inc., Indianapolis, IN, USA; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L.), Indianapolis, IN, USA
| | - Susan E Hickman
- Department of Community and Health Systems (K.L., S.E.H.), Indiana University School of Nursing, Indianapolis, IN, USA; Indiana University Center for Aging Research (K.L., S.E.H.), Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Areej El Jawahri
- Cancer Center (A.E.J.), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Department of Medicine (V.J.), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care (J.A.T.), Dana-Farber Cancer Institute, Boston, MA; Division of Palliative Medicine, Department of Medicine (J.A.T.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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31
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Maters J, van der Steen JT, de Vugt ME, Bakker C, Koopmans RT. Palliative Care in Nursing Home Residents with Young-Onset Dementia: Professional and Family Caregiver Perspectives. J Alzheimers Dis 2024; 97:573-586. [PMID: 38217594 PMCID: PMC10836558 DOI: 10.3233/jad-230486] [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] [Accepted: 11/01/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND The evidence underpinning palliative care in dementia is mostly based on research in older populations. Little is known about the palliative care needs of people with young-onset dementia (YOD). OBJECTIVE To describe palliative care practices including advance care planning (ACP) in people with YOD residing in Dutch nursing homes. METHODS The study presents baseline questionnaire data from an observational cohort study. Physicians, family caregivers, and nursing staff completed questionnaires about 185 residents with YOD. The questionnaires included items on sociodemographics, quality of life measured with the quality of life in late-stage dementia (QUALID) scale, dementia-related somatic health problems, symptoms, pain medication, psychotropic drugs, and ACP. RESULTS The mean age was 63.9 (SD 5.8) years. Half (50.3%) of them were female. Alzheimer's disease dementia (42.2%) was the most prevalent subtype. The mean QUALID score was 24.0 (SD 7.9) as assessed by family caregivers, and 25.3 (SD 8.6) as assessed by the nursing staff. Swallowing problems were the most prevalent dementia-related health problem (11.4%). Agitation was often reported by physicians (42.0%) and nursing staff (40.5%). Psychotropics were prescribed frequently (72.3%). A minority had written advance directives (5.4%) or documentation on treatment preferences by the former general practitioner (27.2%). Global care goals most often focused on comfort (73.9%). Proportions of do-not-treat orders were higher than do-treat orders for all interventions except for hospitalization and antibiotics. CONCLUSIONS ACP must be initiated earlier, before nursing home admission. A palliative approach seems appropriate even though residents are relatively young and experience few dementia-related health problems.
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Affiliation(s)
- Jasper Maters
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Alzheimer Center, Nijmegen, the Netherlands
| | - Jenny T. van der Steen
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Alzheimer Center, Nijmegen, the Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Marjolein E. de Vugt
- School for Mental Health and Neuroscience, Alzheimer Center Limburg, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Christian Bakker
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Alzheimer Center, Nijmegen, the Netherlands
- Groenhuysen, Center for Geriatric Care, Roosendaal, the Netherlands
| | - Raymond T.C.M. Koopmans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Alzheimer Center, Nijmegen, the Netherlands
- Joachim en Anna, Center for Specialized Geriatric Care, Nijmegen, the Netherlands
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Murray GF, Lakin JR, Paasche-Orlow MK, Tulsky JA, Volandes A, Davis AD, Zupanc SN, Carney MT, Burns E, Martins-Welch D, LaVine N, Itty JE, Fix GM. Structural Barriers to Well-grounded Advance Care Planning for the Seriously Ill: a Qualitative Study of Clinicians' and Administrators' Experiences During a Pragmatic Trial. J Gen Intern Med 2023; 38:3558-3565. [PMID: 37488368 PMCID: PMC10713958 DOI: 10.1007/s11606-023-08320-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/03/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Advance Care Planning (ACP) comprises an iterative communication process aimed at understanding patients' goals, values, and preferences in the context of considering and preparing for future medical treatments and decision making in serious illness. The COVID pandemic heightened patients' and clinicians' awareness of the need for ACP. OBJECTIVE Our goal was to explore the experiences of clinicians and administrators in the context of an intervention to improve ACP during the COVID pandemic. DESIGN Qualitative interview study. PARTICIPANTS Clinicians and administrators across five sites that participated in the ACP-COVID trial. APPROACH We conducted semi-structured, qualitative interviews examining the context and approach to ACP. Interviews were analyzed using template analysis to systematically organize the data and facilitate review across the categories and participants. Templates were developed with iterative input and line-by-line review by the analytic team, to reach consensus. Findings were then organized into emergent themes. KEY RESULTS Across 20 interviews (4 administrators, 16 clinicians) we identified three themes related to how participants thought about ACP: (1) clinicians have varying views of what constitutes ACP; (2) the health system critically shapes ACP culture and norms; and (3) the centrality of clinicians' affective experience and own needs related to ACP. Varying approaches to ACP include a forms-focused approach; a discussion-based approach; and a parental approach. System features that shape ACP norms are (1) the primacy of clinician productivity measures; (2) the role of the EHR; and (3) the culture of quality improvement. CONCLUSIONS Despite high organizational commitment to ACP, we found that the health system channeled clinicians' ACP efforts narrowly on completion of forms, in tension with the ideal of well-grounded ACP. This resulted in a state of moral distress that risks undermining confidence in the process of ACP and may increase risk of harm for patients, family/caregivers, and providers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Genevra F Murray
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA
| | - Joshua R Lakin
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Michael K Paasche-Orlow
- Tufts University School of Medicine, Division of General Internal Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - James A Tulsky
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Section of General Internal Medicine, Boston, MA, USA
- ACP Decisions, Waban, MA, USA
| | | | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maria T Carney
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Edith Burns
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Diana Martins-Welch
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Nancy LaVine
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jennifer E Itty
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Gemmae M Fix
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, Bedford VA Healthcare System, Bedford, MA, USA
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Rosa WE, Gilliland J, McDarby M, Nelson JE, Desai AV, Epstein AS. Patient and Clinician Stakeholder Perspectives on a Patient Portal Questionnaire Eliciting Illness and Treatment Understanding and Core Health-Related Values. Palliat Med Rep 2023; 4:316-325. [PMID: 38089435 PMCID: PMC10712361 DOI: 10.1089/pmr.2023.0057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 12/29/2023] Open
Abstract
Introduction Person-centered communication is foundational to cancer care. In pilot research, a questionnaire eliciting patients' illness and treatment understanding (ITU) and core health-related values (HRV) through the electronic patient portal demonstrated feasibility, acceptability, and efficacy. The aim of this study was to elicit stakeholder feedback to refine the design of the portal-based intervention, remain end-user centered, and optimize future system-wide integration. Methods Between April and June 2023, we purposively sampled patients and clinicians from a previous pilot study to participate in a 20-30-minute semistructured interview about their opinions of and experiences with the portal questionnaire on ITU and HRV. An interdisciplinary coding team used a two-phase rapid analysis to identify themes, subthemes, and illustrative participant quotations. Results Fourteen patients (mean age = 68 years) and 12 clinicians participated (total n = 26). Colorectal cancer was the commonest malignancy (64%) among patients. Clinicians were mostly physicians (50%), nurse practitioners (33%), and registered nurses (17%), with two-thirds having >15 years of experience in their specialty. Analysis generated four themes: (1) clinical utility of questionnaire, (2) barriers to questionnaire implementation, (3) considerations and strategies for modifying the questionnaire, and (4) considerations and strategies for questionnaire implementation. Themes captured key information about incorporating this questionnaire into clinical practice. Conclusion Patients with cancer and their clinicians found a portal-based ITU and HRV questionnaire clinically useful to improve multiple aspects of person-centered communication. Participant recommendations about questionnaire timing and sharing of questionnaire responses with the clinical team will inform future questionnaire implementation and scaling in clinical settings.
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Affiliation(s)
- William E. Rosa
- Department of Psychiatry, Behavioral Sciences and Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jaime Gilliland
- Department of Psychiatry, Behavioral Sciences and Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Meghan McDarby
- Department of Psychiatry, Behavioral Sciences and Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Judith E. Nelson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Anjali V. Desai
- Oncology Palliative Care Services, Atlantic Health System, Morristown, New Jersey, USA
| | - Andrew S. Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Carter RZ, Hassan E, Porterfield P, Barwich D. A model for community-led peer-facilitated advance care planning workshops for the public. Palliat Care Soc Pract 2023; 17:26323524231212515. [PMID: 38033874 PMCID: PMC10685751 DOI: 10.1177/26323524231212515] [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: 08/14/2023] [Accepted: 10/19/2023] [Indexed: 12/02/2023] Open
Abstract
Background The core to successful advance care planning (ACP) facilitation is helping people determine their values, beliefs and wishes, and understand substitute decision-making. Recognizing the potential for community members to support public awareness and education we developed a model of ACP education, whereby peer facilitators associated with community organizations host workshops that educate and assist members of the public with ACP. Objectives Describe the development and evaluation of the model for community-led peer-facilitated ACP workshops for the public. Design Descriptive mixed methods. Methods A training curriculum and program model were co-developed with two community organizations that had been successful in delivering ACP workshops independently in their communities. Herein we describe a mixed-methods evaluation of three cycles of implementation and improvement of the model. Results The model centers on three key concepts; the right content (based around three steps Think, Talk, Plan), the right facilitator, and the right approach. A suite of tools was designed to support the three groups involved in the delivery of the ACP workshops: the public participants, the peer facilitators, and the community-based organizations. The peer-facilitator training addresses the facilitator's learning needs of ACP content knowledge, facilitation skills, and understanding change behavior. Training evaluation data from 106 facilitators confirmed that the curriculum prepared them to facilitate the workshops. Qualitative data revealed that support from organizations with established reputations in their community is critical, with mentoring from more experienced facilitators beneficial. Conclusion Our model demonstrates the potential of community-led, peer-facilitated ACP initiatives to enhance the capacity of community to upstream ACP conversations. Reaching a broader audience and creating a supportive, inclusive environment for individuals to comfortably learn about ACP can drive the much-needed culture shift to normalize ACP. Meaningful community engagement, empowerment, and partnerships are essential for the successful development and widespread impact of these initiatives.
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Affiliation(s)
- Rachel Z Carter
- Division of Palliative Care, The University of British Columbia, 6389 Stadium Road, Vancouver, BC V6T 1Z4, Canada
- BC Centre for Palliative Care, PMB 691, 101-1001 W. Broadway, Vancouver, BC V6H 4E4, Canada
| | - Eman Hassan
- BC Centre for Palliative Care, Vancouver, BC, Canada
- Division of Palliative Care, The University of British Columbia, Vancouver, BC, Canada
| | | | - Doris Barwich
- BC Centre for Palliative Care, Vancouver, BC, Canada
- Division of Palliative Care, The University of British Columbia, Vancouver, BC, Canada
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Gabbard JL, Carpenter JG, Ernecoff NC, Mournighan K, Cornea I, McKone M, Hanson LC. Evaluating the pragmatic characteristics of advance care planning outcome measures in dementia clinical trials: A scoping review. J Am Geriatr Soc 2023; 71:3595-3608. [PMID: 37439456 PMCID: PMC10787044 DOI: 10.1111/jgs.18495] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Advance care planning (ACP) is a process that involves discussing a person's goals, values, and preferences; it is particularly important for persons living with dementia (PLWD) given that dementia is incurable and progressive. To ensure results that will impact real-world practices, ACP outcome measures must be psychometrically strong, meaningful to key partners, and pragmatic to collect. Therefore, we conducted a scoping review of outcome measures utilized in ACP randomized controlled clinical trials (RCTs) enrolling PLWD or their care partners and evaluated their pragmatic characteristics. METHODS We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for peer-reviewed ACP RCTs enrolling PLWD or their care partners from 2011 to 2021. We abstracted characteristics of primary and secondary outcome measures, including pragmatic characteristics using an adapted Psychometric and Pragmatic Evidence Rating Scale and ACP outcome domains using the standardized ACP Outcome Framework (i.e., process, action, healthcare, or quality of care). RESULTS We included 21 ACP RCTs. Trials included 103 outcome measures (39 primary and 64 secondary), of which 11% measured process, 14% measured action, 49% measured healthcare, and 26% measured quality of care. Twenty-four (23%) outcome measures were highly pragmatic, the majority of which (67%) reflected healthcare outcome measures. Sixty-one (59%) outcomes were assessed as highly relevant to PLWD or their care partners. Only 20% (n = 21) of outcome measures were embedded into clinical practice. Most (62%) RCTs were conducted in nursing homes, and 33% were focused PLWD with advanced stage disease. CONCLUSIONS In RCTs testing ACP interventions to support PLWD, only 23% of outcome measures were highly pragmatic, and most of these measured healthcare utilizations. Outcome assessments were rarely integrated into the EHR during routine clinical care. New outcome measures that address the lived experience of PLWD and their care partners plus have high pragmatic characteristics are needed for embedded pragmatic clinical trials.
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Affiliation(s)
- Jennifer L Gabbard
- School of Medicine, Section of Gerontology and Geriatrics, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Joan G Carpenter
- School of Nursing, Department of Organizational and Adult Health, University of Maryland, College Park, Maryland, USA
| | | | - Kimberly Mournighan
- Division of Geriatric Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Isabella Cornea
- School of Medicine, Section of Gerontology and Geriatrics, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Mark McKone
- School of Medicine, Section of Gerontology and Geriatrics, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
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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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Mindo-Panusis D, Sudore RL, Cenzer I, Smith AK, Kotwal AA. Disparities in advance care planning among older US immigrants. J Am Geriatr Soc 2023; 71:3244-3253. [PMID: 37431769 PMCID: PMC10592399 DOI: 10.1111/jgs.18498] [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: 12/12/2022] [Revised: 05/08/2023] [Accepted: 06/18/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Despite known racial disparities in advance care planning (ACP), little is known about ACP disparities experienced by US immigrants. METHODS We used data from the 2016 wave of the Health and Retirement Study. We defined ACP engagement as self-reported end-of-life (EOL) discussions, designation of a power of attorney (DPOA), documented living will, or "any" of the three behaviors. Immigration status was determined by respondent-reported birth outside the United States. Time in the United States was calculated by subtracting the year of arrival in the United States from the survey year of 2016. We used multivariable logistic regression to estimate the association between ACP engagement and immigration status and the relationship of acculturation to ACP engagement, adjusting for sociodemographics, religiosity, and life expectancy. RESULTS Of the total cohort (N = 9928), 10% were immigrants; 45% of immigrants identified as Hispanic. After adjustment, immigrants had significantly lower adjusted probability of any ACP engagement (immigrants: 74% vs. US-born: 83%, p < 0.001), EOL discussions (67% vs. 77%, p < 0.001), DPOA designation (50% vs. 59%, p = 0.001) and living will documentation (50% vs. 56%, p = 0.03). Among immigrants, each year in the United States was associated with a 4% increase in the odds of any ACP engagement (aOR 1.04, 95% CI 1.03-1.06), ranging from 36% engaged 10 years after immigration to 78% after 70 years. CONCLUSION ACP engagement was lower for US immigrants compared to US-born older adults, particularly for those that recently immigrated. Future studies should explore strategies to reduce disparities in ACP and the unique ACP needs among different immigrant populations.
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Affiliation(s)
- Dallas Mindo-Panusis
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center
| | - Irena Cenzer
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center
| | - Alexander K. Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center
| | - Ashwin A. Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center
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Gotanda H, Walling AM, Zhang JJ, Xu H, Tsugawa Y. Timing and setting of billed advance care planning among Medicare decedents in 2017-2019. J Am Geriatr Soc 2023; 71:3237-3243. [PMID: 37335260 PMCID: PMC10592584 DOI: 10.1111/jgs.18476] [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: 11/14/2022] [Revised: 05/08/2023] [Accepted: 05/27/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services (CMS) began to reimburse clinicians for advance care planning (ACP) discussions, effective January 1, 2016. We sought to characterize the timing and setting of first-billed ACP discussions among Medicare decedents to inform future research on ACP billing codes. METHODS Using a random 20% sample of Medicare fee-for-service beneficiaries aged 66 years and older who died in 2017-2019, we described the timing (relative to death) and setting (inpatient, nursing home, office, or outpatient with or without Medicare Annual Wellness Visit [AWV], home or community, or elsewhere) of the first-billed ACP discussion for each beneficiary. RESULTS Our study included 695,985 decedents (mean [SD] years of age, 83.2 [8.8]; 54.2% female); the proportion of decedents who had at least one billed ACP discussion increased from 9.7% in 2017 to 21.9% in 2019. We found that the proportion of first-billed ACP discussions held during the last month of life decreased from 37.0% in 2017 to 26.2% in 2019, while the proportion of first-billed ACP discussions held more than 12 months before death increased from 11.1% in 2017 to 35.2% in 2019. We also found that the proportion of first-billed ACP discussions held in the office or outpatient setting along with AWV increased over time (from 10.7% in 2017 to 14.1% in 2019), while the proportion held in the inpatient setting decreased (from 41.7% in 2017 to 38.0% in 2019). CONCLUSIONS We found that with increasing exposure to the CMS policy change, uptake of the ACP billing code has increased; first-billed ACP discussions are occurring sooner before the end-of-life stage and are more likely to occur with AWV. Future studies should evaluate changes in ACP practice patterns, rather than only an increasing uptake in ACP billing codes, following the policy implementation.
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Affiliation(s)
- Hiroshi Gotanda
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jessica J. Zhang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Haiyong Xu
- Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Yusuke Tsugawa
- Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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Shepherd V, Hood K, Wood F. Planning ahead for research participation: survey of public and professional stakeholders' views about the acceptability and feasibility of advance research planning. BMC Med Ethics 2023; 24:70. [PMID: 37689636 PMCID: PMC10492324 DOI: 10.1186/s12910-023-00948-3] [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: 05/17/2023] [Accepted: 08/29/2023] [Indexed: 09/11/2023] Open
Abstract
BACKGROUND Anticipatory planning in the UK focuses on supporting people who anticipate periods of impaired capacity to express their wishes about future care through processes such as advance care planning. Other countries have extended anticipatory planning to include processes for people to prospectively express their preferences about research participation. Advance research planning (ARP) is thought to extend autonomy and ensure that 'proxy' decisions about research are based on their wishes and preferences. METHODS A cross-sectional survey was conducted with two stakeholder groups (members of the public including people living with capacity-affecting conditions and family members; researchers and other professionals) who were recruited via research registries and other routes. Online questionnaires were used to capture the perspectives of the two groups. Responses were analysed using descriptive statistics and content analysis. RESULTS A total of 327 participants (members of the public n = 277, professionals n = 50) completed the survey (November 2022 - March 2023). ARP was supported by 97% of public contributors and 94% of professionals. Participants thought that ARP should include the person's general wishes about research, specific types of studies, and who should make decisions on their behalf. They identified a number of challenges, including how ARP could take account of changes in individuals' preferences or circumstances whilst protecting their rights and interests. Implementation barriers included the potential time, complexity, and cost involved. These could be addressed by embedding ARP in existing anticipatory planning pathways and aligning it with other research enrolment activities. Relationships and trust played a key role, including underpinning who should support the delivery of ARP, how they are trained, and when it is undertaken. CONCLUSIONS There were high levels of support for introducing ARP in the UK. Further research should explore practical barriers and stakeholder concerns and identify any unintended consequences. Future activities should include developing ARP interventions alongside training and other resources, and also focus on public awareness campaigns, and engaging policymakers and other stakeholders.
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Affiliation(s)
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Fiona Wood
- PRIME Centre Wales, Cardiff, UK
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Sudore RL, Walling AM, Gibbs L, Rahimi M, Wenger NS. Implementation Challenges for a Multisite Advance Care Planning Pragmatic Trial: Lessons Learned. J Pain Symptom Manage 2023; 66:e265-e273. [PMID: 37098388 PMCID: PMC10358280 DOI: 10.1016/j.jpainsymman.2023.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/06/2023] [Accepted: 04/16/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND/PROBLEM Advance care planning (ACP) pragmatic trials are needed. PROPOSED SOLUTION We determined key system-level activities to implement ACP interventions for a cluster-randomized pragmatic trial. We identified patients with serious illness from 50 primary care clinics across three University of California health systems using a validated algorithm. If patients lacked documented ACP within the last 3 years, they were eligible for an intervention: (Arm 1) an advance directive (AD); (Arm 2) AD + PREPAREforYourCare.org; (Arm 3) AD + PREPARE + lay health navigator outreach. Triggered by an appointment, we mailed and sent interventions through automated electronic health record (EHR) messaging. We collaborated with patients/caregivers, clinicians, payors, and national/health system leader advisors. We are currently finalizing 24 months follow-up data. OUTCOMES/METHODS We used the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to track secular trends and implementation efforts. KEY MESSAGE/RESULTS Required multisite, system-level activities: 1) obtaining leadership, legal/privacy, and EHR approvals; 2) standardizing ACP documentation; 3) providing clinician education; 3) validating an automated serious illness identification algorithm; 4) standardizing ACP messaging with input from over 100 key advisors; 5) monitoring secular trends (e.g., COVID); and 6) standardizing ACP workflows (e.g., scanned ADs). Of 8707 patients with serious illness, 6883 were eligible for an intervention. Across all arms, 99% received the mailed intervention, 78.3% had an active patient portal (64.2% opened intervention), and 90.5% of arm three patients (n = 2243) received navigator outreach. LESSONS LEARNED Implementing a multisite health system-wide ACP program and pragmatic trial, with automated EHR-based cohort identification and intervention delivery, requires a high level of multidisciplinary key advisor engagement, standardization, and monitoring. These activities provide guidance for the implementation of other large-scale, population-based ACP efforts.
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Affiliation(s)
- Rebecca L Sudore
- Department of Medicine (R.L.S.), University of California, San Francisco, California; San Francisco VA Medical Center (R.L.S), San Francisco, California
| | - Anne M Walling
- Department of Medicine (A.M.W., N.S.W.), University of California, Los Angeles, California; VA Greater Los Angeles Health System (A.M.W.), Los Angeles, California.
| | - Lisa Gibbs
- Division of Geriatric Medicine and Gerontology (L.G.), Department of Family Medicine, University of California, Irvine, California
| | - Maryam Rahimi
- Division of General Internal Medicine and Primary Care (M.R.), Department of Medicine, University of California, Irvine, California
| | - Neil S Wenger
- Department of Medicine (A.M.W., N.S.W.), University of California, Los Angeles, California
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