'Planning ahead' among community-dwelling older people from culturally and linguistically diverse background: a cross-sectional survey

A Systematic Review of Non-Seriously Ill Community-Dwelling Asians' Views on Advance Care Planning

OBJECTIVES

To systematically synthesize the views of community-dwelling Asians on Advance care planning and to summarize the factors and reasons affecting their uptake of ACP.

DESIGN

Mixed-methods systematic review (PROSPERO: CRD42018091033).

SETTING AND PARTICIPANTS

Asian adults (≥18 years old) living in the community globally.

METHODS

Medline (Ovid), Web of Science, CINAHL (EBSCO), Open Grey, and Google Scholar were searched from inception to June 30, 2022. Qualitative, quantitative, or mixed-methods studies reporting on the views of non-seriously ill community-dwelling Asian adults on ACP or the factors influencing their ACP uptake were included. Secondary research, studies not published in English, or studies not available as full text were excluded. Two independent teams of researchers extracted data, assessed methodologic quality, and performed the data analysis. Data analysis was conducted using the multistep convergent integrated approach based on Joanna Briggs Institute methodology for mixed-methods systematic review.

RESULTS

Fifty-eight studies were included. Non-seriously ill community-dwelling Asians were willing to engage in ACP (46.5%-84.4%) although their awareness (3.1%-42.9%) and uptake of ACP remained low (14.0%-53.4%). Background factors (sociodemographic factors, and health status, as well as experience and exposure to information) and underlying beliefs (attitude toward ACP, subjective norm, and perceived behavioral control) were found to affect their uptake of ACP. A conceptual framework was developed to facilitate a proper approach to ACP for this population.

CONCLUSIONS AND IMPLICATIONS

A flexible approach toward ACP is needed for non-seriously ill community-dwelling Asians. There is also a need to raise end-of-life and ACP literacy, and to explore ways to narrow the gap in the expectations and implementation of ACP so that trust in its effective execution can be built.

The end-of-life needs of Aboriginal and immigrant communities: a challenge to conventional medical models

Introduction

Concerns have been raised internationally about the palliative care needs of migrants and First Nations people. This article presents insights from research investigating the end-of-life needs of Aboriginal and culturally and linguistically diverse people living in Western Sydney, Australia. This region has a large rapidly growing, and highly diverse population and on average low socioeconomic status. The research was guided by an advisory panel made up of representatives of supportive and palliative medicine, bereavement support, Aboriginal health, and multicultural health facilities. It aimed to generate findings to support the delivery of culturally sensitive services in the public health system.

Method

The multi-method design and the conduct of the research were informed by the literature on researching with marginalized groups which highlights the ethical considerations needed to avoid replicating past injustices. Qualitative data was generated from key informants and community focus groups.

Results

The analysis revealed seven themes and some suggested solutions which were relevant across several themes. The seven themes were: the Need for trusted relationships; Talking about death and dying; Knowledge of key services; Decision-making and obtaining consent from the patient; Appropriate physical spaces; Cultural practices around EOL; and Language barriers.

Discussion

Within each theme a variety of cultural beliefs and practices were revealed that conflicted with mainstream medical systems, indicating the need for changes in such systems. 'Compassionate Communities' was identified as a model to support the necessary changes.

Making an Advance Research Directive: An Interview Study with Adults Aged 55 and Older with Interests in Dementia Research

Many people with dementia are interested in taking part in research, including when they no longer have capacity to provide informed consent. Advance research directives (ARD) enable people to document their wishes about research participation prior to becoming decisionally incapacitated. However, there are few available ARD resources. This Australian interview study elicited the views of people aged 55 years and older about the content of an ARD form and guidance booklet and processes to support research planning. Participants (n = 25; 55 to 83 years) had interests in dementia research. All participants described the ARD materials as easy to understand, and all expressed willingness to take part in future research. Nearly half believed that an ARD should be legally enforceable, while others saw it as a nonbinding document to guide decisions about their participation in research. Close family members were preferred as proxy decision-makers. The ARD form and guidance booklet may be adapted for use elsewhere.

Cultural considerations at end-of-life for people of culturally and linguistically diverse backgrounds: A critical interpretative synthesis

PURPOSE/AIM

To establish cultural considerations for people from culturally or linguistically diverse backgrounds at the end-of-life in Australia.

BACKGROUND

Globally, there is a rapidly increasing proportion of the ageing population, and high levels of migration to Australia, the Australian healthcare community must recognise individualised and cultural needs when approaching death and end-of-life care. Many people from culturally and linguistically diverse backgrounds do not traditionally practice the palliative care approaches that have been developed and practised in Australia.

DESIGN

A Critical Interpretive Synthesis.

METHODS

A review protocol was established using PRISMA 2020 guidelines and the literature searched using CINAHL, PubMed, Psych INFO and Medline from January 2011 to 27th February 2021. This search protocol results in 19 peer-reviewed results for inclusion in critical analysis.

RESULTS

Included studies were qualitative (14), quantitative (4) and mixed methods (1). Four themes were identified from the literature: (i) communication and health literacy; (ii) access to end-of-life care services; (iii) cultural norms, traditions and rituals; and (iv) cultural competence of healthcare workers.

CONCLUSIONS

Healthcare workers have an essential role in providing care to people with life-limiting illnesses. Cultural considerations during end-of-life care are imperative for the advancement of nursing practice. To achieve effective care for people of culturally and linguistically diverse backgrounds during end-of-life care, healthcare workers need to increase their education and cultural competency. There is inadequate research conducted within specific cultural groups, rural and remote Australian communities and individual cultural competence of healthcare workers.

IMPLICATIONS FOR PRACTICE

Continuing advancement within nursing practice relies on health professionals adopting a person-centred and culturally appropriate approach to care. To ensure individualised person-centred care is provided in a culturally appropriate way, healthcare workers must learn to reflect on their practice and actively advocate for people with culturally and linguistically diverse backgrounds during end-of-life care.

Palliative and End-of-Life Care Access for Immigrants Living in High-income Countries: A Scoping Review

This scoping review aimed to explore what is known about palliative and End-of-Life (EOL) care access by immigrants with culturally and linguistically diverse (CALD) background living in high-income Organization for Economic Co-operation and Development (OECD) countries. CaLD immigrants have low utilization of palliative care services with patients' family members taking up the role of caring, leading to immigrants not fully benefiting from the specialized services that are offered to alleviate suffering and promote quality of life. While there is some research in this area mainly in Europe, it cannot be said about all high-income OECD countries. Achieving person-centered care in high-income countries, requires identifying and addressing barriers to care access, especially by immigrants with CaLD background. Five-stage methodological framework by Arksey and O'Malley was used to undertake the review. Immigrants in OECD countries experience challenges in accessing palliative and EOL care services. The review also identified limited literature on the subject and establishes need for more research on the subject.

Knowledge, attitude and practice of community-dwelling adults regarding advance care planning in Malaysia: a cross-sectional study

OBJECTIVES

This study aimed to assess the knowledge, attitude and practice (KAP) among community-dwelling adults in Malaysia regarding advance care planning (ACP), and its associated factors.

DESIGN

This cross-sectional study was conducted from July-September 2018.

SETTING

This study was conducted at the University Malaya Medical Centre, Kuala Lumpur, Malaysia.

PARTICIPANTS

We recruited community-dwelling adults (ambulatory care patients or their accompanying persons) who were ≥21 years old and able to understand English or Malay. A 1:10 systematic sampling procedure was used. Excluded were community-dwelling adults with intellectual disabilities or non-Malaysian accompanying persons. A trained researcher administered the validated English or Malay Advance Care Planning Questionnaire at baseline and 2 weeks later.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the KAP regarding ACP. The secondary outcomes were factors associated with KAP.

RESULTS

A total of 385/393 community-dwelling adults agreed to participate (response rate 98%). Only 3.1% of the community-dwelling adults have heard about ACP and 85.7% of them felt that discussion on ACP was necessary after explanation of the term. The desire to maintain their decision-making ability when seriously ill (94.9%) and reducing family burden (91.6%) were the main motivating factors for ACP. In contrast, resorting to fate (86.5%) and perceived healthy condition (77.0%) were the main reasons against ACP. Overall, 84.4% would consider discussing ACP in the future. Community-dwelling adults who were employed were less likely to know about ACP (OR=0.167, 95% CI 0.050 to 0.559, p=0.004) whereas those with comorbidities were more likely to favour ACP (OR=2.460, 95% CI 1.161 to 5.213, p=0.019). No factor was found to be associated with the practice of ACP.

CONCLUSIONS

Despite the lack of awareness regarding ACP, majority of community-dwelling adults in Malaysia had a positive attitude towards ACP and were willing to engage in a discussion regarding ACP after the term 'ACP' has been explained to them.

Nurse-led normalised advance care planning service in hospital and community health settings: a qualitative study

BACKGROUND

Advance Care Planning (ACP) by Registered Nurses (RNs) has been emerging. However, there is limited understanding about what RNs experience as they incorporate ACP into their practice. This study aimed to elicit the experiences of ACP RNs with the implementation of a normalised ACP (NACP) service in hospital and community care settings.

METHODS

A qualitative descriptive study invited four ACP RNs who delivered a nurse-led NACP for a 6 months duration at two hospital and two community health care settings in New South Wales (NSW), Australia. The experiences of the ACP RNs were captured through a semi-structured interview and weekly debriefing meetings. The interview recordings were transcribed verbatim and the minutes of weekly debriefing meetings were utilized. Data were analysed by two independent researchers using thematic analysis with the Normalisation Process Theory (NPT) as a methodological framework.

FINDINGS

The ACP RNs were females with a mean age of 43 years old. Their nursing experiences ranged 2 to 25 years but they had minimal experiences with ACP and had not attended any education about ACP previously. The following four themes were identified in the experiences of the ACP RNs; 1) Embracing NACP service; 2) Enablers and barriers related to patients and health professionals; 3) Enablers and barriers related to ACP RNs; and 4) What it means to be an ACP RN.

CONCLUSION

The introduction of a NACP service into existing clinical systems is complex. The study demonstrated the capacity of RNs to engage in ACP processes, and their willingness to deliver an NACP service with a raft of locally specific enablers and barriers.

TRIAL REGISTRATION

The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record.

Efficacy of Normalisation of Advance Care Planning (NACP) for people with chronic diseases in hospital and community settings: a quasi-experimental study

Background

Advance Care Planning (ACP) has emerged to improve end-of-life processes and experiences. However, the available evidence presents the gloomy picture of increasing number of older people living with chronic diseases and the mismatch between their preferences for and the actual place of death. The study aimed to investigate the efficacy of normalisation of an Advance Care Planning (NACP) service delivered by specially trained Registered Nurses (RNs) in hospital and community settings.

Methods

A quasi-experimental study was conducted involving 16 sites (eight hospital and eight community sites) in Australia. Patients who were aged ≥18 years, who had at least one of nine chronic conditions, and who did not have an Advance Care Directive (ACD) were offered the NACP service. ACP was normalised as part of routine service on admission. The intervention, NACP, was a series of facilitated conversations about the components of ACP. The primary outcomes which included the completion of ACDs, and/or appointment of an Enduring Guardian (EG), were assessed in both intervention and control sites at pre and post intervention stages. Numbers of patients who completed an ACD or appointed an EG were described by count (percentage). ACD completion was compared between intervention and control sites using a logistic mixed effects regression model. The model includes fixed effects for treatment group, period, and their interaction, as well as random site level intercepts. Secondary model included potentially confounding variables as covariates, including age, sex and chronic diseases.

Results

The prevalence of legally binding ACDs in intervention sites has increased from five to 85 (from 0.85% in pre to 17.6% in post), whereas it has slightly decreased from five to 2 (from 1.2% in pre and to 0.49% in post) in control sites (the difference in these changes being statistically significant p < 0.001). ACD completion rate was 3.6% (n = 4) in LHD1 and 1.2% (n = 3) in LHD2 in hospital whereas it was 53% (n = 26) in LHD1 and 80% (n = 52) in LHD2 in community.

Conclusions

The study demonstrated that NACP service delivered by ACP RNs was effective in increasing completion of ACDs (interaction odds ratio = 50) and was more effective in community than hospital settings. Involvement of various healthcare professionals are warranted to ensure concordance of care.

Trial registration

The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246) on 03/10/2018. The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06928-w.

A cost-consequence analysis of normalised advance care planning practices among people with chronic diseases in hospital and community settings

BACKGROUND

A growing body of international literature concurs that comprehensive and complex Advance Care Planning (ACP) programs involving specially qualified or trained healthcare professionals are effective in increasing documentation of Advance Care Directives (ACDs), improving compliance with patients' wishes and satisfaction with care, and quality of care for patients and their families. Economic analyses of ACDs and ACP have been more sporadic and inconclusive. This study aimed to contribute to the evidence on resource use associated with implementation of ACP and to inform key decision-makers of the resource implications through the conduct of a cost-consequence analysis of the Normalised Advance Care Planning (NACP) trial.

METHODS

The outcomes for the economic evaluation included the number of completed "legally binding" ACDs and the number of completed Conversation Cards (CC). The cost analysis assessed the incremental difference in resource utilisation between Usual Practice and the Intervention. Costs have been categorised into: 1) Contract staff costs; 2) Costs associated with the development of the intervention; 3) Implementation costs; 4) Intervention (delivery) costs; and 5) Research costs.

RESULTS

The cost incurred for each completed ACD was A$13,980 in the hospital setting and A$1248 in the community setting. The cost incurred for each completed Conversation Card was A$7528 in the hospital setting and A$910 in the community setting.

CONCLUSIONS

The cost-consequence analysis does not support generalisation of the specified intervention within the hospital setting. The trial realised an estimated incremental cost per completed ACD of $1248, within the community setting. This estimate provides an additional benchmark against which decision-makers can assess the value of either 1) this approach towards the realisation of additional completed ACDs; and/or 2) the value of ACP and ACDs more broadly, when this estimate is positioned within the potential health outcomes and downstream health service implications that may arise for people with or without a completed ACD.

TRIAL REGISTRATION

The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record.

Advance care planning for older people in mainland China: An integrative literature review

BACKGROUND

Recently, the attempts to promote advance care planning (ACP) and advance directives (ADs) have appeared in mainland China. However, anecdotal evidence suggests that the concept of ACP and ADs is not widely known to the public and healthcare professionals.

AIM

To examine and synthesise currently available research about ACP and ADs for older people in mainland China, and to discuss implications for future nursing practice and research.

DESIGN

An integrative literature review.

METHODS

A systematic search was conducted in seven English electronic databases (CINAHL, MEDLINE, ProQuest, Cochrane, JBI, Scopus and Wiley) and four Chinese electronic databases (CNKI, Wanfang, VIP and CBM). Eligible articles were critically appraised using the Mixed Methods Appraisal Tool (MMAT).

FINDINGS

From various groups including older people, families and healthcare professionals, low levels of knowledge and awareness about ACP and ADs are reported. Demographic characteristics such as age, gender, education and clinical conditions were related to positive or negative attitude towards ACP. The main reason people cited for being 'reluctant/fairly reluctant' to make an AD was that they were 'Not familiar with it'.

CONCLUSIONS

Given that older people showed positive attitudes towards ACP, policy support and practice guidelines about ADs and ACP are necessary to respect their wishes and to guide healthcare professionals in mainland China.

Prevalence of advance care planning practices among people with chronic diseases in hospital and community settings: a retrospective medical record audit

BACKGROUND

Advance Care Planning (ACP) enables healthcare professionals to embrace the important process where patients think about their values in life and goals for health care, and discuss their future health care preferences with family members for a time when they are not able to make health care decisions. Despite the promotion of ACP last two decades, and well-known benefits of ACP and a written Advance Care Directive (ACD), they are still underutilised in Australia and across the world. Previous studies have provided some insights, however, an uptake of ACP and prevalence of ACDs in community settings is rarely reported.

METHODS

The aim of this study was to determine the uptake of ACP and prevalence of ACDs among people with chronic diseases in hospital and community settings. A retrospective medical record audit of eligible patients looking for evidence of ACP was conducted in 16 research sites in eight hospital and eight community care settings. Participants included those who were admitted to one of the research sites, and who were aged 18 years and over with at least one of nine nominated chronic diseases. The primary outcome measures included the number of patients with evidence of ACP through the following practices: completion of an ACD, appointment of an Enduring Guardian (EG), or completion of a resuscitation plan.

RESULTS

The overall prevalence of ACD was 2.8% (n = 28) out of 1006 audited records, and only 10 (1%) of them were legally binding. The number of EGs appointed was 39 (3.9%) across the sites. A total of 151 (15.4%) resuscitation plans were found across the eight hospital sites. 95% (n = 144) of the resuscitation plans indicated 'Not-for-resuscitation'.

CONCLUSIONS

The uptake of ACP is very low. Current medical recording system reveals the challenges in ACP lie in the process of storage, access and execution of the ACDs. Given that having an ACD or Enduring Guardian in place is only useful if the treating physician knows how and where to access the information, it has implications for policy, information system, and healthcare professionals' education.

TRIAL REGISTRATION

The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx.

End-of-life care for older first-generation migrants: a scoping review

BACKGROUND

The unprecedented scale of contemporary migration across countries over the last decade means that ageing and dying occur in a more globalised, multicultural context. It is therefore essential to explore the end-of-life experiences of older people from migrant backgrounds.

METHODS

A scoping review of peer-reviewed articles published in English from 2008 to 2018. Included studies addressed end-of-life preferences, attitudes, values and beliefs of first-generation international migrants who were at least 50 years of age.

RESULTS

Fifteen studies met the inclusion criteria for this review, which addressed six key themes: (1) the reluctance among older migrants and their families to talk about death and dying; (2) difficult communication in patient-clinician relationships; (3) the contrast between collectivistic and individualistic norms and its associated end-of-life preferences; (4) limited health literacy in older adults from migrant backgrounds; (5) experiences with systemic barriers like time pressure, inflexibility of service provision and lack of cultural sensitivity and (6) the need for care providers to appreciate migrants' 'double home experience' and what this means for end-of-life decision-making regarding place of care and place of death.

DISCUSSION

To respond effectively to an increasingly culturally diverse population, healthcare staff, researchers and policymakers need to invest in the provision of culturally sensitive end-of-life care. Areas for improvement include: (a) increased awareness of cultural needs and the role of family members; (b) cultural training for healthcare staff; (c) access to interpreters and translated information and (d) involvement of older migrants in end-of-life discussions, research and policymaking.

Toward Culturally Tailored Advance Care Planning for the Chinese Diaspora: An Integrative Systematic Review

Background: The Chinese diaspora experiences disparate end-of-life (EOL) care outcomes. Advance care planning (ACP) may be an effective intervention to improve EOL care, but its reception and uptake in the Chinese diaspora are unknown. Objective: Review and synthesize current literature to develop a culturally tailored ACP framework for the Chinese diaspora. Design: A systematic integrative review framed by Whittemore and Knafl's method was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Data Sources: PubMed, Embase, CINAHL, Web of Science, Cochrane Library, and University of York Center for Reviews and Dissemination were systematically searched for articles published before February 2020. All English, peer-reviewed quantitative, qualitative, and mixed-method literature studying ACP in Chinese adults living outside China and Taiwan were included. A mixed-method appraisal tool was utilized for quality assessment. Results: The search yielded 836 unique articles, from which we included 30. Integrative synthesis resulted in a novel framework to guide culturally tailored ACP among the Chinese diaspora. The framework highlights the importance of an authority-initiated, indirect approach to ACP that maximizes individual and collective harmony. Furthermore, due to evolving sociodemographic and acculturation factors, the perception of harmony may differ between individuals and generations. Conclusion: The Chinese diaspora population is willing to engage in ACP. An individualized, culturally sensitive approach that captures and maximizes harmony will be central to the success of ACP in this population. Further work is required to understand the influence of serious illness, spirituality, and family on ACP.

The effectiveness of a modified advance care planning programme

BACKGROUND

Frailty is a natural consequence of the aging process. With the increasing aging population in Mainland China, the quality of life and end-of-life care for frail older people need to be taken into consideration. Advance Care Planning has also been used worldwide in long-term facilities, hospitals and communities to improve the quality of end-of-life care, increase patient and family satisfaction, and reduce healthcare costs and hospital admissions in Western countries. However, it has not been practiced in China.

RESEARCH OBJECTIVE

This study aimed to evaluate the effectiveness of a modified Advance Care Planning intervention in certainty of end-of-life care, preferences for end-of-life care, quality of life concerns, and healthcare utilization among frail older people.

RESEARCH DESIGN

This study used a quasi-experimental design, with a single-blind, control group, pretest and repeated posttest approach.

PARTICIPANTS AND RESEARCH CONTEXT

A convenience sample of 74 participates met the eligibility criteria in each nursing home. A total of 148 frail older people were recruited in two nursing homes in Zhejiang Province, China.

ETHICAL CONSIDERATIONS

The study received ethical approval from the Clinical Research Ethics Committee, the Faculty of Medicine, and The Chinese University of Hong Kong, CREC Ref. No: 2016.059.

FINDINGS

The results indicated the Advance Care Planning programme was effective at increasing autonomy in decision making on end-of-life care issues, decreasing decision-making conflicts over end-of-life care issues, and increasing their expression about end-of-life care.

DISCUSSION

This study promoted the participants' autonomy and broke through the inherent custom of avoiding talking about death in China.

CONCLUSION

The modified Advance Care Planning intervention is effective and recommended to support the frail older people in their end-of-life care decision in Chinese society.

Experience of gerotranscendence among community-dwelling older people: A cross-sectional study

AIMS AND OBJECTIVES

To investigate the experience of gerotranscendence among older people in community in Korea and the factors that influence their experience.

BACKGROUND

While the literature provides estimates of how many older people are affected by negative aspects of ageing, it is not known to what extent and why some older people experience gerotranscendence, despite the challenges they encounter throughout their lifetime.

DESIGN

A cross-sectional survey.

METHODS

A 55-item questionnaire was distributed to 109 older people between March and June 2017. Univariable and multivariable linear regressions were conducted on the four question group sum scores to identify factors associated with gerotranscendence.

RESULTS

Older people aged 65-93 who live in a community in Korea reported the experience of gerotranscendence. Age and religion showed a statistically significant association with gerotranscendence. Religiosity showed a statistically significant association with beliefs about death and dying. Age and beliefs about death and dying have significant relationship with the experience of gerotranscendence.

CONCLUSIONS

Older people who have more positive views about death and dying are more likely to experience gerotranscendence. The study results provide nurses and other healthcare professionals with new understandings and insights about the factors potentially related to positive ageing process.

IMPLICATIONS FOR PRACTICE

It is essential for nurses to investigate their own beliefs about death and dying, and their understanding of gerotranscendence which will contribute to developing education programs and practice guidelines as an essential part of promoting gerotranscendence and positive ageing.

Enduring Powers of Attorney and Financial Exploitation of Older People: A Conceptual Analysis and Strategies for Prevention

Enduring powers of attorney (POAs) are commonly used legal instruments that enable older people to plan for asset management in the event of future incapacity. The policy objective of POAs - empowering control over money and property - are frustrated when POAs are misused to financially exploit older people. This commentary integrates theory and evidence to propose a conceptual framework for POA-facilitated financial exploitation (POA-FE). Identified risk factors include inadequate knowledge about the POA role; family conflicts; attitudes of entitlement; and lack of planning and preparation for financial decision-making. POA-FE occurs on a continuum of behavior and strategies for preventing POA-FE are suggested using strengths-based approaches for older people and their attorneys.

Prevalence, perceived barriers and sociodemographic correlates of advance care planning in a sample of outpatients

This study aimed to examine the prevalence and perceived barriers to uptake of advance care planning (ACP), including appointment of an enduring guardian (EG) and completion of an advance care directive (ACD) among Australian adults attending hospital outpatient clinics. Sociodemographic correlates of not completing ACP were also assessed. A cross-sectional survey exploring the uptake of ACP was conducted with outpatients and their accompanying persons aged >18 years (n =191) at one regional hospital in New South Wales, Australia. Rates of completion of an ACD and appointment of an EG were 20% (n =37) and 35% (n =67) respectively. The most common reason for non-completion of an ACD and not appointing an EG was: 'didn't think I needed this'. Younger age was associated with not having appointed an EG (OR 3.8, 95% CI 1.2-12.1, P =0.02). No sociodemographic characteristics were significantly associated with non-completion of ACDs. Uptake of ACP is suboptimal among outpatients. Community-based healthcare providers are well positioned to promote ACP with outpatients.

An integrative review of stakeholder views on Advance Care Directives (ACD): Barriers and facilitators to initiation, documentation, storage, and implementation

OBJECTIVE

To examine the views and experiences of patients and their health care providers on developing advance care planning (ACP) and advance care directives (ACD); and determine barriers and facilitators to ACD development, storage, and use, including implications for people with communication disability.

METHOD

An integrative review of 93 studies, analysed according to their content themes.

RESULTS

Content themes encapsulated the initiation, documentation, and implementation stages of ACP/ACD. Lack of guidance for initiating and supporting ACP/ACD impedes discussions, and both patients and healthcare providers avoid discussions owing to fear of dying and reluctance to think about end-of-life.

CONCLUSIONS

There are several barriers and facilitators to the initiation of ACP discussions, documentation and implementation of ACD, and little research exploring the views of legal professionals on the development, storage, or use of ACP documents. Further research is needed to explore the timing and responsibility of both legal and health professionals in initiating and supporting ACP discussions.

PRACTICE IMPLICATIONS

It is important for healthcare providers to raise ACP discussions regularly so that patients have time to make informed advance care decisions. Storage of the document in an electronic health record might facilitate better access to and implementation of patients' end-of-life care decisions.

Study protocol to investigate the efficacy of normalisation of Advance Care Planning (ACP) for people with chronic diseases in acute and community settings: a quasi-experimental design

BACKGROUND

Advanced care planning (ACP) is a process that involves thinking about what medical care one would like should individuals be seriously ill and cannot communicate decisions about treatment for themselves. The literature indicates that ACP leads to increased satisfaction from both patients and healthcare professionals. Despite the well-known benefits of ACP, it is still underutilised in Australia.

METHODS

The aim of this study is to investigate the effects of normalising ACP in acute and community settings with the use of specially trained normalisation agents. This is a quasi-experimental study, involving 16 sites (8 intervention and 8 control) in two health districts in Australia. A minimum of total 288 participants will be recruited (144 intervention, 144 control). We will train four registered nurses as normalisation agents in the intervention sites, who will promote and facilitate ACP discussions with adult patients with chronic conditions in hospital and community settings. An audit of the prevalence of ACP and Advanced Care Directives (ACDs) will be conducted before and after the 6-month intervention period at the 16 sites to assess the effects of the ACP service delivered by these agents. We will also collect interview and survey data from patients and families who participate, and healthcare professionals who are involved in this service to capture their experiences with ACP.

DISCUSSION

This study will potentially contribute to better patient outcomes with their health care services. Completion of ACDs will allow patients to express their wishes for care and receive the care that they wish for, as well as ease their family from the burden of making difficult decisions. The study will contribute to development of a new best practice model to normalise ACP that is sustainable and transferable in the processes of: 1) initiation of conversation; 2) discussion of important issues; 3) documentation of the wishes; 4) storage of the documented wishes; and 5) access and execution of the documented wishes. The study will generate new evidence on the challenges, strategies and benefits of normalising ACP into practice in acute and community settings.

TRIAL REGISTRATION

This project has been approved by the Hunter New England Human Research Ethics Committee (Approval No. 17/12/13/4.16). It has also been retrospectively registered on 3 October 2018 with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). This study will operate in accordance with the National Health and Medical Research Council's National Statement on Ethical Conduct in Human Research (2007) and the CPMP/ICH Note for Guidance on Good Clinical Practice.

Involvement of Japanese Care Managers and Social Workers in Advance Care Planning

Successful advance care planning relies heavily on effective communication between the elderly and their families, care managers, and social workers. However, care managers and social workers are often not adequately prepared to conduct such discussion. The aim of the present study was to identify the specific challenges facing Japanese care managers and social workers when involvement in advance care planning. Two focus group discussions were held between August and November 2017, involving eleven care managers and three social workers employed at two long-term care facilities actively pursuing advance care planning initiatives. Four main themes were identified, through content analysis, as barriers and facilitators: client readiness, communication, variation-rich client individuality, and difficult-to-explain end-of-life options. This study revealed the importance of building rapport with the residents and their families in order to assess their readiness to discuss care options and preferences. Obstacles included lack of medical knowledge of care managers and social workers. Study findings suggested that a multi-disciplinary team, facilitated by care managers and social workers, was fundamental to achieving the goals of advance care planning.

[Factors related to parent-child communication about end-of-life care -A survey of adult children with an elderly parent]

AIM

In Japan, because adult children are expected to perform a key role in decision-making on end-of-life care for older adults, conversing with parents on their wished-for end-of-life care can help these children to become prepared for this filial responsibility. Our aim in this study was to explore how likely Japanese adult children were to discuss end-of-life care with their parents as well as correlates of such discussions.

METHODS

We conducted an online survey using a sample of 1,590 adult children with at least one living parent aged 65 or older. We analyzed data from 1,010 children who responded during three consecutive days in October, 2015.

RESULTS

A small portion of our participants (22.8%) had discussed end-of-life care with their parents. Logistic regression analysis revealed that such discussions were likely in son-mother (Odds Ratio 〈OR〉 = 3.01) and daughter-mother (OR = 3.15) dyads compared with son-father ones as the reference. Occurrence of such discussions was also associated with having older parents (OR = 1.03), parental experience of severe diseases (OR = 1.47), parent-child coresiding (OR = 2.08), a higher level of perceived necessity for (OR = 1.36) and a lower level of emotional avoidance of (OR = 0.68) end-of-life communication.

CONCLUSION

Generally, adult children rarely discuss end-of-life care with their aging parents, suggesting the need to promote such familial communication while considering both children's and parents' circumstances.

Increasing advance personal planning: the need for action at the community level

BACKGROUND

Advance personal planning is the process by which people consider, document and communicate their preferences for personal, financial and health matters in case they lose the ability to make decisions or express their wishes in the future.

DISCUSSION

Advance personal planning is most often undertaken by individuals who are seriously ill, often in the context of a medical crisis and/or at the time of admission to hospital. However, the clinical utility and legal validity of the planning process may be compromised in these circumstances. Patients may lack sufficient capacity to meaningfully engage in advance personal planning; there may be insufficient time to adequately reflect on and discuss wishes with key others; and there may also be limited opportunity for inter-professional input and collaboration in the process. Here, we propose an agenda for research to advance the science of advance personal planning by promoting a 'whole community' approach. Adoption of advance personal planning at a community level may be achieved using a variety of strategies including public media campaigns, intervening with professionals across a range of health care and legal settings, and mobilising support from influential groups and local government. One potentially promising method for encouraging earlier adoption of advance personal planning among a broader population involves a community action approach, whereby multiple evidence-based strategies are integrated across multiple access points. Community action involves calling on community members, professionals, community and/or government organisations to work collaboratively to design and systematically implement intervention strategies with the aim of bringing about desired behaviour change. An example of a community action trial to improving uptake and quality of advance personal planning is described.

CONCLUSION

While promising, there is a need for rigorous evidence to demonstrate whether a community action approach is effective in establishing whole community adoption of advance personal planning.

Health-Related Decisions for Serious Illness Among Ethnically Diverse Older Adults

We investigated the influence of sociodemographic factors, acculturation, ethnicity, health status, and spirituality on older adults' health-related decisions when confronted with a choice between competing options. The sample included 451 participants: African Americans (15.74%), Afro-Caribbeans (25.5%), European Americans (36.36%), and Hispanic Americans (22.4%). Compared with others, European Americans and Hispanic Americans favored quality of life over a lengthy life. Sociodemographic factors, acculturation, ethnicity, health status, and spirituality accounted for variations of decisions. The variability of decisions calls for multiple care options to explore the value of different trade-offs in order to avoid predetermined clinical practice guidelines, especially in nursing.

Have You Talked about It: Advance Care Planning among African Americans Living with HIV in Baltimore

Advance care planning (ACP) is the process of planning for when individuals are unable to make their own healthcare decisions. Research suggests ACP is understudied among HIV-positive African Americans. We explored ACP knowledge, preferences, and practices with HIV-positive African Americans from an urban HIV-specialty clinic (AFFIRM study). Participants completed surveys and interviews. Descriptive analyses and Poisson regression were conducted on survey data. Qualitative interviews were coded using grounded theory/constant comparative method. Participants were mostly male (55.1%). Half rated their current pain as at least six out of ten (50.8%). Two-thirds had discussed ACP with providers or supporters (66.2%). Qualitative themes were: (1) impact of managing pain on quality of life and healthcare, (2) knowledge/preferences for ACP, and (3) sources of HIV supportive care and coping (N = 39). Correlates of having discussed ACP included: moderate pain intensity (p < 0.10), including supporters in health decisions (p < 0.001), religious attendance (p < 0.05), and knowledge of healthcare mandates (p < 0.01; N = 276). Findings highlight the need for patient education to document healthcare preferences and communication skills development to promote inclusion of caregivers in decision-making.

Exploring the knowledge, attitudes and needs of advance care planning in older Chinese Australians

AIMS AND OBJECTIVES

To identify factors that influence the engagement of Chinese Australians with advance care planning.

BACKGROUND

Despite the benefits of advance care planning, there is a low prevalence of advance care planning in the Chinese Australian community. Reasons for this are often cited as cultural considerations and taboos surrounding future medical planning and death; however, other logistical factors may also be important.

DESIGN

This qualitative study used a thematic analysis grounded theory approach to explore facilitators and barriers to engagement in advance care planning.

METHODS

Semistructured interviews were conducted in-language (Mandarin or Cantonese) exploring the views of a purposive sample of 30 community-dwelling older Chinese Australians within Victoria, Australia.

RESULTS

Three key themes were identified: knowledge of, attitudes towards and needs for undertaking advance care planning amongst the Chinese Australians. There was a low awareness of advance care planning amongst the participants and some confusion regarding the concept. Most participants reported positive attitudes towards advance care planning but acknowledged that others may be uncomfortable discussing death-related topics. Participants would want to know the true status of their health and plan ahead in consultation with family members to reduce the burden on the family and suffering for themselves. Language was identified as the largest barrier to overcome to increase advance care planning awareness. In-language materials and key support networks including GPs, family and Chinese community groups were identified as ideal forums for the promotion of advance care planning.

CONCLUSIONS

The participants of this study were open to conversations regarding future medical planning and end-of-life care, suggesting the low uptake of advance care planning amongst Chinese Australians is not culturally motivated but may be due a lack of knowledge relating to advance care planning.

RELEVANCE TO CLINICAL PRACTICE

The results highlight the need to provide access to appropriate in-language advance care planning resources and promotion of advance care planning across the Chinese community.

Health and death literacy and cultural diversity: insights from hospital-employed interpreters

Objectives

001225The aim of this qualitative study is to better understand, through the experiences and insights of hospital interpreters, how people from culturally and linguistic diverse (CALD) communities might respond to advance care planning (ACP) and end-of-life discussions.

Methods

Hospital interpreters from five Melbourne metropolitan health services were recruited for in-depth semi-structured interviews that explored the question, ‘What can be learnt from hospital interpreters about cultural issues related to ACP and end-of-life decision-making?’ Thirty-nine interpreters, representing 22 language groups, were interviewed. Analysis of the transcribed interviews used qualitative description.

Results

Thematic analysis identified three major themes: (1) moral difference; (2) health and death literacy; and (3) diversity within culture.

Conclusion

A value-based approach to ACP is recommended as a way to capture the person’s individual values and beliefs. Health and death literacy have been identified as areas that may be over-estimated; areas that can be addressed and improved, if recognised. Health and death literacy is a particular area that needs to be assessed and addressed as a pre-requisite to ACP discussions.

Older Adults of Underrepresented Populations and Their End-of-Life Preferences: An Integrative Review

This integrative review was conducted to examine the evidence for understanding diversity in end-of-life preferences among older adults of underrepresented groups. Findings from 21 studies were critically examined, grouped, and compared across studies, populations, and settings. Five major themes emerged: advance directives, hospice and palliative care, communication, knowledge and information, and home and family. Despite multidisciplinary attention, content and methodological limitations narrowed understanding of what matters most to these groups when making decisions at end of life. Rigorous longitudinal studies with more ethnically diverse samples are needed to detect modifiable factors related to disparities at the end of life.

Attitudes towards Advance Care Planning and Healthcare Autonomy among Community-Dwelling Older Adults in Beijing, China

OBJECTIVES

To investigate the preferences of ACP and healthcare autonomy in community-dwelling older Chinese adults.

METHODS

A community-based cross-sectional study was conducted with older adults living in the residential estate of Chaoyang District, Beijing.

RESULTS

900 residents were enrolled. 80.9% of them wanted to hear the truth regarding their own condition from the physician; 52.4% preferred to make their own healthcare decisions. Only 8.9% of them preferred to endure life-prolonging interventions when faced with irreversible conditions. 78.3% of the respondents had not heard of an ACP; only 39.4% preferred to document in an ACP. Respondents with higher education had significantly higher proportion of having heard of an ACP, as well as preferring to document in an ACP, compared to those with lower education. Those aged <70 years had higher proportion of having heard of an ACP, as well as refusing life-prolonging interventions when faced with irreversible conditions, compared to those aged ≥ 70 years.

CONCLUSIONS

Although the majority of community-dwelling older Chinese adults appeared to have healthcare autonomy and refuse life-prolonging interventions in terms of end-of-life care, a low level of "Planning ahead" awareness and preference was apparent. Age and education level may be the influential factors.

Let's talk about death: data collection for verbal autopsies in a demographic and health surveillance site in Malaysia

BACKGROUND

Verbal autopsies have gained considerable ground as an acceptable alternative to medically determined cause of death. Unlike with clinical or more administrative settings for data collection, verbal autopsies require significant involvement of families and communities, which introduces important social and cultural considerations. However, there is very little clear guidance about the methodological issues in data collection. The objectives of this case study were: to explore the range of bereavement rituals within the multi-ethnic, multi-faith population of the district; to investigate the preparedness of communities to talk about death; to describe the verbal autopsy process; to assess the effects of collecting verbal autopsy data on data collectors; and to determine the most accurate sources of information about deaths in the community.

METHODS

A case study approach was used, using focus group discussions, indepth interviews and field notes. Thematic analyses were undertaken using NVivo.

RESULTS

Consideration of cultural bereavement practices is importance to acceptance and response rates to verbal autopsies. They are also important to the timing of verbal autopsy interviews. Well trained data collectors, regardless of health qualifications are able to collect good quality data, but debriefing is important to their health and well being. This article contributes to guidance on the data collection procedures for verbal autopsies within community settings.