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Xu Y, Han PP, Su XQ, Xue P, Guo YJ. Exploration of decision aids to support advance care planning: A scoping review. J Clin Nurs 2024; 33:3477-3497. [PMID: 38661107 DOI: 10.1111/jocn.17187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/09/2024] [Accepted: 04/12/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Advance care planning is a process through which people communicate their goals and preferences for future medical care. Due to the complexity of the decision-making process, decision aids can assist individuals in balancing potential benefits and risks of treatment options. OBJECTIVE While decision aids have the potential to better promote advance care planning, their characteristics, content and application effectiveness are unclear and lack systematic review. Therefore, we aimed to explore these three aspects and establish a foundation for future research. DESIGN Scoping review. METHODS This scoping review adheres to the framework proposed by Arksey and O'Malley and the PRISMA-ScR list. Six English-language databases were systematically searched from the time of construction until 1 December 2023. Two researchers conducted the article screening and data extraction, and the extracted data was presented in written tables and narrative summaries. RESULTS Of the 1479 titles and abstracts, 20 studies fulfilled the inclusion criteria. Types of decision aids were employed, mainly websites and videos. Decision aid's primary components center around 11 areas, such as furnishing information, exploring treatment and care preferences. The main manifestations were a significant increase in knowledge and improved recognition of patients' target value preferences. Among the aids, websites and videos for advance care planning have relatively high content acceptability and decision-making process satisfaction, but their feasibility has yet to be tested. CONCLUSIONS Decision aids were varied, with content focused on describing key information and exploring treatment and care preferences. Regarding application effects, the aids successfully facilitated the advance care planning process and improved the quality of participants' decisions. Overall, decision aids are efficient in improving the decision-making process for implementing advance care planning in cancer and geriatric populations. In the future, personalised decision aids should be developed based on continuous optimization of tools' quality and promoted for clinical application. REPORTING METHOD The paper has adhered to the EQUATOR guidelines and referenced the PRISMAg-ScR checklist. NO PATIENT OR PUBLIC CONTRIBUTION This is a review without patient and public contribution. REGISTRATION https://doi.org/10.17605/OSF.IO/YPHKF, Open Science DOI: 10.17605/OSF.IO/YPHKF.
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Affiliation(s)
- Ying Xu
- School of Nursing and Rehabilitation, Nantong University, Nantong, Jiangsu, China
| | - Ping-Ping Han
- School of Nursing and Rehabilitation, Nantong University, Nantong, Jiangsu, China
| | - Xiao-Qin Su
- School of Nursing and Rehabilitation, Nantong University, Nantong, Jiangsu, China
| | - Ping Xue
- Office of Joint Medicine, Taizhou Second People's Hospital, Taizhou, Jiangsu, China
| | - Yu-Jie Guo
- School of Nursing and Rehabilitation, Nantong University, Nantong, Jiangsu, China
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Khemai C, Leão DLL, Janssen DJA, Schols JMGA, Meijers JMM. Interprofessional collaboration in palliative dementia care. J Interprof Care 2024; 38:675-694. [PMID: 38757957 DOI: 10.1080/13561820.2024.2345828] [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: 05/04/2022] [Accepted: 04/16/2024] [Indexed: 05/18/2024]
Abstract
Interprofessional collaboration (IPC) is essential for high-quality palliative care (PC) for persons with dementia. The aim of this scoping review was to identify IPC approaches in palliative dementia care and explore the elements constituting these approaches. We performed a search in PubMed, CINAHL, and PsychINFO using the Joanna Briggs Institute Reviewers' manual and PRISMA guidelines, and conducted content analysis of the included articles. In total, 28 articles were included, which described 16 IPC approaches in palliative dementia care. The content analysis revealed three overall elements of these approaches: 1) collaborative themes, 2) collaborative processes, and 3) resources facilitating collaboration. Frequently reported collaborative themes embraced pain management and providing care in the dying phase. These themes were addressed through intertwined collaborative processes including communication, coordination, assessing and monitoring, and reflecting and evaluating. To ensure optimal IPC in palliative dementia care, various resources were required, such as PC knowledge, skills to manage symptoms, skills to communicate with collaborators, and a facilitating environment. In conclusion, the identified IPC approaches in palliative dementia care involve diverse collaborating professionals who mainly manage symptoms, prepare for the dying phase and require material and immaterial resources to enable optimal IPC in palliative dementia care.
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Affiliation(s)
- C Khemai
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - D L L Leão
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - D J A Janssen
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
- Department of Research and Development, Ciro, Horn, the Netherlands
| | - J M G A Schols
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - J M M Meijers
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
- Zuyderland Care, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
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Davies N, Aker N, West E, Rait G, Sampson EL. Acceptability of Using a Decision Aid to Support Family Carers of People With Dementia Towards the End of Life: A Qualitative Study. Health Expect 2024; 27:e14123. [PMID: 38896012 PMCID: PMC11187896 DOI: 10.1111/hex.14123] [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: 03/22/2024] [Revised: 05/13/2024] [Accepted: 06/07/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVES To explore the experiences, acceptability and utility of a decision aid for family carers of people with dementia towards the end of life. METHODS We conducted semi-structured interviews with a sample of family carers enroled into a 6-month feasibility study in England, sampling to gain a range of experiences and views, based on relationship to person they cared for (e.g., spouse, adult child), age, gender, and self-reported use of the decision aid during the feasibility study. Interviews were conducted in March 2021-July 2021 and analysed using reflexive thematic analysis. We used COREQ checklist to report our methods and results. RESULTS Family carers found the decision aid acceptable, describing it as comprehensive, accessible with relevant information and its presentation enabled good engagement. Experiences of the decision aid covered four main themes which demonstrated the perceived acceptability and utility: 1. A source of support and reassurance; 2. Empowering conversations and confidence; 3. Including the person living with dementia; and 4. Breaking down complexity. CONCLUSIONS An aid focussing on decisions about dementia end of life care supported family carers break down complex and emotive decisions, not only with making decisions in the moment but also in future planning. PATIENT OR PUBLIC CONTRIBUTION Our three Patient and Public Involvement (PPI) members (all former family carers) were crucial throughout the wider study. PPI supported development of the topic guides, supported trialling the topic guide and interview procedures and finally supported the development of themes as part of the analysis.
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Affiliation(s)
- Nathan Davies
- Research Department of Primary Care and Population Health, Centre for Ageing Population StudiesUniversity College LondonLondonUK
| | - Narin Aker
- Research Department of Primary Care and Population Health, Centre for Ageing Population StudiesUniversity College LondonLondonUK
| | - Emily West
- Marie Curie Palliative Care Research Department, Division of PsychiatryUniversity College LondonLondonUK
| | - Greta Rait
- PRIMENT Clinical Trials Unit, Research Department of Primary Care and Population HealthUniversity College LondonLondonUK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, Division of PsychiatryUniversity College LondonLondonUK
- Department of Psychological Medicine, Royal London HospitalEast London NHS Foundation TrustLondonUK
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Davies N, West E, Smith EM, Vickerstaff V, Manthorpe J, Shah M, Rait G, Wilcock J, Ward J, Sampson EL. Development of a decision-support framework to support professionals and promote comfort among older hospital inpatients living with dementia. Health Expect 2024; 27:e13922. [PMID: 38010078 PMCID: PMC10757206 DOI: 10.1111/hex.13922] [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: 06/27/2023] [Revised: 10/20/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Acute hospital wards can be difficult places for many people living with dementia. Promoting comfort and wellbeing can be challenging in this environment. There is little evidence-based support for professionals working on acute care wards on how to respond to distress and maximise comfort and wellbeing among patients living with dementia. OBJECTIVES Our overall aim was to codesign an evidence-based easy-to-use heuristic decision-support framework, which was acceptable and practical but acknowledges the complex and acute nature of caring for patients with dementia in the hospital. This paper presents the development process and resulting framework. METHODS A codesign study was informed by data from (1) a literature review of the care and management of people living with dementia in acute hospitals; (2) a cohort study of comfort and discomfort in people with dementia in acute hospitals; and (3) interviews with family carers and health care professionals. We synthesised evidence from these data sources and presented to key stakeholders through codesign meetings and workshops to produce our decision-support framework. RESULTS The framework consists of a series of flowcharts and operates using a three-stage process of: (1) assess comfort/discomfort; (2) consider causes of discomfort; and (3) address patient needs to manage the discomfort. CONCLUSION Working with key stakeholders, synthesising diverse quantitative and qualitative evidence to build a clinical framework is a feasible approach to help address the needs of patients living with dementia in an acute hospital setting. The result is a framework which is now ready for evaluation and implementation. PATIENT AND PUBLIC CONTRIBUTION We worked closely with people living with dementia and family carers throughout this study, including the development of the study protocol with input on study development and design, through to inclusion in stakeholder workshops and codesign of the decision support framework.
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Affiliation(s)
- Nathan Davies
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free CampusUniversity College LondonLondonUK
| | - Emily West
- Marie Curie Palliative Care Research DepartmentUniversity College LondonLondonUK
| | - Ellen M. Smith
- South West London and St George's Mental Health NHS TrustLondonUK
| | - Victoria Vickerstaff
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free CampusUniversity College LondonLondonUK
| | - Jill Manthorpe
- NIHR Applied Research Collaborative (ARC) South LondonKing's College London, StrandLondonUK
- NIHR Policy Research Unit in Health and Social Care WorkforceKing's College London, StrandLondonUK
| | - Malvi Shah
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free CampusUniversity College LondonLondonUK
| | - Greta Rait
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free CampusUniversity College LondonLondonUK
| | - Jane Wilcock
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free CampusUniversity College LondonLondonUK
| | - Jane Ward
- Patient and Public Involvement RepresentativeLonodnUK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research DepartmentUniversity College LondonLondonUK
- Department of Psychological Medicine, Royal London HospitalEast London NHS Foundation TrustLondonUK
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Erel M, Marcus EL, DeKeyser Ganz F. Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings. Front Med (Lausanne) 2023; 10:1145142. [PMID: 37425320 PMCID: PMC10325688 DOI: 10.3389/fmed.2023.1145142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction Palliative care (PC) delivery for persons with advanced dementia (AD) remains low, particularly in acute-care settings. Studies have shown that cognitive biases and moral characteristics can influence patient care through their effect on the thinking patterns of healthcare workers (HCWs). This study aimed to determine whether cognitive biases, including representativeness, availability, and anchoring, are associated with treatment approaches, ranging from palliative to aggressive care in acute medical situations, for persons with AD. Methods Three hundred fifteen HCWs participated in this study: 159 physicians and 156 nurses from medical and surgical wards in two hospitals. The following questionnaires were administered: a socio-demographic questionnaire; the Moral Sensitivity Questionnaire; the Professional Moral Courage Scale; a case scenario of a person with AD presenting with pneumonia, with six possible interventions ranging from PC to aggressive care (referring to life-prolonging interventions), each given a score from (-1) (palliative) to 3 (aggressive), the sum of which is the "Treatment Approach Score;" and 12 items assessing perceptions regarding PC for dementia. Those items, the moral scores, and professional orientation (medical/surgical) were classified into the three cognitive biases. Results The following aspects of cognitive biases were associated with the Treatment Approach Score: representativeness-agreement with the definition of dementia as a terminal disease and appropriateness of PC for dementia; availability-perceived organizational support for PC decisions, apprehension regarding response to PC decisions by seniors or family, and apprehension regarding a lawsuit following PC; and anchoring-perceived PC appropriateness by colleagues, comfort with end-of-life conversations, guilt feelings following the death of a patient, stress, and avoidance accompanying care. No association was found between moral characteristics and the treatment approach. In a multivariate analysis, the predictors of the care approach were: guilt feelings about the death of a patient, apprehension regarding senior-level response, and PC appropriateness for dementia. Conclusion Cognitive biases were associated with the care decisions for persons with AD in acute medical conditions. These findings provide insight into the potential effects of cognitive biases on clinical decisions, which may explain the disparity between treatment guidelines and the deficiency in the implementation of palliation for this population.
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Affiliation(s)
- Meira Erel
- Henrietta Szold Hadassah-Hebrew University School of Nursing, Jerusalem, Israel
| | | | - Freda DeKeyser Ganz
- Henrietta Szold Hadassah-Hebrew University School of Nursing, Jerusalem, Israel
- Faculty of Health and Life Sciences, Jerusalem College of Technology, Jerusalem, Israel
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Nimmons D, Manthorpe J, West E, Rait G, Sampson EL, Iliffe S, Davies N. Views of people living with dementia and their carers on their present and future: a qualitative study. BMC Palliat Care 2023; 22:38. [PMID: 37032342 PMCID: PMC10084652 DOI: 10.1186/s12904-023-01165-w] [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: 10/28/2022] [Accepted: 04/03/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND Dementia leads to multiple issues including difficulty in communication and increased need for care and support. Discussions about the future often happen late or never, partly due to reluctance or fear. In a sample of people living with dementia and carers, we explored their views and perceptions of living with the condition and their future. METHODS Semi-structured interviews were conducted in 2018-19 with 11 people living with dementia and six family members in England. Interviews were audio-recorded, transcribed and analysed using reflexive thematic analysis. RESULTS Findings were explored critically within the theory of social death and three themes were developed: (1) loss of physical and cognitive functions, (2) loss of social identity, and (3) social connectedness. Most participants living with dementia and carers wanted to discuss the present, rather than the future, believing a healthy lifestyle would prevent the condition from worsening. Those with dementia wanted to maintain control of their lives and demonstrated this by illustrating their independence. Care homes were often associated with death and loss of social identity. Participants used a range of metaphors to describe their dementia and the impact on their relationships and social networks. CONCLUSION Focusing on maintaining social identity and connectedness as part of living well with dementia may assist professionals in undertaking advance care planning discussions.
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Affiliation(s)
- Danielle Nimmons
- Research Department of Primary Care and Population Health, Centre for Ageing and Population Studies, UCL, London, UK.
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Emily West
- Division of Psychiatry, Marie Curie Palliative Care Research Department, Centre for Dementia Palliative Care Research, UCL, London, UK
| | - Greta Rait
- Research Department of Primary Care and Population Health, Centre for Ageing and Population Studies, UCL, London, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, Centre for Dementia Palliative Care Research, UCL, London, UK
- Barnet, Enfield and Haringey Mental Health Liaison Service, North Middlesex University Hospital NHS Trust, London, UK
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, Centre for Ageing and Population Studies, UCL, London, UK
| | - Nathan Davies
- Research Department of Primary Care and Population Health, Centre for Ageing and Population Studies, UCL, London, UK
- Division of Psychiatry, Marie Curie Palliative Care Research Department, Centre for Dementia Palliative Care Research, UCL, London, UK
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Davies N, Barrado-Martín Y, Vickerstaff V, Rait G, Fukui A, Candy B, Smith CH, Manthorpe J, Moore KJ, Sampson EL. Enteral tube feeding for people with severe dementia. Cochrane Database Syst Rev 2021; 8:CD013503. [PMID: 34387363 PMCID: PMC8407048 DOI: 10.1002/14651858.cd013503.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing. OBJECTIVES To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake. SEARCH METHODS We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs), or controlled non-randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post-pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers. DATA COLLECTION AND ANALYSIS Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non-randomised Studies of Interventions' (ROBINS-I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre-agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta-analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study. MAIN RESULTS We found no eligible RCTs. We included fourteen controlled, non-randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low-certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate-certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very-low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low-certainty evidence. Five studies reported a variety of harm-related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia. AUTHORS' CONCLUSIONS We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here.
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Affiliation(s)
- Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Yolanda Barrado-Martín
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Greta Rait
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Akiko Fukui
- Medical School, St George's, University of London, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Christina H Smith
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, Policy Institute at King's, King's College London, London, UK
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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Davies N, De Souza T, Rait G, Meehan J, Sampson EL. Developing an applied model for making decisions towards the end of life about care for someone with dementia. PLoS One 2021; 16:e0252464. [PMID: 34043728 PMCID: PMC8158904 DOI: 10.1371/journal.pone.0252464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Many people with dementia reach the end-of-life without an advance care plan. Many are not ready to have conversations about end-of-life, and decision-making is left to their families and professionals when they no longer have capacity. Carers may benefit from further support with decision-making. To develop this support, it is important to understand the decision-making process. AIM Explore with family carers and people living with dementia the decision-making process and factors that influence decision-making in dementia end of life care, to produce a model of decision-making in the context of dementia end-of-life care. METHODS Semi-structured interviews with 21 family carers and 11 people with dementia in England (2018-2019) from memory clinics, general practice and carer organisations. Interviews were analysed using thematic analysis and findings were mapped onto the Interprofessional Shared Decision Making model, refined to produce a modified model of decision-making in dementia. RESULTS Participants described five key decisions towards the end-of-life as examples of decision making. We used these experiences to produce a modified model of decision-making in dementia end-of-life-care. The model considers the contextual factors that influence the decision-making process, including: personal preferences; advance care planning and Lasting Power of Attorney; capacity and health and wellbeing of the person with dementia; support from others and clarity of roles. The decision-making process consists of seven inter-linked stages: 1) identifying the decision maker or team; 2) sharing and exchanging information; 3) clarifying values and preferences; 4) managing and considering emotions; 5) considering the feasibility of options; 6) balancing preferred choice and the actual choice; and 7) implementation and reflecting on outcomes. CONCLUSIONS The modified model breaks down the decision-making process and attempts to simplify the process while capturing the subtle nuances of decision making. It provides a framework for conversations and supporting decisions by carers.
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Affiliation(s)
- Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
- Centre for Dementia Palliative Care Research, Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Tanisha De Souza
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Greta Rait
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Jessica Meehan
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Elizabeth L. Sampson
- Centre for Dementia Palliative Care Research, Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, United Kingdom
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Mitchell A, Elbourne S. Advance care planning and syringe drivers in palliative and end-of-life care. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:1010-1015. [PMID: 32972232 DOI: 10.12968/bjon.2020.29.17.1010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article discusses the practicalities of syringe drivers (subcutaneous continuous infusion pumps) for symptom control in patients requiring palliative or end-of-life care, which may form part of an advance care plan. It includes a discussion of palliative and end-of-life care, advance care planning, and when a syringe driver might be beneficial for the patient. It also provides step-by-step clinical guidance on setting up a syringe driver.
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Affiliation(s)
- Aby Mitchell
- Senior Lecturer, Adult Nursing, University of West London
| | - Scott Elbourne
- Lecturer, Nursing Associates and Adult Nursing University of West London
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Samuriwo R, Lovell-Smith C, Anstey S, Job C, Hopkinson J. Nurses' decision-making about cancer patients' end-of-life skin care in Wales: an exploratory mixed-method vignette study protocol. BMJ Open 2020; 10:e034938. [PMID: 32624470 PMCID: PMC7337620 DOI: 10.1136/bmjopen-2019-034938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Patients with cancer are at high risk of developing pressure ulcers at the end of life as a result of their underlying condition or cancer treatment. There are many guidelines which set out best practice with regard to end-of-life skin care. However, the complexity of palliative cancer care often means that it is challenging for nurses to make the appropriate person-centred decisions about end-of-life skin care. This study seeks to explore the perceived importance that nurses place on different factors in their end-of-life skin care for patients with cancer. The utility, face validity and content validity of a prototype decision-making tool for end-of-life skin care will also be evaluated. METHODS AND ANALYSIS A mixed-method design will be used to gather data from primary and secondary care nurses working in different hospitals and local authority areas across Wales. Clinical vignettes will be used to gather qualitative and quantitative data from nurses in individual interviews. Qualitative data will be subject to thematic analysis and quantitative data will be subject to descriptive statistical analysis. Qualitative and quantitative data will then be synthesised, which will enhance the rigour of this study, and pertinently inform the further development of an end-of-life skin care decision-making tool for patients with cancer. ETHICS AND DISSEMINATION Ethical approval to undertake the study has been granted by Cardiff University School of Healthcare Sciences Research Governance and Ethics Screening Committee. Informed consent will be obtained in writing from all the participants in this study. The results of this study will be disseminated through journal articles, as well as presentations at national and international conferences. We will also report our findings to patient and public involvement groups with an interest in improving cancer care, palliative care as well as skin care.
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Affiliation(s)
- Ray Samuriwo
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
- Wales Centre for Evidence Based Care, School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | | | - Sally Anstey
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Claire Job
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Jane Hopkinson
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
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12
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Schultz SK, Llorente MD, Sanders AE, Tai WA, Bennett A, Shugarman S, Roca R. Quality improvement in dementia care. Neurology 2020; 94:210-216. [DOI: 10.1212/wnl.0000000000008678] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/04/2019] [Indexed: 11/15/2022] Open
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Schultz SK, Llorente MD, Sanders AE, Tai WA, Bennett A, Shugarman S, Roca R. Quality Improvement in Dementia Care: Dementia Management Quality Measurement Set 2018 Implementation Update. Am J Psychiatry 2020; 177:175-181. [PMID: 32008398 DOI: 10.1176/appi.ajp.2019.19121290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Susan K Schultz
- From the James A. Haley Veterans Hospital (S.K.S.), University of Iowa Carver College of Medicine, Iowa City; Department of Psychiatry and Behavioral Sciences (S.K.S.), University of South Florida, Tampa; Department of Psychiatry (M.D.L.), VA Medical Center, Georgetown University School of Medicine, Wash., DC; Memory Care Center (A.E.S.), Ayer Neuroscience Institute, Hartford Healthcare Medical Group, Wethersfield, Conn.; Department of Neurology (W.A.T.), Christiana Care, Newark, Del.; American Academy of Neurology (A.B.), Minneapolis, Minn.; American Psychiatric Association (S.S.), Washington, DC; Sheppard Pratt Health System (R.R.), Towson, Md.; Department of Psychiatry (R.R.), University of Maryland School of Medicine; and Department of Psychiatry (R.R.), Johns Hopkins University School of Medicine, Baltimore, Md
| | - Maria D Llorente
- From the James A. Haley Veterans Hospital (S.K.S.), University of Iowa Carver College of Medicine, Iowa City; Department of Psychiatry and Behavioral Sciences (S.K.S.), University of South Florida, Tampa; Department of Psychiatry (M.D.L.), VA Medical Center, Georgetown University School of Medicine, Wash., DC; Memory Care Center (A.E.S.), Ayer Neuroscience Institute, Hartford Healthcare Medical Group, Wethersfield, Conn.; Department of Neurology (W.A.T.), Christiana Care, Newark, Del.; American Academy of Neurology (A.B.), Minneapolis, Minn.; American Psychiatric Association (S.S.), Washington, DC; Sheppard Pratt Health System (R.R.), Towson, Md.; Department of Psychiatry (R.R.), University of Maryland School of Medicine; and Department of Psychiatry (R.R.), Johns Hopkins University School of Medicine, Baltimore, Md
| | - Amy E Sanders
- From the James A. Haley Veterans Hospital (S.K.S.), University of Iowa Carver College of Medicine, Iowa City; Department of Psychiatry and Behavioral Sciences (S.K.S.), University of South Florida, Tampa; Department of Psychiatry (M.D.L.), VA Medical Center, Georgetown University School of Medicine, Wash., DC; Memory Care Center (A.E.S.), Ayer Neuroscience Institute, Hartford Healthcare Medical Group, Wethersfield, Conn.; Department of Neurology (W.A.T.), Christiana Care, Newark, Del.; American Academy of Neurology (A.B.), Minneapolis, Minn.; American Psychiatric Association (S.S.), Washington, DC; Sheppard Pratt Health System (R.R.), Towson, Md.; Department of Psychiatry (R.R.), University of Maryland School of Medicine; and Department of Psychiatry (R.R.), Johns Hopkins University School of Medicine, Baltimore, Md
| | - Waimei A Tai
- From the James A. Haley Veterans Hospital (S.K.S.), University of Iowa Carver College of Medicine, Iowa City; Department of Psychiatry and Behavioral Sciences (S.K.S.), University of South Florida, Tampa; Department of Psychiatry (M.D.L.), VA Medical Center, Georgetown University School of Medicine, Wash., DC; Memory Care Center (A.E.S.), Ayer Neuroscience Institute, Hartford Healthcare Medical Group, Wethersfield, Conn.; Department of Neurology (W.A.T.), Christiana Care, Newark, Del.; American Academy of Neurology (A.B.), Minneapolis, Minn.; American Psychiatric Association (S.S.), Washington, DC; Sheppard Pratt Health System (R.R.), Towson, Md.; Department of Psychiatry (R.R.), University of Maryland School of Medicine; and Department of Psychiatry (R.R.), Johns Hopkins University School of Medicine, Baltimore, Md
| | - Amy Bennett
- From the James A. Haley Veterans Hospital (S.K.S.), University of Iowa Carver College of Medicine, Iowa City; Department of Psychiatry and Behavioral Sciences (S.K.S.), University of South Florida, Tampa; Department of Psychiatry (M.D.L.), VA Medical Center, Georgetown University School of Medicine, Wash., DC; Memory Care Center (A.E.S.), Ayer Neuroscience Institute, Hartford Healthcare Medical Group, Wethersfield, Conn.; Department of Neurology (W.A.T.), Christiana Care, Newark, Del.; American Academy of Neurology (A.B.), Minneapolis, Minn.; American Psychiatric Association (S.S.), Washington, DC; Sheppard Pratt Health System (R.R.), Towson, Md.; Department of Psychiatry (R.R.), University of Maryland School of Medicine; and Department of Psychiatry (R.R.), Johns Hopkins University School of Medicine, Baltimore, Md
| | - Samantha Shugarman
- From the James A. Haley Veterans Hospital (S.K.S.), University of Iowa Carver College of Medicine, Iowa City; Department of Psychiatry and Behavioral Sciences (S.K.S.), University of South Florida, Tampa; Department of Psychiatry (M.D.L.), VA Medical Center, Georgetown University School of Medicine, Wash., DC; Memory Care Center (A.E.S.), Ayer Neuroscience Institute, Hartford Healthcare Medical Group, Wethersfield, Conn.; Department of Neurology (W.A.T.), Christiana Care, Newark, Del.; American Academy of Neurology (A.B.), Minneapolis, Minn.; American Psychiatric Association (S.S.), Washington, DC; Sheppard Pratt Health System (R.R.), Towson, Md.; Department of Psychiatry (R.R.), University of Maryland School of Medicine; and Department of Psychiatry (R.R.), Johns Hopkins University School of Medicine, Baltimore, Md
| | - Robert Roca
- From the James A. Haley Veterans Hospital (S.K.S.), University of Iowa Carver College of Medicine, Iowa City; Department of Psychiatry and Behavioral Sciences (S.K.S.), University of South Florida, Tampa; Department of Psychiatry (M.D.L.), VA Medical Center, Georgetown University School of Medicine, Wash., DC; Memory Care Center (A.E.S.), Ayer Neuroscience Institute, Hartford Healthcare Medical Group, Wethersfield, Conn.; Department of Neurology (W.A.T.), Christiana Care, Newark, Del.; American Academy of Neurology (A.B.), Minneapolis, Minn.; American Psychiatric Association (S.S.), Washington, DC; Sheppard Pratt Health System (R.R.), Towson, Md.; Department of Psychiatry (R.R.), University of Maryland School of Medicine; and Department of Psychiatry (R.R.), Johns Hopkins University School of Medicine, Baltimore, Md
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Davies N, Barrado-Martin Y, Rait G, Fukui A, Candy B, Smith CH, Manthorpe J, Moore KJ, Vickerstaff V, Sampson EL. Enteral tube feeding for people with severe dementia. Hippokratia 2019. [DOI: 10.1002/14651858.cd013503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nathan Davies
- University College London; Centre for Ageing Population Studies, Research Department of Primary Care and Population Health; Rowland Hill Street London UK NW3 2PF
| | - Yolanda Barrado-Martin
- University College London; Centre for Ageing Population Studies, Research Department of Primary Care and Population Health; Rowland Hill Street London UK NW3 2PF
| | - Greta Rait
- University College London; Centre for Ageing Population Studies, Research Department of Primary Care and Population Health; Rowland Hill Street London UK NW3 2PF
| | - Akiko Fukui
- St George's, University of London; Medical School; Cranmer Terrace London UK SW17 0RE
| | - Bridget Candy
- University College London; Marie Curie Palliative Care Research Department, Division of Psychiatry; 6th Floor, Maple House 149 Tottenham Court Road London UK W1T 7NF
| | - Christina H Smith
- University College London; Division of Psychology and Language Sciences; London UK
| | - Jill Manthorpe
- King's College London; NIHR Health and Social Care Workforce Research Unit, The Policy Institute; Strand London UK WC2 6LB
| | - Kirsten J Moore
- University College London; Marie Curie Palliative Care Research Department, Division of Psychiatry; 6th Floor, Maple House 149 Tottenham Court Road London UK W1T 7NF
| | - Victoria Vickerstaff
- University College London; Marie Curie Palliative Care Research Department, Division of Psychiatry; 6th Floor, Maple House 149 Tottenham Court Road London UK W1T 7NF
| | - Elizabeth L Sampson
- University College London; Marie Curie Palliative Care Research Department, Division of Psychiatry; 6th Floor, Maple House 149 Tottenham Court Road London UK W1T 7NF
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Abstract
OBJECTIVES We aimed to critically evaluate decision aids developed for practitioners and caregivers when providing care for someone with dementia or for use by people with dementia themselves. Decision aids may be videos, booklets, or web-based tools that explicitly state the decision, provide information about the decision, and summarize options along with associated benefits and harms. This helps guide the decision maker through clarifying the values they place on the benefits or harms of the options. DESIGN We conducted a systematic review of peer-reviewed literature in electronic databases (CINAHL, The Cochrane Library, EMBASE, MEDLINE, and PsychINFO) in March 2018. Reference lists were searched for relevant papers and citations tracked. Data were synthesized with meta-analysis and narrative synthesis. Papers were included if they met the following criteria: 1) the focus of the paper was on the evaluation of a decision aid; 2) the decision aid was used in dementia care; and 3) the decision aid was aimed at professionals, people with dementia, or caregivers. RESULTS We identified 3618 studies, and 10 studies were included, covering three topics across six decision aids: 1) support with eating/feeding options, 2) place of care, and 3) goals of care. The mode of delivery and format of the decision aids varied and included paper-based, video-based, and audio-based decision aids. The decision aids were shown to be effective, increasing knowledge and the quality of communication. The meta-analysis demonstrated that decisions are effective in reducing decisional conflict among caregivers (standardized mean difference = -0.50, 95% confidence interval [ - 0.97, - 0.02]). CONCLUSION Decision aids offer a promising approach for providing support for decision-making in dementia care. People are often faced with more than one decision, and decisions are often interrelated. The decision aids identified in this review focus on single topics. There is a need for decision aids that cover multiple topics in one aid to reflect this complexity and better support caregivers.
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Minaglia C, Giannotti C, Boccardi V, Mecocci P, Serafini G, Odetti P, Monacelli F. Cachexia and advanced dementia. J Cachexia Sarcopenia Muscle 2019; 10:263-277. [PMID: 30794350 PMCID: PMC6463474 DOI: 10.1002/jcsm.12380] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/20/2018] [Indexed: 12/22/2022] Open
Abstract
Cachexia is a complex metabolic process that is associated with several end-stage organ diseases. It is known to be also associated with advanced dementia, although the pathophysiologic mechanisms are still largely unknown. The present narrative review is aimed at presenting recent insights concerning the pathophysiology of weight loss and wasting syndrome in dementia, the putative mechanisms involved in the dysregulation of energy balance, and the interplay among the chronic clinical conditions of sarcopenia, malnutrition, and frailty in the elderly. We discuss the clinical implications of these new insights, with particular attention to the challenging question of nutritional needs in advanced dementia and the utility of tube feeding in order to optimize the management of end-stage dementia.
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Affiliation(s)
- Cecilia Minaglia
- Department of Internal Medicine and Medical Specialties (DIMI), Section of Geriatrics, University of Genoa, Genoa, Italy
| | - Chiara Giannotti
- Department of Internal Medicine and Medical Specialties (DIMI), Section of Geriatrics, University of Genoa, Genoa, Italy
| | - Virginia Boccardi
- Department of Medicine, Institute of Gerontology and Geriatrics, University of Perugia, Perugia, Italy
| | - Patrizia Mecocci
- Department of Medicine, Institute of Gerontology and Geriatrics, University of Perugia, Perugia, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,Section of Psychiatry, I.R.C.C.S. Ospedale Policlinico San Martino, Genoa, Italy
| | - Patrizio Odetti
- Department of Internal Medicine and Medical Specialties (DIMI), Section of Geriatrics, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Fiammetta Monacelli
- Department of Internal Medicine and Medical Specialties (DIMI), Section of Geriatrics, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Davies N, Manthorpe J, Sampson EL, Lamahewa K, Wilcock J, Mathew R, Iliffe S. Guiding practitioners through end of life care for people with dementia: The use of heuristics. PLoS One 2018; 13:e0206422. [PMID: 30427873 PMCID: PMC6235299 DOI: 10.1371/journal.pone.0206422] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/12/2018] [Indexed: 11/19/2022] Open
Abstract
Background End of life care (EOLC) for people with dementia can present a multitude of challenges and difficult decisions for practitioners. These challenges may include assessment and management of difficulties with eating and swallowing, responding to agitation, treating pain, and managing recurrent infections. Practitioners sometimes lack both confidence in making end of life decisions and guidance. This study developed an alternative to lengthy guidelines, in the form of heuristics which were tested in clinical settings. The aim of this study was to test the usability and acceptability of a set of heuristics which could be used by practitioners providing EOLC for people with dementia in a variety of clinical and care settings. Methods A three phase co-design process was adopted: 1) Synthesis of evidence and outputs from interviews and focus groups with family carers and practitioners, by a co-design group, to develop heuristics; 2) Testing of the heuristics in five clinical or care settings for six months; 3) Evaluation of the heuristics at three and six months using qualitative individual and group interviews. Results Four heuristics were developed covering: eating and swallowing difficulties, agitation and restlessness, reviewing treatment and interventions at the end of life, and providing routine care. The five sites reported that the heuristics were simple and easy to use, comprehensive, and made implicit, tacit knowledge explicit. Four themes emerged from the qualitative evaluation: authority and permission; synthesis of best practice; providing a structure and breaking down complexity; and reassurance and instilling confidence. Conclusion Use of heuristics is a novel approach to end of life decision making in dementia which can be useful to both experienced and junior members of staff making decisions. Heuristics are a practical tool which could overcome a lack of care pathways and direct guidance in end of life care for people with dementia.
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Affiliation(s)
- Nathan Davies
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
- Centre for Dementia Palliative Care Research, Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom
- * E-mail:
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King’s College London, London, United Kingdom
| | - Elizabeth L. Sampson
- Centre for Dementia Palliative Care Research, Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, United Kingdom
| | - Kethakie Lamahewa
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Jane Wilcock
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Rammya Mathew
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
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Willekens F, Bijak J, Klabunde A, Prskawetz A. The science of choice: an introduction. Population Studies 2017; 71:1-13. [PMID: 29061096 DOI: 10.1080/00324728.2017.1376921] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Frans Willekens
- a Netherlands Interdisciplinary Demographic Institute (NIDI)
| | | | | | - Alexia Prskawetz
- d Vienna University of Technology and Wittgenstein Centre for Demography and Global Human Capital (IIASA, VID/ÖAW, WU)
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Barker S, Lynch M, Hopkinson J. Decision making for people living with dementia by their carers at the end of life: a rapid scoping review. Int J Palliat Nurs 2017; 23:446-456. [DOI: 10.12968/ijpn.2017.23.9.446] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lamahewa K, Mathew R, Iliffe S, Wilcock J, Manthorpe J, Sampson EL, Davies N. A qualitative study exploring the difficulties influencing decision making at the end of life for people with dementia. Health Expect 2017. [PMID: 28640487 PMCID: PMC5750695 DOI: 10.1111/hex.12593] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Dementia is a progressive neurodegenerative condition characterized by declining functional and cognitive abilities. The quality of end of life care for people with dementia in the UK can be poor. Several difficult decisions may arise at the end of life, relating to the care of the person with dementia, for example management of comorbidities. Objective To explore difficulties in decision making for practitioners and family carers at the end of life for people with dementia. Design Qualitative methodology using focus groups and semi‐structured interviews and thematic analysis methods. Settings and participants Former (n=4) and current (n=6) family carers of people with experience of end of life care for a person with dementia were recruited from an English dementia voluntary group in 2015. A further 24 health and care professionals were purposively sampled to include a broad range of expertise and experience in dementia end of life care. Results Four key themes were identified as follows: challenges of delivering coherent care in dynamic systems; uncertainty amongst decision makers; internal and external conflict amongst decision makers; and a lack of preparedness for the end of life. Overarching difficulties such as poor communication, uncertainty and conflict about the needs of the person with dementia as well as the decision maker's own role can characterize decision making at the end of life. Conclusions This study suggests that decision making at the end of life for people with dementia has the potential to be improved. More planning earlier in the course of dementia with an on‐going approach to conversation may increase preparedness and family carers’ expectations of end of life.
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Affiliation(s)
- Kethakie Lamahewa
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rammya Mathew
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Jane Wilcock
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, UK.,Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, UK
| | - Nathan Davies
- Research Department of Primary Care and Population Health, University College London, London, UK
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Davies N, Mathew R, Wilcock J, Manthorpe J, Sampson EL, Lamahewa K, Iliffe S. A co-design process developing heuristics for practitioners providing end of life care for people with dementia. BMC Palliat Care 2016; 15:68. [PMID: 27484683 PMCID: PMC4969644 DOI: 10.1186/s12904-016-0146-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The end of life for someone with dementia can present many challenges for practitioners; such as, providing care if there are swallowing difficulties. This study aimed to develop a toolkit of heuristics (rules-of-thumb) to aid practitioners making end-of-life care decisions for people with dementia. METHODS An iterative co-design approach was adopted using a literature review and qualitative methods, including; 1) qualitative interviews and focus groups with family carers and 2) focus groups with health and care professionals. Family carers were recruited from a national charity, purposively sampling those with experience of end-of-life care for a person with dementia. Health and care professionals were purposively sampled to include a broad range of expertise including; general practitioners, palliative care specialists, and geriatricians. A co-design group was established consisting of health and social care experts and family carers, to synthesise the findings from the qualitative work and produce a toolkit of heuristics to be tested in practice. RESULTS Four broad areas were identified as requiring complex decisions at the end of life; 1) eating/swallowing difficulties, 2) agitation/restlessness, 3) ending life-sustaining treatment, and 4) providing "routine care" at the end of life. Each topic became a heuristic consisting of rules arranged into flowcharts. Eating/swallowing difficulties have three rules; ensuring eating/swallowing difficulties do not come as a surprise, considering if the situation is an emergency, and considering 'comfort feeding' only versus time-trialled artificial feeding. Agitation/restlessness encourages a holistic approach, considering the environment, physical causes, and the carer's wellbeing. Ending life-sustaining treatment supports practitioners through a process of considering the benefits of treatment versus quality-of-life and comfort. Finally, a heuristic on providing routine care such as bathing, prompts practitioners to consider adapting the delivery of care, in order to promote comfort and dignity at the end of life. CONCLUSIONS The heuristics are easy to use and remember, offering a novel approach to decision making for dementia end-of-life care. They have the potential to be used alongside existing end-of-life care recommendations, adding more readily available practical assistance. This is the first study to synthesise experience and existing evidence into easy-to-use heuristics for dementia end-of-life care.
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Affiliation(s)
- Nathan Davies
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
| | - Rammya Mathew
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Jane Wilcock
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, London, WC2B 6NR, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, 6th Floor, Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.,Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, Sterling Way, London, N18 1QX, UK
| | - Kethakie Lamahewa
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Steve Iliffe
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
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