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Gerger H, van Dijk-de Vries A, Moser A, Jochem I, Veenstra M, Perry M, van Bokhoven M. Adjusting advance care planning to older people's needs: results from focus groups and interviews. BMC Health Serv Res 2024; 24:51. [PMID: 38200528 PMCID: PMC10782636 DOI: 10.1186/s12913-023-10491-x] [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: 07/10/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Advance care planning (ACP) is becoming increasingly important in medical care. Some suggest standardized approaches to initiate ACP with all older adults. However, the idea of patient-centered care suggests more nuanced approaches tailored to individual older adults' needs. This study investigated how older adults with different views and needs about ACP can be approached in an adequate and most beneficial way by health care professionals. METHODS We used questionnaires, interviews, focus groups and informal conversations with older adults, living in their own homes, who volunteered to take part in our research. The research was participatory as we collaborated closely with practice partners and we used the obtained findings immediately and continuously to inform the next steps of our research throughout the process. RESULTS We identified three subgroups of older adults with differential needs regarding ACP-related activities: The first group avoids talking about their needs and wishes for care towards the end of life. These older people benefit from activities, which aim at motivating them to concern themselves with ACP-related topics. The second group consists of older adults who are in principle open for ACP-conversations but do not initiate these themselves. This group either trusts their next-of-kin or their healthcare professional to act in accordance with their wishes or does not bring up the topic in order to avoid confronting relevant others with possibly unpleasant topics. This group of people benefits from information about ACP and from healthcare professionals initiating the ACP process. The third group of older people initiates the ACP process themselves, gathers information, and takes the necessary steps for ACP. With this group it remains relevant to check carefully whether they have indeed taken all relevant steps and shared the information with all relevant involved care institutions and relatives. CONCLUSIONS We propose a model to simplify adjustments of ACP to individuals' needs. Our suggested approach might contribute to increasing the motivation of older people to engage in ACP conversations if these are more closely related to their own needs. Further, it might also contribute to simplifying the individual shaping of the ACP process for healthcare professionals as our suggested model offers clear guidance for approaching different types of older people in different ways. The suggested approach may in future be used for training health care professionals in the conduct of ACP conversations.
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Affiliation(s)
- Heike Gerger
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands.
| | - Anneke van Dijk-de Vries
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Albine Moser
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Research Centre Autonomy and Participation of Chronically Ill People, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | | | | | - Marieke Perry
- Department of Primary Care Medicine and Geriatrics, Radboudumc, Nijmegen, the Netherlands
| | - Marloes van Bokhoven
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
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van der Steen JT, Engels Y, Touwen DP, Kars MC, Reyners AKL, van der Linden YM, Korfage IJ. Advance Care Planning in the Netherlands. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:133-138. [PMID: 37482528 DOI: 10.1016/j.zefq.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 07/25/2023]
Abstract
The Dutch health care system fosters a strong public health sector offering accessible generalist care including generalist palliative care. General practitioners are well positioned to conduct ACP, for example, to continue or initiate conversations after hospitalization. However, research shows that ACP conversations are often ad hoc and in frail patients, ACP is often only initiated when admitted to a nursing home by elderly care physicians who are on the staff. Tools that raise awareness of triggers to initiate ACP, screening tools, information brochures, checklists and training have been developed and implemented with funding by national programs which currently focus on implementation projects rather than or in addition to, research. The programs commonly require educational deliverables, patient and public involvement and addressing diversity in patient groups. A major challenge is how to implement ACP systematically and continuously across sectors and disciplines in a way that supports a proactive yet person-centered approach rather than an approach with an exclusive focus on medical procedures. Digital solutions can support continuity of care and communication about care plans. Solutions should fit a culture that prefers trust-based, informal deliberative approaches. This may be supported by involving disciplines other than medicine, such as nursing and spiritual caregiving, and public health approaches.
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Affiliation(s)
- Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands; Department of Primary and Community Care and Radboudumc Alzheimer center, Radboud university medical center, Nijmegen, the Netherlands.
| | - Yvonne Engels
- Department of anesthesiology, pain and palliative medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - Dorothea P Touwen
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, the Netherlands
| | - Marijke C Kars
- Center of Expertise of Palliative Care, Julius Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Anna K L Reyners
- Center of Expertise of Palliative Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Yvette M van der Linden
- Center of Expertise of Palliative Care, Leiden University Medical Center, Leiden, the Netherlands/Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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McIlfatrick S, Slater P, Bamidele O, Muldrew D, Beck E, Hasson F. ' It's almost superstition: If I don't think about it, it won't happen'. Public knowledge and attitudes towards advance care planning: A sequential mixed methods study. Palliat Med 2021; 35:1356-1365. [PMID: 34000901 PMCID: PMC8267083 DOI: 10.1177/02692163211015838] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Internationally, participation in advance care planning is low. Whilst a community action approach is advocated, what the public know and understand about advance care planning is unknown. AIM To assess public awareness, knowledge and attitudes towards advance care planning and identify strategies to raise awareness within a public health framework. DESIGN Sequential mixed methods comprising a cross-sectional survey and focus group/interviews. SETTING/PARTICIPANTS A random representative sample of adults from one region of the United Kingdom (n = 1201; response rate 56%) completed a face-to-face survey. Twenty-five participants consented to an additional focus group/interview held in a secure accessible location or via telephone. RESULTS Most participants (78.7%) acknowledged the benefits of advance care planning conversations, however, two thirds did not want to think about advance care planning or find out more at present. Respondents were reluctant to broach advance care planning as it was linked to end of life care and funeral plans, and they did not wish to cause distress to their loved one. Respondents trusted their family to respect their wishes and they considered having an advance care plan in place would be of assistance in the future. Top-down leadership, normalisation, and increased education were identified as potential approaches to overcome barriers. CONCLUSIONS Advance care planning was recognised as important despite limited awareness, lack of knowledge and misperceptions. Whilst a community action approach to enhance understanding and engagement was supported, a 'one size fits all' approach will not work; rather bespoke targeting is required with educational and media messaging aligned.
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Affiliation(s)
- Sonja McIlfatrick
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Northern Ireland
| | - Paul Slater
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Northern Ireland
| | - Olufikayo Bamidele
- Institute of Clinical and Applied Health Research, Hull York Medical School, University of Hull, Hull, UK
| | - Deborah Muldrew
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Northern Ireland
| | - Esther Beck
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Northern Ireland
| | - Felicity Hasson
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Northern Ireland
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van der Smissen D, Rietjens JAC, van Gemert-Pijnen L, van Dulmen S, van der Heide A, Korfage IJ. Information needs of patients with chronic diseases and their relatives for web-based advance care planning: a qualitative interview study. BMC Palliat Care 2021; 20:77. [PMID: 34053435 PMCID: PMC8164830 DOI: 10.1186/s12904-021-00770-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) enables persons to identify preferences for future treatment and care, and to discuss, record and review these preferences. However, the uptake of ACP among patients with chronic diseases is relatively low. Web-based ACP programs can support patients and their relatives in ACP. However, information needs of patients and their relatives for ACP are unknown. The aim of this study is to explore information needs of patients with chronic disease and their relatives for web-based ACP. METHODS We conducted semi-structured interviews with patients with chronic diseases and relatives at their home or at the study center. In three cases, the patient and relative were paired since they preferred to be interviewed together. We asked about information they would search for when to start with ACP, where they would search for information, what search terms they would use on the Internet, and what content and information they would consider important on an ACP website. The interviewer asked participants to clarify their responses during the interview. We used thematic analysis to analyze the interviewees' responses. RESULTS We interviewed nine patients with different chronic diseases including amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD) and kidney diseases, and seven relatives, namely partners or (adult) children. The interviewees were aged 24 to 80 years, nine were female and seven were male. Both patients with a chronic disease and relatives mentioned comparable information needs. Many interviewees indicated they would use the Internet to search for information about ACP. Mentioned search terms were "advance care planning", "treatment plan", "disease trajectory" and names of patient associations. Information needs concerned their disease trajectory and quality of life, medical treatment decisions, practical support in arranging care, the concept of ACP and guidance in ACP, communication of treatment and care preferences, peer support of others with chronic diseases, and information for relatives. Many appreciated encouragement of their healthcare providers to take a pro-active role in ACP. CONCLUSIONS We conclude that information needs for ACP included guidance in ACP, support in making decisions about medical treatment, and practical support in arranging care. We recommend adapting web-based ACP information to the information needs of patients and their relatives to increase its findability, uptake and usefulness.
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Affiliation(s)
- Doris van der Smissen
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000 the Netherlands
| | - Judith A. C. Rietjens
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000 the Netherlands
| | - Lisette van Gemert-Pijnen
- grid.6214.10000 0004 0399 8953Department of Psychology, Health and Technology, University of Twente, Enschede, the Netherlands
| | - Sandra van Dulmen
- grid.10417.330000 0004 0444 9382Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands ,grid.416005.60000 0001 0681 4687Nivel (Netherlands institute for health services research), Utrecht, the Netherlands
| | - Agnes van der Heide
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000 the Netherlands
| | - Ida J. Korfage
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000 the Netherlands
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Grande G, Vetrano DL, Mazzoleni F, Lovato V, Pata M, Cricelli C, Lapi F. Detection and Prediction of Incident Alzheimer Dementia over a 10-Year or Longer Medical History: A Population-Based Study in Primary Care. Dement Geriatr Cogn Disord 2021; 49:384-389. [PMID: 33242874 DOI: 10.1159/000509379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/11/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite the crucial role played by general practitioners in the identification and care of people with cognitive impairment, few data are available on how they may improve the early recognition of patients with Alzheimer dementia (AD), especially those with long (i.e., 10 years and longer) medical history. AIMS To investigate the occurrence and the predictors of AD during a 10-year or longer period prior AD diagnosis in primary care patients aged 60 years or older. MATERIALS AND METHODS A cohort study with a nested case-control analysis has been conducted. Data were extracted from the Italian Health Search Database (HSD), an Italian database with primary care data. AD cases have been defined in accordance with the International Classification of Diseases, ninth edition (ICD-9-CM) codes and coupled with the use of anti-dementia drugs. Prevalence and incidence rates of AD have been calculated. To test the association between candidate predictors, being identified in a minimum period of 10 years, and incident cases of AD, we used a multivariate conditional logistic regression model. RESULTS As recorded in the primary care database, AD prevalence among patients aged 60 years or older was 0.8% during 2016, reaching 2.4% among nonagenarians. Overall, 1,889 incident cases of AD have been identified, with an incidence rate as high as 0.09% person-year. Compared with 18,890 matched controls, history of hallucinations, agitation, anxiety, aberrant motor behavior, and memory deficits were positively associated with higher odds of AD (p < 0.001 for all) diagnosis. A previous diagnosis of depression and diabetes and the use of low-dose aspirin and non-steroidal anti-inflammatory drugs were associated with higher odds of AD (p < 0.05 for all). CONCLUSION Our findings show that, in accordance with primary care records, 1% of patients aged 60 years and older have a diagnosis of AD, with an incident AD diagnosis of 0.1% per year. AD is often under-reported in primary care settings; yet, several predictors identified in this study may support general practitioners to early identify patients at risk of AD.
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Affiliation(s)
- Giulia Grande
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Davide L Vetrano
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden.,Department of Geriatrics, Catholic University of Rome, Rome, Italy.,Centro di Medicina dell'Invecchiamento, Fondazione Policlinico "A. Gemelli" IRCCS, Rome, Italy
| | | | | | | | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy,
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Jeong S, Barrett T, Ohr SO, Cleasby P, Davey R, David M. Prevalence of advance care planning practices among people with chronic diseases in hospital and community settings: a retrospective medical record audit. BMC Health Serv Res 2021; 21:303. [PMID: 33820535 PMCID: PMC8022421 DOI: 10.1186/s12913-021-06265-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/10/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Sarah Jeong
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia.
| | - Tomiko Barrett
- Department of Aged Care Services, Wyong Hospital, Central Coast Local Health District, PO Box 4200, Lakehaven, NSW, 2263, Australia
| | - Se Ok Ohr
- Hunter New England Nursing and Midwifery Research Centre, Hunter New England Local Health District, James Fletcher Campus, Gate Cottage, 72 Watt St, Newcastle, NSW, 2300, Australia
| | - Peter Cleasby
- Division of Aged, Subacute and Complex Care, Central Coast Local Health District, PO Box 6088, Long Jetty, NSW, 2261, Australia
| | - Ryan Davey
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia
| | - Michael David
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
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Glaudemans JJ, Willems DL, Wind J, Onwuteaka Philipsen BD. Preventing unwanted situations and gaining trust: a qualitative study of older people and families' experiences with advance care planning in the daily practice of primary care. Fam Pract 2020; 37:519-524. [PMID: 31816034 PMCID: PMC7474529 DOI: 10.1093/fampra/cmz089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Using advance care planning (ACP) to anticipate future decisions can increase compliance with people's end-of-life wishes, decrease inappropriate life-sustaining treatment and reduce stress, anxiety and depression. Despite this, only a minority of older people engage in ACP, partly because care professionals lack knowledge of approaches towards ACP with older people and their families. OBJECTIVE To explore older people's and their families' experiences with ACP in primary care. METHODS We conducted qualitative, semi-structured, face-to-face interviews with 22 older people (aged >70 years, v/m: 11/11), with experience in ACP, and eight of their family members (aged 40-79 years, f/m: 7/1). Transcripts were inductively analysed using a grounded theory approach. RESULTS We distinguished three main themes. (i) Openness and trust: Respondents were more open to ACP if they wanted to prevent specific future situations and less open if they lacked trust or had negative thoughts regarding general practitioners' (GPs') time for and interest in ACP. Engaging in ACP appeared to increase trust. (ii) Timing and topics: ACP was not initiated too early. Quality of ACP seemed to improve if respondents' views on their current life and future, a few specific future care scenarios and expectations and responsibilities regarding ACP were discussed. (iii) Roles of family: Quality of ACP appeared to improve if family was involved in ACP. CONCLUSIONS Quality and accessibility of ACP may improve if GPs and nurses involve family, explain GPs' interest in ACP and discuss future situations older people may want to prevent, and views on their current life and future.
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Affiliation(s)
- Jolien J Glaudemans
- Section of Medical Ethics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Dick L Willems
- Section of Medical Ethics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jan Wind
- Department of General Practice, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bregje D Onwuteaka Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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