The balancing point: understanding uptake of advance directive forms in a rural Australian community

Enhanced Advance care planning and life Review Longitudinal Intervention (EARLI): Protocol for a cluster randomized controlled cross-over trial of life story work and facilitated advance care planning among older Australian adults in community settings

BACKGROUND

Advance care planning (ACP) is potentially helpful for older adults, however, the rate of uptake in community aged care settings is low. Previous pilot studies suggest that holistic, person-centered ACP approaches may be effective for older adults who experience functional impairment but do not necessarily have life-limiting conditions with clear prognoses. This paper describes the protocol of a randomized trial to test the effectiveness of combined life story work and facilitated ACP in promoting ACP engagement among older adults receiving community aged care services.

METHODS

The Enhanced Advance care planning and life Review Longitudinal Intervention (EARLI) trial is an open-label, cross-over, cluster randomized controlled trial with 12 participating aged care organizations in New South Wales and Western Australia. Participants are aged 65 years or older, receiving home care services and capable of providing informed consent at initial recruitment. Recruitment occurs across a two-year period, with study sites randomized to receive the four-session intervention in the first or second year (or a single session 'active control' condition). Primary outcomes are participant-reported ACP engagement and ACP documentation in the aged care client record 12 weeks post-recruitment. Secondary outcomes include measures of decisional conflict, anxiety and depression, meaning-based coping and relationship quality. Analysis will take an intention-to-treat approach.

CONCLUSION

This trial tests a novel method of reaching older adults using a holistic, person-centered approach to promoting ACP engagement. Enhancing ACP engagement may reduce decisional conflict, minimize hospital admissions and improve outcomes for people and their families. ANZCTR Trial Registration ID: ACTRN12622001399785.

Do advance directive attitudes and perceived susceptibility and end-of-life life-sustaining treatment preferences between patients with heart failure and cancer differ?

There is limited evidence on the relationships of preference for end-of-life life-sustaining treatments [LSTs] and diagnostic contexts like heart failure [HF] or cancer, and patient attitudes toward and perceived susceptibility to use advance directives [ADs]. Thus, this study aimed to compare attitudes and perceived susceptibility between HF patients and community-dwelling patients with cancer, and examine the associations of these variables with their preference for each LST (cardiopulmonary resuscitation [CPR], ventilation support, hemodialysis, and hospice care). Secondary data were obtained from 36 outpatients with HF (mean age, 65.44 years; male, 69.4%) and 107 cancer patients (mean age, 67.39 years; male, 32.7%). More patients with HF preferred CPR than cancer patients (41.7% and 15.9%, χ2 = 8.88, P = 0.003). Attitudes and perceived susceptibility were similar between the two diagnostic cohorts. HF patients and those with more positive attitudes had greater odds of preferring CPR (odds ratio [OR] = 3.02, confidence interval [CI] = 1.19, 7.70) and hospice care (OR = 1.14, CI = 1.06, 1.23), respectively. HF diagnosis and AD attitudes increased the preference for CPR and hospice care, respectively. This suggests that it is important to gain positive attitudes toward ADs and consider diagnostic context to facilitate informed decision-making for LSTs.

Advance Care Planning in Rural Montana: Exploring the Nurse's Role

It is recommended that advance care planning take place across the lifespan. Rural populations have a heightened risk for poor quality and high cost of end-of-life care. A doctoral project was completed to assess rural nurses' knowledge, attitudes, and experiences with advance directives using the Knowledge, Attitudinal, and Experimental Surveys on Advance Directives. Descriptive statistics were used for analysis. Participants were nurses who practice in rural settings (N = 22). The average age was 46.4 years; all were white (n = 22), and the majority were baccalaureate prepared (n = 12). Practice settings were primarily in home care and hospice. Knowledge scores on advance directives were low (57%). Nurses felt confident in counseling and initiating discussions with patients and families. Less than one-half of the nurses reported they feel part of the advance care planning team. The majority reported advance directive resources and mentorship of younger nurses would be beneficial and indicated the need for additional education, training, knowledge, time, and support to better assist with advance care planning. Project results and recommendations were presented to the participating health care organization. Recommendations included workplace education, support, mentorship, resources, and education on cultural sensitivity using the rural nursing theory.

Exploring Advance Directive Perspectives and Associations with Preferences for End-of-Life Life-Sustaining Treatments among Patients with Implantable Cardioverter-Defibrillators

Deactivation of an implantable cardioverter-defibrillator (ICD) is a critical issue in the advance care planning (ACP) of ICD recipients; however, related perspectives have rarely been explored. Thus, this study aimed to provide an initial investigation of ICD recipients’ perceived susceptibility and barriers/benefits regarding ACP and/or advance directives (ADs), and associations of these modifiable factors with preferences for end-of-life life-sustaining treatments (LSTs) (cardiopulmonary resuscitation (CPR), ventilator support, hemodialysis, and hospice care). Using a descriptive correlational design, 48 ICD recipients (age, 50.1 years; male, 85.4%) completed survey questionnaires. “No burden on family” was the most highly valued (59.1%), followed by “comfortable death” (20.4%), and both (11.4%). LST preference was 43.8% for ventilator support, 45.8% for both hemodialysis and hospice care, and 54.2% for CPR. Perceived susceptibility to having unexpected end-of-life experiences increased the likelihood of preference for aggressive LSTs, with preferences increasing by 15% for CPR, 17% for ventilator support, and 23% for hemodialysis. A non-modifiable factor, older age, was the only predictor of increased preference for hospice care (odds ratio = 1.09, p = 0.016). Among the modifiable factors, a higher perceived susceptibility increased the likelihood of aggressive LST preferences. The findings imply that to facilitate informed decisions for LSTs, early ACP discussion could be helpful and enhance these modifiable factors.

Psychometric Testing of the Korean Version of the Attitudes toward the Advance Directives in Low-Income Chronically Ill Older Adults

The purpose of this study was to examine the psychometric properties of the Advance Directive Attitude Survey in Korean (K-ADAS), a measure of attitudes toward advance directives (ADs). A total of 118 low-income, community-dwelling older adults (mean age, 75.09 years) participated. An exploratory factor analysis (EFA) was conducted to determine the factor structure of the K-ADAS. Validity was further assessed by known associations of the K-ADAS with perceived susceptibility and severity using part of the Advance Care Planning surveys. Its reliability was examined by calculating alpha coefficients. EFA determined a three-factor structure model with good model fit. Validity was further supported with significant correlations between the K-ADAS and susceptibility and severity. Reliability was supported by adequate level of Cronbach’s alpha. The K-ADAS was a valid and reliable measure for assessment of AD attitudes with a sound model fit. Thus, the K-ADAS can be used to assess AD attitudes among community-dwelling elders.

Rural health services' relationships with patients: An enabler and a barrier to advance care planning

OBJECTIVE

The barriers and enablers to the uptake of advance care plans has been well documented but more so in metropolitan health services. Rural and regional areas have their own challenges of higher rates of chronic illness and an aging population when considering end of life care. This study aimed to explore the creation of advance care plans in a regional location that has service links to smaller health services.

DESIGN

A qualitative study involving thematic analysis of interview data.

SETTING

A regional local government area in Victoria, Australia.

PARTICIPANTS

Twelve representatives from rural and regional health services, including hospital, private practice and community organisation staff.

MAIN OUTCOME MEASURES

Barriers and enablers to the creation of advance care planning documents.

RESULTS

The data analysis yielded two main identified themes around Plan creation and communication of patient wishes: system and societal challenges to the creation and communication in advance care planning; and rural communities' expectation of the health service-patient relationship and advance care planning.

CONCLUSION

Although barriers to advance care planning are well known, rural and regional practitioners need to be aware of the effect long-term continuity of care from health practitioners and connections with health services has on advance care plan creation, and whether the paucity of written Plans effects end-of-life care. A potential solution was seen in the pending linkages to the national electronic patient record.

Correlates of life-support treatment preferences among low-income home-based cancer management recipients

PURPOSE

To examine the correlates of life-support treatment (LST) preferences from attitudes toward advance directives (ADs), perceived susceptibility, symptom frequency, symptom burden, and global health among low-income community-dwelling cancer management recipients, controlling for age, sex, education, and duration after cancer diagnosis.

METHODS

A cross-sectional, correlational study design was used to assess LST preferences and correlates. Data were collected from low-income cancer survivors during nurses' home visits.

RESULTS

Survivors who had mostly solid cancer participated (N = 107, mean age = 67.39 ± 11.57 years, 32.7% males). Hospice care was the most desired (66.4%), while aggressive treatments were less preferred: cardiopulmonary resuscitation (15.9%), ventilation support (15.0%), hemodialysis (18.7%), or chemotherapy (12.1%). Higher symptom frequency was associated with a greater likelihood of preferring all aggressive treatments (odds ratios = 1.44-1.75). In addition, longer cancer duration was associated with a greater likelihood of preferring ventilation support; females had a lesser likelihood of preferring hemodialysis and chemotherapy. Higher education was associated with a lesser likelihood of preferring chemotherapy. More positive attitudes (B = 0.15, p = .001) were associated with a greater likelihood of preferring hospice care, and greater symptom burden of pain (B = -0.03, p = .047) was associated with a lesser likelihood.

CONCLUSION

Results support the feasibility of incorporating ADs into cancer management among community-dwelling cancer survivors, with consideration of AD attitudes and symptom monitoring. An integration of AD discussion into the home visiting service could be a liaison for the quality and continuity of cancer survivorship care that guides and manages patients' survivorship issues.

Rural health professionals' experiences in implementing advance care planning: a focus group study

Advance care planning (ACP) is described as an ongoing discussion between a patient, their family and healthcare professionals (HCPs) to understand a patient's wishes for future health care. Legislation supporting ACP in Western Australia is relatively new and HCPs are still learning about the process and implementation. This study aimed to provide a rich description of rural health professionals' perceptions and experiences with ACP within the context of their professional role and to identify systemic issues and training needs. Ten focus groups were conducted throughout 2014 with a total of 55 rural participants including general practitioners (n=15), general practice registrars (n=6), practice nurses (n=18), community nurses (n=4) and hospital nurses (n=12) in the south-western regions of Western Australia. Thematic analysis has identified the following themes regarding ACP: benefits to patients and families; professional roles in ACP; barriers and enablers; and systems for communicating ACP. HCPs have self-determined their roles in the ACP process, which currently leaves some components of the process unaccounted for, suggesting that collaboration between HCPs working together in a rural health setting and a standardised system for distributing these documents may assist with the implementation of ACP.

Prospective comparative effectiveness cohort study comparing two models of advance care planning provision for Australian community aged care clients

OBJECTIVES

Conduct a prospective comparative effectiveness cohort study comparing two models of advance care planning (ACP) provision in community aged care: ACP conducted by the client's case manager (CM) ('Facilitator') and ACP conducted by an external ACP service ('Referral') over a 6-month period.

METHODS

This Australian study involved CMs and their clients. Eligible CM were English speaking, ≥18 years, had expected availability for the trial and worked ≥3 days per week. CMs were recruited via their organisations, sequentially allocated to a group and received education based on the group allocation. They were expected to initiate ACP with all clients and to facilitate ACP or refer for ACP. Outcomes were quantity of new ACP conversations and quantity and quality of new advance care directives (ACDs).

RESULTS

30 CMs (16 Facilitator, 14 Referral) completed the study; all 784 client's files (427 Facilitator, 357 Referral) were audited. ACP was initiated with 508 (65%) clients (293 Facilitator, 215 Referral; p<0.05); 89 (18%) of these (53 Facilitator, 36 Referral) and 41 (46%) (13 Facilitator, 28 Referral; p<0.005) completed ACDs. Most ACDs (71%) were of poor quality/not valid. A further 167 clients (facilitator 124; referral 43; p<0.005) reported ACP was in progress at study completion.

CONCLUSIONS

While there were some differences, overall, models achieved similar outcomes. ACP was initiated with 65% of clients. However, fewer clients completed ACP, there was low numbers of ACDs and document quality was generally poor. The findings raise questions for future implementation and research into community ACP provision.

Experiences and perspectives of older people regarding advance care planning: A meta-synthesis of qualitative studies

BACKGROUND

Studies have indicated that family members or health professionals may not know or predict their older relatives' or patients' health preferences. Although advance care planning is encouraged for older people to prepare end-of-life care, it is still challenging.

AIM

To understand the experiences and perspectives of older people regarding advance care planning.

DESIGN

A systematic review of qualitative studies and meta-synthesis was conducted.

DATA SOURCES

CINAHL, MEDLINE, EMBASE, and PsycINFO databases were searched.

RESULTS

A total of 50 articles were critically appraised and a thematic synthesis was undertaken. Four themes were identified: life versus death, internal versus external, benefits versus burdens, and controlling versus being controlled. The view of life and death influenced older people's willingness to discuss their future. The characteristics, experiences, health status, family relationship, and available resources also affected their plans of advance care planning. Older people needed to balance the benefits and burdens of advance care planning, and then judge their own ability to make decisions about end-of-life care.

CONCLUSION

Older people's perspectives and experiences of advance care planning were varied and often conflicted; cultural differences amplified variances among older people. Truthful information, available resources, and family support are needed to enable older people to maintain dignity at the end of life. The views of life and death for older people from different cultures should be compared to assist health professionals to understand older people's attitudes toward advance care planning, and thus to develop appropriate strategies to promote advance care planning in different cultures.

Advance care planning uptake among patients with severe lung disease: a randomised patient preference trial of a nurse-led, facilitated advance care planning intervention

OBJECTIVE

Advance care planning (ACP) clarifies goals for future care if a patient becomes unable to communicate their own preferences. However, ACP uptake is low, with discussions often occurring late. This study assessed whether a systematic nurse-led ACP intervention increases ACP in patients with advanced respiratory disease.

DESIGN

A multicentre open-label randomised controlled trial with preference arm.

SETTING

Metropolitan teaching hospital and a rural healthcare network.

PARTICIPANTS

149 participants with respiratory malignancy, chronic obstructive pulmonary disease or interstitial lung disease.

INTERVENTION

Nurse facilitators offered facilitated ACP discussions, prompted further discussions with doctors and loved ones, and assisted participants to appoint a substitute medical decision-maker (SDM) and complete an advance directive (AD).

OUTCOME MEASURES

The primary measure was formal (AD or SDM) or informal (discussion with doctor) ACP uptake assessed by self-report (6 months) and medical notes audit. Secondary measures were the factors predicting baseline readiness to undertake ACP, and factors predicting postintervention ACP uptake in the intervention arm.

RESULTS

At 6 months, formal ACP uptake was significantly higher (p<0.001) in the intervention arm (54/106, 51%), compared with usual care (6/43, 14%). ACP discussions with doctors were also significantly higher (p<0.005) in the intervention arm (76/106, 72%) compared with usual care (20/43, 47%). Those with a strong preference for the intervention were more likely to complete formal ACP documents than those randomly allocated. Increased symptom burden and preference for the intervention predicted later ACP uptake. Social support was positively associated with ACP discussion with loved ones, but negatively associated with discussion with doctors.

CONCLUSIONS

Nurse-led facilitated ACP is acceptable to patients with advanced respiratory disease and effective in increasing ACP discussions and completion of formal documents. Awareness of symptom burden, readiness to engage in ACP and relevant psychosocial factors may facilitate effective tailoring of ACP interventions and achieve greater uptake.

TRIAL REGISTRATION NUMBER

ACTRN12614000255684.

Factors Influencing Australian General Practitioners' Clinical Decisions Regarding Advance Care Planning: A Factorial Survey

CONTEXT

Primary care physicians are well placed to identify patients in need of advance care planning (ACP) and initiate ACP in advance of an acute situation.

OBJECTIVES

This study aimed to understand Australian general practitioner (GP) clinical decision making relating to a patient's "need for ACP" and the likelihood of initiating ACP.

METHODS

An experimental vignette study pseudorandomly manipulated factors thought to influence decision making regarding ACP. Patient-level factors included gender, age, type of disease, medical severity, openness to ACP, doctor-patient relationship, and family support. An accompanying demographic survey assessed health professional-level factors, including gender, years of experience, place of training, place of practice, caseload of patients with ACP, direct personal experience in ACP, and self-reported attitudes toward ACP. Seventy GPs were recruited, and each completed six unique vignettes, providing ratings of patient need for ACP, importance of initiating ACP in the coming months, and likelihood of initiating ACP at the next consultation.

RESULTS

Older patients, with malignant or cardiovascular disease, severe clinical presentations, good doctor-patient relationship, female gender, and poor family support were more likely to receive prompt ACP. Positive GP attitudes toward ACP were associated with greater likelihood of initiating ACP promptly.

CONCLUSION

Patients with presentations suggesting higher mortality risk were identified as being in need of ACP; however, the likelihood of initiating ACP was sensitive to GP attitudes and psychosocial aspects of the doctor-patient interaction. Training materials aimed at encouraging GP involvement in ACP should target attitudes toward ACP and communication skills, rather than focusing solely on prognostic risk.

A public health approach to promoting advance care planning to Aboriginal people in regional communities

OBJECTIVE

To explore perceptions of Noongar community members towards advance care planning (ACP), while developing culturally appropriate information resources for use in community and hospital settings.

DESIGN

Qualitative research methods, combining active health promotion with interviews and group discussions for participant feedback.

SETTING

Six rural communities across the Great Southern region of Western Australia.

PARTICIPANTS

Eighteen Noongar community members consented to participate in interviews or group discussions.

INTERVENTIONS

Community members received information about ACP at community events or home visits, from an Aboriginal health worker and palliative care researcher.

MAIN OUTCOME MEASURES

Semi-structured interviews and group discussions were thematically analysed using a descriptive, exploratory approach. Research team reflections on community events also constituted data.

RESULTS

Key themes impacting on perceptions of ACP included cultural approaches to dying, importance of family and kin, and appropriate communication. Participants were satisfied with the information resource and method of community engagement.

CONCLUSIONS

Culturally appropriate methods of engaging Aboriginal people in ACP discussions should include Aboriginal health workers and take a whole of community approach to awareness raising.

Discussing dying in the diaspora: attitudes towards advance care planning among first generation Dutch and Italian migrants in rural Australia

Western cultural practices and values have largely shaped advance care planning (ACP) policies across the world. Low uptake of ACP among ethnic minority groups in Western countries has been interpreted with reference to cultural differences. This paper adopts a life-history approach to explore attitudes towards ACP among older, first-generation Dutch-Australian and Italian-Australian migrants. Thirty people participated in extended ethnographic interviews (N = 17) and group discussions (N = 13) during 2012. Transcripts were thematically analyzed and interpreted using a Foucauldian perspective on knowledge and power. Migration experiences, ongoing contact with the native country and participation in migrant community support networks influenced attitudes towards ACP. Dutch participants framed ACP discussions with reference to euthanasia, and adopted a more individualist approach to medical decision-making. Italian participants often spoke of familial roles and emphasized a family-based decision making style. The importance of migrant identity has been neglected in previous discussions of cultural factors influencing ACP uptake among ethnic minority groups. The unique migration experience should be considered alongside culturally appropriate approaches to decision-making, in order to ensure equitable access to ACP among migrant groups.