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Tierney AP, Milnes S, Phillips A, Simpson N, Bailey M, Corke C, Orford NR. Effect of a person-centred goals-of-care form and clinical communication training on shared decision-making and outcomes in an acute hospital: a prospective longitudinal interventional study. Intern Med J 2024; 54:1197-1204. [PMID: 38520171 DOI: 10.1111/imj.16381] [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: 10/19/2023] [Accepted: 02/09/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Patients with a life-limiting illness (LLI) requiring hospitalisation have a high likelihood of deterioration and 12-month mortality. To avoid non-aligned care, we need to understand our patients' goals and values. AIM To describe the association between the implementation of a shared decision-making (SDM) programme and documentation of goals of care (GoC) for hospitalised patients with LLI. METHODS A prospective longitudinal interventional study of patients admitted to acute general medicine wards in an Australian tertiary hospital over 5 years was conducted. A SDM programme with a new GoC form, communication training and clinical support was implemented. The primary outcome was the proportion of patients with a documented person-centred GoC discussion (PCD). Clinical outcomes included hospital utilisation and 90-day mortality. RESULTS 1343 patients were included. The proportion of patients with PCDs increased from 0% to 35.4% (adjusted odds ratio (aOR), 2.38; 95% confidence interval (CI), 2.01-2.82; P < 0.001). During this time, median hospital length of stay decreased from 8 days (interquartile range (IQR), 4-14) to 6 days (IQR, 3-11) (adjusted estimate effect, -0.38; 95% CI, -0.64 to -0.11; P = 0.005) and rapid response team activation from 28% to 13% (aOR, 0.87; 95% CI, 0.78-0.97; P value = 0.01). Documented treatment preference of high-dependency unit care decreased from 39.7% to 24.4% (aOR, 0.81; 95% CI, 0.73-0.89; P value < 0.001), and ward-based care increased from 31.9% to 55.1% (aOR, 1.24; 95% CI, 1.14-1.36; P value < 0.001). CONCLUSION The implementation of a SDM programme was associated with increased documentation of person-centred GoC, changed patient treatment preference to lower intensity care and reduced hospital utilisation.
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Affiliation(s)
- Andrew P Tierney
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Sharyn Milnes
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Anita Phillips
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Nicholas Simpson
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine (SPHPM), Monash University, Melbourne, Victoria, Australia
| | - Charlie Corke
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Neil R Orford
- Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine (SPHPM), Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
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Button E, Baniahmadi S, Chambers S, Yates P. Addressing the end-of-life actions in the National Safety and Quality Health Service Standards (2nd edn): a national survey. AUST HEALTH REV 2023; 47:574-585. [PMID: 37704436 DOI: 10.1071/ah22136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/09/2023] [Indexed: 09/15/2023]
Abstract
Objectives To describe current and planned processes and outcome measures to address implementation of the six end-of-life actions in the National Safety and Quality Health Service (NSQHS) Standards (2nd edn) and explore associated barriers and enablers. Methods This study used an exploratory mixed methods national survey of acute healthcare facilities between September 2018 and March 2019. This study involved public and private facilities (N = 765) that provided end-of-life care, which are required to be accredited to the NSQHS Standards. Participants include those responsible for reporting implementation of end-of-life care actions at a facility providing end-of-life care. Participants were asked what processes and outcome measures were implemented or being planned to address the end-of-life care actions, and the associated barriers and enablers. Results Fifty respondents (6.5% response rate) from across Australia contributed data, reporting greater confidence in addressing Actions 5.16: Clinicians have access to Specialist Palliative Care Services; 5.17: Advance care plans can be received from patients and stored in medical records; and 5.18: Supervision and support is available for workforce providing end-of-life care. Barriers associated with the actions that were the most challenging to address included: competing clinical priorities, and insufficient resources to provide best practice end-of-life care; and the burdensome nature of conducting audits. Enablers included: (1) local, jurisdictional, and national strategic plans and policies; (2) support from Specialist Palliative Care Services; (3) access to resources and data; (4) standardised approaches to implementation and measuring outcomes; and (5) clinician, consumer and community engagement and education on end-of-life care. Conclusion Enablers and barriers in implementing the six end-of-life care actions were identified. Respondents reported that high-level support and direction, system-wide approaches, practical clinical support, and widespread community and clinician engagement would enable their facility to better address the end-of-life actions.
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Affiliation(s)
- Elise Button
- Centre for Healthcare Transformation, Queensland University of Technology, Level 7, Q Block, Musk Avenue, Kelvin Grove, Qld 4059, Australia; and Cancer Care Services, Royal Brisbane and Women's Hospital, Qld, Australia
| | - Sara Baniahmadi
- Centre for Healthcare Transformation, Queensland University of Technology, Level 7, Q Block, Musk Avenue, Kelvin Grove, Qld 4059, Australia
| | - Shirley Chambers
- Centre for Healthcare Transformation, Queensland University of Technology, Level 7, Q Block, Musk Avenue, Kelvin Grove, Qld 4059, Australia
| | - Patsy Yates
- Centre for Healthcare Transformation, Queensland University of Technology, Level 7, Q Block, Musk Avenue, Kelvin Grove, Qld 4059, Australia; and Faculty of Health, Queensland University of Technology, Qld, Australia
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Virdun C, Garcia M, Phillips JL, Luckett T. Description of patient reported experience measures (PREMs) for hospitalised patients with palliative care needs and their families, and how these map to noted areas of importance for quality care: A systematic review. Palliat Med 2023; 37:898-914. [PMID: 37092501 PMCID: PMC10320712 DOI: 10.1177/02692163231169319] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND The global need for focused improvements in palliative care within the acute hospital setting is well noted. A large volume of evidence exists detailing what hospitalised patients with palliative care needs and their families note as important for high quality care. Patient Reported Experience Measures (PREMs) are one mechanism that hospitals could use to inform improvement work. To date there has not been a review of PREMs available for hospitalised patients with palliative care needs and/or their family, nor how they align with noted priorities for high quality care. AIM To identify and describe PREMs designed for hospitalised patients with palliative care needs and their families; and their alignment with patient and family identified domains for high quality care. DESIGN A systematic review. DATA SOURCES A systematic search of CINAHL, Medline and PsycInfo was conducted up to September 23, 2022 and supplemented by handsearching article reference lists and internet searches. PREMs written in English and designed for patients with palliative care needs in acute hospitals were eligible for inclusion. Included PREMs were described by: summarising key characteristics; and mapping their items to domains noted to be important to hospitalised patients with palliative care needs and their families informed by outcomes from a published study completed in 2021. Evidence for psychometric properties were reviewed. RESULTS Forty-four PREMs with 827 items were included. Items per PREM varied from 2 to 85 (median 25, IQR 13-42). Two-thirds (n = 534, 65%) of the items were designed for families and a third (n = 283, 34%) for hospitalised patients, and very few (n = 10, 1%) for both. Sixty-six percent of items measured person-centred care, 30% expert care and 4% environmental aspects of care. Available PREMs address between 1 and 11 of the 14 domains of importance for quality palliative care. PREMs had a median of 38% (IQR 25.4-56.3) of items >Grade 8 measured by the Flesch-Kincaid readability test, with Grade 8 or lower recommended to ensure health information is as accessible as possible across the population. CONCLUSIONS Whilst 44 PREMs are available for hospitalised patients with palliative care needs or their families, a varied number of items are available for some domains of care provision that are important, compared to others. Few are suitable for people with lower levels of literacy or limited cognitive capacity due to illness.
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Affiliation(s)
- Claudia Virdun
- Faculty of Health, School of Nursing, Queensland University of Technology, Brisbane, Australia
- Faculty of Health, Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Ultimo, NSW, Australia
| | - Maja Garcia
- Faculty of Health, Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Ultimo, NSW, Australia
| | - Jane L Phillips
- Faculty of Health, School of Nursing, Queensland University of Technology, Brisbane, Australia
- Faculty of Health, Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Ultimo, NSW, Australia
| | - Tim Luckett
- Faculty of Health, Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Ultimo, NSW, Australia
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Zhu N, Yang L, Wang X, Tuo J, Chen L, Deng R, Kwan RYC. Experiences and perspectives of healthcare professionals implementing advance care planning for people suffering from life-limiting illness: a systematic review and meta-synthesis of qualitative studies. BMC Palliat Care 2023; 22:55. [PMID: 37149560 PMCID: PMC10163819 DOI: 10.1186/s12904-023-01176-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/24/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Life-limited patients may lose decision-making abilities during disease progression. Advance care planning can be used as a discussion method for healthcare professionals to understand patients' future care preferences. However, due to many difficulties, the participation rate of healthcare professionals in advance care planning is not high. AIM To explore the facilitators of and barriers to healthcare professionals' provision of advance care planning to life-limited patients to better implement it for this population. METHODS We followed ENTREQ and PRISMA to guide this study. We conducted a systematic search of PubMed, Web of Science, Embase, CINAHL, PsycINFO, CNKI, and SinoMed to include qualitative data on the experiences and perspectives of healthcare professionals in different professional fields in providing advance care planning for life-limited patients. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to assess the quality of the included studies. RESULTS A total of 11 studies were included. Two themes were identified: unsupported conditions and facilitative actions. Healthcare professionals regarded cultural concepts, limited time, and fragmented record services as obstacles to implementation. They had low confidence and were overly concerned about negative effects. They needed to possess multiple abilities, learn to flexibly initiate topics, and facilitate effective communication based on multidisciplinary collaboration. CONCLUSION Healthcare professionals need an accepting cultural environment to implement advance care planning, a sound legal system, financial support, and a coordinated and shared system to support them. Healthcare systems need to develop educational training programs to increase the knowledge and skills of healthcare professionals and to promote multidisciplinary collaboration to facilitate effective communication. Future research should compare the differences in the needs of healthcare professionals in different cultures when implementing advance care planning to develop systematic implementation guidelines in different cultures.
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Affiliation(s)
- Nanxi Zhu
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
- Nursing Department, Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, 519100, China
| | - Liu Yang
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
| | - Xianlin Wang
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
| | - Jinmei Tuo
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
| | - Liuliu Chen
- School of Health, Zhuhai College of Science and Technology, Zhuhai, 519041, China
| | - Renli Deng
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China.
- Nursing Department, Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, 519100, China.
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Milnes SL, Kerr DC, Hutchinson A, Simpson NB, Mantzaridis Y, Corke C, Bailey M, Orford NR. Effect of communication skills training on documentation of shared decision-making for patients with life-limiting illness: An observational study in an intensive care unit. CRIT CARE RESUSC 2023; 25:20-26. [PMID: 37876985 PMCID: PMC10581275 DOI: 10.1016/j.ccrj.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objectives This article aims to examine the association between a shared decision-making (SDM) clinical communication training program and documentation of SDM for patients with life-limiting illness (LLI) admitted to intensive care. Methods This article used a prospective, longitudinal observational study in a tertiary intensive care unit (ICU). Outcomes included the proportion of patients with SDM documented on an institutional Goals of Care Form during hospital admission, as well as characteristics, outcomes, and factors associated with an SDM admission. Intervention Clinical communication skills training (iValidate) and clinical support program are the intervention for this study. Results A total of 325 patients with LLI were admitted to the ICU and included in the study. Overall, 184 (57%) had an SDM admission, with 79% of Goals of Care Form completed by an iValidate-trained doctor. Exposure to an iValidate-trained doctor was the strongest predictor of an ICU patient with LLI having an SDM admission (odds ratio: 22.72, 95% confidence interval: 11.91-43.54, p < 0.0001). A higher proportion of patients with an SDM admission selected high-dependency unit-level care (29% vs. 12%, p < 0.001) and ward-based care (36% vs. 5%, p < 0.0001), with no difference in the proportion of patients choosing intensive care or palliative care. The proportion of patients with no deterioration plan was higher in the non-SDM admission cohort (59% vs. 0%, p < 0.0001). Conclusions Clinical communication training that explicitly teaches identification of patient values is associated with improved documentation of SDM for critically ill patients with LLI. Understanding the relationship between improved SDM and patient, family, and clinical outcomes requires appropriately designed high-quality trials randomised at the patient or cluster level.
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Affiliation(s)
- Sharyn L. Milnes
- University Hospital Geelong, Barwon Health, Geelong, Australia
- Institute for Healthcare Transformation, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Geelong, Australia
- Institute for Innovation in Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Deakin University, Geelong, Australia
| | - Debra C. Kerr
- Institute for Healthcare Transformation, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Geelong, Australia
| | - Ana Hutchinson
- Institute for Healthcare Transformation, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Geelong, Australia
| | - Nicholas B. Simpson
- University Hospital Geelong, Barwon Health, Geelong, Australia
- Institute for Innovation in Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Deakin University, Geelong, Australia
| | | | - Charlie Corke
- University Hospital Geelong, Barwon Health, Geelong, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia
| | - Neil R. Orford
- University Hospital Geelong, Barwon Health, Geelong, Australia
- Institute for Innovation in Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Deakin University, Geelong, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Australia
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Davis M, Vanenkevort E, Young A, Wojtowicz M, Lagerman B, Gupta M, Adonizio C, Panikkar R. Validation of the Surprise Question and the Development of a Multivariable Model. J Pain Symptom Manage 2023; 65:456-464. [PMID: 36736500 DOI: 10.1016/j.jpainsymman.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/21/2022] [Accepted: 01/17/2023] [Indexed: 02/04/2023]
Abstract
CONTEXT The Surprise Question (SQ) (would you be surprised if this patient died within a year?) is a prognostic variable explored in chronic illnesses. Validation is limited to sensitivity, specificity, and predictive values. OBJECTIVES Our objective is to validate the SQ in cancer patients and develop a predictive model with additional variables. METHODS A prospective cohort study of adult (age>18) cancer patients seen between October 1, 2019, through March 31, 2021, undergoing systemic therapies had the SQ completed by oncologists prior to each change in systemic therapy. The primary outcome was survival for one year. Secondary outcomes were predictions of survival at three, six, and nine months. Patients were grouped into negative SQ (not surprised) and positive SQ (surprised). Sensitivity, specificity, predictive values, and likelihood ratios (LR) were calculated for the SQ. Additional prognostic variables were age, gender, cancer stage, line of therapy, Charleson Comorbid Index (CCI), palliative care consultation (prior to, after the SQ, or not at all), and healthcare utilization (outpatient, inpatient, and emergency department (ED). Logistic regression and receiver operating characteristics (ROC) were used for discrimination and modeling. Akaike information criterion (AIC) was used to compare the model fit as each predictor. RESULTS 1366 patients had 1 SQ; 784 died within a year. The SQ predicted survival at one year (P = 0.008), with a positive LR of 1.459 (95%CI 1.316-1.602) and a c-statistic of 0.565 (95%CI 0.530-0.600). Additional variables increased the c-statistic to 0.648 (95% CI 0.608-0.686). The total model best predicted survival at three months, c-statistic of 0.663 (95% CI 0.616-0.706). However, the total model c-statistic remained <0.70. CONCLUSIONS The SQ, as a single factor, poorly predicts survival and should not be used to alter therapies. Adding additional objective variables improved prognostication, but further refinement and external validation are needed.
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Affiliation(s)
- Mellar Davis
- Department of Palliative Care (M.D.), Geisinger Medical Center, Danville, PA.
| | - Erin Vanenkevort
- Henry Hood Research Center (E.V., A.Y.), Geisinger Medical Center, Danville, PA
| | - Amanda Young
- Henry Hood Research Center (E.V., A.Y.), Geisinger Medical Center, Danville, PA
| | - Mark Wojtowicz
- Knapper Cancer Center (M.W., C.A., R.P.), Geisinger Medical Center, Danville, PA
| | - Braxton Lagerman
- Department of Data Management (B.L., M.G.), Geisinger Health System, Danville, PA
| | - Mudit Gupta
- Department of Data Management (B.L., M.G.), Geisinger Health System, Danville, PA
| | - Christian Adonizio
- Knapper Cancer Center (M.W., C.A., R.P.), Geisinger Medical Center, Danville, PA
| | - Rajiv Panikkar
- Knapper Cancer Center (M.W., C.A., R.P.), Geisinger Medical Center, Danville, PA
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Calsina-Berna A, Amblàs Novellas J, González-Barboteo J, Bardés Robles I, Beas Alba E, Martínez-Muñoz M, Madariaga Sánchez R, Gómez Batiste Alentorn X. Prevalence and clinical characteristics of patients with Advanced Chronic Illness and Palliative Care needs, identified with the NECPAL CCOMS-ICO© Tool at a Tertiary Care Hospital. Palliat Care 2022; 21:210. [PMID: 36443761 PMCID: PMC9703744 DOI: 10.1186/s12904-022-01101-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/10/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The identification of patients with advanced chronic conditions and palliative care needs is essential since their care represents one of the main challenges for public health systems. The study aimed to determine the prevalence and characteristics of inpatients with palliative care needs in different services of a tertiary care hospital using the NECPAL CCOMS-ICO© tool. METHODS A descriptive, cross-sectional cohort study was conducted in a tertiary hospital. The NECPAL tool identifies patients who require palliative care. Any patient with the Surprise Question with the answer "NO" and at least another question of the tool with a positive answer is considered a positive identification. Patients were classified as Non-NECPAL, NECPAL I-II, and NECPAL III, depending on the NECPAL tool criteria they met. The presence of physical symptoms, emotional distress, and social risk factors was assessed. RESULTS Of the 602 inpatients, 236 (39.2%) were enrolled. Of them, 34 (14.4%) non-NECPAL, 202 (85.6%) NECPAL+ [105 (44.5%) NECPAL I-II, and 97 (41.1%) NECPAL III]. Physical symptom burden was high (pain intensity ≥ 1 in 68.3% of patients; tiredness ≥ 1 in 83.5%; somnolence ≥ 1 in 50.6%; dyspnea ≥ 1 in 37.9%; anorexia ≥ 1 in 59.5%). 64.1% had emotional distress, and 83.6% had social risk factors. The NECPAL-III group contained a higher percentage of cancer patients, higher demand for palliative care, and greater need for palliative care (p < 0.001). In 50.8% of cases, no referrals were made to psychology, social work, or hospital palliative and supportive care teams. The three services with the higher number of patients with palliative care needs were: Palliative Care Unit (100%), Oncology (54.54%), and Emergency Short-stay Unit (54.16%). CONCLUSION A high percentage of patients admitted to tertiary care hospitals presented palliative care needs, with multiple unmet physical, emotional, and social needs. Less than 50% are referred to specialized care teams, such as hospital palliative and supportive care teams.
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Affiliation(s)
- Agnès Calsina-Berna
- grid.418701.b0000 0001 2097 8389Palliative Care Service. Research and knowledge group in palliative care of Catalan Institute of Oncology (GRICOPAL), Institut Català d’Oncologia-Badalona, Badalona, Spain
| | - Jordi Amblàs Novellas
- grid.440820.aCentral Catalonia Chronicity Research Group, Chair of Palliative Care, Faculty of Medicine, University of Vic-Central University of Catalonia, Vic, Spain
| | - Jesús González-Barboteo
- grid.418701.b0000 0001 2097 8389Palliative Care Service. Research and knowledge group in palliative care of Catalan Institute of Oncology (GRICOPAL), Institut Català d’Oncologia- L’Hospitalet. Hospitalet de Llobregat, Barcelona, Spain
| | - Ignasi Bardés Robles
- grid.411129.e0000 0000 8836 0780Emergency Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Elba Beas Alba
- grid.418701.b0000 0001 2097 8389Chair of Palliative Care, Faculty of Medicine, The Qualy Observatory, WHO Collaborating Center for Palliative Care Public Health Programs, University of Vic/Central Catalonia, Catalan Institute of Oncology, Barcelona, Spain
| | - Marisa Martínez-Muñoz
- grid.418701.b0000 0001 2097 8389Chair of Palliative Care, Faculty of Medicine, The Qualy Observatory, WHO Collaborating Center for Palliative Care Public Health Programs, University of Vic/Central Catalonia, Catalan Institute of Oncology, Barcelona, Spain
| | | | - Xavier Gómez Batiste Alentorn
- grid.440820.aCentral Catalonia Chronicity Research Group, Chair of Palliative Care, Faculty of Medicine, University of Vic-Central University of Catalonia, Vic, Spain
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Brunelli C, Zecca E, Pigni A, Bracchi P, Caputo M, Lo Dico S, Fusetti V, Tallarita A, Bergamini C, Brambilla M, Raimondi A, Niger M, Provenzano S, Sepe P, Alfieri S, Tinè G, De Braud F, Caraceni AT. Outpatient palliative care referral system (PCRS) for patients with advanced cancer: an impact evaluation protocol. BMJ Open 2022; 12:e059410. [PMID: 36307164 PMCID: PMC9621186 DOI: 10.1136/bmjopen-2021-059410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Early palliative care (PC) in the clinical pathway of advanced cancer patients improves symptom control, quality of life and has a positive impact on overall quality of care. At present, standardised criteria for appropriate referral for early PC in oncology care are lacking. The aim of this project is to develop a set of standardised referral criteria and procedures to implement appropriate early PC for advanced cancer patients (the palliative care referral system, PCRS) and test its impact on user perception of quality of care received, on patient quality of life and on the use of healthcare resources. SETTING Selected oncology clinics and PC outpatient clinic. METHODS AND ANALYSIS A scoping literature review and an expert consultation through a nominal group technique will be used to revise existing referral tools and to develop a new one, the PCRS. 25 patients will be enrolled in a pilot study to assess feasibility of the implementation of PCRS; 10 interviews with patients and healthcare professionals will be carried out to evaluate applicability.A pretest-post-test quasiexperimental study involving 150 patients before implementation of the PCRS and 150 patients after implementation will be carried out.Patient satisfaction with care received, quality of life and use of resources, and caregiver satisfaction with care will also be assessed to explore the impact of the intervention. ETHICS AND DISSEMINATION Ethical approval for the study has been granted by the Institutional Review board of the Fondazione IRCCS Istituto Nazionale Tumori; approval reference INT201/19.Results will be disseminated through open access publications and through scientific communication presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT04936568.
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Affiliation(s)
- Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Ernesto Zecca
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Alessandra Pigni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Paola Bracchi
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Mariangela Caputo
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Silvia Lo Dico
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Viviana Fusetti
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- Università degli Studi di Roma Tor Vergata, Roma, Lazio, Italy
| | - Antonino Tallarita
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Cristiana Bergamini
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Marta Brambilla
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Alessandra Raimondi
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Monica Niger
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Salvatore Provenzano
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Pierangela Sepe
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Sara Alfieri
- Clinical Psychology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Gabriele Tinè
- Unit of Clinical Epidemiology and Trial Organisation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Filippo De Braud
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- Università degli Studi di Milano, Milano, Italy
| | - Augusto Tommaso Caraceni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- Università degli Studi di Milano, Milano, Italy
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Simpson N, Milnes S, Martin P, Phillips A, Silverman J, Keely G, Forrester M, Dunning T, Corke C, Orford N. iValidate: a communication-based clinical intervention in life-limiting illness. BMJ Support Palliat Care 2022; 12:e510-e516. [PMID: 30975713 PMCID: PMC9510415 DOI: 10.1136/bmjspcare-2018-001669] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/06/2019] [Accepted: 02/20/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Report the implementation, user evaluation and key outcome measures of an educational intervention-the iValidate educational programme-designed to improve engagement in shared decision-making by health professionals caring for patients with life-limiting illness (LLI). DESIGN Prospective, descriptive, cohort study. PARTICIPANTS Health professionals working in acute care settings caring for patients with an LLI. MAIN OUTCOMES MEASURED Participant evaluation of learning outcomes for communication skills and shared decision-making; demographic data of participants attending education workshops; and documentation of patients with LLI goals of management, including patient values and care decision based on area in acute care and seniority of doctor. RESULTS The programme was well accepted by participants. Participant evaluations demonstrated self-reported improved confidence in the areas of patient identification, information gathering to ascertain patient values and shared decision-making. There was strong agreement with the course-enhanced knowledge of core communication skills and advanced skills such as discussing mismatched agendas. CONCLUSIONS We described the educational pedagogy, implementation and key outcome measures of the iValidate education programme, an intervention designed to improve person-centred care for patients with an LLI. A targeted education programme could produce cultural and institutional change for vulnerable populations within a healthcare institution. A concurrent research programme suggests effectiveness within the current service and the potential for transferability.
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Affiliation(s)
| | - Sharyn Milnes
- ICU, Barwon Health, Geelong, Victoria, Australia
- Clinical Education and Training Unit, Barwon Health, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Deakin University Faculty of Health, Geelong, Victoria, Australia
| | - Peter Martin
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Anita Phillips
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | | | - Gerry Keely
- ICU, Barwon Health, Geelong, Victoria, Australia
| | - Mike Forrester
- Paediatric Unit, Barwon Health, Geelong, Victoria, Australia
| | - Trisha Dunning
- Centre for Quality and Patient Safety Research, Deakin University Faculty of Health, Geelong, Victoria, Australia
| | | | - Neil Orford
- ICU, Barwon Health, Geelong, Victoria, Australia
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van Lummel EV, Ietswaard L, Zuithoff NP, Tjan DH, van Delden JJ. The utility of the surprise question: A useful tool for identifying patients nearing the last phase of life? A systematic review and meta-analysis. Palliat Med 2022; 36:1023-1046. [PMID: 35769037 PMCID: PMC10941345 DOI: 10.1177/02692163221099116] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The surprise question is widely used to identify patients nearing the last phase of life. Potential differences in accuracy between timeframe, patient subgroups and type of healthcare professionals answering the surprise question have been suggested. Recent studies might give new insights. AIM To determine the accuracy of the surprise question in predicting death, differentiating by timeframe, patient subgroup and by type of healthcare professional. DESIGN Systematic review and meta-analysis. DATA SOURCES Electronic databases PubMed, Embase, Cochrane Library, Scopus, Web of Science and CINAHL were searched from inception till 22nd January 2021. Studies were eligible if they used the surprise question prospectively and assessed mortality. Sensitivity, specificity, negative predictive value, positive predictive value and c-statistic were calculated. RESULTS Fifty-nine studies met the inclusion criteria, including 88.268 assessments. The meta-analysis resulted in an estimated sensitivity of 71.4% (95% CI [66.3-76.4]) and specificity of 74.0% (95% CI [69.3-78.6]). The negative predictive value varied from 98.0% (95% CI [97.7-98.3]) to 88.6% (95% CI [87.1-90.0]) with a mortality rate of 5% and 25% respectively. The positive predictive value varied from 12.6% (95% CI [11.0-14.2]) with a mortality rate of 5% to 47.8% (95% CI [44.2-51.3]) with a mortality rate of 25%. Seven studies provided detailed information on different healthcare professionals answering the surprise question. CONCLUSION We found overall reasonable test characteristics for the surprise question. Additionally, this study showed notable differences in performance within patient subgroups. However, we did not find an indication of notable differences between timeframe and healthcare professionals.
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Affiliation(s)
- Eline Vtj van Lummel
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Larissa Ietswaard
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicolaas Pa Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Dave Ht Tjan
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Johannes Jm van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Kerr D, Milnes S, Martin P, Ammentorp J, Wolderslund M, Chiswell M. Responding to nurses' communication challenges: Evaluating a blended learning program for communication knowledge and skills for nurses. PATIENT EDUCATION AND COUNSELING 2022; 105:2285-2291. [PMID: 34895774 DOI: 10.1016/j.pec.2021.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 11/15/2021] [Accepted: 11/19/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of the Blended Communication Skills Training Program for Nurses (CSTN). The program aims to improve nurses' knowledge about communication skills and structure for interactions with individuals who a have life limiting illness. METHODS This was a quasi-experimental study using a pre- and post-test quiz and self-efficacy questionnaire undertaken in Victoria, Australia. Nurses employed across three wards participated. The Blended CSTN comprised two major components: Asynchronous Web-Based Education Program and Experiential Workshop. The program focused on specific communication challenges: Gathering Information, Dealing with Difficult Questions, and Articulating Empathy. The primary outcome was improvement in knowledge of communication skills and structure. Self-efficacy and perceived importance of communication skills were assessed as secondary outcomes. RESULTS Eighteen nurses completed both Web-Based and Workshop components. Statistically significant increases in knowledge regarding communication skills and structure were found, with a large effect size for Gathering Information (r = 0.80) and moderate effect for Articulating Empathy (r = 0.62), and Responding to Difficult Questions (r = 0.532). Self-efficacy significantly increased for all measured communication skills. CONCLUSIONS Knowledge improvements and perceived self-efficacy in communication were observed after nurses participated in a blended education program PRACTICE IMPLICATIONS: A blended CSTN may improve nurse-patient communication in the clinical setting, worthy of further study.
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Affiliation(s)
- Debra Kerr
- School of Nursing and Midwifery, Deakin University, Victoria, Australia; Centre for Organisational Change in Person-Centred Healthcare, Deakin University, Victoria, Australia.
| | | | - Peter Martin
- Centre for Organisational Change in Person-Centred Healthcare, Deakin University, Victoria, Australia; Barwon Health, Geelong, Australia; School of Medicine, Deakin University, Victoria, Australia.
| | - Jette Ammentorp
- Centre for Research in Patient Communication, Odense University Hospital & University of Southern Denmark, Denmark.
| | - Maiken Wolderslund
- Centre for Research in Patient Communication, Odense University Hospital & University of Southern Denmark, Denmark.
| | - Meg Chiswell
- Centre for Organisational Change in Person-Centred Healthcare, Deakin University, Victoria, Australia.
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Waller A, Hobden B, Fakes K, Clark K. A Systematic Review of the Development and Implementation of Needs-Based Palliative Care Tools in Heart Failure and Chronic Respiratory Disease. Front Cardiovasc Med 2022; 9:878428. [PMID: 35498028 PMCID: PMC9043454 DOI: 10.3389/fcvm.2022.878428] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/25/2022] [Indexed: 11/19/2022] Open
Abstract
Background The impetus to develop and implement tools for non-malignant patient groups is reflected in the increasing number of instruments being developed for heart failure and chronic respiratory diseases. Evidence syntheses of psychometric quality and clinical utility of these tools is required to inform research and clinical practice. Aims This systematic review examined palliative care needs tools for people diagnosed with advanced heart failure or chronic respiratory diseases, to determine their: (1) psychometric quality; and (2) acceptability, feasibility and clinical utility when implemented in clinical practice. Methods Systematic searches of MEDLINE, CINAHL, Embase, Cochrane and PsycINFO from database inception until June 2021 were undertaken. Additionally, the reference lists of included studies were searched for relevant articles. Psychometric properties of identified measures were evaluated against pre-determined and standard criteria. Results Eighteen tools met inclusion criteria: 11 were developed to assess unmet patient palliative care needs. Of those, 6 were generic, 4 were developed for heart failure and 1 was developed for interstitial lung disease. Seven tools identified those who may benefit from palliative care and include general and disease-specific indicators. The psychometric qualities of the tools varied. None met all of the accepted criteria for psychometric rigor in heart failure or respiratory disease populations. There is limited implementation of needs assessment tools in practice. Conclusion Several tools were identified, however further validation studies in heart failure and respiratory disease populations are required. Rigorous evaluation to determine the impact of adopting a systematic needs-based approach for heart failure and lung disease on the physical and psychosocial outcomes of patients and carers, as well as the economic costs and benefits to the healthcare system, is required.
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Affiliation(s)
- Amy Waller
- Health Behaviour Research Collaborative, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- *Correspondence: Amy Waller
| | - Breanne Hobden
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Kristy Fakes
- Health Behaviour Research Collaborative, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Katherine Clark
- Northern Sydney Local Health District (NSLHD) Supportive and Palliative Care Network, St Leonards, NSW, Australia
- Northern Clinical School, The University of Sydney, Darlington, NSW, Australia
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
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Thomas K, Armstrong-Wilson J, Clifford C. The Gold Standards Framework Hospital programme: implementation and progress. Int J Palliat Nurs 2022; 28:172-177. [PMID: 35465704 DOI: 10.12968/ijpn.2022.28.4.172] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM The implementation and impact of the Gold Standards Framework Hospitals (GSFH) service development programme is described. BACKGROUND A third of hospital inpatients may be in their last year of life when admitted to hospital. Many will be repeat and unplanned admissions. National policy guidance seeks to change this pattern through implementing patient choice in end-of-life care (EOLC) planning. METHOD GSFH training and resources help general hospital staff teams develop skills as they identify patients nearing the end of life, rapidly assess their needs and offer advance care planning (ACP). FINDINGS Audit data shows teams that have undergone GSFH training demonstrate earlier identification of patients needing EOLC and offer ACP targeting their individual care needs. CONCLUSION The model has been taken up by over 350 hospital wards, with a large number seeking accreditation to demonstrate sustainability of good practice in EOLC management.
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Affiliation(s)
- Keri Thomas
- GSF National Clinical Lead and Honorary Professor End of Life Care, GSF Centre CIC for End of Life Care, UK
| | | | - Collette Clifford
- Emeritus Professor, School of Nursing, University of Birmingham, Birmingham, UK
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Buck K, Nolte L, Sellars M, Sinclair C, White BP, Kelly H, Macleod A, Detering KM. Advance care directive prevalence among older Australians and associations with person-level predictors and quality indicators. Health Expect 2021; 24:1312-1325. [PMID: 33932311 PMCID: PMC8369087 DOI: 10.1111/hex.13264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/25/2021] [Accepted: 04/02/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Advance care planning (ACP) conversations may result in preferences for medical care being documented. OBJECTIVE To explore the uptake and quality of advance care directives (ACDs) among older Australians accessing health and aged care services, by overall ACP documentation prevalence, person-level predictors and ACD quality indicators. DESIGN AND SETTING National multi-centre health record audit in general practices (GP), hospitals and residential aged care facilities (RACF). PARTICIPANTS A total of 4187 people aged ≥65 years attending their GP (n = 676), admitted to hospital (n = 1122) or residing in a RACF (n = 2389). MAIN OUTCOME MEASURES ACP documentation prevalence by setting and type including person-completed ACDs and non-ACD documents (completed by a health professional or someone else); person-level predictors and quality indicators of ACDs. RESULTS Overall ACP documentation prevalence was 46.5% (29.2% weighted). ACD prevalence was 25.3% (14.2% weighted). Unweighted ACD prevalence was higher in RACFs (37.7%) than in hospitals (11.1%) and GPs (5.5%). 35.8% of ACP documentation was completed by a health professional (9.7% weighted), and 18.1% was completed by someone else (10.6% weighted). Having an ACD was positively associated with being female, older, having two or more medical conditions, receiving palliative care, being divorced/separated and being in a RACF. Only 73% of ACDs included full name, signature, document date and witnessing. CONCLUSIONS AND CONTRIBUTION Low ACP documentation prevalence and a lack of accessible, person-completed and quality ACDs represent an important ACP implementation issue. Low prevalence is complicated by poor document quality and a higher prevalence of documents being completed by someone other than the person.
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Affiliation(s)
- Kimberly Buck
- Advance Care Planning AustraliaAustin HealthHeidelbergVicAustralia
| | - Linda Nolte
- Advance Care Planning AustraliaAustin HealthHeidelbergVicAustralia
| | - Marcus Sellars
- Advance Care Planning AustraliaAustin HealthHeidelbergVicAustralia
- Department of Health Services Research & PolicyResearch School of Population HealthAustralian National UniversityACTAustralia
| | - Craig Sinclair
- Australian Research Council Centre of Excellence in Population Ageing ResearchUniversity of New South WalesSydneyNSWAustralia
- Neuroscience Research Australia (NeuRA)SydneyAustralia
- School of PsychologyUniversity of New South WalesSydneyNSWAustralia
| | - Ben P. White
- Australian Centre for Health Research LawFaculty of LawQueensland University of TechnologyBrisbaneQldAustralia
| | - Helana Kelly
- Advance Care Planning AustraliaAustin HealthHeidelbergVicAustralia
| | - Ashley Macleod
- Advance Care Planning AustraliaAustin HealthHeidelbergVicAustralia
| | - Karen M. Detering
- Advance Care Planning AustraliaAustin HealthHeidelbergVicAustralia
- Faculty of Health, Arts and InnovationSwinburne UniversityHawthornVic.Australia
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Strupp J, Kasdorf A, Dust G, Hower KI, Seibert M, Werner B, Kuntz L, Schulz-Nieswandt F, Meyer I, Pfaff H, Hellmich M, Voltz R. Last Year of Life Study-Cologne (LYOL-C) (Part II): study protocol of a prospective interventional mixed-methods study in acute hospitals to analyse the implementation of a trigger question and patient question prompt sheets to optimise patient-centred care. BMJ Open 2021; 11:e048681. [PMID: 34312205 PMCID: PMC8314737 DOI: 10.1136/bmjopen-2021-048681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The Last Year of Life Study-Cologne Part I (LYOL-C I) has identified general hospital units as the most important checkpoints for transitions in the last year of life of patients. Yet, satisfaction with hospitals, as reported by bereaved relatives, is the lowest of all health service providers. Thus, the LYOL-C Part II (LYOL-C II) focuses on optimising patient-centred care in acute hospitals for patients identified to be in their last year of life. LYOL-C II aims to test an intervention for hospitals by using a two-sided (healthcare professionals (HCPs) and patients) trigger question-based intervention to 'shake' the system in a minimally invasive manner. METHODS AND ANALYSIS Prospective interventional mixed-methods study following a two-phase approach: phase I, individual interviews with HCPs and patient representatives to design the intervention to maximise ease of implementation and phase II, exploratory study with two arms and a prepost design with patients in their last year of life. The intervention will consist of the Surprise Question and the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE) for HCPs to identify patients and provide patient-centred care, plus question prompt sheets for patients, encouraging them to initiate discussions with their HCPs. Data on transitions, changes in therapy, quality of care, palliative care integration and death of patients will be analysed. Furthermore, a staff survey (pre/post) and guided interviews with staff, patients and relatives (post) will be conducted. Finally, a formative socioeconomic impact assessment to provide evidence regarding the sustainability of the intervention will be performed. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of the Faculty of Medicine of the University of Cologne (#20-1431). Results will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER DRKS00022378.
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Affiliation(s)
- Julia Strupp
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Alina Kasdorf
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Gloria Dust
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Kira Isabel Hower
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Melissa Seibert
- Department of Business Administration and Health Care Management, University of Cologne, Cologne, Germany
| | - Belinda Werner
- Faculty of Management, Economics and Social Sciences, University of Cologne, Cologne, Germany
| | - Ludwig Kuntz
- Department of Business Administration and Health Care Management, University of Cologne, Cologne, Germany
| | - Frank Schulz-Nieswandt
- Faculty of Management, Economics and Social Sciences, University of Cologne, Cologne, Germany
| | - Ingo Meyer
- PMV Research Group, Department of Child and Adolescence Psychiatry, University of Cologne, Cologne, Germany
| | - Holger Pfaff
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Martin Hellmich
- Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
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Heath L, Egan R, Ross J, Iosua E, Walker R, MacLeod R. Preparing nurses for palliative and end of life care: A survey of New Zealand nursing schools. NURSE EDUCATION TODAY 2021; 100:104822. [PMID: 33705968 DOI: 10.1016/j.nedt.2021.104822] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 01/31/2021] [Accepted: 02/13/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Nurses play a vital role in the care of people with advanced life-limiting illnesses, so palliative and end of life care is an essential skill nurses need to learn. Despite numerous reports in the international literature about educational developments in this area, there are widespread inconsistencies in undergraduate education, and graduates continue to report feeling unprepared for this part of their work. Little is known about how New Zealand nursing students learn about this important area of clinical practice. OBJECTIVES To obtain information about teaching content, organisation, delivery, assessment and clinical learning opportunities in palliative and end of life care in undergraduate nurse education in New Zealand. DESIGN Quantitative descriptive cross sectional study. SETTINGS Tertiary education institutions that provide the Bachelor of Nursing programme in New Zealand. PARTICIPANTS Academic leads and course coordinators. METHODS National online survey. RESULTS A total of 13/18 (72%) educational institutions completed the survey. All integrate palliative and end of life care in their teaching with an identified coordinator at 12 (92%) institutions. Between 1 and 10 h of formal teaching is provided at 11 (85%) institutions where lectures and tutorials are most comon. Clinical placements with specialist palliative care providers are scarce and limited to senior students as elective placements. Assessment of student learning in palliative and end of life care is carried out at seven (54%) institutions, and formally evaluated at 12 (92%). Lack of teaching time and clinical placements with palliative care providers are barriers to increased learning opportunities in palliative and end of life care. CONCLUSIONS This article provides comprehensive information about palliative and end of life care teaching in undergraduate nurse education in New Zealand. Teaching on this subject is not a mandatory requirement so there are inconsistencies in the teaching provided between educational institutions, and significant barriers to development. Mandatory competencies need to be introduced to ensure graduates have the knowledge, skills and attitudes required to provide optimal care for people near the end of life.
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Affiliation(s)
- Lis Heath
- Department of Medicine, University of Otago, Dunedin, New Zealand.
| | - Richard Egan
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand.
| | - Jean Ross
- School of Nursing, Otago Polytechnic, Dunedin, New Zealand.
| | - Ella Iosua
- Centre for Biostatistics, University of Otago, Dunedin, New Zealand.
| | - Robert Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand.
| | - Rod MacLeod
- School of Population Health, University of Auckland, Auckland, New Zealand
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Virdun C, Luckett T, Lorenz K, Davidson PM, Phillips J. Hospital patients' perspectives on what is essential to enable optimal palliative care: A qualitative study. Palliat Med 2020; 34:1402-1415. [PMID: 32857012 DOI: 10.1177/0269216320947570] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The majority of expected deaths in high income countries occur in hospital where optimal palliative care cannot be assured. In addition, a large number of patients with palliative care needs receive inpatient care in their last year of life. International research has identified domains of inpatient care that patients and carers perceive to be important, but concrete examples of how these might be operationalised are scarce, and few studies conducted in the southern hemisphere. AIM To seek the perspectives of Australian patients living with palliative care needs about their recent hospitalisation experiences to determine the relevance of domains noted internationally to be important for optimal inpatient palliative care and how these can be operationalised. DESIGN An exploratory qualitative study using semi-structured interviews. SETTING/PARTICIPANTS Participants were recruited through five hospitals in New South Wales, Australia. RESULTS Twenty-one participants took part. Results confirmed and added depth of understanding to domains previously identified as important for optimal hospital palliative care, including: Effective communication and shared decision making; Expert care; Adequate environment for care; Family involvement in care provision; Financial affairs; Maintenance of sense of self/identity; Minimising burden; Respectful and compassionate care; Trust and confidence in clinicians and Maintenance of patient safety. Two additional domains were noted to be important: Nutritional needs; and Access to medical and nursing specialists. CONCLUSIONS Taking a person-centred focus has provided a deeper understanding of how to strengthen inpatient palliative care practices. Future work is needed to translate the body of evidence on patient priorities into policy reforms and practice points.
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Affiliation(s)
- Claudia Virdun
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia
| | - Tim Luckett
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia
| | - Karl Lorenz
- VA Palo Alto-Stanford Palliative Care Program and Professor of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Patricia M Davidson
- Johns Hopkins University School of Nursing, Baltimore, MD, USA.,Nursing and Member of IMPACCT, University of Technology Sydney, Broadway, NSW, Australia.,Cardiovascular Research, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Jane Phillips
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia
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Voltz R, Dust G, Schippel N, Hamacher S, Payne S, Scholten N, Pfaff H, Rietz C, Strupp J. Improving regional care in the last year of life by setting up a pragmatic evidence-based Plan-Do-Study-Act cycle: results from a cross-sectional survey. BMJ Open 2020; 10:e035988. [PMID: 33234614 PMCID: PMC7689073 DOI: 10.1136/bmjopen-2019-035988] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To set up a pragmatic Plan-Do-Study-Act cycle by analysing patient experiences and determinants of satisfaction with care in the last year of life. DESIGN Cross-sectional postbereavement survey. SETTING Regional health services research and development structure representing all health and social care providers involved in the last year of life in Cologne, a city with 1 million inhabitants in Germany. PARTICIPANTS 351 bereaved relatives of adult decedents, representative for age and gender, accidental and suspicious deaths excluded. RESULTS For the majority (89%) of patients, home was the main place of care during their last year of life. Nevertheless, 91% of patients had at least one hospital admission and 42% died in hospital. Only 60% of informants reported that the decedent had been told that the disease was leading to death. Hospital physicians broke the news most often (58%), with their communication style often (30%) being rated as 'not sensitive'. Informants indicated highly positive experiences with care provided by hospices (89% 'good') and specialist palliative home care teams (87% 'good'). This proportion dropped to 41% for acute care hospitals, this rating being determined by the feeling of not being treated with respect and dignity (OR=23.80, 95% CI 7.503 to 75.498) and the impression that hospitals did not work well together with other services (OR=8.37, 95% CI 2.141 to 32.71). CONCLUSIONS Following those data, our regional priority for action now is improvement of care in acute hospitals, with two new projects starting, first, how to recognise and communicate a limited life span, and second, how to improve care during the dying phase. Results and further improvement projects will be discussed in a working group with the city of Cologne, and repeating this survey in 2 years will be able to measure regional achievements. TRIAL REGISTRATION NUMBER DRKS00011925.
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Affiliation(s)
- Raymond Voltz
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO ABCD), University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital, Clinical Trials Center(ZKS), University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital, Center for Health Services Research, University of Cologne, Cologne, Germany
| | - Gloria Dust
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany
| | - Nicolas Schippel
- Faculty of Human Sciences and Faculty of Medicine, Institute for Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Stefanie Hamacher
- Faculty of Medicine and University Hospital, Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Sheila Payne
- Faculty of Health and Medicine, Division of Health Research, University of Lancaster, Lancaster, UK
| | - Nadine Scholten
- Faculty of Human Sciences and Faculty of Medicine, Institute for Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Holger Pfaff
- Faculty of Human Sciences and Faculty of Medicine, Institute for Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Christian Rietz
- Faculty of Educational and Social Sciences, Department of Educational Science, Heidelberg University of Education, Heidelberg, Germany
| | - Julia Strupp
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany
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Tabernero Huguet E, Ortiz de Urbina Antia B, González Quero B, Garay Llorente E, Andia Iturrate J, Pérez Fernández S, Gómez Larrauri A, Iriberri Pascual M. Prevalence and Mortality of Patients with Palliative Needs in an Acute Respiratory Setting. Arch Bronconeumol 2020; 57:345-350. [PMID: 33069460 DOI: 10.1016/j.arbres.2020.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION NECPAL is a tool for identification of patients with advanced chronic disease in need of palliative care. The main objective of the study is to know the prevalence of patients with palliative needs in an acute respiratory ward in a Spanish tertiary hospital using NECPAL. A second objective of the study is to know the annual mortality rate of these patients. MATERIALS AND METHODS Cross sectional study and prospective monitoring of a cohort identified as palliative patients with the NECPAL tool for 12 months. Patient identification was performed in patients admitted to the respiratory ward of our hospital for longer than 3 days. We have assessed the annual vital status (deceased or not deceased) of patients and have recorded demographics, clinical and functional data, as well as the use of healthcare resources. RESULTS We monitored a cohort of 363 patients. Of them, 87 patients (24.3%) (IC 95% 19-30) were identified as NECPAL positive. 60% of patients (n = 64) died within 12 months of their admission. There was no significant difference in the mortality ratio of oncologic versus non oncologic patients. In a multivariable analysis, mortality was associated with demand by patients or relatives for palliative care and with the presence of specific disease progression markers or indicators. CONCLUSIONS prevalence of patients with palliative needs in acute respiratory wards is high (one out of four patients). 60% of the patients identified as NECPAL positive in our cohort died in the first 12 months. Training of healthcare professionals as well as availability of appropriate resources are indispensable factors to improve care of this population.
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Remawi BN, Gadoud A, Murphy IMJ, Preston N. Palliative care needs-assessment and measurement tools used in patients with heart failure: a systematic mixed-studies review with narrative synthesis. Heart Fail Rev 2020; 26:137-155. [PMID: 32748015 PMCID: PMC7769784 DOI: 10.1007/s10741-020-10011-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Patients with heart failure have comparable illness burden and palliative care needs to those with cancer. However, few of them are offered timely palliative care. One main barrier is the difficulty in identifying those who require palliative care. Several palliative care needs-assessment/measurement tools were used to help identify these patients and assess/measure their needs, but it is not known which one is the most appropriate for this population. This review aimed to identify the most appropriate palliative care needs-assessment/measurement tools for patients with heart failure. Cochrane Library, MEDLINE Complete, AMED, PsycINFO, CINAHL Complete, EMBASE, EThOS, websites of the identified tools, and references and citations of the included studies were searched from inception to 25 June 2020. Studies were included if they evaluated palliative care needs-assessment/measurement tools for heart failure populations in terms of development, psychometrics, or palliative care patient/needs identification. Twenty-seven papers were included regarding nineteen studies, most of which were quantitative and observational. Six tools were identified and compared according to their content and context of use, development, psychometrics, and clinical applications in identifying patients with palliative care needs. Despite limited evidence, the Needs Assessment Tool: Progressive Disease - Heart Failure (NAT:PD-HF) is the most appropriate palliative care needs-assessment tool for use in heart failure populations. It covers most of the patient needs and has the best psychometric properties and evidence of identification ability and appropriateness. Psychometric testing of the tools in patients with heart failure and evaluating the tools to identify those with palliative care needs require more investigation.
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Affiliation(s)
- Bader Nael Remawi
- Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG, UK.
| | - Amy Gadoud
- Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG, UK.,International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG, UK
| | - Iain Malcolm James Murphy
- Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG, UK.,Trinity Hospice and Palliative Care Services, Low Moor Road, Blackpool, FY2 0BG, UK
| | - Nancy Preston
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG, UK
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21
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Ragg M, Ragg J, Milnes S, Bailey M, Orford N. Patients with life-limiting illness presenting to the emergency department. Emerg Med Australas 2019; 32:288-294. [PMID: 31668017 DOI: 10.1111/1742-6723.13409] [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: 05/06/2019] [Revised: 09/13/2019] [Accepted: 09/25/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine characteristics, outcomes and flow for patients over the age of 45 years with a life-limiting illness (LLI) presenting to a regional ED. METHODS Retrospective, observational cohort study of patients with LLI in an Australian regional ED over a 15-day period. Eligible patients were 45 years of age or older who fulfilled criteria for having an LLI. Data included demographics, diagnosis for current presentation, presence of advance care documentation, LLI category, admission and discharge destination from ED, ED and hospital length of stay and outcome for patients admitted to the acute hospital. RESULTS A total of 152 (12%) patients had an LLI. The LLI group were older, had a significantly longer median length of stay in the ED (5.9 [interquartile range 4.0-8.4] vs 3.9 h [interquartile range 2.5-6.3], P < 0.0001) and were less likely to leave the ED within 4 h (26% vs 51.5%, P < 0.0001). Forty-six percent of patients with an LLI had some form of advanced care documentation. Patients with an LLI were more likely to require hospital admission. In relation to illness trajectory, the frailty/dementia trajectory group had comparatively the longest ED length of stay with less than 10% leaving the ED within 4 h. This group were more likely to be discharged to a residential care facility. CONCLUSION A significant proportion of patients 45 years or older had an LLI which had implications for their length of ED stay and discharge destination.
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Affiliation(s)
- Michael Ragg
- Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - James Ragg
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Sharyn Milnes
- Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Neil Orford
- Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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22
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Peck V, Valiani S, Tanuseputro P, Mulpuru S, Kyeremanteng K, Fitzgibbon E, Forster A, Kobewka D. Advance care planning after hospital discharge: qualitative analysis of facilitators and barriers from patient interviews. BMC Palliat Care 2018; 17:127. [PMID: 30518345 PMCID: PMC6282276 DOI: 10.1186/s12904-018-0379-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 11/13/2018] [Indexed: 11/24/2022] Open
Abstract
Background Patients who engage in Advance Care Planning (ACP) are more likely to get care consistent with their values. We sought to determine the barriers and facilitators to ACP engagement after discharge from hospital. Methods Prior to discharge from hospital eligible patients received a standardized conversation about prognosis and ACP. Each patient was given an ACP workbook and asked to complete it over the following four weeks. We included frail elderly patients with a high risk of death admitted to general internal medicine wards at a tertiary care academic teaching hospital. Four weeks after discharge we conducted semi-structured interviews with patients. Interviews were transcribed, coded and analysed with thematic analysis. Themes were categorized according to the theoretical domains framework. Results We performed 17 interviews. All Theoretical Domain Framework components except for Social/Professional Identity and Behavioral Regulation were identified in our data. Poor knowledge about ACP and physician communication skills were barriers partially addressed by our intervention. Some patients found it difficult to discuss ACP during an acute illness. For others acute illness made ACP discussions more relevant. Uncertainty about future health motivated some participants to engage in ACP while others found that ACP discussions prevented them from living in the moment and stripped them of hope that better days were ahead. Conclusions For some patients acute illness resulting in admission to hospital can be an opportunity to engage in ACP conversations but for others ACP discussions are antithetical to the goals of hospital care. Electronic supplementary material The online version of this article (10.1186/s12904-018-0379-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vanessa Peck
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Sabira Valiani
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sunita Mulpuru
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Edward Fitzgibbon
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alan Forster
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Daniel Kobewka
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada. .,Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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23
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Bloomer MJ, Botti M, Runacres F, Poon P, Barnfield J, Hutchinson AM. Communicating end-of-life care goals and decision-making among a multidisciplinary geriatric inpatient rehabilitation team: A qualitative descriptive study. Palliat Med 2018; 32:1615-1623. [PMID: 30074431 PMCID: PMC6238176 DOI: 10.1177/0269216318790353] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND In geriatric inpatient rehabilitation settings, where the goal is to optimise function, providing end-of-life care can be challenging. AIM The aim of this study is to explore how end-of-life care goals and decision-making are communicated in a geriatric inpatient rehabilitation setting. DESIGN The design is a qualitative descriptive design using semi-structured individual and group interviews. SETTING/PARTICIPANTS This study was conducted in a 154-bed facility in metropolitan Melbourne, Australia, providing geriatric inpatient rehabilitation for older patients; medical, nursing and allied health clinicians, who had cared for an inpatient who died, were recruited. DATA COLLECTION Participants were interviewed using a conversational approach, guided by an 'aide memoire'. RESULTS A total of 19 clinicians participated in this study, with 12 interviewed individually and the remaining 7 clinicians participating in group interviews. The typical patient was described as older, frail and with complex needs. Clinicians described the challenge of identifying patients who were deteriorating towards death, with some relying on others to inform them. How patient deterioration and decision-making was communicated among the team varied. Communication with the patient/family about dying was expected but did not always occur, nor was it always documented. Some clinicians relied on documentation, such as commencement of a dying care pathway to indicate when a patient was dying. CONCLUSION Clinicians reported difficulties recognising patient deterioration towards death. Uncertainty and inconsistent communication among clinicians about patient deterioration negatively impacted team understanding, decision-making, and patient and family communication. Further education for all members of the multidisciplinary team focusing on how to recognise and communicate impending death will aid multidisciplinary teams to provide quality end-of-life care when required.
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Affiliation(s)
- Melissa J Bloomer
- 1 Deakin University, Burwood, VIC, Australia.,2 Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,3 Epworth/Deakin Centre for Clinical Nursing Research, Richmond, VIC, Australia.,4 Centre for Nursing Research, Deakin University and Monash Health Partnership, Monash Health, Clayton, VIC, Australia
| | - Mari Botti
- 1 Deakin University, Burwood, VIC, Australia.,2 Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,3 Epworth/Deakin Centre for Clinical Nursing Research, Richmond, VIC, Australia
| | - Fiona Runacres
- 5 Supportive and Palliative Care Unit, Monash Health, Clayton, VIC, Australia.,6 School of Medicine, Monash University, Clayton, VIC, Australia.,7 Department of Palliative Care, Calvary Health Care Bethlehem, South Caulfield, VIC, Australia.,8 The University of Notre Dame, Darlinghurst, NSW, Australia
| | - Peter Poon
- 5 Supportive and Palliative Care Unit, Monash Health, Clayton, VIC, Australia.,6 School of Medicine, Monash University, Clayton, VIC, Australia.,9 Eastern Palliative Care Association, Melbourne, VIC, Australia
| | - Jakqui Barnfield
- 10 Rehabilitation, Aged Persons Mental Health and Residential Services, Clayton, VIC, Australia.,11 School of Nursing and Midwifery, Monash University, Clayton, VIC, Australia
| | - Alison M Hutchinson
- 1 Deakin University, Burwood, VIC, Australia.,2 Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,4 Centre for Nursing Research, Deakin University and Monash Health Partnership, Monash Health, Clayton, VIC, Australia
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24
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Lightbody CJ, Campbell JN, Herbison GP, Osborne HK, Radley A, Taylor DR. Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method. BMJ Open 2018; 8:e024264. [PMID: 30385448 PMCID: PMC6252685 DOI: 10.1136/bmjopen-2018-024264] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/25/2018] [Accepted: 09/13/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital. DESIGN A retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as 'expected' or 'unexpected' using the Gold Standard Framework Prognostic Indicator Guidance. SETTING Medical, surgical and intensive care units of a district general hospital. OUTCOMES The primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical 'problems' identified using the Structured Judgement Review Method. RESULTS 289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were 'expected'. Among patients with 'expected' deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for 'problems', 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and 'problems' were significantly lower in the group with a TELP/DNACPR compared with 'DNACPR only' and 'neither': harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and 'problems': 42.3, 146.2 (p<0.01) and 333.3 (p<0.001). CONCLUSIONS The use of a TELP was associated with a significant reduction in harms, NBIs and 'problems' in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.
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Affiliation(s)
- Calvin J Lightbody
- Department of Emergency Medicine, University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, UK
| | - Jonathan N Campbell
- Department of Medicine,, University Hospital Wishaw, NHS Lanarkshire, Wishaw, UK
| | - G Peter Herbison
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Heather K Osborne
- Department of Emergency Medicine, University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, UK
| | - Alice Radley
- Department of Emergency Medicine, University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, UK
| | - D Robin Taylor
- Department of Medicine,, University Hospital Wishaw, NHS Lanarkshire, Wishaw, UK
- Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, UK
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25
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Calsina-Berna A, Martinez-Muñoz M, Bardés Robles I, Beas Alba E, Madariaga Sánchez R, Gómez Batiste Alentorn X. Intrahospital Mortality and Survival of Patients with Advanced Chronic Illnesses in a Tertiary Hospital Identified with the NECPAL CCOMS-ICO© Tool. J Palliat Med 2018; 21:665-673. [DOI: 10.1089/jpm.2017.0339] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Agnès Calsina-Berna
- Comprehensive Support Unit, Catalan Institute of Oncology, Badalona, Spain
- Department of Palliative Care, University of Vic—Central University of Catalonia, Barcelona, Spain
| | - Marisa Martinez-Muñoz
- Department of Palliative Care, University of Vic—Central University of Catalonia, Barcelona, Spain
- The Qualy Observatory, WHO Collaborating Centre for Public Health Palliative Care Programs, Catalan Institute of Oncology, Barcelona, Spain
| | | | - Elba Beas Alba
- Department of Palliative Care, University of Vic—Central University of Catalonia, Barcelona, Spain
- The Qualy Observatory, WHO Collaborating Centre for Public Health Palliative Care Programs, Catalan Institute of Oncology, Barcelona, Spain
| | | | - Xavier Gómez Batiste Alentorn
- Department of Palliative Care, University of Vic—Central University of Catalonia, Barcelona, Spain
- The Qualy Observatory, WHO Collaborating Centre for Public Health Palliative Care Programs, Catalan Institute of Oncology, Barcelona, Spain
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26
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Mudge AM, Douglas C, Sansome X, Tresillian M, Murray S, Finnigan S, Blaber CR. Risk of 12-month mortality among hospital inpatients using the surprise question and SPICT criteria: a prospective study. BMJ Support Palliat Care 2018; 8:213-220. [DOI: 10.1136/bmjspcare-2017-001441] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 01/04/2023]
Abstract
ObjectivesPeople with serious life-limiting disease benefit from advance care planning, but require active identification. This study applied the Gold Standards Framework Proactive Identification Guidance (GSF-PIG) to a general hospital population to describe high-risk patients and explore prognostic performance for 12-month mortality.MethodsProspective cohort study conducted in a metropolitan teaching hospital in Australia. Hospital inpatients on a single day aged 18 years and older were eligible, excluding maternity and neonatal, mental health and day treatment patients. Data sources included medical record and structured questions for medical and nursing staff. High-risk was predefined as positive response to the surprise question (SQ) plus two or more SPICT indicators of general deterioration. Descriptive variables included demographics, frailty and functional measures, treating team, advance care planning documentation and hospital utilisation. Primary outcome for prognostic performance was 12-month mortality.ResultsWe identified 540 eligible inpatients on the study day and 513 had complete data (mean age 60, 54% male, 30% living alone, 19% elective admissions). Of these, 191 (37%) were high-risk; they were older, frailer, more dependent and had been in hospital longer than low-risk participants. Within 12 months, 92 participants (18%) died (72/191(38%) high-risk versus 20/322(6%) low-risk, P<0.001), providing sensitivity 78%, specificity 72%, positive predictive value 38% and negative predictive value 94%. SQ alone provided higher sensitivity, adding advanced disease indicators improved specificity.ConclusionsThe GSF-PIG approach identified a large minority of hospital inpatients who might benefit from advance care planning. Future studies are needed to investigate the feasibility, cost and impact of screening in hospitals.
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27
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Taylor DR, Lightbody CJ. Futility and appropriateness: challenging words, important concepts. Postgrad Med J 2018; 94:238-243. [PMID: 29477988 DOI: 10.1136/postgradmedj-2018-135581] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 01/27/2018] [Indexed: 11/04/2022]
Abstract
The provision of healthcare is being challenged by a 'perfect storm' of forces including an increasing population with multiple comorbidities, high expectations and resource limitations, and in the background, the pre-eminence of the 'curative medical model'. Non-beneficial (futile) treatments are wasteful and costly. They have a negative impact on quality of life especially in the last year of life. Among professionals, frequent encounters with futility cause moral distress and demoralisation. The factors that drive non-beneficial treatments include personal biases, patient-related pressures and institutional imperatives. Breaking loose from the perceived necessity to deliver non-beneficial treatment is a major challenge. Curative intent should give way to appropriateness such that curative and palliative interventions are valued equally. Goals of treatment should be shaped by illness trajectory, the risk of harms as well as potential benefits and patient preferences. This strategy should be reflected in professional training and the design of acute services.
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Affiliation(s)
- D Robin Taylor
- Department of Respiratory Medicine, University Hospital Wishaw, Wishaw, UK.,Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Calvin J Lightbody
- Emergency Medicine Department, University Hospital Hairmyres, East Kilbride, UK
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28
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Stevens CL, Brown C, Watters DAK. Measuring Outcomes of Clinical Care: Victorian Emergency Laparotomy Audit Using Quality Investigator. World J Surg 2017; 42:1981-1987. [DOI: 10.1007/s00268-017-4418-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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29
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Ruseckaite R, Detering KM, Evans SM, Perera V, Walker L, Sinclair C, Clayton JM, Nolte L. Protocol for a national prevalence study of advance care planning documentation and self-reported uptake in Australia. BMJ Open 2017; 7:e018024. [PMID: 29101142 PMCID: PMC5695482 DOI: 10.1136/bmjopen-2017-018024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Advance care planning (ACP) is a process between a person, their family/carer(s) and healthcare providers that supports adults at any age or stage of health in understanding and sharing their personal values, life goals and preferences regarding future medical care. The Australian government funds a number of national initiatives aimed at increasing ACP uptake; however, there is currently no standardised Australian data on formal ACP documentation or self-reported uptake. This makes it difficult to evaluate the impact of ACP initiatives. This study aims to determine the Australian national prevalence of ACP and completion of Advance Care Directives (ACDs) in hospitals, aged care facilities and general practices. It will also explore people's self-reported use of ACP and views about the process. METHODS AND ANALYSIS Researchers will conduct a national multicentre cross-sectional prevalence study, consisting of a record audit and surveys of people aged 65 years or more in three sectors. From 49 participating Australian organisations, 50 records will be audited (total of 2450 records). People whose records were audited, who speak English and have a decision-making capacity will also be invited to complete a survey. The primary outcome measure will be the number of people who have formal or informal ACP documentation that can be located in records within 15 min. Other outcomes will include demographics, measure of illness and functional capacity, details of ACP documentation (including type of document), location of documentation in the person's records and whether current clinical care plans are consistent with ACP documentation. People will be surveyed, to measure self-reported interest, uptake and use of ACP/ACDs, and self-reported quality of life. ETHICS AND DISSEMINATION This protocol has been approved by the Austin Health Human Research Ethics Committee (reference HREC/17/Austin/83). Results will be submitted to international peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBER ACTRN12617000743369.
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Affiliation(s)
- Rasa Ruseckaite
- Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen M Detering
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Sue M Evans
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Veronica Perera
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Lynne Walker
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Craig Sinclair
- Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia
| | - Josephine M Clayton
- Hammond Care Palliative and Supportive Care Service, Greenwich Hospital, Sydney, New South Wales, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
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30
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Orford NR, Milnes S, Simpson N, Keely G, Elderkin T, Bone A, Martin P, Bellomo R, Bailey M, Corke C. Effect of communication skills training on outcomes in critically ill patients with life-limiting illness referred for intensive care management: a before-and-after study. BMJ Support Palliat Care 2017; 9:e21. [PMID: 28659433 DOI: 10.1136/bmjspcare-2016-001231] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 02/16/2017] [Accepted: 05/17/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To describe the effect of a communication skills training programme on patient-centred goals of care documentation and clinical outcomes in critically ill patients with life-limiting illnesses (LLI) referred for intensive care management. METHODS Prospective before-and-after cohort study in a tertiary teaching hospital in Australia. The population was 222 adult patients with LLI referred to the intensive care unit (ICU). The study was divided into two periods, before (1 May to 31 July 2015) and after (15 September to 15December 2015) the intervention. The intervention was a 2-day, small group, simulated-patient, communication skills course, and process of care for patients with LLI. The primary outcome was documentation of patient-centred goals of care discussion (PCD) within 48 hours of referral to the ICU. Secondary outcomes included clinical outcomes and 90-day mortality. RESULTS The intervention was associated with increased documentation of a PCD from 50% to 69% (p=0.004) and 43% to 94% (p<0.0001) in patients deceased by day 90. A significant decrease in critical care as the choice of resuscitation goal (61% vs 42%, p=0.02) was observed. Although there was no decrease in admission to ICU, there was a significant decrease in medical emergency team call prevalence (87% vs 73%, p=0.009). The cancer and organ failure groups had a significant decrease in 90-day mortality (75% vs 44%, p=0.02; 42% vs 16%, p=0.01), and the frailty group had a significant decrease in 90-day readmissions (48% vs 19%, p=0.003). CONCLUSIONS The intervention was associated with increased PCD documentation and decrease in the choice of critical care as the resuscitation goal. Admissions to ICU did not decrease, and although limited by study design, condition-specific trajectory changes, clinical interventions and outcomes warrant further study.
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Affiliation(s)
- Neil R Orford
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.,School of Medicine, Deakin University, Geelong, Australia.,Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, Australia
| | - Sharyn Milnes
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.,School of Medicine, Deakin University, Geelong, Australia
| | - Nicholas Simpson
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.,School of Medicine, Deakin University, Geelong, Australia
| | - Gerry Keely
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Tania Elderkin
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Allison Bone
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Peter Martin
- School of Medicine, Deakin University, Geelong, Australia.,Palliative Care Unit, Barwon Health, Geelong, Australia
| | - Rinaldo Bellomo
- Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, Australia.,School of Medicine, The University of Melbourne, Parkville, Melbourne, Australia
| | - Michael Bailey
- Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, Australia
| | - Charlie Corke
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.,School of Medicine, Deakin University, Geelong, Australia
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31
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Milnes S, Corke C, Orford NR, Bailey M, Savulescu J, Wilkinson D. Patient values informing medical treatment: a pilot community and advance care planning survey. BMJ Support Palliat Care 2017. [PMID: 28255070 DOI: 10.1136/bmjspcare-2016-001177.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Medicine regards the prevention of death as an important priority. Yet patients may have a range of priorities of equal or greater importance. These other priorities are often not discussed or appreciated by treating doctors. OBJECTIVES We sought to identify priorities of care for patients attending an advance care planning (ACP) clinic and among the general population, and to identify factors associated with priorities other than prolonging life. METHODS We used a locally developed survey tool 'What Matters Most' to identify values. Choices presented were: maintaining dignity, avoiding pain and suffering, living as long as possible, and remaining independent. Participants rated the importance of each and then selected a main priority for their doctor. Participant groups were a purposive sample of 382 lay people from the general population and 100 attendees at an ACP clinic. RESULTS Living as long as possible was considered to be less important than other values for ACP patients and for the general population. Only 4% of ACP patients surveyed and 2.6% of our general population sample selected 'living as long as possible' as their top priority for medical treatment. CONCLUSIONS 'Living as long as possible' was not the most important value for ACP patients, or for a younger general population. Prioritisation of other goals appeared to be independent of extreme age or illness. When end of life treatment is being discussed with patients, priorities other than merely prolonging life should be considered.
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Affiliation(s)
- S Milnes
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - C Corke
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - N R Orford
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia.,Department of Epidemiology and Preventive Medicine (DEPM), Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
| | - M Bailey
- Department of Epidemiology and Preventive Medicine (DEPM), Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
| | - J Savulescu
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - D Wilkinson
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK.,John Radcliffe Hospital, Oxford, UK
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32
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Milnes S, Corke C, Orford NR, Bailey M, Savulescu J, Wilkinson D. Patient values informing medical treatment: a pilot community and advance care planning survey. BMJ Support Palliat Care 2017; 9:e23. [PMID: 28255070 PMCID: PMC6817704 DOI: 10.1136/bmjspcare-2016-001177] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 08/31/2016] [Accepted: 12/28/2016] [Indexed: 01/03/2023]
Abstract
Medicine regards the prevention of death as an important priority. Yet patients may have a range of priorities of equal or greater importance. These other priorities are often not discussed or appreciated by treating doctors.
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Affiliation(s)
- S Milnes
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - C Corke
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - N R Orford
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia.,Department of Epidemiology and Preventive Medicine (DEPM), Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
| | - M Bailey
- Department of Epidemiology and Preventive Medicine (DEPM), Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
| | - J Savulescu
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - D Wilkinson
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK.,John Radcliffe Hospital, Oxford, UK
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