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Felber SJ, Zambrano SC, Guffi T, Schmitz FM, Brem BG, Schnabel KP, Guttormsen S, Eychmüller S. How to talk about dying? The development of an evidence-based model for communication with patients in their last days of life and their family caregivers. PEC INNOVATION 2024; 5:100309. [PMID: 39027227 PMCID: PMC11254737 DOI: 10.1016/j.pecinn.2024.100309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 06/06/2024] [Accepted: 06/17/2024] [Indexed: 07/20/2024]
Abstract
Objective To help healthcare professionals (HCP) act with more confidence when communicating about approaching death, we sought to develop a communication model for HCP to facilitate conversations with dying patients and family caregivers (FC) in nonemergency situations. Methods We used a four-phase integrative approach: (1) creation of a preliminary model based on a systematic literature review and expert knowledge, (2) review of the model draft by international palliative care experts, (3) review by key stakeholders, and (4) final appraisal by communication experts. Results After the clinical recognition of dying, the communication model provides a structure and practical communication aids for navigating the conversation based on three phases. It describes the content and relational level as core dimensions of effective conversations about approaching death and highlights the importance of HCP self-awareness and self-care when caring for the dying. Conclusion Based on systematic involvement of key stakeholders, the model supports clinicians navigating challenging conversations about approaching death with dying patients and their FC successfully and with more confidence. Innovation This study expands the theoretical basis for communication about approaching death and offers a pragmatic model for educational interventions and clinical use.
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Affiliation(s)
- Sibylle J. Felber
- University Centre for Palliative Care (UZP), Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sofia C. Zambrano
- University Centre for Palliative Care (UZP), Bern University Hospital, University of Bern, Bern, Switzerland
- Institute for Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Tommaso Guffi
- Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Felix M. Schmitz
- Institute for Medical Education (IML), University of Bern, Bern, Switzerland
| | - Beate G. Brem
- Institute for Medical Education (IML), University of Bern, Bern, Switzerland
| | - Kai P. Schnabel
- Institute for Medical Education (IML), University of Bern, Bern, Switzerland
| | - Sissel Guttormsen
- Institute for Medical Education (IML), University of Bern, Bern, Switzerland
| | - Steffen Eychmüller
- University Centre for Palliative Care (UZP), Bern University Hospital, University of Bern, Bern, Switzerland
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Markgraf M, Meyer G, Kirchner Ä. [Advance care planning in the acute hospital: A qualitative analysis of terms and conditions]. Pflege 2024. [PMID: 39171355 DOI: 10.1024/1012-5302/a001011] [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: 08/23/2024]
Abstract
Advance care planning in the acute hospital: A qualitative analysis of terms and conditions Abstract: Background: Advance Care Planning (ACP) is an internationally established concept aimed to facilitate anticipatory care planning in the event of future inability to consent. In Germany, ACP is currently not regularly offered to patients in acute care hospitals. Aim: We aimed to identify preconditions for implementation of ACP in acute care hospitals in Germany through review of the international literature and expert interviews. Methods: A systematic literature search was carried out in the databases MEDLINE and CINAHL for internationally used strategies for implementing ACP in acute care hospitals. Consecutively, a guide for interviews with experts to evaluate the strategies was developed. Interviews were analyzed by qualitative content analysis according to Mayring. Results: Out of 13 included publications, 17 preconditions were identified and assigned to 16 categories after evaluation by experts. In international ACP programs, it was described how to proceed and organize the ACP conversation. German experts emphasized that appropriate preconditions, such as sufficient time resources and training, must be granted, whereas the literature search revealed the conversation process and organization as important determinants. Conclusions: The implementation of ACP programs is conceivable, but requires specific conditions as legal regulation and defining and structuring of the processes.
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Affiliation(s)
- Miriam Markgraf
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Gabriele Meyer
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Änne Kirchner
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
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Breen BM, Flohr C, Wendt H, Chalk K, Haase U, Hartog C, Tafelski S. [Frequency and barriers to the patient advanced directive and lasting power of attorney: findings from a prospective observation study in palliative care services]. Med Klin Intensivmed Notfmed 2024:10.1007/s00063-024-01149-5. [PMID: 38740593 DOI: 10.1007/s00063-024-01149-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/26/2024] [Accepted: 04/12/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND The advance directive and lasting power of attorney are instruments to strengthen patients' autonomy. A hospital-based palliative care consultation service can advise patients and family members about these instruments. This study investigates the need for such consultation among patients with life-limiting illness. METHODS This prospective observational study on intensive and non-intensive care units includes patients with a request for palliative care consultation. Patient-related factors were evaluated for their possible association with the presence or absence of advance directives or power of attorney. In addition, focus group interviews with members of the palliative care consultation team were carried out to identify barriers which prevent patients from drawing up such documents. RESULTS A total of 241 oncological and 53 non-oncological patients were included with a median age of 67 years; 69 (23%) patients were treated in the intensive care unit (ICU). Overall, 98 (33%) patients had advance directives, and 133 (45%) had determined a legal health care proxy in advance. A total of 52 patients died in hospital (17.7%). Only age and relationship status were associated with directives. In interviews, the following barriers were identified: information deficit, concern regarding discontinuation of treatment, loss of autonomy and wish to avoid a burden for the family. CONCLUSION The majority in this severely ill patient population lack advance directives. In order to remove barriers, more effective information and counseling is required about such directives. In particular, guidance should include potential clinical situations in which such directives are potentially beneficial.
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Affiliation(s)
| | - Claudia Flohr
- Zentrales Pflegecenter (ZPC), Palliativkonsildienst, Charité - Universitätsmedizin Berlin, Gliedkörperschaft der Freien Universität Berlin, der Humboldt Universität zu Berlin und dem Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Heike Wendt
- Klinik für Anästhesiologie und Intensivmedizin, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charité - Universitätsmedizin Berlin, Corporate Member der Freien Universität Berlin und Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Katharina Chalk
- Klinik für Anästhesiologie und Intensivmedizin, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charité - Universitätsmedizin Berlin, Corporate Member der Freien Universität Berlin und Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Ulrike Haase
- Zentrum für Schmerzmedizin, Ostseestraße 107, 10409, Berlin, Deutschland
| | - Christiane Hartog
- Klinik für Anästhesiologie und Intensivmedizin, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charité - Universitätsmedizin Berlin, Corporate Member der Freien Universität Berlin und Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
- Klinik Bavaria Kreischa, 01731, Kreischa, Deutschland
| | - Sascha Tafelski
- Klinik für Anästhesiologie und Intensivmedizin, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charité - Universitätsmedizin Berlin, Corporate Member der Freien Universität Berlin und Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
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Jöbges S, Dutzmann J, Barndt I, Burchardi H, Duttge G, Grautoff S, Gretenkort P, Hartog C, Knochel K, Nauck F, Neitzke G, Meier S, Michalsen A, Rogge A, Salomon F, Seidlein AH, Schumacher R, Riegel R, Stopfkuchen H, Janssens U. Ethisch begründet entscheiden in der Intensivmedizin. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:52-57. [PMID: 38190826 DOI: 10.1055/a-2211-9608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
The process recommendations of the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) for ethically based decision-making in intensive care medicine are intended to create the framework for a structured procedure for seriously ill patients in intensive care. The processes require appropriate structures, e.g., for effective communication within the treatment team, with patients and relatives, legal representatives, as well as the availability of palliative medical expertise, ethical advisory committees and integrated psychosocial and spiritual care services. If the necessary competences and structures are not available in a facility, they can be consulted externally or by telemedicine if necessary. The present recommendations are based on an expert consensus and are not the result of a systematic review or a meta-analysis.
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Clavien C, Ehlers U, J Jox R, Karzig I, Krones T, Loupatzatzis B, Monteverde S, Theile G. Advance Care Planning in Switzerland: Chances and challenges of delivering high-quality ACP in a small high-income, multilingual, federally organized country. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:115-120. [PMID: 37438170 DOI: 10.1016/j.zefq.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 07/14/2023]
Abstract
We describe the development of ACP in Switzerland during the last decade in the German- and French-speaking cantons and on the national level. In 2013, a revision of the Swiss civil law came into force, declaring advance directives (ADs) as binding. Since then, ACP has been researched and implemented primarily by universities and university hospitals. Despite the foundation of the national association "ACP Swiss" in 2020, several national initiatives, and a roadmap for a national implementation, many challenges and barriers still remain. There is, however, reasonable hope to implement high-quality ACP throughout Switzerland within the next ten years.
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Affiliation(s)
| | - Ulrike Ehlers
- Saint Gallen Cantonal Hospital, Saint Gallen, Switzerland
| | - Ralf J Jox
- University of Lausanne, Lausanne, Switzerland
| | | | - Tanja Krones
- University Hospital Zurich, Zurich, Switzerland.
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Lereim Sævareid TJ, Aasmul I, Hjorth NE. Implementation of Advance Care Planning in Norway. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:163-167. [PMID: 37394337 DOI: 10.1016/j.zefq.2023.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/16/2023] [Accepted: 05/21/2023] [Indexed: 07/04/2023]
Abstract
Advance Care Planning has a relatively short history in the Norwegian health care services. This article gives an overview of advance care planning research and its implementation in the health care services in Norway. Advance care planning has received increased attention from policymakers and the health care services. Research projects have been performed, and several are on-going. Implementation has largely treated advance care planning as a complex intervention, with a whole-system approach that puts emphasis on the conversation and patient activation. Advance directives have a peripheral role in this context.
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Affiliation(s)
| | - Irene Aasmul
- The Dignity Centre - Care for the old, Bergen, Norway
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Götze K, Bausewein C, Feddersen B, Fuchs A, Hot A, Hummers E, Icks A, Kirchner Ä, Kleinert E, Klosterhalfen S, Kolbe H, Laag S, Langner H, Lezius S, Meyer G, Montalbo J, Nauck F, Reisinger C, Rieder N, Schildmann J, Schunk M, Stanze H, Vogel C, Wegscheider K, Zapf A, Marckmann G, in der Schmitten J, Albert A, Alheid C, Bausewein C, Bruene M, Calles C, Camci H, Daubmann A, Dahlke S, Enger S, Feddersen B, Felder G, Fluck C, Freienstein A, Freytag T, Fuchs A, Icks A, in der Schmitten J, Hensel L, Hummers E, Hot A, Kirchner Ä, Kleinert E, Klosterhalfen S, Kolbe H, Laag S, Langner H, Lezius S, Marckmann G, Meyer G, Montalbo J, Nauck F, Nguyen T, Nowak A, Ossenberg M, Reisinger C, Reuter S, Rieder N, Riester T, Rosu I, Rösgen H, Salanta K, Sassi Z, Schildmann J, Schulenberg T, Schunk M, Sommer D, Stanze H, Stöhr A, Theuerkauf A, Thilo N, Tönjann J, Partowinia-Peters M, Prommersberger S, Przybylla S, Vogel C, Vomhof M, Wilken J, Zapf A, Zimprich J. Effectiveness of a complex regional advance care planning intervention to improve care consistency with care preferences: study protocol for a multi-center, cluster-randomized controlled trial focusing on nursing home residents (BEVOR trial). Trials 2022; 23:770. [PMID: 36096948 PMCID: PMC9465132 DOI: 10.1186/s13063-022-06576-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background According to recent legislation, facilitated advance care planning (ACP) for nursing home (NH) residents is covered by German sickness funds. However, the effects of ACP on patient-relevant outcomes have not been studied in Germany yet. This study investigates whether implementing a complex regional ACP intervention improves care consistency with care preferences in NH residents. Methods This is a parallel-group cluster-randomized controlled trial (cRCT) with 48 NHs (≈ 3840 resident beds) between 09/2019 and 02/2023. The intervention group will receive a complex, regional ACP intervention aiming at sustainable systems redesign at all levels (individual, institutional, regional). The intervention comprises comprehensive training of ACP facilitators, implementation of reliable ACP processes, organizational development in the NH and other relevant institutions of the regional healthcare system, and education of health professionals caring for the residents. Control group NHs will deliver care as usual. Primary outcome is the hospitalization rate during the 12-months observation period. Secondary outcomes include the rate of residents whose preferences were known and honored in potentially life-threatening events, hospital days, index treatments like resuscitation and artificial ventilation, advance directives, quality of life, psychological burden on bereaved families, and costs of care. The NHs will provide anonymous, aggregated data of all their residents on the primary outcome and several secondary outcomes (data collection 1). For residents who have given informed consent, we will evaluate care consistency with care preferences and further secondary outcomes, based on chart reviews and short interviews with residents, surrogates, and carers (data collection 2). Process evaluation will aim to explain barriers and facilitators, economic evaluation the cost implications. Discussion This study has the potential for high-quality evidence on the effects of a complex regional ACP intervention on NH residents, their families and surrogates, NH staff, and health care utilization in Germany. It is the first cRCT investigating a comprehensive regional ACP intervention that aims at improving patient-relevant clinical outcomes, addressing and educating multiple institutions and health care providers, besides qualification of ACP facilitators. Thereby, it can generate evidence on the potential of ACP to effectively promote patient-centered care in the vulnerable population of frail and often chronically ill elderly. Trial registration ClinicalTrials.gov ID NCT04333303. Registered 30 March 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06576-3.
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Dahmke K, Nielsen-Hannerup E, Madsen IS, Rerup S, Ramberg E, Lembeck MA, Pedersen H, Holm EA. Perspective of geriatric patients on advance care planning in Denmark: a qualitative study. BMJ Open 2022; 12:e056115. [PMID: 35260460 PMCID: PMC8905984 DOI: 10.1136/bmjopen-2021-056115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Most previous studies on advance care planning (ACP) have focused on patients with specific diseases and only a few on frail ageing individuals. We therefore decided to examine the perspective of geriatric patients on ACP. Our research questions include if, when, with whom and with which content geriatric patients wish to have ACP conversations. DESIGN Participants were interviewed either in the hospital or in their own home. The interviewer followed a semistructured interview guide. Interviews were transcribed and analysed using the systemic text condensation method. SETTING Geriatric department in a regional hospital in a rural area in Region Zealand, Denmark. PARTICIPANTS We included 11 geriatric patients aged above 65 who had been referred for geriatric inpatient or outpatient assessment. Participants were clinically judged by experienced geriatricians to have sufficient physical and mental capacity to take part in an interview. RESULTS This study's main finding is that geriatric patients have varying preferences and feelings towards ACP. Some expressed concerns about ACP, especially regarding personal fear to talk about end-of-life (EOL) decisions, and whether a busy healthcare system has the resources to conduct ACP. Proper timing of ACP seemed unrelated to specific age but related to perception of health situation. The health professional involved should be well trained and a person the participant could trust. Most participants wanted family members to participate. Concerning content, participants mentioned quality of life, fear of losing their spouse, earlier experience with death, and practical concerns regarding funeral and will. CONCLUSION Among geriatric patients, feelings towards ACP are mixed. Even participants who were generally positive towards the concept uttered concerns about the circumstances when talking about EOL topics. Health professionals therefore should approach ACP discussions with caution. Further studies aiming to develop guidelines describing the proper way to introduce and perform ACP in this patient group are needed.
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Affiliation(s)
- Kirstine Dahmke
- Department of Internal Medicine, Nykøbing Falster Sygehus, Nykobing, Denmark
| | | | | | - Sofie Rerup
- Department of Social Medicine, Frederiksberg Hospital, Frederiksberg, Denmark
| | - Emilie Ramberg
- Department of Internal Medicine, Nykøbing Falster Sygehus, Nykobing, Denmark
| | - Maurice A Lembeck
- Department of Internal Medicine, Nykøbing Falster Sygehus, Nykobing, Denmark
| | - Hanne Pedersen
- Internal Medicine, Zealand University Hospital Koge, Koge, Denmark
| | - Ellen Astrid Holm
- Internal Medicine, Zealand University Hospital Koge, Koge, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Kobenhavns, Denmark
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Biller-Andorno N, Ferrario A, Joebges S, Krones T, Massini F, Barth P, Arampatzis G, Krauthammer M. AI support for ethical decision-making around resuscitation: proceed with care. JOURNAL OF MEDICAL ETHICS 2022; 48:175-183. [PMID: 33687916 DOI: 10.1136/medethics-2020-106786] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/15/2020] [Accepted: 01/15/2021] [Indexed: 06/12/2023]
Abstract
Artificial intelligence (AI) systems are increasingly being used in healthcare, thanks to the high level of performance that these systems have proven to deliver. So far, clinical applications have focused on diagnosis and on prediction of outcomes. It is less clear in what way AI can or should support complex clinical decisions that crucially depend on patient preferences. In this paper, we focus on the ethical questions arising from the design, development and deployment of AI systems to support decision-making around cardiopulmonary resuscitation and the determination of a patient's Do Not Attempt to Resuscitate status (also known as code status). The COVID-19 pandemic has made us keenly aware of the difficulties physicians encounter when they have to act quickly in stressful situations without knowing what their patient would have wanted. We discuss the results of an interview study conducted with healthcare professionals in a university hospital aimed at understanding the status quo of resuscitation decision processes while exploring a potential role for AI systems in decision-making around code status. Our data suggest that (1) current practices are fraught with challenges such as insufficient knowledge regarding patient preferences, time pressure and personal bias guiding care considerations and (2) there is considerable openness among clinicians to consider the use of AI-based decision support. We suggest a model for how AI can contribute to improve decision-making around resuscitation and propose a set of ethically relevant preconditions-conceptual, methodological and procedural-that need to be considered in further development and implementation efforts.
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Affiliation(s)
- Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
- Collegium Helveticum, Zurich, Switzerland
| | - Andrea Ferrario
- Department of Management, Technology, and Economics, Eidgenössische Technische Hochschule Zürich, Zurich, Switzerland
| | - Susanne Joebges
- Institute of Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
| | - Tanja Krones
- Institute of Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
- Clinical Ethics, Universitätsspital Zürich, Zurich, Switzerland
| | - Federico Massini
- Institute of Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
- Collegium Helveticum, Zurich, Switzerland
| | - Phyllis Barth
- Institute of Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
- Collegium Helveticum, Zurich, Switzerland
| | - Georgios Arampatzis
- Collegium Helveticum, Zurich, Switzerland
- Computational Science and Engineering Laboratory, Eidgenössische Technische Hochschule Zürich, Zurich, Switzerland
| | - Michael Krauthammer
- Department of Quantitative Biomedicine, Chair of Medical Informatics, Universität Zürich, Zurich, Switzerland
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10
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Dem Tod ins Gesicht schauen – müssen wir Gespräche über Entscheidungen am Lebensende führen? Ethik Med 2022. [DOI: 10.1007/s00481-021-00679-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Limitation of life-sustaining treatment and patient involvement in decision-making: a retrospective study of a Danish COVID-19 patient cohort. Scand J Trauma Resusc Emerg Med 2021; 29:173. [PMID: 34930420 PMCID: PMC8686092 DOI: 10.1186/s13049-021-00984-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/29/2021] [Indexed: 12/29/2022] Open
Abstract
Background The coronavirus (COVID-19) pandemic and the risk of an extensive overload of the healthcare systems have elucidated the need to make decisions on the level of life-sustaining treatment for patients requiring hospitalisation. The purpose of the study was to investigate the proportion and characteristics of COVID-19 patients with limitation of life-sustaining treatment decisions and the degree of patient involvement in the decisions. Methods A retrospective observational descriptive study was conducted in three Danish regional hospitals, looking at all patients ≥ 18 years of age admitted in 2020 with COVID-19 as the primary diagnosis. Lists of hospitalised patients admitted due to COVID-19 were extracted. The data registration included age, gender, comorbidities, including mental state, body mass index, frailty, recent hospital admissions, COVID-19 life-sustaining treatment, ICU admission, decisions on limitations of life-sustaining treatment before and during current hospitalisation, hospital length of stay, and hospital mortality. Results A total of 476 patients were included. For 7% (33/476), a decision about limitation of life-sustaining treatment had been made prior to hospital admission. At the time of admission, one or more limitations of life-sustaining treatment were registered for 16% (75/476) of patients. During the admission, limitation decisions were made for an additional 11 patients, totaling 18% (86/476). For 40% (34/86), the decisions were either made by or discussed with the patient. The decisions not made by patients were made by physicians. For 36% (31/86), no information was disclosed about patient involvement. Conclusions Life-sustaining treatment limitation decisions were made for 18% of a COVID-19 patient cohort. Hereof, more than a third of the decisions had been made before hospital admission. Many records lacked information on patient involvement in the decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00984-1.
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Biller-Andorno N, Biller A. The Advance Care Compass- A New Mechanics for Digitally Transforming Advance Directives. Front Digit Health 2021; 3:753747. [PMID: 34723244 PMCID: PMC8554048 DOI: 10.3389/fdgth.2021.753747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Advance directives allow people to declare their treatment preferences for a potential future state of incompetency. Covid-19, with its high numbers of quickly deteriorating patients requiring intensive care, has acutely demonstrated how helpful it would be for clinicians to have reliable, readily available, up-to-date information at hand to be able to act in accordance with what the individual patient would have wanted. Yet for the past few decades advance directives have fallen short of their potential, for various reasons. At worst, advance directives are perceived as unwieldy legal documents that put excessive demands on patients without providing useful guidance for better care. Recent efforts such as advance care planning have tried to remedy some of these shortcomings but have so far met with limited success. We suggest a new concept-the Advance Care Compass-that harnesses the potential of digitalization in healthcare to overcome many of difficulties encountered so far.
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Affiliation(s)
- Nikola Biller-Andorno
- Faculty of Medicine, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
| | - Armin Biller
- Multi-Dimensional Medical Information Lab, Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
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13
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Bosisio F, Sterie AC, Rubli Truchard E, Jox RJ. Implementing advance care planning in early dementia care: results and insights from a pilot interventional trial. BMC Geriatr 2021; 21:573. [PMID: 34666711 PMCID: PMC8524211 DOI: 10.1186/s12877-021-02529-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 10/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is particularly appropriate for persons with early dementia (PWED) since it promotes conversations about dementia-specific illness scenarios, addresses inconsistencies between advance directives and patients' observed behavior, emphasizes prospective and relational autonomy, and may be generally consistent with older persons' decision-making needs. However, despite evidence of its benefits, ACP is yet to become widely used among PWED. In this paper, we present a dementia-specific tool developed in Western Switzerland, discuss results of a pilot trial designed to promote ACP among PWED and their relatives, and discuss the feasibility and acceptability of the intervention and the study protocol in prevision of a large scale trial. METHODS This one-arm pre-post pilot trial consisted of four visits, with visits 2 and 3 being the ACP intervention. Quantitative outcome measures during visit 1 and 4 assessed the aptitude of the intervention to support PWED autonomy and relatives' knowledge of PWED's preferences. Feasibility was explored according to how the recruitment procedure unfurled and based on the necessary revisions to the study protocol and healthcare providers' reason for excluding a PWED from the study. Acceptability was assessed according to pre-post evaluations, difficulties regarding the intervention or trial participation, and pre-post qualitative interviews regarding participants' reasons to participate to the study, satisfaction with the tool and difficulties perceived. RESULTS The ACP intervention itself was well received by PWED and their relatives that expressed satisfaction with the procedure, especially regarding the opportunity to discuss a sensitive topic with the help of a facilitator. Five main challenges in terms of feasibility were 1) to locate eligible patients, 2) to tailor recruitment procedures to recruitment locations, 3) to adapt inclusion criteria to clinical routines, 4) to engage PWED and their relatives in ACP, and 5) to design a trial that does not burden PWED. Despite these challenges, the intervention increased the number of advance directives, the concordance between PWED's preferences and relatives' decision on their behalf, and relatives' perceived control over healthcare decisions. CONCLUSION Misconceptions about dementia and ACP, in the patient, relatives, and healthcare providers, combined with structural and institutional challenges, have the power to impede research and implementation of ACP in dementia care. For this reason, we conclude that a large scale trial to test a dementia-specific tool of ACP is currently not feasible in Western Switzerland and should be endorsed in a systemic approach of ACP. TRIAL REGISTRATION This trial was registered in the database clinicaltrial.gov with the number NCT03615027 .
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Affiliation(s)
- Francesca Bosisio
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland. .,Service of Palliative and Supportive Care, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland. .,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland.
| | - Anca-Cristina Sterie
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Service of Palliative and Supportive Care, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland
| | - Eve Rubli Truchard
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland
| | - Ralf J Jox
- Service of Palliative and Supportive Care, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland.,Institute of Humanities in Medicine, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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Yeun YR. The Effects of Advance Care Planning on Decision Conflict and Psychological Distress: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2021; 24:144-153. [PMID: 37674564 PMCID: PMC10180057 DOI: 10.14475/jhpc.2021.24.3.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 09/08/2023]
Abstract
Purpose Advance care planning (ACP) is widely understood to improve end-of-life care. This systematic review and meta-analysis aimed to examine the effects of ACP interventions on decision conflict and psychological distress. Methods A search of PubMed, CINAHL, CENTRAL, EMBASE, KISS, KoreaMed, and RISS was conducted in November 2020. The study included randomized controlled trials. Data were pooled using fixed- and random-effects models. Results Fourteen studies were identified that cumulatively included 1,548 participants. ACP interventions were effective in alleviating decision conflict (d=-0.53; 95% CI -0.83 to -0.23), depression (d=-1.22; 95% CI -1.71 to -0.74) and anxiety (d=-0.76; 95% CI -1.12 to -0.39). Conclusion ACP interventions have significant positive effects on reducing decision conflict and psychological distress. A high level of bias was shown related to allocation concealment and blinding. The results of this study are expected to be useful for end-of-life care providers to improve the effectiveness of ACP interventions.
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Affiliation(s)
- Young-Ran Yeun
- Department of Nursing, Kangwon National University, Samcheok, Korea
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15
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[Advance care planning during the coronavirus pandemic-A chance for patient autonomy in acute situations]. Med Klin Intensivmed Notfmed 2020; 115:571-572. [PMID: 32876802 PMCID: PMC7463222 DOI: 10.1007/s00063-020-00717-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Severity-Adjusted ICU Mortality Only Tells Half the Truth—The Impact of Treatment Limitation in a Nationwide Database. Crit Care Med 2020; 48:e1242-e1250. [DOI: 10.1097/ccm.0000000000004658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Physicians' perspectives on estimating and communicating prognosis in palliative care: a cross-sectional survey. BJGP Open 2020; 4:bjgpopen20X101078. [PMID: 32967841 PMCID: PMC7606137 DOI: 10.3399/bjgpopen20x101078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/27/2020] [Indexed: 12/14/2022] Open
Abstract
Background Advance care planning (ACP) can help to enhance the care of patients with limited life expectancy. Despite physicians’ key role in ACP, the ways in which physicians estimate and communicate prognosis can be improved. Aim To determine how physicians in different care settings self-assess their performance in estimating and communicating prognosis to patients in palliative care, and how they perceive their communication with other physicians about patients’ poor prognosis. Design & setting A survey study was performed among a random sample of GPs, hospital physicians (HPs), and nursing home physicians (NHPs) in the southwest of the Netherlands (n = 2212). Method A questionnaire was developed that had three versions for GPs, HPs, and NHPs. Each specialism filled in an appropriate version. Results A total of 547 physicians participated: 259 GPs, 205 HPs, and 83 NHPs. In the study, 61.1% of physicians indicated being able to adequately estimate whether a patient will die within 1 year, which was associated with use of the Surprise Question (odds ratio [OR] = 1.65, P = 0.042). In the case of a prognosis of <1 year, 75.0% of physicians indicated that they communicate with patients about preferences regarding treatment and care, which was associated with physicians being trained in palliative care (OR = 2.02, P=0.007). In cases where patients with poor prognosis are discharged after hospital admission, 83.4% of HPs indicated that they inform GPs about these patients’ preferences compared with 29.0% of GPs, and 21.7% of NHPs, who indicated that they are usually adequately informed about the preferences. Conclusion The majority of physicians indicated that they believe they can adequately estimate patients’ limited life expectancy and that they discuss patients’ preferences for care. However, more physicians should be trained in communicating about patients’ poor prognosis and care preferences.
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Bosisio F, Barazzetti G. Advanced Care Planning: Promoting Autonomy in Caring for People with Dementia. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:93-95. [PMID: 32757918 DOI: 10.1080/15265161.2020.1781958] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Seidlein AH, Hannich A, Nowak A, Gründling M, Salloch S. Ethical aspects of time in intensive care decision making. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2019-105752. [PMID: 32332151 DOI: 10.1136/medethics-2019-105752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 03/06/2020] [Accepted: 03/15/2020] [Indexed: 06/11/2023]
Abstract
The decision-making environment in intensive care units (ICUs) is influenced by the transformation of intensive care medicine, the staffing situation and the increasing importance of patient autonomy. Normative implications of time in intensive care, which affect all three areas, have so far barely been considered. The study explores patterns of decision making concerning the continuation, withdrawal and withholding of therapies in intensive care. A triangulation of qualitative data collection methods was chosen. Data were collected through non-participant observation on a surgical ICU at an academic medical centre followed by semi-structured interviews with nurses and physicians. The transcribed interviews and observation notes were coded and analysed using qualitative content analysis according to Mayring. Three themes related to time emerged regarding the escalation or de-escalation of therapies: influence of time on prognosis, time as a scarce resource and timing in regards to decision making. The study also reveals the ambivalence of time as a norm for decision making. The challenge of dealing with time-related efforts in ICU care results from the tension between the need to wait to optimise patient care, which must be balanced against the significant time pressure which is characteristic of the ICU setting.
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Affiliation(s)
- Anna-Henrikje Seidlein
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Arne Hannich
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Andre Nowak
- Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle(Saale), Germany
| | - Matthias Gründling
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
| | - Sabine Salloch
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
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Petri S, Zwißler B, in der Schmitten J, Feddersen B. Behandlung im Voraus Planen – Weiterentwicklung der Patientenverfügung. Anaesthesist 2019; 69:78-88. [DOI: 10.1007/s00101-019-00697-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Skorstengaard MH, Jensen AB, Andreassen P, Brogaard T, Brendstrup E, Løkke A, Aagaard S, Wiggers H, Neergaard MA. Advance care planning and place of death, hospitalisation and actual place of death in lung, heart and cancer disease: a randomised controlled trial. BMJ Support Palliat Care 2019; 10:e37. [DOI: 10.1136/bmjspcare-2018-001677] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/04/2019] [Accepted: 02/20/2019] [Indexed: 11/04/2022]
Abstract
ObjectivesAdvance care planning (ACP) can be a way to meet patients’ end-of-life preferences and enhance awareness of end-of-life care. Thereby it may affect actual place of death (APOD) and decrease the rate of hospitalisations. The aim was to investigate if ACP among terminally ill patients with lung, heart and cancer diseases effects fulfilment of preferred place of death (PPOD), amount of time spent in hospital and APOD.MethodsThe study was designed as a randomised controlled trial. Patients were assessed using general and disease-specific criteria and randomised into groups: one received usual care and one received usual care plus ACP. The intervention consisted of a discussion between a healthcare professional, the patient and their relatives about preferences for end-of-life care. The discussion was documented in the hospital file.ResultsIn total, 205 patients were randomised, of which 111 died during follow-up. No significant differences in fulfilment of PPOD (35% vs 52%, p=0.221) or in amount of time spent in hospital among deceased patients (49% vs 23%, p=0.074) were found between groups. A significant difference in APOD was found favouring home death in the intervention group (17% vs 40%, p=0.013).ConclusionConcerning the primary outcome, fulfilment of PPOD, and the secondary outcome, time spent in hospital, no differences were found. A significant difference concerning APOD was found, as more patients in the intervention group died at home, compared with the usual care group.Trial registration numberNCT01944813.
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