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Taylor EP, Halpin SN, Marconi VC, Justice AC, Johnson TM, McInnes DK, Perkins MM. "Call 911 - That's my [Advance Care] Plan": Factors that Inform Advance Care Planning Conversation Readiness Among Aging Persons Living With HIV. J Appl Gerontol 2024; 43:1156-1164. [PMID: 38375619 PMCID: PMC11305961 DOI: 10.1177/07334648241233377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
Antiretroviral therapy has dramatically increased the lifespan of people living with HIV (PLWH), but advance care planning (ACP) and hospice services are underutilized in this population. The purpose of this study was to understand barriers and facilitators to ACP among this group. PLWH (n = 25) were recruited from an HIV Clinic at a Veterans Affairs (VA) Medical Center in Atlanta, GA to represent a range of sociodemographic characteristics and experiences. Semi-structured interviews were analyzed using thematic analysis. More than half of participants (64%) indicated not engaging in ACP. We identified four key barriers to ACP: (1) a self-image among PLWH as "survivors" (and a reluctance to think about ACP); (2) a history of mistrust and mistreatment; (3) weak social ties and a desire to avoid disclosure of HIV status; and (4) a value for self-reliance. Findings have important implications for interventions to overcome these barriers.
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Affiliation(s)
- Emily Pinto Taylor
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sean N Halpin
- RTI International, Research Triangle Park, Raleigh, NC, USA
| | - Vincent C. Marconi
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Atlanta Veterans Affairs Health System, Decatur, GA, USA
| | - Amy C Justice
- Yale University School of Medicine, New Haven, CT, USA
- Veterans Affairs Medical Center, West Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Theodore M Johnson
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Birmingham-Atlanta Geriatric Research Education and Clinical Center (GRECC), Atlanta Veterans Affairs Health System, Decatur, GA, USA
| | - D. Keith McInnes
- Boston University School of Public Health, Boston, MA, USA
- Veterans Affairs Medical Center, Bedford, MA, USA
| | - Molly M Perkins
- Birmingham-Atlanta Geriatric Research Education and Clinical Center (GRECC), Atlanta Veterans Affairs Health System, Decatur, GA, USA
- Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Britten Muehlensiepen F, Stanze H, May S, Stahlhut K, Helm C, Hakam HT, Bała MM, Peričić TP, Vrbová T, Klugarova J, Prill R. Cross-disciplinary advance care planning in oncology and palliative care amidst a pandemic: a best practice implementation project. JBI Evid Implement 2024:02205615-990000000-00117. [PMID: 39036875 DOI: 10.1097/xeb.0000000000000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
INTRODUCTION Advance care planning (ACP) ensures that patients receive medical care aligned with their values, goals, and preferences, especially regarding end-of-life decisions in serious chronic illnesses. OBJECTIVE This project aimed to introduce and promote evidence-based ACP in oncology and palliative care at a midsized hospital near Berlin, Germany, during the COVID-19 pandemic. METHODS This project was guided by the JBI Evidence Implementation Framework and used a mixed methods audit cycle. A baseline audit was conducted using qualitative interviews and workshops with representatives from all the health care disciplines involved in oncology and palliative care at the hospital. The findings were compared with eight best practice recommendations. Targeted strategies aimed at the key stakeholders involved in ACP practice were then implemented. Finally, a semi-quantitative questionnaire was used in a follow-up audit with the same participants as in the baseline audit. RESULTS The baseline audit revealed a high level of familiarity with the concept of ACP. However, there was a lack of a uniformly accepted definition and understanding of ACP among the health care professionals, leading to a lack of coordination in task distribution. The follow-up audit revealed improvements with regard to education and training in ACP (Criterion 1: 50% to 100%) and organizational support to facilitate ACP conversations (Criterion 3: 87.5% to 100%). Other audit criteria compliance rates remained unchanged. CONCLUSION Clinical education and team-based process analysis can facilitate ACP implementation across disciplines in oncology and palliative care facilities. However, the project did not succeed in implementing lasting changes in clinical processes and best practice ACP due to the COVID-19 pandemic. Such an endeavor would demand considerable resources and time, both of which were constrained during the pandemic. SPANISH ABSTRACT http://links.lww.com/IJEBH/A236.
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Affiliation(s)
- Felix Britten Muehlensiepen
- Center for Health Services Research, Faculty of Health Sciences, Brandenburg Medical School, Rüdersdorf, Germany
- Evidence-Based Practice in Brandenburg: A JBI Affiliated Group, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
| | - Henrikje Stanze
- Department of Social and Nursing Science, City University of Applied Science Bremen, Bremen, Germany
| | - Susann May
- Center for Health Services Research, Faculty of Health Sciences, Brandenburg Medical School, Rüdersdorf, Germany
| | - Kerstin Stahlhut
- Department of Oncology and Palliative Medicine, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Carolin Helm
- Department of Social and Nursing Science, City University of Applied Science Bremen, Bremen, Germany
| | - Hassan Tarek Hakam
- Evidence-Based Practice in Brandenburg: A JBI Affiliated Group, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
- Center of Orthopaedics and Trauma Surgery, University Hospital Brandenburg/Havel, Brandenburg medical School Theodor Fontane, Germany
| | - Małgorzata M Bała
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Kraków, Poland
| | - Tina Poklepović Peričić
- Department of Prosthodontics, Study of Dental Medicine, University of Split School of Medicine, Split, Croatia
| | - Tereza Vrbová
- Cochrane Czech Republic, Czech Republic: A JBI Centre of Excellence, Czech GRADE Network, Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
- Institute of Special Education Studies, Palacký University Olomouc, Olomouc, Czech Republic
| | - Jitka Klugarova
- Cochrane Czech Republic, Czech Republic: A JBI Centre of Excellence, Czech GRADE Network, Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
- Institute of Special Education Studies, Palacký University Olomouc, Olomouc, Czech Republic
| | - Robert Prill
- Evidence-Based Practice in Brandenburg: A JBI Affiliated Group, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
- Center of Orthopaedics and Trauma Surgery, University Hospital Brandenburg/Havel, Brandenburg medical School Theodor Fontane, Germany
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Winnifrith T, Millington-Sanders C, Husbands E, Haros J, Ballinger H. Proactive advance care planning conversations in general practice: a quality improvement project. BMJ Open Qual 2024; 13:e002679. [PMID: 38977313 PMCID: PMC11256018 DOI: 10.1136/bmjoq-2023-002679] [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: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 07/10/2024] Open
Abstract
Advance care planning (ACP) is a process of discussion, reflection and communication, enabling planning for future medical treatment. Despite evidence of benefits of ACP to patients, families and the healthcare system, many die without an opportunity for such conversations, particularly those living with progressive non-malignant conditions. The Royal College of General Practitioners and Marie Curie Daffodil Standards launched in 2020 provide primary care with a structure for improving end-of-life care, including delivery of ACP. Proactive identification of patients is integral to the approach.We report on a quality improvement project which aimed to assess the take-up rate and acceptability in general practice of a timely and personalised ACP conversation using a 'What matters to you' (WMTY) framework, and to ensure that different diagnostic and demographic groups were included.Patients without previous ACP and potentially in the last year of life were offered an ACP conversation; a survey sought feedback.81% accepted the offer and in most cases, future care guidance was documented using the recognised format in Gloucestershire for recording ACP conversations, the Recommended Summary for Emergency Care and Treatment (ReSPECT) plan. Clinician and patient satisfaction was high.We concluded that an ACP discussion using a 'WMTY' format was highly acceptable to most. With recognised enablers in place and known barriers minimised, valuable personalised conversations occurred. Reframing the conversation to focus on how someone wants to live, while including their priorities for death, could alter how such conversations are perceived by clinicians and the public. It could remove negative associations (such as linking these conversations with an imminent death), which may increase motivation for all to initiate discussions.ACP conversations are evidenced best practice and could become routine in general practice with adjustments to practice processes and clinician education; the Daffodil Standards facilitate continued quality improvement.
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Affiliation(s)
| | | | - Emma Husbands
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
| | - Jane Haros
- Gloucestershire Health and Care NHS FoundationTrust, Brockworth, UK
| | - Helen Ballinger
- Gloucestershire Health and Care NHS FoundationTrust, Brockworth, UK
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Serna MK, Yoon C, Fiskio J, Lakin JR, Schnipper JL, Dalal AK. The Association of Standardized Documentation of Serious Illness Conversations With Healthcare Utilization in Hospitalized Patients: A Propensity Score Matched Cohort Analysis. Am J Hosp Palliat Care 2024; 41:479-485. [PMID: 37385609 PMCID: PMC10983774 DOI: 10.1177/10499091231186818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Background: Serious Illness Conversations (SICs) conducted during hospitalization can lead to meaningful patient participation in the decision-making process affecting medical management. The aim of this study is to determine if standardized documentation of a SIC within an institutionally approved EHR module during hospitalization is associated with palliative care consultation, change in code status, hospice enrollment prior to discharge, and 90-day readmissions. Methods: We conducted retrospective analyses of hospital encounters of general medicine patients at a community teaching hospital affiliated with an academic medical center from October 2018 to August 2019. Encounters with standardized documentation of a SIC were identified and matched by propensity score to control encounters without a SIC in a ratio of 1:3. We used multivariable, paired logistic regression and Cox proportional-hazards modeling to assess key outcomes. Results: Of 6853 encounters (5143 patients), 59 (.86%) encounters (59 patients) had standardized documentation of a SIC, and 58 (.85%) were matched to 167 control encounters (167 patients). Encounters with standardized documentation of a SIC had greater odds of palliative care consultation (odds ratio [OR] 60.10, 95% confidence interval [CI] 12.45-290.08, P < .01), a documented code status change (OR 8.04, 95% CI 1.54-42.05, P = .01), and discharge with hospice services (OR 35.07, 95% CI 5.80-212.08, P < .01) compared to matched controls. There was no significant association with 90-day readmissions (adjusted hazard ratio [HR] .88, standard error [SE] .37, P = .73). Conclusions: Standardized documentation of a SIC during hospitalization is associated with palliative care consultation, change in code status, and hospice enrollment.
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Affiliation(s)
- Myrna K. Serna
- Division of General Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Catherine Yoon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Julie Fiskio
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Joshua R. Lakin
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey L. Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anuj K. Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Mertens V, Cottignie C, van de Wiel M, Vandewoude M, Perkisas S, Roelant E, Moorkens G, Hans G. Comprehensive geriatric assessment as an essential tool to register or update DNR codes in a tertiary care hospital. Eur Geriatr Med 2024; 15:295-303. [PMID: 38277096 DOI: 10.1007/s41999-023-00925-4] [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: 10/06/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024]
Abstract
PURPOSE To investigate the prevalence of Do not Resuscitate (DNR) code registration in patients with a geriatric profile admitted to Antwerp University Hospital, a tertiary care hospital in Flanders, Belgium, and the impact of comprehensive geriatric assessment (CGA) on DNR code registration. PATIENTS AND METHODS Retrospective analysis of a population of 543 geriatric patients (mean age 82.4 ± 5.19 years, 46.4% males) admitted to Antwerp University Hospital from 2018 to 2020 who underwent a CGA during admission. An association between DNR code registration status before and at hospital admission and age, gender, ethnicity, type of residence, clinical frailty score (CFS), cognitive and oncological status, hospital ward and stay on intensive care was studied. Admissions before and during the first wave of the pandemic were compared. RESULTS At the time of hospital admission, a DNR code had been registered for 66.3% (360/543) of patients. Patients with a DNR code at hospital admission were older (82.7 ± 5.5 vs. 81.7 ± 4.6 years, p = 0.031), more frail (CFS 5.11 ± 1.63 vs. 4.70 ± 1.61, p = 0.006) and less likely to be admitted to intensive care. During the hospital stay, the proportion of patients with a DNR code increased to 77% before and to 85.3% after CGA (p < 0.0001). Patients were consulted about and agreed with the registered DNR code in 55.8% and 52.1% of cases, respectively. The proportion of patients with DNR codes at the time of admission or registered after CGA did not differ significantly before and after the start of the COVID-19 pandemic. CONCLUSION After CGA, a significant increase in DNR registration was observed in hospitalized patients with a geriatric profile.
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Affiliation(s)
- Veerle Mertens
- Department of Geriatrics, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium.
| | - Charlotte Cottignie
- Department of Geriatrics, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium
| | - Mick van de Wiel
- Department of Geriatrics, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium
| | - Maurits Vandewoude
- Department of Geriatrics, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium
| | | | - Ella Roelant
- Clinical Trial Center (CTC), CRC Antwerp, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Greta Moorkens
- Department of Internal Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Guy Hans
- Multidisciplinary Pain Center, Antwerp University Hospital, Antwerp, Belgium
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Peerboom FB, Friesen-Storms JH, Coenegracht BJ, Pieters S, van der Steen JT, Janssen DJ, Meijers JM. Fundamentals of end-of-life communication as part of advance care planning from the perspective of nursing staff, older people, and family caregivers: a scoping review. BMC Nurs 2023; 22:363. [PMID: 37803343 PMCID: PMC10559445 DOI: 10.1186/s12912-023-01523-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/20/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Nursing staff is ideally positioned to play a central role in end-of-life communication as part of advance care planning for older people. However, this requires specific skills and competences. Only fragmented knowledge is available concerning important fundamentals in end-of-life communication performed by nursing staff. OBJECTIVE This review aimed to explore the fundamentals of end-of-life communication as part of advance care planning in the hospital, nursing home and home care setting, from the perspective of the nursing staff, the older person, and the family caregiver. DESIGN Scoping review. METHODS A literature search in PubMed, PsycINFO, CINAHL and Google (Scholar) was conducted on August 20, 2022. The search strategy followed the sequential steps as described in the Joanna Briggs Institute Manual. Peer-reviewed articles of empirical research and gray literature written in English or Dutch and published from 2010 containing fundamentals of end-of-life communication as part of advance care planning from the perspective of nursing staff, older people, and family caregivers in the hospital nursing home or home care setting were considered eligible for review. RESULTS Nine studies were included, and four themes were composed, reflecting 11 categories. Nursing staff attunes end-of-life communication to the values and needs of older people to approach the process in a person-centered manner. This approach requires additional fundamentals: building a relationship, assessing readiness, timing and methods to start the conversation, communication based on information needs, attention to family relationships, a professional attitude, improving communication skills, listening and non-verbal observation skills, and verbal communication skills. CONCLUSIONS This review is the first to compile an overview of the fundamentals of end-of-life communication performed by nursing staff. Building a nursing staff-older-person relationship is the most important foundation for engaging in a person-centered end-of-life communication process. Knowing each other enables nursing staff to have a sense of older people's readiness, determine the right timing to initiate an end-of-life conversation, identify specific needs, and accurately apply (non-)verbal observation skills. end-of-life communication is not a one-time conversation, but a complex process that takes time, effort, and genuine interest in each other.
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Affiliation(s)
- Fran B.A.L. Peerboom
- Zuyderland Medical Center, Dr. H. van der Hoffplein 1, Sittard-Geleen, 6162 BG The Netherlands
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Duboisdomein 30, Maastricht, 6229 GT The Netherlands
| | - Jolanda H.H.M. Friesen-Storms
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Duboisdomein 30, Maastricht, 6229 GT The Netherlands
- Research Centre for Autonomy and Participation for Persons with a Chronic Illness, Zuyd University of Applied Sciences, Nieuw Eyckholt 300, Heerlen, 6419DJ The Netherlands
- Academy for Nursing, Zuyd Health, Zuyd University of Applied Sciences, Nieuw Eyckholt 300, Heerlen, 6419DJ The Netherlands
| | | | - Sabine Pieters
- Academy for Nursing, Zuyd Health, Zuyd University of Applied Sciences, Nieuw Eyckholt 300, Heerlen, 6419DJ The Netherlands
| | - Jenny T. van der Steen
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center, Leiden, the Netherlands
- Radboudumc Alzheimer Center and Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Daisy J.A. Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Duboisdomein 30, Maastricht, 6229 GT The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
- Department of Research and Development, CIRO, Hornerheide 1, Horn, 6085 NM The Netherlands
| | - Judith M.M. Meijers
- Zuyderland Medical Center, Dr. H. van der Hoffplein 1, Sittard-Geleen, 6162 BG The Netherlands
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Duboisdomein 30, Maastricht, 6229 GT The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
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Lound A, Bruton J, Jones K, Shah N, Williams B, Gross J, Post B, Day S, Brett SJ, Ward H. "I'd rather wait and see what's around the corner": A multi-perspective qualitative study of treatment escalation planning in frailty. PLoS One 2023; 18:e0291984. [PMID: 37733669 PMCID: PMC10513333 DOI: 10.1371/journal.pone.0291984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION People living with frailty risk adverse outcomes following even minor illnesses. Admission to hospital or the intensive care unit is associated with potentially burdensome interventions and poor outcomes. Decision-making during an emergency is fraught with complexity and potential for conflict between patients, carers and clinicians. Advance care planning is a process of shared decision-making which aims to ensure patients are treated in line with their wishes. However, planning for future care is challenging and those living with frailty are rarely given the opportunity to discuss their preferences. The aim of the ProsPECT (Prospective Planning for Escalation of Care and Treatment) study was to explore perspectives on planning for treatment escalation in the context of frailty. We spoke to people living with frailty, their carers and clinicians across primary and secondary care. METHODS In-depth online or telephone interviews and online focus groups. The topic guide explored frailty, acute decision-making and planning for the future. Data were thematically analysed using the Framework Method. Preliminary findings were presented to a sample of study participants for feedback in two online workshops. RESULTS We spoke to 44 participants (9 patients, 11 carers and 24 clinicians). Four main themes were identified: frailty is absent from treatment escalation discussions, planning for an uncertain future, escalation in an acute crisis is 'the path of least resistance', and approaches to facilitating treatment escalation planning in frailty. CONCLUSION Barriers to treatment escalation planning include a lack of shared understanding of frailty and uncertainty about the future. Emergency decision-making is focussed on survival or risk aversion and patient preferences are rarely considered. To improve planning discussions, we recommend frailty training for non-specialist clinicians, multi-disciplinary support, collaborative working between patients, carers and clinicians as well as broader public engagement.
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Affiliation(s)
- Adam Lound
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Jane Bruton
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Kathryn Jones
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Nira Shah
- ProsPECT Study Public Advisor, Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Barry Williams
- ProsPECT Study Public Advisor, Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Jamie Gross
- London North West University Healthcare NHS Trust, London, United Kingdom
| | - Benjamin Post
- Department of Bioengineering and Department of Computing, Imperial College London, London, United Kingdom
- UKRI Centre in AI for Healthcare, Imperial College London, London, United Kingdom
| | - Sophie Day
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Stephen J. Brett
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Helen Ward
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
- National Institute for Health Research Imperial Biomedical Research Centre, London, United Kingdom
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Potter K, Etherton-Beer C. Using residential aged care data to understand natural deaths. J Prim Health Care 2023; 15:184-185. [PMID: 37390025 DOI: 10.1071/hc22146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/19/2023] [Indexed: 07/02/2023] Open
Affiliation(s)
- Kathleen Potter
- Ryman Healthcare, Airport Business Park, 92 Russley Road, Christchurch 8140, New Zealand
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Wang X, Huang XL, Wang WJ, Liao L. Advance care planning for frail elderly: are we missing a golden opportunity? A mixed-method systematic review and meta-analysis. BMJ Open 2023; 13:e068130. [PMID: 37247960 DOI: 10.1136/bmjopen-2022-068130] [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] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVE The aim is to integrate quantitative and qualitative evidence to understand the effectiveness and experience of advance care planning (ACP) for frail elderly. DESIGN A mixed-methods systematic review and meta-analysis was conducted. Quality evaluation was conducted using critical appraisal tools from the Joanna Briggs Institute. Data were synthesised and pooled for meta-analysis or meta-aggregation as needed. DATA SOURCES An electronic search of MEDLINE, CINAHL, Embase, PubMed, PsycINFO, and Cochrane Library databases from January 2003 to April 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included experimental and mixed-methods studies. The quantitative component attempts to incorporate a broader study design. The qualitative component aids in comprehending the participant's experience with ACP and its efficacy. DATA EXTRACTION AND SYNTHESIS Two independent reviewers undertook screening, data extraction and quality assessment. The quantitative and qualitative data were synthesised and integrated using a convergent segregated approach. RESULTS There were 12 158 articles found, and 17 matched the inclusion criteria. The quality of the quantitative component of most included studies (6/10) was rated as low, and the qualitative component of half included studies (4/8) was rated as moderate. The meta-analysis showed that the intervention of ACP for frail elderly effectively increases readiness, knowledge and process of ACP behaviours. The meta-aggregation showed that the participants hold a positive attitude towards ACP and think it facilitates expressing their preferences for the medical decision. CONCLUSION ACP is an effective and feasible strategy to facilitate frail elderly to express their healthcare wishes timely and improve their outcomes. This study could provide proof for a better understanding of the subject and help direct future clinical practice. More well-designed randomised controlled trials evaluating the most effective ACP interventions and tools are needed for the frail elderly population. PROSPERO REGISTRATION NUMBER CRD42022329615.
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Affiliation(s)
- Xinying Wang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Xin-Lin Huang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Wei-Jia Wang
- University of South China School of Nursing, Hengyang, Hunan, China
| | - Li Liao
- University of South China School of Nursing, Hengyang, Hunan, China
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Falk Erhag H, Guðnadóttir G, Alfredsson J, Cederholm T, Ekerstad N, Religa D, Nellgård B, Wilhelmson K. The Association Between the Clinical Frailty Scale and Adverse Health Outcomes in Older Adults in Acute Clinical Settings - A Systematic Review of the Literature. Clin Interv Aging 2023; 18:249-261. [PMID: 36843633 PMCID: PMC9946013 DOI: 10.2147/cia.s388160] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/14/2022] [Indexed: 02/19/2023] Open
Abstract
Background Frail older adults experience higher rates of adverse health outcomes. Therefore, assessing pre-hospital frailty early in the course of care is essential to identify the most vulnerable patients and determine their risk of deterioration. The Clinical Frailty Scale (CFS) is a frailty assessment tool that evaluates pre-hospital mobility, energy, physical activity, and function to generate a score that ranges from very fit to terminally ill. Purpose To synthesize the evidence of the association between the CFS degree and all-cause mortality, all-cause readmission, length of hospital stay, adverse discharge destination, and functional decline in patients >65 years in acute clinical settings. Design Systematic review with narrative synthesis. Methods Electronic databases (PubMed, EMBASE, CINAHL, Scopus) were searched for prospective or retrospective studies reporting a relationship between pre-hospital frailty according to the CFS and the outcomes of interest from database inception to April 2020. Results Our search yielded 756 articles, of which 29 studies were included in this review (15 were at moderate risk and 14 at low risk of bias). The included studies represented 26 cohorts from 25 countries (N = 44166) published between 2011 and 2020. All included studies showed that pre-hospital frailty according to the CFS is an independent predictor of all adverse health outcomes included in the review. Conclusion A primary purpose of the CFS is to grade clinically increased risk (i.e. risk stratification). Our results report the accumulated knowledge on the risk-predictive performance of the CFS and highlight the importance of routinely including frailty assessments, such as the CFS, to estimate biological age, improve risk assessments, and assist clinical decision-making in older adults in acute care. Further research into the potential of the CFS and whether implementing the CFS in routine practice will improve care and patients' quality of life is warranted.
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Affiliation(s)
- Hanna Falk Erhag
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,Centre for Ageing and Health (Agecap), University of Gothenburg, Gothenburg, Sweden,Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden,Correspondence: Hanna Falk Erhag, Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Wallinsgatan 6, Gothenburg, SE 431 41, Sweden, Tel +46 760 476888, Fax +46 31 786 60 77, Email
| | - Gudny Guðnadóttir
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Tommy Cederholm
- Clinical Nutrition and Metabolism Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden,Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
| | - Niklas Ekerstad
- Department of Health, Medicine, and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden,The Research and Development Unit, NU Hospital Group, Trollhättan, Sweden
| | - Dorota Religa
- Department of Neurobiology, Care Sciences, and Society, Clinical Geriatrics, Karolinska Institute, Stockholm, Sweden,Division for Clinical Geriatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Nellgård
- Department of Anesthesiology and Intensive Care, Institute of Clinical Studies, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Wilhelmson
- Centre for Ageing and Health (Agecap), University of Gothenburg, Gothenburg, Sweden,Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden,Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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11
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Canny A, Mason B, Atkins C, Patterson R, Moussa L, Boyd K. Online public information about advance care planning: An evaluation of UK and international websites. Digit Health 2023; 9:20552076231180438. [PMID: 37377564 PMCID: PMC10291539 DOI: 10.1177/20552076231180438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 05/19/2023] [Indexed: 06/29/2023] Open
Abstract
Introduction Healthcare information is increasingly internet-based. Standards require websites to be 'perceivable, operable, understandable and robust' with relevant content for citizens in appropriate language. This study examined UK and international websites offering public healthcare information on advance care planning (ACP) using current recommendations for website accessibility and content and informed by a public engagement exercise. Methods Google searches identified websites in English from health service providers, governmental or third sector organisations based in the UK and internationally. Target keywords that would be used by a member of the public informed the search terms. Data extraction used criterion-based assessment and web content analysis of the first two pages of each search result. Public patient representatives as key members of the multidisciplinary research team guided the development of the evaluation criteria. Results A total of 1158 online searches identified 89 websites, reduced to 29 by inclusion/exclusion criteria. Most sites met international recommendations for knowledge/understanding about ACP. Differences in terminology, lack of information about ACP limitations and non-adherence to recommended reading levels, accessibility standards and translation options were apparent. Sites targeting members of the public used more positive, non-technical language than those for both professional and lay users. Conclusions Some websites met accepted standards required to facilitate understanding and public engagement in ACP. Others could be improved significantly. Website providers have important roles and responsibilities in increasing people's understanding of their health conditions, future care options and ability to take an active role in planning for their health and care.
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Affiliation(s)
- Anne Canny
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Bruce Mason
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Clare Atkins
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | | | - Lorna Moussa
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Kirsty Boyd
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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12
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Qureshi SP, Jones D, Dewar A. Physicians' Conceptions of the Dying Patient: Scoping Review and Qualitative Content Analysis of the United Kingdom Medical Literature. QUALITATIVE HEALTH RESEARCH 2022; 32:1881-1896. [PMID: 35981561 PMCID: PMC9511242 DOI: 10.1177/10497323221119939] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Most people in high income countries experience dying while receiving healthcare, yet dying has no clear beginning, and contexts influence how dying is conceptualised. This study investigates how UK physicians conceptualise the dying patient. We employed Scoping Study Methodology to obtain medical literature from 2006-2021, and Qualitative Content Analysis to analyse stated and implied meanings of language used, informed by social-materialism. Our findings indicate physicians do not conceive a dichotomous distinction between dying and not dying, but construct conceptions of the dying patient in subjective ways linked to their practice. We argue that the focus of future research should be on exploring practice-based challenges in the workplace to understanding patient dying. Furthermore, pre-Covid-19 literature related dying to chronic illness, but analysis of literature published since the pandemic generated conceptions of dying from acute illness. Researchers should note the ongoing effects of Covid-19 on societal and medical awareness of dying.
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Affiliation(s)
- Shaun Peter Qureshi
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Derek Jones
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Avril Dewar
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
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13
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Pyles O, Hritz CM, Gulker P, Straveler JD, Grudzen CR, Briggs C, Southerland LT. Locating Advance Care Planning Documents in the Electronic Health Record during Emergency Care. J Pain Symptom Manage 2022; 63:e489-e494. [PMID: 34896277 PMCID: PMC9199955 DOI: 10.1016/j.jpainsymman.2021.12.002] [Citation(s) in RCA: 4] [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] [Received: 10/19/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
CONTEXT Emergency Departments (EDs) care for people at critical junctures in their illness trajectories, but Advanced Care Planning (ACP) seldom happens during ED visits. One barrier to incorporating patient goals into ED care may be locating ACP documents in the electronic health record (EHR). OBJECTIVES To determine the ease and accuracy of locating ACP documentation in the EHR during an ED visit. METHODS Academic ED with 82,000 visits per year. The EHR system includes a Storyboard with the patient's code status and a link to ACP documents. A real-time chart audit study was performed of ED patients who were either ≥65 years old or had a cancer diagnosis. Data elements included age, Emergency Severity Index, ACP document location(s) in the EHR, Storyboard accuracy, ED code status orders, and discussions of ACP or code status. RESULTS Of the 160 audited charts, 51 (32%) were for adults <65 years old with a cancer diagnosis. Code status was discussed and updated during the ED visit in 68% (n=108). ACP documents were found in 3 different EHR places. Only 30% (n=48) had ACP documents in the EHR, and of these (22%, n=13) were found in only one of the three EHR locations. The Storyboard was inaccurate for 5% (n=8). ED case managers frequently discussed APC documentation (78%, 43/55 charts). CONCLUSIONS Even under optimal conditions with social work availability, ACP documents are lacking for ED patients. Multiple potential locations of ACP documents and inaccurate linkage to the Storyboard are potentially addressable barriers to ACP conversations.
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Affiliation(s)
- Olivia Pyles
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Christopher M Hritz
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Peg Gulker
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Jansi D Straveler
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Corita R Grudzen
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Cole Briggs
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Lauren T Southerland
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA.
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14
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Johansson T, Tishelman C, Eriksson LE, Cohen J, Goliath I. Use, usability, and impact of a card-based conversation tool to support communication about end-of-life preferences in residential elder care – a qualitative study of staff experiences. BMC Geriatr 2022; 22:274. [PMID: 35366816 PMCID: PMC8976536 DOI: 10.1186/s12877-022-02915-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 03/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Proactive conversations about individual preferences between residents, relatives, and staff can support person-centred, value-concordant end-of-life (EOL) care. Nevertheless, prevalence of such conversations is still low in residential care homes (RCHs), often relating to staff’s perceived lack of skills and confidence. Using tools may help staff to facilitate EOL conversations. While many EOL-specific tools are script-based and focus on identifying and documenting treatment priorities, the DöBra card tool is developed to stimulate reflection and conversation about EOL care values and preferences. In this study, we explore staff’s experiences of use, usability, and perceived impact of the DöBra cards in supporting discussion about EOL care in RCH settings.
Methods
This qualitative study was based on data from two participatory action research processes in which RCH staff tested and evaluated use of DöBra cards in EOL conversations. Data comprise 6 interviews and 8 group meetings with a total of 13 participants from 7 facilities. Qualitative content analysis was performed to identify key concepts in relation to use, usability, and impact of the DöBra cards in RCH practice.
Results
Based on participants’ experiences of using the DöBra cards as an EOL conversation tool in RCHs, we identified three main categories in relation to its usefulness. Outcomes of using the cards (1) included the outlining of content of conversations and supporting connection and development of rapport. Perceived impact (2) related to enabling openings for future communication and aligning care goals between stakeholders. Use and usability of the cards (3) were influenced by supporting and limiting factors on the personal and contextual level.
Conclusions
This study demonstrates how the DöBra cards was found to be useful by staff for facilitating conversations about EOL values, influencing both the content of discussion and interactions between those present. The tool encouraged reflection and interaction, which staff perceived as potentially helpful in building preparedness for future care-decision making. The combination of providing a shared framework and being adaptable in use appeared to be key features for the DöBra cards usability in the RCH setting.
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15
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Mason B, Carduff E, Laidlaw S, Kendall M, Murray SA, Finucane A, Moine S, Kerssens J, Stoddart A, Tucker S, Haraldsdottir E, Ritchie SL, Fallon M, Keen J, Macpherson S, Moussa L, Boyd K. Integrating lived experiences of out-of-hours health services for people with palliative and end-of-life care needs with national datasets for people dying in Scotland in 2016: A mixed methods, multi-stage design. Palliat Med 2022; 36:478-488. [PMID: 35354412 PMCID: PMC8972951 DOI: 10.1177/02692163211066256] [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: 11/15/2022]
Abstract
BACKGROUND Unscheduled care is used increasingly during the last year of life by people known to have significant palliative care needs. AIM To document the frequency and patterns of use of unscheduled healthcare by people in their last year of life and understand the experiences and perspectives of patients, families and professionals about accessing unscheduled care out-of-hours. DESIGN A mixed methods, multi-stage study integrating a retrospective cohort analysis of unscheduled healthcare service use in the last year of life for all people dying in Scotland in 2016 with qualitative data from three regions involving service users, bereaved carers and general practitioners. SETTING Three contrasting Scottish Health Board regions and national datasets for the whole of Scotland. RESULTS People who died in Scotland in 2016 (n = 56,407) had 472,360 unscheduled contacts with one of five services: telephone advice, primary care, ambulance service, emergency department and emergency hospital admission. These formed 206,841 individual continuous unscheduled care pathways: 65% starting out-of-hours. When accessing healthcare out-of-hours, patients and carers prioritised safety and a timely response. Their choice of which service to contact was informed by perceptions and previous experiences of potential delays and whether the outcome might be hospital admission. Professionals found it difficult to practice palliative care in a crisis unless the patient had previously been identified. CONCLUSION Strengthening unscheduled care in the community, together with patient and public information about how to access these services could prevent hospital admissions of low benefit and enhance community support for people living with advanced illness.
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Affiliation(s)
- Bruce Mason
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Bruce Mason, CPHS, University of Edinburgh, Doorway 3, Teviot Place, Edinburgh, EH8 9AG, UK.
| | | | | | - Marilyn Kendall
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Scott A Murray
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Anne Finucane
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Clinical Psychology, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
| | - Sebastien Moine
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Joannes Kerssens
- Electronic Data Research & Innovation Service (eDRIS), Public Health Scotland, Edinburgh, UK
| | - Andrew Stoddart
- Edinburgh Clinical Trials Unit, The University of Edinburgh, Edinburgh, UK
| | | | | | | | | | | | - Stella Macpherson
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Kirsty Boyd
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
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16
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Hall A, Boulton E, Kunonga P, Spiers G, Beyer F, Bower P, Craig D, Todd C, Hanratty B. Identifying older adults with frailty approaching end-of-life: A systematic review. Palliat Med 2021; 35:1832-1843. [PMID: 34519246 PMCID: PMC8637378 DOI: 10.1177/02692163211045917] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND People with frailty may have specific needs for end-of-life care, but there is no consensus on how to identify these people in a timely way, or whether they will benefit from intervention. AIM To synthesise evidence on identification of older people with frailty approaching end-of-life, and whether associated intervention improves outcomes. DESIGN Systematic review (PROSPERO: CRD42020462624). DATA SOURCES Six databases were searched, with no date restrictions, for articles reporting prognostic or intervention studies. Key inclusion criteria were adults aged 65 and over, identified as frail via an established measure. End-of-life was defined as the final 12 months. Key exclusion criteria were proxy definitions of frailty, or studies involving people with cancer, even if also frail. RESULTS Three articles met the inclusion criteria. Strongest evidence came from one study in English primary care, which showed distinct trajectories in electronic Frailty Index scores in the last 12 months of life, associated with increased risk of death. We found no studies evaluating established clinical tools (e.g. Gold Standards Framework) with existing frail populations. We found no intervention studies; the literature on advance care planning with people with frailty has relied on proxy definitions of frailty. CONCLUSION Clear implications for policy and practice are hindered by the lack of studies using an established approach to assessing frailty. Future end-of-life research needs to use explicit approaches to the measurement and reporting of frailty, and address the evidence gap on interventions. A focus on models of care that incorporate a palliative approach is essential.
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Affiliation(s)
- Alex Hall
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Elisabeth Boulton
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Patience Kunonga
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Gemma Spiers
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Fiona Beyer
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Peter Bower
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Dawn Craig
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Chris Todd
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Barbara Hanratty
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
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17
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Kinley J, Flemming K. Understanding what is important to older people living with frailty in relation to advance care planning. Int J Palliat Nurs 2021; 27:471-480. [PMID: 34846935 DOI: 10.12968/ijpn.2021.27.9.471] [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: 11/11/2022]
Abstract
BACKGROUND Advance care planning (ACP) provides opportunities for people to make decisions about future care. Internationally, the approach to this varies. Older people living with frailty could considerably benefit from discussing and undertaking advance care planning. However, this has not traditionally been a particular focus of their care. AIM To provide recommendations to support nurses and health professionals to undertake ACP conversations with older people living with frailty through a review of contemporary literature. METHODS The following electronic databases were searched: CINAHL, British Nursing Index and the Cochrane Library. Information about the process and outcome of undertaking an ACP conversation with older people living with frailty was extracted and categorised in relation to care setting. FINDINGS A total of 69 papers were identified, of which eight met the inclusion criteria. The importance of preparation before starting an ACP conversation was highlighted, as well as key considerations when undertaking such a conversation. From these papers five clinical recommendations, one policy recommendation and two research recommendations are made. CONCLUSIONS Maintaining and improving wellness is important to older people living with frailty. In order that conversations about ACP are acceptable and meaningful to older people living with frailty, they should include: the opportunity to discuss both 'current' and 'future' care; be focused on their goals of care; and, to be offered routinely to the older person.
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Affiliation(s)
- Julie Kinley
- Research and Clinical Innovation Project Lead, Hospice UK
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18
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Braude P, Carter B, Parry F, Ibitoye S, Rickard F, Walton B, Short R, Thompson J, Shipway D. Predicting 1 year mortality after traumatic injury using the Clinical Frailty Scale. J Am Geriatr Soc 2021; 70:158-167. [PMID: 34624144 DOI: 10.1111/jgs.17472] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/16/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Frailty is known to affect how people admitted with traumatic injuries recover during their inpatient stay and shortly after discharge. However, few studies have examined the effect of frailty on long-term mortality when adjusted for significant factors including age. We aimed to determine the effect of frailty on 1-year morality in older adults admitted with traumatic injuries. METHODS We undertook an observational study at the Severn Major Trauma Network's major trauma centre based in South West England. Patients ≥65 years old admitted between November 2018 and September 2019 with traumatic injuries were included. Isolated hip fractures and inpatient injuries were excluded. A geriatrician assessed all patients for frailty using the Clinical Frailty Scale. Follow-up occurred at 1 year. A multivariable Cox proportional baseline hazards model assessed the effect of frailty on time-to-mortality. The adjusted model included age, sex, multimorbidity, surgery, most injured site, injury severity, postinjury complications, and geriatrician review. RESULTS Five hundred and eighty-five patients were included. Median age was 81 years old (IQR 74-88), and median injury severity score was 13 (IQR 9-25). At 1 year 147 (25.1%) patients had died. Living with frailty was associated with mortality. The risk of dying increased with frailty severity. Compared to CFS 1-3: CFS 4 aHR = 1.73 (95% CI 0.89-3.36, p = 0.11); CFS 5 aHR = 3.82 (95% CI 2.11-6.93, p < 0.001); CFS 6 aHR = 4·05 (95% CI 2.21-7.45, p < 0.001); CFS 7-8 aHR = 6.57 (95% CI 3.43-12.59, p < 0.001). CONCLUSION This study is the first to demonstrate a consistent effect of frailty, at all levels of severity and independent of age, on older peoples' survival 1 year after traumatic injury. These data support performing an admission frailty assessment to aid long-term management decisions and provide opportunity to modify frailty to improve outcomes.
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Affiliation(s)
- Philip Braude
- North Bristol NHS Trust, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | | | | | | | - Roxanna Short
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - David Shipway
- North Bristol NHS Trust, Bristol, UK.,Population Health Sciences, University of Bristol, Bristol, UK
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19
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Deschasse G, Bloch F, Drumez E, Charpentier A, Visade F, Delecluse C, Loggia G, Lescure P, Attier-Żmudka J, Bloch J, Gaxatte C, Van Den Berghe W, Puisieux F, Beuscart JB. Development of a predictive score for mortality at 3- and 12-month after discharge from an acute geriatric unit as a trigger for advanced care planning. J Gerontol A Biol Sci Med Sci 2021; 77:1665-1672. [PMID: 34375411 DOI: 10.1093/gerona/glab217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is a need for a mortality score that can be used to trigger advanced care planning among older patients discharged from acute geriatric units (AGUs). OBJECTIVE To develop a prognostic score for 3- and 12-month mortality after discharge from an AGU, based on a comprehensive geriatric assessment, in-hospital events, and the exclusion of patients already receiving palliative care. METHODS DAMAGE is a French multicentre, prospective, cohort study. The broad inclusion criteria ensured that the cohort is representative of patients treated in an AGU. The DAMAGE participants underwent a comprehensive geriatric assessment, a daily clinical check-up, and follow-up visits 3 and 12 months after discharge. Multivariable logistic regression models were used to develop a prognostic score for the derivation and validation subsets. RESULTS 3509 patients were assessed and 3112 were included. The patient population was very older and frail or dependant, with a high proportion of deaths at 3 months (n=455, 14.8%) and at 12 months (n=1014, 33%). The score predicted an individual risk of mortality ranging from 1% to 80% at 3 months and between 5% and 93% at 12 months, with an area under the receiving operator characteristic curve in the validation cohort of 0.728 at 3 months and 0.733 at 12 months. CONCLUSIONS Our score predicted a broad range of risks of death after discharge from the AGU. Having this information at the time of hospital discharge might trigger a discussion on advanced care planning and end-of-life care with very old, frail patients.
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Affiliation(s)
- Guillaume Deschasse
- CHU Amiens-Picardie, Department of Geriatrics, Amiens, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | - Frédéric Bloch
- CHU Amiens-Picardie, Department of Geriatrics, Amiens, France
| | - Elodie Drumez
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,CHU Lille, Department of Biostatistics, Lille, France
| | | | - Fabien Visade
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,Lille Catholic Hospitals, Geriatrics Department, Lille, France
| | | | - Gilles Loggia
- Normandie Univ, UNICAEN, INSERM, COMETE, Caen, France.,Department of Geriatrics, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Pascale Lescure
- Department of Geriatrics, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Jadwiga Attier-Żmudka
- Geriatric department, General Hospital of Saint-Quentin, Saint-Quentin, France.,CHIMERE EA 7516 team research, Jules Verne University, Amiens, France
| | | | | | | | | | - Jean-Baptiste Beuscart
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,CHU Lille, Department of Geriatrics, Lille, France
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20
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Lagrotteria A, Swinton M, Simon J, King S, Boryski G, Ma IWY, Dunne F, Singh J, Bernacki RE, You JJ. Clinicians' Perspectives After Implementation of the Serious Illness Care Program: A Qualitative Study. JAMA Netw Open 2021; 4:e2121517. [PMID: 34406399 PMCID: PMC8374609 DOI: 10.1001/jamanetworkopen.2021.21517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Discussions about goals of care with patients who are seriously ill typically occur infrequently and late in the illness trajectory, are of low quality, and focus narrowly on the patient's resuscitation preferences (ie, code status), risking provision of care that is inconsistent with patients' values. The Serious Illness Care Program (SICP) is a multifaceted communication intervention that builds capacity for clinicians to have earlier, more frequent, and more person-centered conversations. OBJECTIVE To explore clinicians' experiences with the SICP 1 year after implementation. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted at 2 tertiary care hospitals in Canada. The SICP was implemented at Hamilton General Hospital (Hamilton, Ontario) from March 1, 2017, to January 19, 2018, and at Foothills Medical Centre (Calgary, Alberta) from March 1, 2018, to December 31, 2020. A total of 45 clinicians were invited to participate in the study, and 23 clinicians (51.1%) were enrolled and interviewed. Semistructured interviews of clinicians were conducted between August 2018 and May 2019. Content analysis was used to evaluate information obtained from these interviews between May 2019 and May 2020. EXPOSURES The SICP includes clinician training, communication tools, and processes for system change. MAIN OUTCOMES AND MEASURES Clinicians' experiences with and perceptions of the SICP. RESULTS Among 23 clinicians interviewed, 15 (65.2%) were women. The mean (SD) number of years in practice was 14.6 (9.1) at the Hamilton site and 12.0 (6.9) at the Calgary site. Participants included 19 general internists, 3 nurse practitioners, and 1 social worker. The 3 main themes were the ways in which the SICP (1) supported changes in clinician behavior, (2) shifted the focus of goals-of-care conversations beyond discussion of code status, and (3) influenced clinicians personally and professionally. Changes in clinician behavior were supported by having a unit champion, interprofessional engagement, access to copies of the Serious Illness Conversation Guide, and documentation in the electronic medical record. Elements of the program, especially the Serious Illness Conversation Guide, shifted the focus of goals-of-care conversations beyond discussion of code status and influenced clinicians on personal and professional levels. Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity. CONCLUSIONS AND RELEVANCE In this qualitative study, hospital clinicians described components of the SICP as supporting changes in their behavior and facilitating meaningful patient interactions that shifted the focus of goals-of-care conversations beyond discussion of code status. The perceived benefits of SICP implementation stimulated uptake within the medical units. These findings suggest that the SICP may prompt hospital culture changes in goals-of-care dialogue with patients and the care of hospitalized patients with serious illness.
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Affiliation(s)
- Andrew Lagrotteria
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marilyn Swinton
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Simon
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Seema King
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Irene Wai Yan Ma
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Dunne
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Japteg Singh
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Rachelle E. Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - John J. You
- Division of General Internal and Hospitalist Medicine, Department of Medicine, Trillium Health Partners, Credit Valley Hospital, Mississauga, Ontario, Canada
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21
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Lei L, Gan Q, Gu C, Tan J, Luo Y. Life-and-Death Attitude and Its Formation Process and End-of-Life Care Expectations Among the Elderly Under Traditional Chinese Culture: A Qualitative Study. J Transcult Nurs 2021; 33:57-64. [PMID: 34120528 PMCID: PMC8671652 DOI: 10.1177/10436596211021490] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction With the global aging process intensified, the demand for end-of-life care has surged, especially in China. However, its development is restricted. Understanding the life and death attitude among the elderly and its formation process, and clarifying their needs, are so important to promote social popularization of end-of-life care. Methodology This qualitative study included 20 elderly residents in Nan and Shuangbei Communities, Chongqing City, People’s Republic of China. Data were collected through semistructured in-depth individual interviews and processed by thematic analysis method. Results Three themes and eight subthemes were identified: Characteristics of formation process (passive thinking, closed and single), life-and-death attitude (cherish and enjoy life, quality of life priority, let death take its course) and expectations of end-of-life care (preferences, basic needs, good death). Discussion Life-and-death attitude and end-of-life care expectations of the elderly support the development and delivery of end-of-life care. Furthermore, the individual-family-hospital linkage discussion channel needs to be further explored.
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Affiliation(s)
- Lei Lei
- Army Medical University (Third Military Medical University), Chongqing, People's Republic of China
| | - Quanxi Gan
- Southwest University Hospital, Chongqing, People's Republic of China
| | - Chunyan Gu
- Shuangbei Community Health Service Center, Chongqing, People's Republic of China
| | - Jing Tan
- Army Medical University (Third Military Medical University), Chongqing, People's Republic of China
| | - Yu Luo
- Army Medical University (Third Military Medical University), Chongqing, People's Republic of China
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22
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Combes S, Gillett K, Norton C, Nicholson CJ. The importance of living well now and relationships: A qualitative study of the barriers and enablers to engaging frail elders with advance care planning. Palliat Med 2021; 35:1137-1147. [PMID: 33934669 PMCID: PMC8189003 DOI: 10.1177/02692163211013260] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The population of frail elders is growing, and due to their vulnerability to sudden deterioration, advance care planning is particularly important. However, advance care planning is uncommon for multiple reasons, some of which are linked to the perceptions of frail elders and their families. AIM To explore the barriers and enablers to advance care planning engagement with frail elders. DESIGN Qualitative in-depth interviews with thematic analysis. SETTING/PARTICIPANTS Purposive sample of 10 frail elders and 8 nominated family members using a community-based older persons' service run by a large urban UK hospice. Frail elders had capacity, were ⩾65 (median 85, range 71-95), scored 6 or 7 (median 6.5) on the Clinical Frailty Scale, and 70% were female. RESULTS Key barriers were: Advance care planning is unclear, in terms of meaning and the language used; Lack of relevance, with frail elders preferring to focus on living well now; and the Importance of family, relationships and home, and the influence of relationship on end of life decision-making. Engagement strategies included preparing the frail elder for advance care planning conversations and using a gentle, honest, individualised approach. CONCLUSIONS Essential enablers for frail elders are understanding what advance care planning is and why it may be relevant to them. For professionals, enablers include recognising the importance of living well now and relational decision-making. To further support advance care planning, recommendations include early engagement and re-conceptualising advance care planning as an ongoing process which encompasses current and future care. Further research is needed in different cultures and care contexts.
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Affiliation(s)
- Sarah Combes
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,St Christopher's Hospice, London, UK
| | - Karen Gillett
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Caroline Jane Nicholson
- St Christopher's Hospice, London, UK.,Faculty of Health and Medical Sciences, Surrey University, Guildford, UK
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23
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Moon F, Mooney C, McDermott F, Miller A, Poon P. Bereaved families' experiences of end-of-life decision making for general medicine patients. BMJ Support Palliat Care 2021:bmjspcare-2020-002743. [PMID: 33722814 DOI: 10.1136/bmjspcare-2020-002743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Family involvement in decision making for hospitalised patients is associated with improved end-of-life care. Yet, these discussions can be challenging for physicians and families and associated with distress, confusion and conflict. There is a need to understand how best to support families involved in decisions regarding the transition from active to palliative treatment in hospital settings. AIM To explore bereaved families' experiences of end-of-life decision making for general medicine patients. DESIGN A qualitative exploratory study framed by social constructionism using semistructured interviews and thematic analysis. SETTING AND PARTICIPANTS The general medicine units of one large public hospital in Melbourne, Australia. We recruited 28 bereaved family members of patients who had received end-of-life care. FINDINGS Patients and families depended on physicians to explain clinical complexity and treatment beneficence; however, trust in medical judgement was mediated by participant's own interpretations of clinical progress. Families sought to be respected as advocates and experienced distress if physicians disregarded their perspectives and insight concerning patient preferences. Ideally, families supported patients to express their preferences to physicians. Otherwise, families contextualised treatment decisions through their knowledge of patient's values and quality of life. Families often felt burdened by or excluded from medical decision making and experienced distress and confusion regarding their rights to request or refuse treatment. CONCLUSION Our study highlights how families contribute to decision making to ensure end-of-life care treatments reflect patient preferences. Physicians can ease families' distress around treatment withdrawal by providing a meaningful explanation of complex clinical issues, clarifying decision-making roles and acknowledge families' desire to protect and advocate for their loved one.
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Affiliation(s)
- Felicity Moon
- Department of Social Work, Monash Health, Clayton, Victoria, Australia
- Department of Social Work, Monash University, Caulfield East, Victoria, Australia
| | - Christine Mooney
- Department of Supportive & Palliative Care, Monash Health, Clayton, Victoria, Australia
| | - Fiona McDermott
- Department of Social Work, Monash University, Caulfield East, Victoria, Australia
| | - Alistair Miller
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Peter Poon
- Department of Supportive & Palliative Care, Monash Health, Clayton, Victoria, Australia
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24
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Bryant J, Hobden B, Waller A, Clapham M, Sanson-Fisher R. Participation in future planning by community-dwelling older Australians receiving aged care services: Findings from a cross-sectional survey. Australas J Ageing 2021; 40:373-380. [PMID: 33719124 DOI: 10.1111/ajag.12927] [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: 08/30/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine in a sample of older community-dwelling adults: (1) the proportion who have engaged in medical and financial planning; (2) the factors associated with advance care directive (ACD) completion and substitute decision maker (SDM) appointment; and (3) for those without an ACD, what might prompt completion. METHODS A cross-sectional survey was undertaken with individuals receiving community aged care services in metropolitan and regional communities. Data collection was conducted by case managers during a home visit. RESULTS Overall, 158 individuals (M = 78 years, SD = 8.7) participated (53.5% consent rate). Financial planning participation (will = 85%; enduring power of attorney = 66%) was higher than medical planning participation (SDM: 54%; ACD: 30%). No health status factors were significantly associated with ACD completion or SDM appointment. Diagnosis of a life-limiting illness was most likely to prompt ACD completion (77.6%). CONCLUSIONS One third of older people residing in the community have completed an ACD. Strategies to improve uptake in this vulnerable population require further exploration.
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Affiliation(s)
- Jamie Bryant
- Health Behaviour Research Collaborative, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Breanne Hobden
- Health Behaviour Research Collaborative, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Amy Waller
- Health Behaviour Research Collaborative, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Matthew Clapham
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Robert Sanson-Fisher
- Health Behaviour Research Collaborative, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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25
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Yildirim H, Işik K. Psychometric evaluation of the Hospitalisation-Related Stressors Questionnaire for Elderly Patients. Psychogeriatrics 2021; 21:166-174. [PMID: 33354854 DOI: 10.1111/psyg.12651] [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: 10/08/2020] [Revised: 11/26/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Stress can threaten the health and recovery of patients, and determining the level of stress can be an important factor in curing illnesses. The aim was to adapt the Hospitalisation-Related Stressors Questionnaire for Elderly Patients (HRSQ-EP) and perform its psychometric evaluation. METHODS In the study, the method of developing a scale and determining the construct validity and reliability of this scale was used. The research was carried out with elderly patients who were hospitalised. The research was conducted in two main phases; in the first phase, after providing expert opinion for the language validity of the scale, the content and face validity were confirmed and then confirmatory and exploratory factor analyses were applied for content validity and reliability in the second phase. RESULTS The new scale, which was formed as a result of evaluating the construct validity, consisted of three factors and 15 items, and all factors explained 67.1% of the total variance. Kaiser-Meyer-Olkin, which determined the suitability of the measurement tool for factor analysis, was determined as 0.901 and Bartlett test 0.000. The adapted short form is a simple and easy-to-understand tool for determining the stress levels of hospitalised elderly individuals. HRSQ-EP provided evidence that it demonstrates adequate internal consistency, reliability and construct validity. CONCLUSION The results suggested that the adapted measurement tool will be useful. The scale is recommended to be evaluated in different populations to determine cultural differences.
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Affiliation(s)
- Hilal Yildirim
- Department of Puplic Health Nursing, Faculty of Nursing, Inonu University, Malatya, Turkey
| | - Kevser Işik
- Department of Public Health Nursing, Faculty of Health Sciences, Kahramanmaraş Sütçü İmam University, Kahramanmaraş, Turkey
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26
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Ahmed N, Ahmedzai SH, Harwood RH. The geriatrician's role in end-of-life care. Age Ageing 2021; 50:366-369. [PMID: 33301023 DOI: 10.1093/ageing/afaa266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Indexed: 11/14/2022] Open
Abstract
Healthcare aims to help older people to live well, but ultimately must also support them to die well. Most people die in old age, but predicting death in both short- and long-term is impossible for many, although not all, older people. Frail older people live with hope and pride in coping, and often anticipate recovery when ill. Key objectives of healthcare for older people are to maintain independence, minimise suffering and preserve dignity, which requires active medical, mental health and rehabilitation management, even when extending life is not the main goal. Thorough medical diagnosis and appropriate treatment and rehabilitation minimise disability, physical and mental distress and problems resulting from acute illness and crises. In these terms, 'health gain' can be achieved from medical intervention, even when life expectancy is short. Assumptions derived from cancer care about lack of reversibility with medical interventions are sometimes unwarranted. This has to be balanced against investigation- and treatment-burden, including that associated with hospital admission and the adverse effects of drugs and therapy interventions, and the need to respect the identity and autonomy of individuals. The resolution of these tensions requires anticipation of care options, multi-professional assessment, judicious and targeted treatment, good communication with patients and stakeholders and rigorous shared decision-making. In this commentary, we compare geriatric and palliative medicine, and describe how the geriatric medical approach can deliver appropriate healthcare towards the end of life. This is well supported by the broad knowledge, skill-set, flexibility and professional values displayed by geriatricians working in multi-professional teams.
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Affiliation(s)
- Nisar Ahmed
- School of Health Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2HA, UK
| | - Sam H Ahmedzai
- Medical School, University of Sheffield, Western Bank, Sheffield S10 2TN, UK
| | - Rowan H Harwood
- School of Health Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2HA, UK
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27
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Bryant J, Sellars M, Sinclair C, Detering K, Buck K, Waller A, White B, Nolte L. Inadequate completion of advance care directives by individuals with dementia: national audit of health and aged care facilities. BMJ Support Palliat Care 2021; 12:bmjspcare-2020-002767. [PMID: 33397661 PMCID: PMC9380476 DOI: 10.1136/bmjspcare-2020-002767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES (i) Describe the prevalence and type of advance care directives (ACDs) and other advance care planning (ACP) documentation completed by persons with dementia, healthcare providers and others on behalf of a person with dementia; (ii) identify the personal and ACP programme characteristics associated with having ACP documentation in the health record; (iii) identify the personal and ACP programme characteristics associated with having a self-completed ACD. METHODS A multicentre audit was undertaken in Australian hospitals, general practices and residential aged care facilities. Auditors extracted demographic and ACP data from the records of eligible patients. ACP programme characteristics were provided by a site representative. Logistic and multinomial regression were used respectively to examine the factors associated with completion of any ACP documentation, and self-completion of an ACD by persons with dementia. RESULTS A total of 1388 people with dementia (33.2%) from 96 sites were included. Overall, 60.8% (n=844) had ACP documentation; 31.6% (n=438) had a self-completed ACD and 29.3% (n=406) had an ACP document completed by a health professional or someone else on their behalf. Older participants were more likely to have ACP documented. Multivariate analyses indicated the odds of having self-completed ACP documents, compared with no advance care plan or ACP completed by someone else, were significantly influenced by age, country of birth, setting and whether the site had ACP training, policies or guidelines. DISCUSSION While 60% of people with dementia had some form of ACP documentation, only half of the cases in which ACP was documented included an ACD completed by the person themselves.
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Affiliation(s)
- Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Marcus Sellars
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Craig Sinclair
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney, New South Wales, Australia
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
| | - Karen Detering
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Kimberly Buck
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Ben White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
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28
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Frechman E, Dietrich MS, Walden RL, Maxwell CA. Exploring the Uptake of Advance Care Planning in Older Adults: An Integrative Review. J Pain Symptom Manage 2020; 60:1208-1222.e59. [PMID: 32645455 PMCID: PMC7342022 DOI: 10.1016/j.jpainsymman.2020.06.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Advance care planning (ACP) is essential to elicit goals, values, and preferences of care in older adults with serious illness and on trajectories of frailty. An exploration of ACP uptake in older adults may identify barriers and facilitators. OBJECTIVE To conduct an integrative review of research on the uptake of ACP in older adults and create a conceptual model of the findings. METHODS Using Whittemore and Knafl's methodology, we systematically searched four electronic databases of ACP literature in older adults from 1996 through December 2019. Critical appraisal tools were used to assess study quality, and articles were categorized according to level of evidence. Statistical and thematic analysis was then undertaken. RESULTS Among 1081 studies, 78 met inclusion criteria. Statistical analysis evaluated ACP and variables within the domains of demographics, psychosocial, disability and functioning, and miscellaneous. Thematic analysis identified a central category of enhanced communication, followed by categories of 1) provider role and preparation; 2) patient/family relationship patterns; 3) standardized processes and structured approaches; 4) contextual influences; and 5) missed opportunities. A conceptual model depicted categories and relationships. CONCLUSIONS Enhanced communication and ACP facilitators improve uptake of ACP. Clinicians should be cognizant of these factors. This review provides a guide for clinicians who are considering implementation strategies to facilitate ACP in real-world settings.
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Affiliation(s)
- Erica Frechman
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA.
| | - Mary S Dietrich
- Vanderbilt University Schools of Medicine and Nursing, Nashville, Tennessee, USA
| | - Rachel Lane Walden
- Vanderbilt University Eskind Biomedical Library, Nashville, Tennessee, USA
| | - Cathy A Maxwell
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA
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29
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Stolz-Baskett P, Taylor C, Glaus A, Ream E. Supporting older adults with chemotherapy treatment: A mixed methods exploration of cancer caregivers' experiences and outcomes. Eur J Oncol Nurs 2020; 50:101877. [PMID: 33248360 DOI: 10.1016/j.ejon.2020.101877] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 08/16/2020] [Accepted: 11/12/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE Due to delivery of chemotherapy being mostly in ambulatory care settings, support of people with cancer relies heavily on caregivers (e.g. relatives). Whilst cancer caregiver research has been flourishing, there has been little focus on the specific experiences of caregivers of older people (>70yrs) with cancer, and little considerations of cultural influences on their experiences. This study explored caregiver experiences and outcomes in the geriatric oncology context in Switzerland. METHODS Sequential mixed-methods design, comprising a) cross-sectional survey (n = 86/RR52%; age range 37-85) and b) interviews (n = 19) to explore experiences of caregivers of older people (mean age in yrs 74.6 (sd 4.3) with cancer, and factors related to caregivers' psychological morbidity and health related quality of life (HrQoL). RESULTS Caregivers reported a median of three moderate/high unmet needs (range 0-41) and 44% reported clinically significant psychological morbidity. Demographics (caregiver age, gender, and marital status), caregiving tasks (physical, psycho-emotional, social and/or treatment related care), unmet needs and caregiver burden collectively explained between 20 and 57% of variance in caregiver psychological morbidity and HRQoL. Two main themes emerged from interviews: "Being a caregiver and doing caregiving" and "Living through the situation." These indicated that caregiver roles are multiple and fluid, and identified responsibilities not previously reported outside of palliative care settings, such as thinking about and planning for death and dying. CONCLUSIONS Caregiving for an older person with cancer can have detrimental impacts on caregivers' wellbeing and quality of life. Consideration needs to be given to the particular needs of caregivers in geriatric oncology settings. Their support needs appear different to those of their counterparts caring for younger people with cancer, notably related to spiritual needs; this may in part relate to possible differences arising from caregivers themselves being older.
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Affiliation(s)
- Petra Stolz-Baskett
- Zürich University of Applied Sciences (ZHAW), Institute of Nursing, Winterthur - CHPresent Address: Nelson Marlborough Health, Nelson Hospital PO Box Nelson, 7048, New Zealand.
| | - Cath Taylor
- School of Health Sciences, University of Surrey, Guilford, UK.
| | - Agnes Glaus
- Tumour & Breast Centre ZeTuP, St. Gallen, Switzerland
| | - Emma Ream
- School of Health Sciences, University of Surrey, Guilford, UK.
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30
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Willis D, George R. Are advance care plans of any value? BMJ Support Palliat Care 2020; 11:3. [PMID: 32826267 DOI: 10.1136/bmjspcare-2020-002612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 07/31/2020] [Indexed: 11/04/2022]
Affiliation(s)
| | - Rob George
- Medicine, King's College London, London, UK
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31
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Hopkins SA, Lovick R, Polak L, Bowers B, Morgan T, Kelly MP, Barclay S. Reassessing advance care planning in the light of covid-19. BMJ 2020; 369:m1927. [PMID: 32423988 DOI: 10.1136/bmj.m1927] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Sarah A Hopkins
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Roberta Lovick
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Louisa Polak
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Ben Bowers
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Tessa Morgan
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Michael P Kelly
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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