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Cagle JG, Reiff JS, Smith A, Echavarria D, Scerpella D, Zhang T, Roth DL, Hanna V, Boyd CM, Hussain NA, Wolff JL. Assessing Advance Care Planning Fidelity within the Context of Cognitive Impairment: The SHARE Trial. J Pain Symptom Manage 2024; 68:180-189. [PMID: 38754769 PMCID: PMC11334724 DOI: 10.1016/j.jpainsymman.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/01/2024] [Accepted: 05/07/2024] [Indexed: 05/18/2024]
Abstract
CONTEXT Advance care planning (ACP) is critical among primary care patients with cognitive impairment, but few interventions have tested ACP with this population. OBJECTIVE Describe the development and evaluation of a tool for assessing ACP fidelity within the context of cognitive impairment, including inter-rater reliability, convergent validity, and overall fidelity using clinical trial data. DESIGN SHARE is a multicomponent intervention inclusive of facilitated ACP conversations. From a two group, single blind, randomized controlled trial, recorded ACP conversations were rated for fidelity. 145 primary care patients and their care partners were randomized to receive the intervention. Participating patients were 80+ years, had a care partner, and indications of cognitive impairment. An ACP Fidelity Checklist was developed with three subscales: Meeting Set-Up; ACP Meeting Topics; and Communication Skills. Scores were converted to percentages (100% = perfect fidelity) with a target of ≥80% fidelity. A post-ACP meeting report completed by ACP facilitators was used to assess convergent validity of the checklist. Intra-class correlation (ICC) was to evaluate inter-rater reliability. RESULTS ACP conversations averaged 33.6 minutes (SD = 14.1). The mean fidelity score across N = 91 rated meetings was 82.9%, with a range of 77.3%-90.6% for subscales. 63.7% of meetings achieved a rating of ≥80%. Cognitive function was positively associated with patient participation (rho = .59, P < 0.001). For checklist items, ICC scores ranged from 0.43-0.96. Post-ACP meeting form scores were correlated with the checklist Meeting Topics subscale (r = 0.36, P = 0.001). CONCLUSIONS Assessing the fidelity of ACP conversations involving primary care patients living with cognitive impairment and their care partners is feasible.
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Affiliation(s)
- John G Cagle
- School of Social Work (J.G.C.), University of Maryland, Baltimore, Maryland, USA.
| | - Jenni S Reiff
- Department of Health Policy and Management (J.S.R., D.E., D.S., V.H., J.L.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ambrym Smith
- MedStar Union Memorial Hospital (A.S.), Baltimore, Maryland, USA
| | - Diane Echavarria
- Department of Health Policy and Management (J.S.R., D.E., D.S., V.H., J.L.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Danny Scerpella
- Department of Health Policy and Management (J.S.R., D.E., D.S., V.H., J.L.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Talan Zhang
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology (T.Z., D.L.R.), Johns Hopkins University, Baltimore, Maryland, USA
| | - David L Roth
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology (T.Z., D.L.R.), Johns Hopkins University, Baltimore, Maryland, USA
| | - Valecia Hanna
- Department of Health Policy and Management (J.S.R., D.E., D.S., V.H., J.L.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology (C.M.B.), Johns Hopkins University, Baltimore, Maryland, USA
| | - Naaz A Hussain
- Johns Hopkins Community Physicians (N.A.H.), Frederick, Maryland, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management (J.S.R., D.E., D.S., V.H., J.L.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Tan M, Ding J, Johnson CE, Cook A, Huang C, Xiao L, Tang S. Stages of readiness for advance care planning: Systematic review and meta-analysis of prevalence rates and associated factors. Int J Nurs Stud 2024; 151:104678. [PMID: 38262171 DOI: 10.1016/j.ijnurstu.2023.104678] [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: 07/25/2023] [Revised: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Advance care planning has been widely recommended to respect the medical care preferences of patients in the final stages of life. However, uptake of advance care planning in healthcare settings remains suboptimal. It may be beneficial to take into account individuals' readiness for advance care planning based on the stages to change identified in the Transtheoretical Model. OBJECTIVE To identify the measurements used to assess readiness of advance care planning based on the Transtheoretical Model, to pool the prevalence of readiness stages, and to summarize the factors affecting people's readiness for advance care planning. DESIGN Systematic review and meta-analysis. METHODS We systematically searched the databases of PubMed, EMBASE, The Cochrane Library, CINAHL, and Web of Science for relevant studies from inception to February 2023. A random effects model was used to estimate the pooled prevalence. And a narrative review on the factors associated with stages of readiness was conducted. RESULTS This meta-analysis included 25 studies involving a total of 4237 individuals. The precontemplation stage was the most commonly identified stage of readiness among advance care planning behaviors (26-72 %). The prevalence of readiness stages for advance care planning varied among different types of behavior. The behavior of "talking to health care proxy/family/loved ones about thoughts on quality versus quantity of life" had the highest level of readiness among all listed behaviors, followed by "talking to health care proxy/family/loved ones about living will", "signing a health care proxy form" and "signing a living will", "signing an advance directive", as well as "talking to doctors about living will". Regarding to influencing factors, a majority of sociodemographic and clinical factors did not show consistent associations with readiness, but some studies did suggest potential links with age, health status, countries, type of assessment, core structures of the Transtheoretical Model, and intervention modalities. CONCLUSIONS A majority of individuals were unaware of advance care planning. There is an urgent need to promote readiness for such planning. Starting with preliminary activities such as "talking to health care proxy/family/loved ones about thoughts on quality versus quantity of life" can help initiate advance care planning. Better integration of the Transtheoretical Model and interventions into the research of advance care planning readiness are needed. REGISTRATION Not registered.
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Affiliation(s)
- Minghui Tan
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Jinfeng Ding
- Xiangya School of Nursing, Central South University, Changsha, China.
| | - Claire E Johnson
- Palliative Aged Care Outcomes Program, University of Wollongong, Wollongong, Australia
| | - Angus Cook
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Chongmei Huang
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Lin Xiao
- School of Nursing, Southern Medical University, Guangzhou, China
| | - Siyuan Tang
- Xiangya School of Nursing, Central South University, Changsha, China.
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Demmer I, Belz M, Oberbach L, Hummers E, Wiltfang J, Bartels C. [Evaluation of satisfaction with and relief vs. workload by a general practitioner-centered dementia care project: early information and support in dementia (FIDEM) in Göttingen, Germany]. DER NERVENARZT 2023; 94:1034-1042. [PMID: 37796324 PMCID: PMC10620282 DOI: 10.1007/s00115-023-01557-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Early information and support in dementia (FIDEM) is a cross-sectoral, general practitioner-centered network model for the improvement of community-based care of people with dementia and their caregivers by systematically assigning them to non-physician healthcare providers. OBJECTIVE To describe the implementation of FIDEM in Göttingen, Germany and to exploratorily evaluate satisfaction and relief vs. additional workload. MATERIAL AND METHODS FIDEM was established in Göttingen in 2017. Community-based and district-based networks consisted of medical (general practitioners) and non-medical cooperation partners (occupational therapists, care counselling, other non-medical care providers) and were instructed to efficiently share information. During biannual network meetings from August 2017 to October 2019, a self-developed questionnaire for quality management and evaluation of the aspects of the project described above was filled out by participants attending the meetings. RESULTS Consecutive recruitment resulted in 7 networks by October 2019, with participation of 29 general practitioners and 46 non-medical care providers, serving as cooperation partners. Quantitative evaluation of 80 FIDEM cooperation partners revealed high satisfaction ratings with all aspects of the model (M from 7.22 to 7.87 out of possible "10"), with partially higher ratings on the part of primary care physicians. Furthermore, all participants reported a reduction in workload due to participation, which was significantly higher for primary care physicians across all scales (all p-values < 0.001). CONCLUSION FIDEM has been implemented in Göttingen beyond a funded pilot project phase. High satisfaction ratings and considerable relief in workload suggest the continuation of FIDEM along with a full evaluation and, provided positive results, its consolidation of and transfer to other regions in Germany.
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Affiliation(s)
- Iris Demmer
- Institut für Allgemeinmedizin, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Michael Belz
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Sieboldt-Straße 5, 37075, Göttingen, Deutschland
| | - Lea Oberbach
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Sieboldt-Straße 5, 37075, Göttingen, Deutschland
| | - Eva Hummers
- Institut für Allgemeinmedizin, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Jens Wiltfang
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Sieboldt-Straße 5, 37075, Göttingen, Deutschland
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Göttingen, Deutschland
- Neurosciences and Signaling Group, Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Claudia Bartels
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Sieboldt-Straße 5, 37075, Göttingen, Deutschland.
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Tetrault A, Nyback MH, Fagerström L, Vaartio-Rajalin H. 'A perfect storm' or missed care? Focus group interviews with dementia care professionals on Advance Care Planning. BMC Geriatr 2023; 23:313. [PMID: 37210508 DOI: 10.1186/s12877-023-04033-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/10/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Dementia is one of the leading causes of dependency and disability among older people and currently the seventh leading cause of death among all diseases. In recent years, healthcare research in Advance Care Planning in dementia care has received increased attention. Advance Care Planning is a discussion process conducted in anticipation of future deterioration of a person's health condition. The purpose of the study was to investigate the views of dementia nurses and geriatricians on Advance Care Planning in dementia care. METHODS The study design is a qualitative study using semi-structured focus group interviews with dementia care professionals in a region in Western Finland. A total of seventeen dementia care professionals participated. A modified version of the Qualitative Analysis Guide of Leuven was used for the data analysis. RESULTS The data analysis identified one main theme and three sub-themes describing the views of dementia nurses and geriatricians on Advance Care Planning in dementia care. The main theme was the 'perfect storm' with sub-themes relating to the person with dementia, the care process, and the care professional. The unfavorable circumstances creating a 'perfect storm' are related to the nature of the illness and the associated stigma, to the unclarity in the suggested care path with inadequate guidelines for Advance Care Planning, and to the demands placed on dementia nurses and geriatricians, as well as to insufficient resources. CONCLUSIONS Dementia nurses and geriatricians acknowledge the importance of advance directives and express a generally positive view of Advance Care Planning in dementia care. They also hold views on a number of factors which affect the conditions for conducting Advance Care Planning. The lack of Advance Care Planning in dementia care can be seen as a form of missed care caused by multiple forces coming together simultaneously.
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Affiliation(s)
- Annika Tetrault
- Department of Caring Science, Faculty of Education and Welfare Studies, Åbo Akademi University, Strandgatan 2, 65100, Vaasa, Finland.
- The Wellbeing Services County of Ostrobothnia, Sandviksgatan 2-4, Vasa, 65100, Finland.
| | - Maj-Helen Nyback
- Novia University of Applied Sciences, Wolffska Vägen 31, 65200, Vaasa, Finland
| | - Lisbeth Fagerström
- Department of Caring Science, Faculty of Education and Welfare Studies, Åbo Akademi University, Strandgatan 2, 65100, Vaasa, Finland
- Faculty of Health and Social Sciences, University of South-Eastern Norway, PO 235, 3603, Kongsberg, Norway
| | - Heli Vaartio-Rajalin
- Department of Caring Science, Faculty of Education and Welfare Studies, Åbo Akademi University, Strandgatan 2, 65100, Vaasa, Finland
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Afshar K, van Baal K, Wiese B, Schleef T, Stiel S, Müller-Mundt G, Schneider N. Structured implementation of the Supportive and Palliative Care Indicators Tool in general practice - A prospective interventional study with follow-up. Palliat Care 2022; 21:214. [PMID: 36451172 PMCID: PMC9714240 DOI: 10.1186/s12904-022-01107-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/15/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND General practitioners (GPs) play a key role in the provision of primary palliative care (PC). The identification of patients who might benefit from PC and the timely initiation of patient-centred PC measures at the end of life are essential, yet challenging. Although different tools exist to support these key tasks, a structured approach is often missing. OBJECTIVE The study aimed at implementing the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE™) in general practices, following a structured and regional approach, in order to evaluate the effects of this tool on the identification of patients with potential PC needs and the initiation of patient-centred PC measures. METHODS The intervention of this mixed-methods study comprised a standardised training of 52 GPs from 34 general practices in two counties in Lower Saxony, Germany, on the use of the SPICT-DE™. The SPICT-DE™ is a clinical tool which supports the identification of patients with potential PC needs. Subsequently, over a period of 12 months, GPs applied the SPICT-DE™ in daily practice with adult patients with chronic, progressive diseases, and completed a follow-up survey 6 months after the initial patient assessment. The outcome parameters were alterations in the patient's clinical situation, and the type and number of initiated patient-centred PC measures during the follow-up interval. Additionally, 12 months after the standardised training, GPs provided feedback on their application of the SPICT-DE™. RESULTS A total of 43 GPs (n = 15 female, median age 53 years) out of an initial sample of 52 trained GPs assessed 580 patients (n = 345 female, median age 84 years) with mainly cardiovascular (47%) and cancer (33%) diseases. Follow-up of 412 patients revealed that 231 (56%) experienced at least one critical incident in their disease progression (e.g. acute crisis), 151 (37%) had at least one hospital admission, and 141 (34%) died. A review of current treatment/medication (76%) and a clarification of treatment goals (53%) were the most frequently initiated patient-centred PC measures. The majority of GPs deemed the SPICT-DE™ practical (85%) and stated an intention to continue applying the tool in daily practice (66%). CONCLUSIONS The SPICT-DE™ is a practical tool that supports the identification of patients at risk of deterioration or dying and promotes the initiation of patient-centred PC measures. TRIAL REGISTRATION The study was registered in the German Clinical Trials Register (N° DRKS00015108; 22/01/2019).
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Affiliation(s)
- Kambiz Afshar
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Katharina van Baal
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Birgitt Wiese
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Tanja Schleef
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Stephanie Stiel
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Gabriele Müller-Mundt
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Nils Schneider
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
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Perry J. Challenges of anticipation of future decisions in dementia and dementia research. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2022; 44:62. [PMID: 36376514 PMCID: PMC9663374 DOI: 10.1007/s40656-022-00541-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
Anticipation of future decisions can be important for individuals at risk for diseases to maintain autonomy over time. For future treatment and care decisions, advance care planning is accepted as a useful anticipation tool. As research with persons with dementia seems imperative to develop disease-modifying interventions, and with changing regulations regarding research participation in Germany, advance research directives (ARDs) are considered a solution to include persons with dementia in research in an ethically sound manner. However, little is known about what affected people deem anticipatable.This contribution provides a critical reflection of the literature on anticipation and of a qualitative study on the assessment of ARDs with persons with cognitive impairment in Germany. It combines theoretical and empirical reflections to inform the ethical-legal discourse.Anticipation involves the conceptual separation of the past, the present, and the future. Including dimensions such as preparedness, injunction, and optimization helps in establishing a framework for anticipatory decision-making. While dementia may offer a window of time to consider future decisions, individual beliefs about dementia including fears about stigma, loss of personhood, and solitude strongly impact anticipating sentiments. Concepts of anticipation can be useful for the examination of uncertainty, changing values, needs, and preferences interconnected with the dementia trajectory and can serve as a means to make an uncertain future more concrete. However, fears of losing one's autonomy in the process of dementia also apply to possibilities of anticipation as these require cognitive assessment and reassessment of an imagined future with dementia.
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Affiliation(s)
- Julia Perry
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Humboldtallee 36, 37073, Göttingen, Germany.
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Sussman T, Tétrault B. "People are more afraid of a dementia diagnosis than of death": The challenges of supporting advance care planning for persons with dementia in community settings. FRONTIERS IN DEMENTIA 2022; 1:1043661. [PMID: 39081479 PMCID: PMC11285647 DOI: 10.3389/frdem.2022.1043661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/05/2022] [Indexed: 08/02/2024]
Abstract
Improving early uptake of advance care planning (ACP) for persons with dementia and their families requires that staff in community-based settings feel armed and equipped to encourage and support this process. Yet few studies have explored whether staff within non-medical environments feel prepared to support early ACP engagement for persons with early-stage dementia and their families. Our qualitative interpretivist study aimed to fill this gap by facilitating, transcribing and thematically analyzing deliberations from three focus groups with 17 community-based staff. Our findings revealed four key barriers to ACP activation in community settings: (1) the stigma associated with the condition; (2) lack of knowledge about end-of-life concerns for persons with dementia; (3) uncertainties about managing complex family dynamics and (4) worries that opening up conversations about future care may lead to the expression of wishes that could not be actualized (e.g., dying at home). Our findings further revealed that ACP engagement was facilitated when staff expressed confidence in their capacities to gauge readiness, viewed themselves as guides rather than experts and had access to resources to supplement their knowledge. Reflexive training opportunities and access to materials and resources around end-of-life care for persons with dementia, could equip staff in these non-medical settings with the skills to engage in ongoing dialogue about future care issues with persons living with dementia and their families.
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Affiliation(s)
- Tamara Sussman
- School of Social Work, McGill University, Montreal, QC, Canada
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Möllers T, Stocker H, Perna L, Rujescu D, Holleczek B, Schöttker B, Brenner H. Subjective short-term memory difficulties at ages 50-75 predict dementia risk in a community-based cohort followed over 17 years. Age Ageing 2022; 51:6607610. [PMID: 35697354 DOI: 10.1093/ageing/afac113] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Subjective cognitive decline (SCD) is an established precursor of dementia. However, the relationship between SCD and dementia has been mostly studied among people aged 65+. We aimed to assess the association between subjective memory difficulties at ages 50-75 with all-cause dementia and dementia-subtypes in a community-based cohort with long-term follow-up. METHODS 6,190 individuals (51% female) aged 50-75 years (median age, 62) attending a general health examination (by a total of 684 general practitioners) in Saarland, Germany, in 2000-2002 were recruited for a community-based cohort study. Subjective difficulties regarding short-term and long-term memory were assessed at baseline with two simple yes/no questions. Associations with dementia (-subtypes) diagnoses during 17 years of follow-up were estimated by Cox proportional hazards models. RESULTS 492 participants were diagnosed with dementia during 17 years of follow-up. Participants with short-term memory difficulties were at higher risk to receive incident all-cause dementia and vascular dementia diagnoses both within 0-9 years (age and sex adjusted hazard ratios (aHR), 1.80 and 2.00, respectively) and within 0-17 years (aHR 1.55 and 1.78, respectively) from recruitment (P < 0.05 in all cases). For clinical Alzheimer's disease, a significant association was only seen within the initial 6 years. There were no associations of long-term memory difficulties with any type of dementia. CONCLUSIONS Subjective difficulties in short-term memory predict both intermediate and long-term risk of vascular and all-cause dementia even among late middle-age adults. These results underline the importance of cardiovascular disease prevention efforts well before old age for maintaining cognitive health.
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Affiliation(s)
- Tobias Möllers
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Hannah Stocker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Laura Perna
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Department of Translational Research in Psychiatry - Max Planck Institute of Psychiatry, München, Germany
| | - Dan Rujescu
- Department of Psychiatry and Psychotherapy, Division of General Psychiatry, Medical University Vienna, Vienna, Austria
| | | | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Network Aging Research, Heidelberg University, Heidelberg, Germany
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Azizi B, Tilburgs B, van Hout HPJ, van der Heide I, Verheij RA, Achterberg WP, van der Steen JT, Joling KJ. Occurrence and Timing of Advance Care Planning in Persons With Dementia in General Practice: Analysis of Linked Electronic Health Records and Administrative Data. Front Public Health 2022; 10:653174. [PMID: 35392479 PMCID: PMC8980429 DOI: 10.3389/fpubh.2022.653174] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Advance care planning (ACP) is a process of communication in which patients and family caregivers discuss preferences for future care with the healthcare team. For persons with dementia, it is crucial to timely engage in ACP. Therefore, we study ACP in dementia using electronic health record data. This study aims to determine how often ACP conversations are recorded, analyze time from dementia diagnosis until the first recorded conversation and time from the first recorded conversation to death, and analyze which factors are associated with the timing of ACP. Methods Electronic records of 15,493 persons with dementia in Dutch general practice between 2008 and 2016 were linked to national administrative databases. ACP conversations and indicators of health deficits to determine frailty were obtained from electronic records coded with the International Classification of Primary Care. Socio-demographic characteristics were derived from the national population registry managed by Statistics Netherlands. Date of death was derived from the Personal Records Database (2008–2018). Results ACP was recorded as such as 22 (95% CI, 20–23) first conversations per 1,000 person-years of follow-up. The hazard ratio (HR) for the first conversation increased every year after dementia diagnosis, from 0.01 in the first year to 0.07 in the 7th and 8th year after diagnosis. Median time from a first conversation to death was 2.57 years (95% CI, 2.31–2.82). Migrant status [non-Western vs. Western (HR 0.31, 95% CI, 0.15–0.65)] was significantly associated with a longer time from dementia diagnosis to the first conversation. Being pre-frail (HR 2.06, 95% CI, 1.58–2.69) or frail (HR 1.40, 95% CI, 1.13–1.73) vs. non-frail was significantly associated with a shorter time from dementia diagnosis to the first ACP conversation. Conclusion ACP conversations in Dutch general practice were rare for persons with dementia, or was rarely recorded as such. In particular among persons with a non-Western migration background and those who are non-frail, it started long after diagnosis. We advise further research into public health and practical strategies to engage persons with dementia with a non-Western migration background and non-frail persons early in the disease trajectory in ACP.
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Affiliation(s)
- Bahar Azizi
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Bram Tilburgs
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Science, Nijmegen, Netherlands
| | - Hein P. J. van Hout
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Iris van der Heide
- Nivel, Netherlands Institute for Health Services Research, Utrecht, Netherlands
| | - Robert A. Verheij
- Nivel, Netherlands Institute for Health Services Research, Utrecht, Netherlands
- Tilburg School of Social and Behavioral Sciences (TRANZO), Tilburg University, Tilburg, Netherlands
| | - Wilco P. Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Jenny T. van der Steen
| | - Karlijn J. Joling
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Sedini C, Biotto M, Crespi Bel'skij LM, Moroni Grandini RE, Cesari M. Advance care planning and advance directives: an overview of the main critical issues. Aging Clin Exp Res 2022; 34:325-330. [PMID: 34655048 PMCID: PMC8847241 DOI: 10.1007/s40520-021-02001-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/14/2021] [Indexed: 01/05/2023]
Abstract
Advance care planning (ACP) is a process that guarantees the respect of the patient's values and priorities about his/her future care at the end of life. It consists of multiple conversations with the health professional that may lead to the completion of Advance Directives (AD), a set of legal documents helpful to clinicians and family members for making critical decisions on behalf of the patient, whereas he/she might become incapable. Over the past years, ACP has become particularly relevant for the growth of chronic diseases, the increase in life expectancy, and the growing attention paid to the patient's decisional autonomy. Several nations have introduced specific regulations of ACP and AD. However, their diffusion is accompanied by unforeseen limitations and issues, burdening their complete and systematic adoption. The present article describes several controversial aspects of ACP and some of the most significant challenges in end-of-life care.
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Affiliation(s)
- Cristina Sedini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Martina Biotto
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | | | | | - Matteo Cesari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
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Giordano A, De Panfilis L, Perin M, Servidio L, Cascioli M, Grasso MG, Lugaresi A, Pucci E, Veronese S, Solari A. Advance Care Planning in Neurodegenerative Disorders: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:803. [PMID: 35055625 PMCID: PMC8775509 DOI: 10.3390/ijerph19020803] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 01/27/2023]
Abstract
Advance care planning (ACP) is increasingly acknowledged as a key step to enable patients to define their goals/preferences for future medical care, together with their carers and health professionals. We aimed to map the evidence on ACP in neurodegenerative disorders. We conducted a scoping review by searching PubMed (inception-December 28, 2020) in addition to trial, review, and dissertation registers. From 9367 records, we included 53 studies, mostly conducted in Europe (45%) and US-Canada (41%), within the last five years. Twenty-six percent of studies were qualitative, followed by observational (21%), reviews (19%), randomized controlled trials (RCTs, 19%), quasi-experimental (11%), and mixed-methods (4%). Two-thirds of studies addressed dementia, followed by amyotrophic lateral sclerosis (13%), and brain tumors (9%). The RCT interventions (all in dementia) consisted of educational programs, facilitated discussions, or videos for patients and/or carers. In conclusion, more research is needed to investigate barriers and facilitators of ACP uptake, as well as to develop/test interventions in almost all the neurodegenerative disorders. A common set of outcome measures targeting each discrete ACP behavior, and validated across the different diseases and cultures is also needed.
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Affiliation(s)
- Andrea Giordano
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (A.G.); (L.S.)
| | - Ludovica De Panfilis
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, 42100 Reggio Emilia, Italy; (L.D.P.); (M.P.)
| | - Marta Perin
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, 42100 Reggio Emilia, Italy; (L.D.P.); (M.P.)
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy
| | - Laura Servidio
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (A.G.); (L.S.)
| | - Marta Cascioli
- Hospice ‘La Torre sul Colle’, Azienda USL Umbria 2, 06049 Spoleto, Italy;
| | | | - Alessandra Lugaresi
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, 40126 Bologna, Italy;
- IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Eugenio Pucci
- UOC Neurologia, ASUR Marche-AV4, 63900 Fermo, Italy;
| | | | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (A.G.); (L.S.)
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Alam A, Barton C, Prathivadi P, Mazza D. Advance care planning in dementia: a qualitative study of Australian general practitioners. Aust J Prim Health 2021; 28:69-75. [PMID: 34844662 DOI: 10.1071/py20307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022]
Abstract
As the population ages, so does the prevalence of dementia, a condition in which timely advance care planning (ACP) is recommended. This study explored the barriers and enablers of ACP for Australian GPs caring for people with dementia. Semi-structured qualitative telephone interviews informed by the theoretical domains framework (TDF) were conducted with 16 GPs from the south-east region of metropolitan Melbourne. The most prevalent domains of the TDF were: (1) environmental context and resources; (2) beliefs about consequences; and (3) social/professional role and identity. Further thematic analysis found that: (1) ACP was felt to be within the scope of general practice, but more so before the onset of dementia because lack of confidence in capacity assessment acted as a barrier once a diagnosis was made; (2) beliefs about the perceived benefits of ACP motivated GPs to engage patients in ACP; and (3) doctors felt that patients were often reluctant to discuss ACP, especially in the time-pressured context of the standard consultation. This study's use of the TDF provides direction for potential interventions to alleviate challenges faced by Australian GPs with ACP in dementia. Improving ACP in general practice may require a focus on public health campaigns to educate patients about the benefits of ACP before the onset of dementia. GPs' difficulty assessing a patient's decisional capacity may be addressed through skills development workshops.
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Affiliation(s)
- Adnan Alam
- Hobart Place General Practice, Level 2 & 3, 28 University Avenue, Canberra, ACT 2601, Australia; and Corresponding author
| | - Christopher Barton
- Department of General Practice, Monash University, Level 1, Building 1, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia
| | - Pallavi Prathivadi
- Department of General Practice, Monash University, Level 1, Building 1, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Level 1, Building 1, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia
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Nicholas R, Nicholas E, Hannides M, Gautam V, Friede T, Koffman J. Influence of individual, illness and environmental factors on place of death among people with neurodegenerative diseases: a retrospective, observational, comparative cohort study. BMJ Support Palliat Care 2021:bmjspcare-2021-003105. [PMID: 34489324 DOI: 10.1136/bmjspcare-2021-003105] [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: 04/07/2021] [Accepted: 07/11/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND In long-term neurological conditions, location of death is poorly understood but is seen as a marker of quality of dying. OBJECTIVE To examine individual, illness and environmental factors on place of death among people with multiple sclerosis (MS) and Parkinson's disease (PD) in isolation or in combination and compare them with people without either condition. METHODS Retrospective, observational, comparative cohort study of 582 people with MS, 579 people with PD and 95 controls from UK Multiple Sclerosis and Parkinson's Disease Tissue Bank. A subset of people with MS and PD were selected for analysis of individual clinical encounters 2 years before death and further subset of all groups for analysis of impact of advance care planning (ACP) and recognition of dying. RESULTS People with MS died more often (50.8%) in hospital than those with PD (35.3%). Examining individual clinical encounters over 2 years (4931 encounters) identified increased contact with services 12 months before death (F(1, 58)=69.71, p<0.0001) but was not associated with non-hospital deaths (F(1, 58)=1.001, p=0.321). The presence of ACPs and recognition of dying were high among people with MS and PD and both associated with a non-hospital death. ACPs were more likely to prevent hospital deaths when initiated by general practitioners (GPs) compared with other professional groups (χ2=68.77, p=0.0007). CONCLUSIONS For people with MS and PD, ACPs contribute to reducing dying in hospital. ACPs appear to be most effective when facilitated by GPs underlining the importance of primary care involvement in delivering holistic care at the end of life.
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Affiliation(s)
- Richard Nicholas
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Emma Nicholas
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Mike Hannides
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Vishal Gautam
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Tim Friede
- Department of Medical Statistics, University Medical Center, University of Göttingen, Göttingen, Germany
| | - Jonathan Koffman
- Department of Palliative Care, Policy and Rehabiltation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Lech S, O'Sullivan JL, Wellmann L, Supplieth J, Döpfmer S, Gellert P, Kuhlmey A, Nordheim J. Recruiting general practitioners and patients with dementia into a cluster randomised controlled trial: strategies, barriers and facilitators. BMC Med Res Methodol 2021; 21:61. [PMID: 33784967 PMCID: PMC8008594 DOI: 10.1186/s12874-021-01253-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 03/16/2021] [Indexed: 11/27/2022] Open
Abstract
Background Recruitment of general practitioners (GPs) and their patients is reported as one of the most challenging steps when undertaking primary care research. The present paper describes the recruitment process of a cluster randomised controlled trial (cRCT) aiming to improve dementia care in the primary care setting. Methods Recruitment data was analysed descriptively using frequency tables to investigate comparisons of recruitment rates and results of different recruitment strategies as well as reasons for participation and non-participation of GPs, patients with dementia (PwD) and their caregivers. Results Over a period of 23 months, N = 28 GPs were successfully included in the cRCT. This represents an overall recruitment rate of 4.6%. The most efficient strategy in terms of high response and low labour-intensity involved the dissemination of calls for participation in a GP research network. Most frequently reported reasons for GP’s participation were Improvement of patient’s well-being (n = 22, 79%) followed by Interest in dementia research (n = 18, 64%). The most common reasons for non-participation were Lack of time (n = 71, 34%) followed by Not interested in participation (n = 63, 30%). On a patient level, N = 102 PwD were successfully recruited. On average, each GP referred about n = 7 PwD (range: 1–17; mdn = 6; IQR = 3.5) and successfully recruited about n = 4 PwD (range: 1–11; mdn = 3; IQR = 3.5). Conclusion First, our findings propose GP research networks as a promising strategy to promote recruitment and participation of GPs and their patients in research. Second, present findings highlight the importance of including GPs and their interests in specific research topics in early stages of research in order to ensure a successful recruitment. Finally, results do not support cold calls as a successful strategy in the recruitment of GPs. Trial registration The trial was prospectively registered with the ISRCTN registry (Trial registration number: ISRCTN15854413). Registered 01 April 2019.
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Affiliation(s)
- Sonia Lech
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany.
| | - Julie L O'Sullivan
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany
| | - Leonard Wellmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany
| | - Juliana Supplieth
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany
| | - Susanne Döpfmer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
| | - Paul Gellert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany
| | - Adelheid Kuhlmey
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany
| | - Johanna Nordheim
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany
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15
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Anzai T, Sato T, Fukumoto Y, Izumi C, Kizawa Y, Koga M, Nishimura K, Ohishi M, Sakashita A, Sakata Y, Shiga T, Takeishi Y, Yasuda S, Yamamoto K, Abe T, Akaho R, Hamatani Y, Hosoda H, Ishimori N, Kato M, Kinugasa Y, Kubozono T, Nagai T, Oishi S, Okada K, Shibata T, Suzuki A, Suzuki T, Takagi M, Takada Y, Tsuruga K, Yoshihisa A, Yumino D, Fukuda K, Kihara Y, Saito Y, Sawa Y, Tsutsui H, Kimura T. JCS/JHFS 2021 Statement on Palliative Care in Cardiovascular Diseases. Circ J 2021; 85:695-757. [PMID: 33775980 DOI: 10.1253/circj.cj-20-1127] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Toshihisa Anzai
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Takuma Sato
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Akihiro Sakashita
- Department of Palliative Medicine, Kobe University Graduate School of Medicine
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Kazuhiro Yamamoto
- Department of Cardiovascular Medicine and Endocrinology and Metabolism, Tottori University Hospital
| | - Takahiro Abe
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Rie Akaho
- Department of Psychiatry, Tokyo Women's Medical University
| | - Yasuhiro Hamatani
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Hayato Hosoda
- Department of Cardiovascular Medicine, Chikamori Hospital
| | - Naoki Ishimori
- Department of Community Heart Failure Healthcare and Pharmacy, Hokkaido University Graduate School of Medicine
| | - Mika Kato
- Nursing Department, Hokkaido University Hospital
| | - Yoshiharu Kinugasa
- Department of Cardiovascular Medicine and Endocrinology and Metabolism, Tottori University Hospital
| | - Takuro Kubozono
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Shogo Oishi
- Department of Cardiovascular Medicine, Hyogo Brain and Heart Center
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tatsuhiro Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University
| | | | - Masahito Takagi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasuko Takada
- Nursing Department, National Cerebral and Cardiovascular Center
| | | | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine
| | | | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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16
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Evaluation of decision-making capacity in patients with dementia: challenges and recommendations from a secondary analysis of qualitative interviews. BMC Med Ethics 2020; 21:55. [PMID: 32631304 PMCID: PMC7339476 DOI: 10.1186/s12910-020-00498-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/26/2020] [Indexed: 11/24/2022] Open
Abstract
Background Evaluation of decision-making capacity to consent to medical treatment has proved to be difficult in patients with dementia. Studies showed that physicians are often insufficiently trained in the evaluation of decision-making capacity. In this study, we present findings from a secondary analysis of a qualitative interviews with physicians. These interviews were initially used to assess usability of an instrument for the evaluation of decision-making capacity. By looking at difficult cases of decision-making capacity evaluation in patients with dementia, we provide recommendations for such evaluations in clinical practice. Methods We used thematic coding to analyse physicians’ narratives of problematic decision-making capacity evaluations in patients with dementia to uncover challenging issues of decision-making capacity evaluation. Results In this study, decision-making capacity evaluations in patients with dementia were mainly perceived as challenging when they pertained to treatment refusals and treatment unrelated circumstances, such as psychiatric consultation, advance directives, and new living arrangements. Furthermore, the physicians reported training needs regarding situation-independent challenges with decision-making capacity evaluation. Conclusions Upon further examining self-reported training needs and challenging cases, we have developed recommendations to improve decision-making capacity evaluations in clinical practice. In these recommendations, we argue that being able to evaluate decision-making capacity is an integral part of the informed consent process.
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Raftery C, Lewis E, Cardona M. The Crucial Role of Nurses and Social Workers in Initiating End-of-Life Communication to Reduce Overtreatment in the Midst of the COVID-19 Pandemic. Gerontology 2020; 66:427-430. [PMID: 32516766 PMCID: PMC7316661 DOI: 10.1159/000509103] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/30/2020] [Indexed: 11/19/2022] Open
Abstract
The large scale and rapid spread of the current COVID-19 pandemic has changed the way hospitals and other health services operate. Opportunities for patient-centered decision-making at the end of life are being jeopardized by a scarcity of health system resources. In response, the traditional doctor-initiated advanced care planning (ACP) for critical illness may also need to be readjusted. We propose nurse-led and allied health-led ACP discussions to ensure patient and family inclusion and understanding of the disease prognosis, prevention of overtreatment, and potential outcomes in crisis times. We highlight known barriers and list enablers, long-term and short-term opportunities to assist in the culture change.
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Affiliation(s)
- Chris Raftery
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Ebony Lewis
- School of Public Health and Community Medicine, The Universityof New South Wales, Randwick, New South Wales, Australia.,School of Psychology, The University of New South Wales, Randwick, New South Wales, Australia
| | - Magnolia Cardona
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia, .,Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia,
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