Advance Care Planning: A Story of Trust Within the Family

As the family usually plays a central role at the end of life, the quality of family relationships may influence how individuals approach advance care planning (ACP). Our study investigates the associations of trust in relatives with regard to end-of-life (EOL) issues-used as a proxy measure of family relationship quality-with individuals' engagement in EOL discussions, advance directive (AD) awareness, approval and completion, and designation of a healthcare proxy. Using nationally representative data of adults aged 55 years and over from wave 6 (2015) of the Survey of Health, Ageing, and Retirement in Europe (SHARE) in Switzerland (n = 1911), we show that complete trust in relatives is related to higher engagement in ACP. Subject to patient consent, the family should, therefore, be included in the ACP process, as such practice could enhance patient-centered EOL care and quality of life at the end of life.

Testing the What Matters to Me workbook in a diverse sample of seriously ill patients and caregivers

Objectives

We evaluated the What Matters to Me Workbook, a patient-facing version of the Serious Illness Conversation Guide co-created by Ariadne Labs and The Conversation Project.

Methods

We purposively recruited diverse seriously ill patients and caregivers in the US. Participants completed the Workbook, a survey, and a semi-structured in-depth interview about their experience. Qualitative analysis of interviews and notes was employed to extract themes. Simple descriptive statistics were employed to analyze eight investigator authored questions.

Results

Twenty-nine study participants completed twenty-one interviews and twenty-five surveys. Ratings for safety (3.87/4, SD = 0.43) and acceptability (3.59/4, SD = 0.956) were higher than ratings for ease of use (3.30/4, SD = 0.97) and usefulness (3.24/4, SD = 0.80). Qualitative analysis identified that while the workbook was safe, acceptable, easy to use, and useful, it is more important who is recommending it and how they are explaining it.

Conclusion

If presented in the right way by a trustworthy person, the What Matters to Me Workbook can be an easy to use, useful, and safe resource for patients with serious illness and their caregivers.

Innovation

The Workbook focuses on serious illness rather than end-of-life and meshes with a clinician-facing conversation guide and a health-system level intervention.

Expectations and behaviour of older adults with neurological disorders regarding general practitioner consultations: an observational study

Background

Patients’ relationship with their GPs is linked to adherence, patient behaviour and satisfaction with healthcare. Several factors pertaining to this relationship have already been identified, however expectations and preferences vary depending on age and diagnosis. Chronically ill elderly patients constitute a group of patients with specific needs that are not yet understood.

Methods

For this observational study, 100 (44 female, mean age 72.72 + − 8.28 years) patients were interviewed. Multiple linear or binary logistic regression as well as analysis of variance was used to understand the link between factors pertaining to GP relationship and patient behaviour, and principal component analysis was performed to understand the underlying structure of patients’ needs.

Results

Patients attribute high importance to their GP’s opinion of them. On average, what the GP thinks about the patients is almost as important as what their partners think. Patients primarily want to be perceived as engaged, friendly and respected individuals, and it is important for patients to be liked by their GP. This importance is linked to active preparation; 65% of the patients prepared actively for GP consultations. Expectations regarding GP consultations can be split into two components: a medical aspect with a subfactor concerning emotional support, and a social component. Prominent factors influencing the relationship are the possibility to talk about emotions and mental well-being, trust, and GP competency. Satisfaction and trust were mainly linked to medical competency. Being able to show emotions or talk about mental well-being enhances perceived GP competence, satisfaction, and active patient preparation. However, a focus on the social component such as frequent talking about private topics reduces both perceived GP competency as well as active patient preparation.

Conclusion

Older patients take GP consultations seriously, and their expectations regarding GP consultations focus on medical competence and care as well as empathetic listening and understanding. Older persons seek a deeper connection to their GPs and are willing to be active and cooperative. As the patient–GP relationship influences health outcomes, treatment of older patients should be adjusted to enable this active participation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02469-3.

Preferences for Health Inquiry among Adults Aged 50 and Over

The study has two main objectives: (1) to determine the proportion of adults ≥ 50 years of age who prefer to have their physician inquire about their functional and emotional health status, and (2) what physician, patient, and medical care system factors are associated with these preferences. The findings suggest that 76% of patients want their physician to inquire about their functional health and 72% want their physician to inquire about their emotional health during the medical encounter. Further analyses show that type of inquiry is strongly associated with patient's preference. Multiple regression models showed congruence regarding physician inquiry about functional and emotional health and patients' preferences for this type of inquiry. The current study is valuable because it highlights the importance of communication exchange during the medical encounter. Physicians are encouraged to inquire into older patients' functional and emotional health status.

Emotional and informational patient cues: the impact of nurses' responses on recall

OBJECTIVE

To investigate older cancer patients' informational and emotional cues, how nurses respond to these cues and the effect of cues and responses on patients' information recall.

METHODS

105 cancer patients (aged >or=65 years) completed a recall questionnaire after an educational session preceding chemotherapy treatment. Recall was checked against the actual communication in videorecordings of the consultations. Patients' emotional and informational cues and subsequent responses by the nurse were rated using an adaptation of the Medical Interview Aural Rating Scale (MIARS).

RESULTS

Patients gave more informational than emotional cues. The most frequent response to emotional cues was distancing followed by acknowledgement. Nurses gave appropriate information in response to the majority of informational cues. Patients' expression of emotional or informational cues did not influence recall; neither did nurses' responses to informational cues. Responses to emotional cues did affect recall. The more nurses responded by giving 'minimal' encouragements (e.g. 'Hmmm'), the more patients recalled, while distancing responses (e.g. switching focus) were associated with lower recall scores.

CONCLUSION

Responding to patients' emotions is likely to impact information recall.

PRACTICE IMPLICATIONS

These results highlight the importance of addressing patients' expressions of emotions in the context of patient education, as it enhances information recall.

Psychosocial problems in primary care: patient and provider perceptions

Primary care physicians and clinics have become the frontline of health care for most Americans-they are the first point of contact and the source of both treatment and referrals. Psychosocial problems, such as difficulty with finances, family, housing, and work, are associated with a high demand for medical care in primary care practice, yet little is known about the prevalence of psychosocial problems in primary care settings. The purpose of this study is to assess the type and level of psychosocial problems in primary care patients by examining patient and provider perceptions at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS). A purposive sample of 684 veterans and a convenience sample of 59 providers anonymously completed the Social Needs Checklist. Patients reported an average of five psychosocial problems, with finances, personal stress, transportation, employment, and legal issues being the most prevalent. Thirty-two percent of patients indicated a desire to see a social worker. Provider and patient differences were compared. Provider estimates of patients' problems were consistently lower than patient estimates in all psychosocial problem areas except need for nursing home placement and problem drinking or drug use. Implications for social work in primary care are discussed.

Nonverbal communication in doctor-elderly patient transactions (NDEPT): development of a tool

OBJECTIVE

There are several measurement tools to assess verbal dimensions in clinical encounters; in contrast, there is no established tool to evaluate physical nonverbal dimensions in geriatric encounters. The present paper describes the development of a tool to assess the physical context of exam rooms in doctor-older patient visits.

METHOD

Salient features of the tool were derived from the medical literature and systematic observations of videotapes and refined during current research.

RESULTS

The tool consists of two main dimensions of exam rooms: (1) physical dimensions comprising static and dynamic attributes that become operational through the spatial configuration and can influence the manifestation of (2) kinesic attributes.

CONCLUSION

Details of the coding form and inter-rater reliability are presented. The usefulness of the tool is demonstrated through an analysis of 50 National Institute of Aging videotapes. Physicians in exam rooms with no desk in the interaction, no height difference and optimal interaction distance were observed to have greater eye contact and touch than physicians' in exam rooms with a desk, similar height difference and interaction distance.

PRACTICE IMPLICATIONS

The tool can enable physicians to assess the spatial configuration of exam rooms (through Parts A and B) and thus facilitate the structuring of kinesic attributes (Part C).

By-person factor analysis in clinical ethical decision making: Q methodology in end-of-life care decisions

OBJECTIVE

To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues.

DESIGN

Qualitative study using by-person factor analysis of subjective Q sort data matrix.

SETTING

University medical center.

PARTICIPANTS

Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern academic health sciences center.

INTERVENTIONS

Presented with four hypothetical cases involving urgent decision making near the end of life, participants selected one of three specific clinical actions offered for each case. Immediately afterward and while considering their decision, each respondent sorted twenty-five subjective self-referent items in terms of the influence of each statement on their decision-making process. By-person factor analysis, where participants are defined as variates, yielded information about the attitudinal background the physicians brought to their consideration of each hypothetical case. We performed a second-order factor analysis on all of the subjective viewpoints to determine if a smaller core of shared attitudes existed across some or all of the four case vignettes. Factor scores for each item and post-sort comments from interviews conducted individually with each respondent guided the interpretation of ethical perspective used by these respondents in making clinical decisions about the cases.

MEASUREMENTS AND MAIN RESULTS

Second-order factor analysis on seventeen viewpoints used by physicians in the four hypothetical urgent decision cases revealed three moderately correlated (r2 < 40%) subjective core attitudinal guides used broadly among all the cases and among sixteen of the seventeen original factors. Across all the cases, our participants were guided in general by: (1) patient-focused beneficence, (2) a patient- and surrogate-focused perspective that includes risk avoidance, and (3) best interest of the patient guided by ethical values. Economic impact on the physician, expediency in resolution of the situation, and the expense of medical treatment were not found to be influential determinants in this study.

CONCLUSIONS

Q sorting and by-person factor analysis are useful qualitative methodological tools to study the complex structure of subjective attitudes that influence physicians in making medical decisions. This study revealed the subjective viewpoints used by our physician participants as they made ethically challenging treatment decisions. The three second-order factors identified here are grounded in current bioethical values as well as the personal traits of physicians. The participants' decision methods appear to resemble casuistry more than principle-based decision making. Generalizability of results will require further studies.

Honing an Advance Care Planning Intervention Using Qualitative Analysis: The Living Well Interview

Advance care planning requires an explicit and comprehensive discussion of patient values and conceptualization of quality of life. The Living Well open-ended interview intervention was developed to help patients and their health care agents to engage in a meaningful discussion of values so that decisions made in the last year of life are made with the patients' values in mind. We used qualitative and quantitative analysis to streamline this 10-question interview, and to generate hypotheses for future research. Interviews with 52 terminally ill patients were coded according to methodological weaknesses and content (support, spirit/feelings, palliative care, and quality of life). Node analysis revealed that three primary and three backup/probe questions yielded information that minimized misinformation, sampled from all four content areas, led to discussions of importance for good planning and decision-making, and may have led to earlier hospice admission than the national average. Two emerging themes, Generativity (passing on values or assets to the next generation) and essence (simple pleasures in everyday life), and were then quantitatively analyzed. People who mentioned generativity tended to be older, had a longer length of hospice stay, and a longer time to death after interview, compared to those who did not mention the theme. People who mentioned essence also tended to be older, but tended to have a shorter length of hospice stay and a shorter time to death after the interview. We conclude that this interview may improve access to hospice, and that generativity and essence are worthwhile themes for future research.

Promoting communication with older adults: protocols for resolving interpersonal conflicts and for enhancing interactions with doctors

In this paper, we review the importance of effective communication in older adulthood, and ideas for promoting it. We focus on theoretical and applied work in two communicative encounters that have particular relevance for older adult health, i.e., interpersonal conflict and visits with a healthcare provider. Little applied work has aimed to adapt training protocols for older adults in these two areas. We will present training protocols we have developed in constructive conflict resolution for older adults, and on enhancing doctor-patient communication. We present these protocols to stimulate ideas on the part of the reader on how to further develop and refine training efforts for older adults in effective communication.

Integrating the communicative predicament and enhancement of aging models: the case of older Native Americans

This article addresses issues of diversity in intergenerational communication by introducing a model that integrates key aspects of the communication predicament and enhancement models of aging with other potent constructs (e.g., group vitality, mindfulness). The model is then applied to the health care experience of an understudied population-older Native Americans. Specifically, it is used to illuminate how intergenerational communication may be facilitated or, indeed, hindered by communicative processes born out of categorization and stereotyping. Health care professionals (in particular), whose working environment is increasingly populated by older economically, culturally, and ethnically diverse patients, should be made aware of some of the strengths and weaknesses of their communicative practices in such intergenerational interactions.

Analyzing end-of-life care legislation: a social work perspective

Several policy approaches are currently being considered in an attempt to organize a national response to the crisis surrounding quality end-of-life care. Recent healthcare efforts aimed at supporting individuals facing advanced illness are marked by debate over assisted suicide, untimely referrals to hospice care, inconsistent adherence to advance directives, and substantive amounts of unrelieved pain in end-of-life. Social workers require a clear understanding of the current political and social climate if they are to navigate the ethical dilemmas as they are presented in end-of-life care. This article discusses recently proposed policy responses to the various political and social controversies surrounding end-of-life care for individuals facing advanced illness. The analysis will suggest criteria for evaluating end-of-life policy in general and offer a framework for evaluating proposed legislation. Suggestions for making end-of-life policy more effective and areas for future research will be proposed. Finally, the implications of this policy analysis for social work will be delineated.

Communication between older patients and their physicians

This article provides an overview of communication between older patients and their physicians. The authors discuss distinctive features of geriatric medical visits and empirical investigations of communication between physicians and older patients in real life clinical encounters highlighting the content, interactional processes, and outcomes of care. They also discuss strategies for improving communication between physicians and older patients using new and innovative technologies. The authors conclude that healing in its broadest sense can occur only through a humanistic approach to geriatric care.

The outpatient medical encounter and elderly patients

There is little evidence of systematic negative bias against older patients in medical visits. The nature of the current narrative review, largely based on studies conducted after 1985, is consistent with the author's previous metaanalysis of over 40 studies published between 1965 and 1985. In that review, based on videotapes or audiotapes of medical visits, consistent relationships between patient age and physicians' interviewing skills were found. Older patients received more information, more total communication and questions concerning drugs, more courtesy, and perhaps more formality reflected in less laughter and joking than younger patients. Ultimately, the subtle ageism that may be present in medical visits with older patients is probably balanced somewhat by communication advantages afforded them challenging the negative views of older patients' care prevalent in the literature. This balance may help explain the ubiquitous finding that older patients are more satisfied with their health care, despite poorer health status, than younger patients. Nevertheless, other patients, especially those in the oldest cohorts, are at high risk for passive relationships and communication complications related to low literacy and poor health status and deserve the attention and special consideration of providers and health service researchers.