The effectiveness of interventions to increase advance directive completion rates

Advance Directives Revisited (2002 vs 2023): Are We Closer to Uniformity?

BACKGROUND AND OBJECTIVES

Advance directives (ADs) are based on state-specific statutes that vary in structure, terminology, and options. This variability leads to inconsistent end-of-life (EOL) care for patients who have executed an AD in 1 state but fall ill in another state. This study revisits a 2002 article that identified considerable differences in ADs to determine whether ADs have become more uniform.

RESEARCH DESIGN AND METHODS

ADs from all 50 states and the District of Columbia were examined to determine the frequency of document types and seven key issues. The results were compared to the 2002 study using nonparametric approaches. Mean numbers of key issues were compared using t-tests and 1-way analysis of variance.

RESULTS

Consistent with 2002, 3 states in 2023 provide statutes for a healthcare power of attorney (HCPOA). However, states offering a combined HCPOA, and living will (LW), deemed an advance directive for healthcare (ADHC), increased from 13 to 30. Between both studies, Long-Term Care increased significantly in LW and ADHC, whereas Artificial Sustenance significantly increased in LW. Despite the rising prevalence of Alzheimer's in the United States, only 10% of states included this issue in 2023.

DISCUSSION AND IMPLICATIONS

Despite evolving healthcare trends, minimal revisions have been made to ADs since 2002. This lack of uniformity can cause confusion regarding the proper understanding of EOL wishes. The authors recommend that the Uniform Act for Advance Directives be revisited to promote greater uniformity in ADs and ensure that individuals' preferences are understood and respected across different states.

Dyadic advance care planning: systematic review of patient-caregiver interventions and effects

INTRODUCTION

Family caregiver's involvement in advance care planning (ACP) is essential to provide high-quality end-of-life (EOL) care and to ease the surrogate decision-making burden. However, no systematic review has focused on existing ACP interventions involving patients and their families.

AIM

To systematically summarise current ACP interventions involving patients and their families.

METHODS

Five English and two Chinese databases were searched from inception to September 2022. The eligible studies were experimental studies describing original data. The Joanna Briggs Institute critical appraisal tools assessed the methodological quality. Narrative synthesis was conducted for data analysis.

RESULTS

In total, twenty-eight articles were included. Fifteen studies were randomised controlled trials, and the rest 13 studies were quasi-experimental studies. The data synthesis identified: (1) Key intervention components: strategies to promote ACP, ACP discussion and follow-up, as well as the role of family caregivers; (2) Effects on intended outcomes: interventions have shown benefit on completion of ACP actions, while inconsistent findings were found on the process outcomes and quality of EOL care. In addition, a logic model for patient-caregiver dyadic ACP was created, and the underlying mechanisms of action included well-preparation, open discussion and adequate support for plan/action.

CONCLUSIONS

This review provides comprehensive evidence about patient-caregiver dyadic ACP, a promising intervention to better prepare for EOL communication and decision-making. A logic model has been mapped to give a preliminary indication for future implementation. More empirical studies are needed to improve this model and culturally adapt it in a real-world setting.

Improving Advance Care Planning for Hospitalized Patients With Heart Failure

Advance care planning (ACP) is a valuable and proven approach for enhancing end-of-life communication and quality of life for individuals with heart failure (HF) and their family members. However, the adoption of ACP in practice is still lower than desired. According to University of California, Irvine Medical Center HF metrics, only 15.3% of hospitalized HF patients had completed ACP documentation before discharge, as recorded in the electronic medical record (EMR). This quality improvement project aimed to investigate whether the rate of ACP completion could be increased by utilizing EMR reminders to health care teams regarding individual patients. Personalized reminders were sent to providers for each hospitalized patient diagnosed with HF, who did not have existing ACP documentation in the EMR, to encourage completion of ACP documentation. Our findings have shown that, during the three-month intervention period, the average ACP completion rate was 21.0%. This represents a 5.7% absolute increase in ACP completion compared to the six months before our intervention (15.3%); a relative increase of 37.3%. Direct message reminders to providers prove to be an effective method for enhancing ACP completion among this specific patient group.

Promoting advance care planning (ACP) in community health clinics in Israel: Perceptions of older adults with pro-ACP attitudes and their family physicians

OBJECTIVE

We examined barriers and facilitators to patient-family physician discussions in Israel about advance care planning, including preparation of an advance directive by adults over age 65, as part of a program in two community health clinics which afforded family physicians the opportunity to dedicate time to such discussions with patients. To the best of our knowledge, the program is the first of its kind in Israel.

METHOD

We used thematic analyses of qualitative data collected through 22 interviews with patients with pro-advanced care planning attitudes and three focus groups with eleven family physicians.

RESULTS

Overall, three themes in the interviews with patients and two themes in the focus groups with physicians emerged. The program gave people with pro-advanced care planning attitudes the opportunity to follow through with their ideas. We found that patients viewed their family physicians as facilitators and that the use of an information leaflet was an effective way to promote advance directives. Family physicians expressed positive attitudes toward assisting patients in the preparation of advance directives and welcomed an allotment of time for this endeavor as part of their schedule but expressed hesitation about assisting patients concerning legal and moral issues.

SIGNIFICANCE OF RESULTS

A pro-advanced care planning attitude is not enough for patients to complete the process of creating an advance directive; patients need active encouragement and intervention in order to turn their ideas into action. More patient and physician education are necessary to enable patients to protect their right to self-determination in end-of-life medical decision-making and to support physicians as facilitators of the process.

Preoperative Advance Care Planning for Older Adults Undergoing Major Abdominal Surgery

BACKGROUND

Advance care planning (ACP) is recommended for older patients undergoing surgery. ACP consists of creating advance directives (ADs), identifying surrogate decision makers (SDMs), and documenting goals of care. We identified factors associated with documentation of preoperative ACP to identify opportunities to optimize ACP for older surgical patients.

METHODS

This was a retrospective study of surgical patients ≥70 years old who underwent elective, high-risk abdominal procedures between 01/2015-08/2019. Clinical data were obtained from our institution's National Surgical Quality Improvement Project database. ACP metrics were extracted from the electronic medical record. We analyzed the data to identify patient factors associated with ACP metrics. We also analyzed whether ACP was more frequent for patients who experienced postoperative complications or death.

RESULTS

267/1,651 patients were included. 97 patients (36%) had an AD available on the day of surgery, 57 (21%) had an SDM identified, and 31 (12%) had a documented goals of care conversation. On multivariable analysis, older age and white race were associated with an increased likelihood of having an AD available on the day of surgery. Women were 1.7 times more likely to have an SDM (p = 0.02). No patient or surgeon factors were significantly associated with goals of care documentation. ACP was not performed more frequently in patients who experienced postoperative complications or death.

CONCLUSION

In this series, ACP was not routinely documented for older patients undergoing major surgery. ACP was not more frequent in patients who experienced complications or death, demonstrating the importance of universal preoperative ACP in older patients.

Completion of electronic nursing documentation of inpatient admission assessment: Insights from Australian metropolitan hospitals

INTRODUCTION

Electronic nursing documentation is an essential aspect of inpatient care and multidisciplinary communication. Analysing data in electronic medical record (eMR) systems can assist in understanding clinical workflows, improving care quality, and promoting efficiency in the healthcare system. This study aims to assess timeliness of completion of an electronic nursing admission assessment form and identify patient and facility factors associated with form completion in three metropolitan hospitals.

MATERIALS AND METHODS

Records of 37,512 adult inpatient admissions (November 2018-November 2019) were extracted from the hospitals' eMR system. A dichotomous variable descriptive of completion of the nursing assessment form (Yes/No) was created. Timeliness of form completion was calculated as the interval between date and time of admission and form completion. Univariate and multivariate multilevel logistic regression were used to identify factors associated with form completion.

RESULTS

An admission assessment form was completed for 78.4% (n = 29,421) of inpatient admissions. Of those, 78% (n = 22,953) were completed within the first 24 h of admission, 13.3% (n = 3,910) between 24 and 72 h from admission, and 8.7% (n = 2,558) beyond 72 h from admission. Patient length of hospital stay, admission time, and admitting unit's nursing hours per patient day were associated with form completion. Patient gender, age, and admitting unit type were not associated with form completion.

DISCUSSION

Form completion rate was high, though more emphasis needs to be placed on the importance of timely completion to allow for adequate patient care planning. Staff education, qualitative understanding of delayed form completion, and streamlined guidelines on nursing admission and eMR use are recommended.

Effect of Behavior Change Techniques Targeting Clinicians to Improve Advance Care Planning in Heart Failure: A Systematic Review and Meta-Analysis

BACKGROUND

National and international guidelines recommend advance care planning (ACP) for patients with heart failure. But clinicians seem hesitant to engage with ACP.

PURPOSE

Our aim was to identify behavioral interventions with the greatest potential to engage clinicians with ACP in heart failure.

METHODS

A systematic review and meta-analysis. We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index, and PsycINFO for randomized controlled trials (RCTs) from inception to August 2018. Three reviewers independently extracted data, assessed risk of bias (Cochrane risk of bias tool), the quality of evidence (Grading of Recommendation Assessment, Development, and Evaluation), and intervention synergy according to the behavior change wheel and behavior change techniques (BCTs). Odds ratios (ORs) were calculated for pooled effects.

RESULTS

Of 14,483 articles screened, we assessed the full text of 131 studies. Thirteen RCTs including 3,709 participants met all of the inclusion criteria. The BCTs of prompts/cues (OR: 4.18; 95% confidence interval [CI]: 2.03-8.59), credible source (OR: 3.24; 95% CI: 1.44-7.28), goal setting (outcome; OR: 2.67; 95% CI: 1.56-4.57), behavioral practice/rehearsal (OR: 2.64; 95% CI: 1.50-4.67), instruction on behavior performance (OR: 2.49; 95% CI: 1.63-3.79), goal setting (behavior; OR: 2.12; 95% CI: 1.57-2.87), and information about consequences (OR: 2.06; 95% CI: 1.40-3.05) showed statistically significant effects to engage clinicians with ACP.

CONCLUSION

Certain BCTs seem to improve clinicians' practice with ACP in heart failure and merit consideration for implementation into routine clinical practice.

Prospective Randomized Study of Advance Directives in Allogeneic Hematopoietic Cell Transplantation Recipients

Patients undergoing allogeneic hematopoietic cell transplantation (HCT) are at risk for high morbidity and mortality. Advance directives (AD) allow patients to express wishes regarding their care at the end of life, but these are not completed in the majority of patients undergoing HCT, with only 44% of deceased allogeneic HCT recipients at this institution completing an AD in the past decade. Increasing the AD completion rate can improve the quality of care for allogeneic HCT recipients. Our objective was to evaluate whether an alternative AD instrument can increase AD completion rate and patient satisfaction. We conducted a prospective, randomized controlled study of the traditional California AD versus a novel Letter AD, the Stanford What Matters Most Letter, in adult allogeneic HCT recipients. Patients age ≥18 years undergoing first allogeneic HCT at Stanford University were eligible. Prior to HCT conditioning, enrolled patients were assigned at random to complete either the traditional AD or the Letter AD. The primary endpoint was AD completion. The chi-square test was used to compare the AD completion rate between arms. The Wilcoxon rank-sum test was used to compare uncertainty, satisfaction with decision making, and satisfaction with the AD. Of the 212 patients who were eligible, 126 (59.4%) were enrolled and randomized. The mean age was 53.7 years, 57 (45.2%) were female, and 74 (58.7%) were non-Hispanic white. The overall AD completion rate was 71.4% and did not differ between the traditional and Letter AD arms (70.3% versus 72.6%; P = .78). Of those who completed the Letter AD, 66.7%, 42.2%, and 46.7% of patients wished to die gently/naturally, at home, and/or with hospice, respectively. In the traditional AD arm, 60.0% wished to not prolong life if recovery was unlikely. Opinion surveys did not find differences in levels of satisfaction between the traditional AD and Letter AD. Completion rates of AD on this study were high (71.4%) compared with historically reported completion rates and did not significantly differ based on AD version.

Rapid Neurocognitive Deterioration and Mortality in a Healthcare Professional With Spongiform Encephalopathy: Implications for Neurologic and End-of-Life Care

Spongiform encephalopathy (SE) is a rare prion disorder characterized by progressive cognitive dysfunction and mortality. Affected patients can observe a wide variety of neurological symptoms, such as myoclonus, dementia, cerebellar signs, and others. We present a case of laboratory-confirmed SE in an otherwise healthy 57-year-old medical professional who initially presented with nonspecific and unique "head in a fish-bowl" dissociation and cognitive decline. No social risk factors were ever identified other than his healthcare career, but subsequent neuroimaging, serology, and lumbar puncture confirmed a diagnosis of sporadic SE due to unknown etiology. He was then treated symptomatically and referred ultimately to palliative care. The patient passed while in hospice care with time from the initial diagnosis to mortality being only 42 days. Given his vague but uniquely rapid deterioration and subsequent mortality, we highlight an opportunity to discuss diagnosis, management, quality improvement, and ethical concerns associated with SE prognosis. We aim to help primary care physicians and neurologists better elucidate the risk factors, signs and symptoms, and pathophysiology of SE to make an early diagnosis. Symptoms can then be managed effectively and palliative services coordinated via a legal and compassionate shared decision-making approach. We recommend that once a diagnosis is made, a discussion with the patient and their family about advance directives and end-of-life care be coordinated as soon as reasonably possible. This should be carried out by a multidisciplinary team consisting of the patient's primary care physician and neurologist, as well as a social worker, palliative care physician, and counselor (spiritual or otherwise). It is our hope that through a better understanding of these factors in SE care, quality of life improvement protocols in similarly-debilitating neurocognitive diseases can be developed.

Evaluation of a quality improvement initiative to increase rates of advance directive conversation documentation in primary care

As life expectancy increases, long periods of comorbidity and low quality of life commonly precede death. Advance care planning within primary care settings is necessary to increase patient agency and prioritize personal wishes. This article disseminates a quality improvement initiative within a federally qualified health center. New procedures were developed to systematically track advance directive conversations using current procedural terminology codes. The systems change resulted in a substantial and sustained increase in advance directive conversation documentation. The increase was presumably due to the implementation of small-scale changes, providers' commitment to geriatric primary care, increases in appointment times, allocation of tasks across disciplines, availability of Spanish speaking staff and translated forms, and the change to record keeping that enabled codes to be easily captured and tracked in the electronic medical record. This work may inform future quality improvement efforts to boost advance care planning among underserved populations in diverse settings.

The Effect of Advance Care Planning on Heart Failure: a Systematic Review and Meta-analysis

BACKGROUND

Advance care planning is widely advocated to improve outcomes in end-of-life care for patients suffering from heart failure. But until now, there has been no systematic evaluation of the impact of advance care planning (ACP) on clinical outcomes. Our aim was to determine the effect of ACP in heart failure through a meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index and PsycINFO (inception to July 2018). We selected RCTs including adult patients with heart failure treated in a hospital, hospice or community setting. Three reviewers independently screened studies, extracted data, assessed the risk of bias (Cochrane risk of bias tool) and evaluated the quality of evidence (GRADE tool) and analysed interventions according to the Template for Intervention Description and Replication (TIDieR). We calculated standardized mean differences (SMD) in random effects models for pooled effects using the generic inverse variance method.

RESULTS

Fourteen RCTs including 2924 participants met all of the inclusion criteria. There was a moderate effect in favour of ACP for quality of life (SMD, 0.38; 95% CI [0.09 to 0.68]), patients' satisfaction with end-of-life care (SMD, 0.39; 95% CI [0.14 to 0.64]) and the quality of end-of-life communication (SMD, 0.29; 95% CI [0.17 to 0.42]) for patients suffering from heart failure. ACP seemed most effective if it was introduced at significant milestones in a patient's disease trajectory, included family members, involved follow-up appointments and considered ethnic preferences. Several sensitivity analyses confirmed the statistically significant direction of effect. Heterogeneity was mainly due to different study settings, length of follow-up periods and compositions of ACP.

CONCLUSIONS

ACP improved quality of life, patient satisfaction with end-of-life care and the quality of end-of-life communication for patients suffering from heart failure and could be most effective when the right timing, follow-up and involvement of important others was considered.

Culture and personal influences on cardiopulmonary resuscitation- results of international survey

Background

The ethical principle of justice demands that resources be distributed equally and based on evidence. Guidelines regarding forgoing of CPR are unavailable and there is large variance in the reported rates of attempted CPR in in-hospital cardiac arrest. The main objective of this work was to study whether local culture and physician preferences may affect spur-of-the-moment decisions in unexpected in-hospital cardiac arrest.

Methods

Cross sectional questionnaire survey conducted among a convenience sample of physicians that likely comprise code team members in their country (Indonesia, Israel and Mexico). The questionnaire included details regarding respondent demographics and training, personal value judgments and preferences as well as professional experience regarding CPR and forgoing of resuscitation.

Results

Of the 675 questionnaires distributed, 617 (91.4%) were completed and returned. Country of practice and level of knowledge about resuscitation were strongly associated with avoiding CPR performance. Mexican physicians were almost twicemore likely to forgo CPR than their Israeli and Indonesian/Malaysian counterparts [OR1.84 (95% CI 1.03, 3.26), p = 0.038]. Mexican responders also placed greater emphasison personal and patient quality of life (p <  0.001). In multivariate analysis, degree of religiosity was most strongly associated with willingness to forgo CPR; orthodox respondents were more than twice more likely to report having forgone CPR for apatient they do not know than secular and observant respondents, regardless of the country of practice [OR 2.12 (95%CI 1.30, 3.46), p = 0.003].

Conclusions

In unexpected in-hospital cardiac arrest the decision to perform or withhold CPR may be affected by physician knowledge and local culture as well as personal preferences. Physician CPR training should include information regarding predictors of patient outcome at as well as emphasis on differentiating between patient and personal preferences in an emergency.

Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis

OBJECTIVES

How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice?

DESIGN

A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting.

SETTING

Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews.

RESULTS

The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging.

CONCLUSION

Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice.

PROSPERO REGISTRATION NUMBER

CRD42018088838.

Feasibility of Advance Care Planning in Primary Care for Homeless Adults

Objectives: As the homeless population ages, it is imperative to improve access to advance care planning (ACP) and document preferences in case medical decision-making capacity is lost. Methods: We implemented an ACP Project to discuss and document advance care plans with all patients aged 45 and older who received primary care at our adult Homeless Program clinics. Results: Over 14 months, ACP was discussed with 48% ( n = 138) of the population and health care proxy (HCP) appointment with 91% ( n = 125) of these patients. Most (62%; n = 77) appointed a HCP from personal relationships, though a significant minority (38%; n = 48) could not and were considered “surrogateless.” End-of-life preferences varied. Approximately 20% of patients wanted to defer to a surrogate for each decision. Discussion: ACP is feasible in primary care for adults who have experienced homelessness and should be incorporated into routine care.

Clinician-targeted interventions to improve advance care planning in heart failure: a systematic review and meta-analysis

OBJECTIVE

Advance care planning (ACP) is widely advocated to contribute to better outcomes for patients suffering from heart failure. But clinicians appear hesitant to engage with ACP. Our aim was to identify interventions with the greatest potential to engage clinicians with ACP in heart failure.

METHODS

A systematic review and meta-analysis. We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index and PsycINFO for randomised controlled trials (RCTs) from inception to January 2018. Three reviewers independently extracted data, assessed risk of bias (Cochrane risk of bias tool), the quality of evidence (GRADE) and intervention synergy according to Template for Intervention Description and Replication. ORs were calculated for pooled effects.

RESULTS

Of 14 175 articles screened, we assessed the full text of 131 studies. 13 RCTs including 3709 participants met all of the inclusion criteria. The intervention categories of patient-mediated interventions (OR 5.23; 95% CI 2.36 to 11.61), reminder systems (OR 3.65; 95% CI 1.47 to 9.04) and educational meetings (OR 2.35; 95% CI 1.29 to 4.26) demonstrated a favourable effect to engage clinicians with the completion of ACP.

CONCLUSION

The review provides evidence from 13 published RCTs and suggests that interventions that involve patients to change clinical practice, reminder systems and educational meetings have the greatest effect in improving the implementation of ACP in heart failure.

Advance Care Planning Program and the Knowledge and Attitude Concerning Palliative Care

OBJECTIVES

The study aimed to evaluate the effects of an advance care planning (ACP) program on knowledge and attitudes concerning palliative care, and decisions regarding DNR orders in the older residents in a long-term care institution.

METHODS

A quasi-experimental design was used. Participants were cognitively unimpaired older residents in a long-term care institution in Taiwan. The experimental group (n = 29) received the intervention including an individual interview using an ACP handbook and a group patient education; whereas the control group (n = 28) received the group patient education only.

RESULTS

There were significant positive effects of the ACP program on understanding of DNR and palliative care, willingness to sign a DNR order, and knowledge of and attitude towards palliative care; however, there was no significant effect on willingness to receive palliative care. Six participants signed the DNR order after the intervention compared to none in the control group.

CONCLUSIONS

The ACP program can improve knowledge and attitudes towards palliative care in older residents in long-term care institutions.

CLINICAL IMPLICATIONS

The ACP program could incorporate multiple components, including individual interview using ACP handbook and group patient education, and address knowledge and attitudes towards palliative care.

Skills Training to Support Patients considering place of End-Of-Life Care: A Randomized Control Trial

The effect of a program to train clinicians to support patients making decisions about place of end-of-life care was evaluated. In all, 88 oncology and/or palliative care nursing and allied health providers from three Ontario health networks were randomly assigned to an education or control condition. Quality of decision support provided to standardized patients was measured before and after training, as were participants’ perceptions about the acceptability of the training program and their intentions to engage in patient decision support. Compared to controls, intervention group members improved the quality of decision support provided and were more likely to address a wider range of decision-making needs. Intervention group members scored higher on a knowledge test of decision support than controls and rated the components as acceptable. Improvements in the quality of decision support can be made by providing training and practical tools such as a patient decision aid.

Advance Care Planning in Community: An Evaluation of a Pilot 2-Session, Nurse-Led Workshop

BACKGROUND:

Engaging patients in advance care planning (ACP) is challenging but crucial to improving the quality of end-of-life care. Group visits and multiple patient-clinician interactions may promote advance directive (AD) completion.

OBJECTIVE:

Facilitate ACP discussions with patients and caregivers and the creation of notarized AD's at a comprehensive cancer center.

DESIGN:

Two-session, nurse-led ACP workshops for patients and their family caregivers.

SETTING/PARTICIPANTS:

The workshop was offered to patients with cancer at a comprehensive cancer center and their family caregivers.

MEASUREMENTS:

Validated 4-question ACP engagement survey, creation of a notarized AD by end of the workshop, and semistructured interviews.

RESULTS:

Thirty-five patients participated in 10 workshops held March 2017 to February 2018. Median age was 52. Of 35, 24 (68.5%) patients completed pre- and postworkshop evaluation surveys. Mean preworkshop ACP readiness was 3.64 of 5; postworkshop readiness increased to 4.26 of 5 ( P = .001). Of 26, 17 (65.4%) of the patients who attended both workshop sessions had a new notarized AD scanned into the electronic medical record at the completion of the workshop series. Three family caregivers completed and had their own ADs notarized. Patient and family member response was overwhelmingly positive, with participants citing opportunities for group discussion and inclusion of family caregivers as important.

CONCLUSIONS:

The ACP workshop was well received by participants and increased ACP readiness, discussion, and completion. Attendance at the workshop was low and barriers to attending workshops must be explored.

State of advance care planning research: A descriptive overview of systematic reviews

OBJECTIVE

To provide an overview of the current state of research of advance care planning (ACP), highlighting most studied topics, publication time, quality of studies and reported outcomes, and to identify gaps to improve ACP receptivity, utilization, implementation, and outcomes.

METHOD

Cochrane methodology for conducting overviews of systematic reviews. Study quality was assessed using a modified version of the Assessing the Methodological Quality of Systematic Reviews tool. The following databases were searched from inception to April 2017: MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE. Searches were supplemented with gray literature and manual searches.

RESULT

Eighty systematic reviews, covering 1,662 single articles, show that ACP-related research focuses on nine main topics: (1) ACP as part of end-of-life or palliative care interventions, (2) care decision-making; (3) communication strategies; (4) factors influencing ACP implementation; (5) ACP for specific patient groups, (6) ACP effectiveness; (7) ACP experiences; (8) ACP cost; and (9) ACP outcome measures. The majority of this research was published since 2014, its quality ranges from moderate to low, and reports on documentation, concordance, preferences, and resource utilization outcomes.

SIGNIFICANCE OF RESULTS

Despite the surge of ACP research, there are major knowledge gaps about ACP initiation, timeliness, optimal content, and impact because of the low quality and fragmentation of the available evidence. Research has mostly focused on discrete aspects within ACP instead of using a holistic evaluative approach that takes into account its intricate working mechanisms, the effects of systems and contexts, and the impacts on multilevel stakeholders. Higher quality studies and innovative interventions are needed to develop effective ACP programs and address research gaps.

Active Choice Intervention Increases Advance Directive Completion: A Randomized Trial

Background. Many people recognize the potential benefits of advance directives (ADs), yet few actually complete them. It is unknown whether an active choice intervention influences AD completion. Methods. New employees were randomized to an active choice intervention (n = 642) or usual care (n = 637). The active choice intervention asked employees to complete an AD, confirm prior AD completion, or fill out a declination form. In usual care, participants could complete an AD, confirm prior completion, or skip the task. We used multivariable logistic regression to assess the relationship between the intervention arm and both AD completion online and the return of a signed AD by mail, as well as assess interactions between intervention group and age, gender, race, and clinical degree status. Results. Participants assigned to the active choice intervention more commonly completed ADs online (35.1% v. 20.4%, P < 0.001) (odds ratio [OR] = 2.10; 95% confidence interval [CI] = 1.63–2.71; number needed to treat = 6.8) and returned signed ADs by mail (7.8% v. 3.9%, P = 0.003; number needed to treat = 25.6). The effect of the intervention was significantly greater among men (OR = 4.13; 95% CI = 2.32–7.35) than among women (OR = 1.74; 95% CI = 1.30–2.32) (interaction P value < 0.001). Responses to all eight choices made in the ADs were similar between groups (all P > 0.10). Limitations. A young and healthy participant may not benefit from AD completion as an older or seriously ill patient would. Conclusions. The active choice intervention significantly increased the proportion of participants completing an AD without changing the choices in ADs. This relationship was especially strong among men and may be a useful method to increase AD completion rates without altering choices.

Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety

CONTEXT

Documenting patients' advance care planning (ACP) wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about ACP documentation practices in the electronic health record.

OBJECTIVES

The objective of this study was to describe ACP documentation practices and the accessibility of documented discussions in the electronic health record.

METHODS

Participants were primary care patients at the San Francisco Veterans Affairs Medical Center, were ≥60 years old, and had ≥2 chronic/serious health conditions. In this cross-sectional study, we assessed the prevalence of ACP documentation, including any legal forms/orders and discussions in the prior five years. We also determined accessibility of discussions (i.e., accessible centralized posting vs. inaccessible free text in progress notes).

RESULTS

The mean age of 414 participants was 71 years (SD ± 8), 9% were women, 43% were nonwhite, and 51% had documented ACP including 149 (36%) with forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders lacked accompanying explanatory documentation. Most (55%) discussions were not easily accessible, including 70% of those documenting changes in treatment preferences from prior forms/orders.

CONCLUSION

Half of chronically ill, older participants had documented ACP, including one-third with documented discussions. However, half of the patients with completed legal forms/orders had no accompanying documented explanatory discussions, and the majority of documented discussions were not easily accessible, even when wishes had changed. Ensuring that patients' preferences are documented and easily accessible is an important patient safety and quality improvement target to ensure patients' wishes are honored.

Advance care planning with individuals experiencing homelessness: Literature review and recommendations for public health practice

Vulnerable populations in the United States experience disparities in access to advance care planning and may have significant unmet health care needs at the end of life, including unrelieved suffering. People who are homeless have increased morbidity and mortality risks, yet lack opportunities to communicate end-of-life preferences. This paper includes a narrative literature review of advance care planning interventions and qualitative investigations into end-of-life concerns among people experiencing homelessness. Trials of clinician-guided interventions with homeless individuals demonstrated effectiveness in achieving advance directive completion and surrogate decision-maker designation. End-of-life concerns among homeless persons included fears of dying alone, dying unnoticed, or remaining unidentified after death. Research participants also reported concerns regarding burial and notification of family members. Public health practitioners should facilitate advance care planning for people who are homeless by providing opportunities for education and discussion on care options and advance directives.

A nurse practitioner-led community workshop: Increasing adult participation in advance care planning

BACKGROUND AND PURPOSE

Advance directives (ADs) and advance care planning (ACP) aid in expressing an individual's preferences and guide future medical decision-making. Despite the potential of ADs and ACP to positively impact care, consistently low rates of ADs and ACP (5%-39%) have been documented. The purpose of this project was to increase understanding and participation in the ACP process among rural-dwelling community members.

METHODS

A pre-post repeated measures design with an evaluation component to measure understanding, completion, discussion, and dissemination of ADs and ACP. A sample of N = 40 were recruited to participate in a one-time nurse practitioner-led Five Wishes workshop delivered in a community setting.

CONCLUSIONS

Postworkshop evaluations indicated an overall acceptance and understanding of ADs and ACP. Completion rates of ADs and discussion in the ACP process significantly increased at 1-month follow-up.

IMPLICATIONS FOR PRACTICE

Nurses and advanced practice nurses are well positioned to educate individuals and facilitate the ACP process. There is a need to educate individuals on importance of sharing their AD wishes with their family and primary care provider. This nurse practitioner-led workshop using the Five Wishes demonstrated the feasibility and potential effectiveness of initiating the ACP process in the community.

Efficacy of a Church-Based, Culturally Tailored Program to Promote Completion of Advance Directives Among Asian Americans

Having an Advance Directive (AD) can help to guide medical decision-making. Asian Americans (AA) are less likely than White Americans to complete an AD. This pilot study investigated the feasibility and efficacy of a church-based intervention to increase knowledge and behavior change related to AD among Chinese and Vietnamese Americans. This study utilized a single group pre- and post-intervention design with 174 participants from 4 churches. Domain assessed: demographics; AD-related knowledge, beliefs, attitudes, and intentions; AD completion; and conversations with a healthcare proxy. Data were analyzed using Chi square and multiple logistic regression techniques. We observed significant increases in participants' AD-related knowledge, intentions, and a gain in supportive beliefs and attitudes about AD, resulting in 71.8 % AD completion, and 25.0 % having had a proxy conversation. Providing culturally-tailored intervention and step-by-step guidance can help to achieve significant changes in AD related knowledge and behavior in AA church goers.

Advance care planning for patients with amyotrophic lateral sclerosis

PURPOSE

To determine whether an advance care planning (ACP) decision-aid could improve communication about end-of-life treatment wishes between patients with amyotrophic lateral sclerosis (ALS) and their clinicians.

METHODS

Forty-four patients with ALS (>21, English-speaking, without dementia) engaged in ACP using an interactive computer based decision-aid. Before participants completed the intervention, and again three months later, their clinicians reviewed three clinical vignettes, and made treatment decisions (n = 18) for patients. After patients indicated their agreement with the team's decisions, concordance was calculated.

RESULTS

The mean concordance between patient wishes and the clinical team decisions was significantly higher post-intervention (post = 91.9%, 95% CI = 87.8, 96.1, vs. pre = 52.4%, 95% CI = 41.9, 62.9; p <0.001). Clinical team members reported greater confidence that their decisions accurately represented each patient's wishes post-intervention (mean = 6.5) compared to pre-intervention (mean = 3.3, 1 = low, 10 = high, p <0.001). Patients reported high satisfaction (mean = 26.4, SD = 3.2; 6 = low, 30 = high) and low decisional conflict (mean = 28.8, SD = 8.2; 20 = low, 80 = high) with decisions about end-of-life care, and high satisfaction with the decision-aid (mean = 52.7, SD = 5.7, 20 = low, 60 = high). Patient knowledge regarding ACP increased post-intervention (pre = 47.8% correct responses vs. post = 66.3%; p <0.001) without adversely affecting patient anxiety or self-determination.

CONCLUSION

A computer based ACP decision-aid can significantly improve clinicians' understanding of ALS patients' wishes with regard to end-of-life medical care.

What Can a Primary Care Physician Discuss With Older Patients to Improve Advance Directive Completion Rates? A Clin-IQ

Advance directives (ADs) provide patients with the opportunity to indicate their preferences for medical care while they still maintain the capacity to express their wishes, thus retaining autonomy. ADs increase the likelihood that patients will receive the care they desire, as their family members and physicians will better understand the level of care desired. Despite this, the AD completion rate by elderly patients continues to be low, especially for patients not facing serious illnesses. Primary care physicians (PCPs) are uniquely positioned to engage patients in discussions about ADs before a health crisis arises yet often do not due to time constraints. Using assets associated with the PCP relationship to and longitudinal care for patients, findings reveal that PCPs who emphasize the importance of ADs and who normalize the discussion during office visits by asking questions to understand patients' health goals and holding short conversations over several visits can improve AD completion rates.

Predicting Racial and Ethnic Disparities in Advance Care Planning Using the Integrated Behavioral Model

Purpose To explain and predict racial or ethnic disparities in advance care planning (ACP) behaviors among American adults by using the Integrated Behavioral Model (IBM) and the Precaution Adoption Process Model. Methods A randomized, observational, nonexperimental, cross-sectional study design was used to survey American adults between 40 and 80 years of age ( n = 386). Results The majority of respondents (75%) had not completed ACP. Significant differences were found by race or ethnicity: 33% of Whites had completed ACP versus Hispanics (18%) and Blacks (8%). Whites had statistically significantly higher levels of most IBM constructs compared with Blacks and Hispanics. The IBM predicted 28% of the variance in behavioral intention. After controlling for sociodemographic variables, direct attitudes, indirect attitudes, and indirect perceived norms were significant predictors of behavioral intention. Conclusion The IBM and the Precaution Adoption Process Model are useful frameworks for interventions designed to increase ACP among racial or ethnic minorities in the United States.

A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion

BACKGROUND

Evidence suggests that advance directives may improve end-of-life care among seriously ill patients, but improving completion rates remains a challenge.

OBJECTIVE

This study tested the influence of increasing the number of options for completing an advance directive among seriously ill patients.

METHODOLOGY

Outpatients ( N = 316) receiving hemodialysis across 15 dialysis centers in the Philadelphia region between July 2014 and July 2015 were randomized to receive either the option to complete a brief advance directive form or expanded options including a brief, expanded, or comprehensive form. Patients in both groups could decline to complete an advance directive or take their selected version home. The primary outcome was a returned, completed advance directive. Secondary outcomes included whether patients wanted to complete an advance directive, decision satisfaction, quality of life at 3 months, and patient factors associated with advance directive completion.

RESULTS

Although offering more advance directive options was not significantly associated with increased rates of completion (13.1% in the standard group v. 12.2% in the expanded group, P = 0.80), it did significantly increase the proportion of patients who wanted to complete an advance directive and took one home (71.9% in standard v. 85.3% in expanded, P = 0.004). There was no difference in satisfaction ( P = 0.65) or change in quality of life between groups ( P = 0.63). A higher baseline quality of life was independently associated with advance directive completion ( P = 0.006).

CONCLUSIONS AND RELEVANCE

These results suggest that although an expanded choice set may initially nudge patients toward completing advance directives without restricting choice, increasing actual completion requires additional interventions that overcome downstream barriers.

Exploring the utility of the vignette technique in promoting advance care planning discussions with cancer patients and caregivers

OBJECTIVE

We aimed to specifically examine patients' and caregivers' perspectives about the use of the vignette technique (VT) integrating clinical scenarios, as a potential tool for facilitating advance care planning (ACP) discussions.

METHODS

Secondary analysis of data from three studies that incorporated the VT, focusing on statements specific to use of the VT and using a qualitative descriptive design informed by grounded theory.

RESULTS

Data from 85 participants were analyzed. Participants varied in their personal identification with scenarios, with caregivers being more accurate. Scenarios prompted consideration and participation in ACP discussions, sometimes steering conversations in directions that participants were ready to consider. However, scenarios also risked evoking distress in participants who may have chosen to avoid discussions.

CONCLUSIONS

For some patients, scenarios of possible clinical outcomes may provide a neutral platform to promote ACP conversations in a non-threatening manner and allow for exploration of ACP domains to greater depth.

PRACTICE IMPLICATIONS

Vignettes may be used in staff training through role-play or case discussions; as part of face-to-face interventions to improve knowledge and information processing and to facilitate the initiation of sensitive conversations. Its use in audio-visual formats may further enhance end-of-life dialogue and warrants further consideration.

Can Playing an End-of-Life Conversation Game Motivate People to Engage in Advance Care Planning?

BACKGROUND

Advance care planning (ACP) involves several behaviors that individuals undertake to prepare for future medical care should they lose decision-making capacity. The goal of this study was to assess whether playing a conversation game could motivate participants to engage in ACP.

METHODS

Sixty-eight English-speaking, adult volunteers (n = 17 games) from communities around Hershey, Pennsylvania, and Lexington, Kentucky, played a conversation card game about end-of-life issues. Readiness to engage in 4 ACP behaviors was measured by a validated questionnaire (based on the transtheoretical model) immediately before and 3 months postgame and a semistructured phone interview. These behaviors were (1) completing a living will; (2) completing a health-care proxy; (3) discussing end-of-life wishes with loved ones; and (4) discussing quality versus quantity of life with loved ones.

RESULTS

Participants' (n = 68) mean age was 51.3 years (standard deviation = 0.7, range: 22-88); 94% of the participants were caucasian and 67% were female. Seventy-eight percent of the participants engaged in ACP behaviors within 3 months of playing the game (eg, updating documents, discussing end-of-life issues). Furthermore, 73% of the participants progressed in stage of change (ie, readiness) to perform at least 1 of the 4 behaviors. Scores on measures of decisional balance and processes of change increased significantly by 3 months postintervention.

CONCLUSION

This pilot study found that individuals who played a conversation game had high rates of performing ACP behaviors within 3 months. These findings suggest that using a game format may be a useful way to motivate people to perform important ACP behaviors.

Does Volunteering Experience Influence Advance Care Planning in Old Age?

Advance care planning (ACP) increases the likelihood patients will receive end-of-life care that is congruent with their preferences and lowers stress among both patients and caregivers. Previous efforts to increase ACP have mainly focused on information provision in the very late stage of life. This study examines whether a relationship exists between volunteering and ACP, and whether this relationship is associated with social support. The sample comprises 877 individuals who were aged 55+ in 2008, and were deceased before 2010. The sample is derived from seven waves (1998-2010) of data from the Health and Retirement Study. Logistic regression results showed that overall ACP and durable power of attorney for health care (DPAHC) were both higher (OR = 1.61 and 1.71, respectively) for older adults with volunteering experience in the past 10 years than those without such experience. Available social support (relatives and friends living nearby) was not associated with the relationship between volunteering and ACP. Other factors related to ACP included poorer health, death being expected, death due to cancer, older age, and being a racial minority. Involving older people in volunteer work may help to increase ACP. Future research is encouraged to identify reasons for the association between volunteering and ACP.

[Can the vascular specialist improve patient awareness about advanced directives?]

INTRODUCTION

In France, the Leonetti law, adopted on April 22, 2005, stipulates the regulations concerning advanced directives. This is a patient's right that is not well known and rarely applied. In 2015, a new law project was thus presented in which the French National Authority for Health recommended that doctors, including all specialists, bring up the subject, especially during consultation.

OBJECTIVES

To evaluate the vascular specialist's possibility to mention the topic of advanced directives during consultations.

METHOD

A single and non-interventional prospective study conducted with the help of patients who consulted a private practitioner vascular specialist: recurrent patients regularly consulting a private practitioner vascular specialist were included. First-time consultants, minors and patients to whom it was not adapted to speak about the subject were not included.

RESULTS

Between July 27 and September 23, 2015, 159 consecutive patients were examined. Fifty-five first-time consultants and four patients for whom the interview was unsuitable were excluded. In all, 100 patients were questioned. None of them refused to talk about the subject. Women made up a majority of the population (63 %) with an average age of 67 years (23-97). The principal diagnostics were common to vascular medicine consultations: deep vein thrombosis (20 %), peripheral arterial disease (15 %), varicose veins (11 %), lymphedema (11 %) and leg ulcers (9 %). Thirteen percent of the people had a history of cancer. Half of the patients had had follow-ups for over 10 years. The average time devoted to discussing the topic was 12minutes (5-40). Only 22 % of the patients declared having been familiar with advance directives. Once informed however, 78 % chose to write up an adapted form: 36 % with the help of their doctor and 42 % with a doctor and a relative. Seventy-three percent of the consultants thought that talking about the advance directives would reinforce the confidence link between the doctor and the patient.

CONCLUSION

In private practice vascular medicine, it seems possible to mention the subject of advance directives, as recommended by the French authorities. The procedure is well perceived by the patients. It nevertheless implies allotting a non-negligible amount of additional consultation time. The reinforcement of the doctor-patient relationship suggested by these results should be confirmed by a qualitative study made up of meetings.

Perceptions of Advance Care Planning Among Latino Adults in the Community Setting

Rates of advance care planning (ACP) among Latinos are as low as 10% compared to an average of 26% among adults living in the United States. Typical American values of autonomy and self-determination that underlie ACP often conflict with the values of group decision-making, fatalism, and respect for hierarchy that influence decision making in the Latino community. Research suggests that community-based initiatives and culturally competent patient education improves rates of ACP in the Latino community. Findings discuss the use of culturally sensitive and linguistically appropriate ACP video education with Latinos in a metropolitan community setting, as well as recommendations for practice.

Uptake of a newly implemented advance care planning program in a dementia diagnostic service

BACKGROUND

Advance care planning (ACP) provides a framework for discussion and documentation of future care preferences when a person loses cognitive capacity. It can assist people in the early stages of dementia to document their preferences for care at later stages of the illness.

METHOD

A three-stage project introduced ACP to clients with mild cognitive impairment (MCI) or recently diagnosed dementia and their families through a specialist memory clinic. Over 8 months, all English-speaking clients (n = 97) and carers (n = 92) were mailed a survey assessing completed documentation for future care; understanding of the principles of ACP and willingness to get further information about ACP (Stage 1). Participants wanting more information were invited to a seminar introducing the ACP program and service (Stage 2). Participants wanting to complete ACP documentation could make an appointment with the ACP clinicians (Stage 3).

RESULTS

Forty-eight (52.2%) carers and 34 clients (35.1%) responded to the survey. Most clients (62.1%) and carers (79.1%) expressed interest in ACP, and 78.6% of clients and 63.6% of carers believed that clients should be involved in their future medical decisions. Nine clients (26.5%; diagnoses: MCI = 5; AD = 3; mixed dementia = 1) and 9 carers (18.8%) attended the seminars, and 2/48 (4%) carers and 3/34 (8.8%) clients (diagnoses: MCI = 2; AD = 1) completed ACP.

CONCLUSION

Despite initial interest, ACP completion was low. The reasons for this need to be determined. Approaches that may better meet the needs of people newly diagnosed with MCI and dementia are discussed.

Chronically homeless persons' participation in an advance directive intervention: A cohort study

BACKGROUND

Chronically homeless individuals have high rates of hospitalization and death, and they may benefit from the completion of advance directives.

AIM

To determine the rate of advance directive completion using a counselor-guided intervention, identify characteristics associated with advance directive completion, and describe end-of-life care preferences in a group of chronically homeless individuals.

DESIGN

Participants completed a survey and were offered an opportunity to complete an advance directive with a trained counselor.

PARTICIPANTS

A total of 205 residents of a shelter in Canada for homeless men (89.1% of those approached) participated from April to June 2013.

RESULTS

Duration of homelessness was ⩾12 months in 72.8% of participants, and 103 participants (50.2%) chose to complete an advance directive. Socio-demographic characteristics, health status, and health care use were not associated with completion of an advance directive. Participants were more likely to complete an advance directive if they reported thinking about death on a daily basis, believed that thinking about their friends and family was important, or reported knowing their wishes for end-of-life care but not having told anyone about these wishes. Among individuals who completed an advance directive, 61.2% named a substitute decision maker, and 94.1% expressed a preference to receive cardiopulmonary resuscitation in the event of a cardiorespiratory arrest if there was a chance of returning to their current state of health.

CONCLUSION

A counselor-guided intervention can achieve a high rate of advance directive completion among chronically homeless persons. Most participants expressed a preference to receive cardiopulmonary resuscitation in the event of a cardiorespiratory arrest.

Feasibility and Acceptability of a Brief Motivational Stage-Tailored Intervention to Advance Care Planning: A Pilot Study

AIM

This pilot study explored the feasibility and acceptability of a stage-tailored motivational interviewing intervention with education that focuses on changes in end-of-life (EOL) communication, completion of advance directives (ADs), and readiness for advance care planning (ACP).

METHODS

One group pretest-posttest design was implemented with 30 low-income older adults.

RESULTS

This pilot study showed its feasibility in enhancing ACP. Action for ACP-that is, identifying a proxy for decision making and documenting EOL treatment preference in an AD-increased significantly by 23.3% (n = 7). The participants' readiness for ACP, knowledge, self-efficacy, positive attitudes, and perceived importance of ACP increased significantly after the intervention.

CONCLUSION

Health care professionals and service providers who interact with older adults should tailor ACP dialogues in accordance with individuals' motivation.

A mixed method feasibility study of a patient- and family-centred advance care planning intervention for cancer patients

Background

Advance care planning (ACP) is a process whereby values and goals are sensitively explored and documented to uphold patients’ wishes should they become incompetent to make decisions in the future. Evidenced-based, effective approaches are needed. This study sought to assess the feasibility and acceptability of an ACP intervention informed by phase 1 findings and assessed the suitability of measures for a phase 3 trial.

Methods

Prospective, longitudinal, mixed methods study with convenience sampling. A skilled facilitator conducted an ACP intervention with stage III/IV cancer patients and invited caregivers. It incorporated the vignette technique and optional completion/integration of ACP documents into electronic medical records (EMR). Quantitative and qualitative data were collected concurrently, analysed separately, and the two sets of findings converged.

Results

Forty-seven percent consent rate with 30 patients and 26 caregivers completing the intervention. Ninety percent of patient participants had not or probably not written future care plans. Compliance with assessments was high and missing responses to items low. Small- to medium-sized changes were observed on a number of patients and caregiver completed measures, but confidence intervals were typically wide and most included zero. An increase in distress was reported; however, all believed the intervention should be made available. Eleven documents from nine patients were incorporated into EMR. ACP may not be furthered because of intervention inadequacies, busy lives, and reluctance to plan ahead.

Conclusions

In this phase 2 study we demonstrated feasibility of recruitment and acceptability of the ACP intervention and most outcome measures. However, patient/family preferences about when and whether to document ACP components need to be respected. Thus flexibility to accommodate variability in intervention delivery, tailored to individual patient/family preferences, may be required for phase 3 research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-015-0023-1) contains supplementary material, which is available to authorized users.

A qualitative study: professionals' experiences of advance care planning in dementia and palliative care, 'a good idea in theory but ...'

BACKGROUND

Advance care planning comprises discussions about an individual's wishes for future care while they have capacity.

AIM

To explore professionals' experiences on the implementation of advance care planning in two areas of clinical care, dementia and palliative care.

DESIGN

Qualitative study, focus groups and individual interviews.

SETTING

North East of England.

SAMPLE

Ninety-five participants from one Primary Care Trust, two acute National Health Service Hospital Trusts, one Ambulance Trust, one Local Authority and voluntary organisations and the legal sector.

RESULTS

Fourteen focus groups and 18 interviews were held with 95 participants. While professionals agreed that advance care planning was a good idea in theory, implementation in practice presented them with significant challenges. The majority expressed uncertainty over the general value of advance care planning, whether current service provision could meet patient wishes, their individual roles and responsibilities and which aspects of advance care planning were legally binding; the array of different advance care planning forms and documentation available added to the confusion. In dementia care, the timing of when to initiate advance care planning discussions was an added challenge.

CONCLUSIONS

This study has identified the professional, organisational and legal factors that influence advance care planning implementation; professional training should target these specific areas. There is an urgent need for standardisation of advance care planning documentation. Greater clarity is also required on the roles and responsibilities of different professional groups. More complex aspects of advance care planning may be better carried out by those with specialist skills and experience than by generalists caring for a wide range of patient groups with different disease trajectories.

The era of "e": the use of new technologies in advance care planning

In this article, the authors review developments in technology that can help patients, their loved ones, and healthcare providers engage in more effective advance care planning (ACP). The article begins with a brief description of ACP and its purpose and then discusses various electronically available resources for ACP in the U.S. Finally the authors provide a critical assessment of the achievements, challenges, and future prospects for electronic advance care planning, or "e-planning."

Tracking the route to sustainability: a service evaluation tool for an advance care planning model developed for community palliative care services

AIMS AND OBJECTIVES

The study aim was to develop a service evaluation tool for an advance care planning model implemented in community palliative care.

BACKGROUND

Internationally, advance care planning programmes usually measure success by completion rate of advance directives or plans. This outcome measure provides little information to assist nurse managers to embed advance care planning into usual care and measure their performance and quality over time. An evaluation tool was developed to address this need in Australian community palliative care services.

DESIGN

Multisite action research approach.

METHODS

Three community palliative care services located in Victoria, Australia, participated. Qualitative and quantitative data collection strategies were used to develop the Advance Care Planning-Service Evaluation Tool.

RESULTS

The Advance Care Planning-Service Evaluation Tool identified advance care planning progress over time across three stages of Establishment, Consolidation and Sustainability within previously established Model domains of governance, documentation, practice, education, quality improvement and community engagement. The tool was used by nurses either as a peer-assessment or self-assessment tool that assisted services to track their implementation progress as well as plan further change strategies.

CONCLUSION

The Advance Care Planning-Service Evaluation Tool was useful to nurse managers in community palliative care. It provided a clear outline of service progress, level of achievement and provided clear direction for planning future changes.

RELEVANCE TO CLINICAL PRACTICE

The Advance Care Planning-Service Evaluation Tool enables nurses in community palliative care to monitor, evaluate and plan quality improvement of their advance care planning model to improve end-of-life care. As the tool describes generic healthcare processes, there is potential transferability of the tool to other types of services.

Barriers to Completion of Advance Care Directives among African Americans Ages 25–84: A Cross-Generational Study

Prior studies conducted in the area of Advance Care Directive document completion in African Americans have primarily targeted the elderly who are either institutionalized in skilled nursing facilities or are members of faith communities. Few studies have been done concerning barriers to Advance Care Directive document completion that include non-elderly African Americans. The purpose of this study was to identify the common barriers to advance care directive document completion across generations of African Americans ages 25–84. Using convenience sampling among various Baptist denominations of the African-American faith community of Buncombe County, North Carolina, 40 individuals ranging in age from 25–84 participated in multiple focus group sessions. Findings revealed participants shared three common barriers: 1) surrogate decision-making, 2) lack of education concerning advance care directive discussions and completion and 3) fear and denial. Also revealed were barriers that varied across generations: 1) fatalism, 2) mistrust of the health care system, 3) spirituality, and 4) economics.

A systematic review of the effectiveness of advance care planning interventions for people with cognitive impairment and dementia

BACKGROUND

advance care planning (ACP) allows a patient to state their preferences for care, so that if in future they cannot make decisions their wishes are known. Our aim was to review systematically the effectiveness of ACP interventions in people with cognitive impairment and dementia.

METHODS

systematic searches of key electronic databases, supplemented by hand searches of reference lists and consultation with experts. Two independent reviewers undertook screening, data extraction and quality assessment.

RESULTS

four studies were included; three allocated providers randomly to intervention or control arm. All took place in nursing homes. Three studies reported formal processes of capacity assessment, only up to 36% of participants were judged to have capacity. Three studies reported positive findings in terms of documentation of patient preferences for care. Two studies reported significant reductions in hospitalisation rates; a third found increased use of hospice services in the intervention group. A meta-analysis could not be carried out due to heterogeneity of outcome measures.

CONCLUSIONS

there is limited evidence for the effectiveness of ACP in people with cognitive impairment/dementia in terms of ACP documentation and health-care use. In terms of capacity to discuss ACP, nursing home settings may be too late for people with dementia.

Incidence and predictors of advance care planning among persons with cognitive impairment

OBJECTIVE

Persons with mild cognitive impairment (MCI) and Alzheimer disease (AD) are at heightened risk for future decisional incapacity. We sought to characterize advance care planning (ACP) rates over time in individuals who had no advance directives (living will or durable power of attorney) in place when they initially presented for a cognitive evaluation.

DESIGN

Retrospective analysis of data that had been prospectively collected.

SETTING

Alzheimer's Disease Research Center memory disorders clinic.

PARTICIPANTS

Persons (N = 127) with a diagnosis of MCI or early AD (n = 72) or moderate to severe AD (n = 55) and no advance directives upon initial presentation for a cognitive evaluation.

MEASUREMENTS

Extraction of responses to items pertaining to ACP assessed during annual semistructured interviews.

RESULTS

By 5 years of follow-up, 39% of the sample had initiated ACP, with little difference by baseline diagnosis. Younger subjects (younger than 65 years) were significantly more likely to initiate advance directives (43%) than older subjects (37%). This age effect was more pronounced in men than in women as well as in married subjects, those with a family history of dementia, those with no depressive disorder, and subjects with moderate to severe AD (versus those with MCI or early AD) at baseline.

CONCLUSION

Only a minority of subjects initiated ACP. The findings suggest the need for interventions aimed at enhancing ACP completion rates, particularly among older adults with cognitive impairment, since these individuals may have a time-limited opportunity to plan for future medical, financial, and other major life decisions.

Advance care planning in advanced cancer: can it be achieved? An exploratory randomized patient preference trial of a care planning discussion

OBJECTIVE

Little is known about the effectiveness of advance care planning in the United Kingdom, although policy documents recommend that it should be available to all those with life-limiting illness.

METHOD

An exploratory patient preference randomized controlled trial of advance care planning discussions with an independent mediator (maximum three sessions) was conducted in London outpatient oncology clinics and a nearby hospice. Seventy-seven patients (mean age 62 years, 39 male) with various forms of recurrent progressive cancer participated, and 68 (88%) completed follow-up at 8 weeks. Patients completed visual analogue scales assessing perceived ability to discuss end-of-life planning with healthcare professionals or family and friends (primary outcome), happiness with the level of communication, and satisfaction with care, as well as a standardized measure of anxiety and depression.

RESULTS

Thirty-eight patients (51%) showed preference for the intervention. Discussions with professionals or family and friends about the future increased in the intervention arms, whether randomized or preference, but happiness with communication was unchanged or worse, and satisfaction with services decreased. Trial participation did not cause significant anxiety or depression and attrition was low.

SIGNIFICANCE OF RESULTS

A randomized trial of advance care planning is possible. This study provides new evidence on its acceptability and effectiveness for patients with advanced cancer.