Effects of an Advance Care Planning Training Program for Certified Palliative Care Nurses in Japan

Education programs for certified palliative care nurses who promote advance care planning (ACP) for cancer patients are important, but not currently available in Japan. This study aimed to develop an educational program of ACP for certified palliative care nurses in Japan and evaluate its effectiveness. A program consisting of four modules was implemented for 60 certified palliative care nurses in the Kyushu, Chugoku, and Shikoku regions. Participants attended one training session, and 39 responded to a survey on changes in ACP practice and difficulties with cancer nursing 3 months after the intervention. The Wilcoxon signed-rank test was performed to compare data before and after the intervention. The results obtained showed an increase in dialogue on ACP among patients/families and healthcare professionals (mean before the intervention = 24.49, mean after the intervention = 27.59, p = 0.045), and a significant decrease in the sense of difficulty with knowledge of and skills for ACP (mean before the intervention = 4.85, mean after the intervention = 4.30, p = 0.001). More than 90% of the participants gave positive comments on the evaluation items such as understanding and satisfaction with the educational program and appropriateness of the contents. After attending the training program, participants' sense of difficulty with their knowledge of and skills for ACP decreased, and their practice of ACP increased. This program may promote the practice of ACP for cancer patients in the future.

Culturally Adapted Consensus Definition and Action Guideline: Japan's Advance Care Planning

CONTEXT

A conceptual framework for advance care planning is lacking in societies like Japan's valuing family-centered decision-making.

OBJECTIVES

A consensus definition of advance care planning with action guideline adapted to Japanese society.

METHODS

We conducted a multidisciplinary modified Delphi study 2020-2022. Thirty physicians, 10 healthcare and bioethics researchers, six nurses, three patient care managers, three medical social workers, three law experts, and a chaplain evaluated, in 7 rounds (including two web-based surveys where the consensus level was defined as ratings by ≥70% of panelists of 7-9 on a nine-point Likert scale), brief sentences delineating the definition, scope, subjects, and action guideline for advance care planning in Japan.

RESULTS

The resulting 29-item set attained the target consensus level, with 72%-96% of item ratings 7-9. Advance care planning was defined as "an individual's thinking about and discussing with their family and other people close to them, with the support as necessary of healthcare providers who have established a trusting relationship with them, preparations for the future, including the way of life and medical treatment and care that they wish to have in the future." This definition/action guideline specifically included support for individuals hesitant to express opinions to develop and express preparations for the future.

CONCLUSION

Adaptation of advance care planning to Japanese culture by consciously enhancing and supporting individuals' autonomous decision-making may facilitate its spread and establishment in Japan and other societies with family-centered decision-making cultures.

Trends in places and causes of death among centenarians in Japan from 2006 to 2016

AIM

Amid the global aging, an establishment of healthcare policies for the aged population is a common issue to be addressed. However, few studies on centenarians have reported place and cause of death (PoD and CoD, respectively) as indicators of end-of-life care quality. This study aimed to analyze trends in PoD and CoD among centenarians in Japan.

METHODS

Data from death certificates from Japanese vital statistics were analyzed; 205 513 deaths occurred among centenarians (aged ≥100 years) in Japan during the period from 2006 to 2016. PoD prevalence was calculated for each CoD. Trends in PoD prevalence were analyzed using the Joinpoint regression model. Changing points, annual percentage changes, and average annual percentage changes (AAPCs) were calculated to examine trends.

RESULTS

The number of deaths more than doubled from 10 340 in 2006 to 26 427 in 2016. PoDs were composed of hospitals (52.7%), nursing homes (31.4%), own homes (13.6%) and others (2.2%). Dementia and old age increased rapidly as CoD. Proportions of hospital and home deaths decreased, with AAPCs of -2.3% (95% confidence interval [CI], -2.6 to -1.9) and -2.3% (95% CI, -3.2 to -1.4), respectively. Conversely, the proportion of deaths in nursing homes rapidly increased, with an AAPC of 6.8% (95% CI, 6.0-7.7).

CONCLUSIONS

The results revealed changes in PoD among centenarians in Japan. Understanding these transitions is indispensable for health policy in aging societies. Geriatr Gerontol Int 2022; ••: ••-••.

Healthcare providers' perception of advance care planning for patients with critical illnesses in acute-care hospitals: a cross-sectional study

Background

In acute-care hospitals, patients treated in an ICU for surgical reasons or sudden deterioration are treated in an outpatient ward, ICU, and other multiple departments. It is unclear how healthcare providers are initiating advance care planning (ACP) for such patients and assisting them with it. The purpose of this study is to clarify healthcare providers’ perceptions of the ACP support provided to patients receiving critical care in acute-care hospitals.

Methods

A cross-sectional study was conducted using questionnaires. In this study, 400 acute-care hospitals with ICUs in Japan were randomly selected, and 1490 subjects, including intensivists, surgeons, ICU nurses, surgical floor nurses, and surgical outpatient nurses, participated. Survey items examined whether ICU patients received ACP support, the participants’ degree of confidence in providing ACP support, the patients’ treatment preferences, and the decision-making process, and whether any discussion was conducted on change of values.

Results

Responses were obtained from 598 participants from 157 hospitals, 41.4% of which reportedly supported ACP provision to ICU patients. The subjects with the highest level of ACP understanding were surgeons (45.8%), and differences in understanding were observed across specialties (P < 0.001). Among the respondents, physicians and nurses expressed high levels of confidence in providing ACP support to patients requiring critical care. However, 15.2% of all the subjects mentioned that they would not attempt to resuscitate the patients. In addition, 25.7% of the participants handed over patients’ values to other departments or hospitals, whereas 25.3% handed over the decision-making process.

Conclusions

Among the participating hospitals, 40% provided ACP support to patients receiving critical care. The low number is possibly because support providers lack understanding of the content of patients’ ACP or about how to support and use ACP. Second, it is sometimes too late to start providing ACP support after ICU admission. Third, healthcare providers differ in their perception of ACP, widely considered an ambiguous concept. Finally, in acute-care hospitals with different healthcare settings, it is necessary to confirm and integrate the changes in feelings and thoughts of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00900-5.

Discrepancies among knowledge, practice, and attitudes towards advance care planning among Chinese clinical nurses: A national cross-sectional study

AIMS AND OBJECTIVES

To explore the Chinese nurses' knowledge and attitudes concerning advance care planning (ACP) and their engagement in ACP practice.

BACKGROUND

Nurses' knowledge, attitude, and practice of ACP are important in promoting ACP in patients, but little is known about knowledge, attitudes, and practice of ACP among nurses in countries where there are no national policies or regulations on ACP.

DESIGN

A descriptive study with a cross-sectional design.

METHODS

An online questionnaire survey was distributed to Chinese nurses who attended a national conference.

RESULTS

A total of 531 nurses completed the survey and were included in the final analysis. No nurses answered all questions correctly, while 31 (5.8%) answered all the survey questions wrong. The participants were most knowledgeable about the item "Once ACP is made, the content of advance directives cannot be revoked" and were least knowledgeable about the item "ACP is valid only when the patients are well informed of the medical condition". The implementation of ACP was favored by 92.5% of participants, but only 3.4% of them had actually engaged in all 5 ACP practices listed in the survey. Experience of dealing with death was positively associated with nurses' knowledge concerning ACP. The number of dying patients cared for in the past 6 months, school education of palliative care, knowledge of ACP, and age were related to engagement in the practice of ACP.

CONCLUSION

Chinese nurses have supportive attitudes towards ACP, but they have limited knowledge and little practice in ACP.

Improving Patient Preparedness and Confidence in Discussing Advance Directives for End-of-Life Care with Health Care Providers in the United States and Japan

BACKGROUND

The low completion rate of advance directives (ADs) has received attention in Japan and the United States, as policy makers and health care professionals face aging populations with multiple comorbidities. Among the barriers to AD planning, cultural values and attitudes appear to be particularly influential. A comparison of culturally distinct societies provides a deeper understanding of these barriers. Through such an approach, this study identifies strategies for increasing AD planning among late-middle-age Japanese and US individuals.

METHODS

After giving informed consent for the Institutional Review Board-approved study, Japanese and US respondents (45-65 y; 50% female) without ADs completed a language-appropriate online survey. Participants were asked to review a decision aid as part of a scenario-based physician consultation regarding artificial nutrition and hydration (ANH). Hypotheses were analyzed using multigroup structural equation modeling.

RESULTS

Important similarities were identified across the 2 groups. After reviewing the decision aid, both samples strongly preferred "no ANH." Respondents who strongly valued either self-reliance or interpersonal relationships experienced greater preparedness for AD planning. In both countries, greater decision preparedness and positive death attitude predicted greater confidence to discuss care options with a provider. Finally, cultural values predicted preference for family participation: respondents with a strong interdependent self-concept desired more family involvement, whereas high independents preferred less.

CONCLUSIONS

Findings indicate the importance of documenting care preferences and accounting for individual differences. To increase AD adoption, providers should identify patient segments likely to benefit most from the interventions. Targeting individuals in both countries who value self-reliance and interpersonal relationships appears to be a good place to begin. Such individuals can be identified clinically through administration of validated measures used in this study.

Preferences in end of life care substantially differ between the Netherlands and Japan: Results from a cross-sectional survey study

Strategies to increase appropriateness of EoL care, such as shared decision making (SDM), and advance care planning (ACP) are internationally embraced, especially since the COVID-19 pandemic. However, individuals preferences regarding EoL care may differ internationally. Current literature lacks insight in how preferences in EoL care differ between countries and continents. This study's aim is to compare Dutch and Japanese general publics attitudes and preferences toward EoL care, and EoL decisions. Methods: a cross-sectional survey design was chosen. The survey was held among samples of the Dutch and Japanese general public, using a Nationwide social research panel of 220.000 registrants in the Netherlands and 1.200.000 in Japan. A quota sampling was done (age, gender, and living area). N = 1.040 in each country.More Japanese than Dutch citizens tend to avoid thinking in advance about future situations of dependence (26.0% vs 9.4%; P = .000); say they would feel themselves a burden for relatives if they would become dependent in their last phase of life (79.3% vs 47.8%; P = .000); and choose the hospital as their preferred place of death (19.4% vs 3.6% P = .000). More Dutch than Japanese people say they would be happy with a proactive approach of their doctor regarding EoL issues (78.0% vs 65.1% JPN; P = .000).Preferences in EoL care substantially differ between the Netherlands and Japan. These differences should be taken into account a) when interpreting geographical variation in EoL care, and b) if strategies such as SDM or ACP - are considered. Such strategies will fail if an international "one size fits all" approach would be followed.

Feasibility and acceptability of a culturally adapted advance care planning intervention for people living with advanced cancer and their families: A mixed methods study

BACKGROUND

Increasing evidence shows that advance care planning is effective in improving outcomes. However, its applicability and acceptability outside Western cultures remain unknown. Examination of relevant cultural adaptations is required prior to wider adoption.

AIM

To examine the feasibility and acceptability of a culturally adapted advance care planning intervention in a Taiwanese inpatient hospital for advanced cancer patients, family members and healthcare professionals.

METHODS

A single-group, non-controlled, mixed methods feasibility study guided by a previously developed logic model. The culturally adapted advance care planning intervention represented a one-time intervention, comprising pre-advance care planning preparation and follow-up consultation. Qualitative interviews explored participants' view on their involvement in the study. Patients' medical records were examined to assess intervention fidelity. Findings from both data sets were integrated following analysis.

RESULTS

N = 29 participants (n = 10 patients; n = 10 family members and n = 9 healthcare professionals) participated in the intervention, of who 28 completed follow-up interviews. Of the 10 advance care planning interventions delivered, most components (n = 10/13) were met. Key contextual moderators influencing the intervention feasibility included: (1) resource constraints resulting in increased workload; (2) care decisions informed by relatives' experiences of care; (3) the requirement for financial and policy support; and (4) a presumption for end-of-life care provision and surrogate decision-making. Six areas of intervention refinement were identified for future research.

CONCLUSION

Implementing a culturally adapted advance care planning intervention in an inpatient hospital setting in Taiwan is possible. The participants reported the intervention to be acceptable. However, careful attention to the conceptual underpinning using local primary data is imperative for its success.

Current Engagement in Advance Care Planning in Japan and Its Associated Factors

Using the Ministry of Health, Labour and Welfare national data on perspectives toward medical care at the end of life, this study examined the current status of engagement in advance care planning (ACP) activities among physicians and nurses in Japan and associated factors. Only 28.7% of physicians and 27.6% of nurses answered that they were engaging their patients/clients in ACP. Multinomial regression analysis revealed that more frequent involvement in caring for dying patients was associated with ACP engagement for both physicians and nurses. Increased years of clinical practice experience and working in a hospital were associated with decreased likelihood of nurses’ ACP engagement. Completion of training designed to promote patient self-determination at the end of life was associated with both physicians’ and nurses’ ACP engagement. It is recommended that health care professionals be encouraged to complete such training to promote patients’ autonomy through ACP.

Challenges to Successful Community-based Integrated Approach to Dementia: A Qualitative Study

The aim of this study is to identify key challenges to successful community-based integrated team approach to the management of older adults with dementia. A nationwide community-based qualitative research strategy was applied. We purposively recruited 24 health-care providers and 13 family caregivers from selected 8 prefectures among 47 prefectures. Face to face interviews were conducted from May to September 2017. Qualitative content analysis was used to analyze the qualitative data. Ten themes regarding the challenges were emerged: Ignored wishes, Family caregivers' full responsibilities, Encouragement, Practical and easy-to-understand information, Essential skills of dementia diagnosis and assessment, Gratitude by helping others, Difference between being kind and overly-kind, Legal barrier against information sharing, Coordination between volunteers and clients, and Conflict avoidance in multidisciplinary collaboration. The findings highlight the need to provide practical and easy-to-understand information for family caregivers, educate physicians in dementia diagnosis and assessment, share personal dementia care information among health-care providers, promote platforms which aim to match dementia care volunteers with older adults with dementia and their families in need of help, and raise awareness of advance care planning among both older individuals and health-care providers.

Gender differences in wishes and feelings regarding end-of-life care among Japanese elderly people living at home

Objective: This study aimed to explore the gender differences in wishes and feelings regarding end-of-life care among Japanese elderly people requiring home care services.

Patient/Materials and Methods: This study was a secondary analysis of the qualitative data previously compiled from a total of 102 elderly people living at home. The data was retrospectively collected from the participants’ nursing records, which included a designated advance care planning (ACP) form completed between January and July 2015. Out of the 102 participants, 86 men and women who were either living alone or with a spouse were selected for the present analysis. We reviewed the participants’ ACP forms based on which of the sentiments on the following checklist were expressed: anxiety about the future, abandonment of control, clinging to current daily life, inadequate support from spouse, and a tendency to delegate decision-making.

Results: The most commonly expressed feeling was abandonment of control, among both men and women. Among elderly people living alone, women were more likely to want to be surrounded by good, caring people when approaching the end of their lives. Among elderly people living with a spouse, women were more likely to want to delegate decision-making to others.

Conclusion: Our results pointed to a gender difference in the attitudes of elderly people toward interactions with the people surrounding them during the end-of-life decision-making process. In order to provide better overall care, health care professionals must come to realize the importance of this gender difference, as it has an impact on the ACP choices made by elderly people living in the community.

Advance Care Planning for Older People with Cancer and Its Implications in Asia: Highlighting the Mental Capacity and Relational Autonomy

With dramatically increasing proportions of older people, global ageing has remarkably influenced healthcare services and policy making worldwide. Older people represent the majority of patients with cancer, leading to the increasing demand of healthcare due to more comorbidities and inherent frailty. The preference of older people with cancer are often ignored, and they are considered incapable of making choices for themselves, particularly medical decisions. This might impede the provision of their preferred care and lead to poor healthcare outcomes. Advance care planning (ACP) is considered an effective intervention to assist older people to think ahead and make a choice in accordance with their wishes when they possess capacity to do so. The implementation of ACP can potentially lead to positive impact for patients and families. However, the assessment of mental capacity among older adults with cancer might be a crucial concern when implementing ACP, as loss of mental capacity occurs frequently during disease deterioration and functional decline. This article aims to answer the following questions by exploring the existing evidence. How does ACP develop for older people with cancer? How can we measure mental capacity and what kind of principles for assessment we should apply? What are the facilitators and barriers when implementing an ACP in this population? Furthermore, a discussion about cultural adaptation and relevant legislation in Asia is elucidated for better understanding about its cultural appropriateness and the implications. Finally, recommendations in relation to early intervention with routine monitoring and examination of capacity assessment in clinical practice when delivering ACP, reconciling patient autonomy and family values by applying the concept of relational autonomy, and a corresponding legislation and public education should be in place in Asia. More research on ACP and capacity assessment in different cultural contexts and policy frameworks is highlighted as crucial factors for successful implementation of ACP.