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Cagle JG, Reiff JS, Smith A, Echavarria D, Scerpella D, Zhang T, Roth DL, Hanna V, Boyd CM, Hussain NA, Wolff JL. Assessing Advance Care Planning Fidelity within the Context of Cognitive Impairment: The SHARE Trial. J Pain Symptom Manage 2024; 68:180-189. [PMID: 38754769 PMCID: PMC11334724 DOI: 10.1016/j.jpainsymman.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/01/2024] [Accepted: 05/07/2024] [Indexed: 05/18/2024]
Abstract
CONTEXT Advance care planning (ACP) is critical among primary care patients with cognitive impairment, but few interventions have tested ACP with this population. OBJECTIVE Describe the development and evaluation of a tool for assessing ACP fidelity within the context of cognitive impairment, including inter-rater reliability, convergent validity, and overall fidelity using clinical trial data. DESIGN SHARE is a multicomponent intervention inclusive of facilitated ACP conversations. From a two group, single blind, randomized controlled trial, recorded ACP conversations were rated for fidelity. 145 primary care patients and their care partners were randomized to receive the intervention. Participating patients were 80+ years, had a care partner, and indications of cognitive impairment. An ACP Fidelity Checklist was developed with three subscales: Meeting Set-Up; ACP Meeting Topics; and Communication Skills. Scores were converted to percentages (100% = perfect fidelity) with a target of ≥80% fidelity. A post-ACP meeting report completed by ACP facilitators was used to assess convergent validity of the checklist. Intra-class correlation (ICC) was to evaluate inter-rater reliability. RESULTS ACP conversations averaged 33.6 minutes (SD = 14.1). The mean fidelity score across N = 91 rated meetings was 82.9%, with a range of 77.3%-90.6% for subscales. 63.7% of meetings achieved a rating of ≥80%. Cognitive function was positively associated with patient participation (rho = .59, P < 0.001). For checklist items, ICC scores ranged from 0.43-0.96. Post-ACP meeting form scores were correlated with the checklist Meeting Topics subscale (r = 0.36, P = 0.001). CONCLUSIONS Assessing the fidelity of ACP conversations involving primary care patients living with cognitive impairment and their care partners is feasible.
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Affiliation(s)
- John G Cagle
- School of Social Work (J.G.C.), University of Maryland, Baltimore, Maryland, USA.
| | - Jenni S Reiff
- Department of Health Policy and Management (J.S.R., D.E., D.S., V.H., J.L.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ambrym Smith
- MedStar Union Memorial Hospital (A.S.), Baltimore, Maryland, USA
| | - Diane Echavarria
- Department of Health Policy and Management (J.S.R., D.E., D.S., V.H., J.L.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Danny Scerpella
- Department of Health Policy and Management (J.S.R., D.E., D.S., V.H., J.L.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Talan Zhang
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology (T.Z., D.L.R.), Johns Hopkins University, Baltimore, Maryland, USA
| | - David L Roth
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology (T.Z., D.L.R.), Johns Hopkins University, Baltimore, Maryland, USA
| | - Valecia Hanna
- Department of Health Policy and Management (J.S.R., D.E., D.S., V.H., J.L.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology (C.M.B.), Johns Hopkins University, Baltimore, Maryland, USA
| | - Naaz A Hussain
- Johns Hopkins Community Physicians (N.A.H.), Frederick, Maryland, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management (J.S.R., D.E., D.S., V.H., J.L.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Bryant J, Mansfield E, Cameron E, Sanson-Fisher R. Experiences and preferences for advance care planning following a diagnosis of dementia: Findings from a cross-sectional survey of carers. PLoS One 2023; 18:e0286261. [PMID: 37307258 DOI: 10.1371/journal.pone.0286261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/12/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Future medical and financial planning is important for persons with dementia given the impact of the disease on capacity for decision making. AIMS To explore from the perspective of carers of persons with dementia: (1) Participation in future medical and financial planning by the person they care for, including when planning was undertaken and the characteristics associated with having an advance care directive completed; (2) The type of healthcare providers who discussed advance care planning following diagnosis; and (3) Preferences for timing of discussions about advance care planning following diagnosis. METHODS Recruitment and data collection took place between July 2018 and June 2020. Carers of persons with dementia aged 18 years and older were mailed a survey. Participants completed questions regarding completion of various future planning documents by the person they support, including time of completion and who discussed advance care planning following diagnosis. Participants were presented with information about the benefits and consequences of early and late discussions of advance care planning and asked when discussions about advance care planning were best initiated. RESULTS 198 carers participated. Most participants were female (74%) and had been a carer for more than 2 years (82%). Most participants reported that the person with dementia they support had made a Will (97%) and appointed an Enduring Guardian (93%) and Enduring Power of Attorney (89%). Only 47% had completed an advance care directive. No significant associations were found between characteristics of persons with dementia and completion of an advance care directive. Geriatricians (53%) and GPs (51%) most often discussed advance care planning following diagnosis. Most carers thought that discussions about advance care planning should occur in the first few weeks or months following diagnosis (32%), at the healthcare provider's discretion (31%), or at the time of diagnosis (25%). CONCLUSIONS More than half of persons with dementia do not have an advance care directive. There is variability in preferences for timing of discussions following dementia diagnosis.
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Affiliation(s)
- Jamie Bryant
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Elise Mansfield
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Emilie Cameron
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Rob Sanson-Fisher
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
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Mattos MK, Gibson JS, Wilson D, Jepson L, Ahn S, Williams IC. Shared decision-making in persons living with dementia: A scoping review. DEMENTIA 2023; 22:875-909. [PMID: 36802973 PMCID: PMC10866150 DOI: 10.1177/14713012231156976] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Evidence supports that older adults with cognitive impairment can reliably communicate their values and choices, even as cognition may decline. Shared decision-making, including the patient, family members, and healthcare providers, is critical to patient-centered care. The aim of this scoping review was to synthesize what is known about shared decision-making in persons living with dementia. A scoping review was completed in PubMed, CINAHL, and Web of Science. Keywords included content areas of dementia and shared decision-making. Inclusion criteria were as follows: description of shared or cooperative decision making, cognitively impaired patient population, adult patient, and original research. Review articles were excluded, as well as those for which the formal healthcare provider was the only team member involved in the decision-making (e.g., physician), and/or the patient sample was not cognitively impaired. Systematically extracted data were organized in a table, compared, and synthesized. The search yielded 263 non-duplicate articles that were screened by title and abstract. Ninety-three articles remained, and the full text was reviewed; 32 articles were eligible for this review. Studies were from across Europe (n = 23), North America (n = 7), and Australia (n = 2). The majority of the articles used a qualitative study design, and 10 used a quantitative study design. Categories of similar shared decision-making topics emerged, including health promotion, end-of-life, advanced care planning, and housing decisions. The majority of articles focused on shared decision-making regarding health promotion for the patient (n = 16). Findings illustrate that shared decision-making requires deliberate effort and is preferred among family members, healthcare providers, and patients with dementia. Future research should include more robust efficacy testing of decision-making tools, incorporation of evidence-based shared decisionmaking approaches based on cognitive status/diagnosis, and consideration of geographical/cultural differences in healthcare delivery systems.
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Affiliation(s)
| | | | - Dan Wilson
- Health Sciences Library, 2358University of Virginia, USA
| | - Laura Jepson
- School of Nursing, 2358University of Virginia, USA
| | - Soojung Ahn
- School of Nursing, Vanderbilt University, USA
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Isabel V, Joachim C, Peter H, Chantal VA, Luc D, Aline DV. Support from healthcare professionals in empowering family carers to discuss advance care planning: A population-based survey. Palliat Med 2022; 37:719-729. [PMID: 36349646 DOI: 10.1177/02692163221135032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Family carers have a prominent role in end-of-life care for seriously ill persons. However, most of the Advance Care Planning literature is focused on the role of healthcare professionals. AIMS To investigate (1) what proportion of family carers discussed advance care planning with their relative and associated socio-demographic and clinical characteristics (2) what proportion received support from healthcare professionals for these conversations, (3) what type of support they received and (4) to what extent the type of support received was considered sufficient. DESIGN/PARTICIPANTS Population-based cross-sectional survey in Belgium of bereaved family carers of persons with a serious chronic illness (N = 3000) who died 2-6 months before the sample was drawn, identified through three sickness funds. The survey explored support from healthcare professionals for family carers during the last 3 months of the patient's life. RESULTS Response rate was 55%. The proportion of family carers that engaged in an advance care planning conversation with their relative was 46.9%. Of these family carers, 78.1% received support from a healthcare professional, mostly by doing the advance care planning conversation together (53.8%). Of family carers receiving support from a healthcare professional, 57.4% deemed the support sufficient. CONCLUSION Many family carers engage in advance care planning conversations with their dying relative. Healthcare professionals often support them by performing the advance care planning conversations together. More insight into how family carers can be supported to conduct these advance care planning conversations, both with and without involvement of healthcare professionals, is necessary.
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Affiliation(s)
- Vandenbogaerde Isabel
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Cohen Joachim
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Hudson Peter
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,Centre for Palliative Care, St Vincents Hospital, The University of Melbourne, Melbourne, Australia
| | | | - Deliens Luc
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - De Vleminck Aline
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
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Chen PJ, Smits L, Miranda R, Liao JY, Petersen I, Van den Block L, Sampson EL. Impact of home healthcare on end-of-life outcomes for people with dementia: a systematic review. BMC Geriatr 2022; 22:80. [PMID: 35081914 PMCID: PMC8793202 DOI: 10.1186/s12877-022-02768-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 01/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Home healthcare (HHC) comprises clinical services provided by medical professionals for people living at home with various levels of care needs and health conditions. HHC may reduce care transitions from home to acute hospitals, but its long-term impact on homebound people living with dementia (PLWD) towards end-of-life remains unclear. We aim to describe the impact of HHC on acute healthcare utilization and end-of-life outcomes in PLWD. METHODS Design: Systematic review of quantitative and qualitative original studies which examine the association between HHC and targeted outcomes. INTERVENTIONS HHC. PARTICIPANTS At least 80% of study participants had dementia and lived at home. MEASUREMENTS Primary outcome was acute healthcare utilization in the last year of life. Secondary outcomes included hospice palliative care, advance care planning, continuity of care, and place of death. We briefly reviewed selected national policy to provide contextual information regarding these outcomes. RESULTS From 6831 articles initially identified, we included five studies comprising data on 4493 participants from USA, Japan, and Italy. No included studies received a "high" quality rating. We synthesised core properties related to HHC at three implementational levels. Micro-level: HHC may be associated with a lower risk of acute healthcare utilization in the early period (e.g., last 90 days before death) and a higher risk in the late period (e.g. last 15 days) of the disease trajectory toward end-of-life in PLWD. HHC may increase palliative care referrals. Advance care planning was an important factor influencing end-of-life outcomes. Meso-level: challenges for HHC providers in medical decision-making and initiating palliative care for PLWD at the end-of-life may require further training and external support. Coordination between HHC and social care is highlighted but not well examined. Macro-level: reforms of national policy or financial schemes are found in some countries but the effects are not clearly understood. CONCLUSIONS This review highlights the dearth of dementia-specific research regarding the impact of HHC on end-of-life outcomes. Effects of advance care planning during HHC, the integration between health and social care, and coordination between primary HHC and specialist geriatric/ palliative care services require further investigation.
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Affiliation(s)
- Ping-Jen Chen
- grid.83440.3b0000000121901201Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7BN UK ,grid.412027.20000 0004 0620 9374Department of Family Medicine and Division of Geriatrics and Gerontology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan ,grid.412019.f0000 0000 9476 5696School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Lisanne Smits
- grid.83440.3b0000000121901201Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7BN UK ,grid.7177.60000000084992262Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands
| | - Rose Miranda
- grid.8767.e0000 0001 2290 8069End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium ,grid.8767.e0000 0001 2290 8069Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jung-Yu Liao
- grid.412019.f0000 0000 9476 5696Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Irene Petersen
- grid.83440.3b0000000121901201Research Department of Primary Care and Population Health, University College London, London, UK
| | - Lieve Van den Block
- grid.8767.e0000 0001 2290 8069End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium ,grid.8767.e0000 0001 2290 8069Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Elizabeth L. Sampson
- grid.83440.3b0000000121901201Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7BN UK ,grid.439355.d0000 0000 8813 6797Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
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Dujardin J, Schuurmans J, Westerduin D, Wichmann AB, Engels Y. The COVID-19 pandemic: A tipping point for advance care planning? Experiences of general practitioners. Palliat Med 2021; 35:1238-1248. [PMID: 34041987 DOI: 10.1177/02692163211016979] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2020, the COVID-19 pandemic caused an acute risk of deterioration and dying for many, and an urgent need to start advance care planning. AIM To explore how general practitioners (GPs) experienced discussing values, goals and preferences with patients during COVID-19. DESIGN AND SETTING Qualitative research in general practice. METHODS Semi-structured interviews for which Dutch GPs were recruited via purposive sampling. Content analysis was used. RESULTS Fifteen GPs were interviewed. Six themes were identified: (i) urge of advance care planning, (ii) the GP's perceived role in it, (iii) preparations for it, (iv) (proactively) discussing it, (v) essentials for good communication and (vi) advance care planning in the (near) future. Calls for proactively discussing advance care planning in the media and in COVID-guidelines caused awareness of it's importance. GPs envisaged an important role for themselves in initiating it, especially with patients at risk to deteriorate or die from COVID-19. Timing advance care planning appeared difficult but crucial. The recommended digital way of communication was considered problematic due to missing nonverbal communication and difficulties in involving relatives. It was noted that admission to the ICU, which was hardly discussed before the COVID-19 pandemic, should remain a topic during advance care planning. CONCLUSION The COVID-19 pandemic brought advance care planning into a new light, GPs were more experienced with discussing it and patients were more aware of their frailty. Because of the nearing 'grey wave', advance care planning should remain top priority. Therefore, it should be central in GP and post-academic training.
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Affiliation(s)
- Janneke Dujardin
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Jaap Schuurmans
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Dieke Westerduin
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Anne B Wichmann
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
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van der Steen JT, Heck S, Juffermans CC, Garvelink MM, Achterberg WP, Clayton J, Thompson G, Koopmans RT, van der Linden YM. Practitioners' perceptions of acceptability of a question prompt list about palliative care for advance care planning with people living with dementia and their family caregivers: a mixed-methods evaluation study. BMJ Open 2021; 11:e044591. [PMID: 33846153 PMCID: PMC8048016 DOI: 10.1136/bmjopen-2020-044591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES In oncology and palliative care, patient question prompt lists (QPLs) with sample questions for patient and family increased patients' involvement in decision-making and improved outcomes if physicians actively endorsed asking questions. Therefore, we aim to evaluate practitioners' perceptions of acceptability and possible use of a QPL about palliative and end-of-life care in dementia. DESIGN Mixed-methods evaluation study of a QPL developed with family caregivers and experts comprising a survey and interviews with practitioners. SETTING Two academic medical training centres for primary and long-term care in the Netherlands. PARTICIPANTS Practitioners (n=66; 73% woman; mean of 21 (SD 11) years of experience) who were mostly general practitioners and elderly care physicians. OUTCOMES The main survey outcome was acceptability measured with a 15-75 acceptability scale with ≥45 meaning 'acceptable'. RESULTS The survey response rate was 21% (66 of 320 participated). The QPL was regarded as acceptable (mean 51, SD 10) but 64% felt it was too long. Thirty-five per cent would want training to be able to answer the questions. Those who felt unable to answer (31%) found the QPL less acceptable (mean 46 vs 54 for others; p=0.015). We identified three themes from nine interviews: (1) enhancing conversations through discussing difficult topics, (2) proactively engaging in end-of-life conversations and (3) possible implementation. CONCLUSION Acceptability of the QPL was adequate, but physicians feeling confident to be able to address questions about end-of-life care is crucial when implementing it in practice, and may require training. To facilitate discussions of advance care planning and palliative care, families and persons with dementia should also be empowered to access the QPL themselves.
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Affiliation(s)
- Jenny T van der Steen
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Sten Heck
- Leiden University, Leiden, The Netherlands
| | - Carla Cm Juffermans
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Wilco P Achterberg
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Josephine Clayton
- Centre for Learning & Research in Palliative Care, Hammond Care, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia
| | - Genevieve Thompson
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Raymond Tcm Koopmans
- Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Radboud university medical center, Nijmegen, The Netherlands
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