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Mróz LL, Soheilipour S, Siden E, Carter RZ, Kryworuchko J, Sawatzky R, Husband A, Stajduhar K, Barwich D, Hassan E. "Now I get what's important" - Shifting philosophies of hospice society staff and trained volunteers involved in peer-facilitated Advance Care Planning workshops for the public. PATIENT EDUCATION AND COUNSELING 2023; 115:107925. [PMID: 37499447 DOI: 10.1016/j.pec.2023.107925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 07/20/2023] [Accepted: 07/23/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE Community-led approaches can increase public engagement in Advance Care Planning (ACP). Better understanding of the experiences and perspectives of community staff and volunteers who host and facilitate community-led, peer-facilitated ACP workshops is valuable when considering the spread of these approaches. METHODS Content analysis of qualitative data from community-based hospice societies delivering ACP workshops to the public in British Columbia: one-on-one interviews with 5 organizational representatives and focus groups with 13 peer facilitators. RESULTS Three main categories emerged: 1) ACP is about 'Living well'; 2) Transitioning focus from legal forms to conversations; 3) Benefits to all involved. CONCLUSIONS Community staff and volunteers acknowledge the role they could play in promoting ACP in their communities. They recognize the benefits to the facilitators and public participants from following a community-led approach that emphasizes the importance of ACP conversations over the completion of relevant legal forms. Additional potential benefits of this approach, as reported by the organizational representatives, are increased volunteer engagement, more community partnerships, and an enhanced organizational profile. PRACTICE IMPLICATIONS This community-led model can be a meaningful and approachable way to engage the public in ACP. Hospice societies are well positioned in the community to incorporate ACP workshops into their programming.
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Affiliation(s)
- Lawrence Larry Mróz
- School of Nursing, University of British Columbia, Canada; BC Centre for Palliative Care, Canada
| | - Shimae Soheilipour
- School of Population and Public Health, University of British Columbia, Canada; Department of Oral Public Health, Dental School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ellie Siden
- Faculty of Medicine, University of British Columbia, Canada
| | - Rachel Z Carter
- BC Centre for Palliative Care, Canada; Division of Palliative Care, Department of Medicine, University of British Columbia, Canada.
| | | | - Richard Sawatzky
- School of Nursing, Trinity Western University, Canada; Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Canada
| | | | | | - Doris Barwich
- BC Centre for Palliative Care, Canada; Division of Palliative Care, Department of Medicine, University of British Columbia, Canada
| | - Eman Hassan
- BC Centre for Palliative Care, Canada; Division of Palliative Care, Department of Medicine, University of British Columbia, Canada
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Ben-Moshe S, Curseen KA. Advance Care Planning in the Geriatrics Clinic. Clin Geriatr Med 2023; 39:407-416. [PMID: 37385692 DOI: 10.1016/j.cger.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Advance care planning (ACP) is a process that allows individuals to express their health-care preferences and make decisions about their future medical care. Clinicians practicing in a Geriatrics clinic or with many patients who are aged 65 years or older have a unique opportunity to discuss patients' goals of care. ACP is particularly important for older adults, who may be facing serious health issues and/or end-of-life decisions. This review article will provide an overview of the importance of ACP in the geriatrics clinic, discuss the barriers to implementation, and explore strategies for successful integration..
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Affiliation(s)
- Sivan Ben-Moshe
- Department of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine, Geriatrics Clinic, Emory Healthcare, 1525 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Kimberly A Curseen
- Division of Palliative Medicine, Emory Palliative Care Center, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30322, USA.
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Hwang IY, Han Y, Kim MS, Kim KH, Cho B, Choi W, Kim Y, Yoo SH, Lee SY. Preferred versus Actual Place of Care and Factors Associated with Home Discharge among Korean Patients with Advanced Cancer: A Retrospective Cohort Study. Healthcare (Basel) 2023; 11:1939. [PMID: 37444773 DOI: 10.3390/healthcare11131939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
Respecting the preference for a place of care is essential for advance care planning in patients with advanced cancer. This retrospective study included adult patients with cancer referred to an inpatient palliative care consultation team at a tertiary acute care hospital in South Korea between April 2019 and December 2020. Patients' preference for place of care and demographic and clinical factors were recorded, and the actual discharge locations were categorized as home or non-home. Patients discharged home but with unintended hospital visits within 2 months were also investigated. Of the 891 patients referred to the palliative care consultation team, 210 (23.6%) preferred to be discharged home. Among them, 113 (53.8%) were discharged home. No significant differences were found between patients who preferred home discharge and those who did not. Home discharge was higher among female patients (p = 0.04) and lower in those with poor oral intake (p < 0.001) or dyspnea (p = 0.02). Of the 113 patients discharged home, 37 (32.8%) had unintended hospital visits within 2 months. Approximately one-quarter of hospitalized patients with advanced cancer preferred to be discharged home, but only half of them received the home discharge. To meet patients' preferences for end-of-life care, individual care planning considering relevant factors is necessary.
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Affiliation(s)
- In Young Hwang
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Yohan Han
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Min Sun Kim
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Pediatrics, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Kyae Hyung Kim
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Belong Cho
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Wonho Choi
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Yejin Kim
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Sun Young Lee
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
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Islam Z, Pollock K, Patterson A, Hanjari M, Wallace L, Mururajani I, Conroy S, Faull C. Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-135. [PMID: 37464868 DOI: 10.3310/jvfw4781] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background This study explored whether or not, and how, terminally ill patients from ethnically diverse backgrounds and their family caregivers think ahead about deterioration and dying, and explored their engagement with health-care professionals in end-of-life care planning. Objective The aim was to address the question, what are the barriers to and enablers of ethnically diverse patients, family caregivers and health-care professionals engaging in end-of-life care planning? Design This was a qualitative study comprising 18 longitudinal patient-centred case studies, interviews with 19 bereaved family caregivers and 50 public and professional stakeholder responses to the findings. Setting The study was set in Nottinghamshire and Leicestershire in the UK. Results Key barriers - the predominant stance of patients was to live with hope, considering the future only in terms of practical matters (wills and funerals), rather than the business of dying. For some, planning ahead was counter to their faith. Health-care professionals seemed to feature little in people's lives. Some participants indicated a lack of trust and experienced a disjointed system, devoid of due regard for them. However, religious and cultural mores were of great importance to many, and there were anxieties about how the system valued and enabled these. Family duty and community expectations were foregrounded in some accounts and concern about being in the (un)care of strangers was common. Key enablers - effective communication with trusted individuals, which enables patients to feel known and that their faith, family and community life are valued. Health-care professionals getting to 'know' the person is key. Stakeholder responses highlighted the need for development of Health-care professionals' confidence, skills and training, Using stories based on the study findings was seen as an effective way to support this. A number of behavioural change techniques were also identified. Limitations It was attempted to include a broad ethnic diversity in the sample, but the authors acknowledge that not all groups could be included. Conclusions What constitutes good end-of-life care is influenced by the intersectionality of diverse factors, including beliefs and culture. All people desire personalised, compassionate and holistic end-of-life care, and the current frameworks for good palliative care support this. However, health-care professionals need additional skills to navigate complex, sensitive communication and enquire about aspects of people's lives that may be unfamiliar. The challenge for health-care professionals and services is the delivery of holistic care and the range of skills that are required to do this. Future work Priorities for future research: How can health professionals identify if/when a patient is 'ready' for discussions about deterioration and dying? How can discussions about uncertain recovery and the need for decisions about treatment, especially resuscitation, be most effectively conducted in a crisis? How can professionals recognise and respond to the diversity of faith and cultural practices, and the heterogeneity between individuals of beliefs and preferences relating to the end of life? How can conversations be most effectively conducted when translation is required to enhance patient understanding? Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. X. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Zoebia Islam
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Anne Patterson
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Matilda Hanjari
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Louise Wallace
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
| | - Irfhan Mururajani
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Christina Faull
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
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Whitney K, Peck V, Huang AR, Park J, Menard P, MacDonald J, Spilg E, Khoury L. Changing the channel: a qualitative analysis of an innovative video intervention to explore resident attitudes towards interprofessional collaboration on a Geriatric Medicine Unit. CANADIAN MEDICAL EDUCATION JOURNAL 2023; 14:51-60. [PMID: 37304634 PMCID: PMC10254114 DOI: 10.36834/cmej.71529] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Background Medical learners develop a more positive attitude toward Interprofessional Collaboration (IPC) following Interprofessional Education (IPE) programs. However, IPE is not standardized, and the most effective teaching tool is unclear. The purpose of our study was to develop an IPE teaching tool for medical residents during an inpatient geriatric medicine rotation at an academic hospital, evaluate and explore the impact of the program on resident attitudes towards teamwork, and identify barriers and facilitators to interprofessional collaboration. Methods An innovative video was developed which simulated a common IPC scenario. Near the start of the rotation, learners watched the video then participated in a facilitated discussion around principles of IPE, using the Canadian Interprofessional Health Collaborative (CIHC) framework, which highlights interprofessional communication, patient-centered care, role clarification, team functioning, collaborative leadership, and interprofessional conflict resolution. At the end of their four-week rotation, focus groups were conducted to explore resident attitudes towards IPE. The Theoretical Domain Framework (TDF) was used for qualitative analysis. Results Data from 23 participants in five focus groups were analyzed using the TDF framework. Residents were able to identify barriers and facilitators to IPC in five TDF domains: environmental context and resources, social/professional role and identity, knowledge, social influences, and skills. Their observations correlated with the CIHC framework. Conclusion The use of a scripted video and facilitated group discussion gave insights into residents' attitudes, perceived barriers, and facilitators towards IPC on a geriatric medicine unit. Future research could explore the use of this video intervention in other hospital services where team-based care is important.
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Affiliation(s)
- Krista Whitney
- University of Ottawa, Ontario, Canada
- The Ottawa Hosptial, Ontario, Canada
| | | | - Allen R Huang
- The Ottawa Hosptial, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ontario, Canada
| | - Junghyun Park
- University of Ottawa, Ontario, Canada
- The Ottawa Hosptial, Ontario, Canada
| | - Prudy Menard
- University of Ottawa, Ontario, Canada
- The Ottawa Hosptial, Ontario, Canada
| | - Jason MacDonald
- University of Ottawa, Ontario, Canada
- The Ottawa Hosptial, Ontario, Canada
| | - Edward Spilg
- The Ottawa Hosptial, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ontario, Canada
| | - Lara Khoury
- The Ottawa Hosptial, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ontario, Canada
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Preferred Place of End-of-Life Care Based on Clinical Scenario: A Cross-Sectional Study of a General Japanese Population. Healthcare (Basel) 2023; 11:healthcare11030406. [PMID: 36766981 PMCID: PMC9914905 DOI: 10.3390/healthcare11030406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
In Japan, which has an aging society with many deaths, it is important that people discuss preferred place for end-of-life care in advance. This study aims to investigate whether the preferred place of end-of-life care differs by the assumed clinical scenario. This clinical scenario-based survey used data from a nationwide survey conducted in Japan in December 2017. Participants aged 20 years and older were randomly selected from the general population. The survey contained questions based on three scenarios: cancer, end-stage heart disease, and dementia. For each scenario, respondents were asked to choose the preferred place of end-of-life care among three options: home, nursing home, and medical facility. Eight hundred eighty-nine individuals participated in this study (effective response rate: 14.8%). The proportions of respondents choosing home, nursing home, and medical facility for the cancer scenario were 49.6%, 10.9%, and 39.5%, respectively; for the end-stage heart disease scenario, 30.5%, 18.9%, and 50.6%; and for the dementia scenario, 15.2%, 54.5%, and 30.3% (p < 0.0001, chi-square test). The preferred place of end-of-life care differed by the assumed clinical scenario. In clinical practice, concrete information about diseases and their status should be provided during discussions about preferred place for end-of-life care to reveal people's preferences more accurately.
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McDonald J, Marco D, Howard R, Fox E, Weil J. Implementation of an integrated respiratory palliative care service for patients with advanced lung disease. AUST HEALTH REV 2022; 46:713-721. [PMID: 36223731 DOI: 10.1071/ah22103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/21/2022] [Indexed: 12/13/2022]
Abstract
Objectives This study describes the model of care provided by an integrated respiratory and palliative care service for patients with advanced lung disease, and assesses the potential impact of the service on acute hospital utilisation and cost. Methods This study implemented an integrated specialist care service at a single tertiary teaching hospital in Melbourne, Victoria, Australia. The service provided disease-orientated care, alongside symptom management and advance care planning, and comprised both outpatient clinic (OPC) and home visit (HV) capacity for those with barriers to accessing OPC. Acute hospital utilisation and hospital cost were analysed with a paired t -test 90 days before/after the first physician review. Results Between April 2017 and 2019, 51 patients received 59 HVs, whereas between July 2018 and 2020, 58 patients received 206 OPC reviews. Acute hospital admissions decreased by 51% in the HV cohort (P < 0.05) and by 46% in the OPC cohort (P = 0.01); total bed days of acute admissions decreased by 29% in the HV cohort (P = n.s.), and by 60% in the OPC cohort (P < 0.05); and specialist outpatient clinic attendances decreased in the OPC cohort by 55% (P < 0.01). There was a decrease in hospital cost for the HV cohort by 3% (cost savings of A$18 579), and in the OPC cohort by 23% (cost savings of A$109 149). Conclusions This model of care provided specialist respiratory management with seamless integration of palliative care, with the capacity for home visits. There was a decrease in acute hospital utilisation and overall cost savings observed in both HV and OPC cohorts.
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Affiliation(s)
- Julie McDonald
- Respiratory and Sleep Medicine Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Vic. 3065, Australia; and Palliative Care Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Vic. 3065, Australia
| | - David Marco
- Centre for Palliative Care, St Vincent's Hospital Melbourne and University of Melbourne, Fitzroy, Vic. 3065, Australia
| | - Rebecca Howard
- Health Independence Program, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Vic. 3065, Australia
| | - Euan Fox
- Respiratory and Sleep Medicine Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Vic. 3065, Australia
| | - Jennifer Weil
- Palliative Care Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Vic. 3065, Australia; and Centre for Palliative Care, St Vincent's Hospital Melbourne and University of Melbourne, Fitzroy, Vic. 3065, Australia; and Department of Medicine, University of Melbourne, Parkville, Vic. 3052, Australia
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Views of advance care planning in older hospitalized patients following an emergency admission: A qualitative study. PLoS One 2022; 17:e0273894. [PMID: 36048853 PMCID: PMC9436063 DOI: 10.1371/journal.pone.0273894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 08/17/2022] [Indexed: 11/19/2022] Open
Abstract
Background There is increasing evidence of the need to consider advance care planning (ACP) for older adults who have been recently admitted to hospital as an emergency. However, there is a gap in knowledge regarding how to facilitate ACP following acute illness in later life. Aim/Objectives To explore the perceived impact of ACP on the lives of older persons aged 70+ who have been acutely admitted to hospital. Method Semi-structured qualitative interviews were conducted with older adults aged 70+ who were admitted to hospital as an emergency. Thematic analysis was enhanced by dual coding and exploration of divergent views within an interdisciplinary team. Results Twenty participants were interviewed. Thematic analysis generated the following themes: (1) Bespoke planning to holistically support a sense of self, (2) ACP as a socio-cultural phenomenon advocating for older persons rights, (3) The role of personal relationships, (4) Navigating unfamiliar territory and (5) Harnessing resources. Conclusion These findings indicate that maintaining a sense of personal identity and protecting individuals’ wishes and rights during ACP is important to older adults who have been acutely unwell. Following emergency hospitalization, older persons believe that ACP must be supported by a network of relationships and resources, improving the likelihood of adequate preparation to navigate the uncertainties of future care in later life. Therefore, emergency hospitalization in later life, and the uncertainty that may follow, may provide a catalyst for patients, carers and healthcare professionals to leverage existing or create new relationships and target resources to enable ACP, in order to uphold older persons’ identity, rights and wishes following acute illness.
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Saretta M, Doñate-Martínez A, Alhambra-Borrás T. Barriers and facilitators for an effective palliative care communication with older people: A systematic review. PATIENT EDUCATION AND COUNSELING 2022; 105:2671-2682. [PMID: 35459530 DOI: 10.1016/j.pec.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/30/2022] [Accepted: 04/04/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The present mixed-method systematic review identifies facilitators and barriers in palliative care communication among health professionals and older people. METHODS The review process was conducted by three reviewers who searched studies in four different databases (January 2009-January 2022), exploring experiences of communication among health professionals and older people without cognitive impairments. Relevant articles were quality assessed with a standardized tool. RESULTS Twenty-eight articles were included and the following 5 clusters were identified: 1) training and education for health professionals, 2) team working and coordination among health professionals, 3) communication skills, 4) time and availability, 5) emotional, cultural and psychological factors. The articles highlighted the need for greater preparation of health professionals around the management of palliative care communication with older people. CONCLUSION Palliative care communication among health professionals and older people are characterized by several challenges. However, there are facilitating aspects that may be considered to improve the quality of communication. PRACTICE IMPLICATIONS Facilitators are promising approaches to support health professionals in providing high-quality palliative care communication to older people, developing a person-centred practice. Facilitators include palliative care training and educational opportunities for health professionals, like ELNEC Geriatric Curriculum, permitting them to develop specific competences in communication and aging.
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Affiliation(s)
- Michela Saretta
- Polibienestar Research Institute, University of Valencia, Valencia, Spain.
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Understanding public attitudes to death talk and advance care planning in Northern Ireland using health behaviour change theory: a qualitative study. BMC Public Health 2022; 22:906. [PMID: 35524295 PMCID: PMC9077935 DOI: 10.1186/s12889-022-13319-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 04/19/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Advance care planning is a key preparatory step in ensuring high-quality palliative and end of life care, and should be considered as a process, beginning with community-level conversations among lay persons. There is, however, indication that death talk among community-dwelling adults is not occurring, and there is a dearth of research examining why this is the case. This study aims to provide the first examination of barriers and facilitators to talking about death and dying among the general population in a UK region (Northern Ireland), and to provide a novel application of health behaviour change theory towards developing a theoretical understanding of the sources of this behaviour. METHODS The study involved qualitative analysis of responses (n = 381 participants) to two open-ended questions within a cross-sectional online survey, with recruitment via social media of adults currently living in Northern Ireland. Reflexive thematic analysis was conducted on open text responses per question, with the barriers and facilitators mapped on to health behaviour change models (the Behaviour Change Wheel COM-B and the Theoretical Domains Framework). RESULTS The findings evidence a myriad of barriers and facilitators to engaging in death talk, with themes aligning to areas such as lack of acceptance of death in social contexts and fear of upsetting self or others, and a need to improve interpersonal communication skills for facilitating conversations and improve knowledge of the existing services around death and dying. A theoretical understanding of the drivers of death talk is presented with findings mapped across most components of the COM-B Behaviour Change Model and the Theoretical Domains Framework. CONCLUSIONS This study contributes to a small but emergent research area examining barriers and facilitators to talking about death and dying. Findings from this study can be used to inform new public health programmes towards empowering adults to have these conversations with others in their community towards upstreaming advance care planning.
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Sun F, Lipinsky DeGette R, Cummings EC, Deng LX, Hauser KA, Kopp Z, Penner JC, Scott BS, Raffel KE, Kantor MA. Capturing what matters: A retrospective observational study of advance care planning documentation at an academic medical center during the COVID-19 pandemic. Palliat Med 2022; 36:342-347. [PMID: 34920691 DOI: 10.1177/02692163211065928] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advance care planning allows patients to share their preferences for medical care with the aim of ensuring goal-concordant care in times of serious illness. The morbidity and mortality of the COVID-19 pandemic has increased the importance and public visibility of advance care planning. However, little is known about the frequency and quality of advance care planning documentation during the pandemic. AIM This study examined the frequency, quality, and predictors of advance care planning documentation among hospitalized medical patients with and without COVID-19. DESIGN This retrospective cohort analysis used multivariate logistic regression to identify factors associated with advance care planning documentation. SETTING/PARTICIPANTS This study included all adult patients tested for COVID-19 and admitted to a tertiary medical center in San Francisco, CA during March 2020. RESULTS Among 262 patients, 31 (11.8%) tested positive and 231 (88.2%) tested negative for SARS-CoV-2. The rate of advance care planning documentation was 38.7% in patients with COVID-19 and 46.8% in patients without COVID-19 (p = 0.45). Documentation consistently addressed code status (100% and 94.4% for COVID-positive and COVID-negative, respectively), but less often named a surrogate decision maker, discussed prognosis, or elaborated on other wishes for care. Palliative care consultation was associated with increased advance care planning documentation (OR: 6.93, p = 0.004). CONCLUSION This study found low rates of advance care planning documentation for patients both with and without COVID-19 during an evolving global pandemic. Advance care planning documentation was associated with palliative care consultation, highlighting the importance of such consultation to ensure timely, patient-centered advance care planning.
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Affiliation(s)
- Fangdi Sun
- Department of Medicine, University of California, San Francisco, CA, USA
| | | | | | - Lisa X Deng
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Karen A Hauser
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Zoë Kopp
- Department of Medicine, University of California, San Francisco, CA, USA
| | - John C Penner
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Brandon S Scott
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Katie E Raffel
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Molly A Kantor
- Department of Medicine, University of California, San Francisco, CA, USA
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Siden EG, Carter RZ, Barwich D, Hassan E. Part of the solution: A survey of community organisation perspectives on barriers and facilitating actions to Advance Care Planning in British Columbia, Canada. Health Expect 2021; 25:345-354. [PMID: 34904336 PMCID: PMC8849222 DOI: 10.1111/hex.13390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/19/2021] [Accepted: 11/07/2021] [Indexed: 12/01/2022] Open
Abstract
Background Despite the established benefits of Advance Care Planning (ACP), engagement remains low in British Columbia. Since 2016, a growing number of community‐based nonprofits have offered ACP education. To date, no study has focused on the perspectives of nonprofits on ACP in British Columbia. Objective This study aimed to identify barriers and facilitating actions to ACP as perceived by British Columbian nonprofits. Design A mixed‐methods design was used. Data were collected through online surveys and telephone interviews. Setting and Participants Staff and volunteers from British Columbian nonprofits that are providing or interested in providing public education on ACP were recruited for this study. Results The lack of public awareness of ACP, the emotional difficulty of the conversation, the complicated ACP process, the belief that ACP is synonymous with completing a medical order form, the challenge of introducing ACP in different cultural contexts and the siloed approach to ACP education were rated as the most important barriers to ACP engagement. The most important facilitating actions were developing clear messages, improving ACP literacy, reframing ACP as part of life planning, simplifying ACP documentation and transfer, integrating ACP conversations into clinical practice and better collaboration between the health system and nonprofits. Discussion This study identifies numerous opportunities to improve ACP engagement in British Columbia from a community lens. To maximize ACP engagement, community‐led ACP education should be offered in coordination with the health system. Conclusion Community‐led ACP education as well as collaboration and consultation with nonprofits are part of the solution to the low ACP engagement in British Columbia. Public Contribution Study participants, including staff and volunteers at nonprofits, are members of the public.
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Affiliation(s)
- Ellie G Siden
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,BC Centre for Palliative Care, New Westminster, British Columbia, Canada
| | - Rachel Z Carter
- BC Centre for Palliative Care, New Westminster, British Columbia, Canada.,Department of Medicine, Division of Palliative Care, University of British Columbia, Vancouver, British Columbia, Canada
| | - Doris Barwich
- BC Centre for Palliative Care, New Westminster, British Columbia, Canada.,Department of Medicine, Division of Palliative Care, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eman Hassan
- BC Centre for Palliative Care, New Westminster, British Columbia, Canada.,Department of Medicine, Division of Palliative Care, University of British Columbia, Vancouver, British Columbia, Canada
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13
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Aaron SP, Gazaway SB, Harrell ER, Elk R. Disparities and Racism Experienced Among Older African Americans Nearing End of Life. CURRENT GERIATRICS REPORTS 2021; 10:157-166. [PMID: 34956825 PMCID: PMC8685164 DOI: 10.1007/s13670-021-00366-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/23/2022]
Abstract
Purpose of Review The purpose of this review is to examine racism in healthcare as it relates to older African American adults. We focus on health disparities in old age and medical mismanagement throughout their lifespan. Recent Findings In the United States there have been extensive medical advances over the past several decades. Individuals are living longer, and illnesses that were deemed terminal in the past are now considered chronic illnesses. While most individuals living with chronic illness have experienced better quality of life, this is not the case for many African American older adults. Summary Older African American adults are less likely to have their chronic illness sufficiently managed and are more likely to die from chronic illnesses that are well controlled in Whites. African American older adults also continue to suffer from poorer healthcare outcomes throughout the lifespan to end-of-life.
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Affiliation(s)
- Siobhan P Aaron
- College of Nursing, University of Utah, 10 2000 E, Salt Lake City, UT 84112 U.S.A
| | - Shena B Gazaway
- School of Nursing, University of Alabama Birmingham, Birmingham, AL U.S.A
| | - Erin R Harrell
- Department of Psychology, University of Alabama, Tuscaloosa, AL U.S.A
| | - Ronit Elk
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL U.S.A
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14
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Carter C, Leanza F, Mohammed S, Upshur REG, Kontos P. A rapid scoping review of end-of-life conversations with frail older adults in Canada. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:e298-e305. [PMID: 34772723 DOI: 10.46747/cfp.6711e298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To explore what is known about end-of-life (EOL) conversations with frail older adults across all settings including primary care in Canada, and to understand the barriers to, and recommendations for, EOL conversations. DATA SOURCES Comprehensive searches were conducted in CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), AgeLine (EBSCO), Sociological Abstracts (ProQuest), and Applied Social Sciences Index and Abstracts (ProQuest). Searches used text words and subject headings (eg, MeSH, Emtree) related to 3 concepts: frailty, Canada, and EOL conversations. STUDY SELECTION Twenty-one English-language articles were selected (ie, 4 reviews, 10 commentaries, 3 quantitative studies, 3 qualitative studies, 1 mixed-methods study) that included information about EOL conversations with frail older adults in the Canadian health care context. SYNTHESIS In terms of having EOL conversations with frail older adults, this study found that many clinicians do not often and adequately discuss frailty and impending death with their older patients. Moreover, patients and their care partners do not have enough knowledge about frailty and death to make informed EOL decisions, leading to patients choosing more aggressive therapies instead of care focused on symptom management. In terms of barriers to EOL discussions, common barriers included a lack of trust between clinician and patient, inadequate EOL training for clinicians, and ineffective clinician communication with patients and families. Recommendations for improving EOL conversations include regular screening for frailty to prompt conversations about care and the use of an interprofessional approach. CONCLUSION More empirical research is needed that uses exploratory methods to shed light on the contextual factors that may act as a barrier to EOL conversations. More research is also needed on the roles and responsibilities of interprofessional teams in screening for frailty and engaging in EOL conversations. Moreover, there is a need to better understand how frail older patients and their families want EOL conversations to unfold and what best facilitates these conversations.
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Affiliation(s)
- Celina Carter
- PhD candidate in the Dalla Lana School of Public Health at the University of Toronto in Ontario.
| | - Francesco Leanza
- Family physician and Assistant Professor in the Department of Family and Community Medicine at the University of Toronto
| | - Shan Mohammed
- Assistant Professor, Teaching Stream, in the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto, and a faculty member in the Global Institute of Psychosocial, Palliative and End-of-Life Care, at the University Health Network in Toronto
| | - Ross E G Upshur
- Family physician and Professor in the Department of Family and Community Medicine and the Dalla Lana School of Public Health at the University of Toronto, Head of the Division of Clinical Public Health at the Dalla Lana School of Public Health, and Scientific Director of the Bridgepoint Collaboratory for Research and Innovation
| | - Pia Kontos
- Senior Scientist in the KITE-Toronto Rehabilitation Institute at the University Health Network, and Professor in the Dalla Lana School of Public Health at the University of Toronto
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15
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Muraya T, Akagawa Y, Andoh H, Chiang C, Hirakawa Y. Improving person-centered advance care planning conversation with older people: a qualitative study of core components perceived by healthcare professionals. J Rural Med 2021; 16:222-228. [PMID: 34707731 PMCID: PMC8527630 DOI: 10.2185/jrm.2021-022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/17/2021] [Indexed: 12/23/2022] Open
Abstract
Objective: The non-medical needs of patients, such as values and personal
preferences, are likely to be omitted from advance care planning (ACP) discussions because
of a lack of readiness and awareness on the part of healthcare professionals. The aim of
the present study was to identify core components perceived by multidisciplinary
healthcare professionals to improve person-centered ACP conversations with older
people. Methods: The study participants were healthcare professionals (physicians,
nurses, and care managers) working in different cities. This qualitative study was
performed online using eight individual in-depth interviews and one subsequent focus group
composed of eight healthcare professionals. The interviews and focus group discussion were
audio-recorded online and transcribed verbatim. The aim of the analysis of the individual
in-depth interviews was to summarize the transcribed results, create a conceptual
framework for person-centered ACP conversation, and provide meaningful interpretations of
the focus group participant discourse. The qualitative data were then analyzed by
inductive manual coding using a qualitative content analysis approach. Results: Five themes capturing the core components for successful
person-centered ACP were extracted from the ideas voiced by participants: Placing highest
value on patient autonomy and human life; uncovering patient’s true feelings and desires;
sharing collected information on patients’ end-of-life wishes with other team members;
relaying patients’ wishes to the physician; and handling conflicts among patients,
relatives, and healthcare professionals. Conclusion: The results provide guidelines for the future development of
novel, value-based, person-centered ACP practice for multidisciplinary healthcare
professionals.
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Affiliation(s)
| | - Yuko Akagawa
- Department of Clinical Nursing, Akita University Graduate School of Health Science, Japan
| | - Hideaki Andoh
- Department of Clinical Nursing, Akita University Graduate School of Health Science, Japan
| | - Chifa Chiang
- Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Japan
| | - Yoshihisa Hirakawa
- Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Japan
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16
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Deschasse G, Bloch F, Drumez E, Charpentier A, Visade F, Delecluse C, Loggia G, Lescure P, Attier-Żmudka J, Bloch J, Gaxatte C, Van Den Berghe W, Puisieux F, Beuscart JB. Development of a predictive score for mortality at 3- and 12-month after discharge from an acute geriatric unit as a trigger for advanced care planning. J Gerontol A Biol Sci Med Sci 2021; 77:1665-1672. [PMID: 34375411 DOI: 10.1093/gerona/glab217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is a need for a mortality score that can be used to trigger advanced care planning among older patients discharged from acute geriatric units (AGUs). OBJECTIVE To develop a prognostic score for 3- and 12-month mortality after discharge from an AGU, based on a comprehensive geriatric assessment, in-hospital events, and the exclusion of patients already receiving palliative care. METHODS DAMAGE is a French multicentre, prospective, cohort study. The broad inclusion criteria ensured that the cohort is representative of patients treated in an AGU. The DAMAGE participants underwent a comprehensive geriatric assessment, a daily clinical check-up, and follow-up visits 3 and 12 months after discharge. Multivariable logistic regression models were used to develop a prognostic score for the derivation and validation subsets. RESULTS 3509 patients were assessed and 3112 were included. The patient population was very older and frail or dependant, with a high proportion of deaths at 3 months (n=455, 14.8%) and at 12 months (n=1014, 33%). The score predicted an individual risk of mortality ranging from 1% to 80% at 3 months and between 5% and 93% at 12 months, with an area under the receiving operator characteristic curve in the validation cohort of 0.728 at 3 months and 0.733 at 12 months. CONCLUSIONS Our score predicted a broad range of risks of death after discharge from the AGU. Having this information at the time of hospital discharge might trigger a discussion on advanced care planning and end-of-life care with very old, frail patients.
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Affiliation(s)
- Guillaume Deschasse
- CHU Amiens-Picardie, Department of Geriatrics, Amiens, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | - Frédéric Bloch
- CHU Amiens-Picardie, Department of Geriatrics, Amiens, France
| | - Elodie Drumez
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,CHU Lille, Department of Biostatistics, Lille, France
| | | | - Fabien Visade
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,Lille Catholic Hospitals, Geriatrics Department, Lille, France
| | | | - Gilles Loggia
- Normandie Univ, UNICAEN, INSERM, COMETE, Caen, France.,Department of Geriatrics, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Pascale Lescure
- Department of Geriatrics, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Jadwiga Attier-Żmudka
- Geriatric department, General Hospital of Saint-Quentin, Saint-Quentin, France.,CHIMERE EA 7516 team research, Jules Verne University, Amiens, France
| | | | | | | | | | - Jean-Baptiste Beuscart
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,CHU Lille, Department of Geriatrics, Lille, France
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17
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Implementing advance care planning in heart failure: a qualitative study of primary healthcare professionals. Br J Gen Pract 2021; 71:e550-e560. [PMID: 33947665 PMCID: PMC8103928 DOI: 10.3399/bjgp.2020.0973] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/19/2021] [Indexed: 02/06/2023] Open
Abstract
Background Advance care planning (ACP) can improve the quality of life of patients suffering from heart failure (HF). However, primary care healthcare professionals (HCPs) find ACP difficult to engage with and patient care remains suboptimal. Aim To explore the views of primary care HCPs on how to improve their engagement with ACP in HF. Design and setting A qualitative interview study with GPs and primary care nurses in England. Method Semi-structured interviews were conducted with a purposive sample of 24 primary care HCPs. Data were analysed using reflexive thematic analysis. Results Three main themes were constructed from the data: ACP as integral to holistic care in HF; potentially limiting factors to the doctor–patient relationship; and approaches to improve professional performance. Many HCPs saw the benefits of ACP as synonymous with providing holistic care and improving patients’ quality of life. However, some feared that initiating ACP could irrevocably damage their doctor–patient relationship. Their own fear of death and dying, a lack of disease-specific communication skills, and uncertainty about the right timing were significant barriers to ACP. To optimise their engagement with ACP in HF, HCPs recommended better clinician–patient dialogue through question prompts, enhanced shared decision-making approaches, synchronising ACP across medical specialties, and disease-specific training. Conclusion GPs and primary care nurses are vital to deliver ACP for patients suffering from HF. HCPs highlighted important areas to improve their practice and the urgent need for investigations into better clinician–patient engagement with ACP.
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18
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Pilch M, Lunt V, May P, Mockler D, Thomas S, Doyle F. Facilitators and barriers to stakeholder engagement in advance care planning for older adults in community settings: a hybrid systematic review protocol. HRB Open Res 2021; 3:38. [PMID: 34212126 PMCID: PMC8212429 DOI: 10.12688/hrbopenres.13082.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Poor stakeholder engagement in advance care planning (ACP) poses national and international challenges, preventing maximisation of its potential benefits. Conceptualisation of advance care planning as a health behaviour highlights the need to design innovative, evidence-based strategies that will facilitate meaningful end-of-life care decision-making. Aim: To review systematically and synthesise quantitative and qualitative evidence on barriers and facilitators to stakeholders` engagement in ACP for older adults (≥ 50 years old) in a community setting. Methods: A hybrid systematic review will be conducted, identifying studies for consideration in two phases. First, databases will be searched from inception to identify relevant prior systematic reviews, and assess all studies included in those reviews against eligibility criteria (Phase 1). Second, databases will be searched systematically for individual studies falling outside the timeframe of those reviews (Phase 2). A modified SPIDER framework informed eligibility criteria. A study will be considered if it (a) included relevant adult stakeholders; (b) explored engagement in ACP among older adults (≥50 years old); (c) employed any type of design; (d) identified enablers and/or barriers to events specified in the Organising Framework of ACP Outcomes; (e) used either quantitative, qualitative, or mixed methods methodology; and (f) evaluated phenomena of interest in a community setting (e.g., primary care or community healthcare centres). Screening, selection, bias assessment, and data extraction will be completed independently by two reviewers. Integrated methodologies will be employed and quantitative and qualitative data will be combined into a single mixed method synthesis. The Behaviour Change Wheel will be used as an overarching analytical framework and to facilitate interpretation of findings. The Joanna Briggs Institute (JBI) Reviewers` Manual and PRISMA-P guidelines have been used to inform this protocol development. Registration: This protocol has been submitted for registration on PROSPERO, registration number CRD42020189568 and is awaiting review.
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Affiliation(s)
- Monika Pilch
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, D2, Ireland
| | - Victoria Lunt
- Beaumont Hospital and St Luke's Radiation Oncology Centre at Beaumont Hospital, Beaumont Hospital, Beaumont, Dublin, D9, Ireland
| | - Peter May
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, D2, Ireland
- The Irish Longitudinal study on Ageing (TILDA), Trinity College Dublin, Dublin, D2, Ireland
| | - David Mockler
- The Library of Trinity College Dublin, Trinity College Dublin, University of Dublin, Dublin, D2, Ireland
| | - Stephen Thomas
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, D2, Ireland
| | - Frank Doyle
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, D2, Ireland
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19
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Phung LH, Barnes DE, Volow AM, Li BH, Shirsat NR, Sudore RL. English and Spanish-speaking vulnerable older adults report many barriers to advance care planning. J Am Geriatr Soc 2021; 69:2110-2121. [PMID: 34061370 DOI: 10.1111/jgs.17230] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 04/06/2021] [Accepted: 04/20/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND/OBJECTIVES Advance care planning (ACP) rates are low in diverse, vulnerable older adults, yet little is known about the unique barriers they face and how these barriers impact ACP documentation rates. DESIGN Validated questionnaires listing patient, family/friend, and clinician/system-level ACP barriers and an open-ended question on ACP barriers. SETTING Two San Francisco public/Department of Veterans Affairs hospitals. PARTICIPANTS One thousand two hundred and forty-one English and Spanish-speaking patients, aged 55 and older, with two or more chronic conditions. MEASUREMENTS The open-ended question on ACP barriers was analyzed using content analysis. We conducted chart review for prior ACP documentation. We used chi-square/Wilcoxon rank-sum tests and logistic regression to assess associations between ACP barriers and demographic characteristics/ACP documentation. RESULTS Participant mean age was 65 ± 7.4 years; they were 74% from racial/ethnic minority groups, 36% Spanish-speaking, and 36% with limited health literacy. A total of 26 barriers were identified (15 patient, 4 family/friend, 7 clinician/system-level), and 91% reported at least one ACP barrier (mean: 5.6 ± 4.0). The most common barriers were: (patient-level) discomfort thinking about ACP (60%), wanting to leave health decisions to "God" (44%); (family/friend-level) not wanting to burden friends/family (33%), assuming friends/family already knew their preferences (31%); (clinician/system-level) assuming doctors already knew their preferences (41%), and mistrust (37%). Compared with those with no barriers, participants with at least one reported barrier were more likely to be from a racial/ethnic minority group (76% vs 53%), Spanish-speaking (39% vs 6%), with fair-to-poor health (48% vs 34%), and limited health literacy (39% vs 9%) (p < 0.001 for all). Participants who reported barriers were less likely to have ACP documentation (adjusted odds ratio = 0.64, 95% confidence interval [0.42, 0.98]). CONCLUSION English- and Spanish-speaking older adults reported 26 unique barriers to ACP, with higher barriers among vulnerable populations, and barriers were associated with lower ACP documentation. Barriers must be considered when developing customized ACP interventions for diverse older adults.
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Affiliation(s)
- Linda H Phung
- School of Medicine, Duke University, Durham, North Carolina, USA.,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Deborah E Barnes
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA.,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California, USA.,Innovation and Implementation Center for Aging and Palliative Care (I-CAP), Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Research Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Aiesha M Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brookelle H Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Nikita R Shirsat
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Innovation and Implementation Center for Aging and Palliative Care (I-CAP), Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Research Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
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20
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Suutari AM, Thor J, Nordin AMM, Kjellström S, Areskoug Josefsson K. Improving Health for People Living With Heart Failure: Focus Group Study of Preconditions for Co-Production of Health and Care. J Particip Med 2021; 13:e27125. [PMID: 33973859 PMCID: PMC8150411 DOI: 10.2196/27125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/24/2021] [Accepted: 03/06/2021] [Indexed: 12/28/2022] Open
Abstract
Background Co-production of health and care involving patients, families of patients, and professionals in care processes can create joint learning about how to meet patients’ needs. Although barriers and facilitators to co-production have been examined previously in various health care contexts, the preconditions in Swedish chronic cardiac care contexts are yet to be explored. This study is set in the health system of the Swedish region of Jönköping County and is part of system-wide efforts to promote better health for persons with heart failure (HF). Objective The objective of this study was to test the usefulness of the Capability, Opportunity, and Motivation Behavior (COM-B) model when assessing the barriers to and facilitators of co-production of health and care perceived by patients with HF, family members of patients with HF, and professionals in a Swedish chronic cardiac care context as a guide for subsequent initiatives. Methods Data collection involved 1 focus group interview (FGI) with patients with HF (n=5), 1 FGI with family members of patients with HF (n=5), 1 FGI with professionals in primary care (n=7), and 1 FGI with professionals in cardiac care (n=4). In addition, patients with HF kept diaries of their thoughts regarding co-production. Using a deductive approach to content analysis, underpinned by the COM-B model, barriers and facilitators were categorized into capabilities, opportunities, and motivations to co-produce health and care. Results The participants showed limited understanding of co-production as a practice. They appeared to view it as a privilege to be offered to patients on top of traditional care and rarely as an approach for improving health care processes. The interviews revealed the limited health literacy among patients and the struggle of professionals to convey health information to these patients. Co-production was considered to be more resource-intensive than traditional care. Different expectations of stakeholders’ roles were revealed: professionals expected older patients not to want to co-produce health and care, and all participants expected professionals to be in charge of health care services. The family members’ position involved trying to balance their desire to support their relatives with understanding when, how, and with whom to co-produce. Presumed benefits motivated stakeholders: co-production was recognized to motivate patients to improve self-care. However, the participants recognized that motivation to get involved in health and care decisions varies over time among stakeholders. Conclusions Co-production can be facilitated by the stakeholders’ motivation. However, varying levels of understanding of co-production, patients’ limited health literacy, unease with power sharing between patients and professionals, and resource constraints are barriers that need to be managed to promote co-produced care and better health for persons living with HF. Further research is warranted to explore how to co-produce health care services with patients with HF and how leaders can facilitate the inevitable cultural change it requires and represents.
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Affiliation(s)
- Anne-Marie Suutari
- Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden.,Department of Internal Medicine and Geriatrics, The Highland Hospital, Eksjö, Sweden
| | - Johan Thor
- Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Annika M M Nordin
- Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Sofia Kjellström
- Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Kristina Areskoug Josefsson
- Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden.,Faculty of Health Studies, VID Specialized University, Oslo, Norway.,Department of Behavioral Science, Oslo Metropolitan University, Oslo, Norway
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21
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When do Physicians and Nurses Start Communication about Advance Care Planning? A Qualitative Study at an Acute Care Hospital in Japan. Asian Bioeth Rev 2021; 12:289-305. [PMID: 33717339 PMCID: PMC7747333 DOI: 10.1007/s41649-020-00135-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 10/28/2022] Open
Abstract
Although advance care planning (ACP) can lead to more patient-centered care, the communication around it can be challenging in acute care hospitals, where saving a life or shortening hospitalization is important priorities. Our qualitative study in an acute care hospital in Japan revealed when specifically physicians and nurses start communication to facilitate ACP. Seven physicians and 19 nurses responded to an interview request, explaining when ACP communication was initiated with 32 patients aged 65 or older. Our qualitative approach employed descriptive analysis to identify major themes, which included "initiation by patients" and "initiation by healthcare professionals." In the latter case, seven specific triggers were identified: (1) when the patients' medical condition changed in terms of symptom relief, (2) when the patients' medical condition changed in terms of prognostic prediction, (3) when serious events occurred, (4) when a choice of treatment was presented, (5) when the location for end-of-life care was chosen, (6) when the patients' cognitive function deteriorated, and (7) when serious events settled down. Within this group of healthcare professionals, physicians were more focused on changes in their patients' medical condition, whereas nurses focused more on their patients' desire for a long-term perspective. Nurses encouraged patients to consider ACP themselves, which developed into an approach to respect patients' autonomy. In acute care hospitals, it appeared to be desirable to have an early discussion where patients could understand the significance ACP, which would matter even after their discharge from the hospital.
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22
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Bielinska AM, Archer S, Obanobi A, Soosipillai G, Darzi LA, Riley J, Urch C. Advance care planning in older hospitalised patients following an emergency admission: A mixed methods study. PLoS One 2021; 16:e0247874. [PMID: 33667272 PMCID: PMC7935239 DOI: 10.1371/journal.pone.0247874] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/16/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Although advance care planning may be beneficial for older adults in the last year of life, its relevance following an emergency hospitalisation requires further investigation. This study quantifies the one-year mortality outcomes of all emergency admissions for patients aged 70+ years and explores patient views on the value of advance care planning following acute hospitalisation. METHOD This mixed methods study used a two-stage approach: firstly, a quantitative longitudinal cohort study exploring the one-year mortality of patients aged 70+ admitted as an emergency to a large multi-centre hospital cohort; secondly, a qualitative semi-structured interview study gathering information on patient views of advance care planning. RESULTS There were 14,260 emergency admissions for 70+-year olds over a 12-month period. One-year mortality for admissions across all conditions was 22.6%. The majority of these deaths (59.3%) were within 3 months of admission. Binary logistic regression analysis indicated higher one-year mortality with increasing age and male sex. Interviews with 20 patients resulted in one superordinate theme, "Planning for health and wellbeing in the spectrum of illness". Sub-themes entitled (1) Advance care planning benefitting healthcare for physical and psycho-social health, (2) Contemplation of physical deterioration death and dying and 3) Collaborating with healthcare professionals to undertake advance care planning, suggest that views of advance care planning are shaped by experiences of acute hospitalisation. CONCLUSION Since approximately 1 in 5 patients aged 70+ admitted to hospital as an emergency are in the last year of life, acute hospitalisation can act as a trigger for tailored ACP. Older hospitalised patients believe that advance care planning can benefit physical and psychosocial health and that discussions should consider a spectrum of possibilities, from future health to the potential of chronic illness, disability and death. In this context, patients may look for expertise from healthcare professionals for planning their future care.
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Affiliation(s)
- Anna-Maria Bielinska
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
- * E-mail:
| | - Stephanie Archer
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- The University of Cambridge, Cambridge, United Kingdom
| | | | - Gehan Soosipillai
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Lord Ara Darzi
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Julia Riley
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Catherine Urch
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
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Overview of the Motivation of Advance Care Planning: A Study from a Medical Center in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020417. [PMID: 33430302 PMCID: PMC7825806 DOI: 10.3390/ijerph18020417] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/25/2020] [Accepted: 01/04/2021] [Indexed: 01/08/2023]
Abstract
(1) Background: Since Taiwan's Patient Right to Autonomy Act took effect in 2019, up to ten thousand declarants have participated in advance care planning (ACP) and have signed advance directives (ADs). Relative to the entire population of Taiwan, only a small percentage have completed ACP. This study sought to understand the motivations of Taiwanese who have participated in ACP, so as to increase the percentage of individuals participating in ACP and signing ADs; (2) Objectives: To understand the motivations that drive Taiwanese individuals to participate in ACP discussions.; (3) Methods: A retrospective secondary data analysis was performed in this study. The participants consisted of declarants who completed their ACP at a medical center in Taiwan in 2019; (4) Results: During the study period, 946 individuals completed their ACP. Of those declarants, 66.7% were over 60 years of age; 66.5% completed the process in groups of three or more; 49.5% completed their ACP free of charge; and 35 declarants had designated a health care agent (HCA). The declarants' four main motivations for participating in ACP were "looking forward to dying with dignity," "making end-of-life preparations," "fear of being a social and economic burden on family members," and "reluctance to let family members take on the responsibility of making decisions." Furthermore, statistically significant differences were observed between the declarants in terms of gender, age, designation of an HCA, and motivations for participating in ACP. Females, declarants aged below 60 years, and declarants with a designated HCA tended to participate in ACP due to "reluctance to let family members to take on the responsibility of making decisions". Males, declarants aged above 60 years, and declarants without an HCA came for ACP because of "fear of being a social and economic burden on family members". (5) Conclusions: The main motivations of Taiwanese individuals who sought ACP were to die with dignity and to have an early understanding of end-of-life treatment and care models. Secondly, these individuals hoped that their families would not have to take on the responsibility of making decisions. They also did not want to impact their families socially and economically. In this regard, providing economic subsidies might enhance the Taiwanese public's intentions to seek ACP discussions on their own initiative.
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Frechman E, Dietrich MS, Walden RL, Maxwell CA. Exploring the Uptake of Advance Care Planning in Older Adults: An Integrative Review. J Pain Symptom Manage 2020; 60:1208-1222.e59. [PMID: 32645455 PMCID: PMC7342022 DOI: 10.1016/j.jpainsymman.2020.06.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Advance care planning (ACP) is essential to elicit goals, values, and preferences of care in older adults with serious illness and on trajectories of frailty. An exploration of ACP uptake in older adults may identify barriers and facilitators. OBJECTIVE To conduct an integrative review of research on the uptake of ACP in older adults and create a conceptual model of the findings. METHODS Using Whittemore and Knafl's methodology, we systematically searched four electronic databases of ACP literature in older adults from 1996 through December 2019. Critical appraisal tools were used to assess study quality, and articles were categorized according to level of evidence. Statistical and thematic analysis was then undertaken. RESULTS Among 1081 studies, 78 met inclusion criteria. Statistical analysis evaluated ACP and variables within the domains of demographics, psychosocial, disability and functioning, and miscellaneous. Thematic analysis identified a central category of enhanced communication, followed by categories of 1) provider role and preparation; 2) patient/family relationship patterns; 3) standardized processes and structured approaches; 4) contextual influences; and 5) missed opportunities. A conceptual model depicted categories and relationships. CONCLUSIONS Enhanced communication and ACP facilitators improve uptake of ACP. Clinicians should be cognizant of these factors. This review provides a guide for clinicians who are considering implementation strategies to facilitate ACP in real-world settings.
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Affiliation(s)
- Erica Frechman
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA.
| | - Mary S Dietrich
- Vanderbilt University Schools of Medicine and Nursing, Nashville, Tennessee, USA
| | - Rachel Lane Walden
- Vanderbilt University Eskind Biomedical Library, Nashville, Tennessee, USA
| | - Cathy A Maxwell
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA
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Roch C, Schendzielorz P, Scherzad A, van Oorschot B, Scheich M. [Needs and burdens of palliative care patients with advanced and/or metastatic head and neck tumors]. HNO 2020; 68:510-516. [PMID: 32430668 PMCID: PMC8241647 DOI: 10.1007/s00106-020-00888-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hintergrund Neue Therapieformen ermöglichen auch bei Patienten mit fortgeschrittenen und metastasierten Kopf-Hals-Tumoren gute Behandlungsansätze. Gespräche über das Lebensende, vorausschauende Versorgungsplanung und auch palliativmedizinische Konzepte geraten dadurch oft in den Hintergrund. Ziel der Arbeit Analyse von Symptomen, Belastungen sowie dem Vorliegen von Vorsorgedokumenten, von stationär palliativmedizinisch mitbetreuten Patienten durch Selbsteinschätzung. Erhebung der Integration der spezialisierten Palliativversorgung in die Versorgung stationär verstorbener Patienten anhand des Qualitätsindikators nach Earle. Material und Methoden Retrospektive Analyse der vom Palliativdienst mitbetreuten Patienten mit Kopf-Hals-Tumoren durch Nutzung des standardisierten IPOS Fragebogens. Ergebnisse Die häufigsten physischen Symptome waren „Schwäche“ (77 %), „Appetitlosigkeit“ (65 %) und „eingeschränkte Mobilität“ (65 %). „Schmerzen“ wurden von 42 % der Patienten angegeben. Die häufigsten emotionalen und psychosozialen Belastungen waren „Traurigkeit“ (97 %) und „Sorgen des Patienten“ (94 %), die „fehlende Möglichkeit Gefühle“ zu teilen (77 %), „unzureichende Informiertheit“ (85 %) und „organisatorische Probleme“ (77 %). Bei 23 % der Patienten lagen Vorsorgedokumente vor. Das Qualitätsziel nach Earle wurde nicht erreicht. Diskussion Die Patienten berichten in der Auswertung in hohem Maß Symptome und Belastungen, am häufigsten im emotionalen Bereich und bezüglich kommunikativer und praktischer Bedürfnisse. Hier zeigt sich möglicherweise auch ein Gesprächsbedarf über Wünsche und Vorstellungen im Hinblick auf das Lebensende. Palliativdienste sollten deshalb besonders auf die psychosozialen Bedürfnisse einzugehen.
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Affiliation(s)
- C Roch
- Interdisziplinäres Zentrum Palliativmedizin, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Deutschland.
| | - P Schendzielorz
- Klinik und Poliklinik für Hals‑, Nasen- und Ohrenkrankheiten, plastische und ästhetische Operationen, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - A Scherzad
- Klinik und Poliklinik für Hals‑, Nasen- und Ohrenkrankheiten, plastische und ästhetische Operationen, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - B van Oorschot
- Interdisziplinäres Zentrum Palliativmedizin, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Deutschland
| | - M Scheich
- Klinik und Poliklinik für Hals‑, Nasen- und Ohrenkrankheiten, plastische und ästhetische Operationen, Universitätsklinikum Würzburg, Würzburg, Deutschland
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Pilch M, Lunt V, May P, Mockler D, Thomas S, Doyle F. Facilitators and barriers to stakeholder engagement in advance care planning for older adults in community settings: a hybrid systematic review protocol. HRB Open Res 2020; 3:38. [PMID: 34212126 PMCID: PMC8212429 DOI: 10.12688/hrbopenres.13082.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2020] [Indexed: 04/03/2024] Open
Abstract
Background: Poor stakeholder engagement in advance care planning (ACP) poses national and international challenges, preventing maximisation of its potential benefits. Conceptualisation of advance care planning as a health behaviour highlights the need to design innovative, evidence-based strategies that will facilitate meaningful end-of-life care decision-making. Aim: To review systematically and synthesise quantitative and qualitative evidence on barriers and facilitators to stakeholders` engagement in ACP for older adults (≥ 50 years old) in a community setting. Methods: A hybrid systematic review will be conducted, identifying studies for consideration in two phases. First, databases will be searched from inception to identify relevant prior systematic reviews, and assess all studies included in those reviews against eligibility criteria (Phase 1). Second, databases will be searched systematically for individual studies falling outside the timeframe of those reviews (Phase 2). A modified SPIDER framework informed eligibility criteria. A study will be considered if it (a) included relevant adult stakeholders; (b) explored engagement in ACP among older adults (≥50 years old); (c) employed any type of design; (d) identified enablers and/or barriers to events specified in the Organising Framework of ACP Outcomes; (e) used either quantitative, qualitative, or mixed methods methodology; and (f) evaluated phenomena of interest in a community setting (e.g., primary care or community healthcare centres). Screening, selection, bias assessment, and data extraction will be completed independently by two reviewers. Integrated methodologies will be employed and quantitative and qualitative data will be combined into a single mixed method synthesis. The Behaviour Change Wheel will be used as an overarching analytical framework and to facilitate interpretation of findings. The Joanna Briggs Institute (JBI) Reviewers` Manual and PRISMA-P guidelines have been used to inform this protocol development. Registration: This protocol has been submitted for registration on PROSPERO and is awaiting review.
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Affiliation(s)
- Monika Pilch
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, D2, Ireland
| | - Victoria Lunt
- Beaumont Hospital and St Luke's Radiation Oncology Centre at Beaumont Hospital, Beaumont Hospital, Beaumont, Dublin, D9, Ireland
| | - Peter May
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, D2, Ireland
- The Irish Longitudinal study on Ageing (TILDA), Trinity College Dublin, Dublin, D2, Ireland
| | - David Mockler
- The Library of Trinity College Dublin, Trinity College Dublin, University of Dublin, Dublin, D2, Ireland
| | - Stephen Thomas
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, D2, Ireland
| | - Frank Doyle
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, D2, Ireland
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Hopkins SA, Bentley A, Phillips V, Barclay S. Advance care plans and hospitalized frail older adults: a systematic review. BMJ Support Palliat Care 2020; 10:164-174. [PMID: 32241957 PMCID: PMC7286036 DOI: 10.1136/bmjspcare-2019-002093] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/27/2020] [Accepted: 02/10/2020] [Indexed: 12/28/2022]
Abstract
Introduction Frail older people are known to have low rates of advance care planning (ACP). Many frail patients prefer less aggressive treatment, but these preferences are often not known or respected. Frail patients often have multiple hospital admissions, potentially providing opportunities for ACP. Objective To systematically review the literature concerning ACP with frail older people in the acute hospital, with particular reference to: (1) Does ACP improve outcomes? (2) What are the views of patients, relatives and healthcare professionals regarding ACP? (3) Does ACP currently occur? (4) What are the facilitators and barriers to ACP? Design Systematic literature review and narrative synthesis. Electronic search of MEDLINE, CINAHL, ASSIA, PsycINFO and Embase databases from January 1990 to May 2019 inclusive. Studies in the acute setting of populations with a mean age >75 years, not focused on a disease-specific terminal condition were included. Results 16 133 articles were retrieved, 14 met inclusion criteria. No studies used an objective measure of frailty. One randomised controlled trial (RCT) found that ACP improves outcomes for older patients. Although 74%–84% of capacitous older inpatients are receptive to ACP, rates of ACP are 0%–5%; the reasons for this discrepancy have been little studied. The nature of ACP in clinical practice is unknown thus the extent to which it reflects the RCT intervention cannot be assessed. The outcomes that are important to patients are poorly understood and family and physician experiences have not been explored. Conclusions A better understanding of this area could help to improve end-of-life care for frail older people. PROSPERO registration number CRD42017080246.
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Affiliation(s)
- Sarah A Hopkins
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Allison Bentley
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Veronica Phillips
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Knight T, Malyon A, Fritz Z, Subbe C, Cooksley T, Holland M, Lasserson D. Advance care planning in patients referred to hospital for acute medical care: Results of a national day of care survey. EClinicalMedicine 2020; 19:100235. [PMID: 32055788 PMCID: PMC7005412 DOI: 10.1016/j.eclinm.2019.12.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/24/2019] [Accepted: 12/04/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is a voluntary process of discussion about future care between an individual and their care provider. ACP is a key focus of national policy as a means to improve patient centered care at the end-of-life. Despite a wide held belief that ACP is beneficial, uptake is sporadic with considerable variation depending on age, ethnicity, location and disease group. METHODS This study looked to establish the prevalence of ACP on initial presentation to hospital with a medical emergency within The Society for Acute Medicine Benchmarking Audit (SAMBA18). 123 acute hospitals from across the UK collected data during a day of care survey. The presence of ACP and the presence of 'Do Not Attempt Cardiopulmonary Resuscitation' orders were recorded separately. FINDINGS Among 6072 patients presenting with an acute medical emergency, 290 patients (4.8%) had an ACP that was available for the admitting medical team. The prevalence of ACP increased incrementally with age, in patients less than 80 years old the prevalence was 2·9% (95% CI 2·7-3·1) compared with 9·5% (95% CI 9·1-10·0%) in patients aged over 80. In the patients aged over 90 the prevalence of ACP was 12·6% (95% CI 9·8-16·0). ACP was present in 23·3% (95% CI 21.8-24.8%) of patients admitted from institutional care compared with 3·5% (95% CI 3·3-3·7) of patients admitted from home. The prevalence of ACP was 7.1% (95% CI 6·6-7·6) amongst patients re-admitted to the hospital within the previous 30 days. INTERPRETATION Very few patients have an ACP that is available to admitting medical teams during an unscheduled hospital admission. Even among patients with advanced age, and who have recently been in hospital, the prevalence of available ACP remains low, in spite of national guidance. Further interventions are needed to ensure that patients' wishes for care are known by providers of acute medical care.
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Affiliation(s)
- Thomas Knight
- Institute of Applied Health Research, University of Birmingham, United Kingdom
- Corresponding author.
| | - Alexandra Malyon
- Cambridge University Hospital NHS Foundation Trust, United Kingdom
| | - Zoe Fritz
- University of Cambridge, United Kingdom
| | - Chris Subbe
- School of Medical Sciences, Bangor University, United Kingdom
| | - Tim Cooksley
- Manchester University NHS Foundation Trust, United Kingdom
| | - Mark Holland
- School of Health and Social Care, University of Bolton, United Kingdom
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, United Kingdom
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29
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Mansfield E, Jeong S, Waller A, Chan S. Prevalence, perceived barriers and sociodemographic correlates of advance care planning in a sample of outpatients. Aust J Prim Health 2019; 26:76-80. [PMID: 31864425 DOI: 10.1071/py19096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/20/2019] [Indexed: 11/23/2022]
Abstract
This study aimed to examine the prevalence and perceived barriers to uptake of advance care planning (ACP), including appointment of an enduring guardian (EG) and completion of an advance care directive (ACD) among Australian adults attending hospital outpatient clinics. Sociodemographic correlates of not completing ACP were also assessed. A cross-sectional survey exploring the uptake of ACP was conducted with outpatients and their accompanying persons aged >18 years (n =191) at one regional hospital in New South Wales, Australia. Rates of completion of an ACD and appointment of an EG were 20% (n =37) and 35% (n =67) respectively. The most common reason for non-completion of an ACD and not appointing an EG was: 'didn't think I needed this'. Younger age was associated with not having appointed an EG (OR 3.8, 95% CI 1.2-12.1, P =0.02). No sociodemographic characteristics were significantly associated with non-completion of ACDs. Uptake of ACP is suboptimal among outpatients. Community-based healthcare providers are well positioned to promote ACP with outpatients.
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Affiliation(s)
- Elise Mansfield
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and Hunter Medical Research Institute, Lot 1, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia; and Corresponding author
| | - Sarah Jeong
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and Hunter Medical Research Institute, Lot 1, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - Sally Chan
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
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30
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Zwakman M, Pollock K, Bulli F, Caswell G, Červ B, van Delden JJM, Deliens L, van der Heide A, Jabbarian LJ, Koba-Čeh H, Lunder U, Miccinesi G, Arnfeldt CAM, Seymour J, Toccafondi A, Verkissen MN, Kars MC. Trained facilitators' experiences with structured advance care planning conversations in oncology: an international focus group study within the ACTION trial. BMC Cancer 2019; 19:1026. [PMID: 31672145 PMCID: PMC6822448 DOI: 10.1186/s12885-019-6170-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 09/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In oncology, Health Care Professionals often experience conducting Advance Care Planning (ACP) conversations as difficult and are hesitant to start them. A structured approach could help to overcome this. In the ACTION trial, a Phase III multi-center cluster-randomized clinical trial in six European countries (Belgium, Denmark, Italy, the Netherlands, Slovenia, United Kingdom), patients with advanced lung or colorectal cancer are invited to have one or two structured ACP conversations with a trained facilitator. It is unclear how trained facilitators experience conducting structured ACP conversations. This study aims to understand how facilitators experience delivering the ACTION Respecting Choices (RC) ACP conversation. METHODS A qualitative study involving focus groups with RC facilitators. Focus group interviews were recorded, transcribed, anonymized, translated into English, and thematically analysed, supported by NVivo 11. The international research team was involved in data analysis from initial coding and discussion towards final themes. RESULTS Seven focus groups were conducted, involving 28 of in total 39 trained facilitators, with different professional backgrounds from all participating countries. Alongside some cultural differences, six themes were identified. These reflect that most facilitators welcomed the opportunity to participate in the ACTION trial, seeing it as a means of learning new skills in an important area. The RC script was seen as supportive to ask questions, including those perceived as difficult to ask, but was also experienced as a barrier to a spontaneous conversation. Facilitators noticed that most patients were positive about their ACTION RC ACP conversation, which had prompted them to become aware of their wishes and to share these with others. The facilitators observed that it took patients substantial effort to have these conversations. In response, facilitators took responsibility for enabling patients to experience a conversation from which they could benefit. Facilitators emphasized the need for training, support and advanced communication skills to be able to work with the script. CONCLUSIONS Facilitators experienced benefits and challenges in conducting scripted ACP conversations. They mentioned the importance of being skilled and experienced in carrying out ACP conversations in order to be able to explore the patients' preferences while staying attuned to patients' needs. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number registry 63110516 ( ISRCTN63110516 ) per 10/3/2014.
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Affiliation(s)
- M Zwakman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - K Pollock
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - F Bulli
- Oncological network, research and prevention Institute - ISPRO, Florence, Italy
| | - G Caswell
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - B Červ
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - J J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - A van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - L J Jabbarian
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - H Koba-Čeh
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - U Lunder
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - G Miccinesi
- Oncological network, research and prevention Institute - ISPRO, Florence, Italy
| | - C A Møller Arnfeldt
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, The Research Unit, Copenhagen, Denmark
| | - J Seymour
- University of Sheffield, Sheffield, UK
| | - A Toccafondi
- Oncological network, research and prevention Institute - ISPRO, Florence, Italy
| | - M N Verkissen
- End-of-life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Ghent University, Brussels, Belgium
| | - M C Kars
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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