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Cilluffo S, Bassola B, Pucciarelli G, Vellone E, Clari M, Dimonte V, Lusignani M. Mutuality between nurses and patients with chronic illnesses: A cross-sectional descriptive study. Scand J Caring Sci 2024; 38:487-495. [PMID: 38459748 DOI: 10.1111/scs.13251] [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] [Received: 09/29/2023] [Revised: 01/16/2024] [Accepted: 02/24/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND AND AIM Mutuality is a process in which the patient participates and is involved in decision-making and care interventions. The aim of this study was to measure mutuality in the relationship between nurses and chronic illness patients. METHODS This study had a cross-sectional design; the sample included 249 patients and 249 nurses. Mutuality was measured with the Nurse-Patient Mutuality in Chronic Illness scale. RESULTS Patients had higher scores in almost all items (p < 0.001). Patients demonstrate high reciprocity towards nurses and the ability to express and share their emotions. Patients consider nurses their point of reference and share with them their health goals. Nurses show more difficulty in being mutual with the patient, especially in the aspects related to the sharing of emotions, objectives, and planning. The egalitarian relationship score was low in both patients and nurses. CONCLUSION These findings are important to consider at clinical, educational, organisational, and policy levels. Nurse education and organisation must push towards respect for the wishes of patients, the possibility of expressing their choices, and their involvement in the care plan. PRACTICE IMPLICATIONS In clinical practice, it is necessary to put the patients more at the centre, involving them in the identification of objectives and in making decisions.
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Affiliation(s)
- Silvia Cilluffo
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
- School of Nursing, Niguarda Hospital, University of Milan, Milan, Italy
| | - Barbara Bassola
- School of Nursing, Niguarda Hospital, University of Milan, Milan, Italy
| | - Gianluca Pucciarelli
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Ercole Vellone
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
- Department of Nursing and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Marco Clari
- Department of Public Health and Pediatrics Sciences, University of Turin, Turin, Italy
| | - Valerio Dimonte
- Department of Public Health and Pediatrics Sciences, University of Turin, Turin, Italy
| | - Maura Lusignani
- School of Nursing, Niguarda Hospital, University of Milan, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Eli K, Harlock J, Huxley CJ, Bernstein C, Mann C, Spencer R, Griffiths F, Slowther AM. Patient and relative experiences of the ReSPECT process in the community: an interview-based study. BMC PRIMARY CARE 2024; 25:115. [PMID: 38632508 PMCID: PMC11022317 DOI: 10.1186/s12875-024-02283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/19/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was launched in the UK in 2016. ReSPECT is designed to facilitate meaningful discussions between healthcare professionals, patients, and their relatives about preferences for treatment in future emergencies; however, no study has investigated patients' and relatives' experiences of ReSPECT in the community. OBJECTIVES To explore how patients and relatives in community settings experience the ReSPECT process and engage with the completed form. METHODS Patients who had a ReSPECT form were identified through general practice surgeries in three areas in England; either patients or their relatives (where patients lacked capacity) were recruited. Semi-structured interviews were conducted, focusing on the participants' understandings and experiences of the ReSPECT process and form. Data were analysed using inductive thematic analysis. RESULTS Thirteen interviews took place (six with patients, four with relatives, three with patient and relative pairs). Four themes were developed: (1) ReSPECT records a patient's wishes, but is entangled in wider relationships; (2) healthcare professionals' framings of ReSPECT influence patients' and relatives' experiences; (3) patients and relatives perceive ReSPECT as a do-not-resuscitate or end-of-life form; (4) patients' and relatives' relationships with the ReSPECT form as a material object vary widely. Patients valued the opportunity to express their wishes and conceptualised ReSPECT as a process of caring for themselves and for their family members' emotional wellbeing. Participants who described their ReSPECT experiences positively said healthcare professionals clearly explained the ReSPECT process and form, allocated sufficient time for an open discussion of patients' preferences, and provided empathetic explanations of treatment recommendations. In cases where participants said healthcare professionals did not provide clear explanations or did not engage them in a conversation, experiences ranged from confusion about the form and how it would be used to lingering feelings of worry, upset, or being burdened with responsibility. CONCLUSIONS When ReSPECT conversations involved an open discussion of patients' preferences, clear information about the ReSPECT process, and empathetic explanations of treatment recommendations, working with a healthcare professional to co-develop a record of treatment preferences and recommendations could be an empowering experience, providing patients and relatives with peace of mind.
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Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
| | - Jenny Harlock
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Caroline J Huxley
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Celia Bernstein
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Claire Mann
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Rachel Spencer
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Frances Griffiths
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Anne-Marie Slowther
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
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Szmuilowicz E, Clepp RK, Neagle J, Ogunseitan A, Twaddle M, Wood GJ. The PACT Project: Feasibility of a Multidisciplinary, Multi-Faceted Intervention to Promote Goals of Care Conversations. Am J Hosp Palliat Care 2024; 41:355-362. [PMID: 37272769 DOI: 10.1177/10499091231181557] [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: 06/06/2023] Open
Abstract
BACKGROUND Patients living with serious illness generally want their physicians to facilitate Goals of Care conversations (GoCc), yet physicians may lack time and skills to engage in these conversations in the outpatient setting. The problem may be addressed by supporting multiple members of the clinical team to facilitate GoCc with the patient while admitted to the hospital. METHODS A multi-modal training and mentored implementation program was developed. A group of 10 hospitals were recruited to participate. Each hospital selected a primary inpatient unit on which to start the intervention, then expanded to a secondary unit later in the project. The number of trained facilitators (champions) and the number of documented GoCc were tracked over time. RESULTS Nine of 10 hospitals completed the 3-year project. Most of the units were general medical-surgical units. Forty-eight champions were trained at the kick-off conference, attended primarily by nurses, physicians, and social workers. By the end of the project, 153 champions had been trained. A total of 51 087 patients were admitted to PACT units with 85.4% being screened for eligibility. Of the patients who were eligible, over 68% had documented GoCc. CONCLUSION A multifaceted quality improvement intervention focused on serious illness communication skills can support a diverse clinical workforce to facilitate inpatient GoCc over time.
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Affiliation(s)
- Eytan Szmuilowicz
- Department of Medicine, Northwestern Medicine, Chicago, IL, USA
- Section of Palliative Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Rebecca K Clepp
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jayson Neagle
- Department of Medicine, Northwestern Medicine, Chicago, IL, USA
- Section of Palliative Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Adeboye Ogunseitan
- Department of Medicine, Northwestern Medicine, Chicago, IL, USA
- Section of Palliative Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Martha Twaddle
- Department of Medicine, Northwestern Medicine, Chicago, IL, USA
- Palliative Medicine and Supportive Care, Northwestern Lake Forest Hospital, Lake Forest, IL, USA
| | - Gordon J Wood
- Department of Medicine, Northwestern Medicine, Chicago, IL, USA
- Section of Palliative Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
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Wilkin K, Fang ML, Sixsmith J. Implementing advance care planning in palliative and end of life care: a scoping review of community nursing perspectives. BMC Geriatr 2024; 24:294. [PMID: 38549045 PMCID: PMC10976700 DOI: 10.1186/s12877-024-04888-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 03/13/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Advance care planninganning (ACP) is a priority within palliative care service provision. Nurses working in the community occupy an opportune role to engage with families and patients in ACP. Carers and family members of palliative patients often find ACP discussions difficult to initiate. However, community nurses caring for palliative patients can encourage these discussions, utilising the rapport and relationships they have already built with patients and families. Despite this potential, implementation barriers and facilitators continue to exist. To date, no research synthesis has captured the challenges community nurses face when implementing ACP, nor the facilitators of community nurse-led ACP. Considering this, the review question of: 'What factors contribute to or hinder ACP discussion for nurses when providing care to palliative patients?' was explored. METHOD To capture challenges and facilitators, a global qualitative scoping review was undertaken in June 2023. The Arksey and O'Malley framework for scoping reviews guided the review methodology. Six databases were searched identifying 333 records: CINAHL (16), MEDLINE (45), PUBMED (195), EMBASE (30), BJOCN (15), IJOPN (32). After de-duplication and title and abstract screening, 108 records remained. These were downloaded, hand searched (adding 5 articles) and subject to a full read. 98 were rejected, leaving a selected dataset of 15 articles. Data extracted into a data extraction chart were thematically analysed. RESULTS Three key themes were generated: 'Barriers to ACP', 'Facilitators of ACP' and 'Understanding of professional role and duty'. Key barriers were - lack of confidence, competence, role ambiguity and prognostic uncertainty. Key facilitators concerned the pertinence of the patient-practitioner relationship enabling ACP amongst nurses who had both competence and experience in ACP and/or palliative care (e.g., palliative care training). Lastly, nurses understood ACP to be part of their role, however, met challenges understanding the law surrounding this and its application processes. CONCLUSIONS This review suggests that community nurses' experience and competence are associated with the effective implementation of ACP with palliative patients. Future research is needed to develop interventions to promote ACP uptake in community settings, enable confidence building for community nurses and support higher standards of palliative care via the implementation of ACP.
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Affiliation(s)
| | - Mei Lan Fang
- School of Health Sciences, University of Dundee, Dundee, Scotland
- Urban Studies and Department of Gerontology, Simon Fraser University, Vancouver, Canada
| | - Judith Sixsmith
- School of Health Sciences, University of Dundee, Dundee, Scotland.
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Kolstrøm A, Driller B, Aasen EM. From difficulty to meaning - Experiences of patients with advanced cancer having advance care planning conversations and a palliative care plan. Eur J Oncol Nurs 2023; 67:102456. [PMID: 37976754 DOI: 10.1016/j.ejon.2023.102456] [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] [Received: 07/24/2023] [Revised: 10/19/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This study aimed to explore the experiences of patients with advanced cancer with Advanced care planning (ACP) communication and drawing up a palliative plan in primary healthcare settings in Norway. METHODS In this exploratory qualitative study, data were collected using semi-structured interviews with five patients with cancer who had undergone ACP and had a palliative care plan. RESULTS The result shows three main themes with subthemes; (1) The difficult ACP conversation about cancer and death was tough, painful, and considered a "taboo." The patients wished they had been prepared for the conversation and had it in their own homes. (2) Interactions with the doctor/nurse about the palliative care plan helped the patients feel valued and involved and brought their wishes into focus. The next of kin was present but not involved in the process. (3) Having a palliative plan was meaningful for the patients; they felt safe, and it gave them a sense of security. CONCLUSIONS Patients with advanced cancer in a home setting in Norway experienced ACP for the preparation of a palliative plan as a process from difficulty to meaning. In this process, the context and interactions provided by the doctor/nurse and their competency in communicating with the patients and involving them as persons was important. The palliative plan gave the patients a sense of meaning, control, and safety connected to the time for the end of life.
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Affiliation(s)
- Adriana Kolstrøm
- Department of Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Ålesund, Norway; Home Care Department, Kristiansund Municipality, Kristiansund N, Norway.
| | - Bardo Driller
- Department of Oncology and Department for Research and Innovation, Møre og Romsdal Hospital Trust, Aalesund, Norway; Department for Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Elin Margrethe Aasen
- Department of Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Ålesund, Norway.
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Rhee J, Carey M, Zucca A, Lambkin D. Exploring patients' advance care planning needs during the annual 75+ health assessment: survey of Australian GPs' views and current practice. Aust J Prim Health 2023; 29:637-642. [PMID: 37558212 DOI: 10.1071/py22227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 07/07/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND The 75+ health assessment has been identified as a suitable trigger to introduce advance care planning (ACP) to general practice patients. Australian general practitioners (GPs) were surveyed to explore their perceptions, attitudes and practices in introducing ACP during 75+ health assessments. METHODS A cross-sectional postal survey of Australian GPs covering their personal, professional and workplace characteristics, their current practice regarding ACP within a 75+ health assessment, and their attitude towards ACP. Multivariate logistic regression was used to analyse the factors associated with routinely discussing ACP as part of the 75+ health assessment. RESULTS A total of 185 (19.2%) out of 964 eligible GPs returned a completed survey. Most GPs reported that patients interested in ACP were supported by the GPs or the practice nurse. Two factors, (1) attitude that ACP is an essential component of the 75+ health assessment, and (2) regional or rural location of the practice, had a statistically and clinically significant association with the GP's self-reported discussion of ACP during 75+ health assessments. CONCLUSIONS GPs showed a high level of support and involvement in discussing ACP during 75+ health assessments. ACP support during 75+ health assessments was often provided directly by the GP or via the practice nurse. Given the international evidence that ACP training programs improve skills and knowledge, and foster positive attitudes towards ACP, there is an important need to continue funding ACP training programs for GPs and practice nurses.
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Affiliation(s)
- Joel Rhee
- The Discipline of General Practice, School of Population Health, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia; and General Practice Academic Unit, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Mariko Carey
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia; and Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Alison Zucca
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia; and Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - David Lambkin
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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Briedé S, Brandwijk ON, van Charldorp TC, Kaasjager HAH. A patient's perspective on care decisions: a qualitative interview study. BMC Health Serv Res 2023; 23:1335. [PMID: 38041103 PMCID: PMC10693144 DOI: 10.1186/s12913-023-10342-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 11/17/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Discussing treatment wishes and limitations during medical consultations aims to enable patients to define goals and preferences for future care. Patients and physicians, however, face multiple barriers, resulting in postponing or avoiding the conversation. The aim of this study was to explore an internal medicine outpatient clinic population's perception on (discussing) treatment wishes and limitations. METHODS Semi-structured interviews were conducted in two rounds with 44 internal medicine outpatient clinic patients at the University Medical Centre Utrecht, a tertiary care teaching medical centre in the Netherlands. Interviews were transcribed verbatim and thematically analysed with a phenomenological approach and inductive, data-driven coding. RESULTS Four themes were identified, two (1-2) represent a deep conviction, two (3-4) are practically oriented: (1) patients associate treatment wishes and limitations with the end-of-life, making it sensitive and currently irrelevant, (2) patients assume this process leads to fixed choices, whilst their wishes might be situation dependent, (3) treatment wishes and limitations are about balancing whether a treatment 'is worth it', in which several subthemes carry weight, (4) the physician is assigned a key role. CONCLUSION AND PRACTICE IMPLICATIONS The themes provide starting points for future interventions. It should be emphasized that care decisions are a continuous, dynamic process, relevant at any time in any circumstance and the physician should be aware of his/her key role.
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Affiliation(s)
- S Briedé
- Department of Internal Medicine and Dermatology, University Medical Centre Utrecht, Postbus 85500, Utrecht, GA, 3508, the Netherlands.
| | - O N Brandwijk
- Department of Internal Medicine and Dermatology, University Medical Centre Utrecht, Postbus 85500, Utrecht, GA, 3508, the Netherlands
| | - T C van Charldorp
- Department of Languages, Literature and Communication, Faculty of Humanities, Utrecht University, Utrecht, the Netherlands
| | - H A H Kaasjager
- Department of Internal Medicine and Dermatology, University Medical Centre Utrecht, Postbus 85500, Utrecht, GA, 3508, the Netherlands
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Asaumi K, Oki M, Murakami Y. When should Home-visit nurses initiate end-of-life discussions for patients with Organ failure and family caregivers? A qualitative study. BMC Nurs 2023; 22:258. [PMID: 37550676 PMCID: PMC10405459 DOI: 10.1186/s12912-023-01401-x] [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: 02/22/2023] [Accepted: 07/19/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND End-of-life (EOL) discussions for organ-failure patients with family caregivers are important factors for successful EOL care. However, identifying the appropriate time to initiate these discussions is difficult owing to the unpredictability of the disease trajectory. No practical tools or clinical indicators currently exist that can help identify non-cancer patients receiving home care who need EOL discussions. METHODS The survey was conducted from February 2020 to June 2021. To identify the appropriate time at which to initiate EOL discussions for patients with organ failure and their caregivers, we determined the time when home-visit nurses initiated EOL discussions. We interviewed 19 home-visit nurses (mean total home-visit nursing experience: 6.7 ± 5.9 years) and analyzed the data using Hsieh and Shannon's qualitative content approach. RESULTS Three themes related to home-visit nurses' experiences of identifying the appropriate time to start EOL discussions were identified: symptomatic worsening, lack of patients' and family caregivers' EOL awareness, and decline in activities of daily living. CONCLUSIONS It is necessary to develop a tool that will enable home-visit nurses to implement EOL discussions at the appropriate time.
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Affiliation(s)
- Kurumi Asaumi
- Department of Nursing, School of Health Sciences, Tokyo University of Technology, 5-23-22 Nishikamata, Ota-ku, Tokyo, 144-8535, Japan.
| | - Masataka Oki
- Department of Nursing, School of Health Sciences, Tokyo University of Technology, 5-23-22 Nishikamata, Ota-ku, Tokyo, 144-8535, Japan
| | - Yoshie Murakami
- Faculty of Nursing, Toho University, 4-16-20 Omorinishi, Ota-ku, Tokyo, 143-0015, Japan
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Townsend K, Johnson KS, Jones S, Spurlock A. Nurse Practitioner's Confidence and Competence of Advance Directives: The Benefits of an Educational Program. Hosp Top 2023:1-7. [PMID: 37129933 DOI: 10.1080/00185868.2023.2201693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
The increase in the number of people developing dementia, the growing number of geriatric patients suffering and dying from serious chronic diseases, and the rising costs of health care as a result of an aging population have centered attention on advance care planning. Advance care planning is the recurrent conversation between competent patients, their families, and the health care provider about end of life care. Although vital, advance care planning discussions between providers and patients are not occurring regularly, and completion rates of advance directives are low. Barriers to health care providers discussing advance directives include lack of time, knowledge, and confidence. The purpose of this project was to evaluate the effectiveness of an educational program regarding advance directives on nurse practitioner's competency and confidence to start advance care planning discussions. Wilcoxon signed rank test indicated that post-education, confidence improved significantly for all items (average rank of 4.5 vs average rank of 10.65). The study showed that most of the nurse practitioners were knowledgeable about advance directives and the educational program increased their level of confidence about initiating advance directive discussions.
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Affiliation(s)
| | | | - Stacey Jones
- School of Nursing, Troy University, Troy, AL, USA
| | - Amy Spurlock
- School of Nursing, Troy University, Troy, AL, USA
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Hamzehpour H, Ashktorab T, Esmaeili M. Safe acceptance in the nurses' cultural care of medical tourists in Iran: a qualitative study. BMC Health Serv Res 2023; 23:399. [PMID: 37098493 PMCID: PMC10127161 DOI: 10.1186/s12913-023-09378-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/07/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Medical tourism is traveling to another country to promote, restore and maintain health, recreation, and pleasure. There are different types of health tourism, including medical tourism, recovery tourism, and preventive tourism. This study aimed to explain safe acceptance in the nurses' cultural care of medical tourists in Iran. METHODS In this qualitative study, 18 semi-structured interviews were conducted with nurses, patients, and patients' relatives, who had been selected by purposeful sampling in 2021-2022. The interviews were recorded, transcribed, and then analyzed by conventional content analysis. RESULTS The statistical analysis revealed that the main theme of this study was safe acceptance which included the five categories of trust building, safety, maintaining comfort and peace, stress control, and identifying patients' expectations. CONCLUSIONS The present study demonstrated that safe acceptance of cultural care was essential to medical tourism. Iranian nurses were aware of the factors that affected cultural care and the safe acceptance of medical tourists. Moreover, they carried out the necessary measures to achieve safe acceptance. In this regard, solutions such as developing a comprehensive and mandatory national qualification program and evaluating its periodic performance in this field are suggested.
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Affiliation(s)
- Hero Hamzehpour
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences Islamic Azad University, Tehran, Iran
| | - Tahereh Ashktorab
- Department of Management, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, 00 98 912 236 1149, Iran.
| | - Maryam Esmaeili
- Nursing and Midwifery Care Research Center, Critical Care Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
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van Lummel EVTJ, Meijer Y, Tjan DHT, van Delden JJM. Barriers and facilitators for healthcare professionals to the implementation of Multidisciplinary Timely Undertaken Advance Care Planning conversations at the outpatient clinic (the MUTUAL intervention): a sequential exploratory mixed-methods study. BMC Palliat Care 2023; 22:24. [PMID: 36922796 PMCID: PMC10015131 DOI: 10.1186/s12904-023-01139-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 03/01/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Advance Care Planning (ACP) enables patients to define and discuss their goals and preferences for future medical treatment and care. However, the structural implementation of ACP interventions remains challenging. The Multidisciplinary Timely Undertaken Advance Care Planning (MUTUAL) intervention has recently been developed which takes into account existing barriers and facilitators. We aimed to evaluate the MUTUAL intervention and identify the barriers and facilitators healthcare professionals experience in the implementation of the MUTUAL intervention and also to identify suggestions for improvement. METHODS We performed a sequential exploratory mixed-methods study at five outpatient clinics of one, 300-bed, non-academic hospital. Firstly, semi-structured interviews were performed with a purposive sample of healthcare professionals. The content of these interviews was used to specify the Measurement Instrument for Determinants of Innovations (MIDI). The MIDI was sent to all healthcare professionals. The interviews and questionnaires were used to clarify the results. RESULTS Eleven healthcare professionals participated in the interviews and 37 responded to the questionnaire. Eight barriers and 20 facilitators were identified. Healthcare professionals agreed that the elements of the MUTUAL intervention are clear, correct, complete, and simple - and the intervention is relevant for patients and their proxies. The main barriers are found within the user and the organisational domain. Barriers related to the organisation include: inadequate replacement of staff, insufficient staff, and insufficient time to introduce and invite patients. Several suggestions for improvement were made. CONCLUSION Our results show that healthcare professionals positively evaluate the MUTUAL intervention and are very receptive to implementing the MUTUAL intervention. Taking into account the suggestions for improvement may enhance further implementation.
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Affiliation(s)
- Eline V T J van Lummel
- Department of Intensive Care, Gelderse Vallei hospital, Ede, Netherlands. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands.
| | - Yoeki Meijer
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Dave H T Tjan
- Department of Intensive Care, Gelderse Vallei hospital, Ede, Netherlands
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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Wong K, Yuan HB, Kunaviktikul W. Advance care planning readiness for Chinese older people: An integrative review and conceptual framework. FRONTIERS OF NURSING 2023. [DOI: 10.2478/fon-2023-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Abstract
Advance care planning is a process of discussion in which patients can communicate their end-of-life care preferences to family members and health care providers for consideration. Readiness for advance care planning is a patient’s preparedness to engage in advance care planning. This review aims to develop the conceptual framework for advance care planning readiness for Chinese older people. The current knowledge from the published studies was identified and synthesized by an integrative review. The conceptual framework was developed based on the social-ecological model and the theory of planned behavior. The factors from the social environment/community, health care professionals, and individual/family layers were defined. These factors may influence an individual’s medical decision-making, which in turn triggers individual behavioral mechanisms that arise from interactions between motivations, attitudes, and beliefs. Relevant factors should be considered when assessing the behavior of personnel engaged in advance care planning or formulating appropriate intervention measures to improve advance care planning participation in China. This framework can be used to guide studies that explore how the social/familial/individual factors predict the readiness for advance care planning among Chinese older people, and to design intervention studies to test the effect of family function on the readiness for advance care planning.
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Affiliation(s)
- Kalok Wong
- a Faculty of Health Sciences and Sports, Macao Polytechnic University , Macao SAR , China
- b Centro Hospitalar Conde de São Januário , Macao SAR , China
| | - Hao-Bin Yuan
- a Faculty of Health Sciences and Sports, Macao Polytechnic University , Macao SAR , China
| | - Wipada Kunaviktikul
- c School of Nursing, Panyapiwat Institute of Management , Bang Talat, Nonthaburi , Thailand
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Lemoyne SEE, Van Bogaert P, Calle P, Wouters K, Deblick D, Herbots H, Monsieurs K. Transferring nursing home residents to emergency departments by emergency physician-staffed emergency medical services: missed opportunities to avoid inappropriate care? Acta Clin Belg 2023; 78:3-10. [PMID: 35234573 DOI: 10.1080/17843286.2022.2042644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The decision to transfer a nursing home (NH) resident to an emergency department (ED) is multifactorial and challenging but many of the emergency physician-staffed emergency medical service (EP-EMS) interventions and ED transfers are probably inappropriate. METHODS We conducted a retrospective, cross-sectional study in three EP-EMSs in Belgium over a period of three years. We registered indicators that are potentially associated with inappropriate transfers: patient characteristics, availability of written do not resuscitate (DNR) orders or treatment restrictions, involvement of a general practitioner (GP) and availability of transfer notes. We also explored the association between age, the Charlson Comordity Index (CCI), polypharmacy, dementia, and the availability of DNR documents. RESULTS We registered 308 EP-EMS interventions in NH residents. In 98% the caller was a health-care professional. In 75% there was no GP present and 40% had no transfer note. Thirty-two percentage of the patients had dementia, 45% had more than two comorbidities and 68% took five medications or more. In 6% cardiopulmonary resuscitation was performed. DNR orders were available in 25%. Eighty-eight percentage of the NH residents were transferred to the ED. Forty-four percent had a CCI >5. In patients of ≥90 years, with a CCI >5, with dementia and with polypharmacy, DNR orders were not available in 81%, 67%%,and 69%, respectively. CONCLUSIONS Improved EMS dispatch centre-NH caller interaction, more involvement of GP's, higher availability of DNR orders and better communication between GPs/NHs and EP-EMS could prevent inappropriate interventions, futile prehospital aactions,and ED transfers.
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Affiliation(s)
- Sabine E E Lemoyne
- Emergency Department, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Peter Van Bogaert
- Centre for Research and Innovation in Care, University of Antwerp, Edegem, Belgium
| | - Paul Calle
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Kristien Wouters
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Clinical Trial Center (CTC), CRC Antwerp, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Dennis Deblick
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Hanne Herbots
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Kg Monsieurs
- Emergency Department, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
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Promoting advance care planning (ACP) in community health clinics in Israel: Perceptions of older adults with pro-ACP attitudes and their family physicians. Palliat Support Care 2023; 21:83-92. [PMID: 35109955 DOI: 10.1017/s1478951521001942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We examined barriers and facilitators to patient-family physician discussions in Israel about advance care planning, including preparation of an advance directive by adults over age 65, as part of a program in two community health clinics which afforded family physicians the opportunity to dedicate time to such discussions with patients. To the best of our knowledge, the program is the first of its kind in Israel. METHOD We used thematic analyses of qualitative data collected through 22 interviews with patients with pro-advanced care planning attitudes and three focus groups with eleven family physicians. RESULTS Overall, three themes in the interviews with patients and two themes in the focus groups with physicians emerged. The program gave people with pro-advanced care planning attitudes the opportunity to follow through with their ideas. We found that patients viewed their family physicians as facilitators and that the use of an information leaflet was an effective way to promote advance directives. Family physicians expressed positive attitudes toward assisting patients in the preparation of advance directives and welcomed an allotment of time for this endeavor as part of their schedule but expressed hesitation about assisting patients concerning legal and moral issues. SIGNIFICANCE OF RESULTS A pro-advanced care planning attitude is not enough for patients to complete the process of creating an advance directive; patients need active encouragement and intervention in order to turn their ideas into action. More patient and physician education are necessary to enable patients to protect their right to self-determination in end-of-life medical decision-making and to support physicians as facilitators of the process.
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Hendry A, Pottle J, Johnstone R, Poolman M, Hiscock J. The intricacy of interactions: qualitative exploration of preferences
and perceptions of advance care planning among healthcare professionals,
patients and those close to them. Palliat Care Soc Pract 2022; 16:26323524221139879. [PMCID: PMC9716444 DOI: 10.1177/26323524221139879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 10/31/2022] [Indexed: 12/05/2022] Open
Abstract
Objectives: Advance care planning (ACP) is a way of documenting preferences in case of a
change or decline in health via verbal discussion and may
include a written document. ACP relates not only to treatment preferences
but to all aspects of future care such as place of death, plans for
dependents and spiritual beliefs. Research has shown that ACP can have a
positive impact but needs further understanding to enhance communication and
increase uptake. This article focusses on the importance and intricacy of
interactions and why a preference-based approach may be beneficial for the
future. Methods: This article reports two separate, but related, pieces of qualitative
research. First, focus groups to evaluate perspectives of healthcare
professionals (HCPs) following their attendance at a North Wales ACP
training workshop. The second study comprised interviews exploring the views
of patients, those close to them and HCPs regarding ACP. Results: ACP interactions are complex and intricate. There is an association with end
of life rather than changes in health among patients and HCPs often view
discussions as akin to ‘breaking bad news’. Good communication between
patients, loved ones and HCPs is essential to reduce distress and ensure
preferences are understood. Trust between patients and HCPs is of high
importance and often a patient will have a preferred HCP who they feel
comfortable discussing ACP with. Conclusion: A preference-based approach to ACP has potential to widen participation in
ACP, relieve anxiety and ease burden for patients and carers. Further
research is needed to identify ways to increase inclusivity.
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Affiliation(s)
| | | | | | - Marlise Poolman
- Bangor Institute for Health and Medical
Research, Bangor University, Wrexham, UK,Betsi Cadwaladr University Health Board, North
Wales, UK
| | - Julia Hiscock
- Bangor Institute for Health and Medical
Research, Bangor University, Wrexham, UK
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16
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Slezáčková A, Malatincová T, Rusinová K, Kopecký O, Kuře J. Evaluation of the Utility of the Advance Care Planning and Decision‑Making Supportive Tool. ANESTEZIOLOGIE A INTENZIVNÍ MEDICÍNA 2022. [DOI: 10.36290/aim.2022.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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17
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Sussman T, Lawrence J, Pimienta R. "This is how I want it": Exploring the use of a workbook with persons with dementia to support advance care planning engagement. DEMENTIA 2022; 21:2601-2618. [PMID: 36151606 PMCID: PMC9583280 DOI: 10.1177/14713012221127358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This mixed method sequential study reports focus group and pilot intervention
findings that (1) explore the views of persons with dementia and their
caregivers on using a self-directed advance care planning engagement workbook
(Your Conversation Starter Kit) and (2) uncover the
conditions that encouraged and hindered workbook use. In Phase 1, we conducted
five focus groups consisting of 10 persons with dementia and eight family
members/caregivers from two urban Canadian cities to explore overall impressions
of the workbook and factors that might affect its use. In Phase 2, we
empirically explored the factors identified in Phase 1 by distributing the
workbook to 24 persons with dementia. The combined findings suggest that the
workbook offers promise in supporting advance care planning engagement for
persons with dementia in the early stages of their condition. Involving
family/caregivers and clarifying some of the ranked questions might improve the
workbook’s use. Persons with dementia without familial support or those who have
never contemplated advance care planning may require additional guidance prior
to workbook distribution.
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Affiliation(s)
- Tamara Sussman
- School of Social Work, 5620McGill University, Montreal, Canada
| | - Jack Lawrence
- School of Social Work, 5620McGill University, Montreal, Canada
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18
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van Gaans D, Erny-Albrecht K, Tieman J. Palliative Care Within the Primary Health Care Setting in Australia: A Scoping Review. Public Health Rev 2022; 43:1604856. [PMID: 36148429 PMCID: PMC9485459 DOI: 10.3389/phrs.2022.1604856] [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: 02/21/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: This scoping review identifies and details the scope of practice of health professionals who provide palliative care within the primary health setting in Australia.Methods: A scoping review approach was conducted on the Cinahl (Ebsco), Scopus, Medline (Ovid) and PubMed databases to extract articles from 1 December 2015 to 1 December 2020. Broad text words and MeSH headings were used with relevance to palliative care, general practice, primary health, and community setting. Extracted journal articles were limited to those based on the Australian population or Australian health system.Results: Eighty-four papers met the inclusion criteria and were included in the review. The review identified the following health professional roles within the Primary Health Care setting undertaking palliative care: General Practitioner, Nurse, Pharmacist, Paramedics, Carers, and Allied Health professionals.Conclusion: This review offers a first understanding of the individual health professional roles and multidisciplinary team approach to actively providing palliative care within the Primary Health Care setting in Australia.
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19
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Davidson AR, Reidlinger DP. A review of the growth and development of Australian practice nursing: Insights for the dietetic workforce. Nutr Diet 2022; 79:497-548. [PMID: 35989542 PMCID: PMC9545586 DOI: 10.1111/1747-0080.12764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 06/09/2022] [Accepted: 06/23/2022] [Indexed: 11/28/2022]
Abstract
Aim The aim of this scoping review was to provide an overview of the development of practice nurses, and the learnings that could be applied to improve the profile of dietetics practice in primary care. Methods A scoping review synthesising peer‐reviewed and other literature relevant to the development of Australian practice nurses was conducted. Structured searches using keywords ‘general practice’, ‘nurse’ and ‘Australia’ were conducted in PubMed and Google Scholar in June 2021. Key government websites, Department of Health and Services Australia, were searched to identify grey literature. One reviewer screened the titles and abstracts against inclusion criteria; two reviewers conducted full‐text screening independently. Data on the evolution of practice nursing were extracted based on its interest and transferability to the dietetics workforce. Results A total of 102 results (82 peer‐reviewed and 20 other literature) were included in the review. Key drivers for practice nurse role development in Australia were government funding, practice nurse practice standards, cost–benefit analyses of practice nurses, career and education opportunities, general practitioner and patient perspectives of practice nurses and, individual, community and local needs. Conclusions The practice nurse role has grown and strengthened and there are three key learnings that could be translated to strengthen the dietetics workforce in primary care. (1) Use and expansion of government funding, (2) furthering post‐tertiary education and career opportunities, including dietetic primary care practice standards and (3) targeting underserviced areas such as those that are rural and remote and building positive relationships with other stakeholders including practice nurses, general practitioners, patients and the broader primary care team.
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Affiliation(s)
- Alexandra R Davidson
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Dianne P Reidlinger
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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20
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Millstein LS, Rosenblatt P, Bellin MH, Whitney L, Eveland SR, Lee MC, Allen J, Mutchie HL, Becker TD, Cagle J. Advance Care Planning and Communication Skills Improve after an Interprofessional Team Simulation with Standardized Patients. Palliat Med Rep 2022; 3:123-131. [PMID: 36059907 PMCID: PMC9438443 DOI: 10.1089/pmr.2021.0086] [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] [Accepted: 06/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Improving rates of advance care planning (ACP) and advance directive completion is a recognized goal of health care in the United States. No prior study has examined the efficacy of standardized patient (SP)-based student interprofessional ACP trainings. Objectives: The present study aims to evaluate an interprofessional approach to ACP education using SP encounters. Design: We designed a pre–post evaluation of an innovative interprofessional ACP training curriculum using multimodal adult learning techniques to test the effects of completing ACP discussions with SPs. Three surveys (pre-training T1, post-training T2, and post-clinical encounter T3) evaluated student knowledge, Communication Self-Efficacy (CSES), ACP self-efficacy, and interprofessional teamwork (using SPICE-R2). Setting/Subjects: Students from the schools of medicine, nursing, and social work attended three training modules and two SP encounters focused on ACP. Measurements/Results: During academic year 2018–2019, 36 students participated in the training at University of Maryland. Results demonstrated statistically significant improvements in ACP self-efficacy, MT1 = 2.9 (standard deviation [SD]T1 = 0.61) compared with MT3 = 3.9 (SDT3 = 0.51), p < 0.001, and CSES, MT1 = 4.6 (SDT1 = 1.35) versus MT3 = 7.3 (SDT3 = 0.51), p < 0.001, from T1 to T3. There was a medium-to-large improvement in knowledge from an average score of 4.3 (SD = 1.0) at T1 to an average score of 5.5 (SD = 1.4) at T2, p = 0.005, d = 0.67. Conclusions: Our interprofessional training module and SP encounter was successful in improving medical, social work, and nursing students' self-reported communication skills and knowledge regarding ACP.
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Affiliation(s)
- Leah S. Millstein
- Department of Medicine, University of Maryland School of Medicine, University of Maryland, Baltimore, Maryland, USA
- Department of Pediatrics, University of Maryland School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Paula Rosenblatt
- Department of Medicine, University of Maryland School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Melissa H. Bellin
- University of Maryland School of Social Work, University of Maryland, Baltimore, Maryland, USA
| | - Laura Whitney
- University of Maryland School of Social Work, University of Maryland, Baltimore, Maryland, USA
| | - Steven R. Eveland
- University of Maryland Medical Center, University of Maryland, Baltimore, Maryland, USA
| | - Mei Ching Lee
- University of Maryland School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - John Allen
- Department of Medicine, University of Maryland School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Heather L. Mutchie
- Department of Medicine, University of Maryland School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Todd D. Becker
- University of Maryland School of Social Work, University of Maryland, Baltimore, Maryland, USA
| | - John Cagle
- University of Maryland School of Social Work, University of Maryland, Baltimore, Maryland, USA
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21
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Abstract
Approximately 1 in 3 adults have some type of advance directive. Advance care planning (ACP) is associated with greater use of supportive care services and decreased patient and family stress. Despite this, organizations continue to have difficulty in implementing effective programs for increasing ACP. Increasing knowledge and comfort of the health care team with end-of-life discussions and ACP is essential. Educational efforts should focus on decreasing known barriers to ACP discussions such as discomfort, unclear role, lack of experience, and limited education. Role playing and case discussions taught by geriatric resources nurses can help increase staff knowledge and comfort regarding ACP. Role playing allows staff to think about their own mortality and what will happen in various situations if ACP is not complete. Team members find that once they have completed their own ACP, they are more comfortable discussing ACP with patients and caregivers. Nurses should collaborate with social workers and chaplains for ACP education and discussing what matters most to them. Patients are encouraged to make sure that they provide advance directives to their health care providers. This article shares an interprofessional team approach to improving processes for ACP as a component of "what matters most" to older adults with cancer.
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22
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Scott IA, Reymond L, Sansome X, Miller L. A whole-of-community program of advance care planning for end-of-life care. AUST HEALTH REV 2022; 46:442-449. [PMID: 35817410 DOI: 10.1071/ah22099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/15/2022] [Indexed: 11/23/2022]
Abstract
Since 2015 a whole-of-community program to promote advance care planning (ACP) within one Queensland Hospital and Health Service (HHS) catchment has spread statewide, financed by Queensland Health (QH) agencies and led by the Statewide Office of Advance Care Planning (SOACP). The program aims to identify ACP-eligible patients, invite and finalise ACP discussions, and ensure documented care preferences are easily retrievable by clinicians to guide future care if a person loses capacity. The SOACP established a digital infrastructure whereby quality-audited ACP documents are uploaded to a software platform accessible to all QH clinicians, private medical specialists, ambulance paramedics, general practitioners (GPs), and registered nurses, including those in residential aged care facilities (RACFs). The SOACP also hosts a website providing resources for clinicians and patients, delivers educational events and mentorship to GPs and hospital and RACF staff, and employs ACP facilitators working across all QH HHSs. The program has seen yearly increases in the numbers of ACP documents uploaded from around the state, with up to 79% of eligible patients in some hospitals receiving ACP, significant ACP uptake in RACFs, and acceptance by GPs to engage in ACP. Audits reveal high concordance between stated preferences and hospital care received, and ACP patients, compared to matched non-ACP controls, more frequently die out of hospital, have fewer inpatient days during their last 6 months of life, and receive less invasive care, with similar results seen among same-patient cohorts post-ACP. Barriers and enablers to ACP have been identified which will inform program evolution.
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Affiliation(s)
- Ian A Scott
- Princess Alexandra Hospital, 199 Ipswich Road, Brisbane, Qld 4102, Australia; and School of Clincial Medicine, University of Queensland, Qld, Australia
| | - Liz Reymond
- Eight Mile Plains Community Health, 51 McKechnie Drive, Eight Mile Plains, Qld 4113, Australia; and School of Public Health, Griffith School of Medicine, Qld, Australia
| | - Xanthe Sansome
- Eight Mile Plains Community Health, 51 McKechnie Drive, Eight Mile Plains, Qld 4113, Australia
| | - Leyton Miller
- Eight Mile Plains Community Health, 51 McKechnie Drive, Eight Mile Plains, Qld 4113, Australia
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van Lummel EVTJ, Savelkoul C, Stemerdink ELE, Tjan DHT, van Delden JJM. The development and feasibility study of Multidisciplinary Timely Undertaken Advance Care Planning conversations at the outpatient clinic: the MUTUAL intervention. BMC Palliat Care 2022; 21:119. [PMID: 35794617 PMCID: PMC9258045 DOI: 10.1186/s12904-022-01005-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patients still receive non-beneficial treatments when nearing the end of life. Advance care planning (ACP) interventions have shown to positively influence compliance with end of life wishes. Hospital physicians seem to miss opportunities to engage in ACP, whereas patients visiting the outpatient clinic usually have one or more chronic conditions and are at risk for medical emergencies. So far, implemented ACP interventions have had limited impact. Structural implementation of ACP may be beneficial. We hypothesize that having ACP conversations more towards the end of life and involving the treating physician in the ACP conversation may help patient wishes and goals to become more concrete and more often documented, thus facilitating goal-concordant care. Aim To facilitate timely shared decision making and increase patient autonomy we aim to develop an ACP intervention at the outpatient clinic for frail patients and determine the feasibility of the intervention. Methods The United Kingdom’s Medical Research Council framework was used to structure the development of the ACP intervention. Key elements of the ACP intervention were determined by reviewing existing literature and an iterative process with stakeholders. The feasibility of the developed intervention was evaluated by a feasibility study of 20 ACP conversations at the geriatrics and pulmonology department of a non-academic hospital. Feasibility was assessed by analysing evaluation forms by patients, nurses and physicians and by evaluating with stakeholders. A general inductive approach was used for analysing comments. The developed intervention was described using the template for intervention description and replication (TIDieR). Results We developed a multidisciplinary timely undertaken ACP intervention at the outpatient clinic. Key components of the developed intervention consist of 1) timely patient selection 2) preparation of patient and healthcare professional 3) a scripted ACP conversation in a multidisciplinary setting and 4) documentation. 94.7% of the patients, 60.0% of the nurses and 68.8% of the physicians agreed that the benefits of the ACP conversation outweighed the potential burdens. Conclusion This study showed that the developed ACP intervention is feasible and considered valuable by patients and healthcare professionals. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01005-3.
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Smedinga M, Bunnik EM, Richard E, Schermer MHN. Should Doctors Offer Biomarker Testing to Those Afraid to Develop Alzheimer's Dementia? : Applying the Method of Reflective Equilibrium for a Clinical Dilemma. JOURNAL OF BIOETHICAL INQUIRY 2022; 19:287-297. [PMID: 35306635 DOI: 10.1007/s11673-022-10167-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 07/23/2021] [Indexed: 06/14/2023]
Abstract
An increasing number of people seek medical attention for mild cognitive symptoms at older age, worried that they might develop Alzheimer's disease. Some clinical practice guidelines suggest offering biomarker testing in such cases, using a brain scan or a lumbar puncture, to improve diagnostic certainty about Alzheimer's disease and enable an earlier diagnosis. Critics, on the other hand, point out that there is no effective Alzheimer treatment available and argue that biomarker tests lack clinical validity. The debate on the ethical desirability of biomarker testing is currently polarized; advocates and opponents tend to focus on their own line of arguments. In this paper, we show how the method of reflective equilibrium (RE) can be used to systematically weigh the relevant arguments on both sides of the debate to decide whether to offer Alzheimer biomarker testing. In the tradition of RE, we reflect upon these arguments in light of their coherence with other argumentative elements, including relevant facts (e.g. on the clinical validity of the test), ethical principles, and theories on societal ideals or relevant concepts, such as autonomy. Our stance in the debate therefore rests upon previously set out in-depth arguments and reflects a wide societal perspective.
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Affiliation(s)
- Marthe Smedinga
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, Rotterdam, The Netherlands.
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Reinier Postlaan 4, 6525 GC, Nijmegen, The Netherlands.
| | - Eline M Bunnik
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Reinier Postlaan 4, 6525 GC, Nijmegen, The Netherlands
| | - Maartje H N Schermer
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, Rotterdam, The Netherlands
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25
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Jackson D. Incontinence in palliative care: assessment to promote dignity. Br J Community Nurs 2022; 27:242-250. [PMID: 35522447 DOI: 10.12968/bjcn.2022.27.5.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article will explore the district nurse (DN) role in caring for palliative service users and their responsibility to prepare them and their family members to understand the trajectory of their prognosis and the possible decline in urinary function and incontinence. Educating DNs to advise service users in appropriate management options and collaborating with the wider multidisciplinary team (MDT) to ensure service users' individual goals and aims are followed as closely as possible. Urinary incontinence (UI) is not a natural part of the ageing process, although the prevalence of UI is increased as people age, through multi-morbidities, polypharmacy, cognitive decline, mobility limitations or life-limiting conditions. UI affects an individual's dignity and can cause a negative impact on self-esteem, and it is often accompanied by a perceived stigma that can lead to anxiety, depression and a reluctance to ask for help and advice.
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Affiliation(s)
- Debra Jackson
- District Nurse Apprentice, Salford Royal NHS Trust (Northern Care Alliance)
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Vilapakkam Nagarajan S, Lewis V, Halcomb EJ, Rhee J, Tieman J, Clayton JM. Australian general practice experiences of implementing a structured approach to initiating advance care planning and palliative care: a qualitative study. BMJ Open 2022; 12:e057184. [PMID: 35351724 PMCID: PMC8961132 DOI: 10.1136/bmjopen-2021-057184] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Initiation of advance care planning (ACP) and palliative care (PC) assessments in general practice is key to quality end-of-life care. The Advance Project promotes a team-based approach to initiating ACP and PC needs assessment in general practices through training, resources and practical support for implementation from local primary health networks (PHNs). This paper aims to understand: (1) general practice participants' experiences of undertaking Advance Project training and implementing the Advance Project resources in their practices; (2) barriers and facilitators to implementation of Advance Project resources; and (3) PHN staff experiences of supporting general practices through training and practical support for implementation of the Advance Project resources. DESIGN Qualitative study using semistructured interviews and thematic analysis. SETTING Twenty-one general practices and four PHNs from three Australian states were recruited between June 2019 and May 2020. PARTICIPANTS General practitioners (GPs), general practice nurses, practice managers (PMs) and PHN staff. RESULTS 45 participants comprising 13 GPs, 13 general practice nurses, 9 PMs, 3 allied health staff and 7 PHN staff were interviewed. The general practice participants generally agreed that the Advance Project training/resources led to changes in their own behaviour and increased their awareness of the importance of ACP/PC discussion with their patients. Participants reported the following benefits for patients: increased awareness of ACP; engagement with families/carers and peace of mind. Key facilitators for successful implementation were a team-based approach, the role of the PHN, the role of practice champions, training facilitators' ability to influence peers and facilitate change, and mentoring support. Barriers to implementation included issues related to workplace culture, cost, time/workload, patients and health system. CONCLUSION Findings suggest that the Advance Project approach facilitated successful implementation of ACP and PC needs assessment into usual care in general practices that encouraged teamwork among GPs and general practice nurses. The ability of the practice to make the best use of practical support and guidance available to them through their local PHN both before and during implementation was a key factor in integration of Advance Project resources into routine practice.
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Affiliation(s)
- Srivalli Vilapakkam Nagarajan
- The Palliative Centre, HammondCare, Greenwich Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Virginia Lewis
- Australian Institute for Primary Care and Ageing, La Trobe University, Melbourne, Victoria, Australia
| | - Elizabeth J Halcomb
- School of Nursing, University of Wollongong, Wollongong, New South Wales, Australia
| | - Joel Rhee
- Centre for Positive Ageing + Care, HammondCare, Hammondville, Sydney, New South Wales, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Jennifer Tieman
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, South Australia, Australia
| | - Josephine M Clayton
- The Palliative Centre, HammondCare, Greenwich Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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27
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Xu L, Sommer RK, Nyeko L, Michael C, Traeger L, Jacobsen J. Patient Perspectives on Serious Illness Conversations in Primary Care. J Palliat Med 2022; 25:940-944. [PMID: 35196134 DOI: 10.1089/jpm.2021.0420] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The Serious Illness Care Program has been shown to improve quality and feasibility of value-based end-of-life conversations in primary care. Objectives: To elicit patients' perspectives on serious illness conversations conducted by primary care clinicians. Subjects and Methods: Telephone interviews were conducted with patients at an academic center in the United States, who had a recent serious illness conversation with their primary care clinician. Interviews were audio-recorded and qualitatively analyzed using thematic analysis. Results: A total of eleven patients were enrolled. We identified three major themes: (1) positive emotional experiences are facilitated by established patient-clinician relationships and/or clinicians' skills in navigating emotional challenges, (2) patients appreciate a personalized conversation, and (3) clinicians should orchestrate the experience of the conversation, from preparation through follow-up. Conclusion: Patients appreciate having serious illness conversations in the primary care setting. Future efforts can be focused on improving clinicians' skills in navigating emotional challenges during conversations and implementing system changes to optimize orchestration.
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Affiliation(s)
- Luyi Xu
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Robert K Sommer
- Department of Educational and Psychological Studies, University of Miami, Coral Gables, Florida, USA
| | - Liza Nyeko
- Office of Patient Experience and Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians Organization, Boston, Massachusetts, USA
| | - Carol Michael
- Massachusetts General Hospital Patient and Family Advisory Council, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Nagarajan SV, Lewis V, Halcomb E, Rhee J, Morton RL, Mitchell GK, Tieman J, Phillips JL, Detering K, Gavin J, Clayton JM. Barriers and facilitators to nurse-led advance care planning and palliative care practice change in primary healthcare: a qualitative study. Aust J Prim Health 2022; 28:151-157. [PMID: 35131028 DOI: 10.1071/py21081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 11/10/2021] [Indexed: 11/23/2022]
Abstract
Primary care settings are ideal for initiating advance care planning (ACP) conversations and assessing palliative and supportive care needs. However, time constraints and a lack of confidence to sensitively and efficiently initiate such discussions are noted barriers. The Advance Project implemented a national multicomponent training package to support Australian general practice nurses (GPNs) to work with GPs to initiate ACP and palliative care conversations in their practice. This paper reports on semistructured interviews conducted with 20 GPNs to explore barriers and facilitators to implementing the Advance Project model. Participants identified a range of factors that affected implementation, including lack of time, limited support from colleagues, lack of knowledge about systems and funding processes in general practice and a need for better alignment of the Advance Project resources and practices with general practice information management platforms. Barriers related to professional roles, particularly the lack of clarity and/or limitations in the scope of practice of GPNs, highlighted the importance of defining and supporting the roles that different primary health practice staff could play to support implementation of the model. The findings underline the need for complementary training in the Advance Project model for GPs and practice managers to enable a team-based approach to implementation.
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Affiliation(s)
- Srivalli V Nagarajan
- Centre for Learning and Research in Palliative Care, HammondCare, Greenwich Hospital, Sydney, NSW, Australia; and Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; and Corresponding author
| | - Virginia Lewis
- Australian Institute for Primary Care and Ageing, La Trobe University, Melbourne, Vic., Australia
| | - Elizabeth Halcomb
- School of Nursing, The University of Wollongong, Wollongong, NSW, Australia
| | - Joel Rhee
- Centre for Positive Ageing and Care, HammondCare, Sydney, NSW, Australia; and Graduate School of Medicine, The University of Wollongong, Wollongong, NSW, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Geoffrey K Mitchell
- Mayne Academy of Primary Care, Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Jennifer Tieman
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, SA, Australia
| | - Jane L Phillips
- Faculty of Health, School of Nursing, Queensland University of Technology, Brisbane, Qld, Australia
| | - Karen Detering
- Department of Health, Arts and Design, Swinburne University, Melbourne, Vic., Australia
| | - Jennifer Gavin
- Centre for Cancer and Palliative Care Outcomes, Faculty of Health, Queensland University of Technology, Brisbane, Qld, Australia
| | - Josephine M Clayton
- Centre for Learning and Research in Palliative Care, HammondCare, Greenwich Hospital, Sydney, NSW, Australia; and Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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29
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Pedrosa Carrasco AJ, Koch M, Machacek T, Genz A, Herzog S, Riera Knorrenschild J, von Blanckenburg P, Seifart C. ' It was like taking an inner bath': A qualitative evaluation of a collaborative advance care planning-approach. Palliat Med 2021; 35:1897-1907. [PMID: 34479460 PMCID: PMC8637376 DOI: 10.1177/02692163211043209] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Impaired readiness may hinder purposeful advance care planning in cancer patients. To reduce barriers to participation in end-of-life decision-making, a collaborative intervention was developed combining a psycho-oncological approach of dignity-based and cognitive-behavioural interventions, followed by a standardised advance care planning-process. AIM To evaluate the novel collaborative advance care planning-approach by synthetising cancer patient and carer perspectives on communicational and relational effects. DESIGN As a sub-project of a mixed-methods evaluation study, we conducted an inductive content analysis of qualitative interviews with advanced cancer patients and caregivers to deeply explore the focused impact of a collaborative advance care planning-approach on communication and relationship dynamics. SETTING/PARTICIPANTS Twelve patients with advanced cancer and 13 carers who participated in a collaborative advance care planning-intervention. RESULTS The collaborative advance care planning-approach was consistently evaluated positively by participants. Transcriptions of the semi-structured interviews were coded, analysed and merged under three main themes concerning communicational and relationship dynamics: action readiness, content readiness and impact on future communication and relationship. CONCLUSIONS The novel intervention served to foster individual readiness - including action and content readiness - for advance care planning-discussions by addressing highly individualised barriers to participation, as well as specific end-of-life issues. In addition, societal readiness could be promoted. Although the brief psycho-oncological intervention could not fully meet the needs of all participants, it can be used to develop individual psychotherapeutic strategies to improve different facets of readiness. The collaborative advance care planning-approach might require more time and human resources, but could pioneer successful advance care planning.
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Affiliation(s)
| | - Martin Koch
- Study Group Ethics in Medicine, Philipps-University Marburg, Marburg, Germany.,Department of Medicine, Haematology Division, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Teresa Machacek
- Study Group Ethics in Medicine, Philipps-University Marburg, Marburg, Germany
| | - Anna Genz
- Study Group Ethics in Medicine, Philipps-University Marburg, Marburg, Germany
| | - Svenja Herzog
- Study Group Ethics in Medicine, Philipps-University Marburg, Marburg, Germany
| | - Jorge Riera Knorrenschild
- Department of Haematology, Oncology and Immunology, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Pia von Blanckenburg
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Carola Seifart
- Study Group Ethics in Medicine, Philipps-University Marburg, Marburg, Germany
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30
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Ellis-Smith C, Tunnard I, Dawkins M, Gao W, Higginson IJ, Evans CJ. Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools. BMC Palliat Care 2021; 20:168. [PMID: 34674695 PMCID: PMC8532380 DOI: 10.1186/s12904-021-00845-9] [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] [Received: 03/08/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022] Open
Abstract
Background Older people with multi-morbidities commonly experience an uncertain illness trajectory. Clinical uncertainty is challenging to manage, with risk of poor outcomes. Person-centred care is essential to align care and treatment with patient priorities and wishes. Use of evidence-based tools may support person-centred management of clinical uncertainty. We aimed to develop a logic model of person-centred evidence-based tools to manage clinical uncertainty in older people. Methods A systematic mixed-methods review with a results-based convergent synthesis design: a process-based iterative logic model was used, starting with a conceptual framework of clinical uncertainty in older people towards the end of life. This underpinned the methods. Medline, PsycINFO, CINAHL and ASSIA were searched from 2000 to December 2019, using a combination of terms: “uncertainty” AND “palliative care” AND “assessment” OR “care planning”. Studies were included if they developed or evaluated a person-centred tool to manage clinical uncertainty in people aged ≥65 years approaching the end of life and quality appraised using QualSyst. Quantitative and qualitative data were narratively synthesised and thematically analysed respectively and integrated into the logic model. Results Of the 17,095 articles identified, 44 were included, involving 63 tools. There was strong evidence that tools used in clinical care could improve identification of patient priorities and needs (n = 14 studies); that tools support partnership working between patients and practitioners (n = 8) and that tools support integrated care within and across teams and with patients and families (n = 14), improving patient outcomes such as quality of death and dying and satisfaction with care. Communication of clinical uncertainty to patients and families had the least evidence and is challenging to do well. Conclusion The identified logic model moves current knowledge from conceptualising clinical uncertainty to applying evidence-based tools to optimise person-centred management and improve patient outcomes. Key causal pathways are identification of individual priorities and needs, individual care and treatment and integrated care. Communication of clinical uncertainty to patients is challenging and requires training and skill and the use of tools to support practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00845-9.
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Affiliation(s)
- Clare Ellis-Smith
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.
| | - India Tunnard
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - Marsha Dawkins
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Guys & St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Wei Gao
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,King's College Hospital NHS Foundation Trust, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, UK
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31
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Chen JO, Lin CC. Exploring the Barriers Faced by Nephrology Nurses in Initiating Patients With Chronic Kidney Disease Into Advance Care Planning Using Focus-Group Interviews. J Nurs Res 2021; 29:e179. [PMID: 34607991 DOI: 10.1097/jnr.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The prevalence of end-stage renal disease in Taiwan is the highest in the world. The rate of signing advance directives in Taiwan is lower than in Western countries, and most of the barriers that have been identified relate to initiating advance care planning (ACP). PURPOSE This study was designed to explore the barriers to discussing ACP with patients with chronic kidney disease faced by nephrology nurses. METHODS A descriptive qualitative study design was adopted. The Consolidated Criteria for Reporting Qualitative Research was used to report the findings of this study. Data were collected using purposive sampling. A total of 34 nephrology nurses were recruited from hospitals in northern (2 groups, 10 participants), central (1 group, 4 participants), and southern (5 groups, 20 participants) Taiwan. A qualitative content analysis was conducted to analyze the transcripts of the eight focus groups. RESULTS Five themes were identified, including (a) lacking the confidence to discuss ACP, (b) difficulty in finding an appropriate opportunity to initiate ACP discussion, (c) personally lacking the characteristics to discuss ACP, (d) conflicting perspectives between doctors and nurses over ACP, and (e) culture and belief-based barriers to discussing ACP. CONCLUSIONS/IMPLICATIONS FOR PRACTICE The findings obtained from the interviews revealed that nurses must enhance their ACP-related knowledge and communication skills and foster personal confidence in initiating ACP discussions. Furthermore, nurses must be empowered to work with other healthcare professionals. To implement the initial process of discussing ACP in clinical settings, clinical guidelines should be developed for healthcare professionals on initiating ACP. These measures may facilitate improved collaboration in healthcare settings and further encourage patients and their families to participate in shared decision-making that may help patients complete advance directives and thereby achieve better care quality at the end of life.
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Affiliation(s)
- Jui-O Chen
- PhD, RN, Assistant Professor, Department of Nursing, Tajen University, Pingtung, Taiwan, ROC
| | - Chiu-Chu Lin
- PhD, RN, Professor, School of Nursing; Department of Renal Care, College of Medicine; and Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
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32
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Lino P, Williams M. Transitioning end-of-life care from hospital to the community: case report. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2021; 30:1010-1014. [PMID: 34605254 DOI: 10.12968/bjon.2021.30.17.1010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Palliative/end-of-life care is an integral part of the district nursing service. There is increasing demand for palliative care to be delivered in the community setting. Therefore, there is a need for excellent collaboration between staff in primary and secondary care settings to achieve optimum care for patients. This article critically analyses the care delivered for a palliative patient in the hospital setting and his subsequent transition to the community setting. The importance of effective communication, holistic assessment in palliative care, advance care planning, organisational structures and the socio-cultural aspects of caring for patients at the end of life are discussed. Additionally, the article highlights the impact of substandard assessment and communication and the consequent effect on patients and families.
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Affiliation(s)
- Pedro Lino
- District Nurse, The Oakridge Centre, High Wycombe
| | - Mary Williams
- Senior Lecturer in Cancer, Palliative Care and End of Life Care, School of Health Care and Social Work, Buckinghamshire New University, Uxbridge, when this article was written, and is now Macmillan Lead Nurse for Specialist Supportive and Palliative Care and Chaplaincy, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London
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33
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Ohr SO, Cleasby P, Jeong SYS, Barrett T. Nurse-led normalised advance care planning service in hospital and community health settings: a qualitative study. BMC Palliat Care 2021; 20:139. [PMID: 34503475 PMCID: PMC8431845 DOI: 10.1186/s12904-021-00835-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance Care Planning (ACP) by Registered Nurses (RNs) has been emerging. However, there is limited understanding about what RNs experience as they incorporate ACP into their practice. This study aimed to elicit the experiences of ACP RNs with the implementation of a normalised ACP (NACP) service in hospital and community care settings. METHODS A qualitative descriptive study invited four ACP RNs who delivered a nurse-led NACP for a 6 months duration at two hospital and two community health care settings in New South Wales (NSW), Australia. The experiences of the ACP RNs were captured through a semi-structured interview and weekly debriefing meetings. The interview recordings were transcribed verbatim and the minutes of weekly debriefing meetings were utilized. Data were analysed by two independent researchers using thematic analysis with the Normalisation Process Theory (NPT) as a methodological framework. FINDINGS The ACP RNs were females with a mean age of 43 years old. Their nursing experiences ranged 2 to 25 years but they had minimal experiences with ACP and had not attended any education about ACP previously. The following four themes were identified in the experiences of the ACP RNs; 1) Embracing NACP service; 2) Enablers and barriers related to patients and health professionals; 3) Enablers and barriers related to ACP RNs; and 4) What it means to be an ACP RN. CONCLUSION The introduction of a NACP service into existing clinical systems is complex. The study demonstrated the capacity of RNs to engage in ACP processes, and their willingness to deliver an NACP service with a raft of locally specific enablers and barriers. TRIAL REGISTRATION The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record.
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Affiliation(s)
- Se Ok Ohr
- HNE Nursing and Midwifery Research Centre, Conjoint Lecturer University of Newcastle, James Fletcher Campus, Gate Cottage, 72 Watt Street, Hunter New England Local Health District, Newcastle, NSW 2300 Australia
| | - Peter Cleasby
- Division of Aged, Subacute and Complex Care, PO Box 6088, Central Coast Local Health District, Long Jetty, NSW 2261 Australia
| | - Sarah Yeun-Sim Jeong
- School of Nursing and Midwifery, The University of Newcastle, 10 Chittaway Road, Ourimbah, NSW 2258 Australia
| | - Tomiko Barrett
- Department of Aged Care Services, Wyong Hospital, PO Box 4200, Central Coast Local Health District, Lakehaven, NSW 2263 Australia
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Lasmarías C, Aradilla-Herrero A, Esquinas C, Santaeugènia S, Cegri F, Limón E, Subirana-Casacuberta M. Primary Care Professionals' Self-Efficacy Surrounding Advance Care Planning and Its Link to Sociodemographics, Background and Perceptions: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179034. [PMID: 34501624 PMCID: PMC8430566 DOI: 10.3390/ijerph18179034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/24/2022]
Abstract
Primary care (PC) professionals have been considered the most appropriate practitioners for leading Advance care planning (ACP) processes with advanced chronic patients. Aim: To explore how PC doctors’ and nurses’ self-efficacy surrounding ACP is linked to their sociodemographic characteristics, background and perceptions of ACP practices. Methods: A cross-sectional study was performed. Sociodemographics, background and perceptions about ACP in practice were collected using an online survey. The Advance Care Planning Self-Efficacy Spanish (ACP-SEs) scale was used for the self-efficacy measurement. Statistical analysis: Bivariate, multivariate and backward stepwise logistic regression analyses were performed to identify variables independently related to a higher score on the ACP-SEs. Results: N = 465 participants, 70.04% doctors, 81.47% female. The participants had a mean age of 46.45 years and 66.16% had spent >15 years in their current practice. The logistic regression model showed that scoring ≤ 75 on the ACP-SEs was related to a higher score on feeling sufficiently trained, having participated in ACP processes, perceiving that ACP facilitates knowledge of preferences and values, and perceiving that ACP improves patients’ quality of life. Conclusion: Professionals with previous background and those who have a positive perception of ACP are more likely to feel able to carry out ACP processes with patients.
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Affiliation(s)
- Cristina Lasmarías
- Department of Education and Training, Catalan Institute of Oncology, 08908 Barcelona, Spain;
- Catalonia Chronic Care Research Group, University of Vic-Central University of Catalonia, 08500 Vic, Spain;
| | - Amor Aradilla-Herrero
- School of Nursing, Escoles Universitàries Gimbernat (Universitat Autònoma de Barcelona), 08174 Sant Cugat del Vallès, Spain
- Correspondence: ; Tel.: +34-935-893-727
| | - Cristina Esquinas
- Department of Pneumology, Hospital Universitari Vall d’Hebron, 08031 Barcelona, Spain;
- Public Health, Mental, Maternal and Child Health Nursing Departament, Faculty of Medicine and Health Sciences, University of Barcelona, 08031 Barcelona, Spain
| | - Sebastià Santaeugènia
- Catalonia Chronic Care Research Group, University of Vic-Central University of Catalonia, 08500 Vic, Spain;
- Chronic Care Program, Health Department, Generalitat de Catalunya, 08028 Barcelona, Spain
| | - Francisco Cegri
- Responsible for Strategy and Innovation of the Association of Family and Community Nursing of Catalonia (AIFiCC), 08001 Barcelona, Spain;
- Primary Care Centre Sant Martí de Provençals, Institut Català de la Salut, 08001 Barcelona, Spain
| | - Esther Limón
- Permanent Board of the Catalan Society of Family and Community Medicine (CAMFiC), 08019 Barcelona, Spain;
- Primary Care Centre Mataró-7, Institut Català de la Salut, 08019 Mataró, Spain
| | - Mireia Subirana-Casacuberta
- Nursing Department, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc TaulíI3PT, Universitat Autònoma de Barcelona, Consorci Sanitari Parc Taulí, 08208 Sabadell, Spain;
- Research Group on Methodology, Methods, Models, and Health and Social Outcomes, Faculty of Health Science and Welfare, Centre for Health and Social Care Research, University of Vic-Central University of Catalonia, 08500 Vic, Spain
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Jo M, Park M, Park EJ, Choi JY. The Acceptability and Effect of a Communication-Based Advance Care Planning Program for Older Adults. J Hosp Palliat Nurs 2021; 23:375-385. [PMID: 34185729 DOI: 10.1097/njh.0000000000000762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study was a preliminary study that assessed the acceptability of a communication-based advance care planning (ACP) intervention for older adults to improve decision making for treatment at the end of life. Twenty dyads were recruited, including patients who were older than 65 years and registered in a home health care center of a teaching hospital in South Korea and their surrogates. The intervention is a patient-centered ACP program with surrogates and a structured and guided discussion by home health care nurses as the trained interventionists. The acceptability of the intervention was assessed by a mixed method including a survey and a structured interview with participants. Findings in this study indicate that recruiting older adults with chronic diseases and their surrogates in a home health care center and conducting the intervention by home health care nurses is feasible. In addition, the outcomes of this study suggest that the intervention may have a potential impact on end-of-life care decision making for older adults in South Korea. A larger-scale trial is required to determine the effects of the ACP program when implemented with various groups. This study suggests that older adults need an ACP program as part of routine care.
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Goodwin J, Shand B, Wiseman R, Brough N, McGeoch G, Hamilton G, Grundy K. Achievements and challenges during the development of an advance care planning program. Australas J Ageing 2021; 40:301-308. [PMID: 33847458 DOI: 10.1111/ajag.12945] [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: 09/08/2020] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 11/26/2022]
Abstract
A nationwide program to promote preparation of advance care plans (AC Plans) was introduced in Canterbury, New Zealand, in 2013. The program was developed by local facilitators who provided support and organised education seminars and an accredited training program for health-care professionals. Information and templates for an AC Plan were available to these professionals and the community on local health-care websites and secure online systems designed to allow plans to be viewed across all health-care sectors. The number of AC Plans prepared has increased steadily, although people in minority ethnic populations or in the most deprived socioeconomic quintile are less likely to have a plan. While nurses have become the predominant group guiding people through the process of preparing an AC Plan, the involvement of staff in residential care homes has remained low. Local audit showed that 82% of people with an AC Plan died in a community setting, frequently their preferred place of death.
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Affiliation(s)
- Jane Goodwin
- The Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Brett Shand
- The Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Rachel Wiseman
- Respiratory Medicine, Canterbury District Health Board, Christchurch, New Zealand
| | - Natalie Brough
- The Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Graham McGeoch
- The Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Greg Hamilton
- Planning and Funding and Decision Support, Canterbury District Health Board, Christchurch, New Zealand
| | - Kate Grundy
- Oncology Services, Canterbury District Health Board, Christchurch, New Zealand
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37
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Nishikawa Y, Fukahori H, Mizuno A, Kwong JSW. Cochrane corner: advance care planning for adults with heart failure. Heart 2021; 107:609-611. [PMID: 33568435 DOI: 10.1136/heartjnl-2020-318458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yuri Nishikawa
- Department of Gerontological Nursing and Healthcare Systems Management, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Fukahori
- Faculty of Nursing and Medical Care, Keio University, Minato-ku, Fujisawa, Japan
| | - Atsushi Mizuno
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan.,Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joey Sum-Wing Kwong
- Global Health Nursing, Graduate School of Nursing Science, St Luke's International University, Chuo-ku, Tokyo, Japan .,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
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Emergency Healthcare Providers' Knowledge about and Attitudes toward Advance Directives: A Cross-Sectional Study between Nurses and Emergency Medical Technicians at an Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031158. [PMID: 33525577 PMCID: PMC7908551 DOI: 10.3390/ijerph18031158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/23/2021] [Accepted: 01/25/2021] [Indexed: 12/20/2022]
Abstract
This study aimed to explore and compare knowledge levels about advance directives (ADs) and life-sustaining treatment (LST) plans in end-of-life patients between emergency nurses and emergency medical technicians (EMTs). Using a cross-sectional study design and convenience sampling, 96 nurses and 68 EMTs were recruited from 12 emergency medical centers. A survey on knowledge about and attitudes toward ADs was performed using both online and offline methods between November and December 2019. Emergency healthcare providers were conceptually knowledgeable regarding ADs and LST, although approximately half or fewer had knowledge about ADs (such as the legal process for preparation, family or healthcare providers’ role, and the healthcare proxy). The knowledge levels of nurses and EMTs were moderate. Nurses had significantly greater knowledge relative to EMTs about ADs and LST. Positive attitudes of emergency healthcare providers were also moderately low, with nurses having less positive views than EMTs. Significant differences regarding ADs were found, with younger emergency healthcare providers having fewer career years, no personal end-of-life experiences, and less need for ADs having less knowledge. Emergency healthcare providers’ knowledge about and attitudes toward ADs were moderately low, with EMTs demonstrating a greater knowledge deficit and nurses exhibiting lower positive attitudes. Younger and novice providers had lower knowledge, but younger providers had more positive attitudes, implying that professional education and training should begin early in their careers to enhance their confidence for emergency delivery of advanced care planning.
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Kim H, Cho J, Park WS, Kim SS. Characteristics of Advance Care Planning Interventions Across Dementia Stages: A Systematic Review. J Nurs Scholarsh 2021; 53:180-188. [PMID: 33476479 DOI: 10.1111/jnu.12624] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE Little is known regarding how advance care planning (ACP) interventions change with the progression of dementia. Thus, the primary purpose of this systematic review is to compare characteristics of ACP interventions across dementia stages. We also identify the role of nurses in implementing ACP interventions for persons with dementia and their surrogates. DESIGN A systematic review of ACP intervention studies. METHODS After searching PubMed, Web of Science, EMBASE, PsycArticles, the Cumulative Index to Nursing and Allied Health Literture (CINAHL), and Scopus, the final sample included 11 studies representing 10 interventions. We conducted a quality assessment and extracted data on dementia stage, intervention characteristics, and the role of nurses in the intervention. The extracted data were categorized according to stages of dementia, and analyzed to identify commonalities and differences between intervention characteristics. FINDINGS Three ACP interventions focused on mild dementia and seven on advanced dementia. We observed four primary findings. First, we found a major difference in intervention recipients between the two dementia stages. Second, most ACP interventions included structured discussions regarding the person's life goals and values, goals of care, and preferences concerning future care via individual, face-to-face interactions. Third, ACP interventions designed to promote ongoing discussions and documentation were lacking. Finally, nurses played important roles in implementing ACP interventions. CONCLUSIONS The findings suggest more nurse-led, dementia-related ACP interventions. In addition, ACP interventions should promote ongoing discussions and documentation and target persons with dementia and their surrogates in various countries. CLINICAL RELEVANCE Many persons with dementia and their surrogates have limited knowledge about ACP; thus, more nurse-led ACP programs that reflect dementia stages may help them prepare for the situations in which persons with dementia lack decision-making capacity.
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Affiliation(s)
- Hyejin Kim
- Xi, Assistant Professor, Red Cross College of Nursing, Chung-Ang University, Seoul, Republic of Korea
| | - Jeonghyun Cho
- Assistant Professor, College of Nursing, Institute for Health Science Research, Inje University, Busan, Republic of Korea
| | - Won Seok Park
- Assistant Direct (Librarian), Subject Information Service Team, Chung-Ang University, Seoul, Republic of Korea
| | - Sang Suk Kim
- Associate Professor, Red Cross College of Nursing, Chung-Ang University, Seoul, Republic of Korea
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Lewis ET, Mahimbo A, Linhart C, Williamson M, Morgan M, Hammill K, Hall J, Cardona M. General practitioners' perceptions on the feasibility and acceptability of implementing a risk prediction checklist to support their end-of-life discussions in routine care: a qualitative study. Fam Pract 2020; 37:703-710. [PMID: 32297645 DOI: 10.1093/fampra/cmaa036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND General practitioners' (GPs) play a central role in facilitating end-of-life discussions with older patients nearing the end-of-life. However, prognostic uncertainty of time to death is one important barrier to initiation of these discussions. OBJECTIVE To explore GPs' perceptions of the feasibility and acceptability of a risk prediction checklist to identify older patients in their last 12 months of life and describe perceived barriers and facilitators for implementing end-of-life planning. METHODS Qualitative, semi-structured interviews were conducted with 15 GPs practising in metropolitan locations in New South Wales and Queensland between May and June 2019. Data were analysed thematically. RESULTS Eight themes emerged: accessibility and implementation of the checklist, uncertainty around checklist's accuracy and usefulness, time of the checklist, checklist as a potential prompt for end-of-life conversations, end-of-life conversations not an easy topic, end-of-life conversation requires time and effort, uncertainty in identifying end-of-life patients and limited community literacy on end-of-life. Most participants welcomed a risk prediction checklist in routine practice if assured of its accuracy in identifying which patients were nearing end-of-life. CONCLUSIONS Most participating GPs saw the value in risk assessment and end-of-life planning. Many emphasized the need for appropriate support, tools and funding for prognostic screening and end-of-life planning for this to become routine in general practice. Well validated risk prediction tools are needed to increase clinician confidence in identifying risk of death to support end-of-life care planning.
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Affiliation(s)
- Ebony T Lewis
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,School of Psychology, University of New South Wales, Sydney, Australia
| | - Abela Mahimbo
- Centre for Primary Health Care & Equity, University of New South Wales, Sydney, Australia
| | - Christine Linhart
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Margaret Williamson
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,Centre for Primary Health Care & Equity, University of New South Wales, Sydney, Australia
| | - Mark Morgan
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Kathrine Hammill
- School of Science & Health, Western Sydney University, Sydney, Australia
| | - John Hall
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Magnolia Cardona
- Gold Coast University Hospital, Gold Coast, Australia.,Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
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Raftery C, Lewis E, Cardona M. The Crucial Role of Nurses and Social Workers in Initiating End-of-Life Communication to Reduce Overtreatment in the Midst of the COVID-19 Pandemic. Gerontology 2020; 66:427-430. [PMID: 32516766 PMCID: PMC7316661 DOI: 10.1159/000509103] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/30/2020] [Indexed: 11/19/2022] Open
Abstract
The large scale and rapid spread of the current COVID-19 pandemic has changed the way hospitals and other health services operate. Opportunities for patient-centered decision-making at the end of life are being jeopardized by a scarcity of health system resources. In response, the traditional doctor-initiated advanced care planning (ACP) for critical illness may also need to be readjusted. We propose nurse-led and allied health-led ACP discussions to ensure patient and family inclusion and understanding of the disease prognosis, prevention of overtreatment, and potential outcomes in crisis times. We highlight known barriers and list enablers, long-term and short-term opportunities to assist in the culture change.
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Affiliation(s)
- Chris Raftery
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Ebony Lewis
- School of Public Health and Community Medicine, The Universityof New South Wales, Randwick, New South Wales, Australia.,School of Psychology, The University of New South Wales, Randwick, New South Wales, Australia
| | - Magnolia Cardona
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia, .,Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia,
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Bernard C, Tan A, Slaven M, Elston D, Heyland DK, Howard M. Exploring patient-reported barriers to advance care planning in family practice. BMC FAMILY PRACTICE 2020; 21:94. [PMID: 32450812 PMCID: PMC7249389 DOI: 10.1186/s12875-020-01167-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 05/14/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Although patient-centred care has become increasingly important across all medical specialties, when it comes to end of life care, research has shown that treatments ordered are not often concordant with people's expressed preferences. Patient and family engagement in Advance Care Planning (ACP) in the primary care setting could improve the concordance between patients' wishes and the healthcare received when patients cannot speak for themselves. The aim of this study was to better understand the barriers faced by older patients regarding talking to their family members and family physicians about ACP. METHODS In this multi-site cross-sectional study, three free text questions regarding reasons patients found it difficult to discuss ACP with their families or their family physicians were part of a self-administered questionnaire about patients' knowledge of and engagement in ACP. The questionnaire, which included closed ended questions followed by three probing open ended questions, was distributed in 20 family practices across 3 provinces in Canada. The free text responses were analyzed using thematic analysis and form the basis of this paper. RESULTS One hundred two participants provided an analyzable response to the survey when asked why they haven't talked to someone about ACP. Two hundred fifty-four answered the question about talking to their physician and 340 answered the question about talking to family members. Eight distinct themes emerged from the free text response analysis: 1. They were too young for ACP; 2. The topic is too emotional; 3. The Medical Doctor (MD) should be responsible for bringing up ACP 4. A fear of negatively impacting the patient-physician relationship; 5. Not enough time in appointments; 6. Concern about family dynamics; 7. It's not a priority; and 8. A lack of knowledge about ACP. CONCLUSIONS Patients in our sample described many barriers to ACP discussions, including concerns about the effect these discussions may have on relationships with both family members and family physicians, and issues relating to patients' knowledge and interpretation of the importance, responsibility for, or relevance of ACP itself. Family physicians may be uniquely placed to leverage the longitudinal, person- centred relationship they have with patients to mitigate some of these barriers.
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Affiliation(s)
- Carrie Bernard
- Department of Family Medicine, McMaster University, DBHSC 100 Main Street West, 5th floor, Hamilton, Ontario L8P 1H6 Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario Canada
| | - Amy Tan
- Department of Family Medicine, University of Calgary, Calgary, Alberta Canada
| | - Marissa Slaven
- Department of Family Medicine, McMaster University, DBHSC 100 Main Street West, 5th floor, Hamilton, Ontario L8P 1H6 Canada
- Division of Palliative Care, McMaster University, Hamilton, Ontario Canada
| | - Dawn Elston
- Department of Family Medicine, McMaster University, DBHSC 100 Main Street West, 5th floor, Hamilton, Ontario L8P 1H6 Canada
| | - Daren K. Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario Canada
- Department of Public Health, Queen’s University, Kingston, Ontario Canada
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, Ontario Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, DBHSC 100 Main Street West, 5th floor, Hamilton, Ontario L8P 1H6 Canada
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Nishikawa Y, Hiroyama N, Fukahori H, Ota E, Mizuno A, Miyashita M, Yoneoka D, Kwong JSW. Advance care planning for adults with heart failure. Cochrane Database Syst Rev 2020; 2:CD013022. [PMID: 32104908 PMCID: PMC7045766 DOI: 10.1002/14651858.cd013022.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND People with heart failure report various symptoms and show a trajectory of periodic exacerbations and recoveries, where each exacerbation event may lead to death. Current clinical practice guidelines indicate the importance of discussing future care strategies with people with heart failure. Advance care planning (ACP) is the process of discussing an individual's future care plan according to their values and preferences, and involves the person with heart failure, their family members or surrogate decision-makers, and healthcare providers. Although it is shown that ACP may improve discussion about end-of-life care and documentation of an individual's preferences, the effects of ACP for people with heart failure are uncertain. OBJECTIVES To assess the effects of advance care planning (ACP) in people with heart failure compared to usual care strategies that do not have any components promoting ACP. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Social Work Abstracts, and two clinical trials registers in October 2019. We checked the reference lists of included studies. There were no restrictions on language or publication status. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ACP with usual care in people with heart failure. Trials could have parallel group, cluster-randomised, or cross-over designs. We included interventions that implemented ACP, such as discussing and considering values, wishes, life goals, and preferences for future medical care. The study participants comprised adults (18 years of age or older) with heart failure. DATA COLLECTION AND ANALYSIS Two review authors independently extracted outcome data from the included studies, and assessed their risk of bias. We contacted trial authors when we needed to obtain missing information. MAIN RESULTS We included nine RCTs (1242 participants and 426 surrogate decision-makers) in this review. The meta-analysis included seven studies (876 participants). Participants' mean ages ranged from 62 to 82 years, and 53% to 100% of the studies' participants were men. All included studies took place in the US or the UK. Only one study reported concordance between participants' preferences and end-of-life care, and it enrolled people with heart failure or renal disease. Owing to one study with small sample size, the effects of ACP on concordance between participants' preferences and end-of-life care were uncertain (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.91 to 1.55; participants = 110; studies = 1; very low-quality evidence). It corresponded to an assumed risk of 625 per 1000 participants receiving usual care and a corresponding risk of 744 per 1000 (95% CI 569 to 969) for ACP. There was no evidence of a difference in quality of life between groups (standardised mean difference (SMD) 0.06, 95% CI -0.26 to 0.38; participants = 156; studies = 3; low-quality evidence). However, one study, which was not included in the meta-analysis, showed that the quality of life score improved by 14.86 points in the ACP group compared with 11.80 points in the usual care group. Completion of documentation by medical staff regarding discussions with participants about ACP processes may have increased (RR 1.68. 95% CI 1.23 to 2.29; participants = 92; studies = 2; low-quality evidence). This corresponded to an assumed risk of 489 per 1000 participants with usual care and a corresponding risk of 822 per 1000 (95% CI 602 to 1000) for ACP. One study, which was not included in the meta-analysis, also showed that ACP helped to improve documentation of the ACP process (hazard ratio (HR) 2.87, 95% CI 1.09 to 7.59; participants = 232). Three studies reported that implementation of ACP led to an improvement of participants' depression (SMD -0.58, 95% CI -0.82 to -0.34; participants = 278; studies = 3; low-quality evidence). We were uncertain about the effects of ACP on the quality of communication when compared to the usual care group (MD -0.40, 95% CI -1.61 to 0.81; participants = 9; studies = 1; very low-quality evidence). We also noted an increase in all-cause mortality in the ACP group (RR 1.32, 95% CI 1.04 to 1.67; participants = 795; studies = 5). The studies did not report participants' satisfaction with care/treatment and caregivers' satisfaction with care/treatment. AUTHORS' CONCLUSIONS ACP may help to increase documentation by medical staff regarding discussions with participants about ACP processes, and may improve an individual's depression. However, the quality of the evidence about these outcomes was low. The quality of the evidence for each outcome was low to very low due to the small number of studies and participants included in this review. Additionally, the follow-up periods and types of ACP intervention were varied. Therefore, further studies are needed to explore the effects of ACP that consider these differences carefully.
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Affiliation(s)
- Yuri Nishikawa
- Tokyo Medical and Dental UniversityDepartment of System Management in Nursing Graduate School of Health Care SciencesTokyoJapan
| | - Natsuko Hiroyama
- Tokyo Medical and Dental UniversityDepartment of System Management in Nursing Graduate School of Health Care SciencesTokyoJapan
| | - Hiroki Fukahori
- Tokyo Medical and Dental UniversityDepartment of System Management in Nursing Graduate School of Health Care SciencesTokyoJapan
- Keio UniversityFaculty of Nursing and Medical CareFujisawaJapan
| | - Erika Ota
- St. Luke's International UniversityGlobal Health Nursing, Graduate School of Nursing Science10‐1 Akashi‐choChuo‐KuTokyoMSJapan104‐0044
| | | | - Mitsunori Miyashita
- Tohoku University Graduate School of MedicineDepartment of Palliative Nursing, Health SciencesSendaiJapan
| | - Daisuke Yoneoka
- St. Luke’s International UniversityDivision of Biostatistics and Bioinformatics, Graduate School of Public HealthSt. Luke’s Center for Clinical Academia, 5th Floor 3‐6‐2 Tsukiji, Chuo‐KuTokyoJapan1040045
| | - Joey SW Kwong
- St. Luke's International UniversityGlobal Health Nursing, Graduate School of Nursing Science10‐1 Akashi‐choChuo‐KuTokyoMSJapan104‐0044
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Risk J, Mohammadi L, Rhee J, Walters L, Ward PR. Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis. BMJ Open 2019; 9:e030275. [PMID: 31537570 PMCID: PMC6756326 DOI: 10.1136/bmjopen-2019-030275] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice? DESIGN A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting. SETTING Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews. RESULTS The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging. CONCLUSION Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice. PROSPERO REGISTRATION NUMBER CRD42018088838.
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Affiliation(s)
- Jo Risk
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Leila Mohammadi
- Library, Flinders University, Adelaide, South Australia, Australia
| | - Joel Rhee
- General Practice Academic Unit, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Lucie Walters
- Rural Health, Flinders University, Adelaide, South Australia, Australia
| | - Paul R Ward
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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