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Piovesan M, Orr P, Tevyaw S, Roussos E, Cherid C, Bouchard S. A Prospective Study with Patients and Families on the Usefulness of Accurate Prognosis for Palliative Care Patients. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2024; 20:133-146. [PMID: 38449073 DOI: 10.1080/15524256.2024.2321330] [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: 03/08/2024]
Abstract
Prediction of life expectancy in terminally ill patients is an important end-of-life care issue for patients, families and mental health workers during the last days of life. This study was conducted to examine the importance/usefulness for patients/families to have an accurate prognosis and its impact on planning their activities prior to death. All patients admitted during a period of one year were included. Patients' and families' viewpoints on the usefulness of an accurate prognosis was documented at admission. There were 285 patients in the cohort. The median time to death was 8 days. Most families (83%) rated the importance of an accurate prognosis as moderately (13%) to very much useful (70%). A total of 42% of patients were able to complete e the questionnaire. Among these, 58% found it moderately to very much useful. For families, having an accurate prognosis influenced the planning of visits (69%), communication/closure (42%) and spiritual needs/funeral arrangements (31%). Patients identified planning of visits (10%), communication/closure (12%), and goals/accomplishments (9%) as very important. Discussing the prognosis and its impact is very helpful for the mental health professionals to have open and honest conversations with patients/families to identify, prioritize and adapt treatment to achieve goals prior to death.
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Affiliation(s)
- Manuela Piovesan
- Clinical Care Department, Montreal Institute for Palliative Care, Kirkland, Quebec, Canada
- Clinical Care Department, Teresa Dellar Palliative Care Residence, Kirkland, Quebec, Canada
| | - Pauline Orr
- Clinical Care Department, Teresa Dellar Palliative Care Residence, Kirkland, Quebec, Canada
| | - Sarah Tevyaw
- Clinical Care Department, Teresa Dellar Palliative Care Residence, Kirkland, Quebec, Canada
| | - Emily Roussos
- Clinical Care Department, Teresa Dellar Palliative Care Residence, Kirkland, Quebec, Canada
| | - Chams Cherid
- Clinical Care Department, Montreal Institute for Palliative Care, Kirkland, Quebec, Canada
| | - Sylvie Bouchard
- Clinical Care Department, Montreal Institute for Palliative Care, Kirkland, Quebec, Canada
- Clinical Care Department, Teresa Dellar Palliative Care Residence, Kirkland, Quebec, Canada
- Department of Oncology, McGill University, Montreal, Quebec, Canada
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van der Padt-Pruijsten A, Leys MB, Oomen-de Hoop E, van der Rijt CCD, van der Heide A. Quality of cancer treatment care before and after a palliative care pathway: bereaved relatives' perspectives. BMJ Support Palliat Care 2023:spcare-2023-004495. [PMID: 37973203 DOI: 10.1136/spcare-2023-004495] [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: 07/18/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Appropriate communication between healthcare providers and patients and their families is an essential part of good (palliative) care. We investigated whether implementation of a standardised palliative care pathway (PCP) facilitated communication, that is, aspects of shared decision-making (SDM), including advance care planning (ACP) conversations and satisfaction with care as experienced by bereaved relatives of patients with advanced cancer. METHODS We conducted a prospective preintervention and postintervention study in a hospital. Questionnaires were sent to relatives of patients who died between February 2014 and February 2015 (pre-PCP period) or between November 2015 and November 2016 (post-PCP period). Relatives' perceptions on communication and satisfaction with care were assessed using parts of the Views of Informal Carers-Evaluation of Services and IN-PATSAT32 Questionnaires. RESULTS 195 (46%) and 180 (42%) bereaved relatives completed the questionnaire in the pre-PCP and post-PCP period, respectively. The majority of all patients in both the pre-PCP period and the post-PCP period had been told they had an incurable illness (92% and 89%, respectively, p=0.544), mostly in the presence of a relative (88% and 85%, respectively, p=0.865) and had discussed their preferences for end-of-life (EOL) treatment (82% and 76%, respectively, p=0.426). Bereaved relatives were reasonably satisfied with the received hospital care in both groups. CONCLUSIONS We found no overall effect of the PCP on the communication process and satisfaction with EOL care of bereaved relatives. Before the use of the PCP bereaved relatives already reported favourably about the EOL care provided.
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Affiliation(s)
- Annemieke van der Padt-Pruijsten
- Internal Medicine, Maasstad Hospital, Rotterdam, The Netherlands
- Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Maria Bl Leys
- Internal Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | | | | | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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van der Plas AGM, Schellekens JEAP, Glaudemans JJ, Onwuteaka-Philipsen BD. The patient’s relationship with the General Practitioner before and after Advance Care Planning: pre/post-implementation study. BMC Geriatr 2022; 22:558. [PMID: 35790910 PMCID: PMC9254656 DOI: 10.1186/s12877-022-03256-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 06/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background General Practitioners (GPs) are central in the care of Dutch older people and in a good position to have Advance Care Planning (ACP) conversations. Interview studies reveal that the doctor-patient relationship is important when initiating ACP conversations and can also be influenced by ACP conversations. We aimed to examine the association between having an ACP conversation and the patient feeling the GP knows him or her and the patient trusting the GP and vice versa. Methods Implementation of ACP in primary care was evaluated in a pre-and post design. Questionnaires before implementation of ACP and 14 months later were sent to patients aged 75 years or older within 10 GP-practices and 2 care homes. Multivariable logistic regression was used to model the relationship between ACP conversations during implementation and the patient-GP relationship before implementation. Odds ratios were adjusted for potential confounders. Generalized ordered logistic regression was used to model the relationship between the changes in patient-GP relationship before and after implementation and ACP conversations during implementation. Results Four hundred fifty-eight patients filled out the pre- and post-test questionnaire. There was no association between the GP knowing the patient and trust in the pre-test and having an ACP conversation during the implementation. For people who had had an ACP conversation at the end of the implementation period their trust remained more often the same or was higher after implementation (trust to provide good care OR 2.93; trust to follow their wishes OR 2.59), compared to patients who did not have an ACP conversation. A reduction in trust was less likely to happen to patients who had an ACP conversation compared to patients who did not have an ACP conversation. Conclusions Although we have not found evidence for trust as a prerequisite for ACP conversations, this paper shows that ACP conversations can be beneficial for the doctor—patient relationship. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03256-4.
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End-of-life care for patients with advanced ovarian cancer in the Netherlands: A retrospective registry-based analysis. Gynecol Oncol 2022; 166:148-153. [DOI: 10.1016/j.ygyno.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/19/2022]
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5
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Ho LYW, Kwong EWY, Song MS, Kawakami A, Boo S, Lai CKY, Yamamoto-Mitani N. Decision-making preferences on end-of-life care for older people: Exploration and comparison of Japan, the Hong Kong SAR and South Korea in East Asia. J Clin Nurs 2022; 31:3498-3509. [PMID: 35032085 DOI: 10.1111/jocn.16178] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 11/13/2021] [Accepted: 12/03/2021] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES The aim of this study was to examine and compare decision-making preferences on end-of-life care for older people in Japan, the Hong Kong SAR and South Korea. BACKGROUND Cultural values and beliefs influence decision-making on end-of-life care. DESIGN A cross-sectional design was adopted. METHODS Community-dwelling people aged ≥65 with additional requirements were recruited in 2016-2017 in the three regions. Their decision-making preferences on end-of-life care were assessed using Pang et al.'s questionnaire. These preferences and their sociodemographic and personal experience variables were compared and analysed using univariate and multiple logistic regressions. The STROBE checklist was followed. RESULTS This study involved 415 participants. In all three regions, the most preferred decision maker and person with whom to discuss end-of-life care issues was a family member. Participants in the Hong Kong SAR were less likely to select a family member as their preferred decision maker than those in Japan (adjusted odds ratio = 0.129). Koreans were less likely to discuss end-of-life care issues with medical professionals than people in Japan (adjusted odds ratio = 0.278). More than 70% of the participants in each region indicated that they would not prefer to leave an advance directive to decide their end-of-life care. CONCLUSION Older Asians prefer to make their own decisions after consulting others. Family members play an important role in helping older people plan their preferred end-of-life care arrangements, even acting as decision makers when older people become incapable of deciding for themselves. RELEVANCE TO CLINICAL PRACTICE Sufficient information should be provided to older people and their families for the older people to determine their preferred care. Helping families to understand and support the planned care and advance directives is a strategy for maximising family compliance with the care. Continuous efforts should be made to promote advance care planning and advance directives.
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Affiliation(s)
- Lily Yuen Wah Ho
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR
| | - Enid Wai Yung Kwong
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR
| | - Mi Sook Song
- College of Nursing, Research Institute of Nursing Sciences, Ajou University, Suwon, Korea
| | - Aki Kawakami
- Department of Critical and Invasive-Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Sunjoo Boo
- College of Nursing, Research Institute of Nursing Sciences, Ajou University, Suwon, Korea
| | - Claudia Kam Yuk Lai
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR
| | - Noriko Yamamoto-Mitani
- Department of Gerontological Homecare & Long-term Care Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Wijnen HH, Schmitz PP, Es-Safraouy H, Roovers LA, Taekema DG, Van Susante JLC. Nonoperative management of hip fractures in very frail elderly patients may lead to a predictable short survival as part of advance care planning. Acta Orthop 2021; 92:728-732. [PMID: 34319206 PMCID: PMC8635672 DOI: 10.1080/17453674.2021.1959155] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Surgical treatment is still the mainstay of care even in very frail elderly hip fracture patients. However, one may argue whether surgery is in the best interest of all patients. We elucidated mortality rates of nonoperative management (NOM) of a hip fracture after shared decision-making in a cohort of very frail elderly patients.Patients and methods - Orthogeriatric patients (age > 70 years) admitted with a hip fracture between 2011 and 2019 were included. In the presence of fragility features the motivation for surgery or NOM was supported by advance care planning (ACP) and shared decision-making through geriatric assessment. Mortality rates after NOM were assessed and also presented for the remaining surgical group for reference.Results - In 1,279 out of 3,467 patients, geriatric assessment was indicated and subsequently 1,188 (93%) had surgery versus 91 (7%) NOM. The motivation for NOM was based on patient and family preferences in only 20% of patients, medical grounds in 54%, and a combination of both in 26%. The 30-day and 1-year mortality in the frail NOM group was 87% and 99% respectively, whereas this was 7% and 28% in the surgery group. No statistical comparison between groups was performed due to profound bias by indication.Interpretation - This study provides further insight into the predictable and high short-term mortality after NOM in carefully selected very frail elderly hip fracture patients. This information may help to consider NOM as an alternative treatment option to surgery when no significant gain from surgery is anticipated.
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Affiliation(s)
- Hugo H Wijnen
- Department of Clinical Geriatrics, Rijnstate, Arnhem
| | - Peter P Schmitz
- Department of Orthopedics, Rijnstate, Arnhem;;,Correspondence:
| | | | - Lian A Roovers
- Clinical Research Department, Rijnstate, Arnhem, the Netherlands
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Schmitz RSJM, Geurts SME, Ibragimova KIE, Tilli DJP, Tjan-Heijnen VCG, de Boer M. Healthcare Use during the Last Six Months of Life in Patients with Advanced Breast Cancer. Cancers (Basel) 2021; 13:cancers13215271. [PMID: 34771434 PMCID: PMC8582356 DOI: 10.3390/cancers13215271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary In the last decades, new treatment options for advanced (breast) cancer have resulted in increased use of health care resources near the end of life. We assessed health care use near the end of life of patients with advanced breast cancer (ABC). In this study, we have shown that ICU admission, and CPR occurred rarely during the last six months of life of ABC patients. However, hospital admissions occurred often, especially in patients who received new chemotherapy within 30 days of end of life. Those patients were also more likely to die in the hospital. However, death was most often due to disease progression. To improve quality of life near the end of life of advanced breast cancer patients, it is vital to develop tools to help clinicians identify those patients who will benefit from chemotherapy at the end of life. Abstract New treatment options in cancer have resulted in increased use of health care resources near the end of life. We assessed health care use near the end of life of patients with advanced breast cancer (ABC). From the Southeast Netherlands Breast cancer (SONABRE) registry, we selected all deceased patients diagnosed with ABC in Maastricht University Medical Center between January 2007 and October 2017. Frequency of health care use in the last six months of life was described and predictors for health care use were assessed. Of 203 patients, 76% were admitted during the last six months, 6% to the intensive care unit (ICU) and 2% underwent cardiopulmonary resuscitation (CPR). Death in hospital occurred in 25%. Nine percent of patients received a new line of chemotherapy ≤30 days before death, which was associated with age <65 years and <1 year survival since diagnosis of metastases. In these patients, the hospital admission rate was 95%, of which 79% died in the hospital, mostly due to progressive disease (80%). In conclusion, the frequency of ICU-admission, CPR or a new line of chemotherapy ≤30 days before death was low. Most patients receiving a new line of chemotherapy ≤30 days before death, died in the hospital.
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8
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Sinclair C, Sellars M, Buck K, Detering KM, White BP, Nolte L. Association Between Region of Birth and Advance Care Planning Documentation Among Older Australian Migrant Communities: A Multicenter Audit Study. J Gerontol B Psychol Sci Soc Sci 2021; 76:109-120. [PMID: 32803263 PMCID: PMC7756686 DOI: 10.1093/geronb/gbaa127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives This study explored associations between birth region, sociodemographic predictors, and advance care planning (ACP) uptake. Methods A prospective, multicenter, cross-sectional audit study of 100 sites across 8 Australian jurisdictions. ACP documentation was audited in the health records of people aged 65 years or older accessing general practice (GP), hospital, and long-term care facility (LTCF) settings. Advance care directives (ACDs) completed by the person (“person completed ACDs”) and ACP documents completed by a health professional or other person (“health professional or someone else ACP”) were counted. Hierarchical multilevel logistic regression assessed associations with birth region. Results From 4,187 audited records, 30.0% (1,152/3,839) were born outside Australia. “Person completed ACDs” were less common among those born outside Australia (21.9% vs 28.9%, X2 (1, N = 3,840) = 20.3, p < .001), while “health professional or someone else ACP” was more common among those born outside Australia (46.4% vs 34.8%, X2 (1, N = 3,840) = 45.5, p < .001). Strongest associations were found for those born in Southern Europe: “person completed ACD” (odds ratio [OR] = 0.56, 95% confidence interval [CI] = 0.36–0.88), and “health professional or someone else ACP” (OR = 1.41, 95% CI = 1.01–1.98). English-language proficiency and increased age significantly predicted both ACP outcomes. Discussion Region of birth is associated with the rate and type of ACP uptake for some older Australians. Approaches to ACP should facilitate access to interpreters and be sensitive to diverse preferences for individual and family involvement in ACP.
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Affiliation(s)
- Craig Sinclair
- School of Psychology, University of New South Wales, Sydney, Australia.,Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney, Australia.,Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Marcus Sellars
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.,Australian Centre for Health Research Law, Faculty of Law, Queensland University of Technology, Brisbane, Australia
| | - Kimberly Buck
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Karen M Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Ben P White
- Australian Centre for Health Research Law, Faculty of Law, Queensland University of Technology, Brisbane, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
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10
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Ermers DJM, van Beuningen-van Wijk MPH, Rit EP, Stalpers-Konijnenburg SC, Taekema DG, Bosch FH, Engels Y, van Mierlo PJWB. Life-sustaining treatment preferences in older patients when referred to the emergency department for acute geriatric assessment: a descriptive study in a Dutch hospital. BMC Geriatr 2021; 21:58. [PMID: 33446116 PMCID: PMC7807792 DOI: 10.1186/s12877-020-02002-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/29/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In many cases, life-sustaining treatment preferences are not timely discussed with older patients. Advance care planning (ACP) offers medical professionals an opportunity to discuss patients' preferences. We assessed how often these preferences were known when older patients were referred to the emergency department (ED) for an acute geriatric assessment. METHODS We conducted a descriptive study on patients referred to the ED for an acute geriatric assessment in a Dutch hospital. Patients were referred by general practitioners (GPs), or in the case of nursing home residents, by elderly care physicians. The referring physician was asked if preferences regarding life-sustaining treatments were known. The primary outcome was the number of patients for whom preferences were known. Secondary outcomes included which preferences, and which variables predict known preferences. RESULTS Between 2015 and 2017, 348 patients were included in our study. At least one preference regarding life-sustaining treatments was known at referral in 45.4% (158/348) cases. In these cases, cardiopulmonary resuscitation (CPR) policy was always included. Preferences regarding invasive ventilation policy and ICU admission were known in 17% (59/348) and 10.3% (36/348) of the cases respectively. Known preferences were more frequent in cases referred by the elderly care physician than the GP (P < 0.001). CONCLUSIONS In less than half the patients, at least one preference regarding life-sustaining treatments was known at the time of referral to the ED for an acute geriatric assessment; in most cases it concerned CPR policy. We recommend optimizing ACP conversations in a non-acute setting to provide more appropriate, desired, and personalized care to older patients referred to the ED.
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Affiliation(s)
- Daisy J M Ermers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, PO Box 9101, Nijmegen, HB, 6500, The Netherlands.
| | | | - Evi Peters Rit
- Department of Geriatrics, Meander medical center, Amersfoort, The Netherlands
| | | | - Diana G Taekema
- Department of Geriatrics, Rijnstate, Arnhem, The Netherlands
| | - Frank H Bosch
- Department of Intensive Care Medicine, Rijnstate, Arnhem, The Netherlands.,Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, PO Box 9101, Nijmegen, HB, 6500, The Netherlands
| | - Patricia J W B van Mierlo
- Department of Geriatrics, Rijnstate, Arnhem, The Netherlands.,Center of Supportive and Palliative Care, Rijnstate, Arnhem, The Netherlands
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Besseling J, Reitsma J, Van Erkelens JA, Schepens MHJ, Siroen MPC, Ziedses des Plantes CMP, van Berge Henegouwen MI, Beerepoot LV, Van Voorthuizen T, Van Zuylen L, Verhoeven RHA, van Laarhoven H. Use of Palliative Chemotherapy and ICU Admissions in Gastric and Esophageal Cancer Patients in the Last Phase of Life: A Nationwide Observational Study. Cancers (Basel) 2021; 13:cancers13010145. [PMID: 33466279 PMCID: PMC7794997 DOI: 10.3390/cancers13010145] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 12/18/2022] Open
Abstract
Simple Summary This is the first nationwide study on chemotherapy use and intensive care unit (ICU) admission in the last three months before death in patients with cancer of the stomach or esophagus. Chemotherapy use and ICU admission shortly before death were relatively infrequent in the Netherlands. Chemotherapy was used less often in hospitals that treat many patients compared to hospitals that treat fewer patients. In patients that received chemotherapy before their final three months before death, chemotherapy was prescribed four times more often in the last three months before death compared to patients without previous chemotherapy use. Abstract Since intensive care unit (ICU) admission and chemotherapy use near death impair the quality of life, we studied the prevalence of both and their correlation with hospital volume in incurable gastroesophageal cancer patients as both impair the quality of life. We analyzed all Dutch patients with incurable gastroesophageal cancer who died in 2017–2018. National insurance claims data were used to determine the prevalence of ICU admission and chemotherapy use (stratified on previous chemotherapy treatment) at three and one month(s) before death. We calculated correlations between hospital volume (i.e., the number of included patients per hospital) and both outcomes. We included 3748 patients (mean age: 71.4 years; 71.4% male). The prevalence of ICU admission and chemotherapy use were, respectively, 5.6% and 21.2% at three months and 4.2% and 8.0% at one month before death. Chemotherapy use at three and one months before death was, respectively, 4.3 times (48.0% vs. 11.2%) and 3.7 times higher (15.7% vs. 4.3%), comparing patients with previous chemotherapy treatment to those without. Hospital volume was negatively correlated with chemotherapy use in the final month (rweighted = −0.23, p = 0.04). ICU admission and chemotherapy use were relatively infrequent. Oncologists in high-volume hospitals may be better equipped in selecting patients most likely to benefit from chemotherapy.
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Affiliation(s)
- Joost Besseling
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.V.Z.); (R.H.A.V.)
- Correspondence: (J.B.); (H.v.L.); Tel.: +31-(0)-682046266 (J.B.); +31-(0)-20-44-44321 (H.v.L.); Fax: +31-(0)-20-44-44355 (H.v.L.)
| | - Jan Reitsma
- Zorgverzekeraars Nederland, 3708 JE Zeist, The Netherlands; (J.R.); (M.H.J.S.)
| | | | | | | | | | - Mark I. van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands;
| | | | | | - Lia Van Zuylen
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.V.Z.); (R.H.A.V.)
| | - Rob H. A. Verhoeven
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.V.Z.); (R.H.A.V.)
- Department of Research & Development, Netherlands Comprehensive Cancer Organisation, 3511 DT Utrecht, The Netherlands
| | - Hanneke van Laarhoven
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.V.Z.); (R.H.A.V.)
- Correspondence: (J.B.); (H.v.L.); Tel.: +31-(0)-682046266 (J.B.); +31-(0)-20-44-44321 (H.v.L.); Fax: +31-(0)-20-44-44355 (H.v.L.)
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Groenewoud AS, Sasaki N, Westert GP, Imanaka Y. Preferences in end of life care substantially differ between the Netherlands and Japan: Results from a cross-sectional survey study. Medicine (Baltimore) 2020; 99:e22743. [PMID: 33126312 PMCID: PMC7598825 DOI: 10.1097/md.0000000000022743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Strategies to increase appropriateness of EoL care, such as shared decision making (SDM), and advance care planning (ACP) are internationally embraced, especially since the COVID-19 pandemic. However, individuals preferences regarding EoL care may differ internationally. Current literature lacks insight in how preferences in EoL care differ between countries and continents. This study's aim is to compare Dutch and Japanese general publics attitudes and preferences toward EoL care, and EoL decisions. Methods: a cross-sectional survey design was chosen. The survey was held among samples of the Dutch and Japanese general public, using a Nationwide social research panel of 220.000 registrants in the Netherlands and 1.200.000 in Japan. A quota sampling was done (age, gender, and living area). N = 1.040 in each country.More Japanese than Dutch citizens tend to avoid thinking in advance about future situations of dependence (26.0% vs 9.4%; P = .000); say they would feel themselves a burden for relatives if they would become dependent in their last phase of life (79.3% vs 47.8%; P = .000); and choose the hospital as their preferred place of death (19.4% vs 3.6% P = .000). More Dutch than Japanese people say they would be happy with a proactive approach of their doctor regarding EoL issues (78.0% vs 65.1% JPN; P = .000).Preferences in EoL care substantially differ between the Netherlands and Japan. These differences should be taken into account a) when interpreting geographical variation in EoL care, and b) if strategies such as SDM or ACP - are considered. Such strategies will fail if an international "one size fits all" approach would be followed.
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Affiliation(s)
- A Stef Groenewoud
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Noriko Sasaki
- Department of Healthcare Economics and Quality Management, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Gert P Westert
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Kyoto University, Graduate School of Medicine, Kyoto, Japan
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Rwabihama JP, Belmin J, Rakotoarisoa DR, Hagege M, Audureau E, Benzengli H, Ambime G, Rabus MT, Bastuji-Garin S, Paillaud E, Oubaya N. Promoting patients' rights at the end of life in a geriatric setting in France: The healthcare professionals' level of knowledge about surrogate decision-makers and advance directives. PATIENT EDUCATION AND COUNSELING 2020; 103:1390-1398. [PMID: 32070651 DOI: 10.1016/j.pec.2020.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 01/24/2020] [Accepted: 01/29/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To assess levels of knowledge about patients' rights, surrogate decision-makers, and advance directives among healthcare professionals at three hospitals in France. METHODS A multicenter, cross-sectional study in three geriatric hospitals in the Paris area (France) in 2015. The participants' level of knowledge was assessed via an 18-item self-questionnaire on surrogate decision-makers, advance directives, and end-of-life decision-making. The characteristics associated with a good level of knowledge were assessed using logistic regression. RESULTS Among the 301 healthcare professionals (median ± standard deviation age: 40.4 ± 10.2 years; women: 73.4 %), only 15.0 % (95 % confidence interval (CI): [19.7-29.5]) correctly answered at least 75 % of the questions on patients' rights. Respectively 24.6 % [19.7-29.5], 36.5 % [31.1-42.0] and 37.5 % [32.0-43.0] had sufficient knowledge regarding "surrogate decision-maker", "advance directives", and "decision-making at the end of life". In a multivariable analysis, the only factor significantly associated with a good level of knowledge about end-of-life policy was employment in a university hospital, with a non-significant trend for status as a physician. CONCLUSIONS Our survey of staff working in geriatric care units highlighted the poor overall level of knowledge about healthcare surrogates and advance directives; the results suggest that additional training in these concepts is required. PRACTICE IMPLICATIONS Continuing education of healthcare professionals on advance directives and surrogate decision-maker should be promoted to ensure rights of elderly patients at the end of life.
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Affiliation(s)
- Jean Paul Rwabihama
- Inserm U955, Université Paris Est Créteil (UPEC), Institut Mondor de Recherche Biomédicale (IMRB), équipe CEpiA (Clinical Epidemiology and Ageing), Créteil, France; Assistance Publique-Hôpitaux de Paris, Joffre-Dupuytren Hospital, Geriatric Department, Draveil, F- 91210, France.
| | - Joël Belmin
- Assistance Publique-Hôpitaux de Paris, Charles Foix Hospital, Geriatric Department, Ivry-sur-seine, F- 94200, France
| | - De Rozier Rakotoarisoa
- Assistance Publique-Hôpitaux de Paris, George Clemenceau Hospital, Geriatric Department, Champceuil, F- 91750, France
| | - Meoïn Hagege
- Inserm U955, Université Paris Est Créteil (UPEC), Institut Mondor de Recherche Biomédicale (IMRB), équipe CEpiA (Clinical Epidemiology and Ageing), Créteil, France
| | - Etienne Audureau
- Inserm U955, Université Paris Est Créteil (UPEC), Institut Mondor de Recherche Biomédicale (IMRB), équipe CEpiA (Clinical Epidemiology and Ageing), Créteil, France; Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Department of Public Health, Créteil, F- 94000, France
| | - Hind Benzengli
- Assistance Publique-Hôpitaux de Paris, Joffre-Dupuytren Hospital, Pharmacy Department, Draveil, F- 91210, France
| | - Gabin Ambime
- Assistance Publique-Hôpitaux de Paris, Joffre-Dupuytren Hospital, Geriatric Department, Draveil, F- 91210, France
| | - Marie-Thérèse Rabus
- Assistance Publique-Hôpitaux de Paris, Joffre-Dupuytren Hospital, Geriatric Department, Draveil, F- 91210, France
| | - Sylvie Bastuji-Garin
- Inserm U955, Université Paris Est Créteil (UPEC), Institut Mondor de Recherche Biomédicale (IMRB), équipe CEpiA (Clinical Epidemiology and Ageing), Créteil, France; Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Department of Public Health, Créteil, F- 94000, France
| | - Elena Paillaud
- Inserm U955, Université Paris Est Créteil (UPEC), Institut Mondor de Recherche Biomédicale (IMRB), équipe CEpiA (Clinical Epidemiology and Ageing), Créteil, France; Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Geriatric Departement, Créteil, F- 94000, France
| | - Nadia Oubaya
- Inserm U955, Université Paris Est Créteil (UPEC), Institut Mondor de Recherche Biomédicale (IMRB), équipe CEpiA (Clinical Epidemiology and Ageing), Créteil, France; Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Department of Public Health, Créteil, F- 94000, France
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Hamano J, Oishi A, Morita T, Kizawa Y. Frequency of discussing and documenting advance care planning in primary care: secondary analysis of a multicenter cross-sectional observational study. BMC Palliat Care 2020; 19:32. [PMID: 32183800 PMCID: PMC7079526 DOI: 10.1186/s12904-020-00543-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 03/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To improve the quality of advance care planning (ACP) in primary care, it is important to understand the frequency of and topics involved in the ACP discussion between patients and their family physicians (FPs). METHODS A secondary analysis of a previous multicenter cross-sectional observational study was performed. The primary outcome of this analysis was the frequency of and topics involved in the ACP discussion between outpatients and FPs. In March 2017, 22 family physicians at 17 clinics scheduled a day to assess outpatients and enrolled patients older than 65 years who were recognized by FPs as having regular visits. We defined three ACP discussion topics: 1) future decline in activities of daily living (ADL), 2) future inability to eat, and 3) surrogate decision makers. FPs assessed whether they had ever discussed any ACP topics with each patient and their family members, and if they had documented the results of these discussions in medical records before patients were enrolled in the present study. We defined patients as being at risk of deteriorating and dying if they had at least 2 positive general indicators or at least 1 positive disease-specific indicator in the Japanese version of the Supportive and Palliative Care Indicators Tool. RESULTS In total, 382 patients with a mean age of 77.4 ± 7.9 years were enrolled, and 63.1% were female. Seventy-nine patients (20.7%) had discussed at least one ACP topic with their FPs. However, only 23 patients (6.0%) had discussed an ACP topic with family members and their FPs, with the results being documented in their medical records. The topic of future ADL decline was discussed and documented more often than the other two topics. Patients at risk of deteriorating and dying discussed ACP topics significantly more often than those not at risk of deteriorating and dying (39.4% vs. 16.8%, p < 0.001). CONCLUSION FPs may discuss ACP with some of their patients, but may not often document the results of this discussion in medical records. FPs need to be encouraged to discuss ACP with patients and family members and describe the decisions reached in medical records.
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Affiliation(s)
- Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Ai Oishi
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Medical School (Doorway 1), Teviot Place, Edinburgh, UK
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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Chiang FM, Hsieh JG, Fan SY, Wang YW, Wang SC. Does the Experience of Caring for a Severely Disabled Relative Impact Advance Care Planning? A Qualitative Study of Caregivers of Disabled Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17051594. [PMID: 32121624 PMCID: PMC7084922 DOI: 10.3390/ijerph17051594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 11/02/2022]
Abstract
The aging of the Taiwanese population has become a major issue. Previous research has focused on the burden and stress faced by caregivers, but has not explored how the experience of these caregivers influences decisions of advance care planning (ACP). Semi-structured and in-depth interviews were conducted. Qualitative content analysis was used to identify important themes. Five themes and fourteen sub-themes were identified: (1) Past experiences: patient wishes, professional recommendations, and expectation about disease progress; (2) Impact of care on family members: positive affirmation, open-minded life, social isolation and health effects, and financial and life planning effects; (3) Attitude toward life: not forcing to stay, and not becoming a burden, (4) Expected proxy dilemmas: torment between doing or not, seeing the extension of suffering and toil, and remorse and self-blame; (5) Expectation of end of life (EOL) care: caregiver's experience and EOL care decisions, and practicality of EOL decision making. After making multiple medical decisions for their disabled relatives, caregivers are able to calmly face their own medical decisions, and "not becoming a burden" is their primary consideration. It's suggested that implementation of shared decision-making on medical care for patients with chronic disability will not only improve the quality of their medical care but also reduce the development of remorse and guilty feelings of caregivers after making medical decisions.
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Affiliation(s)
- Fu-Ming Chiang
- Department of Nursing, Institute of Medical Sciences, Tzu Chi University, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan;
| | - Jyh-Gang Hsieh
- Department of Family Medicine, Institute of Health and Welfare Policy, National Yang-Ming University, Hualien Tzu Chi Hospital Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan;
| | - Sheng-Yu Fan
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan;
| | - Ying-Wei Wang
- Institute of Medical Sciences, School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan
- Correspondence: ; Tel.: +886-2-2522-0888 (ext. 506)
| | - Shu-Chen Wang
- Department of Nursing, Hualien Tzu Chi Hospital Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan;
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De Souza J, Gillett K, Froggatt K, Walshe C. Perspectives of elders and their adult children of Black and minority ethnic heritage on end-of-life conversations: A meta-ethnography. Palliat Med 2020; 34:195-208. [PMID: 31965907 PMCID: PMC7000852 DOI: 10.1177/0269216319887070] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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 People of Black and minority ethnic heritage are more likely to die receiving life supporting measures and less likely to die at home. End-of-life care decision making often involves adult children as advance care planning is uncommon in these communities. Physicians report family distress as being a major factor in continuing with futile care. AIM To develop a deeper understanding of the perspectives of elders of Black and minority ethnic heritage and their children, about end-of-life conversations that take place within the family, using a meta-ethnographic approach. DESIGN Systematic interpretive exploration using the process of meta-ethnography was utilised. DATA SOURCES CINAHL, MEDLINE, PubMed and PsycINFO databases were searched. Inclusion criteria included studies published between 2005 and 2019 and studies of conversations between ethnic minority elders and family about end-of-life care. Citation snowballing was used to ensure all appropriate references were identified. A total of 13 studies met the inclusion criteria and required quality level using Critical Appraisal Skills Programme. RESULTS The following four storylines were constructed: 'My family will carry out everything for me; it is trust'; 'No Mum, don't talk like that'; 'I leave it in God's hands'; and 'Who's going to look after us?' The synthesis reflected the dichotomous balance of trust and burden avoidance that characterises the perspectives of Black and minority ethnic elders to end-of-life care planning with their children.
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Affiliation(s)
- Joanna De Souza
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, UK.,Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Karen Gillett
- Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Katherine Froggatt
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, UK
| | - Catherine Walshe
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, UK
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Picard G, Bier JC, Capron I, De Deyn PP, Deryck O, Engelborghs S, Hanseeuw B, Lemper JC, Mormont E, Petrovic M, Salmon E, Segers K, Sieben A, Thiery E, Ventura M, Versijpt J, Ivanoiu A. Dementia, End of Life, and Euthanasia: A Survey Among Dementia Specialists Organized by the Belgian Dementia Council. J Alzheimers Dis 2019; 69:989-1001. [DOI: 10.3233/jad-181277] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Gaëtane Picard
- Department of Neurology, Clinique Saint-Pierre, Ottignies, Belgium
| | - Jean-Christophe Bier
- Department of Neurology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Isabelle Capron
- Department of Neurology, Cliniques de l’Europe – St Michel, Brussels, Belgium
| | - Peter Paul De Deyn
- Reference Center for Biological Markers of Dementia (BIODEM), Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, University of Antwerp, Belgium
- Department of Neurology and Memory Clinic, Hospital Network Antwerp (ZNA) Middelheim and Hoge Beuken, Antwerp, Belgium
| | - Olivier Deryck
- Department of Neurology, Memory Clinic General Hospital Sint-Jan Brugge-Oostende Brugge, Belgium
| | - Sebastiaan Engelborghs
- Reference Center for Biological Markers of Dementia (BIODEM), Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, University of Antwerp, Belgium
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Bernard Hanseeuw
- Department of Neurology, Cliniques Universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
- Institute of Neuroscience (IoNS), Université catholique de Louvain, Brussels, Belgium
| | | | - Eric Mormont
- Department of Neurology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
- Institute of Neuroscience (IoNS), Université catholique de Louvain, Brussels, Belgium
| | - Mirko Petrovic
- Department of Internal Medicine, Section of Geriatrics, Ghent University, Gent, Belgium
| | - Eric Salmon
- GIGA Cyclotron Research Centre Imaging, University of Liége, Liége, Belgium
- Department of Neurology, Memory Clinic, Centre Hospitalier Universitaire (CHU) Liége, Liége, Belgium
| | - Kurt Segers
- Department of Neurology, Brugmann University Hospital, Brussels, Belgium
| | - Anne Sieben
- Department of Neurology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Evert Thiery
- Department of Neurology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | | | - Jan Versijpt
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Adrian Ivanoiu
- Department of Neurology, Cliniques Universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
- Institute of Neuroscience (IoNS), Université catholique de Louvain, Brussels, Belgium
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18
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Martinez-Tapia C, Canoui-Poitrine F, Caillet P, Bastuji-Garin S, Tournigand C, Assaf E, Varnier G, Pamoukdjian F, Brain E, Rollot-Trad F, Laurent M, Paillaud E. Preferences for surrogate designation and decision-making process in older versus younger adults with cancer: A comparative cross-sectional study. PATIENT EDUCATION AND COUNSELING 2019; 102:429-435. [PMID: 30293935 DOI: 10.1016/j.pec.2018.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To compare the preferences of older (≥70 years old) versus younger (<70 years old) cancer patients regarding surrogate designation and decision making. METHODS A cross-sectional survey. Patient characteristics and information about surrogacy and involvement in decision making were collected. Associations between patient characteristics and preferences were examined. RESULTS The study included 130 patients aged ≥70 years (mean age 80 years) and 102 patients aged <70 years (mean age 55) and. Factors independently associated with surrogate knowledge (66%): younger age, more children living nearby, high income; factors associated with having already designated a surrogate (62%): younger age, decreased number of daily medications; factors associated with designating a surrogate after questionnaire administration (40%): low education, metastasis. Patients requiring an informed consent for any intervention was associated with older age (adjusted OR [aOR]per year = 1.04[95% confidence interval 1.00-1.08]), not living alone (aOR = 2.52[1.00-6.36]), and having children (aOR = 4.49[1.13-17.81]). CONCLUSION All cancer patients, wanted to be fully informed and 72% wanted to be involved in medical decisions. Preferences for decision control vary between age groups, depending on family members' presence and living alone. PRACTICE IMPLICATIONS Sharing complete and clear information should be an important key in the process of cancer patients' care, regardless of patient age.
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Affiliation(s)
- Claudia Martinez-Tapia
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France.
| | - Florence Canoui-Poitrine
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France; Assistance Publique Hôpitaux de Paris (AP-HP), Henri-Mondor Hospital, Public Health Department, Créteil, France
| | - Philippe Caillet
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France; AP-HP, Henri-Mondor Hospital, Internal Medicine and Geriatric Department, Paris- Sud-Val-de-Marne Geriatric Oncology Clinic, Créteil, France; AP-HP, Georges-Pompidou European Hospital (HEGP), Geriatric Department, Paris, France
| | - Sylvie Bastuji-Garin
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France; Assistance Publique Hôpitaux de Paris (AP-HP), Henri-Mondor Hospital, Public Health Department, Créteil, France; AP-HP, Henri-Mondor Hospital, Clinical Research Unit (URC Mondor), Créteil, France
| | - Christophe Tournigand
- AP-HP, Henri-Mondor Hospital, Department of Medical Oncology, Créteil, France; Paris-Est University, UPEC, EC2M3 Unit, VIC DHU, Créteil, France
| | - Elias Assaf
- AP-HP, Henri-Mondor Hospital, Department of Medical Oncology, Créteil, France
| | - Gwénaëlle Varnier
- AP-HP, Henri-Mondor Hospital, Internal Medicine and Geriatric Department, Paris- Sud-Val-de-Marne Geriatric Oncology Clinic, Créteil, France
| | - Frederic Pamoukdjian
- APHP, Avicenne Hospital, Geriatric department, Coordination Unit in Geriatric Oncology, Bobigny, France; Paris 13 University, Sorbonne Paris Cité, Health Education and Practices Laboratory, (LEPS EA3412), Bobigny, France
| | - Etienne Brain
- Institut Curie (Hôpital René Huguenin), Department of Medical Oncology, St Cloud, France
| | - Florence Rollot-Trad
- Institut Curie Hospital, Geriatric oncology and supportive care department, Paris, France
| | - Marie Laurent
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France; AP-HP, Henri-Mondor Hospital, Internal Medicine and Geriatric Department, Paris- Sud-Val-de-Marne Geriatric Oncology Clinic, Créteil, France
| | - Elena Paillaud
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France; AP-HP, Henri-Mondor Hospital, Internal Medicine and Geriatric Department, Paris- Sud-Val-de-Marne Geriatric Oncology Clinic, Créteil, France; AP-HP, Georges-Pompidou European Hospital (HEGP), Geriatric Department, Paris, France
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Physician-related determinants of medical end-of-life decisions - A mortality follow-back study in Switzerland. PLoS One 2018; 13:e0203960. [PMID: 30235229 PMCID: PMC6147437 DOI: 10.1371/journal.pone.0203960] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/30/2018] [Indexed: 12/12/2022] Open
Abstract
Background Medical end-of-life decisions (MELD) and shared decision-making are increasingly important issues for a majority of persons at the end of life. Little is known, however, about the impact of physician characteristics on these practices. We aimed at investigating whether MELDs depend on physician characteristics when controlling for patient characteristics and place of death. Methods and findings Using a random sample (N = 8,963) of all deaths aged 1 year or older registered in Switzerland between 7 August 2013 and 5 February 2014, questionnaires covering MELD details and physicians' demographics, life stance and medical formation were sent to certifying physicians. The response rate was 59.4% (N = 5,328). Determinants of MELDs were analyzed in binary and multinomial logistic regression models. MELDs discussed with the patient or relatives were a secondary outcome. A total of 3,391 non-sudden nor completely unexpected deaths were used, 83% of which were preceded by forgoing treatment(s) and/or intensified alleviation of pain/symptoms intending or taking into account shortening of life. International medical graduates reported forgoing treatment less often, either alone (RRR = 0.30; 95% CI: 0.21–0.41) or combined with the intensified alleviation of pain and symptoms (RRR = 0.44; 0.34–0.55). The latter was also more prevalent among physicians who graduated in 2000 or later (RRR = 1.60; 1.17–2.19). MELDs were generally less frequent among physicians with a religious affiliation. Shared-decision making was analyzed among 2,542 decedents. MELDs were discussed with patient or relatives less frequently when physicians graduated abroad (OR = 0.65, 95% CI: 0.50–0.87) and more frequently when physicians graduated more recently; physician's sex and religion had no impact. Conclusions Physicians' characteristics, including the country of medical education and time since graduation had a significant effect on the likelihood of an MELD and of shared decision-making. These findings call for additional efforts in physicians' education and training concerning end-of-life practices and improved communication skills.
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Ding J, Johnson CE, Cook A. How We Should Assess the Delivery of End-Of-Life Care in General Practice? A Systematic Review. J Palliat Med 2018; 21:1790-1805. [PMID: 30129811 DOI: 10.1089/jpm.2018.0194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The majority of end-of-life (EOL) care occurs in general practice. However, we still have little knowledge about how this care is delivered or how it can be assessed and supported. AIM (i) To review the existing evaluation tools used for assessment of the delivery of EOL care from the perspective of general practice; (ii) To describe how EOL care is provided in general practice; (iii) To identify major areas of concern in providing EOL care in this context. DESIGN A systematic review. DATA SOURCES Systematic searches of major electronic databases (Medline, EMBASE, PsycINFO, and CINAHL) from inception to 2017 were used to identify evaluation tools focusing on organizational structures/systems and process of end-of-life care from a general practice perspective. RESULTS A total of 43 studies representing nine evaluation tools were included. A relatively restricted focus and lack of validation were common limitations. Key general practitioner (GP) activities assessed by the evaluation tools were summarized and the main issues in current GP EOL care practice were identified. CONCLUSIONS The review of evaluation tools revealed that GPs are highly involved in management of patients at the EOL, but there are a range of issues relating to the delivery of care. An EOL care registration system integrated with electronic health records could provide an optimal approach to address the concerns about recall bias and time demands in retrospective analyses. Such a system should ideally capture the core GP activities and any major issues in care provision on a case-by-case basis.
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Affiliation(s)
- Jinfeng Ding
- 1 School of Population and Global Health, University of Western Australia , Perth, Western Australia, Australia
| | - Claire E Johnson
- 2 Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), Medical School, University of Western Australia , Perth, Western Australia, Australia
- 3 School of Nursing and Midwifery, Monash University , Melbourne, Victoria, Australia
| | - Angus Cook
- 1 School of Population and Global Health, University of Western Australia , Perth, Western Australia, Australia
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Johnson CE, McVey P, Rhee JJO, Senior H, Monterosso L, Williams B, Fallon-Ferguson J, Grant M, Nwachukwu H, Aubin M, Yates P, Mitchell G. General practice palliative care: patient and carer expectations, advance care plans and place of death-a systematic review. BMJ Support Palliat Care 2018:bmjspcare-2018-001549. [PMID: 30045939 DOI: 10.1136/bmjspcare-2018-001549] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/20/2018] [Accepted: 07/04/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND With an increasing ageing population in most countries, the role of general practitioners (GPs) and general practice nurses (GPNs) in providing optimal end of life (EoL) care is increasingly important. OBJECTIVE To explore: (1) patient and carer expectations of the role of GPs and GPNs at EoL; (2) GPs' and GPNs' contribution to advance care planning (ACP) and (3) if primary care involvement allows people to die in the place of preference. METHOD Systematic literature review. DATA SOURCES Papers from 2000 to 2017 were sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases. RESULTS From 6209 journal articles, 51 papers were relevant. Patients and carers expect their GPs to be competent in all aspects of palliative care. They valued easy access to their GP, a multidisciplinary approach to care and well-coordinated and informed care. They also wanted their care team to communicate openly, honestly and empathically, particularly as the patient deteriorated. ACP and the involvement of GPs were important factors which contributed to patients being cared for and dying in their preferred place. There was no reference to GPNs in any paper identified. CONCLUSIONS Patients and carers prefer a holistic approach to care. This review shows that GPs have an important role in ACP and that their involvement facilitates dying in the place of preference. Proactive identification of people approaching EoL is likely to improve all aspects of care, including planning and communicating about EoL. More work outlining the role of GPNs in end of life care is required.
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Affiliation(s)
- Claire E Johnson
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- School of Nursing & Midwifery, Monash University, Melbourne, Victoria, Australia
- Eastern Health, Melbourne, Victoria, Australia
| | - Peta McVey
- Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
| | - Joel Jin-On Rhee
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Hugh Senior
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- College of Health, Massey University, Auckland, New Zealand
| | - Leanne Monterosso
- School of Nursing & Midwifery, Notre Dame University, Fremantle, Western Australia, Australia
- Centre for Nursing and Midwifery Research, St John of God Murdoch Hospital, Murdoch, Western Australia, Australia
- School of Nursing & Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Briony Williams
- School of General Practice and Rural Medicine, University of Western Australia, Perth, Western Australia, Australia
- Primary Care Collaborative Cancer Clinical Trials Group, University of Melbourne, Melbourne, Victoria, Australia
| | - Julia Fallon-Ferguson
- School of General Practice and Rural Medicine, University of Western Australia, Perth, Western Australia, Australia
- Primary Care Collaborative Cancer Clinical Trials Group, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew Grant
- Victoria Comprehensive Cancer Centre Palliative Care Research Group, University of Melbourne, Melbourne, Victoria, Australia
| | - Harriet Nwachukwu
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michèle Aubin
- Département de médecine familiale et de médecined\'urgence, Universite Laval, Faculte de medecine, Québec City, Canada
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Cogo SB, Lunardi VL, Quintana AM, Girardon-Perlini NMO, Silveira RSD. Terminal patient care: advantages on the applicability of anticipated will directives in the hospital context. ACTA ACUST UNITED AC 2018; 38:e65617. [PMID: 29933423 DOI: 10.1590/1983-1447.2017.04.65617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 07/04/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To know the advantages related to the applicability of the advance directives of will in the hospital context from the perspective of nurses, doctors and family members. METHOD Qualitative, descriptive and exploratory study with semi structured interviews carried out from October to November 2014, with nurses, doctors and family members of patients in the final stage. Afterwards, a discursive textual analysis was carried out. RESULTS Four categories emerged: respect for patient's autonomy; support in confrontation of conflicts with and from family members; reduction of conflicts in the team about treatments and conducts; disclosure and instrumentation for application of the Advance Directives of Will. CONCLUSION The respect for personal autonomy permeates the advantages when relating the conduct of treatments at the end of life with the Advance Directives of Will. Thus, disagreements involving the processes at the end of life would be supported by the patient's desire, besides implying in the reduction of the fear of professionals in facing lawsuits and in the support of the family.
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Affiliation(s)
- Silvana Bastos Cogo
- Universidade Federal de Santa Maria (UFSM). Programa de Pós-Graduação em Enfermagem. Santa Maria, Rio Grande do Sul, Brasil
| | - Valéria Lerch Lunardi
- Universidade Federal de Rio Grande (FURG). Programa de Pós-Graduação em Enfermagem. Rio Grande, Rio Grande do Sul, Brasil
| | - Alberto Manuel Quintana
- Universidade Federal de Santa Maria (UFSM). Programa de Pós-Graduação em Psicologia. Santa Maria, Rio Grande do Sul, Brasil
| | | | - Rosemary Silva da Silveira
- Universidade Federal de Rio Grande (FURG). Programa de Pós-Graduação em Enfermagem. Rio Grande, Rio Grande do Sul, Brasil
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Hurst SA, Zellweger U, Bosshard G, Bopp M. Medical end-of-life practices in Swiss cultural regions: a death certificate study. BMC Med 2018; 16:54. [PMID: 29673342 PMCID: PMC5909244 DOI: 10.1186/s12916-018-1043-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/23/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND End-of-life decisions remain controversial. Switzerland, with three main languages shared with surrounding countries and legal suicide assistance, allows exploration of the effects of cultural differences on end-of-life practices within the same legal framework. METHODS We conducted a death certificate study on a nationwide continuous random sample of Swiss residents. Using an internationally standardized tool, we sent 4998, 2965, and 1000 anonymous questionnaires to certifying physicians in the German-, French-, and Italian-speaking regions. RESULTS The response rates were 63.5%, 51.9%, and 61.7% in the German-, French-, and Italian-speaking regions, respectively. Non-sudden, expected deaths were preceded by medical end-of-life decisions (MELDs) more frequently in the German- than in the French- or Italian-speaking region (82.3% vs. 75.0% and 74.0%, respectively), mainly due to forgoing life-prolonging treatment (70.0%, 59.8%, 57.4%). Prevalence of assisted suicide was similar in the German- and French-speaking regions (1.6%, 1.2%), with no cases reported in the Italian-speaking region. Patient involvement was smaller in the Italian- than in the French- and German-speaking regions (16.0%, 31.2%, 35.6%). Continuous deep sedation was more frequent in the Italian- than in the French- and German-speaking regions (34.4%, 26.9%, 24.5%), and was combined with MELDs in most cases. CONCLUSION We found differences in MELD prevalence similar to those found between European countries. On an international level, MELDs are comparably frequent in all regions of Switzerland, in line with the greater role given to patient autonomy. Our findings show how cultural contexts and legislation can interact in shaping the prevalence of MELDs.
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Affiliation(s)
- Samia A Hurst
- Institute for Ethics, History, and the Humanities, Geneva University Medical School, 1211, Genève, Switzerland
| | - Ueli Zellweger
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zürich, Switzerland
| | - Georg Bosshard
- Clinic for Geriatric Medicine, Zurich University Hospital, and Center on Aging and Mobility, University of Zurich and City Hospital Waid, Rämistrasse 100, 8091, Zürich, Switzerland
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zürich, Switzerland.
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Howard M, Day AG, Bernard C, Tan A, You J, Klein D, Heyland DK. Development and Psychometric Properties of a Survey to Assess Barriers to Implementing Advance Care Planning in Primary Care. J Pain Symptom Manage 2018; 55:12-21. [PMID: 28803079 DOI: 10.1016/j.jpainsymman.2017.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/31/2017] [Accepted: 08/03/2017] [Indexed: 11/21/2022]
Abstract
CONTEXT Valid and reliable measurement of barriers to advance care planning (ACP) in health care settings can inform the design of robust interventions. OBJECTIVE This article describes the development and psychometric evaluation of an instrument to measure the presence and magnitude of perceived barriers to ACP discussion with patients from the perspective of family physicians. METHODS A questionnaire was designed through literature review and expert input, asking family physicians to rate the importance of barriers (0 = not at all a barrier and 6 = an extreme amount) to ACP discussions with patients and administered to 117 physicians. Floor effects and missing data patterns were examined. Item-by-item correlations were examined using Pearson correlation. Exploratory factor analysis was conducted (iterated principle factor analysis with oblique rotation), internal consistency (Cronbach's alpha) overall and within factors was calculated, and construct validity was evaluated by calculating three correlations with related questions that were specified a priori. RESULTS The questionnaire included 31 questions in three domains relating to the clinician, patient/family and system or external factors. No items were removed due to missing data, floor effects, or high correlation with another item. A solution of three factors accounted for 71% of variance. One item was removed because it did not load strongly on any factor. All other items except one remained in the original domain in the questionnaire. Cronbach's alpha for the three factors ranged from 0.84 to 0.90. Two of three a priori correlations with related questions were statistically significant. CONCLUSION This questionnaire to assess barriers to ACP discussion from the perspective of family physicians demonstrates preliminary evidence of reliability and validity.
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Affiliation(s)
- Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Carrie Bernard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Amy Tan
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John You
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Doug Klein
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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de Caprariis PJ, Rucker B, Lyon C. Discussing Advance Care Planning and Directives in the General Population. South Med J 2017; 110:563-568. [PMID: 28863219 DOI: 10.14423/smj.0000000000000697] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The concept of end-of-life planning, along with medical and legal issues, has been discussed and has evolved over several years. The 1990 Patient Self-Determination Act and individual states' Department of Health Advance Directive forms helped overcome past problems. Patients with terminal and chronic illness are now able to have their wishes recognized for their future care. Any healthy individual's decision during an advance care planning (ACP) discussion can be adversely affected by various factors; however, multiple barriers-religion, culture, education, and family dynamics-can influence the process. Healthcare professionals' reluctance to initiate the conversation may result from limited training during medical school and residency programs. These limitations hinder both the initiation and productiveness of an ACP conversation. We explored ACP issues to provide guidance to healthcare professionals on how best to address this planning process with a healthy adult.
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Affiliation(s)
- Pascal J de Caprariis
- From the Departments of Medicine and Family Medicine, and the Division of General Internal Medicine and Clinical Innovation, NYU Lutheran Medical Center, Brooklyn, and the Palliative Care Consulting Service, Brooklyn Hospital Center, Brooklyn, New York
| | - Bronwyn Rucker
- From the Departments of Medicine and Family Medicine, and the Division of General Internal Medicine and Clinical Innovation, NYU Lutheran Medical Center, Brooklyn, and the Palliative Care Consulting Service, Brooklyn Hospital Center, Brooklyn, New York
| | - Claudia Lyon
- From the Departments of Medicine and Family Medicine, and the Division of General Internal Medicine and Clinical Innovation, NYU Lutheran Medical Center, Brooklyn, and the Palliative Care Consulting Service, Brooklyn Hospital Center, Brooklyn, New York
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Paillaud E, Canoui-Poitrine F, Varnier G, Anfasi-Ebadi N, Guery E, Saint-Jean O, Gisselbrecht M, Aparicio T, Bastuji-Garin S, Laurent M, Caillet P. Preferences about information and decision-making among older patients with and without cancer. Age Ageing 2017; 46:665-671. [PMID: 28104597 DOI: 10.1093/ageing/afw256] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Indexed: 11/14/2022] Open
Abstract
Background information of older patients with cancer is crucial to ensure optimal care. Objectives to compare older patients with and without cancer regarding their preferences about medical information, decision-making and surrogate designation. Design an intention-to-act questionnaire was completed by patients ≥70 y enroled in the ELderly CAncer PAtients cohort between January and June 2013 and by patients in the same age group enroled in a cross-sectional survey conducted in 2005 in acute geriatric wards. Setting Henri-Mondor Teaching Hospital in the Paris conurbation, France. Results the group with cancer had 133 patients [mean age, 79.6 ± 6.5 y; 54.9% women]. The main tumour sites were colorectal [24.1%], breast [23.3%] and prostate [15.8%]; 34.8% had metastases. All these patients wanted full information, 74.2% wanted to participate in decisions about their care, 87.2% would designate a family member to serve as a surrogate in life-threatening situations and 15% had already designated a surrogate. Compared to patients without cancer, those with cancer more often wanted to receive information in a life-threatening situation [93.6% versus 79.2%; P < 0.001]. Factors independently associated with patients wanting their informed consent to be obtained for all interventions were having children [adjusted odds ratio (aOR), 2.13; 95% confidence interval, 1.24; 3.66; P = 0.006], higher Mini Mental State Examination score [aORper point, 1.09; 1.02; 1.17], younger age in the group without cancer [aOR>82 y vs. ≤82 y, 0.50; 0.29-0.88] and being cancer-free [≤82 y, aOR, 0.30; 0.14-0.63; >82 y, aOR, 0.41; 0.17-0.97]. Conclusion older patients with cancer expressed a strong preference for receiving information and participating in decisions about their care.
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Affiliation(s)
- Elena Paillaud
- Department of Internal and Geriatric Medicine, Assistance Publique - Hopitaux de Paris, Henri-Mondor Hospital, Paris, Île-de-France, France
- CEpiA (Clinical Epidemiology and Ageing), University Paris-Est Créteil (UPEC), EA 7376- IMRB, Creteil, France
| | - Florence Canoui-Poitrine
- CEpiA (Clinical Epidemiology and Ageing), University Paris-Est Créteil (UPEC), EA 7376- IMRB, Creteil, France
- Department of Public Health, Assistance Publique - Hopitaux de Paris, Paris, Île-de-France, France
| | - Gwenaelle Varnier
- Department of Internal and Geriatric Medicine, Assistance Publique - Hopitaux de Paris, Henri-Mondor Hospital, Paris, Île-de-France, France
| | - Narges Anfasi-Ebadi
- Department of Internal and Geriatric Medicine, Assistance Publique - Hopitaux de Paris, Henri-Mondor Hospital, Paris, Île-de-France, France
| | - Ester Guery
- CEpiA (Clinical Epidemiology and Ageing), University Paris-Est Créteil (UPEC), EA 7376- IMRB, Creteil, France
- Clinical Research Unit (URC-Mondor), Assistance Publique - Hopitaux de Paris, Creteil, Île-de-France, France
| | - Olivier Saint-Jean
- Geriatrics Department, Assistance Publique - Hopitaux de Paris, Hôpital Européen Georges Pompidou, Paris, Île-de-France, France
| | - Mathilde Gisselbrecht
- Geriatrics Department, Assistance Publique - Hopitaux de Paris, Hôpital Européen Georges Pompidou, Paris, Île-de-France, France
| | - Thomas Aparicio
- Gastroenterology and Digestive Oncology Department, Assistance Publique - Hopitaux de Paris, Avicenne hospital, Bobigny, Île-de-France, France
| | - Sylvie Bastuji-Garin
- CEpiA (Clinical Epidemiology and Ageing), University Paris-Est Créteil (UPEC), EA 7376- IMRB, Creteil, France
- Department of Public Health, Assistance Publique - Hopitaux de Paris, Paris, Île-de-France, France
| | - Marie Laurent
- Department of Internal and Geriatric Medicine, Assistance Publique - Hopitaux de Paris, Henri-Mondor Hospital, Paris, Île-de-France, France
- CEpiA (Clinical Epidemiology and Ageing), University Paris-Est Créteil (UPEC), EA 7376- IMRB, Creteil, France
| | - Philippe Caillet
- Department of Internal and Geriatric Medicine, Assistance Publique - Hopitaux de Paris, Henri-Mondor Hospital, Paris, Île-de-France, France
- CEpiA (Clinical Epidemiology and Ageing), University Paris-Est Créteil (UPEC), EA 7376- IMRB, Creteil, France
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Delineau VMEB, Schultz RR. Dementia and legal determination of capacity. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:349-353. [PMID: 28658403 DOI: 10.1590/0004-282x20170061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 01/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To assess the legal capacity and guardianship proceedings in patients diagnosed with dementia. METHODS Ninety-seven patients diagnosed with dementia and seen at a tertiary hospital were evaluated. RESULTS Of these 97 patients, 60 (62%) were female. The mean age of the patients was 77.9 years; average schooling was 5.5 years. The main diagnosis was Alzheimer's disease (73%): 16 patients were at a mild stage, eight at a moderate stage and 73 at an advanced stage of dementia. Only 28 patients had been legally declared incapable. CONCLUSION The large numbers of patients at an advanced stage of dementia, and the relatively few patients legally declared incapable show that legal issues in dementia are problematic.
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Affiliation(s)
- Valeska Maria Eboli Bello Delineau
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Setor de Neurologia do Comportamento, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brasil
| | - Rodrigo Rizek Schultz
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Setor de Neurologia do Comportamento, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brasil
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Chen CH, Kuo SC, Tang ST. Current status of accurate prognostic awareness in advanced/terminally ill cancer patients: Systematic review and meta-regression analysis. Palliat Med 2017; 31:406-418. [PMID: 27492160 DOI: 10.1177/0269216316663976] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND No systematic meta-analysis is available on the prevalence of cancer patients' accurate prognostic awareness and differences in accurate prognostic awareness by publication year, region, assessment method, and service received. AIM To examine the prevalence of advanced/terminal cancer patients' accurate prognostic awareness and differences in accurate prognostic awareness by publication year, region, assessment method, and service received. DESIGN Systematic review and meta-analysis. METHODS MEDLINE, Embase, The Cochrane Library, CINAHL, and PsycINFO were systematically searched on accurate prognostic awareness in adult patients with advanced/terminal cancer (1990-2014). Pooled prevalences were calculated for accurate prognostic awareness by a random-effects model. Differences in weighted estimates of accurate prognostic awareness were compared by meta-regression. RESULTS In total, 34 articles were retrieved for systematic review and meta-analysis. At best, only about half of advanced/terminal cancer patients accurately understood their prognosis (49.1%; 95% confidence interval: 42.7%-55.5%; range: 5.4%-85.7%). Accurate prognostic awareness was independent of service received and publication year, but highest in Australia, followed by East Asia, North America, and southern Europe and the United Kingdom (67.7%, 60.7%, 52.8%, and 36.0%, respectively; p = 0.019). Accurate prognostic awareness was higher by clinician assessment than by patient report (63.2% vs 44.5%, p < 0.001). CONCLUSION Less than half of advanced/terminal cancer patients accurately understood their prognosis, with significant variations by region and assessment method. Healthcare professionals should thoroughly assess advanced/terminal cancer patients' preferences for prognostic information and engage them in prognostic discussion early in the cancer trajectory, thus facilitating their accurate prognostic awareness and the quality of end-of-life care decision-making.
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Affiliation(s)
- Chen Hsiu Chen
- 1 Department of Nursing, University of Kang Ning, Tainan, Taiwan.,2 Graduate Institute of Clinical Medical Science, Chang Gung University, Tao-Yuan, Taiwan
| | - Su Ching Kuo
- 2 Graduate Institute of Clinical Medical Science, Chang Gung University, Tao-Yuan, Taiwan.,3 Department of Nursing, Yuanpei University, Hsinchu, Taiwan
| | - Siew Tzuh Tang
- 4 School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.,5 Department of Nursing, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,6 Division of Hematology-Oncology, Chang Gung Memorial Hospital, Linkou, Tao-Yuan, Taiwan
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Cogo SB, Lunardi VL, Quintana AM, Girardon-Perlini NMO, Silveira RSD. Desafios da implementação das diretivas antecipadas de vontade à prática hospitalar. Rev Bras Enferm 2016; 69:1031-1038. [DOI: 10.1590/0034-7167-2016-0085] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/13/2016] [Indexed: 11/21/2022] Open
Abstract
RESUMO Objetivo: conhecer as dificuldades e limitações relacionadas à implementação das Diretivas Antecipadas de Vontade no contexto hospitalar. Método: estudo qualitativo, do tipo descritivo e exploratório, mediante entrevista semiestruturada com enfermeiros, médicos residentes e cuidadores familiares. Os dados foram analisados por meio da técnica de análise textual discursiva e ancorados no referencial dos princípios da bioética. Resultados: emergiram as categorias: A terminalidade como expressão de derrota e a cura como opção para o cuidado? Receios das implicações legais; Diretivas Antecipadas de Vontade requerem autonomia do paciente e adequada comunicação. Conclusão: as limitações e dificuldades atribuídas à prática das diretivas antecipadas de vontade, na perspectiva dos participantes, indicam, além dos inúmeros conflitos e dilemas relacionados às questões de final de vida, que vivências da iminência da morte não têm possibilitado que os desejos dos pacientes sejam respeitados.
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Oosterink JJ, Oosterveld-Vlug MG, Glaudemans JJ, Pasman HRW, Willems DL, Onwuteaka-Philipsen BD. Interprofessional communication between oncologic specialists and general practitioners on end-of-life issues needs improvement. Fam Pract 2016; 33:727-732. [PMID: 27587566 DOI: 10.1093/fampra/cmw064] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Timely end-of-life (EOL) discussions between patients and physicians are considered essential for high-quality EOL care, but research shows that these discussions frequently do not occur or occur late. In oncology, one barrier for timely EOL discussions is poor collaboration between oncologic specialists and GPs. OBJECTIVE To explore interprofessional communication and coordination between oncologic specialists and GPs on EOL discussions. METHODS We conducted in-depth interviews with 16 GPs and 14 oncologic specialists. Interviews were recorded, transcribed verbatim and analysed using qualitative content analysis. RESULTS EOL discussions were primarily considered the role of the GP, but oncologists' perceptions of their own roles in discussing EOL issues varied. Interprofessional coordination on who discusses what and when was mostly absent. Interprofessional communication of EOL issues usually proceeded using the patient as intermediary. This functioned well but only if three essential conditions were met: the specialist being realistic to patients about limits of treatment, informing the GP adequately and the GP being proactive in initiating EOL issues in time. However, when these conditions were absent, timely EOL discussions did not seem to occur. CONCLUSIONS EOL discussions are rarely a subject of direct interprofessional communication and mainly proceed through the patient as intermediary. For implementation of EOL discussions into regular care, earlier interprofessional communication and coordination is needed, particularly if barriers for such discussions occur.
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Affiliation(s)
- John J Oosterink
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands.
| | - Mariska G Oosterveld-Vlug
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
| | - Jolien J Glaudemans
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
| | - H Roeline W Pasman
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
| | - Dick L Willems
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
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Robijn L, Cohen J, Rietjens J, Deliens L, Chambaere K. Trends in Continuous Deep Sedation until Death between 2007 and 2013: A Repeated Nationwide Survey. PLoS One 2016; 11:e0158188. [PMID: 27337064 PMCID: PMC4918927 DOI: 10.1371/journal.pone.0158188] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/10/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuous deep sedation until death is a highly debated medical practice, particularly regarding its potential to hasten death and its proper use in end-of-life care. A thorough analysis of important trends in this practice is needed to identify potentially problematic developments. This study aims to examine trends in the prevalence and practice characteristics of continuous deep sedation until death in Flanders, Belgium between 2007 and 2013, and to study variation on physicians' degree of palliative training. METHODS Population-based death certificate study in 2007 and 2013 in Flanders, Belgium. Reporting physicians received questionnaires about medical practices preceding the patient's death. Patient characteristics, clinical characteristics (drugs used, duration, artificial nutrition/hydration, intention and consent), and palliative care training of attending physician were recorded. We posed the following question regarding continuous deep sedation: 'Was the patient continuously and deeply sedated or kept in a coma until death by the use of one or more drugs'. RESULTS After the initial rise of continuous deep sedation to 14.5% in 2007 (95%CI 13.1%-15.9%), its use decreased to 12.0% in 2013 (95%CI 10.9%-13.2%). Compared with 2007, in 2013 opioids were less often used as sole drug and the decision to use continuous deep sedation was more often preceded by patient request. Compared to non-experts, palliative care experts more often used benzodiazepines and less often opioids, withheld artificial nutrition/hydration more often and performed sedation more often after a request from or with the consent of the patient or family. CONCLUSION Worldwide, this study is the first to show a decrease in the prevalence of continuous deep sedation. Despite positive changes in performance and decision-making towards more compliance with due care requirements, there is still room for improvement in the use of recommended drugs and in the involvement of patients and relatives in the decision-making process.
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Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Judith Rietjens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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Gibbs AJO, Malyon AC, Fritz ZBM. Themes and variations: An exploratory international investigation into resuscitation decision-making. Resuscitation 2016; 103:75-81. [PMID: 26976676 PMCID: PMC4879149 DOI: 10.1016/j.resuscitation.2016.01.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/17/2015] [Accepted: 01/25/2016] [Indexed: 10/31/2022]
Abstract
BACKGROUND Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are made in hospitals throughout the globe. International variation in clinicians' perception of DNACPR decision-making and implementation and the factors influencing such variation has not previously been explored. METHODS A questionnaire asking how DNACPR decisions are made, communicated and perceived in their country was composed: it consisted of seven closed-answer and four open-answer questions. It was distributed to 143 medical professionals with prior published material relating to DNACPR decisions. Under-represented geographical areas were identified and an additional 34 physicians were contacted through medical colleagues and students at the university hospital from which this study was based. The respondents had 4 weeks to answer the questionnaire. RESULTS 78 responses (44%) were received from 43 countries. All continents were represented. 88% of respondents reported a method for implementing DNACPR decisions, 90% of which discussed resuscitation wishes with the patient at least half of the time. 94% of respondents thought that national guidance for DNACPR order implementation should exist; 53% of countries surveyed reported existence of such guidance. Cultural attitudes towards death, medical education and culture, health economics and the societal role of family were commonly identified as factors influencing perception of DNACPR decisions. CONCLUSIONS The majority of countries surveyed make some form of DNACPR decision but differing cultures and economic status contribute towards a heterogeneity of approaches to resuscitation decision-making. Adequacy of relevant medical education and national policy are two areas that were regularly identified as impacting upon the processes of DNACPR decision-making and implementation.
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Affiliation(s)
| | - Alexandra C Malyon
- Department of Acute Medicine, Cambridge University Hospitals, Box 148, Hills Road, Cambridge, UK
| | - Zoë B McC Fritz
- Department of Acute Medicine, Cambridge University Hospitals, Box 148, Hills Road, Cambridge, UK; Warwick Medical School, University of Warwick Coventry, CV4 7AL, UK.
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De Vleminck A, Pardon K, Beernaert K, Houttekier D, Vander Stichele R, Deliens L. How Do General Practitioners Conceptualise Advance Care Planning in Their Practice? A Qualitative Study. PLoS One 2016; 11:e0153747. [PMID: 27096846 PMCID: PMC4838248 DOI: 10.1371/journal.pone.0153747] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 04/04/2016] [Indexed: 12/02/2022] Open
Abstract
Objectives To explore how GPs conceptualise advance care planning (ACP), based on their experiences with ACP in their practice. Methods Five focus groups were held with 36 GPs. Discussions were analysed using a constant comparative method. Results Four overarching themes in the conceptualisations of ACP were discerned: (1) the organisation of professional care required to meet patients’ needs, (2) the process of preparing for death and discussing palliative care options, (3) the discussion of care goals and treatment decisions, (4) the completion of advance directives. Within these themes, ACP was both conceptualised in terms of content of ACP and/or in terms of tasks for the GP. A specific task that was mentioned throughout the discussion of the four different themes was (5) the task of actively initiating ACP by the GP versus passively waiting for patients’ initiation. Conclusions This study illustrates that GPs have varying conceptualisations of ACP, of which some are more limited to specific aspects of ACP. A shared conceptualisation and agreement on the purpose and goals of ACP is needed to ensure successful implementation, as well as a systematic integration of ACP in routine practice that could lead to a better uptake of all the important elements of ACP.
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Affiliation(s)
- Aline De Vleminck
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- * E-mail:
| | - Koen Pardon
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kim Beernaert
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Dirk Houttekier
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Heymans Institute, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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Sinclair C, Gates K, Evans S, Auret KA. Factors Influencing Australian General Practitioners' Clinical Decisions Regarding Advance Care Planning: A Factorial Survey. J Pain Symptom Manage 2016; 51:718-727.e2. [PMID: 26706628 DOI: 10.1016/j.jpainsymman.2015.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 11/22/2015] [Accepted: 11/27/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT Primary care physicians are well placed to identify patients in need of advance care planning (ACP) and initiate ACP in advance of an acute situation. OBJECTIVES This study aimed to understand Australian general practitioner (GP) clinical decision making relating to a patient's "need for ACP" and the likelihood of initiating ACP. METHODS An experimental vignette study pseudorandomly manipulated factors thought to influence decision making regarding ACP. Patient-level factors included gender, age, type of disease, medical severity, openness to ACP, doctor-patient relationship, and family support. An accompanying demographic survey assessed health professional-level factors, including gender, years of experience, place of training, place of practice, caseload of patients with ACP, direct personal experience in ACP, and self-reported attitudes toward ACP. Seventy GPs were recruited, and each completed six unique vignettes, providing ratings of patient need for ACP, importance of initiating ACP in the coming months, and likelihood of initiating ACP at the next consultation. RESULTS Older patients, with malignant or cardiovascular disease, severe clinical presentations, good doctor-patient relationship, female gender, and poor family support were more likely to receive prompt ACP. Positive GP attitudes toward ACP were associated with greater likelihood of initiating ACP promptly. CONCLUSION Patients with presentations suggesting higher mortality risk were identified as being in need of ACP; however, the likelihood of initiating ACP was sensitive to GP attitudes and psychosocial aspects of the doctor-patient interaction. Training materials aimed at encouraging GP involvement in ACP should target attitudes toward ACP and communication skills, rather than focusing solely on prognostic risk.
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Affiliation(s)
- Craig Sinclair
- Rural Clinical School of Western Australia - Albany, Albany, Western Australia, Australia.
| | | | - Sharon Evans
- Rural Clinical School of Western Australia-Urban Centre, Perth, Western Australia, Australia
| | - Kirsten Anne Auret
- Rural Clinical School of Western Australia - Albany, Albany, Western Australia, Australia
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Development of a complex intervention to support the initiation of advance care planning by general practitioners in patients at risk of deteriorating or dying: a phase 0-1 study. BMC Palliat Care 2016; 15:17. [PMID: 26868650 PMCID: PMC4750213 DOI: 10.1186/s12904-016-0091-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 02/08/2016] [Indexed: 11/13/2022] Open
Abstract
Background Most patients with life-limiting illnesses are treated and cared for over a long period of time in primary care and guidelines suggest that ACP discussions should be initiated in primary care. However, a practical model to implement ACP in general practice is lacking. Therefore, the objective of this study is to develop an intervention to support the initiation of ACP in general practice. Methods We conducted a Phase 0-I study according to the Medical Research Council (MRC) Framework. Phase 0 consisted of a systematic literature review about the barriers and facilitators for GPs to engage in ACP, focus groups with GPs were held about their experiences, attitudes and concerns regarding initiating ACP in general practice and a review of ACP interventions to identify potential components for the development of our intervention. In Phase 1, we developed a complex intervention to support the initiation of ACP in general practice in patients at risk of deteriorating or dying, based on the results of Phase 0. The complex intervention and its components were reviewed and refined by two expert panels. Results Phase 0 resulted in the identification of the factors inhibiting or enabling GPs’ initiation of ACP and important components underpinning existing ACP interventions. Based on these findings, an intervention was developed in Phase 1 consisting of: (1) a training for GPs in initiating and conducting ACP discussions, (2) a register of patients eligible for ACP discussions, (3) an educational booklet on ACP for patients to prepare the ACP discussions that includes general information on ACP, a section on the role of GPs in the process of ACP and a prompt list, (4) a conversation guide to support GPs in the ACP discussions and (5) a structured documentation template to record the outcomes of discussions. Conclusion Taking into account the barriers and facilitators for GPs to initiate ACP as well as the key factors underpinning successful ACP intervention in other health care settings, a complex intervention for general practice was developed, after gaining feedback from two expert panels. The feasibility and acceptability of the intervention will subsequently be tested in a Phase II study.
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De Vleminck A, Pardon K, Houttekier D, Van den Block L, Vander Stichele R, Deliens L. The prevalence in the general population of advance directives on euthanasia and discussion of end-of-life wishes: a nationwide survey. BMC Palliat Care 2015; 14:71. [PMID: 26643482 PMCID: PMC4671216 DOI: 10.1186/s12904-015-0068-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 11/27/2015] [Indexed: 11/26/2022] Open
Abstract
Background To determine the extent to which members of the general population have talked to their physician about their wishes regarding medical treatment at the end of life, to describe the prevalence of advance directives on euthanasia, and to identify associated factors. Method This study used data from the cross-sectional Health Interview Study (HIS) 2008 that collected data from a representative sample (N = 9651) of the Belgian population. Results Of all respondents, 4.4 % had spoken to their physician about their wishes regarding medical treatment at the end of life, while 1.8 % had an advance directive on euthanasia. Factors positively associated with discussions regarding wishes for medical treatment at the end of life were being female, being older in age, having poorer health status and having more GP contacts. People older than 55 years and living in Flanders or Brussels were more likely than the youngest age categories to have an advance directive on euthanasia. Conclusion Younger people, men, people living in the Walloon region of Belgium, people without a longstanding illness, chronic condition or disability and people with few GP contacts could represent a target group for education regarding advance care planning. Public information campaigns and education of physicians may help to enable the public and physicians to engage more in advance care planning.
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Affiliation(s)
- Aline De Vleminck
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium.
| | - Koen Pardon
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium.
| | - Dirk Houttekier
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium.
| | - Lieve Van den Block
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium. .,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Robert Vander Stichele
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium. .,Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.
| | - Luc Deliens
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium. .,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium.
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Cogo SB, Lunardi VL. Diretivas antecipadas de vontade aos doentes terminais: revisão integrativa. Rev Bras Enferm 2015; 68:464-74, 524-34. [DOI: 10.1590/0034-7167.2015680321i] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 05/08/2015] [Indexed: 11/21/2022] Open
Abstract
RESUMOObjetivo:caracterizar a produção científica nacional e internacional sobre as diretivas antecipadas de vontade aplicadas ao doente terminal.Método:a revisão integrativa, incluindo os artigos publicados no Portal Capes, SCIELO, LILACS, MEDLINE, Revista de Bioética e Bioethikos, a partir dos descritores: Diretivas antecipadas, Testamentos quanto à vida, Advance Directives, Living Will e Terminally Ill totalizando 44 artigos submetidos à análise de conteúdo.Resultados:emergiram três categorias: Estudantes e profi ssionais frente às diretivas antecipadas de vontade: percepções, opiniões e condutas; Receptividade dos pacientes às diretivas antecipadas de vontade; A família diante das diretivas antecipadas de vontade.Conclusão:evidenciou-se a relevância do tema como garantidor do respeito à dignidade e à autonomia do doente, bem como para a redução dos conflitos éticos enfrentados pelos familiares e profi ssionais da saúde frente aos cuidados em fi nal de vida.
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Pattison N, O’Gara G, Wigmore T. Negotiating Transitions: Involvement of Critical Care Outreach Teams in End-of-Life Decision Making. Am J Crit Care 2015; 24:232-40. [PMID: 25934720 DOI: 10.4037/ajcc2015715] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Little research has examined the involvement of critical care outreach teams in end-of-life decision making. OBJECTIVE To establish how much time critical care outreach teams spend with patients who are subsequently subject to limitation of medical treatment and end-of-life decisions and how much influence the teams have on those decisions. METHODS A single-center retrospective review, with qualitative analysis, in a large cancer center. Data from all patients referred emergently for critical care outreach from October 2010 to October 2011 who later had limitation of medical treatment or end-of-life care were retrieved. Findings were analyzed by using SPSS 19 and qualitative free-text analysis. RESULTS Of 890 patients referred for critical care outreach from October 2010 to October 2011, 377 were referred as an emergency; 108 of those had limitation of medical treatment and were included in the review. Thirty-five patients (32.4%) died while hospitalized. As a result of outreach intervention and a decision to limit medical treatment, 56 (51.9%) of the 108 patients received a formal end-of-life care plan (including care pathways, referral to palliative care team, hospice). About a fifth (21.5%) of clinical contact time is being spent on patients who subsequently are subject to limitation of medical treatment. Qualitative document analysis showed 5 emerging themes: difficulty of discussions about not attempting cardiopulmonary resuscitation, complexities in coordinating multiple teams, delays in referral and decision making, decision reversals and opaque decision making, and technical versus ethical imperatives. CONCLUSION A considerable amount of time is being spent on these emergency referrals, and decisions to limit medical treatment are common. The appropriateness of escalation of levels of care is often not questioned until patients become critically or acutely unwell, and outreach teams subsequently intervene.
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Affiliation(s)
- Natalie Pattison
- Natalie Pattison is a senior clinical nursing research fellow, Geraldine O’Gara is a nurse researcher, and Timothy Wigmore is divisional medical director and consultant in critical care and anesthesia, The Royal Marsden NHS Foundation Trust, London, England
| | - Geraldine O’Gara
- Natalie Pattison is a senior clinical nursing research fellow, Geraldine O’Gara is a nurse researcher, and Timothy Wigmore is divisional medical director and consultant in critical care and anesthesia, The Royal Marsden NHS Foundation Trust, London, England
| | - Timothy Wigmore
- Natalie Pattison is a senior clinical nursing research fellow, Geraldine O’Gara is a nurse researcher, and Timothy Wigmore is divisional medical director and consultant in critical care and anesthesia, The Royal Marsden NHS Foundation Trust, London, England
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Critical decisions for older people with advanced dementia: a prospective study in long-term institutions and district home care. J Am Med Dir Assoc 2015; 16:535.e13-20. [PMID: 25843621 DOI: 10.1016/j.jamda.2015.02.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 02/16/2015] [Accepted: 02/16/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe and compare the decisions critical for survival or quality of life [critical decisions (CDs)] made for patients with advanced dementia in nursing homes (NHs) and home care (HC) services. DESIGN Prospective cohort study with a follow-up of 6 months. SETTING Lombardy Region (NHs) and Reggio-Emilia and Modena Districts (HC), Italy. PARTICIPANTS Patients (496 total; 315 in NHs and 181 in HC) with advanced dementia (Functional Assessment Staging Tool score ≥ 7) and expected survival ≥ 2 weeks. MEASUREMENTS At baseline, the patients' demographic data, date of admission and of dementia diagnosis, type of dementia, main comorbidities, presence of pressure sores, ongoing treatments, and current prescriptions were abstracted from clinical records. At baseline and every 15 days thereafter, information regarding the patients' general condition and CDs (deemed critical by the doctor or team) was collected by an interview with the doctor. For each CD, the physician reported the problem that led to the decision, that was eventually made, the purpose of the decision, whether the decision had been discussed with and/or communicated to the family, who made the final decision, whether the decision was maintained after 1 week, whether it corresponded to what the doctor would have judged appropriate, and the expected survival of the patient (≤ 15 days). RESULTS For 267 of the 496 patients (53.8%; 60.3% in NHs and 42.5% at home), 644 CDs were made; for 95 patients, more than 1 CD was made. The problems that led to a CD were mainly infections (respiratory tract and other infections; 46.6%, 300/644 CDs); nutritional/hydration problems (20.6%; 133 CDs); and the worsening of a pre-existing disease (9.3%; 60 CDs). The most frequent type of decision concerned the prescription of antibiotics (overall 41.1%, 265/644; among NH patients 44.6%, 218/488; among HC patients, 30.2%, 47/156). The decision to hospitalize the patient was more frequently reported for HC than NH patients (25.5% vs 3.1%). The most frequent purposes of the CDs in both settings were reducing symptoms or suffering (more so in NHs; 81.1% vs 57.0% in HC) and prolonging survival (NH 27.5%; HC 23.1%; multiple purposes were possible). For 26 decisions (3.8%), the purpose was to ease death or not to prolong life. CONCLUSIONS Decisions critical for the survival or quality of life of patients with advanced dementia were made for approximately one-half of the patients during a 6-month time frame, and such decisions were made more frequently in NHs than in HC. HC patients were more frequently hospitalized, and a sizeable minority of these patients were treated with the goal of prolonging survival. Italian patients with advanced dementia may benefit from the implementation of palliative care principles, and HC patients may benefit from the implementation of measures to avoid hospitalizing patients near the end of life.
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Van den Block L, Pivodic L, Pardon K, Donker G, Miccinesi G, Moreels S, Vega Alonso T, Deliens L, Onwuteaka-Philipsen B. Transitions between health care settings in the final three months of life in four EU countries. Eur J Public Health 2015; 25:569-75. [DOI: 10.1093/eurpub/ckv039] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Oerlemans AJM, van Sluisveld N, van Leeuwen ESJ, Wollersheim H, Dekkers WJM, Zegers M. Ethical problems in intensive care unit admission and discharge decisions: a qualitative study among physicians and nurses in the Netherlands. BMC Med Ethics 2015; 16:9. [PMID: 25880418 PMCID: PMC4344998 DOI: 10.1186/s12910-015-0001-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 01/27/2015] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with. METHODS This was an explorative, descriptive study using qualitative methods (individual and focus group interviews). We conducted 19 individual interviews and 4 focus group interviews with nurses and physicians working in the ICU or the general ward of 10 Dutch hospitals. RESULTS The ethical problems in the context of ICU admission and discharge can be divided into problems concerning full bed occupancy and problems related to treatment decisions. The gap between the high level of care the ICU can provide and the lower care level in the general ward sometimes leads to mutual misunderstandings. Our results indicate that when professionals of different wards feel there is a collective responsibility and effort to solve a problem, this helps to prevent or alleviate moral distress. ICU patients' wishes are often unknown, causing healthcare professionals to err on the side of more treatment. Additionally, the highly technological nature of intensive care appears to encourage over-treatment. CONCLUSIONS It is important for ICUs and general wards to communicate and cooperate well, since there is a mutual dependency for optimal patient flow between the different departments. Interventions that improve the understanding and cooperation between these wards may help mitigate ethical problems. The nature of the ICU environment makes it important for healthcare professionals to be aware of the risk of over-treatment, reflect on why they do what they do, and be mindful of a possible negative impact of over-treatment on their patients. Early discussion of a patient's wishes with regard to treatment options is important in preventing over-treatment.
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Affiliation(s)
- Anke J M Oerlemans
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Nelleke van Sluisveld
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Eric S J van Leeuwen
- Department of Intensive Care Medicine, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Hub Wollersheim
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Wim J M Dekkers
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Marieke Zegers
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
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van der Plas AGM, Onwuteaka-Philipsen BD, Francke AL, Jansen WJJ, Vissers KC, Deliens L. Palliative care case managers in primary care: a descriptive study of referrals in relation to treatment aims. J Palliat Med 2014; 18:324-31. [PMID: 25495143 DOI: 10.1089/jpm.2014.0269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Three important elements of the World Health Organization (WHO) definition of palliative care are: 1) it includes patients who may have cure or life prolongation as treatment aims besides palliative care; 2) it is not exclusively for cancer patients; and 3) it includes attention to the medical, psychological, social, and spiritual needs of the patients and their families. Case managers (nurses with expertise in palliative care) may assist generalist primary care providers in delivery of good palliative care. OBJECTIVES This study investigates the referral of patients to case managers in primary care with regard to the three elements mentioned: diagnosis, treatment aims, and needs as reflected in reasons given for referral. METHODS In this cross-sectional survey in primary care among case managers and referrers to case management, case managers completed questionnaires for 687 patients; referrers completed 448 (65%). RESULTS Most patients referred have a combination of treatment aims (69%). Life expectancy and functional status of patients are lower for those with a treatment aim of palliation. Almost all (96%) of those referred are cancer patients. A need for psychosocial support is frequently given as a reason for referral (66%) regardless of treatment aim. CONCLUSIONS Referrals to case managers reflect two of three elements of the WHO definition. Mainly, patients are referred for support complementary to medical care, and relatively early in their disease trajectory. However, most of those referred are cancer patients. Thus, to fully reflect the definition, broadening the scope to reach other patient groups is important.
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Affiliation(s)
- Annicka G M van der Plas
- 1 Department of Public and Occupational Health, VU University Medical Center , Amsterdam, the Netherlands
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De Vleminck A, Pardon K, Roelands M, Houttekier D, Van den Block L, Vander Stichele R, Deliens L. Information preferences of the general population when faced with life-limiting illness. Eur J Public Health 2014; 25:532-8. [DOI: 10.1093/eurpub/cku158] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Horn R. "I don't need my patients' opinion to withdraw treatment": patient preferences at the end-of-life and physician attitudes towards advance directives in England and France. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2014; 17:425-35. [PMID: 24687368 PMCID: PMC4078234 DOI: 10.1007/s11019-014-9558-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This paper presents the results of a qualitative interview study exploring English and French physicians' moral perspectives and attitudes towards end-of-life decisions when patients lack capacity to make decisions for themselves. The paper aims to examine the importance physicians from different contexts accord to patient preferences and to explore the (potential) role of advance directives (ADs) in each context. The interviews focus on (1) problems that emerge when deciding to withdraw/-hold life-sustaining treatment from both conscious and unconscious patients; (2) decision-making procedures and the participation of proxies/relatives; (3) previous experience with ADs and views on their usefulness; and (4) perspectives on ways in which the decision-making processes in question might be improved. The analysis reveals differences in the way patient preferences are taken into consideration and shows how these differences influence the reasons physicians in each country invoke to justify their reluctance to adhering to ADs. Identifying cultural differences that complicate efforts to develop the practical implementation of ADs can help to inform national policies governing ADs and to better adapt them to practice.
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Affiliation(s)
- Ruth Horn
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Rosemary Rue Building, Oxford, OX3 7LF, UK,
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Koekkoek JAF, Dirven L, Reijneveld JC, Sizoo EM, Pasman HRW, Postma TJ, Deliens L, Grant R, McNamara S, Grisold W, Medicus E, Stockhammer G, Oberndorfer S, Flechl B, Marosi C, Taphoorn MJB, Heimans JJ. End of life care in high-grade glioma patients in three European countries: a comparative study. J Neurooncol 2014; 120:303-10. [DOI: 10.1007/s11060-014-1548-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 07/06/2014] [Indexed: 11/29/2022]
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Pivodic L, Van den Block L, Pardon K, Miccinesi G, Vega Alonso T, Boffin N, Donker GA, Cancian M, López-Maside A, Onwuteaka-Philipsen BD, Deliens L. Burden on family carers and care-related financial strain at the end of life: a cross-national population-based study. Eur J Public Health 2014; 24:819-26. [PMID: 24642602 PMCID: PMC4168044 DOI: 10.1093/eurpub/cku026] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The rising number of deaths from cancer and other life-limiting illnesses is accompanied by a growing number of family carers who provide long-lasting care, including end-of-life care. This population-based epidemiological study aimed to describe and compare in four European countries the prevalence of and factors associated with physical or emotional overburden and difficulties in covering care-related costs among family carers of people at the end of life. Methods: A cross-national retrospective study was conducted via nationwide representative sentinel networks of general practitioners (GPs). Using a standardized form, GPs in Belgium, The Netherlands, Italy and Spain recorded information on the last 3 months of life of every deceased adult practice patient (1 January 2009–31 December 2010). Sudden deaths were excluded. Results: We studied 4466 deaths. GPs judged family carers of 28% (Belgium), 30% (The Netherlands), 35% (Spain) and 71% (Italy) of patients as physically/emotionally overburdened (P < 0.001). For 8% (Spain), 14% (Belgium), 36% (The Netherlands) and 43% (Italy) patients, GPs reported difficulties in covering care-related costs (P < 0.001). Patients <85 years of age (Belgium, Italy) had higher odds of having physically/emotionally overburdened family carers and financial burden. Death from non-malignant illness (vs. cancer) (Belgium and Italy) and dying at home compared with other locations (The Netherlands and Italy) were associated with higher odds of difficulties in covering care-related costs. Conclusion: In all countries studied, and particularly in Italy, GPs observed a considerable extent of physical/emotional overburden as well as difficulties in covering care-related costs among family carers of people at the end of life. Implications for health- and social care policies are discussed.
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Affiliation(s)
- Lara Pivodic
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Koen Pardon
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Guido Miccinesi
- 2 Cancer Prevention and Research Institute (ISPO), Florence, Italy
| | - Tomás Vega Alonso
- 3 Public Health Directorate, Ministry of Health, Autonomous Community of Castile and Leon, Valladolid, Spain
| | - Nicole Boffin
- 4 Scientific Institute of Public Health, Brussels, Belgium
| | - Gé A Donker
- 5 NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Maurizio Cancian
- 6 SIMG, Italian College of General Practitioners, Florence, Italy
| | - Aurora López-Maside
- 7 Public Health General Directorate, Health Department, Valencian Community, Valencia, Spain
| | - Bregje D Onwuteaka-Philipsen
- 8 Department of Public and Occupational Health, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Luc Deliens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium 8 Department of Public and Occupational Health, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Vandervoort A, Houttekier D, Vander Stichele R, van der Steen JT, Van den Block L. Quality of dying in nursing home residents dying with dementia: does advanced care planning matter? A nationwide postmortem study. PLoS One 2014; 9:e91130. [PMID: 24614884 PMCID: PMC3948949 DOI: 10.1371/journal.pone.0091130] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 02/10/2014] [Indexed: 11/29/2022] Open
Abstract
Background Advance care planning is considered a central component of good quality palliative care and especially relevant for people who lose the capacity to make decisions at the end of life, which is the case for many nursing home residents with dementia. We set out to investigate to what extent (1) advance care planning in the form of written advance patient directives and verbal communication with patient and/or relatives about future care and (2) the existence of written advance general practitioner orders are related to the quality of dying of nursing home residents with dementia. Methods Cross-sectional study of deaths (2010) using random cluster-sampling. Representative sample of nursing homes in Flanders, Belgium. Deaths of residents with dementia in a three-month period were reported; for each the nurse most involved in care, GP and closest relative completed structured questionnaires. Findings We identified 101 deaths of residents with dementia in 69 nursing homes (58% response rate). A written advance patient directive was present for 17.5%, GP-orders for 56.7%. Controlling for socio-demographic/clinical characteristics in multivariate regression analyses, chances of having a higher mean rating of emotional well-being (less fear and anxiety) on the Comfort Assessment in Dying with Dementia scale were three times higher with a written advance patient directive and more specifically when having a do-not-resuscitate order (AOR 3.45; CI,1.1–11) than for those without either (AOR 2.99; CI,1.1–8.3). We found no association between verbal communication or having a GP order and quality of dying. Conclusion For nursing home residents with dementia there is a strong association between having a written advance directive and quality of dying. Where wishes are written, relatives report lower levels of emotional distress at the end of life. These results underpin the importance of advance care planning for people with dementia and beginning this process as early as possible.
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Affiliation(s)
- An Vandervoort
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Dirk Houttekier
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Jenny T. van der Steen
- EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine, Vrije Universiteit Brussel, Brussels, Belgium
- * E-mail:
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De Vleminck A, Pardon K, Beernaert K, Deschepper R, Houttekier D, Van Audenhove C, Deliens L, Vander Stichele R. Barriers to advance care planning in cancer, heart failure and dementia patients: a focus group study on general practitioners' views and experiences. PLoS One 2014; 9:e84905. [PMID: 24465450 PMCID: PMC3897376 DOI: 10.1371/journal.pone.0084905] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/28/2013] [Indexed: 12/02/2022] Open
Abstract
Background The long-term and often lifelong relationship of general practitioners (GPs) with their patients is considered to make them the ideal initiators of advance care planning (ACP). However, in general the incidence of ACP discussions is low and ACP seems to occur more often for cancer patients than for those with dementia or heart failure. Objective To identify the barriers, from GPs' perspective, to initiating ACP and to gain insight into any differences in barriers between the trajectories of patients with cancer, heart failure and dementia. Method Five focus groups were held with GPs (n = 36) in Flanders, Belgium. The focus group discussions were transcribed verbatim and analyzed using the method of constant comparative analysis. Results Three types of barriers were distinguished: barriers relating to the GP, to the patient and family and to the health care system. In cancer patients, a GP's lack of knowledge about treatment options and the lack of structural collaboration between the GP and specialist were expressed as barriers. Barriers that occured more often with heart failure and dementia were the lack of GP familiarity with the terminal phase, the lack of key moments to initiate ACP, the patient's lack of awareness of their diagnosis and prognosis and the fact that patients did not often initiate such discussions themselves. The future lack of decision-making capacity of dementia patients was reported by the GPs as a specific barrier for the initiation of ACP. Conclusion The results of our study contribute to a better understanding of the factors hindering GPs in initiating ACP. Multiple barriers need to be overcome, of which many can be addressed through the development of practical guidelines and educational interventions.
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Affiliation(s)
- Aline De Vleminck
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- * E-mail:
| | - Koen Pardon
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kim Beernaert
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Reginald Deschepper
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Dirk Houttekier
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Chantal Van Audenhove
- LUCAS (Center for Care Research and Consultancy), Catholic University of Louvain, Louvain, Belgium
| | - Luc Deliens
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Public and Occupational Health, and EMGO+ Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
| | - Robert Vander Stichele
- End-of-Life Care Research group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
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Pivodic L, Pardon K, Van den Block L, Van Casteren V, Miccinesi G, Donker GA, Alonso TV, Alonso JL, Aprile PL, Onwuteaka-Philipsen BD, Deliens L. Palliative care service use in four European countries: a cross-national retrospective study via representative networks of general practitioners. PLoS One 2013; 8:e84440. [PMID: 24386381 PMCID: PMC3875565 DOI: 10.1371/journal.pone.0084440] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 11/22/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Due to a rising number of deaths from cancer and other chronic diseases a growing number of people experience complex symptoms and require palliative care towards the end of life. However, population-based data on the number of people receiving palliative care in Europe are scarce. The objective of this study is to examine, in four European countries, the number of people receiving palliative care in the last three months of life and the factors associated with receiving palliative care. METHODS Cross-national retrospective study. Over two years (2009-2010), GPs belonging to representative epidemiological surveillance networks in Belgium, the Netherlands, Italy, and Spain registered weekly all deaths of patients (≥ 18 years) in their practices and the care they received in the last three months of life using a standardized form. Sudden deaths were excluded. RESULTS We studied 4,466 deaths. GPs perceived to have delivered palliative care to 50% of patients in Belgium, 55% in Italy, 62% in the Netherlands, and 65% in Spain (p<.001). Palliative care specialists attended to 29% of patients in the Netherlands, 39% in Italy, 45% in Spain, and 47% in Belgium (p<.001). Specialist palliative care lasted a median (inter-quartile range) of 15 (23) days in Belgium to 30 (70) days in Italy (p<.001). Cancer patients were more likely than non-cancer patients to receive palliative care in all countries as were younger patients in Italy and Spain with regard to specialist palliative care. CONCLUSIONS Although palliative care is established in the countries studied, there are considerable differences in its provision. Two potentially underserved groups emerge non-cancer patients in all countries and older people in Italy and Spain. Future research should examine how differences in palliative care use relate to both patient characteristics and existing national health care policies.
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Affiliation(s)
- Lara Pivodic
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Viviane Van Casteren
- Scientific Institute of Public Health (Wetenschappelijk Instituut Volksgezondheid, Institut Scientifique de Santé Publique), Unit of Health Services Research, Brussels, Belgium
| | - Guido Miccinesi
- Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, Florence, Italy
| | - Gé A. Donker
- Dutch Sentinel General Practice Network, NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Tomás Vega Alonso
- Public Health General Directorate, Regional Ministry of Health (Dirección General de Salud Pública, Consejería de Sanidad), Castile and Leon, Valladolid, Spain
| | - José Lozano Alonso
- Public Health General Directorate, Regional Ministry of Health (Dirección General de Salud Pública, Consejería de Sanidad), Castile and Leon, Valladolid, Spain
| | - Pierangelo Lora Aprile
- Italian Society of General Medicine (Società Italiana di Medicina Generale), Florence, Italy
| | - Bregje D. Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO+ Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
- Department of Public and Occupational Health, EMGO+ Institute, VU University Medical Center, Amsterdam, The Netherlands
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Discussing dying in the diaspora: attitudes towards advance care planning among first generation Dutch and Italian migrants in rural Australia. Soc Sci Med 2013; 101:86-93. [PMID: 24560228 DOI: 10.1016/j.socscimed.2013.11.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 11/10/2013] [Accepted: 11/12/2013] [Indexed: 11/22/2022]
Abstract
Western cultural practices and values have largely shaped advance care planning (ACP) policies across the world. Low uptake of ACP among ethnic minority groups in Western countries has been interpreted with reference to cultural differences. This paper adopts a life-history approach to explore attitudes towards ACP among older, first-generation Dutch-Australian and Italian-Australian migrants. Thirty people participated in extended ethnographic interviews (N = 17) and group discussions (N = 13) during 2012. Transcripts were thematically analyzed and interpreted using a Foucauldian perspective on knowledge and power. Migration experiences, ongoing contact with the native country and participation in migrant community support networks influenced attitudes towards ACP. Dutch participants framed ACP discussions with reference to euthanasia, and adopted a more individualist approach to medical decision-making. Italian participants often spoke of familial roles and emphasized a family-based decision making style. The importance of migrant identity has been neglected in previous discussions of cultural factors influencing ACP uptake among ethnic minority groups. The unique migration experience should be considered alongside culturally appropriate approaches to decision-making, in order to ensure equitable access to ACP among migrant groups.
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