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White J, Falcioni D, Barker R, Bajic-Smith J, Krishnan C, Mansfield E, Hullick C. Understanding Dementia Carer Experiences Before Admission to a Residential Aged Care Facility: Implications for Integrated Care. J Appl Gerontol 2024:7334648241261454. [PMID: 39023911 DOI: 10.1177/07334648241261454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024] Open
Abstract
In-depth understanding of dementia carer experience can assist clinicians by providing insight into dementia onset, symptoms and management, and help conceptualize and understand the pattern of dementia progress over time and what help is needed. We undertook a qualitative study to understand dementia carers experiences of providing care and reasons for admission to a residential aged care facility (RACF). Three themes were identified: (1) Challenges in the path to diagnosis and care, leading to delays accessing support; (2) Carer role impacted by living circumstances; and (3) Variation in decision support prior to admission to a RACF. Identifying dementia carer experiences, reinforces the need for more timely diagnosis, referral for support and interventions to promote better quality of life for a people living with dementia and their carer and to delay premature RACF placement.
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Affiliation(s)
- Jennifer White
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Dane Falcioni
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Roslyn Barker
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia
| | | | - Chitra Krishnan
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia
| | - Elise Mansfield
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Carolyn Hullick
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia
- Australian Commission of Safety and Quality in Health Care, Sydney, NSW, Australia
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Song D, Yu T, Zhi S, Chang C, Sun J, Gao S, Gu Y, Sun J. Experiences and perspectives on the optimal timing for initiating advance care planning in patients with mild to moderate dementia: A meta-synthesis. Int J Nurs Stud 2024; 154:104762. [PMID: 38613968 DOI: 10.1016/j.ijnurstu.2024.104762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Advance care planning is typically initiated during the last six months of a patient's life. However, due to the progressive decline in the decision-making process in individuals with dementia, their involvement in advance care planning is limited to the early stages of the disease. Currently, there is no consensus on the optimal timing for initiating advance care planning for people with dementia, and a comprehensive review of the literature addressing this matter is lacking. OBJECTIVE To explore the experiences and perspectives of people with dementia, their family caregivers, and health care professionals with regard to the optimal timing for initiating advance care planning. DESIGN A meta-synthesis was conducted. DATA SOURCE The following eight electronic databases were searched: PubMed, Embase, Web of Science, Cochrane Library, CINAHL and CNKI, WanFang and Vip. REVIEW METHODS This review uses thematic synthesis to systematically synthesize qualitative evidence and report findings according to The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) and the Joanna Briggs Institute Manual for Evidence Synthesis. Study selection and data extraction were conducted independently by two researchers, and quality was evaluated using the Joanna Briggs Institute's Qualitative Research Standard Assessment tool. FINDINGS Twenty-one studies were selected for this review. This review involved an overarching theme: The utilization of pivotal elements to transition from delayed initiation to comprehensive implementation. Three themes emerge, including the prerequisites for initiating advance care planning, not ready to start advance care planning and struggling along narrow roads. For health care professionals, the selection of an opportune moment to initiate advance care planning for people with dementia is not only a challenge but also a crucial prerequisite for the successful implementation of advance care planning. Health care professionals' experience, attitude toward advance care planning, trust relationship with patients, cultural differences among people with dementia and their caregivers, and economic disparities all influence health care professionals' judgment of the timing for initiating advance care planning. CONCLUSIONS Determining the optimal timing for initiating advance care planning is a complex process that requires a comprehensive consideration of the realities faced by health care professionals, people with dementia and their caregivers. Therefore, it is imperative to provide relevant training to health care professionals to ensure the successful implementation of advance care planning.
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Affiliation(s)
- Dongpo Song
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun 130021, Jilin, People's Republic of China
| | - Tao Yu
- The First Hospital of Jilin University, No.1 Xinmin Street, Changchun 130021, Jilin, People's Republic of China.
| | - Shengze Zhi
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun 130021, Jilin, People's Republic of China
| | - Cheng Chang
- The First Hospital of Jilin University, No.1 Xinmin Street, Changchun 130021, Jilin, People's Republic of China.
| | - Juanjuan Sun
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun 130021, Jilin, People's Republic of China
| | - Shizheng Gao
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun 130021, Jilin, People's Republic of China
| | - Yanyan Gu
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun 130021, Jilin, People's Republic of China
| | - Jiao Sun
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun 130021, Jilin, People's Republic of China.
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Kinch S, Schou-Juul F, Skov SS, Kongsholm NCH, Lauridsen S. The use of advance directives for autonomy in dementia care: A scoping meta-review and thematic synthesis. Arch Gerontol Geriatr 2024; 126:105498. [PMID: 38901137 DOI: 10.1016/j.archger.2024.105498] [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: 02/23/2024] [Revised: 05/08/2024] [Accepted: 05/20/2024] [Indexed: 06/22/2024]
Abstract
Dementia may reduce individuals' capacity for autonomy and decision-making competence. Advance directives are subject to theoretical bioethical debate as tools to safeguard or extend autonomy in dementia. However, the extent and manner in which advance directives are actually used for these purposes in practice remain less examined. We aimed to examine how advance directives are used as tools for individual autonomy in dementia care. We systematically searched six databases and performed a thematic analysis and synthesis of included reviews based on an original model of six autonomy-relevant dimensions of advance directives. A total of 18 reviews met the inclusion criteria. We identified 12 themes across six dimensions. We found a lack of knowledge integration on the actual use of advance directives for autonomy in dementia care. Evidence suggests significant variation in the autonomy-relevant dimensions of advance directives, with a tendency towards an inconsistent or low level of implementation as a tool for autonomy. Further reviews and primary studies on all aspects of the use of advance directives for autonomy in dementia care would contribute significantly to dementia research and practice.
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Affiliation(s)
- Simon Kinch
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
| | - Frederik Schou-Juul
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Sofie Smedegaard Skov
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Sigurd Lauridsen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Suen MHP, Chow AYM, Woo RKW, Yuen SK. What makes advance care planning discussion so difficult? A systematic review of the factors of advance care planning in healthcare settings. Palliat Support Care 2024:1-14. [PMID: 38766704 DOI: 10.1017/s1478951524000464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
OBJECTIVES Existing systematic reviews related to advance care planning (ACP) largely focus on specific groups and intervention efficacy or are limited to contextual factors. This research aims to identify the modifiable factors perceived by different users of ACP in healthcare settings and inform healthcare professionals about the factors affecting ACP practice. METHODS Five English-language databases (ProQuest, PubMed, CINAHL Plus, Scopus, and Medline) and two Chinese-language databases (CNKI and NCL) were searched up to November 2022. Empirical research identifying factors related to ACP in healthcare settings was included. ACP is defined as a discussion process on future end-of-life care. Thematic synthesis was performed on all included studies. RESULTS A total of 1871 unique articles were screened; the full texts of 193 were assessed by 4 reviewers, and 45 articles were included for analysis. Twenty-two (54%) studies were qualitative, 15 (33%) were quantitative, and 6 (13%) used mixed methods. Foci varied from 28 (62%) studies on a single subject group (either patient, family, or physician), 11 (25%) on 2 subject groups (either patient and family or patient and healthcare professional), and 6 (13%) covered 3 subject groups (patient, family, and healthcare professional). Among the 17 studies involving more than 1 subject group, only 2 adopted a dyadic lens in analysis. Complex interwoven factors were categorized into (1) intrapersonal factors, (2) interpersonal factors, and (3) socio-environmental factors, with a total of 11 themes: personal belief, emotions, the burden on others, timing, responsiveness, relationship, family dynamics, experience, person taking the lead, culture, and support. SIGNIFICANCE OF RESULTS Patients, families, and healthcare professionals are the essential stakeholders of ACP in healthcare settings. Factors are interweaved among the intrapersonal, interpersonal, and socio-environmental dimensions. Research is warranted to examine the dynamic interactions of the 3 essential stakeholders from a multidimensional perspective, and the mechanism of the interweaving of factors.
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Affiliation(s)
- Margaret Hay Ping Suen
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
| | - Amy Yin Man Chow
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
- Jockey Club End-of-Life Community Care Project, The University of Hong Kong, Hong Kong
| | | | - Sze Kit Yuen
- Caritas Medical Centre, Hospital Authority, Hong Kong
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Konno R, Inoue K, Matsushita Y, Hashimoto K, Wiechula R, To T, Schultz TJ. Barriers to Advance Care Planning in Older Adults With Dementia, Their Families and Healthcare Professionals: An Umbrella Review of Qualitative Evidence. Res Aging 2024; 46:339-358. [PMID: 38242164 DOI: 10.1177/01640275241227909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
This umbrella review aimed to examine and synthesize qualitative studies that explored the barriers and facilitators of advance care planning for persons with dementia, their families, and their healthcare professionals and caregivers. The modified umbrella review approach developed by the Joanna Briggs Institute was followed. Five major English databases were searched. Four reviews based on 38 primary qualitative studies were included. The methodological quality of the included reviews was moderate to high. The synthesis yielded 16 descriptive themes and five analytical themes: making the wishes/preferences of persons with dementia visible; constructive collaboration based on stakeholders having positive relationships; emotional chaos in facing end-of-life substitute decision-making; initiating the advance care planning process; and preparedness and commitment of healthcare providers to advance care planning. Comprehensive and workable strategies are required to overcome complex and interrelated barriers involving not only healthcare professionals but also organizational and systemic challenges.
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Affiliation(s)
- Rie Konno
- Faculty of Nursing, Hyogo Medical University, Kobe-shi, Japan
| | - Kumiyo Inoue
- School of Nursing, University of Tasmania, Hobart, TAS, Australia
| | | | | | - Richard Wiechula
- Adelaide Nursing School, University of Adelaide, Adelaide, SA, Australia
| | - Timothy To
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
| | - Timothy J Schultz
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
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Nakanishi M, Martins Pereira S, Van den Block L, Parker D, Harrison-Dening K, Di Giulio P, In der Schmitten J, Larkin PJ, Mimica N, Sudore RL, Holmerová I, Korfage IJ, van der Steen JT. Future policy and research for advance care planning in dementia: consensus recommendations from an international Delphi panel of the European Association for Palliative Care. THE LANCET. HEALTHY LONGEVITY 2024; 5:e370-e378. [PMID: 38608695 PMCID: PMC11262782 DOI: 10.1016/s2666-7568(24)00043-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 04/14/2024] Open
Abstract
Advance care planning (ACP) is increasingly recognised in the global agenda for dementia care. The European Association for Palliative Care (EAPC) Taskforce on ACP in Dementia aimed to provide recommendations for policy initiatives and future research. We conducted a four-round Delphi study with a 33-country panel of 107 experts between September, 2021, and June, 2022, that was approved by the EAPC Board. Consensus was achieved on 11 recommendations concerning the regulation of advance directives, equity of access, and dementia-inclusive approaches and conversations to express patients' values. Identified research gaps included the need for an evidence-based dementia-specific practice model that optimises engagement and communication with people with fluctuating and impaired capacity and their families to support decision making, while also empowering people to adjust their decisions if their goals or preferences change over time. Policy gaps included insufficient health services frameworks for dementia-inclusive practice. The results highlight the need for more evidence and policy development that support inclusive ACP practice models.
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Affiliation(s)
- Miharu Nakanishi
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands; Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, Sendai-shi, Japan; Mental Health Promotion Unit, Research Center for Social Science and Medicine, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan.
| | - Sandra Martins Pereira
- CEGE: Research Center in Management and Economics - Ethics and Sustainability Research Area, Católica Porto Business School, Universidade Católica Portuguesa, Porto, Portugal
| | - Lieve Van den Block
- Vrije Universiteit Brussel-UGent End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Deborah Parker
- School of Nursing and Midwifery, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Karen Harrison-Dening
- Department of Research and Publications, Dementia UK, London, UK; Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Jürgen In der Schmitten
- Institute of General Practice/Family Practice, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Philip J Larkin
- Institute of Higher Education and Research in Healthcare, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ninoslav Mimica
- School of Medicine, University of Zagreb, Zagreb, Croatia; Department for Biological Psychiatry and Psychogeriatrics, University Psychiatric Hospital Vrapče, Zagreb, Croatia
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Iva Holmerová
- Centre of Expertise in Longevity and Long-Term Care, Faculty of Humanities, Charles University, Prague, Czech Republic
| | - Ida J Korfage
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands; Radboudumc Alzheimer Center and Department of Primary and Community Care, Radboud university medical center, Nijmegen, Netherlands; Cicely Saunders Institute, Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Bonares M, Fisher S, Quinn K, Wentlandt K, Tanuseputro P. Study protocol for the development and validation of a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. Diagn Progn Res 2024; 8:5. [PMID: 38500236 PMCID: PMC10949607 DOI: 10.1186/s41512-024-00168-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/05/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Patients with dementia and their caregivers could benefit from advance care planning though may not be having these discussions in a timely manner or at all. A prognostic tool could serve as a prompt to healthcare providers to initiate advance care planning among patients and their caregivers, which could increase the receipt of care that is concordant with their goals. Existing prognostic tools have limitations. We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. METHODS The derivation cohort will include approximately 235,000 patients with dementia, who were admitted to hospital in Ontario from April 1st, 2009, to December 31st, 2017. Predictor variables will be fully prespecified based on a literature review of etiological studies and existing prognostic tools, and on subject-matter expertise; they will be categorized as follows: sociodemographic factors, comorbidities, previous interventions, functional status, nutritional status, admission information, previous health care utilization. Data-driven selection of predictors will be avoided. Continuous predictors will be modelled as restricted cubic splines. The outcome variable will be mortality within 1 year of admission, which will be modelled as a binary variable, such that a logistic regression model will be estimated. Predictor and outcome variables will be derived from linked population-level healthcare administrative databases. The validation cohort will comprise about 63,000 dementia patients, who were admitted to hospital in Ontario from January 1st, 2018, to March 31st, 2019. Model performance, measured by predictive accuracy, discrimination, and calibration, will be assessed using internal (temporal) validation. Calibration will be evaluated in the total validation cohort and in subgroups of importance to clinicians and policymakers. The final model will be based on the full cohort. DISCUSSION We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. The model would be integrated into the electronic medical records of hospitals to automatically output 1-year mortality risk upon hospitalization. The tool could serve as a trigger for advance care planning and inform access to specialist palliative care services with prognosis-based eligibility criteria. Before implementation, the tool will require external validation and study of its potential impact on clinical decision-making and patient outcomes. TRIAL REGISTRATION NCT05371782.
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Affiliation(s)
- Michael Bonares
- Department of Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Stacey Fisher
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- ICES Ottawa, Ottawa, ON, Canada
| | - Kieran Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
- ICES Toronto, Toronto, ON, Canada
| | - Kirsten Wentlandt
- Department of Supportive Care, University Health Network, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- ICES Ottawa, Ottawa, ON, Canada
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Poelman SW, Ermers DJM, Schers HJ, Vissers KCP, Veldhoven CMM, Kuip EJM, Perry M. Are specialist-provided end-of-life scenarios key to initiation of advance care planning in primary care? A mixed-methods study. Palliat Support Care 2024:1-9. [PMID: 38362721 DOI: 10.1017/s1478951523002055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES Specialist-provided end-of-life scenarios (SP-EOLS) may improve advance care planning (ACP) implementation in primary care by helping overcome barriers such as uncertain prognosis and poor interprofessional collaboration. We aimed to explore the current use and potential impact of SP-EOLS on ACP in Dutch primary care. METHODS We performed a mixed-methods study. From patients discussed in a hospital-based academic palliative care multidisciplinary team meeting between 2016 and 2019 and died, we collected primary care electronic medical records data on SP-EOLS, actual EOLS, and ACP initiation and applied descriptive and comparative analyses. Subsequently, we interviewed general practitioners (GPs) and thematically analyzed the transcripts. RESULTS In 69.7% of 66 reviewed patient files, SP-EOLS were found. In patients whose GP had received SP-EOLS, ACP conversations were more often reported (92.0 vs. 61.0%, p = 0.006). From 11 GP interviews, we identified 4 themes: (1) SP-EOLS guide GPs, patients, and relatives when dealing with an uncertain future perspective; (2) SP-EOLS provide continuity of care between primary and secondary/tertiary care; (3) SP-EOLS should be tailored to the individual patient; and (4) SP-EOLS need to be personalized and uniformly transferred to GPs. SIGNIFICANCE OF RESULTS SP-EOLS may facilitate ACP conversations by GPs. They have the potential to help overcome existing barriers to ACP implementation by providing guidance and supporting interprofessional collaboration. Future research should focus on improving SP-EOLS and tailor them to the needs of all end users, focusing on improving their effect on ACP conversations.
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Affiliation(s)
- Sophie W Poelman
- Department of Primary and Community Care, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Daisy J M Ermers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Henk J Schers
- Department of Primary and Community Care, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Carel M M Veldhoven
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Evelien J M Kuip
- Department of Medical Oncology and Department of Anaesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Marieke Perry
- Department of Geriatrics, Radboudumc, Nijmegen, Gelderland, The Netherlands
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Stevens J, Miranda R, Pype P, Eecloo K, Deliens L, De Vleminck A, Pardon K. Complex advance care planning intervention in general practice (ACP-GP): a cluster-randomised controlled trial. Br J Gen Pract 2024; 74:e78-e87. [PMID: 38253546 PMCID: PMC10824347 DOI: 10.3399/bjgp.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 08/10/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Advance care planning (ACP) is an iterative communication process about patients' preferences for future care. In general practice, there are barriers to ACP at patient, GP, and healthcare-system levels. A complex intervention may be necessary to reduce barriers. AIM To evaluate the effects of a complex ACP intervention for patients with chronic, life-limiting illness in general practice (ACP-GP). DESIGN AND SETTING A cluster-randomised controlled trial was undertaken in Belgian general practice. METHOD ACP-GP included a patient workbook, GP training, ACP conversations, and a documentation template. The control group received usual care. Outcomes were the 15-item ACP Engagement Survey for patients and the ACP Self-Efficacy scale for GPs. Linear mixed models evaluated differences at 3 months (T1, effectiveness evaluation) and 6 months (T2) post-baseline. Analysis was intention-to-treat. RESULTS In total, 35 GPs and 95 patients were randomised. Patient ACP engagement did not differ between the intervention and control group at T1 (baseline-adjusted mean difference = 0.34; 95% confidence interval [CI] = -0.02 to 0.69; P = 0.062) or T2 (baseline-adjusted mean difference = 0.20; 95% CI = -0.17 to 0.57; P = 0.28). For GP ACP self-efficacy, there were no significant differences between groups at T1 (baseline-adjusted mean difference = 0.16; 95% CI = -0.04 to 0.35; P = 0.11) or at T2 (baseline-adjusted mean difference = 0.11; 95% CI = -0.09 to 0.31; P = 0.27). CONCLUSION ACP-GP did not improve patient engagement and GP self-efficacy more than usual care. Both groups showed patterns of increase from baseline. Trial procedures and the COVID-19 pandemic may have increased awareness about ACP.
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Affiliation(s)
- Julie Stevens
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Family Medicine and Chronic Care, VUB, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Rose Miranda
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Family Medicine and Chronic Care, VUB, Brussels
| | - Peter Pype
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Kim Eecloo
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Luc Deliens
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Family Medicine and Chronic Care, VUB, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Aline De Vleminck
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Family Medicine and Chronic Care, VUB, Brussels
| | - Koen Pardon
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Family Medicine and Chronic Care, VUB, Brussels
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Porteri C, Ienco G, Piccinni M, Pasqualetti P. Towards the implementation of law n. 219/2017 on informed consent and advance directives for patients with psychiatric disorders and dementia. Physicians' knowledge, attitudes and practices in four northern Italian health care facilities. BMC Med Ethics 2024; 25:7. [PMID: 38184541 PMCID: PMC10771689 DOI: 10.1186/s12910-023-00997-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 12/22/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND On December 2017 the Italian Parliament approved law n. 219/2017 "Provisions for informed consent and advance directives" regarding challenging legal and bioethical issues related to healthcare decisions and end-of life choices. The law promotes the person's autonomy as a right and provides for the centrality of the individual in every scenario of health care by mean of three tools: informed consent, shared care planning and advance directives. Few years after the approval of the law, we conducted a survey among physicians working in four health care facilities specific for the care of people suffering from psychiatric disorders, cognitive disorders and dementia located in the North of Italy aiming to investigate their perceived knowledge and training need, attitudes regarding law n. 219/2017 provisions, and practices of implementation of the law. METHODS A semi-structured questionnaire was developed on an online platform. The invitation to participate in the survey was sent by email to the potential participants. Information was collected by means of the online platform (Google Forms) which allows to export data in a spreadsheet (Windows Excel) to perform basic statistical analysis (frequency distributions, bar chart representation). RESULTS Twenty-five out of sixty physicians participated in the survey. None of the respondents value their knowledge of the law as very good, 10 good, 13 neither poor nor good, 1 poor and 1 very poor. All the respondents want to learn more about the law (21 yes and 4 absolutely yes). The majority of respondents agrees with the content of the law as a whole (3 absolutely agree, 13 agree), and on each provision. The question on the clarity of the concept of capacity in the law received mixed answers and this impacted on the physicians' opinion regarding the legitimacy in principle for our groups of patients to realize shared care planning and write advance directives. Thirteen physicians neither introduced the theme of shared care planning nor arranged for shared care planning and the main reason for this was that no patient was in a clinical situation to require it. When shared care planning is realized, a variability in terms of type and number of meetings, mode of tracking and communication is registered. CONCLUSIONS Our survey results indicate a need for more clarity regarding the interpretation and implementation of the law in the patient groups under study. There are in particular two related areas that deserve further discussion: (1) the question of whether these patient groups are in principle legitimized by the law to realize shared care planning or write advance directives; (2) the notion of capacity required by the law and how this notion can be declined in real-life situations.
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Affiliation(s)
- Corinna Porteri
- Bioethics Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Via Pilastroni, 4, Brescia, 25125, Italy.
| | - Giulia Ienco
- Bioethics Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Via Pilastroni, 4, Brescia, 25125, Italy
| | - Mariassunta Piccinni
- Department of Political Science, Law and International Studies - SPGI, Università di Padova, Padua, Italy
| | - Patrizio Pasqualetti
- Department of Public Health and Infectious Diseases, Section of Medical Statistics, Sapienza Università di Roma, Rome, Italy
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11
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Maters J, van der Steen JT, de Vugt ME, Bakker C, Koopmans RT. Palliative Care in Nursing Home Residents with Young-Onset Dementia: Professional and Family Caregiver Perspectives. J Alzheimers Dis 2024; 97:573-586. [PMID: 38217594 PMCID: PMC10836558 DOI: 10.3233/jad-230486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND The evidence underpinning palliative care in dementia is mostly based on research in older populations. Little is known about the palliative care needs of people with young-onset dementia (YOD). OBJECTIVE To describe palliative care practices including advance care planning (ACP) in people with YOD residing in Dutch nursing homes. METHODS The study presents baseline questionnaire data from an observational cohort study. Physicians, family caregivers, and nursing staff completed questionnaires about 185 residents with YOD. The questionnaires included items on sociodemographics, quality of life measured with the quality of life in late-stage dementia (QUALID) scale, dementia-related somatic health problems, symptoms, pain medication, psychotropic drugs, and ACP. RESULTS The mean age was 63.9 (SD 5.8) years. Half (50.3%) of them were female. Alzheimer's disease dementia (42.2%) was the most prevalent subtype. The mean QUALID score was 24.0 (SD 7.9) as assessed by family caregivers, and 25.3 (SD 8.6) as assessed by the nursing staff. Swallowing problems were the most prevalent dementia-related health problem (11.4%). Agitation was often reported by physicians (42.0%) and nursing staff (40.5%). Psychotropics were prescribed frequently (72.3%). A minority had written advance directives (5.4%) or documentation on treatment preferences by the former general practitioner (27.2%). Global care goals most often focused on comfort (73.9%). Proportions of do-not-treat orders were higher than do-treat orders for all interventions except for hospitalization and antibiotics. CONCLUSIONS ACP must be initiated earlier, before nursing home admission. A palliative approach seems appropriate even though residents are relatively young and experience few dementia-related health problems.
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Affiliation(s)
- Jasper Maters
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Alzheimer Center, Nijmegen, the Netherlands
| | - Jenny T. van der Steen
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Alzheimer Center, Nijmegen, the Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Marjolein E. de Vugt
- School for Mental Health and Neuroscience, Alzheimer Center Limburg, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Christian Bakker
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Alzheimer Center, Nijmegen, the Netherlands
- Groenhuysen, Center for Geriatric Care, Roosendaal, the Netherlands
| | - Raymond T.C.M. Koopmans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Alzheimer Center, Nijmegen, the Netherlands
- Joachim en Anna, Center for Specialized Geriatric Care, Nijmegen, the Netherlands
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12
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Smaling HJ, Jingyuan X, Nakanishi M, Shinan-Altman S, Mehr DR, Radbruch L, Gaertner J, Werner P, Achterberg WP, van der Steen JT. Interventions that may increase control at the end of life in persons with dementia: the cross-cultural CONT-END acceptability study protocol and pilot-testing. BMC Palliat Care 2023; 22:142. [PMID: 37752467 PMCID: PMC10523619 DOI: 10.1186/s12904-023-01249-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Interventions such as advance care planning (ACP), technology, or access to euthanasia may increase the sense of control over the end of life. In people with advanced dementia, the loss of cognitive and physical function limits the ability to control care. To date, little is known about the acceptability of these interventions from the perspective of persons with dementia and others involved. This study will examine the cross-cultural acceptability, and factors associated with acceptability, of four end-of-life interventions in dementia which contain an element of striving for control. Also, we report on the development and pilot testing of animation video vignettes that explain the interventions in a standardized manner. METHODS Cross-sectional mixed-methods vignette study. We assess acceptability of two ACP approaches, technology use at the end of life and euthanasia in persons with dementia, their family caregivers and physicians in six countries (Netherlands, Japan, Israel, USA, Germany, Switzerland). We aim to include 80 participants per country, 50 physicians, 15 persons with dementia, and 15 family caregivers. After viewing each animation video, participants are interviewed about acceptability of the intervention. We will examine differences in acceptability between group and country and explore other potentially associated factors including variables indicating life view, personality, view on dementia and demographics. In the pilot study, participants commented on the understandability and clarity of the vignettes and instruments. Based on their feedback, the scripts of the animation videos were clarified, simplified and adapted to being less slanted in a specific direction. DISCUSSION In the pilot study, the persons with dementia, their family caregivers and other older adults found the adapted animation videos and instruments understandable, acceptable, feasible, and not burdensome. The CONT-END acceptability study will provide insight into cross-cultural acceptability of interventions in dementia care from the perspective of important stakeholders. This can help to better align interventions with preferences. The study will also result in a more fundamental understanding as to how and when having control at the end of life in dementia is perceived as beneficial or perhaps harmful. TRIAL REGISTRATION The CONT-END acceptability study was originally registered at the Netherlands Trial Register (NL7985) at 31 August, 2019, and can be found on the International Clinical Trials Registry Platform.
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Affiliation(s)
- Hanneke J.A. Smaling
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- University Network for the Care sector Zuid-Holland, Leiden University Medical Center, Leiden, The Netherlands
| | - Xu Jingyuan
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
| | - Miharu Nakanishi
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - David R. Mehr
- Department of Family and Community Medicine, University of Missouri, Columbia, MO USA
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Centre for Palliative Medicine, Helios Hospital Bonn/Rhein-Sieg, Bonn, Germany
| | - Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Perla Werner
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | - Wilco P. Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- University Network for the Care sector Zuid-Holland, Leiden University Medical Center, Leiden, The Netherlands
- Center for Old Age Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
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13
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Nihei S, Ogawa M, Hashimoto Y, Kikuchi N, Nakazato K, Okamoto T. Arterial stiffness and physical fitness on cognitive function in community-dwelling middle-aged and older adults. Aging Clin Exp Res 2023; 35:1845-1854. [PMID: 37329475 DOI: 10.1007/s40520-023-02470-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 06/05/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE This study examined whether decline in cognitive function is related to arterial stiffness and reduction in physical fitness in middle-aged and older adults. METHODS A total of 1554 healthy middle-aged and older adults participated in this study. The trail making test parts-A (TMT-A) and B (TMT-B), brachial-ankle pulse wave velocity (baPWV), grip strength, the 30-s chair stand (CS-30) test, the 6-min walk (6MW) test, the 8-foot up-and-go (8UG) test and gait assessment were performed. Participants were classified into a middle-aged group (40-64 years; mean, 50.4 ± 0.2 years) or an older group (≥ 65 years; mean, 73.1 ± 0.5 years), as well as into three cognition (COG) groups (high, moderate, and low) based on median TMT-A and -B scores (high scores on both, either, or neither TMT-A and -B, respectively). RESULTS The results revealed that baPWV was significantly lower in the high-than in the moderate- and low-COG groups in both middle-aged and older adults (P < 0.05). In addition, except for a few parameters (e.g., 6MW test in middle-aged adults), physical fitness was significantly higher in the high-than in the moderate- and low-COG groups in both middle-aged and older adults (P < 0.05). Multivariate regression analysis revealed that baPWV (P < 0.05) and some physical fitness indicators (grip strength, CS-30, and 8UG) were significantly independently associated with both TMT-A and -B in the middle-aged and older groups (P < 0.05). CONCLUSION These results suggest that increased arterial stiffness and reduced physical fitness are associated with impaired cognitive function in middle-aged and older adults.
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Affiliation(s)
| | - Madoka Ogawa
- Research Institute of Sports Science, Nippon Sport Science University, 7-1-1, Fukasawa, Setagaya-ku, Tokyo, 158-8508, Japan
- Department of Sport Science and Research, Japan Institute of Sports Sciences, Tokyo, Japan
| | - Yuto Hashimoto
- Research Institute of Sports Science, Nippon Sport Science University, 7-1-1, Fukasawa, Setagaya-ku, Tokyo, 158-8508, Japan
| | - Naoki Kikuchi
- Research Institute of Sports Science, Nippon Sport Science University, 7-1-1, Fukasawa, Setagaya-ku, Tokyo, 158-8508, Japan
| | - Koichi Nakazato
- Research Institute of Sports Science, Nippon Sport Science University, 7-1-1, Fukasawa, Setagaya-ku, Tokyo, 158-8508, Japan
| | - Takanobu Okamoto
- Research Institute of Sports Science, Nippon Sport Science University, 7-1-1, Fukasawa, Setagaya-ku, Tokyo, 158-8508, Japan.
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Monnet F, Pivodic L, Dupont C, Dröes RM, Van den Block L. Information on advance care planning on websites of dementia associations in Europe: A content analysis. Aging Ment Health 2023; 27:1821-1831. [PMID: 36420632 DOI: 10.1080/13607863.2022.2146051] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/05/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To gain insight into the advance care planning (ACP) content provided on dementia associations' websites in Europe. METHODS We conducted a content analysis of dementia associations' websites in Europe regarding ACP information, using deductive and inductive approaches and a reference framework derived from two ACP definitions. RESULTS We included 26 dementia associations' websites from 20 countries and one European association, covering 12 languages. Ten websites did not mention ACP. The information on the remaining 16 varied in terms of themes addressed and amount of information. Four explicitly define ACP. Several websites made multiple references to legal frameworks (n = 10, 705 excerpts), choosing legal representatives (n = 12, 274 excerpts), and care and treatment preferences (n = 14, 89 excerpts); while themes such as communication with family (n = 9, 67 excerpts) and professionals (n = 9, 49 excerpts) or identifying personal values (n = 9, 73 excerpts) were mentioned on fewer websites or addressed in fewer excerpts. CONCLUSION ACP content is non-existent in 10 out of 26 dementia associations' websites. On those that have ACP content, legal and medical themes were prominent. It would be beneficial to include more comprehensive ACP information stressing the importance of communication with families and professionals, in line with current ACP conceptualisations framing ACP as an iterative communication process, rather than a documentation-focused exercise.
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Affiliation(s)
- Fanny Monnet
- End-of-Life Care Research Group, Vrije Universiteit (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Lara Pivodic
- End-of-Life Care Research Group, Vrije Universiteit (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Charlèss Dupont
- End-of-Life Care Research Group, Vrije Universiteit (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Rose-Marie Dröes
- Department of Psychiatry, Amsterdam University Medical Centres, location VUmc/Amsterdam Public Health Research institute, Amsterdam, The Netherlands
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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15
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Chu CS, Cheng SL, Bai YM, Su TP, Tsai SJ, Chen TJ, Yang FC, Chen MH, Liang CS. Multimorbidity Pattern and Risk for Mortality Among Patients With Dementia: A Nationwide Cohort Study Using Latent Class Analysis. Psychiatry Investig 2023; 20:861-869. [PMID: 37794668 PMCID: PMC10555512 DOI: 10.30773/pi.2023.0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/16/2023] [Accepted: 06/28/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVE Individuals with dementia are at a substantially elevated risk for mortality; however, few studies have examined multimorbidity patterns and determined the inter-relationship between these comorbidities in predicting mortality risk. METHODS This is a prospective cohort study. Data from 6,556 patients who were diagnosed with dementia between 1997 and 2012 using the Taiwan National Health Insurance Research Database were analyzed. Latent class analysis was performed using 16 common chronic conditions to identify mortality risk among potentially different latent classes. Logistic regression was performed to determine the adjusted association of the determined latent classes with the 5-year mortality rate. RESULTS With adjustment for age, a three-class model was identified, with 42.7% of participants classified as "low comorbidity class (cluster 1)", 44.2% as "cardiometabolic multimorbidity class (cluster 2)", and 13.1% as "FRINGED class (cluster 3, characterized by FRacture, Infection, NasoGastric feeding, and bleEDing over upper gastrointestinal tract)." The incidence of 5-year mortality was 17.6% in cluster 1, 26.7% in cluster 2, and 59.6% in cluster 3. Compared with cluster 1, the odds ratio for mortality was 9.828 (95% confidence interval [CI]=6.708-14.401; p<0.001) in cluster 2 and 1.582 (95% CI=1.281-1.953; p<0.001) in cluster 3. CONCLUSION Among patients with dementia, the risk for 5-year mortality was highest in the subpopulation characterized by fracture, urinary and pulmonary infection, upper gastrointestinal bleeding, and nasogastric intubation, rather than cancer or cardiometabolic comorbidities. These findings may improve decision-making and advance care planning for patients with dementia.
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Affiliation(s)
- Che-Sheng Chu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Non-Invasive Neuromodulation Consortium for Mental Disorders, Society of Psychophysiology, Taipei, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Li Cheng
- Department of Nursing, Mackay Medical College, Taipei, Taiwan
| | - Ya-Mei Bai
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tung-Ping Su
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Psychiatry, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Shih-Jen Tsai
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Psychiatry, Cheng Hsin General Hospital, Taipei, Taiwan
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, Taipei, Taiwan
| | - Mu-Hong Chen
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
- Department of Psychiatry, National Defense Medical Center, Taipei, Taiwan
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16
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Bryant J, Mansfield E, Cameron E, Sanson-Fisher R. Experiences and preferences for advance care planning following a diagnosis of dementia: Findings from a cross-sectional survey of carers. PLoS One 2023; 18:e0286261. [PMID: 37307258 DOI: 10.1371/journal.pone.0286261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/12/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Future medical and financial planning is important for persons with dementia given the impact of the disease on capacity for decision making. AIMS To explore from the perspective of carers of persons with dementia: (1) Participation in future medical and financial planning by the person they care for, including when planning was undertaken and the characteristics associated with having an advance care directive completed; (2) The type of healthcare providers who discussed advance care planning following diagnosis; and (3) Preferences for timing of discussions about advance care planning following diagnosis. METHODS Recruitment and data collection took place between July 2018 and June 2020. Carers of persons with dementia aged 18 years and older were mailed a survey. Participants completed questions regarding completion of various future planning documents by the person they support, including time of completion and who discussed advance care planning following diagnosis. Participants were presented with information about the benefits and consequences of early and late discussions of advance care planning and asked when discussions about advance care planning were best initiated. RESULTS 198 carers participated. Most participants were female (74%) and had been a carer for more than 2 years (82%). Most participants reported that the person with dementia they support had made a Will (97%) and appointed an Enduring Guardian (93%) and Enduring Power of Attorney (89%). Only 47% had completed an advance care directive. No significant associations were found between characteristics of persons with dementia and completion of an advance care directive. Geriatricians (53%) and GPs (51%) most often discussed advance care planning following diagnosis. Most carers thought that discussions about advance care planning should occur in the first few weeks or months following diagnosis (32%), at the healthcare provider's discretion (31%), or at the time of diagnosis (25%). CONCLUSIONS More than half of persons with dementia do not have an advance care directive. There is variability in preferences for timing of discussions following dementia diagnosis.
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Affiliation(s)
- Jamie Bryant
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Elise Mansfield
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Emilie Cameron
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Rob Sanson-Fisher
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
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17
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Mooldijk SS, Licher S, Wolters FJ. Improving Clinical Applicability of Mortality Prediction Models Among Persons With Dementia. JAMA Intern Med 2023; 183:498. [PMID: 36972062 DOI: 10.1001/jamainternmed.2023.0173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- Sanne S Mooldijk
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Silvan Licher
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Frank J Wolters
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
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18
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Tjia J, D’Arcangelo N, Carlston D, Bronzi O, Gazarian P, Reich A, Porteny T, Gonzales K, Perez S, Weissman JS, Ladin K. US clinicians' perspectives on advance care planning for persons with dementia: A qualitative study. J Am Geriatr Soc 2023; 71:1473-1484. [PMID: 36547969 PMCID: PMC10175113 DOI: 10.1111/jgs.18197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although advance care planning (ACP) for persons with dementia (PWD) can promote patient-centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians. METHODS Qualitative study using semi-structured interviews (August 2018-December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision-making was approached, and how decision-making capacity was assessed. RESULTS Of 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as possible with PWD. Three themes emerged: value of early ACP preserves PWD's autonomy in cases of differing PWD carepartner values, acute medical crises, and clinician paternalism; barriers to ACP with PWD including the dynamic and subjective assessment of patient decision-making capacity, inconsistent awareness of cognitive impairment by clinicians, and the need to balance patient and family carepartner involvement; and strategies to support ACP include clarifying clinicians' roles in ACP, standardizing clinicians' approach to PWD and their carepartners, and making time for ACP and decision-making assessments that allow PWD and carepartner involvement regardless of the patients' capacity. CONCLUSIONS Clinicians found early ACP for PWD valuable in promoting patient-centered care among an at-risk population. In sharing their perspectives on conducting ACP for PWD, clinicians described challenges that are amenable to changes in training, workflow, and material support for clinician time. Clinical practices need sustainable scheduling and financial support models.
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Affiliation(s)
- Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Noah D’Arcangelo
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
| | - Daniel Carlston
- Columbia Law School, New York, NY
- College of Nursing and Health Sciences, University of Massachusetts Boston, MA
| | - Olivia Bronzi
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
| | - Priscilla Gazarian
- College of Nursing and Health Sciences, University of Massachusetts Boston, MA
| | - Amanda Reich
- Center for Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Thalia Porteny
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY
| | - Kristina Gonzales
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
| | - Stephen Perez
- Center for Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
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Juhrmann ML, San Martin A, Jaure A, Poulos CJ, Clayton JM. Staff perspectives on end-of-life care for people living with dementia in residential aged care homes: qualitative study. Front Psychiatry 2023; 14:1137970. [PMID: 37181908 PMCID: PMC10166813 DOI: 10.3389/fpsyt.2023.1137970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/04/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction People living with dementia in care homes can benefit from palliative approaches to care; however, not all will require specialist palliative care. The generalist aged care workforce is well placed to provide most of this care with adequate training and support systems in place, but little is known about their experiences. Objective To describe staff perspectives on providing quality end-of-life care for people living with dementia in residential care and their families. Methods Focus groups and semi-structured interviews were conducted with residential aged care managerial and frontline staff in Australia who were caring for residents living with dementia and end-of life needs. A comprehensive, then snowballing sampling strategy was used in participating care homes. Transcripts were analyzed using reflexive thematic analysis. Results Fifteen semi-structured interviews and six focus groups were undertaken with 56 participants across 14 sites across two Australian states. Five themes were identified: putting the resident at the center (creating homes not hospitals, knowing the individual, a case management approach); articulating goals to grant wishes (initiating the conversation, broadening death literacy, avoiding hospitalization); a collective call to action (staffing the home, recognizing deterioration and escalating issues, communication channels and engaging GPs, managing medications, psychosocial supports); educating to empower staff (governance and guidance, mentoring juniors, self-care); and facilitating family acceptance (setting expectations, partnering in care, access at all hours). Discussion Aged care staff are committed to providing person-centered palliative and end-of-life care for people living with dementia, recognizing the intrinsic value of each resident, regardless of their declining state. Frontline and managerial staff consider advance care planning, collectively working as part of a multidisciplinary team, access to targeted palliative and end-of-life education and training, and engaging families as key priorities to providing high quality care in care homes.
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Affiliation(s)
- Madeleine L. Juhrmann
- The Palliative Centre, Greenwich Hospital, HammondCare, Greenwich, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, University of Sydney, St Leonards, NSW, Australia
| | - Aljon San Martin
- The Palliative Centre, Greenwich Hospital, HammondCare, Greenwich, NSW, Australia
| | - Allison Jaure
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Camperdown, NSW, Australia
| | - Christopher J. Poulos
- Centre for Positive Ageing, HammondCare, Hammondville, NSW, Australia
- Faculty of Medicine and Health, School of Population Health, University of New South Wales, Kensington, NSW, Australia
| | - Josephine M. Clayton
- The Palliative Centre, Greenwich Hospital, HammondCare, Greenwich, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, University of Sydney, St Leonards, NSW, Australia
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Van Rickstal R, De Vleminck A, Engelborghs S, Van den Block L. Experiences with and perspectives on advance care planning in young- and late- onset dementia: A focus group study with physicians from various disciplines. Front Aging Neurosci 2023; 15:1130642. [PMID: 37056687 PMCID: PMC10088511 DOI: 10.3389/fnagi.2023.1130642] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
IntroductionDespite the relevance of advance care planning (ACP) for people with dementia, its uptake in this population is particularly low. Several challenges for ACP in dementia have been identified from physicians’ perspectives. However, the literature available mainly includes general practitioners and focuses exclusively on the context of late-onset dementia. This is the first study to inquire physicians from four highly relevant specialisms in dementia care, with a focus toward potential specificities based on patients’ age. The research question of this study is: “What are physicians’ experiences with and perspectives on discussing ACP with people with young- and/or late-onset dementia?”.MethodsFive online focus groups were conducted with 21 physicians (general practitioners, psychiatrists, neurologists and geriatricians) in Flanders, Belgium. Verbatim transcripts were analyzed through the qualitative method of constant comparative analysis.ResultsPhysicians believed that the societal stigma related to dementia influences people’s reaction to their diagnosis, at times characterized by catastrophic expectations for the future. In this regard, they explained that the topic of euthanasia is sometimes addressed by patients very early in the disease trajectory. Respondents paid ample attention to actual end-of-life decisions, including DNR directives, when discussing ACP in dementia. Physicians felt responsible for providing accurate information on both dementia as a condition, and the legal framework of end-of-life decisions. Most participants felt that patients’ and caregivers’ wish for ACP was more driven by who their personality than by their age. Nonetheless, physicians identified specificities for a younger dementia population in terms of ACP: they believed that ACP covered more domains of life than for older persons. A high consistency regarding the viewpoints of physicians from differing specialisms was noted.DiscussionPhysicians acknowledge the added value of ACP for people with dementia and especially their caregivers. However, they face several challenges for engaging in the process. Attending to specific needs in young-onset, in comparison to late-onset dementia, requires ACP to entail more than solely medical domains. However, a medicalized view on ACP still appears to be dominant in practice as opposed to its broader conceptualization in academia.
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Affiliation(s)
- Romy Van Rickstal
- End-of-Life Care Research Group (VUB/UGhent), Brussels, Belgium
- Research Foundation—Flanders (FWO), Brussels, Belgium
- *Correspondence: Romy Van Rickstal,
| | - Aline De Vleminck
- End-of-Life Care Research Group (VUB/UGhent), Brussels, Belgium
- Research Foundation—Flanders (FWO), Brussels, Belgium
| | - Sebastiaan Engelborghs
- Department of Neurology, University Hospital Brussels, Brussels, Belgium
- Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group (VUB/UGhent), Brussels, Belgium
- Research Foundation—Flanders (FWO), Brussels, Belgium
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21
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Dupont C, Monnet F, Pivodic L, Vleminck AD, Audenhove CV, Van den Block L, Smets T. Evaluating an advance care planning website for people with dementia and their caregivers: Protocol for a mixed method study. Digit Health 2023; 9:20552076231197021. [PMID: 37654712 PMCID: PMC10467240 DOI: 10.1177/20552076231197021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/02/2023] Open
Abstract
Background Web-based tools (e.g., websites, apps) for people with dementia and their family caregivers may be useful in supporting advance care planning (ACP). Using a user-centred design approach, we developed an ACP website for people with dementia and their families. This protocol describes how we will test and evaluate the ACP website. Publishing a study protocol can guide others who want to evaluate web-based tools. Moreover, the data collection methods used in this study are very innovative since they aim to involve people living with dementia without overburdening them. Methods We will conduct an evaluation study of the ACP website in Flanders, Belgium, using a convergent parallel mixed methods pre-post-test design with continuous follow-up. Thirty eligible dyads of people with mild to moderate dementia (both early and late onset) and their family caregivers will use the website in their everyday life for 8 weeks. We will evaluate the usage, usability, acceptability, and feasibility of the website, as well as the experiences of users. Additionally, we evaluate the effects of using the website on ACP readiness, ACP knowledge, attitudes, perceived barriers to engage in ACP, self-efficacy and skills to engage in ACP. Results Recruitment and data collection is foreseen between end of 2022 and 2023. Conclusion This evaluation study of an ACP website for people with dementia and their family caregivers will be the first to evaluate how a web-based tool can support people living with dementia and their families in ACP. The strength of this study lies in the combination of interviews, surveys, and ongoing data logging, which provide insights into the use of support tools in people's daily context. We expect that recruiting people with dementia and their families will be difficult so we have set up a thorough strategy to reach the anticipated sample size.
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Affiliation(s)
- Charlèss Dupont
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel, Brussel, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Fanny Monnet
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel, Brussel, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Lara Pivodic
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel, Brussel, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Aline De Vleminck
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel, Brussel, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | | | - Lieve Van den Block
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel, Brussel, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Tinne Smets
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel, Brussel, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
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22
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Huber K, Cassidy J, Brungardt A, Resman K, Plys E, Bogdewiecz T, Matlock DD, Lum HD. Time for More Support? Stakeholder Engagement for a Long-Term Care Planning Dementia Decision Aid Prototype. Gerontol Geriatr Med 2023; 9:23337214231163033. [PMID: 37006886 PMCID: PMC10064152 DOI: 10.1177/23337214231163033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/06/2023] [Accepted: 02/20/2023] [Indexed: 03/31/2023] Open
Abstract
Clinical decision aids around long-term care can help support persons living with dementia (PLWD), family care partners, and healthcare providers navigate current and future care decisions. This study describes the iterative development of a long-term care planning dementia decision aid and explores care partner and geriatric providers’ insights regarding its acceptability and usability. Using a convergent parallel mixed methods design, we gathered surveys and completed interviews with 11 care partners and 11 providers. The quantitative and qualitative data were then converged, resulting in four findings: (1) helpfulness of the decision aid in supporting future care planning; (2) versatility of the decision aid in practice; (3) preferences for structure and content of the decision aid; and (4) perceived shortcomings of the decision aid in decision making. Future work should continue to refine the decision aid, pilot implementation, and evaluate potential effects on decision making as part of dementia care.
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Affiliation(s)
- Kathryn Huber
- University of Colorado School of Medicine, Aurora, USA
| | - Jessica Cassidy
- University of Colorado School of Medicine, Aurora, USA
- University of Texas at Arlington, USA
| | | | | | - Evan Plys
- Massachusetts General Hospital, Boston, USA
| | | | - Dan D. Matlock
- University of Colorado School of Medicine, Aurora, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, USA
| | - Hillary D. Lum
- University of Colorado School of Medicine, Aurora, USA
- Hillary D. Lum, Division of Geriatric Medicine at UC Health Anschutz, Mail Stop B179 12631 E 17th Avenue, Room 8119, Aurora, CO 80045-2527, USA.
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23
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Timmons S, Fox S. Palliative care for people with dementia. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:81-105. [PMID: 36599517 DOI: 10.1016/b978-0-12-824535-4.00013-6] [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: 01/03/2023]
Abstract
Dementia is the most common neurologic disease, affecting approximately 55 million people worldwide. Dementia is a terminal illness, although not always recognized as such. This chapter discusses the key issues in providing palliative care for people with living with dementia and their families. Common palliative care needs and symptoms are presented, including psychosocial, physical, emotional, and spiritual, and the need to actively anticipate and seek symptoms according to the dementia type and stage is emphasized. Families are hugely impacted by a dementia diagnosis, and throughout this chapter, they are considered in the unit of care, and also as a member of the care team. Multiple challenges particular to dementia palliative care are highlighted throughout, such as the lack of timely dementia diagnoses, difficulty with symptom prognostication, the person's inability to verbally express their symptoms and care preferences, and a low threshold for medication side effects. Finally, service models for dementia palliative care in community, residential, and acute hospital settings are discussed, along with the evidence for each. Overall, this chapter reinforces that the individual needs of the person living with dementia and their family must be considered to provide person-centered and comprehensive palliative care, enabling them to live well until death.
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Affiliation(s)
- Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland; Department of Geriatric Medicine, Mercy University Hospital & St. Finbarr's Hospital, Cork, Ireland.
| | - Siobhan Fox
- Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
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24
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Wangler J, Jansky M. Slowing dementia symptoms - a qualitative study on attitudes and experiences of general practitioners in Germany. Eur J Gen Pract 2022; 28:32-39. [PMID: 35249437 PMCID: PMC8903749 DOI: 10.1080/13814788.2022.2037550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND There is currently no cure for dementia but general practitioners (GPs) have therapeutic options available to counteract the progression of mild cognitive impairment, including drug and non-drug treatment. So far, few studies have investigated treatment strategies preferred by GPs. OBJECTIVES This study aimed to gain an overview of GPs' attitudes towards influencing the progression of dementia, their involvement regarding dementia prevention and perceived effective approaches. It also elucidated the challenges experienced by GPs and desired optimisation measures towards reinforcing secondary prevention. METHODS Between June 2020 and March 2021, 64 semi-standardised interviews amongst GPs were conducted in all federal states of Germany. Thirty interviews were carried out in person and 34 by phone. The data were analysed according to qualitative content analysis. RESULTS Many interviewees see great importance in secondary dementia prevention and believe they could make an effective contribution, some of them using non-drug approaches. GPs play a role in guiding patients and relatives towards support services. Some doctors consider drug treatment as the only option towards influencing the progression of dementia, showing low expectations on self-efficacy. Interdisciplinary collaboration is a frequent challenge, which often conflicts with a coherent treatment strategy. CONCLUSION Many GPs feel confident about influencing the progression of dementia and believe they can intervene effectively, using various (non-drug) treatment measures and referrals to support services. GPs perceive challenges, including obstacles in interdisciplinary collaboration and negative impacts after drug administration. To improve the conditions for GP intervention, it depends on expanding interdisciplinary collaboration and care strategies.
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Affiliation(s)
- Julian Wangler
- Centre for General and Geriatric Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Michael Jansky
- Centre for General and Geriatric Medicine, University Medical Centre Mainz, Mainz, Germany
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25
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Sussman T, Tétrault B. "People are more afraid of a dementia diagnosis than of death": The challenges of supporting advance care planning for persons with dementia in community settings. FRONTIERS IN DEMENTIA 2022; 1:1043661. [PMID: 39081479 PMCID: PMC11285647 DOI: 10.3389/frdem.2022.1043661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/05/2022] [Indexed: 08/02/2024]
Abstract
Improving early uptake of advance care planning (ACP) for persons with dementia and their families requires that staff in community-based settings feel armed and equipped to encourage and support this process. Yet few studies have explored whether staff within non-medical environments feel prepared to support early ACP engagement for persons with early-stage dementia and their families. Our qualitative interpretivist study aimed to fill this gap by facilitating, transcribing and thematically analyzing deliberations from three focus groups with 17 community-based staff. Our findings revealed four key barriers to ACP activation in community settings: (1) the stigma associated with the condition; (2) lack of knowledge about end-of-life concerns for persons with dementia; (3) uncertainties about managing complex family dynamics and (4) worries that opening up conversations about future care may lead to the expression of wishes that could not be actualized (e.g., dying at home). Our findings further revealed that ACP engagement was facilitated when staff expressed confidence in their capacities to gauge readiness, viewed themselves as guides rather than experts and had access to resources to supplement their knowledge. Reflexive training opportunities and access to materials and resources around end-of-life care for persons with dementia, could equip staff in these non-medical settings with the skills to engage in ongoing dialogue about future care issues with persons living with dementia and their families.
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Affiliation(s)
- Tamara Sussman
- School of Social Work, McGill University, Montreal, QC, Canada
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26
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Gabbard J, Strahley AE, Pajewski NM, Callahan KE, Foley KL, Brown A, Moses A, Kirkendall E, Williamson JD, Brooten J, Marterre B, Sutfin EL. Development of an Advance Care Planning Portal-Based Tool for Community-Dwelling Persons Living With Cognitive Impairment: The ACPVoice Tool. Am J Hosp Palliat Care 2022:10499091221134030. [PMID: 36239407 PMCID: PMC10102257 DOI: 10.1177/10499091221134030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Patient portals can be an innovative and efficient way to engage patients in advance care planning (ACP). However, comprehension and judgment in older adults with cognitive impairment presents several barriers and challenges to engaging in new technology. Our objective was to develop an ACP portal-based tool (ACPVoice) for community-dwelling persons living with cognitive impairment (PLCI) by engaging end-users in the design process. Methods: Two rounds of cognitive interviews were conducted to identify and resolve cognitive issues related to comprehension, judgment, response, and to assess content validity. Purposive sampling was used with the goal of enrolling 15 different participants (five with mild cognitive impairment and five dyads (those with mild dementia and their care partner) in each round to assess respondents' understanding of questions related to advance care planning to be administered via the patient portal. Results: Twenty PLCI (mean age 78.4, 10 females [50%]) and ten care partners (mean age 60.9, 9 females [90%]) completed cognitive interviews between May 2021 and October 2021. The mean Mini-Mental State Examination score for PLCI was 25.6 (SD 2.6). Unclear wording and undefined vague and/or unfamiliar terms were the major issues identified. Revisions to item wording, response options, and instructions were made to improve question comprehension and response as well as navigational ease. Conclusion: Minor changes to the wording, format, and response options substantially improved respondents' ability to interpret the item content of the ACPVoice tool. Dissemination and implementation of the ACPVoice tool could help to engage community-dwelling PLCI in ACP discussions.
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Affiliation(s)
- Jennifer Gabbard
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Ashley E Strahley
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Nicholas M Pajewski
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Department of Biostatistics and Data Science, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kathryn E Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Department of Implementation Science, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kristie L Foley
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Department of Implementation Science, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrew Brown
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Adam Moses
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Section on General Internal Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Eric Kirkendall
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Department of Pediatrics, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Justin Brooten
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Department of Emergency Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Buddy Marterre
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Erin L Sutfin
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
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27
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Spinal Cord Stimulation in Failed Back Surgery Syndrome: An Integrative Review of Quantitative and Qualitative Studies. Neuromodulation 2022; 25:657-670. [DOI: 10.1016/j.neurom.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/14/2021] [Accepted: 11/02/2021] [Indexed: 11/21/2022]
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28
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Nakanishi M, Nakashima T, Miyamoto Y, Yamasaki S, Nishida A. Family caregivers' concerns about advance care planning for home-dwelling people with dementia: a cross-sectional observational study in Japan. BMC Palliat Care 2022; 21:114. [PMID: 35754050 PMCID: PMC9235165 DOI: 10.1186/s12904-022-01008-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/22/2022] [Indexed: 11/10/2022] Open
Abstract
Background The importance of advance care planning for people with dementia has increased during the Coronavirus Disease 2019 Pandemic. However, family caregivers may have concerns about having conversations regarding advance care planning with their loved ones, which may hinder the initiation of such planning. This study investigated family caregivers’ concerns regarding conducting advance care planning for home-dwelling individuals with dementia. Methods A prospective cross-sectional study compared the level of family-caregiver concern between those who had initiated advance care planning and those who did not. In June 2021, an internet-based questionnaire survey was administered to Japan-based family caregivers of persons with dementia. Registered members of a Japan-based survey company were recruited; inclusion criteria were being aged 40 years or older and having been a primary, non-professional caregiver of a family member with dementia. Respondents rated their level of agreement with six statements regarding advance-care-planning-related concerns. Respondents also reported their psychological well-being using the WHO-5 Well-Being Index. Results Overall, 379 family caregivers participated in this survey. Of these, 155 (40.9%) reported that their loved ones had initiated advance care planning, of whom 88 (56.8%) stated that care professionals were involved in the advance-care-planning conversations. The level of family-caregiver concern was significantly lower when the loved one initiated the conversation concerning advance care planning. After adjusting for the characteristics of persons with dementia and their caregivers, family caregivers with lower psychological well-being showed significantly higher levels of concern. Conclusions Family caregivers reported concerns regarding conducting advance care planning. There is a need for educational and clinical strategies that encourage professionals to address the psychological needs of family caregivers.
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Affiliation(s)
- Miharu Nakanishi
- Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, Miyagi, Japan. .,Research Center for Social Science & Medicine, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan.
| | - Taeko Nakashima
- Department of Social Healthcare and Business, Nihon Fukushi University, Aichi, Japan
| | - Yuki Miyamoto
- Department of Psychiatric Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Syudo Yamasaki
- Research Center for Social Science & Medicine, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Atsushi Nishida
- Research Center for Social Science & Medicine, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
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29
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Ludwick R, Bakerjian D, Zalon ML, Melander SD, Crist JD. Advance care planning at life milestones. Nurs Outlook 2022; 70:451-457. [PMID: 35440365 DOI: 10.1016/j.outlook.2022.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/02/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022]
Abstract
Much progress has been made in advance care planning (ACP), especially related to end of life and palliative care. These advances have moved thinking about ACP from a checklist approach to an upstream recognition that ACP is an iterative process that should begin early in adulthood and be revisited with each milestone or life-changing event. It is recognized that there are many stages and milestones in adult life that contribute to changing loci of responsibility and life goals. These changes impact how individuals view their lives, the complexity of health care, and the myriad of health conditions they may encounter. ACP discussions should routinely be started and reexamined at the time of key life events like starting a career or a marriage and not delayed until hospitalization, the occurrence of a serious accident, or the development of a catastrophic illness.
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Affiliation(s)
- Ruth Ludwick
- Kent State University, College of Nursing, Kent, OH.
| | - Deb Bakerjian
- Betty Irene Moore School of Nursing at UC Davis, Sacramento, CA
| | - Margarete L Zalon
- Health Informatics Program, Department of Nursing, University of Scranton, Scranton, PA
| | - Sheila D Melander
- MSN and DNP Faculty and Practice Affairs, University of Kentucky College of Nursing, Lexington, KY
| | - Janice D Crist
- College of Nursing, The University of Arizona, Tucson, AZ
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30
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Vellani S, Puts M, Iaboni A, McGilton KS. Acceptability of the voice your values, an advance care planning intervention in persons living with mild dementia using videoconferencing technology. PLoS One 2022; 17:e0266826. [PMID: 35472150 PMCID: PMC9041841 DOI: 10.1371/journal.pone.0266826] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 03/28/2022] [Indexed: 11/22/2022] Open
Abstract
Advance care planning (ACP) can improve outcomes for persons living with dementia (PLwD). Clinicians see the lack of acceptability of these conversations as a barrier to ACP in individuals with mild dementia. COVID-19 pandemic has magnified the need for ACP discussions in older adults, particularly for those living with dementia. In light of the pandemic, much of the healthcare is provided virtually, but little evidence exists on how to best implement ACP virtually. We designed Voice Your Values (VYV), a tailored ACP intervention for persons living with mild dementia and their trusted individuals such as friends or family. Purpose Determine the acceptability of the VYV intervention, in terms of its content and the potential utility of videoconferencing to deliver it. Methods For this pilot study, we recruited 21 dyads of older adults with mild dementia and their trusted individuals from five geriatric clinics in Ontario, Canada. The tailored VYV intervention was delivered to dyads over two sessions over videoconferencing. Acceptability was assessed using scores on a modified Treatment Evaluation Inventory. The interventionist diary and Researcher Virtual Experience Questionnaire were used to examine facilitators and barriers, whereas Participant Virtual Experience Questionnaire was used to understand their experience. Qualitative data was analyzed using inductive content analysis. Results 100% of the participants rated VYV as acceptable. Participants and researcher rated video and sound quality highly. PLwD who lived with their trusted individuals were more likely to find the intervention acceptable (t = 3.559, p = 0.001, β = 0.323). Five interrelated themes were established that describe the acceptability of the virtually delivered VYV intervention. All PLwD were able to articulate their values and wishes related to being in a terminal and vegetative states and had them documented. Conclusion The virtual VYV intervention was an acceptable approach to ACP in older adults with mild dementia and their trusted individuals.
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Affiliation(s)
- Shirin Vellani
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Iaboni
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Katherine S. McGilton
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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31
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Tsai WT, Chen CM, Chung MC, Tsai PY, Liu YT, Tang FC, Lin YL. Important Factors Influencing Willingness to Participate in Advance Care Planning among Outpatients: A Pilot Study in Central Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5266. [PMID: 35564659 PMCID: PMC9101214 DOI: 10.3390/ijerph19095266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 11/17/2022]
Abstract
Advance care planning (ACP) and advance directives (ADs) ensure patient autonomy in end-of life care. The number of ADs made and followed in Taiwan is still lacking. This study aimed to determine the factors that influence the willingness to participate in ACP among outpatients in Taiwan. In this study, we conducted a cross-sectional survey based on convenient sampling methods. The questionnaire included questions about participants' basic sociodemographic information, knowledge of ACP, and awareness of ACP. A total of 198 adults who were outpatients of a family medicine clinic in an affiliated hospital in Taiwan were recruited. The associations between each variable were evaluated using the χ2 test. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the logistic regression method to examine the influence of each variable on willingness to participate in ACP. Being happy and being a healthcare professional were positively correlated with ACP participation. A lack of ACP knowledge (OR = 0.30 in model A and OR = 0.42 in model C), valuing "Reducing families' end-of-life decision-making burden" (OR = 2.53 in model B and OR = 2.65 in model C), and a "Belief in a good death" (OR = 4.02 in model B and OR = 4.10 in Model C) were the main factors affecting subjects' willingness to participate in ACP. Knowing which factors influence willingness to participate in ACP helps in the promotion of ACP. Continuously educating both the general public and healthcare professionals strengthens knowledge about the right to autonomy, about its associated laws, and about the ACP process, and thus, programs should be created to provide this education. Additionally, taking into account the differences between cultures can be helpful.
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Affiliation(s)
- Wan-Ting Tsai
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (W.-T.T.); (M.-C.C.); (P.-Y.T.); (Y.-T.L.)
| | - Chun-Min Chen
- Big Data Center, Changhua Christian Hospital, Changhua 500, Taiwan;
| | - Ming-Cheng Chung
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (W.-T.T.); (M.-C.C.); (P.-Y.T.); (Y.-T.L.)
| | - Pei-Yu Tsai
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (W.-T.T.); (M.-C.C.); (P.-Y.T.); (Y.-T.L.)
| | - Yen-Tzu Liu
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (W.-T.T.); (M.-C.C.); (P.-Y.T.); (Y.-T.L.)
- Big Data Center, Changhua Christian Hospital, Changhua 500, Taiwan;
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Holistic Wellness, Mingdao University, Changhua 500, Taiwan
- Post Baccalaureate Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Feng-Cheng Tang
- Department of Occupational Medicine, Changhua Christian Hospital, Changhua 500, Taiwan;
- Department of Leisure Services Management, Chaoyang University of Technology, Taichung 413, Taiwan
- School of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Ying-Li Lin
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (W.-T.T.); (M.-C.C.); (P.-Y.T.); (Y.-T.L.)
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White LW, Dawson N, Saale BP, Lemley T. Physical Therapists' and Physical Therapist Students' Experiences and Views on the Provision of Physical Therapy Services to People With Dementia: A Scoping Review. J Geriatr Phys Ther 2022:00139143-990000000-00002. [PMID: 35420572 DOI: 10.1519/jpt.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Physical therapists (PTs) require specialized education and training to increase the capacity and competence of the dementia care workforce. Four areas of critical dementia workforce education and training gaps that apply to the physical therapy profession have been identified, including recruitment/retention, financing and cost of training, interprofessional education, and translation/implementation of effective dementia care. A critical step in developing effective training programs and educational curricula is to understand PTs' and PT students' experiences and views on working with people with dementia (PwD). Therefore, the purpose of this scoping review was to examine the extent and types of evidence that explore the experiences and views of PTs and PT students on the provision of physical therapy services to PwD. METHODS The Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, ERIC, PEDro, Web of Science, and Medline databases and sources of gray literature were searched for sources of evidence that met the inclusion criteria of the review protocol. The literature was mapped according to author, participant role, setting, publication type, study design, study aim, key findings, and dementia workforce training gaps addressed. RESULTS AND DISCUSSION A total of 552 sources of evidence were screened for eligibility, and 16 studies were selected for inclusion. Twelve studies included PTs as participants, and 5 included PT students. Included sources explored PTs' experiences, behaviors, knowledge, attitudes, and confidence in working with PwD and the influence of educational, organizational, and other factors on these domains. Challenges to and strategies for delivering effective care to PwD were examined in multiple sources. The 4 areas of critical dementia workforce education and training gaps were each addressed by at least 1 of the included studies. CONCLUSIONS The current body of literature identifies several gaps in both research and education that need to be addressed before our profession is truly prepared to effectively manage this challenging population of patients with specialized needs.
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Affiliation(s)
- Laura W White
- Department of Physical Therapy, University of South Alabama, Mobile
| | - Nicole Dawson
- School of Kinesiology and Physical Therapy, University of Central Florida, Orlando
| | - Blair P Saale
- Department of Physical Therapy, University of South Alabama, Mobile
| | - Trey Lemley
- Biomedical Library, University of South Alabama, Mobile
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Wangler J, Jansky M. [Team players or lone fighters? Importance and utilization of practice staff in primary care dementia detection]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2022; 169:75-83. [PMID: 35190285 DOI: 10.1016/j.zefq.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/11/2021] [Accepted: 12/19/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND General practitioners (GP) face major challenges in everyday practice when it comes to identifying dementia cases as early as possible under the condition of time and resource constraints. The involvement of the practice staff promises decisive advantages in detection and diagnosis. So far, there has been a lack of studies exploring the extent to which non-medical practice employees in general practices are integrated into dementia detection, what experiences they have had and how they assess their own potential to contribute to more efficient dementia detection. METHODS Between August 2020 and August 2021, a total of 64 semi-structured, audio-technically recorded individual / expert interviews were conducted with non-medical practice employees (medical assistants) in general practices in all German federal states (four interviewees per federal state). The interview transcripts were evaluated using a qualitative, structuring content analysis according to Mayring (Software MAXQDA 2020). RESULTS The GP team members show a high degree of willingness and motivation to support the doctor in identifying and diagnosing dementia; situations have been reported where their assistance has led to an earlier identification of people with dementia. Observation and detection of dementia patients are rarely based on systematic criteria. On the whole, only some GPs entrust their staff with tasks like this. A large portion of the interviewees expressed considerable uncertainty regarding the assessment of possible signs of incipient dementia, which corresponds to the fact that only a minority of the interviewees have ever completed further training with a focus on dementia. CONCLUSIONS Practice staff can provide invaluable support when it comes to the timely and consistent detection of incipient dementia in general practice. In addition to sensitizing GPs and optimizing practice management, targeted training with regard to geriatric issues will be instrumental in achieving this. Accordingly, more advanced training formats should be developed that are tailored to the perspective of practice employees and convey important dementia-specific diagnostics, action and communication skills.
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Affiliation(s)
- Julian Wangler
- Zentrum für Allgemeinmedizin und Geriatrie, Universitätsmedizin Mainz, Mainz, Deutschland.
| | - Michael Jansky
- Zentrum für Allgemeinmedizin und Geriatrie, Universitätsmedizin Mainz, Mainz, Deutschland
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Azizi B, Tilburgs B, van Hout HPJ, van der Heide I, Verheij RA, Achterberg WP, van der Steen JT, Joling KJ. Occurrence and Timing of Advance Care Planning in Persons With Dementia in General Practice: Analysis of Linked Electronic Health Records and Administrative Data. Front Public Health 2022; 10:653174. [PMID: 35392479 PMCID: PMC8980429 DOI: 10.3389/fpubh.2022.653174] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Advance care planning (ACP) is a process of communication in which patients and family caregivers discuss preferences for future care with the healthcare team. For persons with dementia, it is crucial to timely engage in ACP. Therefore, we study ACP in dementia using electronic health record data. This study aims to determine how often ACP conversations are recorded, analyze time from dementia diagnosis until the first recorded conversation and time from the first recorded conversation to death, and analyze which factors are associated with the timing of ACP. Methods Electronic records of 15,493 persons with dementia in Dutch general practice between 2008 and 2016 were linked to national administrative databases. ACP conversations and indicators of health deficits to determine frailty were obtained from electronic records coded with the International Classification of Primary Care. Socio-demographic characteristics were derived from the national population registry managed by Statistics Netherlands. Date of death was derived from the Personal Records Database (2008–2018). Results ACP was recorded as such as 22 (95% CI, 20–23) first conversations per 1,000 person-years of follow-up. The hazard ratio (HR) for the first conversation increased every year after dementia diagnosis, from 0.01 in the first year to 0.07 in the 7th and 8th year after diagnosis. Median time from a first conversation to death was 2.57 years (95% CI, 2.31–2.82). Migrant status [non-Western vs. Western (HR 0.31, 95% CI, 0.15–0.65)] was significantly associated with a longer time from dementia diagnosis to the first conversation. Being pre-frail (HR 2.06, 95% CI, 1.58–2.69) or frail (HR 1.40, 95% CI, 1.13–1.73) vs. non-frail was significantly associated with a shorter time from dementia diagnosis to the first ACP conversation. Conclusion ACP conversations in Dutch general practice were rare for persons with dementia, or was rarely recorded as such. In particular among persons with a non-Western migration background and those who are non-frail, it started long after diagnosis. We advise further research into public health and practical strategies to engage persons with dementia with a non-Western migration background and non-frail persons early in the disease trajectory in ACP.
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Affiliation(s)
- Bahar Azizi
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Bram Tilburgs
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Science, Nijmegen, Netherlands
| | - Hein P. J. van Hout
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Iris van der Heide
- Nivel, Netherlands Institute for Health Services Research, Utrecht, Netherlands
| | - Robert A. Verheij
- Nivel, Netherlands Institute for Health Services Research, Utrecht, Netherlands
- Tilburg School of Social and Behavioral Sciences (TRANZO), Tilburg University, Tilburg, Netherlands
| | - Wilco P. Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Jenny T. van der Steen
| | - Karlijn J. Joling
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Advance Care Planning for Seniors Diagnosed with Dementia: A Scoping Review of the Canadian Literature. Can J Aging 2022; 41:377-403. [PMID: 35282848 DOI: 10.1017/s0714980821000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Advance care planning (ACP) is commonly recommended for persons living with dementia. Increasing age and uncertain disease trajectory add complexity to this process. A scoping review of the Canadian literature was completed to assess the feasibility and acceptability of ACP for seniors (≥ 65 years of age) diagnosed with dementia and to provide practice, policy, and research recommendations towards ACP as a critical aspect of care. Twenty-nine articles were grouped into five themes: (1) feasibility of patient engagement in ACP; (2) opinions regarding medical assistance in dying (MAiD) for incompetent patients; (3) knowledge translation to support persons living with dementia, professionals, and caregivers; (4) barriers to and facilitators of the delivery of holistic dementia care; and (5) Indigenous health considerations. Additional research should consider socio-demographic and social/cultural factors associated with older persons living with dementia's engagement in ACP. Future policies warrant a multidisciplinary approach when reviewing legalities. Finally, ACP knowledge translation should become a routine aspect of dementia care.
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Naasan G, Boyd ND, Harrison KL, Garrett SB, D'Aguiar Rosa T, Pérez-Cerpa B, McFarlane S, Miller BL, Ritchie CS. Advance Directive and POLST Documentation in Decedents With Dementia at a Memory Care Center: The Importance of Early Advance Care Planning. Neurol Clin Pract 2022; 12:14-21. [PMID: 36157620 PMCID: PMC9491507 DOI: 10.1212/cpj.0000000000001123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/06/2021] [Indexed: 02/03/2023]
Abstract
Background and Objectives To determine the frequency of and challenges to documentation of advance care planning (ACP) in people with dementia, we conducted a chart review of 746 deceased patients seen at a tertiary memory care center between 2012 and 2017. Methods The rates of documented advance directives (ADs), Physician Order for Life-Sustaining Treatment (POLST), and Do Not Resuscitate (DNR) status were calculated from review of institutional electronic health records. Regression analysis was used to determine associations between ACP documentation and patient characteristics. Results At the time of death, approximately half of the patients had a documented AD and/or DNR status and 37% had a documented POLST; 30% of patients did not have any ACP documentation. Whereas most of the ADs were documented more than 5 years before time of death, POLST and DNR status were documented more frequently within 2 years of time of death. People who presented to clinic at a younger age and who primarily spoke English were more likely to have documented ADs. People living in zip codes with lower household incomes were 2-4.5 times less likely to have a POLST or DNR documentation. Discussion ACP is underutilized in people with dementia, even among those seen in a specialty memory care center. ACP should be introduced early on for people with dementia to ensure patients have a voice in their care.
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Macchi ZA, Lum HD. Advance care planning in neurologic illness. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:129-148. [PMID: 36055711 DOI: 10.1016/b978-0-323-85029-2.00004-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Advance care planning (ACP) is an essential element of neuropalliative care for persons living acquired brain injuries or progressive, neurodegenerative conditions like dementia. This includes early recognition of these conditions as needing timely ACP conversations to maximize patient autonomy and capacity in early disease, leading to discussions and documentation of patients' values and preferences for future care. ACP involves assessing patient readiness, evaluating decision-making capacity, initiating discussions early and iteratively in the disease course, identifying and preparing surrogate decision makers, and documenting patients' goals-of-care. However, this process presents unique challenges for clinicians and patients' families as individuals lose the ability to meaningfully engage in conversations due to multiple factors related to brain dysfunction. This includes evaluations of capacity for medical decision-making which consider the context in which discussions are held across multiple timepoints with repeated conversations. Research has shown that engaging in early ACP leads to greater goal-concordant care in advanced neurologic illness and affects end-of-life medical decision-making. Clinicians should be familiar with the significance of ACP in this context, understand ways for approaching these difficult discussions with patients and their families, and be aware of evidence-based tools which prepare and aid patients for these discussions. Here, we review ACP in the context of serious neurologic illness and discuss how clinicians can approach conversations with patients and families, ensure patients' values and preferences are documented and available, and explore tools which may enhance the ACP process.
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Affiliation(s)
- Zachary A Macchi
- Department of Neurology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, United States; Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, United States
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, United States.
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Abstract
Primary palliative care is a fundamental aspect of high-quality care for patients with a serious illness such as dementia. The clinician caring for a patient and family suffering with dementia can provide primary palliative care in numerous ways. Perhaps the most important aspects are high quality communication while sharing a diagnosis, counseling the patient through progression of illness and prognostication, and referral to hospice when appropriate. COVID-19 presents additional risks of intensive care requirement and mortality which we must help patients and families navigate. Throughout all of these discussions, the astute clinician must monitor the patient's decision making capacity and balance respect for autonomy with protection against uninformed consent. Excellent primary palliative care also involves discussion of deprescribing medications of uncertain benefit such as long term use of cholinesterase inhibitors and memantine and being vigilant in the monitoring of pain with its relationship to behavioral disturbance in patients with dementia. Clinicians should follow a standardized approach to pain management in this vulnerable population. Caregiver burden is high for patients with dementia and comprehensive care should also address this burden and implement reduction strategies. When these aspects of care are particularly complex or initial managements strategies fall short, palliative care specialists can be an important additional resource not only for the patient and family, but for the care team struggling to guide the way through a disease with innumerable challenges.
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Affiliation(s)
- Neal Weisbrod
- Department of Neurology, University of Florida, 1505 SW Archer, Gainesville, FL, 32608, USA.
- Department of Medicine Division of Palliative Care, University of Florida, 1505 SW Archer, Gainesville, FL, 32608, USA.
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Lech S, O'Sullivan JL, Drewelies J, Herrmann W, Spang RP, Voigt-Antons JN, Nordheim J, Gellert P. Dementia care and the role of guideline adherence in primary care: cross-sectional findings from the DemTab study. BMC Geriatr 2021; 21:717. [PMID: 34922486 PMCID: PMC8683809 DOI: 10.1186/s12877-021-02650-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 11/12/2021] [Indexed: 11/20/2022] Open
Abstract
Background General practitioners (GPs) play a key role in the care of people with dementia (PwD). However, the role of the German Dementia Guideline in primary care remains unclear. The main objective of the present study was to examine the role of guideline-based dementia care in general practices. Methods A cross-sectional analysis of data obtained from the DemTab study was conducted. Descriptive analyses of sociodemographic and clinical characteristics for GPs (N = 28) and PwD (N = 91) were conducted. Adherence to the German Dementia Guideline of GPs was measured at the level of PwD. Linear Mixed Models were used to analyze the associations between adherence to the German Dementia Guideline and GP factors at individual (age, years of experience as a GP, frequency of utilization of guideline, perceived usefulness of guideline) and structural (type of practice, total number of patients seen by a participating GP, and total number of PwD seen by a participating GP) levels as well as between adherence to the German Dementia Guideline and PwD’s quality of life. Results Self-reported overall adherence of GPs was on average 71% (SD = 19.4, range: 25–100). Adherence to specific recommendations varied widely (from 19.2 to 95.3%) and the majority of GPs (79.1%) reported the guideline as only partially or somewhat helpful. Further, we found lower adherence to be significantly associated with higher numbers of patients (γ10 = − 5.58, CI = − 10.97, − 0.19, p = .04). No association between adherence to the guideline and PwD’s quality of life was found (γ10 = −.86, CI = − 4.18, 2.47, p = .61). Conclusion The present study examined the role of adherence to the German Dementia Guideline recommendations in primary care. Overall, GPs reported high levels of adherence. However, major differences across guideline recommendations were found. Findings highlight the importance of guidelines for the provision of care. Dementia guidelines for GPs need to be better tailored and addressed. Further, structural changes such as more time for PwD may contribute to a sustainable change of dementia care in primary care. Trial registration The DemTab trial was prospectively registered with the ISRCTN registry (Trial registration number: ISRCTN15854413). Registered 01 April 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02650-8.
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Affiliation(s)
- Sonia Lech
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany. .,Brandenburg Medical School Theodor Fontane, Department of Psychiatry, Psychotherapy and Psychosomatics, Neuruppin, Germany.
| | - Julie L O'Sullivan
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany
| | - Johanna Drewelies
- Department of Psychology, Humboldt Universität zu Berlin, Berlin, Germany
| | - Wolfram Herrmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
| | - Robert P Spang
- Technische Universität Berlin, Quality and Usability Lab, Berlin, Germany
| | - Jan-Niklas Voigt-Antons
- Technische Universität Berlin, Quality and Usability Lab, Berlin, Germany.,Deutsches Forschungszentrum für Künstliche Intelligenz GmbH (DFKI), Speech and Language Technology, Berlin, Germany
| | - Johanna Nordheim
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany
| | - Paul Gellert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Medical Sociology and Rehabilitation Science, Charitéplatz 1, 10117, Berlin, Germany
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Alam A, Barton C, Prathivadi P, Mazza D. Advance care planning in dementia: a qualitative study of Australian general practitioners. Aust J Prim Health 2021; 28:69-75. [PMID: 34844662 DOI: 10.1071/py20307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022]
Abstract
As the population ages, so does the prevalence of dementia, a condition in which timely advance care planning (ACP) is recommended. This study explored the barriers and enablers of ACP for Australian GPs caring for people with dementia. Semi-structured qualitative telephone interviews informed by the theoretical domains framework (TDF) were conducted with 16 GPs from the south-east region of metropolitan Melbourne. The most prevalent domains of the TDF were: (1) environmental context and resources; (2) beliefs about consequences; and (3) social/professional role and identity. Further thematic analysis found that: (1) ACP was felt to be within the scope of general practice, but more so before the onset of dementia because lack of confidence in capacity assessment acted as a barrier once a diagnosis was made; (2) beliefs about the perceived benefits of ACP motivated GPs to engage patients in ACP; and (3) doctors felt that patients were often reluctant to discuss ACP, especially in the time-pressured context of the standard consultation. This study's use of the TDF provides direction for potential interventions to alleviate challenges faced by Australian GPs with ACP in dementia. Improving ACP in general practice may require a focus on public health campaigns to educate patients about the benefits of ACP before the onset of dementia. GPs' difficulty assessing a patient's decisional capacity may be addressed through skills development workshops.
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Affiliation(s)
- Adnan Alam
- Hobart Place General Practice, Level 2 & 3, 28 University Avenue, Canberra, ACT 2601, Australia; and Corresponding author
| | - Christopher Barton
- Department of General Practice, Monash University, Level 1, Building 1, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia
| | - Pallavi Prathivadi
- Department of General Practice, Monash University, Level 1, Building 1, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Level 1, Building 1, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia
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Mazza D, McCarthy E, Camões-Costa V, Mansfield E, Bryant J, Waller A, Lin X, Piterman L. Prioritising national dementia guidelines for general practice: A Delphi approach. Australas J Ageing 2021; 41:247-257. [PMID: 34755449 DOI: 10.1111/ajag.13012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Australian guidelines for dementia cover 109 recommendations for dementia care. Knowing which recommendations to implement poses a challenge for general practitioners (GPs). This study aimed to gather general practice perspectives of priority recommendations for GPs in their practice. METHODS To explore which recommendations are most important and those requiring the greatest support in GP implementation, a Delphi study was conducted. Thirty-six GPs, 4 practice nurses and 1 medical services director completed two rounds of email questionnaires. RESULTS Recommendations requiring support for GP implementation relate to early assessment of behavioural and psychological symptoms; mental health interventions tailored to the person's preferences and abilities; language and cultural barriers in access to information and services; and cognitive and learning needs in treatment delivery. CONCLUSION It is critical to understand where support may be needed for GPs to successfully implement recommendations to improve care provided to people with dementia and their carers.
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Affiliation(s)
- Danielle Mazza
- Department of General Practice, Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University, Notting Hill, Victoria, Australia
| | - Edwina McCarthy
- Department of General Practice, Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University, Notting Hill, Victoria, Australia
| | - Vera Camões-Costa
- Department of General Practice, Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University, Notting Hill, Victoria, Australia
| | - Elise Mansfield
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Jamie Bryant
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Amy Waller
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Xiaoping Lin
- Department of General Practice, Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University, Notting Hill, Victoria, Australia
| | - Leon Piterman
- Department of General Practice, Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University, Notting Hill, Victoria, Australia
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Ryan L. Accessing community dementia care services in Ireland: Emotional barriers for caregivers. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:1980-1989. [PMID: 33682982 DOI: 10.1111/hsc.13342] [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: 05/05/2020] [Revised: 01/06/2021] [Accepted: 02/15/2021] [Indexed: 06/12/2023]
Abstract
Despite the benefits of utilising community-based care services (CBS) for people with dementia and their caregiver being well established, people with dementia and caregivers use fewer services in comparison to other people in need of care. While societal, cultural and logistical factors effecting caregiver use of CBS are frequently studied, research of internal emotional barriers, mental limitations created by one's own self that prevents open communication of thoughts and feelings, and their effect on CBS use is limited. This paper explores internal emotional barriers on caregivers' use of CBS within the Irish Healthcare System. Professional Healthcare Providers were also interviewed as a preliminary indicator of their awareness of these internal emotional barriers and their impact on caregivers' use of CBS. Using interpretive description methodology, interviews with 20 caregivers and fourteen dementia professional healthcare providers were transcribed and a thematic analysis methodology applied to illuminate themes/patterns within participants' subjective perceptions of caregivers emotional barriers to using CBS. Four themes emerge: reluctance to question general practitioner (GP) authority; embarrassment during level of care requirement reviews; sense of obligation to provide all care; and fear of stigma. Caregivers interviewed were reluctant to communicate concerns with professional healthcare providers (PHPs), thereby reducing the PHP's awareness of these barriers and delaying/preventing use of CBS. As key gatekeepers within the care pathway, GPs should address the uneven power dynamic with the caregiver through user-centred models of care, which actively encourage open dialogue, and receive training to identify the indicative behaviours of internal emotional barriers and empower the caregiver to communicate their feelings/concerns directly.
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Muraya T, Akagawa Y, Andoh H, Chiang C, Hirakawa Y. Improving person-centered advance care planning conversation with older people: a qualitative study of core components perceived by healthcare professionals. J Rural Med 2021; 16:222-228. [PMID: 34707731 PMCID: PMC8527630 DOI: 10.2185/jrm.2021-022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/17/2021] [Indexed: 12/23/2022] Open
Abstract
Objective: The non-medical needs of patients, such as values and personal
preferences, are likely to be omitted from advance care planning (ACP) discussions because
of a lack of readiness and awareness on the part of healthcare professionals. The aim of
the present study was to identify core components perceived by multidisciplinary
healthcare professionals to improve person-centered ACP conversations with older
people. Methods: The study participants were healthcare professionals (physicians,
nurses, and care managers) working in different cities. This qualitative study was
performed online using eight individual in-depth interviews and one subsequent focus group
composed of eight healthcare professionals. The interviews and focus group discussion were
audio-recorded online and transcribed verbatim. The aim of the analysis of the individual
in-depth interviews was to summarize the transcribed results, create a conceptual
framework for person-centered ACP conversation, and provide meaningful interpretations of
the focus group participant discourse. The qualitative data were then analyzed by
inductive manual coding using a qualitative content analysis approach. Results: Five themes capturing the core components for successful
person-centered ACP were extracted from the ideas voiced by participants: Placing highest
value on patient autonomy and human life; uncovering patient’s true feelings and desires;
sharing collected information on patients’ end-of-life wishes with other team members;
relaying patients’ wishes to the physician; and handling conflicts among patients,
relatives, and healthcare professionals. Conclusion: The results provide guidelines for the future development of
novel, value-based, person-centered ACP practice for multidisciplinary healthcare
professionals.
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Affiliation(s)
| | - Yuko Akagawa
- Department of Clinical Nursing, Akita University Graduate School of Health Science, Japan
| | - Hideaki Andoh
- Department of Clinical Nursing, Akita University Graduate School of Health Science, Japan
| | - Chifa Chiang
- Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Japan
| | - Yoshihisa Hirakawa
- Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Japan
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Abe M, Tsunawaki S, Dejonckheere M, Cigolle CT, Phillips K, Rubinstein EB, Matsuda M, Fetters MD, Inoue M. Practices and perspectives of primary care physicians in Japan and the United States about diagnosing dementia: a qualitative study. BMC Geriatr 2021; 21:540. [PMID: 34635089 PMCID: PMC8503990 DOI: 10.1186/s12877-021-02457-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND While dementia is a common problem in Japan and the US, primary care physicians' practices and perspectives about diagnosing dementia in these different healthcare systems are unknown. METHODS Qualitative research was conducted in an ethnographic tradition using semi-structured interviews and thematic analysis in primary care settings across Japan and in the Midwest State of Michigan, US. Participants were a total of 48 primary care physicians, 24 each from Japan and the US participated. Both groups contained a mixture of geographic areas (rural/urban), gender, age, and years of experience as primary care physicians. RESULTS Participants in Japan and the US voiced similar practices for making the diagnosis of dementia and held similar views about the desired benefits of diagnosing dementia. Differences were found in attitudes about the appropriate timing of formally diagnosing dementia. Japanese physicians tended to make a formal diagnosis when problems that would benefit from long-term care services emerged for family members. US physicians were more proactive in diagnosing dementia in the early stages by screening for dementia in health check-ups and promoting advance directives when the patients were still capable of decision-making. Views about appropriate timing of diagnostic testing for dementia in the two systems reflect what medical or nursing care services physicians can use to support dementia patients and caregivers. CONCLUSIONS Benefits of making the diagnosis included the need to activate the long-term care services in Japan and for early intervention and authoring advance directives in the US. Testing to establish an early diagnosis of dementia by primary care physicians only partly relates to testing and treatment options available. Benefits of making the diagnosis included the need to activate the long-term care services in Japan and for early intervention and authoring advance directives in the US.
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Affiliation(s)
- M Abe
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Shizuoka, Hamamatsu, Japan
| | - S Tsunawaki
- Omaezaki Family Medicine Center, Shizuoka, Omaezaki, Japan
- Shizuoka Family Medicine Program, Shizuoka, Hamamatsu, Japan
| | - M Dejonckheere
- Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI, 48104, USA
| | - C T Cigolle
- Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI, 48104, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Healthcare System (VAAHS) Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA
| | - K Phillips
- VA Ann Arbor Healthcare System (VAAHS) Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA
| | - E B Rubinstein
- Department of Sociology and Anthropology, North Dakota State University, Fargo, North Dakota, USA
| | - M Matsuda
- Shizuoka Family Medicine Program, Shizuoka, Hamamatsu, Japan
- Kikugawa Family Medicine Center, Shizuoka, Kikugawa, Japan
| | - M D Fetters
- Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI, 48104, USA.
- The School of Health Humanities, Peking University Health Science Center, Beijing, China.
| | - M Inoue
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Shizuoka, Hamamatsu, Japan
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45
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Fernandes B, Goodarzi Z, Holroyd-Leduc J. Optimizing the diagnosis and management of dementia within primary care: a systematic review of systematic reviews. BMC FAMILY PRACTICE 2021; 22:166. [PMID: 34380424 PMCID: PMC8359121 DOI: 10.1186/s12875-021-01461-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 05/13/2021] [Indexed: 01/08/2023]
Abstract
Background To understand how best to approach dementia care within primary care and its challenges, we examined the evidence related to diagnosing and managing dementia within primary care. Methods Databases searched include: MEDLINE, Embase, PsycINFO and The Cochrane Database of Systematic Reviews from inception to 11 May 2020. English-language systematic reviews, either quantitative or qualitative, were included if they described interventions involving the diagnosis, treatment and/or management of dementia within primary care/family medicine and outcome data was available. The risk of bias was assessed using AMSTAR 2. The review followed PRISMA guidelines and is registered with Open Science Framework. Results Twenty-one articles are included. The Mini-Cog and the MMSE were the most widely studied cognitive screening tools. The Abbreviated Mental Test Score (AMTS) achieved high sensitivity (100 %, 95 % CI: 70-100 %) and specificity (82 %, 95 % CI: 72-90 %) within the shortest amount of time (3.16 to 5 min) within primary care. Five of six studies found that family physicians had an increased likelihood of suspecting dementia after attending an educational seminar. Case management improved behavioural symptoms, while decreasing hospitalization and emergency visits. The primary care educational intervention, Enhancing Alzheimer’s Caregiver Health (Department of Veterans Affairs), was successful at increasing carer ability to manage problem behaviours and improving outcomes for caregivers. Conclusions There are clear tools to help identify cognitive impairment in primary care, but strategies for management require further research. The findings from this systematic review will inform family physicians on how to improve dementia diagnosis and management within their primary care practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01461-5.
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Affiliation(s)
| | - Zahra Goodarzi
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, Foothills Medical Centre, University of Calgary, North Tower (Rm 930), 1403 29 St NW, Calgary, AB, T2N 2T9, Canada
| | - Jayna Holroyd-Leduc
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, Foothills Medical Centre, University of Calgary, North Tower (Rm 930), 1403 29 St NW, Calgary, AB, T2N 2T9, Canada
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Sævareid TJL, Pedersen R, Magelssen M. Positive attitudes to advance care planning - a Norwegian general population survey. BMC Health Serv Res 2021; 21:762. [PMID: 34334131 PMCID: PMC8327435 DOI: 10.1186/s12913-021-06773-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 07/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background Authorities recommend advance care planning and public acceptance of it is a prerequisite for widespread implementation. Therefore, we did the first study of the Norwegian public with an aim of getting knowledge on their attitudes to issues related to advance care planning. Methods An electronic survey to a nationally representative web panel of Norwegian adults. Results From 1035 complete responses (response rate 40.7%), we found that more than nine out of ten of the general public wanted to participate in advance care planning, believed it to be useful for many, and wanted to make important healthcare decisions themselves. Almost nine out of ten wanted to be accompanied by next of kin during advance care planning. Most (69%) wanted health care personnel to initiate advance care planning and preferred it to be timed to serious illness with limited lifetime (68%). Only about 9% stated that health care personnel should have the final say in healthcare decisions in serious illness. Conclusions Developing and implementing advance care planning as a public health initiative seems warranted based on the results of this study. Patient perspectives should be promoted in decision-making processes. Nevertheless, training of health care personnel should emphasise voluntariness and an individual approach to initiating, timing and conducting advance care planning because of individual variations.
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Affiliation(s)
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166, Frederik Holsts hus, 0450, Oslo, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166, Frederik Holsts hus, 0450, Oslo, Norway
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47
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Exploring Differential Perceptions and Barriers to Advance Care Planning in Dementia among Asian Patient-Caregiver Dyads-A Mixed-Methods Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137150. [PMID: 34281087 PMCID: PMC8297379 DOI: 10.3390/ijerph18137150] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/28/2021] [Accepted: 07/01/2021] [Indexed: 12/17/2022]
Abstract
A parallel mixed-methods study on 20 patient–caregiver dyads in an Asian population was conducted to explore the differential perceptions and barriers to ACP in dementia. We recruited English-speaking patients with mild dementia and their caregivers. A trained ACP facilitator conducted ACP counseling. Patient–caregiver dyads completed pre–post surveys and participated in post-counseling qualitative interviews. We used mixed-methods analysis to corroborate the quantitative and qualitative data. Differential perceptions of ACP were reported among dyads, with caregivers less inclined for further ACP discussions. Post-ACP counseling, caregivers were significantly more likely to acknowledge barriers to ACP discussions than patients (57.9% versus 10.5%, p = 0.005). Thematic analysis of the interview transcripts revealed four themes around barriers to ACP: patient-related factors (transference of decision making, poor cognition and lack of understanding, and dis-inclination to plan for the future), caregiver-related factors (perceived negative impact on the patient, caregiver discomfort, and confidence in congruent decision making), socio-cultural factors (taboos, superstitions, and religious beliefs), and the inappropriate timing of discussions. In a collectivist Asian culture, socio-cultural factors pose important barriers, and a family-centric approach to initiation of ACP may be the first step towards engagement in the ACP process. For ACP in dementia to be effective for patients and caregivers, these discussions should be culturally tailored and address patient, caregiver, socio-cultural, and timing barriers.
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48
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Dujardin J, Schuurmans J, Westerduin D, Wichmann AB, Engels Y. The COVID-19 pandemic: A tipping point for advance care planning? Experiences of general practitioners. Palliat Med 2021; 35:1238-1248. [PMID: 34041987 DOI: 10.1177/02692163211016979] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2020, the COVID-19 pandemic caused an acute risk of deterioration and dying for many, and an urgent need to start advance care planning. AIM To explore how general practitioners (GPs) experienced discussing values, goals and preferences with patients during COVID-19. DESIGN AND SETTING Qualitative research in general practice. METHODS Semi-structured interviews for which Dutch GPs were recruited via purposive sampling. Content analysis was used. RESULTS Fifteen GPs were interviewed. Six themes were identified: (i) urge of advance care planning, (ii) the GP's perceived role in it, (iii) preparations for it, (iv) (proactively) discussing it, (v) essentials for good communication and (vi) advance care planning in the (near) future. Calls for proactively discussing advance care planning in the media and in COVID-guidelines caused awareness of it's importance. GPs envisaged an important role for themselves in initiating it, especially with patients at risk to deteriorate or die from COVID-19. Timing advance care planning appeared difficult but crucial. The recommended digital way of communication was considered problematic due to missing nonverbal communication and difficulties in involving relatives. It was noted that admission to the ICU, which was hardly discussed before the COVID-19 pandemic, should remain a topic during advance care planning. CONCLUSION The COVID-19 pandemic brought advance care planning into a new light, GPs were more experienced with discussing it and patients were more aware of their frailty. Because of the nearing 'grey wave', advance care planning should remain top priority. Therefore, it should be central in GP and post-academic training.
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Affiliation(s)
- Janneke Dujardin
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Jaap Schuurmans
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Dieke Westerduin
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Anne B Wichmann
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
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Wendrich-van Dael A, Gilissen J, Van Humbeeck L, Deliens L, Vander Stichele R, Gastmans C, Pivodic L, Van den Block L. Advance care planning in nursing homes: new conversation and documentation tools. BMJ Support Palliat Care 2021; 11:312-317. [PMID: 34162581 PMCID: PMC8380900 DOI: 10.1136/bmjspcare-2021-003008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/02/2021] [Indexed: 02/07/2023]
Abstract
Although advance care planning (ACP) is highly relevant for nursing home residents, its uptake in nursing homes is low. To meet the need for context-specific ACP tools to support nursing home staff in conducting ACP conversations, we developed the ACP+intervention. At its core, we designed three ACP tools to aid care staff in discussing and documenting nursing home resident's wishes and preferences for future treatment and care: (1) an extensive ACP conversation guide, (2) a one-page conversation tool and (3) an ACP document to record outcomes of conversations. These nursing home-specific ACP tools aim to avoid a purely document-driven or 'tick-box' approach to the ACP process and to involve residents, including those living with dementia according to their capacity, their families and healthcare professionals.
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Affiliation(s)
- Annelien Wendrich-van Dael
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium .,Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
| | - Joni Gilissen
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium.,Neurology, UCSF, San Francisco, California, USA
| | - Liesbeth Van Humbeeck
- Department of Geriatric Medicine, University Hospital Ghent, Gent, Oost-Vlaanderen, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | | | - Chris Gastmans
- Interfacultair Centrum voor Biomedische Ethiek en Recht, KULeuven, Leuven, Belgium
| | - Lara Pivodic
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
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50
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Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews. BMC Palliat Care 2021; 20:89. [PMID: 34162377 PMCID: PMC8223342 DOI: 10.1186/s12904-021-00782-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND As the demand for palliative care increases, more information is needed on how efficient different types of palliative care models are for providing care to dying patients and their caregivers. Evidence on the economic value of treatments and interventions is key to informing resource allocation and ultimately improving the quality and efficiency of healthcare delivery. We assessed the available evidence on the economic value of palliative and end-of-life care interventions across various settings. METHODS Reviews published between 2000 and 2019 were included. We included reviews that focused on cost-effectiveness, intervention costs and/or healthcare resource use. Two reviewers extracted data independently and in duplicate from the included studies. Data on the key characteristics of the studies were extracted, including the aim of the study, design, population, type of intervention and comparator, (cost-) effectiveness resource use, main findings and conclusions. RESULTS A total of 43 reviews were included in the analysis. Overall, most evidence on cost-effectiveness relates to home-based interventions and suggests that they offer substantial savings to the health system, including a decrease in total healthcare costs, resource use and improvement in patient and caregivers' outcomes. The evidence of interventions delivered across other settings was generally inconsistent. CONCLUSIONS Some palliative care models may contribute to dual improvement in quality of care via lower rates of aggressive medicalization in the last phase of life accompanied by a reduction in costs. Hospital-based palliative care interventions may improve patient outcomes, healthcare utilization and costs. There is a need for greater consistency in reporting outcome measures, the informal costs of caring, and costs associated with hospice.
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