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Cameron EC, Ries N, Waller A, Johnston B, Anderson J, Bryant J. Advance personal planning knowledge, attitudes, and participation amongst community-dwelling older people living in regional New South Wales, Australia: A cross-sectional survey. PLoS One 2024; 19:e0309152. [PMID: 39163286 PMCID: PMC11335115 DOI: 10.1371/journal.pone.0309152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 08/06/2024] [Indexed: 08/22/2024] Open
Abstract
BACKGROUND Advance personal planning (APP) involves planning for future periods of incapacity, including making legal decisions and documents. APP ensures that a person's values and preferences are known and respected. This study aimed to examine knowledge of APP, attitudes and confidence towards APP, and participation in APP activities among older people residing in regional and rural areas. METHODS A cross-sectional survey was conducted with people aged over 65 years residing in and around regional towns in New South Wales, Australia. Participants responded to a social media advertisement or information provided through a community organisation. Data was collected via pen and paper survey or an online survey. The survey was developed for the study and included questions about the participant and their experiences with APP. Poisson regression modelling was conducted to explore the relationship between APP participation and APP knowledge, confidence and attitudes as well as the participant characteristics associated with APP participation. RESULTS Overall, 216 people completed the survey. Most participants had a will (90%) but only a third (32%) had documented an advance care directive. Knowledge of APP was low with only 2.8% of participants correctly answering all 6 knowledge questions. Participants had a positive attitude towards APP and high level of confidence that they could discuss APP issues with important people in their life. Those with increased knowledge, confidence and attitude towards APP were significantly more likely to participate in APP activities. Older age and having private health insurance were significantly associated with engaging in APP activities. Increased frailty and the presence of health conditions were not associated with increased APP participation. CONCLUSIONS There is a need to increase engagement with APP particularly among those who may be considered frail or have chronic health conditions. Increasing knowledge of, confidence and attitudes towards, APP could help to increase engagement in APP activities.
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Affiliation(s)
- Emilie C. Cameron
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Equity in Health and Wellbeing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Nola Ries
- Faculty of Law, University of Technology Sydney, Sydney, NSW, Australia
| | - Amy Waller
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
| | - Briony Johnston
- Faculty of Law, University of Technology Sydney, Sydney, NSW, Australia
| | - John Anderson
- School of Law and Justice, College of Human & Social Futures, University of Newcastle, City Campus, Newcastle, NSW, Australia
| | - Jamie Bryant
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Equity in Health and Wellbeing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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Bradshaw A, Birtwistle J, Evans CJ, Sleeman KE, Richards S, Foy R, Millares Martin P, Carder P, Allsop MJ, Twiddy M. Factors Influencing the Implementation of Digital Advance Care Planning: Qualitative Interview Study. J Med Internet Res 2024; 26:e50217. [PMID: 39151167 PMCID: PMC11364948 DOI: 10.2196/50217] [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: 06/23/2023] [Revised: 10/18/2023] [Accepted: 05/30/2024] [Indexed: 08/18/2024] Open
Abstract
BACKGROUND Palliative care aims to improve the quality of life for people with life-limiting illnesses. Advance care planning conversations that establish a patient's wishes and preferences for care are part of a person-centered approach. Internationally, electronic health record systems are digital interventions used to record and share patients' advance care plans across health care services and settings. They aim to provide tools that support electronic information sharing and care coordination. Within the United Kingdom, Electronic Palliative Care Coordination Systems (EPaCCS) are an example of this. Despite over a decade of policy promoting EPaCCS nationally, there has been limited implementation and consistently low levels of use by health professionals. OBJECTIVE The aim of this study is to explore the factors that influence the implementation of EPaCCS into routine clinical practice across different care services and settings in 2 major regions of England. METHODS A qualitative interview study design was used, guided by Normalization Process Theory (NPT). NPT explores factors affecting the implementation of complex interventions and consists of 4 primary components (coherence, cognitive participation, collective action, and reflexive monitoring). Health care and social care practitioners were purposively sampled based on their professional role and work setting. Individual web-based semistructured interviews were conducted. Data were analyzed using thematic framework analysis to explore issues which affected the implementation of EPaCCS across different settings at individual, team, organizational, and technical levels. RESULTS Participants (N=52) representing a range of professional roles were recruited across 6 care settings (hospice, primary care, care home, hospital, ambulatory, and community). In total, 6 themes were developed which mapped onto the 4 primary components of NPT and represented the multilevel influences affecting implementation. At an individual level, these included (1) EPaCCS providing a clear and distinct way of working and (2) collective contributions and buy-in. At a team and organizational level, these included (3) embedding EPaCCS into everyday practice and (4) championing driving implementation. At a technical level, these included (5) electronic functionality, interoperability, and access. Breakdowns in implementation at different levels led to variations in (6) confidence and trust in EPaCCS in terms of record accuracy and availability of access. CONCLUSIONS EPaCCS implementation is influenced by individual, organizational, and technical factors. Key challenges include problems with access alongside inconsistent use and engagement across care settings. EPaCCS, in their current format as digital advance care planning systems are not consistently facilitating electronic information sharing and care coordination. A redesign of EPaCCS is likely to be necessary to determine configurations for their optimal implementation across different settings and locations. This includes supporting health care practitioners to document, access, use, and share information across multiple care settings. Lessons learned are relevant to other forms of digital advance care planning approaches being developed internationally.
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Affiliation(s)
- Andy Bradshaw
- Cicely Saunders Institute, Kings College London, London, United Kingdom
| | | | - Catherine J Evans
- Cicely Saunders Institute, Kings College London, London, United Kingdom
- Sussex Community NHS Foundation Trust, Brighton, United Kingdom
| | | | - Suzanne Richards
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Paul Carder
- NHS West Yorkshire Integrated Care Board, White Rose House, Wakefield, United Kingdom
| | - Matthew J Allsop
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Maureen Twiddy
- Hull York Medical School, Institute of Clinical and Applied Health Research, Allam Medical Building, University of Hull, Hull, United Kingdom
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Winnifrith T, Millington-Sanders C, Husbands E, Haros J, Ballinger H. Proactive advance care planning conversations in general practice: a quality improvement project. BMJ Open Qual 2024; 13:e002679. [PMID: 38977313 PMCID: PMC11256018 DOI: 10.1136/bmjoq-2023-002679] [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: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 07/10/2024] Open
Abstract
Advance care planning (ACP) is a process of discussion, reflection and communication, enabling planning for future medical treatment. Despite evidence of benefits of ACP to patients, families and the healthcare system, many die without an opportunity for such conversations, particularly those living with progressive non-malignant conditions. The Royal College of General Practitioners and Marie Curie Daffodil Standards launched in 2020 provide primary care with a structure for improving end-of-life care, including delivery of ACP. Proactive identification of patients is integral to the approach.We report on a quality improvement project which aimed to assess the take-up rate and acceptability in general practice of a timely and personalised ACP conversation using a 'What matters to you' (WMTY) framework, and to ensure that different diagnostic and demographic groups were included.Patients without previous ACP and potentially in the last year of life were offered an ACP conversation; a survey sought feedback.81% accepted the offer and in most cases, future care guidance was documented using the recognised format in Gloucestershire for recording ACP conversations, the Recommended Summary for Emergency Care and Treatment (ReSPECT) plan. Clinician and patient satisfaction was high.We concluded that an ACP discussion using a 'WMTY' format was highly acceptable to most. With recognised enablers in place and known barriers minimised, valuable personalised conversations occurred. Reframing the conversation to focus on how someone wants to live, while including their priorities for death, could alter how such conversations are perceived by clinicians and the public. It could remove negative associations (such as linking these conversations with an imminent death), which may increase motivation for all to initiate discussions.ACP conversations are evidenced best practice and could become routine in general practice with adjustments to practice processes and clinician education; the Daffodil Standards facilitate continued quality improvement.
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Affiliation(s)
| | | | - Emma Husbands
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
| | - Jane Haros
- Gloucestershire Health and Care NHS FoundationTrust, Brockworth, UK
| | - Helen Ballinger
- Gloucestershire Health and Care NHS FoundationTrust, Brockworth, UK
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Stevens J, Scherrens AL, Pype P, Deliens L, De Vleminck A, Pardon K. Experiences with implementing advance care planning (ACP-GP) in Belgian general practice in the context of a cluster RCT: a process evaluation using the RE-AIM framework. BMC PRIMARY CARE 2024; 25:247. [PMID: 38971761 PMCID: PMC11227713 DOI: 10.1186/s12875-024-02510-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 07/01/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND General practice is often recommended as an ideal setting to initiate advance care planning (ACP), but uptake of ACP in this setting is low. ACP-GP is a complex intervention to facilitate ACP for patients with chronic, life-limiting illness in Belgian general practice. It aims to increase patient ACP engagement and general practitioner (GP) ACP self-efficacy. In a cluster-randomized controlled trial, the intervention was not superior to control in increasing these outcomes. A parallel process evaluation aimed to enhance understanding of how the intervention was implemented, and which factors might have influenced trial results. METHODS We conducted a mixed-methods process evaluation following the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data sources include recruitment and implementation monitoring, questionnaires for patients and GPs, and semi-structured (focus group) interviews with patients and GPs. Questionnaire data were analyzed descriptively. Qualitative data were first analyzed inductively; themes were then assigned deductively to RE-AIM dimensions. RESULTS Thirty-five GPs and 95 patients were recruited to the trial; GP reach was low. Sixteen GPs and 46 patients provided questionnaire data at 3 months post-baseline; qualitative data were transcribed for 14 GPs and 11 patients. Adoption of intervention components was moderate to good, with the exception of the documentation template for GPs. Interviews revealed varying patient attitudes towards ACP, but patients nonetheless emphasized that conversations made them feel reassured. GPs especially valued a positive framing of ACP. When adopted, the intervention was well-implemented and participant satisfaction was high. However, intention for maintenance was moderate, with GPs raising questions of how to sustainably implement ACP conversations in the future. CONCLUSIONS Implementing the complex ACP-GP intervention in general practice is feasible, and can be successful. However, the implementation process is challenging and the sustainability is suboptimal. Our findings will guide future research and recommendations for facilitating and implementing ACP in general practice. TRIAL REGISTRATION ISRCTN12995230; prospectively registered on 19/06/2020.
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Affiliation(s)
- Julie Stevens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium.
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels, 1090, Belgium.
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, Gent, 9000, Belgium.
| | - Anne-Lore Scherrens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, Gent, 9000, Belgium
| | - Peter Pype
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, Gent, 9000, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, Gent, 9000, Belgium
| | - Aline De Vleminck
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels, 1090, Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels, 1090, Belgium
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Baylina Melé M, Villavicencio-Chávez C, Garzón Rodríguez C, Edo-Gual M, Crespo I. Design and development of a new pictorial tool to facilitate communication around advance care planning. Age Ageing 2024; 53:afae148. [PMID: 39023235 DOI: 10.1093/ageing/afae148] [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: 04/03/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Advance care planning (ACP) aims to ensure that people with chronic or advanced disease receive medical care that is consistent with their values and preferences. However, professionals may find it challenging to engage these patients in conversations about the end of life. We sought to develop a pictorial tool to facilitate communication around ACP. METHODS This was a three-phase study. In phase 1, we used the nominal group and Delphi techniques to achieve expert consensus regarding the conceptual content of the tool. In phase 2, a professional cartoonist was commissioned to create a series of cartoons representing each of the content areas resulting from the Delphi process. The pictorial tool was then administered (phase 3) with a sample of individuals with advanced/chronic disease to explore whether the cartoons were easy to understand and conveyed the intended message. RESULTS Following a three-round Delphi process, consensus was reached regarding a set of 12 key content areas that should be considered in the context of an ACP interview. The cartoons created to represent each of the 12 areas were then reviewed and ordered so as to reflect the typical stages of an end-of-life care interview. After administering the pictorial tool with 24 frail older adults with advanced/chronic disease, changes were made to 9 of the 12 cartoons. CONCLUSIONS The new pictorial tool comprises a set of 12 cartoons that can guide professionals as they seek to engage frail older adults with advanced/chronic disease in conversations about the end of life and ACP.
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Affiliation(s)
- Mireia Baylina Melé
- Convalescent Care Geriatric Unit, Centre Assistencial Prytanis, Sant Boi de Llobregat (Barcelona), Spain
- Research Unit, Fundación Caredoctors, Barcelona, Spain
- School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Valles (Barcelona), Spain
| | - Christian Villavicencio-Chávez
- Research Unit, Fundación Caredoctors, Barcelona, Spain
- School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Valles (Barcelona), Spain
| | - Cristina Garzón Rodríguez
- Research Unit, Fundación Caredoctors, Barcelona, Spain
- Department of Internal Medicine, Hospital San Juan de Dios, Seville, Spain
| | - Montserrat Edo-Gual
- Escoles Universitàries Gimbernat, Universitat Autònoma de Barcelona, Sant Cugat del Vallès (Barcelona), Spain
| | - Iris Crespo
- Department of Basic Sciences, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
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Bourmorck D, Pétré B, de Saint-Hubert M, De Brauwer I. Is palliative care a utopia for older patients with organ failure, dementia or frailty? A qualitative study through the prism of emergency department admission. BMC Health Serv Res 2024; 24:773. [PMID: 38956595 PMCID: PMC11218079 DOI: 10.1186/s12913-024-11242-2] [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: 01/24/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Nearly three out of four older people will use the emergency department (ED) during their last year of life. However, most of them do not benefit from palliative care. Providing palliative care is a real challenge for ED clinicians who are trained in acute, life-saving medicine. Our aim is to understand the ED's role in providing palliative care for this population. METHODS We designed a qualitative study based on 1) interviews - conducted with older patients (≥ 75 years) with a palliative profile and their informal caregivers - and 2) focus groups - conducted with ED and primary care nurses and physicians. Palliative profiles were defined by the Supportive and Palliative Indicators tool (SPICT). Qualitative data was collected in French-speaking Belgium between July 2021 and July 2022. We used a constant inductive and comparative analysis. RESULTS Five older patients with a palliative profile, four informal caregivers, 55 primary and ED caregivers participated in this study. A priori, the participants did not perceive any role for the ED in palliative care. In fact, there is widespread discomfort with caring for older patients and providing palliative care. This is explained by multiple areas of tensions. Palliative care is an approach fraught with pitfalls, i.e.: knowledge and know-how gaps, their implementation depends on patients'(co)morbidity profile and professional values, experiences and type of practice. In ED, there are constant tensions between emergency and palliative care requirements, i.e.: performance, clockwork and needs for standardised procedures versus relational care, time and diversity of palliative care projects. However, even though the ED's role in palliative care is not recognised at first sight, we highlighted four roles assumed by ED caregivers: 1) Investigator, 2) Objectifier, 3) Palliative care provider, and 4) Decision-maker on the intensity of care. A common perception among participants was that ED caregivers can assist in the early identification of patients with a palliative profile. CONCLUSIONS Currently, there is widespread discomfort regarding ED caregivers caring for older patients and providing palliative care. Nonetheless, ED caregivers play four roles in palliative care for older patients. In the future, ED caregivers might also perform the role of early identifier.
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Affiliation(s)
- Delphine Bourmorck
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium.
| | - Benoit Pétré
- Department of Public Health Sciences, Faculty of Medecine, University of Liège, Liège, Belgium
| | - Marie de Saint-Hubert
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- CHU-UCL Namur, Yvoir, Belgium
| | - Isabelle De Brauwer
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- Department of Geriatric Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Daenen F, Stevens J, Deliens L, Pype P, Beernaert K, De Vleminck A, Pardon K. General practitioner advance care planning knowledge and attitudes: ACP-GP cluster-randomised controlled trial. BMJ Support Palliat Care 2024:spcare-2024-004977. [PMID: 38925875 DOI: 10.1136/spcare-2024-004977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES Advance care planning (ACP) supports adults understanding and sharing their values, goals, and preferences regarding future medical care. General practitioners (GPs) are key figures in conducting ACP conversations with patients. GPs' ACP knowledge and attitudes have been identified as potential barriers. This study evaluates the effects of ACP-GP, a complex ACP intervention, on GPs' knowledge and attitudes. METHODS A phase-III cluster-randomised controlled trial. 35 Belgian GPs participated. The intervention included a training for GPs, ACP conversations, a patient workbook, and a documentation template. GPs' knowledge and attitudes were assessed using an adaptation of the Next Steps questionnaire, at baseline, three, and six months postintervention. Generalised estimating equations were applied to analyse the data. RESULTS Analyses showed no intervention effect on GPs' knowledge (W(2)=4.18, p=.123) and attitudes (all W(2)<3.85, all p>.146) compared with the control group. CONCLUSIONS The ACP-GP intervention did not improve GPs' knowledge and attitudes. Failure to detect an effect may stem from a ceiling effect, with GPs scoring high on baseline outcomes across groups. Questionnaires may require fine-tuning to accurately map their suggested role as potential barriers. TRIAL REGISTRATION NUMBER Prospectively registered at ISRCTN (ISRCTN12995230) on 19 June 2020.
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Affiliation(s)
- Frederick Daenen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Julie Stevens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Peter Pype
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Aline De Vleminck
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Stevens J, Elston D, Tan A, Barwich D, Carter RZ, Cochrane D, Frenette N, Howard M. Clinicians' experiences implementing an advance care planning pathway in two Canadian provinces: a qualitative study. BMC PRIMARY CARE 2024; 25:217. [PMID: 38879532 PMCID: PMC11179357 DOI: 10.1186/s12875-024-02468-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 06/04/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Advance care planning (ACP) is a process which enables patients to communicate wishes, values, fears, and preferences for future medical care. Despite patient interest in ACP, the frequency of discussions remains low. Barriers to ACP may be mitigated by involving non-physician clinic staff, preparing patients ahead of visits, and using tools to structure visits. An ACP care pathway incorporating these principles was implemented in longitudinal generalist outpatient care, including primary care/family medicine and general internal medicine, in two Canadian provinces. This study aims to understand clinician experiences implementing the pathway. METHODS The pathway was implemented in one family practice in Alberta, two family practices in British Columbia (BC), and one BC internal medicine outpatient clinic. Physicians and allied health professionals delivered structured pathway visits based on the Serious Illness Conversation Guide. Twelve physicians and one social worker participated in interviews or focus groups at the end of the study period. Qualitative data were coded inductively using an iterative approach, with regular meetings between coders. RESULTS Clinicians described experiences with the ACP care pathway, impact at the clinician level, and impact at the patient level. Within each domain, clinicians described barriers and facilitators experienced during implementation. Clinicians also reflected candidly about potential for future implementation and the sustainability of the pathway. CONCLUSIONS While the pathway was implemented slightly differently between provinces, core experiences were that implementation of the pathway, and integration with current practice, were feasible. Across settings, similar themes recurred regarding usefulness of the pathway structure and its tools, impact on clinician confidence and interactions with patients, teamwork and task delegation, compatibility with existing workflow, and patient preparation and readiness. Clinicians were supportive of ACP and of the pathway. TRIAL REGISTRATION The study was prospectively registered with clinicaltrials.gov (NCT03508557). Registered April 25, 2018. https://classic. CLINICALTRIALS gov/ct2/show/NCT03508557 .
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Affiliation(s)
- Julie Stevens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Laarkbeeklaan 103, Brussels, Belgium.
| | - Dawn Elston
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
| | - Amy Tan
- Department of Medicine, Faculty of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, Canada
| | - Doris Barwich
- Department of Medicine, Faculty of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, Canada
- BC Centre for Palliative Care, 300 - 601 Sixth St., New Westminster, BC, Canada
| | - Rachel Zoe Carter
- Department of Medicine, Faculty of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, Canada
- BC Centre for Palliative Care, 300 - 601 Sixth St., New Westminster, BC, Canada
| | - Diana Cochrane
- BC Centre for Palliative Care, 300 - 601 Sixth St., New Westminster, BC, Canada
| | - Nicole Frenette
- Department of Family Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
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Marshall KH, Riddiford-Harland DL, Meller AE, Caplan GA, Naganathan V, Cullen J, Gonski P, Zwar NA, O’Keeffe JA, Krysinska K, Rhee JJ. Feasibility and Acceptability of Facilitated Advance Care Planning in Outpatient Clinics: A Qualitative Study of Patient and Caregivers Experiences. J Appl Gerontol 2024; 43:339-348. [PMID: 37949095 PMCID: PMC10875901 DOI: 10.1177/07334648231206742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023] Open
Abstract
Guidelines recommend advance care planning (ACP) for people with advanced illness; however, evidence supporting ACP as a component of outpatient care is lacking. We sought to establish the feasibility and acceptability of a facilitated ACP intervention for people attending tertiary outpatient clinics. Data from 20 semi-structured interviews with patient (M = 79.3 ± 7.7, 60% male) and caregiver (M = 68.1 ± 11.0, 60% female) participants recruited as part of a pragmatic, randomized controlled trial (RCT) were analyzed using qualitative descriptive methodology. Patients were randomized to intervention (e.g., facilitated support) or control (e.g., standard care). Intervention patients expressed high satisfaction, reporting the facilitated ACP session was clear, straightforward, and suited to their needs. Intervention caregivers did not report any significant concerns with the facilitated ACP process. Control participants reported greater difficulty completing ACP compared to intervention participants. Embedding facilitated ACP into tertiary outpatient care appears feasible and acceptable for people with advanced illnesses.
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Affiliation(s)
- Kate H. Marshall
- UNSW Academic General Practice Network, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Anne E. Meller
- Advance Care Planning Services, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Gideon A. Caplan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - John Cullen
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Peter Gonski
- Southcare Aged and Extended Community Care, Sutherland Hospital, Sydney, NSW, Australia
| | - Nicholas A. Zwar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Julie-Ann O’Keeffe
- Aged, Chronic Care and Rehabilitation, Sydney Local Health District, Sydney, NSW, Australia
| | - Karolina Krysinska
- Centre for Primary Health Care and Equity, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Joel J. Rhee
- UNSW Academic General Practice Network, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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10
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Lou Y. End-of-life care discussions with healthcare providers and dying experiences: A latent class analysis using the health and retirement study. Arch Gerontol Geriatr 2024; 119:105319. [PMID: 38171033 DOI: 10.1016/j.archger.2023.105319] [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: 10/03/2023] [Revised: 12/12/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND The impact of provider-patient end-of-life care conversations on the dying experience as a multi-dimensional concept among non-White population is understudied. The study examines whether such discussions are effective at improving end-of-life experiences among U.S. older adults with diverse backgrounds. METHODS The analytic sample featured 9,733 older adults who died between 2002 and 2019 in the Health and Retirement Study. Latent class analysis was used with sixteen end-of-life indicators, including service utilization of seven aggressive and supportive care, symptom management, and quality of care. Multinomial logistic regression was conducted to estimate the effects of provider-patient end-of-life discussions on the predicted membership. RESULTS Three types of end-of-life experiences were identified. People in "minimum service user with good death" (44.54 %) were least likely to use any type of medical care, either aggressive or comforting, and had best end-of-life symptom management and quality of care. Intensive care users (20.70 %) are characterized by very high use of aggressive treatments and low use of supportive care. "Extensive service user with uncomfortable death" (34.76 %) had high likelihoods of using both aggressive and comforting care and had the worst dying experience. Older adults who discussed their end-of-life wishes with providers were 49 % and 51 % more likely to be an intensive care user and extensive service user with uncomfortable death, respectively, rather than a minimum service user with good death. CONCLUSION Discussing end-of-life care wishes with providers is associated with worse end-of-life experiences. Efforts are needed to facilitate early initiation and effectiveness of the provider-patient end-of-life care conversation.
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Affiliation(s)
- Yifan Lou
- School of Medicine, Department of Internal Medicine, Yale University, 300 George, 7th Floor, New Haven, CT 06511, United States.
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11
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Slobogian V, Vig C, Shirt L, Shuman C, Sondermann M, Vanderveen M, Bouchal SR. How family physicians introduce palliative care to patients with chronic illnesses. Chronic Illn 2024; 20:135-144. [PMID: 37016737 DOI: 10.1177/17423953231168298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
OBJECTIVE Increasing numbers of Canadians living with complex, life-limiting conditions demand high-quality palliative care. Timely access to palliative care can help to reduce stress, improve quality of life, and provide relief for patients and their families. The purpose of this study is to explore the experiences of family physicians (FPs) regarding the decision and process of introducing palliative care to patients with chronic diseases. METHODS Interpretive description methodology was used to guide the investigation of the research question. Thirteen Calgary Zone FPs participated in individual interviews. Data was collected iteratively and analyzed using constant comparative analysis. RESULTS Analysis of interviews identified the overarching themes of dignity and empowerment, which describe the experience of FPs introducing palliative care to chronically ill patients. Four subthemes were woven throughout, including the art of conversation, therapeutic relationships, timing, and preparation of the patient and family. DISCUSSION While the benefits of palliative conversations are widely accepted, a deeper understanding of how FPs can be supported in developing this aspect of their practice is needed. Understanding their experience provides knowledge that can serve as a framework for future education, mentorship, and competency development.
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Affiliation(s)
- Vanessa Slobogian
- Palliative and End of Life Care, Alberta Health Services, Calgary Zone, Calgary, Canada
| | - Chandra Vig
- Palliative and End of Life Care, Alberta Health Services, Calgary Zone, Calgary, Canada
| | - Lisa Shirt
- Palliative and End of Life Care, Alberta Health Services, Calgary Zone, Calgary, Canada
| | - Chelsey Shuman
- Palliative and End of Life Care, Alberta Health Services, Calgary Zone, Calgary, Canada
| | - Margot Sondermann
- Palliative and End of Life Care, Alberta Health Services, Calgary Zone, Calgary, Canada
| | - Monique Vanderveen
- Palliative and End of Life Care, Alberta Health Services, Calgary Zone, Calgary, Canada
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12
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Romøren M, Hermansen KB, Sævareid TJL, Brøderud L, Westbye SF, Wahl AK, Thoresen L, Rostoft S, Førde R, Ahmed M, Aas E, Midtbust MH, Pedersen R. Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial. BMC Health Serv Res 2024; 24:220. [PMID: 38374100 PMCID: PMC10875743 DOI: 10.1186/s12913-024-10666-0] [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: 11/12/2023] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Acutely ill and frail older adults and their next of kin are often poorly involved in treatment and care decisions. This may lead to either over- or undertreatment and unnecessary burdens. The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions. METHODS This is a cluster randomized trial with 12 hospital units. The intervention arm receives implementation support for 18 months; control units receive the same support afterwards. The ACP intervention consists of 1. Clinical intervention: ACP; 2. Implementation interventions: Implementation team, ACP coordinator, network meetings, training and supervision for health care personnel, documentation tools and other resources, and fidelity measurements with tailored feedback; 3. Implementation strategies: leadership commitment, whole ward approach and responsive evaluation. Fidelity will be measured three times in the intervention arm and twice in the control arm. Here, the primary outcome is the difference in fidelity changes between the arms. We will also include 420 geriatric patients with one close relative and an attending clinician in a triadic sub-study. Here, the primary outcomes are quality of communication and decision-making when approaching the end of life as perceived by patients and next of kin, and congruence between the patient's preferences for information and involvement and the clinician's perceptions of the same. For patients we will also collect clinical data and health register data. Additionally, all clinical staff in both arms will be invited to answer a questionnaire before and during the implementation period. To explore barriers and facilitators and further explore the significance of ACP, qualitative interviews will be performed in the intervention units with patients, next of kin, health care personnel and implementation teams, and with other stakeholders up to national level. Lastly, we will evaluate resource utilization, costs and health outcomes in a cost-effectiveness analysis. DISCUSSION The project may contribute to improved implementation of ACP as well as valuable knowledge and methodological developments in the scientific fields of ACP, health service research and implementation science. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.
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Affiliation(s)
- Maria Romøren
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Karin Berg Hermansen
- Department for Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Aalesund, Norway
| | | | - Linn Brøderud
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Siri Færden Westbye
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Astrid Klopstad Wahl
- Department for Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lisbeth Thoresen
- Department for Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Reidun Førde
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Marc Ahmed
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Eline Aas
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
- Division of Health Science, Norwegian Institute of Public Health, Oslo, Norway
| | - May Helen Midtbust
- Department for Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Aalesund, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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13
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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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14
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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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15
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Gomes Souza L, Bouba DA, Corôa RDC, Dofara SG, Robitaille V, Blanchette V, Kastner K, Bergeron F, Guay-Bélanger S, Izumi SS, Totten AM, Archambault P, Légaré F. The Impact of Advance Care Planning on Healthcare Professionals' Well-being: A Systematic Review. J Pain Symptom Manage 2024; 67:173-187. [PMID: 37827454 DOI: 10.1016/j.jpainsymman.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/08/2023] [Accepted: 09/16/2023] [Indexed: 10/14/2023]
Abstract
CONTEXT Advance care planning (ACP) improves care for patients with chronic illnesses and reduces family stress. However, the impact of ACP interventions on healthcare professionals' well-being remains unknown. OBJECTIVE To systematically review the literature evaluating the impact of ACP interventions on healthcare professionals' well-being. METHODS We followed the Joanna Briggs Institute methodology for systematic reviews and registered the protocol in PROSPERO (CRD42022346354). We included primary studies in all languages that assessed the well-being of healthcare professionals in ACP interventions. We excluded any studies on ACP in psychiatric care and in palliative care that did not address goals of care. Searches were conducted on April 4, 2022, and March 6, 2023 in Embase, CINAHL, Web of Science, and PubMed. We used the Mixed Methods Appraisal Tool for quality analysis. We present results as a narrative synthesis because of their heterogeneity. RESULTS We included 21 articles published in English between 1997 and 2021 with 17 published after 2019. All were conducted in high-income countries, and they involved a total of 1278 participants. Three reported an interprofessional intervention and two included patient partners. Studies had significant methodological flaws but most reported that ACP had a possible positive impact on healthcare professionals' well-being. CONCLUSION This review is the first to explore the impact of ACP interventions on healthcare professionals' well-being. ACP interventions appear to have a positive impact, but high-quality studies are scarce. Further research is needed, particularly using more rigorous and systematic methods to implement interventions and report results.
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Affiliation(s)
- Lucas Gomes Souza
- Department of Social and Preventive Medicine (L.G.S., D.A.B.), Faculty of Medicine, Université Laval, Québec, Canada, and VITAM, Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, QC, Canada
| | - Dalil Asmaou Bouba
- Department of Social and Preventive Medicine (L.G.S., D.A.B.), Faculty of Medicine, Université Laval, Québec, Canada, and VITAM, Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, QC, Canada
| | - Roberta de Carvalho Corôa
- Department of Family Medicine and Emergency Medicine (R.C.C.), VITAM, Centre de recherche en santé durable, Unité de soutien au système de santé apprenant, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Suélène Georgina Dofara
- VITAM, Centre de recherche en santé durable (S.G.B., S.G.D.), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, QC, Canada
| | - Vincent Robitaille
- Faculty of Medicine, Université Laval (V.R.), VITAM, Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, QC, Canada
| | - Virginie Blanchette
- Department of Human Kinetics and Podiatric Medicine (V.B.), Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | | | | | - Sabrina Guay-Bélanger
- VITAM, Centre de recherche en santé durable (S.G.B., S.G.D.), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, QC, Canada
| | | | - Annette M Totten
- Department of Medical Informatics and Clinical Epidemiology (A.M.T.), School of Medicine, Oregon Health & Science University, Portland, OR
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine (P.A.), Faculty of Medicine, Université Laval, VITAM, Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Québec, QC, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine (F.L.), Faculty of Medicine, Université Laval, VITAM, Centre de recherche en santé durable, Researcher, Centre de recherche du CHU de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, QC, Canada.
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Vashisht A, Gutman G, Kaur T. ACP Conversations with Chinese and South Asian Patients: Physicians' Perspectives of Barriers and Facilitating Factors. Can Geriatr J 2023; 26:486-492. [PMID: 38045880 PMCID: PMC10684305 DOI: 10.5770/cgj.26.691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Introduction/Objective Advance Care Planning (ACP) discussions are infrequently conducted with physicians, even fewer among minorities. We explored physicians' experiences in engaging Chinese (CH) and South Asian (SA) patients in ACP conversations to understand initiation and participation patterns, topics covered, and barriers and facilitating factors. Method Twenty-two physicians with 15%+ SA patients aged 55+ and 19 with 15%+ CH patients aged 55+ were interviewed. Results SA- and CH-serving physicians described similar initiation patterns, cultural context, and need for standardized ACP routines. However, the SA-serving physicians described greater involvement of family members, while CH-serving physicians described more communication barriers and family members' desire to hide the diagnosis from patients. Conclusion Cultural taboos surrounding discussion around death and dying appear to influence CH older adults and families strongly. Lack of familiarity with ACP amongst the SA population accounts more for their limited engagement in ACP discussions.
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Affiliation(s)
- Avantika Vashisht
- Gerontology Research Center, Simon Fraser University, Vancouver, BC
- Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC
| | - Gloria Gutman
- Gerontology Research Center, Simon Fraser University, Vancouver, BC
| | - Taranjot Kaur
- Gerontology Research Center, Simon Fraser University, Vancouver, BC
- Biological Studies, Simon Fraser University, Burnaby, BC,
Canada
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17
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Apramian T, Virag O, Gallagher E, Howard M. Fighting Fires and Battling the Clock: Advance Care Planning in Family Medicine Residency. Fam Med 2023; 55:574-581. [PMID: 37441757 PMCID: PMC10622132 DOI: 10.22454/fammed.2023.678786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Few family physicians treating patients with life-limiting illness report regularly initiating advance care planning (ACP) conversations about illness understanding, values, or care preferences. To better understand how family medicine training contributes to this gap in clinical care, we asked how family medicine residents learn to engage in ACP in the workplace. METHODS We coded semistructured interviews with family medicine residents (n=9), reflective memos (n=9), and autoethnographic field notes (n=37) using a constructivist-grounded theory approach. We next used the constant comparative method of grounded theory to develop two composite narratives describing participants' experiences that we then member-checked with participants. RESULTS We identified six core categories of social process to describe how participants were taught to engage in advance care planning. These social processes included previously unidentified barriers to ACP that were specific to their role as learners. These barriers appeared to lead to cultural avoidance of prognosis, conflation of ACP and goals of care (GOC) conversations, and deferral of difficult conversations to nonprimary care settings. CONCLUSIONS Family medicine educators should consider developing interventions such as flexible clinic schedules, dedicated ACP time, deliberate observed practice, and structured teaching to address potential barriers identified in this exploratory research. Family medicine leaders may wish to consider directly teaching residents and preceptors about crucial differences between ACP and GOC discussions. Shifting curricular focus toward eliciting values and illness understanding during ACP could help resolve a cultural avoidance of prognosis that limits family medicine residents' attempts to engage in ACP.
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Affiliation(s)
- Tavis Apramian
- Division of Palliative Care, Department of Family & Community Medicine, University of TorontoToronto, ONCanada
| | - Olivia Virag
- Department of Family Medicine, McMaster UniversityHamilton, ONCanada
| | - Erin Gallagher
- Division of Palliative Care, Department of Family Medicine, McMaster UniversityHamilton, ONCanada
| | - Michelle Howard
- Division of Palliative Care, Department of Family Medicine, McMaster UniversityHamilton, ONCanada
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18
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Carter RZ, Ludwig M, Gao A, Tan A, Barwich D, Howard M. Primary care providers' perceptions on the integration of community-led advance care planning activities with primary care: a cross-sectional survey. BMC PRIMARY CARE 2023; 24:197. [PMID: 37743490 PMCID: PMC10519084 DOI: 10.1186/s12875-023-02144-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 08/30/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Advance care planning (ACP) is a process intended to help ensure people receive medical care that is consistent with their values, goals, and preferences during serious and chronic illness. Barriers to implementing ACP in primary care settings exist. Community-led ACP initiatives exist in British Columbia to engage the public directly. These initiatives may help prepare people for conversations with their primary care providers. The objectives of this study were to elicit primary care providers' perceptions of the utility and desired content of community-led ACP activities and suggestions for integrating community-led ACP activities with primary care. METHODS We conducted an online cross-sectional survey of primary care providers practicing in British Columbia, Canada in 2021. Both quantitative and qualitative survey questions addressed ACP engagement in practice, the perceived role and desired outcomes of community-led ACP activities, and ways to integrate community-led ACP activities with primary care. RESULTS Eighty-one providers responded. Over 80% perceived a moderate or greater potential impact of community-led ACP activities. The most common reasons for not referring a patient to a community-led ACP activity were lack of awareness of the option locally (62.1%) and in general (44.8%). Respondents wanted their patients to reflect on their values, wishes and preferences for care, to have at least thought about their goals of care and to have chosen a substitute decision maker in the community. They indicated a desire for a summary of their patient's participation and a follow-up discussion with them about their ACP. They suggested ways to integrate referral to programs into existing health care system structures. CONCLUSIONS Community-led ACP activities were perceived to be useful to engage and prepare patients to continue ACP discussions with clinicians. Efforts should be made to establish and integrate community-based ACP initiatives within existing primary care systems to ensure awareness and uptake.
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Affiliation(s)
- Rachel Z Carter
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada.
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada.
| | - Monika Ludwig
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada
| | - Angela Gao
- Michael G. DeGroote School of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Amy Tan
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Doris Barwich
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
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19
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Guma S, Namisango E, Ddungu H. Advance Care Planning and palliative care for patients with advanced cancer in Uganda. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:29-35. [PMID: 37550121 DOI: 10.1016/j.zefq.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/21/2023] [Accepted: 07/21/2023] [Indexed: 08/09/2023]
Abstract
The study sought to identify the extent to which Advance Care Planning (ACP) is practised by palliative care health professionals providing care to patients with advanced cancer and their families in Uganda. A mixed methods study design using qualitative and quantitative methods was used for the assessment. In-depth interviews with a group of nine highly experienced health professionals were conducted using a semi-structured interview guide. Quantitative data were retrieved and analysed from a survey administered to 124 health professionals of whom only 57 (45.9%) responded. The qualitative data were analysed using inductive thematic analysis and descriptive analysis was used for the quantitative data. Of the 57 health professionals who participated in the survey, 87% were aware of ACP and 55% reported regular practice. Fifty-five (55%) percent reported regular provision of ACP for their patients and 46% reported engaging in informal ACP practices. However, 58.5% resp. 37.5% reported that they routinely provide ACP to more than 50% resp. 75% of their patients. A group of nine highly experienced palliative care professionals had a pooled ACP prevalence of only 1.2%. There was a generally good attitude towards ACP with 98.2% acknowledging that patients should be able to determine their future care. However, 32% reported being uncomfortable withholding or withdrawing life sustaining treatment. There are a number of socio-cultural beliefs and barriers, for instance that discussing death and dying is a "taboo", as well as witchcraft, family influence in decision-making, religious beliefs that do not agree with palliative care practices and a preference to use aggressive treatment like chemotherapy for terminally ill, etc. Institutional barriers like lack of a legal framework for ACP, limited time for health professionals to engage in ACP and other patient factors such as denial of diagnosis and collusion to withhold information from patients were reported by 78.2% resp. 84% of the respondents. Despite the good awareness and attitude to ACP, there is a range of barriers that are affecting the implementation of ACP in Uganda. There is need for development of a legal framework for ACP, more research to understand the contextual barriers and develop appropriate education and public sensitisation programs.
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Affiliation(s)
| | - Eve Namisango
- African Palliative Care Association, Kampala, Uganda
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Nowels MA, Nowels D, Sheffler J, Lum HD. Characteristics of international primary care practices and physicians related to advance care planning: a cross-sectional survey study. BMC PRIMARY CARE 2023; 24:146. [PMID: 37452276 PMCID: PMC10347754 DOI: 10.1186/s12875-023-02103-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Primary care providers (PCPs) are well-situated to delivery primary palliative care such as advance care planning (ACP). The aim of this work is to identify practice characteristics, including features found in advanced primary care models (APCMs), that predict PCP engagement of patients in ACP. METHODS We analyzed characteristics of physician respondents and their practices associated with ACP conversations in older and sicker patients using data from 11 countries who participated in the 2015 Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations. The primary outcome was how routinely these ACP conversations are reported. We used a validated measure to describe practice-level characteristics of advanced primary care models. We conducted bivariate and multivariable analyses to determine PCP and practice characteristics associated with routinely engaging patients in ACP and with documenting patient preferences in medical records. RESULTS Respondents (N = 12,049) predominantly were older than 45 and did not view their jobs as high stress. PCPs reported routinely engaging patients in ACP work in practices with more APCM features. They are more likely to view their jobs as high stress, to work more hours, to practice in rural areas, and to work in smaller practices. Multivariable analyses showed that older PCP age, higher perceived stress of the job, practice location in rural areas, and increased number of APCM features were associated with more ACP conversations. Increased number of APCM features was also associated with higher odds of routinely recording patient preferences in their medical records. CONCLUSIONS In this international survey, physician and practice characteristics, including having features associated with APCMs, were associated with whether physicians routinely discuss ACP with patients who are older and sicker. Many features of APCMs may facilitate ACP discussions between PCPs and patients.
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Affiliation(s)
- Molly A Nowels
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA.
- Institute for Health, Health Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA.
| | - David Nowels
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Julia Sheffler
- Center for Translational Behavioral Science, Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Bryant J, Mansfield E, Cameron E, Sanson-Fisher R. Experiences and preferences for advance care planning following a diagnosis of dementia: Findings from a cross-sectional survey of carers. PLoS One 2023; 18:e0286261. [PMID: 37307258 DOI: 10.1371/journal.pone.0286261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/12/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Future medical and financial planning is important for persons with dementia given the impact of the disease on capacity for decision making. AIMS To explore from the perspective of carers of persons with dementia: (1) Participation in future medical and financial planning by the person they care for, including when planning was undertaken and the characteristics associated with having an advance care directive completed; (2) The type of healthcare providers who discussed advance care planning following diagnosis; and (3) Preferences for timing of discussions about advance care planning following diagnosis. METHODS Recruitment and data collection took place between July 2018 and June 2020. Carers of persons with dementia aged 18 years and older were mailed a survey. Participants completed questions regarding completion of various future planning documents by the person they support, including time of completion and who discussed advance care planning following diagnosis. Participants were presented with information about the benefits and consequences of early and late discussions of advance care planning and asked when discussions about advance care planning were best initiated. RESULTS 198 carers participated. Most participants were female (74%) and had been a carer for more than 2 years (82%). Most participants reported that the person with dementia they support had made a Will (97%) and appointed an Enduring Guardian (93%) and Enduring Power of Attorney (89%). Only 47% had completed an advance care directive. No significant associations were found between characteristics of persons with dementia and completion of an advance care directive. Geriatricians (53%) and GPs (51%) most often discussed advance care planning following diagnosis. Most carers thought that discussions about advance care planning should occur in the first few weeks or months following diagnosis (32%), at the healthcare provider's discretion (31%), or at the time of diagnosis (25%). CONCLUSIONS More than half of persons with dementia do not have an advance care directive. There is variability in preferences for timing of discussions following dementia diagnosis.
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Affiliation(s)
- Jamie Bryant
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Elise Mansfield
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Emilie Cameron
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Rob Sanson-Fisher
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
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Demirkapu H, Hajji R, Chater B, De Maesschalck S, Van den Block L, De Vleminck A, Devroey D. Advance care planning among older adults of Moroccan origin: An interview-based study. PATIENT EDUCATION AND COUNSELING 2023; 113:107794. [PMID: 37196404 DOI: 10.1016/j.pec.2023.107794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 04/12/2023] [Accepted: 05/11/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To explore advance care planning (ACP)-related knowledge, experience, views, facilitators and barriers among older Moroccan adults in Belgium. METHOD General practitioners (GPs) recruited participants for semi-structured interviews. Data were analysed using the constant comparative method. RESULTS The 25 interviewees (average age, 74 years) lacked ACP knowledge and had not discussed it with healthcare professionals. After a brief explanation, most interviewees did not find ACP useful. After more explanation with a specific example, they had fewer religious objections and were more willing to have discussions with their GPs and/or relatives. ACP barriers were a lack of knowledge, current good health, potential harm of talking about death, trust in one's children to make care decisions and fear of worrying one's children. Facilitators were GPs' information provision, children's involvement in ACP discussions and the desire to not depend on children. CONCLUSION Many older Moroccan adults lacked familiarity, but were willing to discuss ACP after receiving understandable concrete information. GPs should facilitate ACP discussions for these patients, ideally with adult children involved, with consideration of barriers, individual preferences and generally low educational levels. PRACTICE IMPLICATIONS GPs should provide comprehensible ACP information with case examples and consider potential barriers and facilitators in this group.
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Affiliation(s)
- Hakki Demirkapu
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Redouan Hajji
- Academic Center for General Practice KU Leuven, Leuven, Belgium
| | - Brahim Chater
- Academic Center for General Practice KU Leuven, Leuven, Belgium
| | | | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, and Ghent University, Ghent, Belgium
| | - Aline De Vleminck
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, and Ghent University, Ghent, Belgium
| | - Dirk Devroey
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
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Zhu N, Yang L, Wang X, Tuo J, Chen L, Deng R, Kwan RYC. Experiences and perspectives of healthcare professionals implementing advance care planning for people suffering from life-limiting illness: a systematic review and meta-synthesis of qualitative studies. BMC Palliat Care 2023; 22:55. [PMID: 37149560 PMCID: PMC10163819 DOI: 10.1186/s12904-023-01176-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/24/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Life-limited patients may lose decision-making abilities during disease progression. Advance care planning can be used as a discussion method for healthcare professionals to understand patients' future care preferences. However, due to many difficulties, the participation rate of healthcare professionals in advance care planning is not high. AIM To explore the facilitators of and barriers to healthcare professionals' provision of advance care planning to life-limited patients to better implement it for this population. METHODS We followed ENTREQ and PRISMA to guide this study. We conducted a systematic search of PubMed, Web of Science, Embase, CINAHL, PsycINFO, CNKI, and SinoMed to include qualitative data on the experiences and perspectives of healthcare professionals in different professional fields in providing advance care planning for life-limited patients. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to assess the quality of the included studies. RESULTS A total of 11 studies were included. Two themes were identified: unsupported conditions and facilitative actions. Healthcare professionals regarded cultural concepts, limited time, and fragmented record services as obstacles to implementation. They had low confidence and were overly concerned about negative effects. They needed to possess multiple abilities, learn to flexibly initiate topics, and facilitate effective communication based on multidisciplinary collaboration. CONCLUSION Healthcare professionals need an accepting cultural environment to implement advance care planning, a sound legal system, financial support, and a coordinated and shared system to support them. Healthcare systems need to develop educational training programs to increase the knowledge and skills of healthcare professionals and to promote multidisciplinary collaboration to facilitate effective communication. Future research should compare the differences in the needs of healthcare professionals in different cultures when implementing advance care planning to develop systematic implementation guidelines in different cultures.
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Affiliation(s)
- Nanxi Zhu
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
- Nursing Department, Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, 519100, China
| | - Liu Yang
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
| | - Xianlin Wang
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
| | - Jinmei Tuo
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
| | - Liuliu Chen
- School of Health, Zhuhai College of Science and Technology, Zhuhai, 519041, China
| | - Renli Deng
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China.
- Nursing Department, Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, 519100, China.
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Stevens J, Miranda R, Deliens L, Pype P, De Vleminck A, Pardon K. Advance care planning engagement in patients with chronic, life-limiting illness: baseline findings from a cluster-randomised controlled trial in primary care. Br J Gen Pract 2023; 73:e384-e391. [PMID: 37012079 PMCID: PMC10098835 DOI: 10.3399/bjgp.2022.0100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 10/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) has been characterised as a complex process of communication and decision making. For ACP behaviour change, underlying processes such as self-efficacy and readiness are needed. However, studies about which patient characteristics are associated with ACP have mainly focused on whether ACP actions are completed, leaving behaviour change processes unexplored. AIM To assess whether patients' characteristics and patient-perceived quality of GP ACP communication were associated with patients' ACP engagement. DESIGN AND SETTING Baseline data were used from the ACP-GP cluster-randomised controlled trial in patients with chronic, life-limiting illness (n = 95). METHOD Patients completed questionnaires detailing demographic and clinical characteristics, and their perception about their GPs' ACP information provision and listening. Engagement was measured using the 15-item ACP Engagement Survey, with self-efficacy and readiness subscales. Linear mixed models tested associations with engagement. RESULTS Demographic and clinical characteristics were not associated with engagement; nor was how much ACP information patients received from their GP or the extent to which the GP listened to what was important for the patient to live well or important to the patient regarding future care. Higher overall ACP engagement (P = 0.002) and self-efficacy (P<0.001) were observed in patients who gave a high rating for the extent to which their GP listened to their worries regarding future health. CONCLUSION This study suggests that GPs providing information about ACP alone is not associated with a patient's ACP engagement; an important element is to listen to patients' worries regarding their future health.
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Affiliation(s)
- Julie Stevens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Universiteit Gent; 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 and Universiteit Gent; Department of Family Medicine and Chronic Care, VUB, Brussels
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Universiteit Gent; Department of Family Medicine and Chronic Care, VUB, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Peter Pype
- End-of-Life Care Research Group, VUB, and Universiteit Gent; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Aline De Vleminck
- End-of-Life Care Research Group, VUB and Universiteit Gent; Department of Family Medicine and Chronic Care, VUB, Brussels
| | - Koen Pardon
- End-of-Life Care Research Group, VUB and Universiteit Gent; Department of Family Medicine and Chronic Care, VUB, Brussels
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Cohen MG, Althouse AD, Arnold RM, White D, Chu E, Rosenzweig M, Smith KJ, Schenker Y. Primary Palliative Care Improves Uptake of Advance Care Planning Among Patients With Advanced Cancers. J Natl Compr Canc Netw 2023; 21:383-390. [PMID: 37015338 PMCID: PMC10477933 DOI: 10.6004/jnccn.2023.7002] [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: 11/14/2022] [Accepted: 01/06/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Palliative care specialists are experts in conducting advance care planning (ACP) but are a limited resource. Oncology nurses often have special relationships with their patients and thus may be poised to provide primary palliative care. We sought to determine the impact of a nurse-led primary palliative care intervention on ACP uptake among patients with advanced cancer. METHODS We performed a secondary analysis of a cluster randomized controlled trial examining the impact of nurse-based primary palliative care. In the parent trial, patients with advanced cancer received either monthly primary palliative care visits with trained nurses within their cancer center or standard care. Nurses in the intervention arm received special training in ACP. ACP uptake was assessed at enrollment and 3 months later evaluating (1) whether an end-of-life conversation (EOLC) occurred with one's oncologist, and (2) completion of an advance directive (AD). Multivariable logistic regression tested differences in ACP uptake by treatment arm adjusted for age, religious importance, education, time with current oncologist, and performance status. RESULTS Of 672 patients enrolled, 182/336 (54%) patients in the intervention arm and 196/336 (58%) in the standard care arm lacked an EOLC at baseline and completed the 3-month assessment. Of those, 82/182 (45.1%) patients in the intervention arm and 29/196 (14.8%) in the standard care arm reported having an EOLC at 3 months (adjusted odds ratio, 5.28; 95% CI, 3.10-8.97; P<.001). Similarly, 111/336 (33%) patients in the intervention arm and 105/336 (31%) in the standard care arm lacked an AD at baseline and completed the 3-month assessment. Of those, 48/111 (43.2%) patients in the intervention arm and 19/105 (18.1%) in the standard care arm completed an AD over the study period (adjusted odds ratio, 3.68; 95% CI, 1.89-7.16; P<.001). CONCLUSIONS Nurse-led primary palliative care increased ACP uptake among patients with advanced cancer. Training oncology nurses embedded within community cancer centers to provide primary palliative care may help improve ACP access.
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Affiliation(s)
- Michael G. Cohen
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andrew D. Althouse
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Section of Palliative Care and Medical Ethics, Palliative Research Center and Division of General Internal Medicine, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania
| | - Douglas White
- Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward Chu
- Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York
| | | | - Kenneth J. Smith
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Palliative Research Center and Division of General Internal Medicine, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania
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De Vleminck A, Craenen L, Stevens J, Lemaigre V, Pype P, Deliens L, Pardon K. Emotional cues and concerns of patients with a life limiting, chronic illness during advance care planning conversations in general practice. PATIENT EDUCATION AND COUNSELING 2023; 107:107563. [PMID: 36428170 DOI: 10.1016/j.pec.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/31/2022] [Accepted: 11/07/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To explore a) to what extent patients with serious illness express emotional cues and concerns during advance care planning (ACP) conversations with their general practitioner (GP), b) the content of cues/concerns and c) GPs' responses to cues/concerns. METHODS Cues/concerns and GPs' responses in 20 conversations were coded using the Verona Codes (VR-CoDES and Verona Codes-P). A qualitative thematic analysis was used to identify overarching themes within the content of the cues/concerns. RESULTS A total of 216 cues/concerns were identified (range: 1-28; mean: 13) in 85% of conversations; with 85% of these being cues/implicit expressions of emotions. In 72% of responses, the GP provided space for the patient to elaborate on cues/concerns. The most common theme cues/concerns were expressed about was "the consequences of illness on quality of life and burdening others". CONCLUSION Emotions were mainly communicated implicitly as cues and the content varied greatly. The amount of cues/concerns expressed show that ACP can evoke many emotions. PRACTICE IMPLICATIONS GPs should be attentive to implicit expressions of emotions as these provide opportunities to engage patients in tailored ACP conversations. As patients expressed many cues/concerns, GPs are recommended to have recurrent conversations with patients and actively ask about diverse ACP topics.
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Affiliation(s)
- Aline De Vleminck
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.
| | - Lara Craenen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium
| | - Julie Stevens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium; Department of Public Health and Primary Care, Ghent University, Belgium
| | - Valentine Lemaigre
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium
| | - Peter Pype
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Public Health and Primary Care, Ghent University, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium; Department of Public Health and Primary Care, Ghent University, Belgium
| | - Koen Pardon
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium
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Smith MA, Brøchner AC, Nedergaard HK, Jensen HI. Facilitators and Barriers for Initiating Conversations About End of Life. Palliat Med Rep 2022; 3:296-307. [PMID: 36636612 PMCID: PMC9805848 DOI: 10.1089/pmr.2022.0042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 11/23/2022] Open
Abstract
Background Conducting a conversation about wishes for treatment at end of life (EOL) has been shown to improve EOL care for patients and relatives. Still, only a minority of physicians conduct the conversation, which might lead to unwanted interventions and treatments. Objectives The purpose of this survey was to examine which factors facilitate and hinder physicians across a wide range of health care facilities to initiate the conversation about wishes for treatment at EOL. Design A questionnaire survey based on a Delphi-developed questionnaire. Setting/Subjects The questionnaire was sent to both hospital physicians and general practitioners (GPs) in a Danish region. Results More than 3000 physicians were invited to participate in the survey. Of these, 782 responded, 622 working at a hospital department, and 160 from general practice clinics. Results showed that senior physicians, GPs, and physicians working in a medical department feel best equipped to conduct the conversation. Moreover, senior physicians pointed to their experience as physicians as being of great importance for conducting the conversation, whereas junior physicians found training in conducting the conversation as an important factor. Conclusion Our study indicates that different factors depending on the health care setting and the seniority of the physician facilitate or hinder physicians from conducting the conversation about wishes for treatment at EOL. Being aware of these differences and making a concerted effort depending on setting and seniority might help implement and conduct the conversation.
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Affiliation(s)
- Mette Aaby Smith
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Address correspondence to: Mette Aaby Smith, MD, PhD Student, Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding 6000, Denmark.
| | - Anne C. Brøchner
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Helene K. Nedergaard
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Hanne I. Jensen
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Kodba‐Čeh H, Lunder U, Bulli F, Caswell G, van Delden JJM, Kars MC, Korfage IJ, Miccinesi G, Rietjens JAC, Seymour J, Toccafondi A, Zwakman M, Pollock K. How can advance care planning support hope in patients with advanced cancer and their families: A qualitative study as part of the international ACTION trial. Eur J Cancer Care (Engl) 2022; 31:e13719. [PMID: 36168108 PMCID: PMC9787960 DOI: 10.1111/ecc.13719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Clinicians' fears of taking away patients' hope is one of the barriers to advance care planning (ACP). Research on how ACP supports hope is scarce. We have taken up the challenge to specify ways in which ACP conversations may potentially support hope. METHODS In an international qualitative study, we explored ACP experiences of patients with advanced cancer and their personal representatives (PRs) within the cluster-randomised control ACTION trial. Using deductive analysis of data obtained in interviews following the ACP conversations, this substudy reports on a theme of hope. A latent thematic analysis was performed on segments of text relevant to answer the research question. RESULTS Twenty patients with advanced cancer and 17 PRs from Italy, the Netherlands, Slovenia, and the United Kingdom were participating in post-ACP interviews. Three themes reflecting elements that provide grounds for hope were constructed. ACP potentially supports hope by being (I) a meaningful activity that embraces uncertainties and difficulties; (II) an action towards an aware and empowered position; (III) an act of mutual care anchored in commitments. CONCLUSION Our findings on various potentially hope supporting elements of ACP conversations provide a constructive way of thinking about hope in relation to ACP that could inform practice.
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Affiliation(s)
- Hana Kodba‐Čeh
- University Clinic of Respiratory and Allergic Diseases GolnikGolnikSlovenia
- Faculty of Arts, Department of PsychologyUniversity of LjubljanaLjubljanaSlovenia
| | - Urška Lunder
- University Clinic of Respiratory and Allergic Diseases GolnikGolnikSlovenia
| | - Francesco Bulli
- Clinical Epidemiology UnitOncological network research and prevention Institute‐ISPROSienaItaly
| | - Glenys Caswell
- School of Health SciencesUniversity of NottinghamNottinghamUK
| | - Johannes J. M. van Delden
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Marijke C. Kars
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Ida J. Korfage
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Guido Miccinesi
- Clinical Epidemiology UnitOncological network research and prevention Institute‐ISPROSienaItaly
| | - Judith A. C. Rietjens
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Jane Seymour
- Division of Nursing and Midwifery, Health Sciences SchoolUniversity of SheffieldSheffieldUK
| | - Alessandro Toccafondi
- Clinical Epidemiology UnitOncological network research and prevention Institute‐ISPROSienaItaly
| | - Marieke Zwakman
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
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Malhotra C, Ramakrishnan C. Complexity of implementing a nationwide advance care planning program: results from a qualitative evaluation. Age Ageing 2022; 51:6770073. [PMID: 36273345 DOI: 10.1093/ageing/afac224] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/18/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND We evaluated Singapore's national advance care planning (ACP) program to understand challenges to its implementation within multiple clinical settings. METHODS We conducted focus group discussions (FGDs) with a purposive sample of health care professionals (HCPs) involved in ACP program delivery within acute care hospitals, primary care clinics and nursing homes. FGDs were stratified into three categories based on HCPs' role within the ACP framework-leaders versus facilitators and advocates versus nursing home heads. Using NVivo 11, we analysed data using thematic analysis and Conceptual Framework for Implementation Research. RESULTS A total of 107 HCPs from 25 organisations participated in 22 FGDs. Findings revealed wide variation in ACP implementation among organisations and identified 12 themes organized within four domains-outer setting (lack of public awareness, shortcomings in inter-organisational partnerships, performance driven policies), inner setting (lack of commitment from organisational leadership, paucity of dedicated resources, absence of an institution-wide ACP culture, lack of physician engagement), characteristics of HCPs (language barriers) and process (inadequate training, complexity of conversations and documentations, challenges to retrieving ACP documents, absence of comprehensive monitoring and evaluation). CONCLUSION ACP program implementation is complex and faces multiple health care system challenges. To integrate ACP within routine clinical care, ACP processes should be simplified, training framework be strengthened, physicians be engaged and an ACP supportive culture be created within and outside organisations. Findings will be used to guide ACP implementation within the country and globally.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore 169857.,Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857
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Ding J, Cook A, Saunders C, Chua D, Licqurish S, Mitchell G, Johnson CE. Uptake of advance care planning and its circumstances: An nationwide survey in Australian general practice. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:1913-1923. [PMID: 34529292 DOI: 10.1111/hsc.13570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/04/2021] [Accepted: 09/03/2021] [Indexed: 06/13/2023]
Abstract
There are potential benefits associated with advance care planning (ACP), and general practitioners (GPs) are well placed to coordinate ACP initiatives with their patients. Few studies have reported on the uptake of different forms of advance care plan conducted by GPs and how this affects patients' place of death. The primary aims of the study were to examine uptake of verbal (conversations regarding care preferences) and written (documented care preferences) advance care plans and their associated factors from the perspective of Australian GPs. The secondary aim was to determine the impact of different types of advance care plans on place of death. Sixty-one GPs from three Australian states used a validated clinic-based data collection process to report on care provided for decedents in the last year of life, including provision of services, place of death, and uptake of ACP. We found that 58 (27.9%), 91 (43.7%) and 59 (28.4%) reported decedents had no advance care plans, verbal plans or written plans, respectively. There were increased uptake of both verbal plans (relative risk ratio [RRR] = 13.10, 95% confidence interval [CI]: 2.18-77.34) and written plans (RRR = 10.61, 95% CI: 1.72-65.57) if GPs foresaw the death for >90 days versus <7 days. Palliative care training history for GPs predicted uptake of verbal plans (RRR = 5.83, 95% CI: 1.46-31.93). Patients with verbal plans versus no plans were more likely to die at a private residence (odds ratio = 4.97, 95% CI: 1.32-18.63). Our findings suggest that expectation of death for at least three months prior to the event (where clinically possible) and palliative care training for GPs improve the uptake of ACP in general practice. Larger pragmatic trials are required to determine the impact of ACP on patients' place of death.
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Affiliation(s)
- Jinfeng Ding
- Xiangya School of Nursing, Central South University, Changsha, P.R. China
- School of Population and Global Health, The University of Western Australia, Perth, Australia
| | - Angus Cook
- School of Population and Global Health, The University of Western Australia, Perth, Australia
| | - Christobel Saunders
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - David Chua
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Australia
| | - Sharon Licqurish
- Monash Nursing and Midwifery, Monash University, Melbourne, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Australia
| | - Claire E Johnson
- Monash Nursing and Midwifery, Monash University, Melbourne, Australia
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, Australia
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Mather M, Pettigrew LM, Navaratnam S. Barriers and facilitators to clinical behaviour change by primary care practitioners: a theory-informed systematic review of reviews using the Theoretical Domains Framework and Behaviour Change Wheel. Syst Rev 2022; 11:180. [PMID: 36042457 PMCID: PMC9429279 DOI: 10.1186/s13643-022-02030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding the barriers and facilitators to behaviour change by primary care practitioners (PCPs) is vital to inform the design and implementation of successful Behaviour Change Interventions (BCIs), embed evidence-based medicine into routine clinical practice, and improve quality of care and population health outcomes. METHODS A theory-led systematic review of reviews examining barriers and facilitators to clinical behaviour change by PCPs in high-income primary care contexts using PRISMA. Embase, MEDLINE, PsychInfo, HMIC and Cochrane Library were searched. Content and framework analysis was used to map reported barriers and facilitators to the Theoretical Domains Framework (TDF) and describe emergent themes. Intervention functions and policy categories to change behaviour associated with these domains were identified using the COM-B Model and Behaviour Change Wheel (BCW). RESULTS Four thousand three hundred eighty-eight reviews were identified. Nineteen were included. The average quality score was 7.5/11. Reviews infrequently used theory to structure their methods or interpret their findings. Barriers and facilitators most frequently identified as important were principally related to 'Knowledge', 'Environmental context and resources' and 'Social influences' TDF domains. These fall under the 'Capability' and 'Opportunity' domains of COM-B, and are linked with interventions related to education, training, restriction, environmental restructuring and enablement. From this, three key areas for policy change include guidelines, regulation and legislation. Factors least frequently identified as important were related to 'Motivation' and other psychological aspects of 'Capability' of COM-B. Based on this, BCW intervention functions of persuasion, incentivisation, coercion and modelling may be perceived as less relevant by PCPs to change behaviour. CONCLUSIONS PCPs commonly perceive barriers and facilitators to behaviour change related to the 'Capability' and 'Opportunity' domains of COM-B. PCPs may lack insight into the role that 'Motivation' and aspects of psychological 'Capability' have in behaviour change and/or that research methods have been inadequate to capture their function. Future research should apply theory-based frameworks and appropriate design methods to explore these factors. With no 'one size fits all' intervention, these findings provide general, transferable insights into how to approach changing clinical behaviour by PCPs, based on their own views on the barriers and facilitators to behaviour change. SYSTEMATIC REVIEW REGISTRATION A protocol was submitted to the London School of Hygiene and Tropical Medicine via the Ethics and CARE form submission on 16.4.2020, ref number 21478 (available on request). The project was not registered on PROSPERO.
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Affiliation(s)
- Melissa Mather
- Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells Hospital, Tonbridge Road, Pembury, Tunbridge Wells, Kent, TN2 4QJ, UK.
| | - Luisa M Pettigrew
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK.,UCL Department of Primary Care and Population Health, UCL Medical School, Upper Third Floor, Rowland Hill Street, London, NW3 2PF, UK
| | - Stefan Navaratnam
- Northern Devon Healthcare NHS Trust, North Devon District Hospital, Raleigh Heights, Barnstaple, EX31 4JB, UK
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Saretta M, Doñate-Martínez A, Alhambra-Borrás T. Barriers and facilitators for an effective palliative care communication with older people: A systematic review. PATIENT EDUCATION AND COUNSELING 2022; 105:2671-2682. [PMID: 35459530 DOI: 10.1016/j.pec.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/30/2022] [Accepted: 04/04/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The present mixed-method systematic review identifies facilitators and barriers in palliative care communication among health professionals and older people. METHODS The review process was conducted by three reviewers who searched studies in four different databases (January 2009-January 2022), exploring experiences of communication among health professionals and older people without cognitive impairments. Relevant articles were quality assessed with a standardized tool. RESULTS Twenty-eight articles were included and the following 5 clusters were identified: 1) training and education for health professionals, 2) team working and coordination among health professionals, 3) communication skills, 4) time and availability, 5) emotional, cultural and psychological factors. The articles highlighted the need for greater preparation of health professionals around the management of palliative care communication with older people. CONCLUSION Palliative care communication among health professionals and older people are characterized by several challenges. However, there are facilitating aspects that may be considered to improve the quality of communication. PRACTICE IMPLICATIONS Facilitators are promising approaches to support health professionals in providing high-quality palliative care communication to older people, developing a person-centred practice. Facilitators include palliative care training and educational opportunities for health professionals, like ELNEC Geriatric Curriculum, permitting them to develop specific competences in communication and aging.
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Affiliation(s)
- Michela Saretta
- Polibienestar Research Institute, University of Valencia, Valencia, Spain.
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van Lummel EVTJ, Savelkoul C, Stemerdink ELE, Tjan DHT, van Delden JJM. The development and feasibility study of Multidisciplinary Timely Undertaken Advance Care Planning conversations at the outpatient clinic: the MUTUAL intervention. BMC Palliat Care 2022; 21:119. [PMID: 35794617 PMCID: PMC9258045 DOI: 10.1186/s12904-022-01005-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patients still receive non-beneficial treatments when nearing the end of life. Advance care planning (ACP) interventions have shown to positively influence compliance with end of life wishes. Hospital physicians seem to miss opportunities to engage in ACP, whereas patients visiting the outpatient clinic usually have one or more chronic conditions and are at risk for medical emergencies. So far, implemented ACP interventions have had limited impact. Structural implementation of ACP may be beneficial. We hypothesize that having ACP conversations more towards the end of life and involving the treating physician in the ACP conversation may help patient wishes and goals to become more concrete and more often documented, thus facilitating goal-concordant care. Aim To facilitate timely shared decision making and increase patient autonomy we aim to develop an ACP intervention at the outpatient clinic for frail patients and determine the feasibility of the intervention. Methods The United Kingdom’s Medical Research Council framework was used to structure the development of the ACP intervention. Key elements of the ACP intervention were determined by reviewing existing literature and an iterative process with stakeholders. The feasibility of the developed intervention was evaluated by a feasibility study of 20 ACP conversations at the geriatrics and pulmonology department of a non-academic hospital. Feasibility was assessed by analysing evaluation forms by patients, nurses and physicians and by evaluating with stakeholders. A general inductive approach was used for analysing comments. The developed intervention was described using the template for intervention description and replication (TIDieR). Results We developed a multidisciplinary timely undertaken ACP intervention at the outpatient clinic. Key components of the developed intervention consist of 1) timely patient selection 2) preparation of patient and healthcare professional 3) a scripted ACP conversation in a multidisciplinary setting and 4) documentation. 94.7% of the patients, 60.0% of the nurses and 68.8% of the physicians agreed that the benefits of the ACP conversation outweighed the potential burdens. Conclusion This study showed that the developed ACP intervention is feasible and considered valuable by patients and healthcare professionals. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01005-3.
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Hart M, Stepita R, Berall A, Sokolowski M, Karuza J, Katz P. Development of an Advance Care Planning Policy within an Evidenced-Based Evaluation Framework. Am J Hosp Palliat Care 2022; 39:1389-1396. [PMID: 35414245 DOI: 10.1177/10499091221077057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Background: As the population is aging and medical advancements enable people to live longer, advance care planning (ACP) becomes increasingly important in guiding future care decisions; however, they are often incomplete or absent from the patient chart. This study describes the development and implementation of an ACP policy in a post-acute care and long-term care setting using a systematic implementation framework. Methods: A process evaluation that parallels the Replicating Effective Programs (REP) framework was used to understand stakeholder experiences with ACP and identify gaps in practice. Physicians, multidisciplinary staff, patients, and substitute decision makers engaged in focus groups and interviews, and completed surveys. A retrospective chart review determined Plan for Life Sustaining Treatment (PLST) form completion rates. Results: Stakeholder feedback identified barriers and facilitators to ACP including a need for staff training, user-friendly resources, and standardization of ACP practice. The PLST form was developed and embedded in the electronic medical record, and had a 92% and an 87% PLST completion rate on 2 pilot units. Conclusion: The study showed the usefulness of the REP model in guiding the evaluation as an effective tool to enhance implementation practices and inform ACP policy development that can be replicated in other organizations.
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Affiliation(s)
| | | | - Anna Berall
- 7942Baycrest Health Sciences, Toronto, ONCanada
| | | | - Jurgis Karuza
- Department of Psychology, 12292Buffalo State University, Buffalo, NY, USA
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University
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Development and preliminary validation of a scale to assess physicians’ emotional distress intolerance in end-of-life care communication. Palliat Support Care 2022; 21:399-410. [PMID: 35369897 DOI: 10.1017/s1478951522000219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Context
End-of-life care (EOLC) communication is beneficial but underutilized, particularly in conditions with a variable course such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). Physicians’ emotional distress intolerance has been identified as a barrier to EOLC communication. However, studies of emotional distress intolerance in EOLC have largely relied on anecdotal reports, qualitative data, or observational studies of physician–patient communication. A free-standing measure of multiple dimensions of distress tolerance is warranted to enable the identification of individuals experiencing distress intolerance and to facilitate the effective targeting of interventions to improve distress tolerance.
Objectives
This study provides preliminary data on the reliability and validity of the Physician Distress Intolerance (PDI) scale. We examine potential subdimensions of emotional distress intolerance.
Method
Family medicine and internal medicine physicians completed the PDI, read vignettes describing patients with COPD or CHF, and indicated whether they initiated or delayed EOLC communication with their patients with similar conditions.
Results
Exploratory and confirmatory factor analyses were performed on separate samples. Confirmatory factor analysis confirmed that a three-factor solution was superior to a two- or one-factor solution. Three subscales were created: Anticipating Negative Emotions, Intolerance of Uncertainty, and Iatrogenic Harm. The full scale and subscales had adequate internal consistency and demonstrated evidence of validity. Higher scores on the PDI, indicating greater distress intolerance, were negatively associated with initiation and positively associated with delay of EOLC communication. Subscales provided unique information.
Significance of results
The PDI can contribute to research investigating and addressing emotional barriers to EOLC communication.
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Jin TH, Tan L, Weng SC, Kiow SL, Low JA. Advance care planning: comparing the views of residents and healthcare professionals in nursing homes in Singapore. Int J Palliat Nurs 2022; 28:178-185. [PMID: 35465698 DOI: 10.12968/ijpn.2022.28.4.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND With more frail elderly living and likely to die in nursing homes, advance care planning (ACP) is critical in overall efforts to provide good palliative care. However, it is unclear how willing older, vulnerable residents in nursing homes are to take on an active role in care decisions. AIM The objective of this pilot study was to examine nursing homes' healthcare professionals' and residents' views on ACP and the extent of similarities and differences in their views. METHODS Our sample of 24 healthcare professionals and 24 residents were identified and recruited through contacts established from existing collaborations with the nursing homes. Surveys were administered to the participants by a trained research assistant between April 2015 and August 2015. RESULTS Almost all the healthcare professionals (95.8%) would like to make an ACP for themselves in the future, while residents were divided in their choices (P<<0.01). Most residents (79.1%) felt that the most important guide for their surrogate in making decisions for them when they lose decision-making capacity should be based on their best interests. However, most healthcare professionals (75.0%) felt that it should be based on the resident's wishes and values. CONCLUSIONS Healthcare professionals tended to overestimate the importance of patient autonomy compared to the residents. This study demonstrates that as much as advocacy and awareness are ongoing, nursing home residents' motivation to participate in ACP is lacking. The lack of motivation in ACP participation could be due to medical paternalism and familial determination, which have been a cultural norm for older Singaporeans. This study demonstrates there is a lack of cultural sensitivity in this group of healthcare professionals in approaching nursing home residents' end-of-life care decision-making.
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Affiliation(s)
- Toh Hui Jin
- Research Executive, Department of GeriCare, Khoo Teck Puat Hospital; Department of Education Research, Geriatric and Education Research Institute, Singapore
| | - Laurence Tan
- Consultant, Department of Geriatric Medicine and Palliative Care; Department of GeriCare, Khoo Teck Puat Hospital; Department of Education Research, Geriatric and Education Research Institute, Singapore
| | - Siew Chee Weng
- Senior Consultant, Medical Services, Yishun Community Hospital, Singapore
| | - Sim Lai Kiow
- Nurse Clinician, Department of Geriatric Medicine and Palliative Care, Khoo Teck Puat Hospital, Singapore
| | - James Alvin Low
- Senior Consultant, Department of Geriatric Medicine and Palliative Care; Department of GeriCare, Khoo Teck Puat Hospital; Department of Education Research, Geriatric and Education Research Institute, Singapore
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Tros W, van der Steen JT, Liefers J, Akkermans R, Schers H, Numans ME, van Peet PG, Groenewoud AS. General practitioners' evaluations of optimal timing to initiate advance care planning for patients with cancer, organ failure, or multimorbidity: A health records survey study. Palliat Med 2022; 36:510-518. [PMID: 34965754 PMCID: PMC8972953 DOI: 10.1177/02692163211068692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND Appropriate timing to initiate advance care planning is difficult, especially for individuals with non-malignant disease in community settings. AIM To identify the optimal moment for, and reasons to initiate advance care planning in different illness trajectories. DESIGN AND METHODS A health records survey study; health records were presented to 83 GPs with request to indicate and substantiate what they considered optimal advance care planning timing within the 2 years before death. We used quantitative and qualitative analyses. SETTING AND PATIENTS We selected and anonymized 90 health records of patients who died with cancer, organ failure or multimorbidity, from a regional primary care registration database in the Netherlands. RESULTS The median optimal advance care planning timing according to the GPs was 228 days before death (interquartile range 392). This moment was closer to death for cancer (87.5 days before death, IQR 302) than for organ failure (266 days before death, IQR 401) and multimorbidity (290 days before death, IQR 389) (p < 0.001). The most frequently mentioned reason for cancer was "receiving a diagnosis" (21.5%), for organ failure it was "after a period of illness" (14.7%), and for multimorbidity it was "age" and "patients" expressed wishes or reflections' (both 12.0%). CONCLUSION The optimal advance care planning timing and reasons to initiate advance care planning indicated by GPs differ between patients with cancer and other illnesses, and they also differ between GPs. This suggests that "the" optimal timing for ACP should be seen as a "window of opportunity" for the different disease trajectories.
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Affiliation(s)
- Willemijn Tros
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janine Liefers
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinier Akkermans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henk Schers
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mattijs E Numans
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Petra G van Peet
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - A Stef Groenewoud
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
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Busa C, Pozsgai E, Zeller J, Csikos A. Who should talk with patients about their end-of-life care wishes? A nationwide survey of the Hungarian population. Scand J Prim Health Care 2022; 40:157-164. [PMID: 35369843 PMCID: PMC9090407 DOI: 10.1080/02813432.2022.2057055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To explore the needs and opportunities of the general population to communicate their end-of-life care wishes and to investigate what roles are assigned to healthcare providers and family members in end-of-life care discussions. DESIGN A cross-sectional social survey was carried out in Hungary. Descriptive analysis and analysis of variance were performed. SETTING Nationwide survey of the Hungarian general population. SUBJECT The sample (n = 1100) was designed to represent the adult population as per distribution by gender, age and geographical region. MAIN OUTCOME MEASURES Needs and opportunities of the general population to communicate end-of-life care wishes. RESULTS 72% of participants found it important to discuss their end-of-life care wishes with someone. Six out of ten believed that it was also the GPs' task to talk with the patients about their end-of-life care wishes. An almost equal level of engagement was expected from healthcare providers (80%) -especially physicians (72%)- and family members (75%) in end-of-life conversations. However, only 36% of participants felt that there was someone among their healthcare providers, and 56% of them had a family member or friend with whom they could speak openly about death, dying and preparing for death. CONCLUSION Compared to their needs, the general population had fewer opportunities to speak about death, dying and preparing for death. Training programs for healthcare providers, particularly GPs, and public awareness campaigns may support the broader application of advance care planning in Hungary.Key PointsCurrent guidelines recommend that GPs initiate advance care planning discussions. However, little is known with whom the general population wish to discuss their end-of-life care preferences and with whom there is an opportunity to do so.An almost equal level of engagement was expected from healthcare providers -especially physicians- and family members in end-of-life conversations. Most of the general population thought that participation in end-of-life discussions was also the GPs' task.The majority of participants reported that there was no one among their healthcare providers and a sizable minority felt that there was no one among their family members or friends with whom they could talk openly about death, dying, and preparing for death.The highest levels of unmet needs regarding end-of-life conversations with healthcare providers were found among those who considered it important to discuss their end-of-life care wishes.
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Affiliation(s)
- Csilla Busa
- Institute of Primary Health Care, Department of Palliative Care, University of Pecs Medical School, Pecs, Hungary
- Doctoral School of Health Sciences, University of Pecs Faculty of Health Sciences, Pecs, Hungary
- CONTACT Csilla Busa Institute of Primary Health Care, Department of Palliative Care, University of Pecs Medical School, Rákóczi út 2, Pecs, H-7623, Hungary
| | - Eva Pozsgai
- Institute of Primary Health Care, Department of Palliative Care, University of Pecs Medical School, Pecs, Hungary
| | - Judit Zeller
- Faculty of Law, University of Pecs, Pecs, Hungary
| | - Agnes Csikos
- Institute of Primary Health Care, Department of Palliative Care, University of Pecs Medical School, Pecs, Hungary
- Doctoral School of Health Sciences, University of Pecs Faculty of Health Sciences, Pecs, Hungary
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Paladino J, Sanders J, Kilpatrick LB, Prabhakar R, Kumar P, O'Connor N, Durieux B, Fromme EK, Benjamin E, Mitchell S. Serious Illness Care Programme-contextual factors and implementation strategies: a qualitative study. BMJ Support Palliat Care 2022:bmjspcare-2021-003401. [PMID: 35168931 DOI: 10.1136/bmjspcare-2021-003401] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/24/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients' values and goals in serious illness. We aim to characterise implementation strategies for programme delivery and the contextual factors that influence implementation in three 'real-world' health system SICP initiatives. METHODS We employed a qualitative thematic framework analysis of field notes collected during the first 1.5 years of implementation and a fidelity survey. RESULTS Analysis revealed empiric evidence about implementation and institutional context. All teams successfully implemented clinician training and an electronic health record (EHR) template for documentation of serious illness conversations. When training was used as the primary strategy to engage clinicians, however, clinician receptivity to the programme and adoption of conversations remained limited due to clinical culture-related barriers (eg, clinicians' attitudes, motivations and practice environment). Visible leadership involvement, champion facilitation and automated EHR-based data feedback on documented conversations appeared to improve adoption. Implementing these strategies depended on contextual factors, including leadership support at the specialty level, champion resources and capacity, and EHR capabilities. CONCLUSIONS Health systems need multifaceted implementation strategies to move beyond the limited impact of clinician training in driving improvement in serious illness conversations. These include EHR-based data feedback, involvement of specialty leaders to message the programme and align incentives, and local champions to problem-solve frontline challenges longitudinally. Implementation of these strategies depended on a favourable institutional context. Greater attention to the influence of contextual factors and implementation strategies may enable sustained improvements in serious illness conversations at scale.
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Affiliation(s)
- Joanna Paladino
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Justin Sanders
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Family Medicine, Palliative Care, McGill University, Montreal, Québec, Canada
| | - Laurel B Kilpatrick
- Division of Supportive and Palliative Care, Baylor Scott and White Health, Temple, Texas, USA
| | | | | | | | | | - Erik K Fromme
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Evan Benjamin
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Suzanne Mitchell
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- UMass Memorial Health Care, Worcester, Massachusetts, USA
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40
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Bekker YAC, Suntjens AF, Engels Y, Schers H, Westert GP, Groenewoud AS. Advance care planning in primary care: a retrospective medical record study among patients with different illness trajectories. BMC Palliat Care 2022; 21:21. [PMID: 35152892 PMCID: PMC8842525 DOI: 10.1186/s12904-022-00907-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Advance Care Planning (ACP) enables physicians to align healthcare with patients’ wishes, reduces burdensome life-prolonging medical interventions, and potentially improves the quality of life of patients in the last phase of life. However, little objective information is available about the extent to which structured ACP conversations are held in general practice.
Our aim was to examine the documentation of ACP for patients with cancer, organ failure and multimorbidity in medical records (as a proxy for ACP application) in Dutch general practice.
Methods
We chose a retrospective medical record study design in seven primary care facilities. Medical records of 119 patients who died non-suddenly (55 cancer, 28 organ failure and 36 multimorbidity) were analysed. Other variables were: general characteristics, data on ACP documentation, correspondence between medical specialist and general practitioner (GP), and healthcare utilization in the last 2 years of life.
Results
In 65% of the records, one or more ACP items were registered by the GP. Most often documented were aspects regarding euthanasia (35%), the preferred place of care and death (29%) and concerns and hopes towards the future (29%). Median timing of the first ACP conversation was 126 days before death (inter-quartile range (IQR) 30–316). ACP was more often documented in patients with cancer (84%) than in those with organ failure (57%) or multimorbidity (42%) (p = 0.000). Patients with cancer had the most frequent (median 3 times, IQR 2–5) and extensive (median 5 items, IQR 2–7) ACP consultations.
Conclusion
Documentation of ACP items in medical records by GPs is present, however limited, especially in patients with multimorbidity or organ failure. We recommend more attention for – and documentation of – ACP in daily practice, in order to start anticipatory conversations in time and address the needs of all people living with advanced conditions in primary care.
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Zehm A, Scott E, Schaefer KG, Nguyen PL, Jacobsen J. Improving Serious Illness Communication: Testing the Serious Illness Care Program with Trainees. J Pain Symptom Manage 2022; 63:e252-e259. [PMID: 34743012 DOI: 10.1016/j.jpainsymman.2021.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/19/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Early conversations about patients' goals and values improve care, but clinicians struggle to conduct them. The systems-based Serious Illness Care Program (SICP) helps clinicians have more, better, and earlier conversations. Central to this approach is a clinician conversation guide for patient encounters. While the SICP works for practicing clinicians, it has not been tested with medical trainees. INTERVENTION We adapted the SICP training to emphasize assessing prognostic awareness and responding to emotion. We developed a 2.5-hour SICP workshop for medical students and medical interns that included large- and small-group work, practice with an actor, and interdisciplinary clinician facilitators. We trained 81 students and 156 interns and obtained anonymous quantitative and qualitative feedback. OUTCOMES Eighty-six percent of students and 91% of residents rated the session as "very good" or "excellent" and >90% of all learners would either recommend this training or intended to apply this to their practice. Post-session learner confidence increased in all communication skills. Learners said the training provided a helpful framework and useful language for these conversations. Resident documentation of serious illness conversations in the medical record increased dramatically during the year following training commencement. CONCLUSIONS Grounded in principles of adult learning theory, this training was rated highly by trainees and resulted in demonstrable practice change. These early learners were more flexible and willing to try this approach than practicing clinicians who tend to resist or revert to old habits. A Guide represents a new paradigm for teaching communication skills and is valued by early learners.
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Affiliation(s)
- April Zehm
- Medical College of Wisconsin (A.Z.), Milwaukee, Wisconsin, USA.
| | - Erin Scott
- The Ohio State University College of Medicine (E.S.), Columbus, Ohio, USA
| | | | - Phuong L Nguyen
- Massachusetts General Hospital (P.L.N., J.J.), Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Harvard Medical School (K.G.S., J.J.), Boston, Massachusetts, USA; Massachusetts General Hospital (P.L.N., J.J.), Boston, Massachusetts, USA
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Giordano A, De Panfilis L, Perin M, Servidio L, Cascioli M, Grasso MG, Lugaresi A, Pucci E, Veronese S, Solari A. Advance Care Planning in Neurodegenerative Disorders: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:803. [PMID: 35055625 PMCID: PMC8775509 DOI: 10.3390/ijerph19020803] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 01/27/2023]
Abstract
Advance care planning (ACP) is increasingly acknowledged as a key step to enable patients to define their goals/preferences for future medical care, together with their carers and health professionals. We aimed to map the evidence on ACP in neurodegenerative disorders. We conducted a scoping review by searching PubMed (inception-December 28, 2020) in addition to trial, review, and dissertation registers. From 9367 records, we included 53 studies, mostly conducted in Europe (45%) and US-Canada (41%), within the last five years. Twenty-six percent of studies were qualitative, followed by observational (21%), reviews (19%), randomized controlled trials (RCTs, 19%), quasi-experimental (11%), and mixed-methods (4%). Two-thirds of studies addressed dementia, followed by amyotrophic lateral sclerosis (13%), and brain tumors (9%). The RCT interventions (all in dementia) consisted of educational programs, facilitated discussions, or videos for patients and/or carers. In conclusion, more research is needed to investigate barriers and facilitators of ACP uptake, as well as to develop/test interventions in almost all the neurodegenerative disorders. A common set of outcome measures targeting each discrete ACP behavior, and validated across the different diseases and cultures is also needed.
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Affiliation(s)
- Andrea Giordano
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (A.G.); (L.S.)
| | - Ludovica De Panfilis
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, 42100 Reggio Emilia, Italy; (L.D.P.); (M.P.)
| | - Marta Perin
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, 42100 Reggio Emilia, Italy; (L.D.P.); (M.P.)
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy
| | - Laura Servidio
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (A.G.); (L.S.)
| | - Marta Cascioli
- Hospice ‘La Torre sul Colle’, Azienda USL Umbria 2, 06049 Spoleto, Italy;
| | | | - Alessandra Lugaresi
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, 40126 Bologna, Italy;
- IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Eugenio Pucci
- UOC Neurologia, ASUR Marche-AV4, 63900 Fermo, Italy;
| | | | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (A.G.); (L.S.)
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Matsui S, Kanamori T, Inoue M, Suzuki M. [Factors related to the awareness of hope at the end of life among older adults who attend community-based preventive services for long-term care]. Nihon Ronen Igakkai Zasshi 2022; 59:323-330. [PMID: 36070906 DOI: 10.3143/geriatrics.59.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION This study explored the factors related to awareness of hope at the end of life among older adults who attend community-based preventive services for long-term care. METHODS Hope at the end of life was determined using a six-item questionnaire inquiring about topics such as "Medical hope when oral intake is not possible" and "Where they wanted to spend the end of their lives." A multiple logistic regression analysis was performed using the six items as dependent variables and hospitalization experience, end-of-life care experience, and one's view of life and death as independent variables. RESULTS Data from 95 retrieved questionnaires were analyzed. The range of hope at the end of life was 14.7%-71.6% for each item. "Where they wanted to spend the end of their lives" was the most frequently considered topic among the respondents. "Medical hope when oral intake was not possible" was considered by 41.1% of respondents, and this topic was related to experience with hospitalization and end-of-life care as well as interest in death. CONCLUSION Hospitalization experience, end-of-life care, and personal views on life and death were shown to be related to awareness of hope at the end of life among community-dwelling older adults.
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Affiliation(s)
- Saki Matsui
- Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital
| | | | - Machiko Inoue
- Department of Family and Community Medicine, Hamamatsu University School of Medicine
| | - Mizue Suzuki
- Faculty of Nursing, Hamamatsu University School of Medicine
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Westerduin D, Dujardin J, Schuurmans J, Engels Y, Wichmann AB. Making complex decisions in uncertain times: experiences of Dutch GPs as gatekeepers regarding hospital referrals during COVID-19-a qualitative study. BMC Med Ethics 2021; 22:158. [PMID: 34847897 PMCID: PMC8631560 DOI: 10.1186/s12910-021-00725-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 11/11/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND General practitioners often act as gatekeeper, authorizing patients' access to hospital care. This gatekeeping role became even more important during the current COVID-19 crisis as uncertainties regarding COVID-19 made estimating the desirability of hospital referrals (for outpatient or inpatient hospitalization) complex, both for COVID and non-COVID suspected patients. This study explored Dutch general practitioners' experiences and ethical dilemmas faced in decision making about hospital referrals in times of the COVID-19 pandemic. METHODS Semi-structured interviews with Dutch general practitioners working in the Netherlands were conducted. Participants were recruited via purposive sampling. Thematic analysis was conducted using content coding. RESULTS Fifteen interviews were conducted, identifying four themes: one overarching regarding (1) COVID-19 uncertainties, and three themes about experienced ethical dilemmas: (2) the patients' self-determination vs. the general practitioners' paternalism, (3) the general practitioners' duty of care vs. the general practitioners' autonomy rights, (4) the general practitioners' duty of care vs. adequate care provision. CONCLUSIONS Lack of knowledge about COVID-19, risks to infect loved ones, scarcity of hospital beds and loneliness of patients during hospital admission were central in dilemmas experienced. When developing guidelines for future crises, this should be taken into account.
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Affiliation(s)
- Dieke Westerduin
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke Dujardin
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Schuurmans
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anne B Wichmann
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
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Assaf G, Jawhar S, Wahab K, El Hachem R, Kaur T, Tanielian M, Feghali L, Al Hazzouri AZ, Elbejjani M. Awareness and attitudes towards advance care planning in primary care: role of demographic, socioeconomic and religiosity factors in a cross-sectional Lebanese study. BMJ Open 2021; 11:e052170. [PMID: 34711599 PMCID: PMC8557299 DOI: 10.1136/bmjopen-2021-052170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess awareness and attitudes towards engaging in advance care planning (ACP) and their relationship with demographic, socioeconomic and religiosity factors among Lebanese middle-aged to older-aged adults in primary care. DESIGN A cross-sectional survey study. SETTING Tertiary referral hospital in Beirut, Lebanon. PARTICIPANTS A total of 215 middle-aged to older-aged adults. RESULTS Out of 215 participants, 18.6% of participants knew about ACP; 94% favoured truth-telling; 87.4% favoured healthcare autonomy; 77.2% favoured documenting their own health values and preferences; and 29.3% were willing to undergo life-prolonging interventions. Among participants who were aware of ACP, 67.5% preferred ACP documentation and 85% had negative attitudes towards life-sustaining interventions. Women were more aware about ACP than men. Those who were willing to undergo life-prolonging interventions were found to be men and had higher religiosity scores. CONCLUSION Large deficit in ACP awareness was evident despite the high preference for healthcare autonomy. Medical and public health efforts should strive to enhance patients' ACP awareness and engagement in ACP while considering factors relevant to gender, culture and religiosity.
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Affiliation(s)
- Georges Assaf
- Department of Family Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Department of Academic Internal Medicine and Geriatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sarah Jawhar
- Department of Family Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Kamal Wahab
- Department of Family Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rita El Hachem
- Clinical Research Institute, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Tanjeev Kaur
- Department of Academic Internal Medicine and Geriatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Maria Tanielian
- Department of Family Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lea Feghali
- Department of Family Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Adina Zeki Al Hazzouri
- Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Martine Elbejjani
- Clinical Research Institute, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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Mills S, Cioletti A, Gingell G, Ramani S. Training Residents in Virtual Advance Care Planning: A New Twist in Telehealth. J Pain Symptom Manage 2021; 62:691-698. [PMID: 33819515 DOI: 10.1016/j.jpainsymman.2021.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/26/2021] [Accepted: 03/23/2021] [Indexed: 11/22/2022]
Abstract
CONTEXT Advance care planning (ACP) conversations represent an important physician skill, a need further highlighted by the COVID-19 pandemic. Most resident ACP training occurs in inpatient, settings, often featuring goals of care (GOC) conversations during a crisis. Outpatient clinics are valuable but underutilized settings to provide skills training for residents, yet little research has been done in these spaces. OBJECTIVE We sought to 1) create an ACP curriculum harnessing the principles of a community of practice in a virtual format, and 2) obtain residents' perspectives regarding their skills and confidence in having early GOC conversations in the outpatient setting. METHODS We interviewed 48 internal medicine residents using questionnaires, reflective narratives, and transcripts of debriefing conversations. We created a virtual curriculum during the ambulatory week which included didactics, virtual role plays, ACP phone conversations with five patients, and group debriefings. Quantitative data were analyzed for changes in resident confidence. Qualitative data were coded using thematic analysis, guided by instructor field notes. RESULTS Residents reported decreased confidence in navigating advance directive conversations following training [Z=2.24, P=0.03, r = 0.33]. Resident reflections indicated that they felt more practiced at inpatient late GOC conversation skills, and that these skills were not fully transferable to the outpatient early GOC setting. Residents also endorsed the ambulatory environment as the best space for ACP conversations. CONCLUSION This study illustrates the feasibility of a virtual format for ACP curriculum. The virtual community of practice created space for a metacognitive unmasking of prior resident unconscious incompetence. Also, inpatient, crisis-oriented late GOC conversation skills may translate poorly to the outpatient setting requiring early and ongoing GOC skills. Residents need more training to navigate ACP conversations in ambulatory environments.
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Affiliation(s)
- Sarah Mills
- Dell Medical School, Department of Internal Medicine, Austin, Texas, USA.
| | - Anne Cioletti
- Dell Medical School, Department of Internal Medicine, Austin, Texas, USA; Dell Medical School, Department of Population Health, Austin, Texas, USA
| | - Gareth Gingell
- The University of Texas at Austin, STEM Education Doctoral Program, Department of Curriculum and Instruction, Austin, Texas, USA
| | - Subha Ramani
- Harvard Medical School and Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts, USA
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Never Waste a Pandemic: Strategies to Increase Advance Care Planning Now. Mayo Clin Proc Innov Qual Outcomes 2021; 5:946-950. [PMID: 34568768 PMCID: PMC8450270 DOI: 10.1016/j.mayocpiqo.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Poveda-Moral S, Falcó-Pegueroles A, Ballesteros-Silva MP, Bosch-Alcaraz A. Barriers to Advance Care Planning Implementation in Health care: An Umbrella Review with Implications for Evidence-Based Practice. Worldviews Evid Based Nurs 2021; 18:254-263. [PMID: 34506051 DOI: 10.1111/wvn.12530] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Advance care planning (ACP) refers to a process of discussions between professionals, patients, and their families, which allows the patient to define and communicate their care and treatment preferences. Understanding the barriers to advance care planning is the first step on the way to overcoming them and to improving person-centred care and attention. AIMS To identify the barriers perceived by professionals, patients, and family members when implementing ACP in a clinical context and to analyse the methodological quality of the evidence. METHODS An umbrella review guided by the Joanna Briggs Institute and a systematic review in accordance with PRISMA 2015 were utilized. Data were obtained from MEDLINE, Cochrane Library, The Joanna Briggs Institute, CINAHL, Scopus, and EMBASE in November 2018. RESULTS Fourteen systematic reviews were included. The main barriers reported by professionals were lack of knowledge and skills to carry out ACP, a certain fear of starting conversations about ACP, and a lack of time for discussions. Patients and family members considered that the main barriers were fear of discussing their relative's end of life, lack of ability to carry out ACP, and not knowing who was responsible for initiating conversations about ACP. LINKING EVIDENCE TO ACTION This review has examined the barriers presented by health professionals, patients, and family members, so that future lines of research can develop preventive or decisive measures that encourage the implementation of ACP in health care.
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Affiliation(s)
- Silvia Poveda-Moral
- Escola Universitària d'Infermeria i Teràpia Ocupacional de Terrassa, School of Nursing, Faculty of Medicine and Health Sciences, Universitat Autònoma de Barcelona, University of Barcelona, Barcelona, Spain
| | - Anna Falcó-Pegueroles
- Department of Fundamental Care and Medical-Surgical Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group SGR 269 Quantitative Psychology, University of Barcelona, Barcelona, Spain
| | | | - Alejandro Bosch-Alcaraz
- School of Nursing, Faculty of Medicine and Health Sciences, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
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Dhingra L, Lam K, Cheung W, Hynes G, Fleming-Damon C, Hicks S, Huang P, Chen J, Chang V, Portenoy R. Development and Pilot Test of a Culturally Relevant Toolkit to Enhance Advance Care Planning With Chinese American Patients. J Pain Symptom Manage 2021; 62:e186-e191. [PMID: 33652094 DOI: 10.1016/j.jpainsymman.2021.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/01/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND First-generation Chinese American patients have low engagement in advance care planning (ACP). Among the causes may be clinician uncertainty about traditional cultural values. AIM Based on a survey identifying barriers to ACP among older ethnic Chinese American patients, we created a toolkit to support clinicians in culturally relevant ACP practices and conducted a pilot test to evaluate usability, acceptability, and preliminary outcomes. DESIGN/SETTING/PARTICIPANTS The toolkit includes culturally relevant information and an ACP guideline with a prompt list of questions. Six clinicians (three physicians, two nurse practitioners, and one physician assistant) in two New York City-based practices piloted the toolkit through discussions with 66 patients. RESULTS Patients' age averaged 70.2 years (SD=12.4); 56.1% were women. Almost two-thirds had not finished high school and 53.0% spoke only Cantonese. More than three-quarters (78.8%) did not understand the purpose of ACP before the discussion. During the discussion, 58 patients (87.9%) completed a new proxy naming a health care agent, 21 (31.8%) requested a nonhospital DNR order, and two (3%) completed a living will. Topics discussed included treatment preferences (discussed with 80.3% of patients); health care values (77.3%); treatment decisions (72.7%); goals of care (68.2%), and hospice (1.5%). Five of the six clinicians expressed satisfaction ("very" or "somewhat") with the toolkit, four were "very" comfortable using it, and three stated that it helped them "a lot" with effective discussions. CONCLUSIONS An ACP toolkit may facilitate culturally relevant ACP discussions by increasing clinician competency and patient engagement. Further studies of this approach are needed.
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Affiliation(s)
- Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Kin Lam
- Community Private Practice, New York, New York, USA
| | | | - Gavin Hynes
- National University of Ireland, Galway, Ireland
| | | | - Stephanie Hicks
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Philip Huang
- University of Kansas, Department of Psychology, Lawrence, Kansas, USA
| | - Jack Chen
- Cohen Children's Medical Center, General Pediatrics, New Hyde Park, New York, USA
| | - Victor Chang
- Section of Hematology/Oncology, Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA; Department of Medicine, Rutgers NJMS, Newark, New Jersey, USA
| | - Russell Portenoy
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, USA
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Emotional and cognitive barriers of bereavement care among clinical staff in hospice palliative care. Palliat Support Care 2021; 18:676-682. [PMID: 32295666 DOI: 10.1017/s147895152000022x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Bereavement care is one of the major components of hospice palliative care. Previous studies revealed the barriers to the success of the system, including lack of time or support from mental health professionals. Few studies have explored the intrapersonal barriers to bereavement care by clinical staff. The aims of the study were to explore (1) the emotional and cognitive barriers of bereavement care by hospice palliative care staff and (2) the demographic and work characteristics related to these emotional and cognitive barriers. METHOD The participants were clinical staff (n = 301) who were working in hospice palliative care units, including hospice wards, home care, and hospital-based palliative care teams. Their professional backgrounds included physicians (n = 12), nurses (n = 172), social workers (n = 59), psychologists (n = 34), spiritual care specialists (n = 15), and others (n = 9). A cross-sectional design was used and a standardized questionnaire including emotional and cognitive barriers was developed. Information on demographic and work characteristics was also collected. Content validity index, an exploratory factor analysis, and multiple regression analysis were conducted. RESULTS One emotional barrier, "negative emotional reactions" (13 items, Cronbach's α = 0.92), and three cognitive barriers, "lack of ability" (7 items, Cronbach's α = 0.85), "belief in avoidance" (5 items, Cronbach's α = 0.86), and "outcome expectancy" (4 items, Cronbach's α = 0.85) were identified. Clinical staff who had higher working stress, lower self-rated ability for bereavement care, and higher negative impact from major life loss tended to have higher emotional and cognitive barriers. SIGNIFICANCE OF RESULTS Clinical staff should be aware of intrapersonal barriers to bereavement care. Educational programs should be developed to improve the ability to engage in bereavement care.
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