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Markgraf M, Meyer G, Kirchner Ä. [Advance care planning in the acute hospital: A qualitative analysis of terms and conditions]. Pflege 2024. [PMID: 39171355 DOI: 10.1024/1012-5302/a001011] [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: 08/23/2024]
Abstract
Advance care planning in the acute hospital: A qualitative analysis of terms and conditions Abstract: Background: Advance Care Planning (ACP) is an internationally established concept aimed to facilitate anticipatory care planning in the event of future inability to consent. In Germany, ACP is currently not regularly offered to patients in acute care hospitals. Aim: We aimed to identify preconditions for implementation of ACP in acute care hospitals in Germany through review of the international literature and expert interviews. Methods: A systematic literature search was carried out in the databases MEDLINE and CINAHL for internationally used strategies for implementing ACP in acute care hospitals. Consecutively, a guide for interviews with experts to evaluate the strategies was developed. Interviews were analyzed by qualitative content analysis according to Mayring. Results: Out of 13 included publications, 17 preconditions were identified and assigned to 16 categories after evaluation by experts. In international ACP programs, it was described how to proceed and organize the ACP conversation. German experts emphasized that appropriate preconditions, such as sufficient time resources and training, must be granted, whereas the literature search revealed the conversation process and organization as important determinants. Conclusions: The implementation of ACP programs is conceivable, but requires specific conditions as legal regulation and defining and structuring of the processes.
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Affiliation(s)
- Miriam Markgraf
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Gabriele Meyer
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Änne Kirchner
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
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2
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Walter C, Lex K. Palliative (farewell) culture in shared housing arrangements : The perspective of everyday nursing practice. Z Gerontol Geriatr 2024; 57:284-289. [PMID: 38832984 PMCID: PMC11208262 DOI: 10.1007/s00391-024-02313-4] [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: 02/20/2024] [Accepted: 04/18/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Shared housing arrangements (SHA) are alternatives to long-term care facilities for care-dependent people. The collective perspective of nursing professionals working in SHA in dealing with death and dying is missing in recent studies. This study aimed to investigate the perspective of professionals concerning a palliative (farewell) culture in SHA. METHODS In this study two group discussions were conducted with nurses and nursing assistants working in SHA. Data were analyzed using the documentary method, with the aim of working out the professional orientation framework concerning a collective palliative culture. RESULTS Nurses enable a palliative (farewell) culture. This leads to the fact that hospice services are not used in these SHA. The distance to relatives as well as a short dying process or incomplete dying support can make a successful palliative culture difficult. Depending on the conscious assumption of responsibility for a palliative culture in the nursing concept of SHA, death and dying are discussed at an early stage with the relatives and care-dependent people. DISCUSSION The constantly progressing palliative culture in SHA is based on nurses' experiences, general practitioners (GP) and relatives. The family carers' role is ambiguous. If they do what they are supposed to do from the professional nurses' point of view and are closely connected to the nurses, they are viewed positively and as enablers of a palliative culture. If family carers' responsibilities are not communicated and they are not in close contact with professional nurses, they are viewed as opponents of a palliative culture. The GPs are seen as enablers of a palliative culture in both discussions. A timely discussion on what might happen in the end of life phase, formalized or not, helps all involved groups to be prepared.
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Affiliation(s)
- Carola Walter
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria.
| | - Katharina Lex
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
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3
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Tenge T, Neukirchen M. [Advance care instruments for emergency rescue services : What is the current situation in Germany?]. DIE ANAESTHESIOLOGIE 2023; 72:748-752. [PMID: 37563316 DOI: 10.1007/s00101-023-01323-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/12/2023]
Abstract
In addition to advance care instruments, such as advance directives and healthcare powers of attorney, adapted directives for emergency situations might be beneficial. These could avoid problems occurring with advance directives (e.g., lack of availability in acute emergencies, insufficient applicability to specific situations) when patients are no longer capable of making decisions but prompt decisions are required. Patients at the end of life are particularly relevant in this context, as they can refuse invasive procedures. Emergency advance directives should provide legally certain, quickly accessible and easily interpretable information about patient wishes regarding procedures such as resuscitation, intubation, and hospital admission. This narrative review provides a compact overview in the form of a needs and current status survey on emergency advance directives in Germany, presenting clinical and research projects. Overall, the current situation is one of inconsistent and insufficient implementation, with a concurrent increase in the proportion of palliative care patients in emergency services.An acute need for action to strengthen the cooperation between palliative medicine, emergency medicine and rescue services emerges. Training on palliative knowledge and care of patients at the end of life is also useful for prehospital care.
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Affiliation(s)
- Theresa Tenge
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland.
- Interdisziplinäres Zentrum für Palliativmedizin, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland.
| | - Martin Neukirchen
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
- Interdisziplinäres Zentrum für Palliativmedizin, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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4
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Pedrosa Carrasco AJ, Berlin P, Betker L, Riera-Knorrenschild J, von Blanckenburg P, Seifart C. Developing a care pathway for hospital-based advance care planning for cancer patients: A modified Delphi study. Eur J Cancer Care (Engl) 2022; 31:e13756. [PMID: 36268891 DOI: 10.1111/ecc.13756] [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] [Received: 04/22/2022] [Revised: 10/03/2022] [Accepted: 10/09/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective of this study is to develop a care pathway for a hospital-based advance care planning service for cancer patients. METHODS A web-based modified Delphi study consulted an expert panel consisting of a convenience sample of stakeholders including professionals with a special interest in advance care planning as well as a 'public and patient involvement group'. After generating ideas for core elements of a care pathway in the first round, numerical ratings and rankings informed the multi-professional research steering group's decision process eventually resulting in a final pathway. RESULTS The 41 participants in the Delphi study identified 177 potential core elements of the pathway in the first round. In two further rounds, consensus was reached on a final version of the pathway with 148 elements covering the 10 domains: prerequisites, organisation and coordination, identification and referral, provision of information, information sources, family involvement, advance care planning discussion, documentation, update and quality assurance. CONCLUSION We propose a care pathway for advance care planning for hospital patients with cancer based on the results of a Delphi study that reached consensus on an implementation strategy. Our study pioneers the standardisation of the process and provides input for further policy and research with the aim of aligning cancer patients' care with their preferences and values.
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Affiliation(s)
| | - Pia Berlin
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Liv Betker
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Jorge Riera-Knorrenschild
- Department of Haematology, Oncology and Immunology, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Pia von Blanckenburg
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Carola Seifart
- Research Group Medical Ethics, Philipps-University Marburg, Marburg, Germany
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5
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Götze K, Bausewein C, Feddersen B, Fuchs A, Hot A, Hummers E, Icks A, Kirchner Ä, Kleinert E, Klosterhalfen S, Kolbe H, Laag S, Langner H, Lezius S, Meyer G, Montalbo J, Nauck F, Reisinger C, Rieder N, Schildmann J, Schunk M, Stanze H, Vogel C, Wegscheider K, Zapf A, Marckmann G, in der Schmitten J, Albert A, Alheid C, Bausewein C, Bruene M, Calles C, Camci H, Daubmann A, Dahlke S, Enger S, Feddersen B, Felder G, Fluck C, Freienstein A, Freytag T, Fuchs A, Icks A, in der Schmitten J, Hensel L, Hummers E, Hot A, Kirchner Ä, Kleinert E, Klosterhalfen S, Kolbe H, Laag S, Langner H, Lezius S, Marckmann G, Meyer G, Montalbo J, Nauck F, Nguyen T, Nowak A, Ossenberg M, Reisinger C, Reuter S, Rieder N, Riester T, Rosu I, Rösgen H, Salanta K, Sassi Z, Schildmann J, Schulenberg T, Schunk M, Sommer D, Stanze H, Stöhr A, Theuerkauf A, Thilo N, Tönjann J, Partowinia-Peters M, Prommersberger S, Przybylla S, Vogel C, Vomhof M, Wilken J, Zapf A, Zimprich J. Effectiveness of a complex regional advance care planning intervention to improve care consistency with care preferences: study protocol for a multi-center, cluster-randomized controlled trial focusing on nursing home residents (BEVOR trial). Trials 2022; 23:770. [PMID: 36096948 PMCID: PMC9465132 DOI: 10.1186/s13063-022-06576-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background According to recent legislation, facilitated advance care planning (ACP) for nursing home (NH) residents is covered by German sickness funds. However, the effects of ACP on patient-relevant outcomes have not been studied in Germany yet. This study investigates whether implementing a complex regional ACP intervention improves care consistency with care preferences in NH residents. Methods This is a parallel-group cluster-randomized controlled trial (cRCT) with 48 NHs (≈ 3840 resident beds) between 09/2019 and 02/2023. The intervention group will receive a complex, regional ACP intervention aiming at sustainable systems redesign at all levels (individual, institutional, regional). The intervention comprises comprehensive training of ACP facilitators, implementation of reliable ACP processes, organizational development in the NH and other relevant institutions of the regional healthcare system, and education of health professionals caring for the residents. Control group NHs will deliver care as usual. Primary outcome is the hospitalization rate during the 12-months observation period. Secondary outcomes include the rate of residents whose preferences were known and honored in potentially life-threatening events, hospital days, index treatments like resuscitation and artificial ventilation, advance directives, quality of life, psychological burden on bereaved families, and costs of care. The NHs will provide anonymous, aggregated data of all their residents on the primary outcome and several secondary outcomes (data collection 1). For residents who have given informed consent, we will evaluate care consistency with care preferences and further secondary outcomes, based on chart reviews and short interviews with residents, surrogates, and carers (data collection 2). Process evaluation will aim to explain barriers and facilitators, economic evaluation the cost implications. Discussion This study has the potential for high-quality evidence on the effects of a complex regional ACP intervention on NH residents, their families and surrogates, NH staff, and health care utilization in Germany. It is the first cRCT investigating a comprehensive regional ACP intervention that aims at improving patient-relevant clinical outcomes, addressing and educating multiple institutions and health care providers, besides qualification of ACP facilitators. Thereby, it can generate evidence on the potential of ACP to effectively promote patient-centered care in the vulnerable population of frail and often chronically ill elderly. Trial registration ClinicalTrials.gov ID NCT04333303. Registered 30 March 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06576-3.
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6
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Bretschneider C, Poeck J, Freytag A, Günther A, Schneider N, Schwabe S, Bleidorn J. [Emergency situations and emergency department visits in nursing homes-a scoping review about circumstances and healthcare interventions]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2022; 65:688-696. [PMID: 35581404 PMCID: PMC9113071 DOI: 10.1007/s00103-022-03543-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Nursing home residents are more likely to be hospitalized as non-institutionalized peers. A large number of emergency medical services (EMS) and emergency department visits are classified as potentially avoidable. OBJECTIVES To identify circumstances that increase the number of emergency situations in nursing homes and approaches to reduce hospital admissions in order to illustrate the complexity and opportunities for action. MATERIALS AND METHODS Scoping review with analysis of current original and peer-reviewed papers (2015-2020) in PubMed, CINAHL, and hand-search databases. RESULTS From 2486 identified studies, 302 studies were included. Injuries, fractures, cardiovascular, respiratory, and infectious diseases are the most frequent diagnostic groups that have been retrospectively recorded. Different aspects could be identified as circumstances inducing emergency department visits: resident-related (e.g., multimorbidity, lack of volition, and advance directives), facility-related (e.g., staff turnover, uncertainties), physician-related (lack of accessibility, challenging access to specialists), and system-related circumstances (e.g., limited possibilities for diagnostics and treatment in facilities). Multiple approaches to reduce emergency department visits are being explored. CONCLUSIONS A variety of circumstances influence the course of action in emergency situations in nursing facilities. Therefore, interventions to reduce emergency department visits address, among other things, strengthening the competence of nursing staff, interprofessional communication, and systemic approaches. A comprehensive understanding of the complex processes of care is essential for developing and implementing effective interventions.
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Affiliation(s)
- Carsten Bretschneider
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland
| | - Juliane Poeck
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland.
| | - Antje Freytag
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland
| | | | - Nils Schneider
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Sven Schwabe
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Jutta Bleidorn
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland
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7
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Petri S, Zwißler B, In der Schmitten J, Feddersen B. [Advance Care Planning-further development of the patient advance directive : What the specialist in internal medicine must know]. Internist (Berl) 2022; 63:533-544. [PMID: 35441880 PMCID: PMC9020146 DOI: 10.1007/s00108-022-01333-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.
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Affiliation(s)
- S Petri
- Caritasverband der Erzdiözese München und Freising e. V., München, Deutschland
| | - B Zwißler
- Klinik für Anästhesiologie, Klinikum der Universität München, LMU München, München, Deutschland
| | - J In der Schmitten
- Institut für Allgemeinmedizin, Universitätsklinik Essen, Essen, Deutschland
| | - B Feddersen
- Klinik und Poliklinik für Palliativmedizin, SAPV, Klinikum der Universität München, LMU München, Schillerstr. 40/III, 80336, München, Deutschland.
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8
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Bosisio F, Sterie AC, Rubli Truchard E, Jox RJ. Implementing advance care planning in early dementia care: results and insights from a pilot interventional trial. BMC Geriatr 2021; 21:573. [PMID: 34666711 PMCID: PMC8524211 DOI: 10.1186/s12877-021-02529-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 10/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is particularly appropriate for persons with early dementia (PWED) since it promotes conversations about dementia-specific illness scenarios, addresses inconsistencies between advance directives and patients' observed behavior, emphasizes prospective and relational autonomy, and may be generally consistent with older persons' decision-making needs. However, despite evidence of its benefits, ACP is yet to become widely used among PWED. In this paper, we present a dementia-specific tool developed in Western Switzerland, discuss results of a pilot trial designed to promote ACP among PWED and their relatives, and discuss the feasibility and acceptability of the intervention and the study protocol in prevision of a large scale trial. METHODS This one-arm pre-post pilot trial consisted of four visits, with visits 2 and 3 being the ACP intervention. Quantitative outcome measures during visit 1 and 4 assessed the aptitude of the intervention to support PWED autonomy and relatives' knowledge of PWED's preferences. Feasibility was explored according to how the recruitment procedure unfurled and based on the necessary revisions to the study protocol and healthcare providers' reason for excluding a PWED from the study. Acceptability was assessed according to pre-post evaluations, difficulties regarding the intervention or trial participation, and pre-post qualitative interviews regarding participants' reasons to participate to the study, satisfaction with the tool and difficulties perceived. RESULTS The ACP intervention itself was well received by PWED and their relatives that expressed satisfaction with the procedure, especially regarding the opportunity to discuss a sensitive topic with the help of a facilitator. Five main challenges in terms of feasibility were 1) to locate eligible patients, 2) to tailor recruitment procedures to recruitment locations, 3) to adapt inclusion criteria to clinical routines, 4) to engage PWED and their relatives in ACP, and 5) to design a trial that does not burden PWED. Despite these challenges, the intervention increased the number of advance directives, the concordance between PWED's preferences and relatives' decision on their behalf, and relatives' perceived control over healthcare decisions. CONCLUSION Misconceptions about dementia and ACP, in the patient, relatives, and healthcare providers, combined with structural and institutional challenges, have the power to impede research and implementation of ACP in dementia care. For this reason, we conclude that a large scale trial to test a dementia-specific tool of ACP is currently not feasible in Western Switzerland and should be endorsed in a systemic approach of ACP. TRIAL REGISTRATION This trial was registered in the database clinicaltrial.gov with the number NCT03615027 .
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Affiliation(s)
- Francesca Bosisio
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland. .,Service of Palliative and Supportive Care, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland. .,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland.
| | - Anca-Cristina Sterie
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Service of Palliative and Supportive Care, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland
| | - Eve Rubli Truchard
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland
| | - Ralf J Jox
- Service of Palliative and Supportive Care, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland.,Institute of Humanities in Medicine, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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Jeong S, Cleasby P, Ohr SO, Barrett T, Davey R, Oldmeadow C. Efficacy of Normalisation of Advance Care Planning (NACP) for people with chronic diseases in hospital and community settings: a quasi-experimental study. BMC Health Serv Res 2021; 21:901. [PMID: 34470636 PMCID: PMC8408987 DOI: 10.1186/s12913-021-06928-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/18/2021] [Indexed: 01/21/2023] Open
Abstract
Background Advance Care Planning (ACP) has emerged to improve end-of-life processes and experiences. However, the available evidence presents the gloomy picture of increasing number of older people living with chronic diseases and the mismatch between their preferences for and the actual place of death. The study aimed to investigate the efficacy of normalisation of an Advance Care Planning (NACP) service delivered by specially trained Registered Nurses (RNs) in hospital and community settings. Methods A quasi-experimental study was conducted involving 16 sites (eight hospital and eight community sites) in Australia. Patients who were aged ≥18 years, who had at least one of nine chronic conditions, and who did not have an Advance Care Directive (ACD) were offered the NACP service. ACP was normalised as part of routine service on admission. The intervention, NACP, was a series of facilitated conversations about the components of ACP. The primary outcomes which included the completion of ACDs, and/or appointment of an Enduring Guardian (EG), were assessed in both intervention and control sites at pre and post intervention stages. Numbers of patients who completed an ACD or appointed an EG were described by count (percentage). ACD completion was compared between intervention and control sites using a logistic mixed effects regression model. The model includes fixed effects for treatment group, period, and their interaction, as well as random site level intercepts. Secondary model included potentially confounding variables as covariates, including age, sex and chronic diseases. Results The prevalence of legally binding ACDs in intervention sites has increased from five to 85 (from 0.85% in pre to 17.6% in post), whereas it has slightly decreased from five to 2 (from 1.2% in pre and to 0.49% in post) in control sites (the difference in these changes being statistically significant p < 0.001). ACD completion rate was 3.6% (n = 4) in LHD1 and 1.2% (n = 3) in LHD2 in hospital whereas it was 53% (n = 26) in LHD1 and 80% (n = 52) in LHD2 in community. Conclusions The study demonstrated that NACP service delivered by ACP RNs was effective in increasing completion of ACDs (interaction odds ratio = 50) and was more effective in community than hospital settings. Involvement of various healthcare professionals are warranted to ensure concordance of care. Trial registration The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246) on 03/10/2018. The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06928-w.
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Affiliation(s)
- Sarah Jeong
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia.
| | - Peter Cleasby
- Division of Aged, Subacute and Complex Care, PO Box 6088, Central Coast Local Health District, Long Jetty, NSW, 2261, Australia
| | - Se Ok Ohr
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia.,Hunter New England Nursing and Midwifery Research Centre, Hunter New England Local Health District, James Fletcher Campus, Gate Cottage, 72 Watt St, Newcastle, NSW, 2300, Australia
| | - Tomiko Barrett
- Department of Aged Care Services, Wyong Hospital, PO Box 4200, Central Coast Local Health District, Lakehaven, NSW, 2263, Australia
| | - Ryan Davey
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, Lot 1, Kookaburra Circuit, New Lambton Heights, Newcastle, NSW, 2305, Australia
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10
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Detering KM, Sinclair C, Buck K, Sellars M, White BP, Kelly H, Nolte L. Organisational and advance care planning program characteristics associated with advance care directive completion: a prospective multicentre cross-sectional audit among health and residential aged care services caring for older Australians. BMC Health Serv Res 2021; 21:700. [PMID: 34271934 PMCID: PMC8283952 DOI: 10.1186/s12913-021-06523-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/12/2021] [Indexed: 11/18/2022] Open
Abstract
Background Advance care planning (ACP) and advance care directive (ACD) completion improve outcomes for patients, family, clinicians and the healthcare system. However, uptake remains low. Despite increasing literature regarding organisational-level ACP characteristics leading to success, there is a lack of data measuring the impact of these factors on ACD prevalence. Methods A prospective multi-centre, cross-sectional audit of health records among older Australians accessing general practices (GP), hospitals and residential aged care facilities (RACF) was undertaken to describe organisational and ACP-program characteristics across services, document ACD prevalence, and assess organisation-level predictors of ACD prevalence. Organisational-level data included general and ACP-program characteristics. Patient/resident data included demographics and presence of ACDs. Results One hundred organisations (GP = 15, hospitals = 27, RACFs = 58) participated, contributing data from 4187 patient/resident health records. Median prevalence of ACDs across organisations was 19.4%, (range = 0–100%). In adjusted models, organisational sector type was the strongest predictor of ACD prevalence, with higher rates in RACFs (unadjusted 28.7%, adjusted 20.6%) than hospitals (unadjusted 6.4%, adjusted 5.8%) or GPs (unadjusted 2.5%, adjusted 6.6%). RACFs in regional and rural/remote areas had higher prevalence than metropolitan organisations. Organisations supported by government funding and those that were Not For Profit had higher prevalence than those that were privately funded, and organisations with an ACP program that had been implemented at least 3 years before data collection had higher prevalence than those with either no program or a more recent program. Conclusions The median ACD prevalence was low, with substantial variation across organisations. Sector type was the strongest predictor, being highest in RACFs. Low prevalence rates, overall and in particular sectors, have implications for improvements. Further research into organisational factors associated with ACP/ACD completion is required.
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Affiliation(s)
- Karen M Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.,Faculty of Health, Arts and Innovation, Swinburne University of Technology, Hawthorn, Australia
| | - Craig Sinclair
- Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney, Australia.,School of Psychology, University of New South Wales, Sydney, Australia
| | - Kimberly Buck
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Marcus Sellars
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.,Department of Health Services Research & Policy, Research School of Population Health, College of Health & Medicine, The Australian National University, Canberra, Australia
| | - Ben P White
- Australian Centre for Health Research Law, Faculty of Law, Queensland University of Technology, Brisbane, Australia
| | - Helana Kelly
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.,Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Melbourne, Australia.
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11
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Wendrich-van Dael A, Gilissen J, Van Humbeeck L, Deliens L, Vander Stichele R, Gastmans C, Pivodic L, Van den Block L. Advance care planning in nursing homes: new conversation and documentation tools. BMJ Support Palliat Care 2021; 11:312-317. [PMID: 34162581 PMCID: PMC8380900 DOI: 10.1136/bmjspcare-2021-003008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/02/2021] [Indexed: 02/07/2023]
Abstract
Although advance care planning (ACP) is highly relevant for nursing home residents, its uptake in nursing homes is low. To meet the need for context-specific ACP tools to support nursing home staff in conducting ACP conversations, we developed the ACP+intervention. At its core, we designed three ACP tools to aid care staff in discussing and documenting nursing home resident's wishes and preferences for future treatment and care: (1) an extensive ACP conversation guide, (2) a one-page conversation tool and (3) an ACP document to record outcomes of conversations. These nursing home-specific ACP tools aim to avoid a purely document-driven or 'tick-box' approach to the ACP process and to involve residents, including those living with dementia according to their capacity, their families and healthcare professionals.
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Affiliation(s)
- Annelien Wendrich-van Dael
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium .,Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
| | - Joni Gilissen
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium.,Neurology, UCSF, San Francisco, California, USA
| | - Liesbeth Van Humbeeck
- Department of Geriatric Medicine, University Hospital Ghent, Gent, Oost-Vlaanderen, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | | | - Chris Gastmans
- Interfacultair Centrum voor Biomedische Ethiek en Recht, KULeuven, Leuven, Belgium
| | - Lara Pivodic
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
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12
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Welsch K, Gottschling S. Wishes and Needs at the End of Life–Communication Strategies, Counseling, and Administrative Aspects. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:303-312. [PMID: 34180804 PMCID: PMC8289964 DOI: 10.3238/arztebl.m2021.0141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 09/19/2020] [Accepted: 01/27/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Managing the last phase of life properly, i.e., taking care that a patient's wishes are respected at the end of life and beyond, is very important and can relieve the patient and his or her family of unnecessary burdens. METHODS This review is based on guidelines, reviews, meta-analyses, selected publications, and the authors' own experiences from everyday clinical practice. RESULTS Most patients want frank information from their physicians about their condition at all times over the course of their treatment, from the moment of diagnosis to the end of their life. This has no lasting adverse effects, but rather enables patients to take decisions that are appropriate to their stage of disease. Early integration in palliative care can improve patients' quality of life, symptom control, and mood. In helping to manage the last phase of life, the physician often serves as a provider of impulses, or else determines which other types of professional should counsel or support the patient. Patients should be enabled to issue directives that reflect their wishes, as well as to choose representatives who are allowed to speak for them. Consideration should also be given to the patient's emotional legacy, e.g., letters or video messages with personal content. CONCLUSION In the care of patients with life-limiting diseases, more attention should be paid to the management of the last phase of life. Palliative-care physicians can take over this task from other medical disciplines, and early integration in palliative care is recommended.
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Affiliation(s)
- Katja Welsch
- Centre of Palliative Care and Pediatric Pain,Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar
| | - Sven Gottschling
- Centre of Palliative Care and Pediatric Pain,Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar
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13
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Jeong S, Barrett T, Ohr SO, Cleasby P, Davey R, David M. Prevalence of advance care planning practices among people with chronic diseases in hospital and community settings: a retrospective medical record audit. BMC Health Serv Res 2021; 21:303. [PMID: 33820535 PMCID: PMC8022421 DOI: 10.1186/s12913-021-06265-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance Care Planning (ACP) enables healthcare professionals to embrace the important process where patients think about their values in life and goals for health care, and discuss their future health care preferences with family members for a time when they are not able to make health care decisions. Despite the promotion of ACP last two decades, and well-known benefits of ACP and a written Advance Care Directive (ACD), they are still underutilised in Australia and across the world. Previous studies have provided some insights, however, an uptake of ACP and prevalence of ACDs in community settings is rarely reported. METHODS The aim of this study was to determine the uptake of ACP and prevalence of ACDs among people with chronic diseases in hospital and community settings. A retrospective medical record audit of eligible patients looking for evidence of ACP was conducted in 16 research sites in eight hospital and eight community care settings. Participants included those who were admitted to one of the research sites, and who were aged 18 years and over with at least one of nine nominated chronic diseases. The primary outcome measures included the number of patients with evidence of ACP through the following practices: completion of an ACD, appointment of an Enduring Guardian (EG), or completion of a resuscitation plan. RESULTS The overall prevalence of ACD was 2.8% (n = 28) out of 1006 audited records, and only 10 (1%) of them were legally binding. The number of EGs appointed was 39 (3.9%) across the sites. A total of 151 (15.4%) resuscitation plans were found across the eight hospital sites. 95% (n = 144) of the resuscitation plans indicated 'Not-for-resuscitation'. CONCLUSIONS The uptake of ACP is very low. Current medical recording system reveals the challenges in ACP lie in the process of storage, access and execution of the ACDs. Given that having an ACD or Enduring Guardian in place is only useful if the treating physician knows how and where to access the information, it has implications for policy, information system, and healthcare professionals' education. TRIAL REGISTRATION The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx.
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Affiliation(s)
- Sarah Jeong
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia.
| | - Tomiko Barrett
- Department of Aged Care Services, Wyong Hospital, Central Coast Local Health District, PO Box 4200, Lakehaven, NSW, 2263, Australia
| | - Se Ok Ohr
- Hunter New England Nursing and Midwifery Research Centre, Hunter New England Local Health District, James Fletcher Campus, Gate Cottage, 72 Watt St, Newcastle, NSW, 2300, Australia
| | - Peter Cleasby
- Division of Aged, Subacute and Complex Care, Central Coast Local Health District, PO Box 6088, Long Jetty, NSW, 2261, Australia
| | - Ryan Davey
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia
| | - Michael David
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
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14
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[Advance care planning in critical care : Potential and requirements]. Med Klin Intensivmed Notfmed 2021; 116:198-204. [PMID: 33687485 DOI: 10.1007/s00063-021-00799-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 02/07/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Lack of knowledge about patient preferences is a contributing factor for inappropriate therapy. Advance care planning (ACP) is a novel concept for meaningful advance directives, but it is still not widely known in Germany. OBJECTIVE An overview of the concept of ACP, development and its implementation with respect to intensive care is provided. METHODS A narrative literature review was performed. RESULTS ACP is a broad concept which requires facilitated discussions with trained medical staff. The process can lead to different ACP documents. It is also possible to facilitate discussions with patient proxies. Furthermore, ACP has potential because of the proven validity of advance directives and the prompt applicability of directives in an emergency. Prerequisites for ACP include the provision of resources, notably for the training of appropriate facilitators, and the implementation or extension of counseling structures. CONCLUSIONS Advanced care planning (ACP) is a promising concept. However, some requirements must be met to implement ACP into daily practice.
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15
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Lyon ME, Caceres S, Scott RK, Benator D, Briggs L, Greenberg I, D'Angelo LJ, Cheng YI, Wang J. Advance Care Planning-Complex and Working: Longitudinal Trajectory of Congruence in End-of-Life Treatment Preferences: An RCT. Am J Hosp Palliat Care 2021; 38:634-643. [PMID: 33530701 DOI: 10.1177/1049909121991807] [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: 12/25/2022] Open
Abstract
CONTEXT The effect of advance care planning (ACP) interventions on the trajectory of end-of-life treatment preference congruence between patients and surrogate decision-makers is unstudied. OBJECTIVE To identify unobserved distinctive patterns of congruence trajectories and examine how the typology of outcome development differed between ACP and controls. METHODS Multisite, assessor-blinded, intent-to-treat, randomized clinical trial enrolled participants between October 2013 to March 2017 from 5 hospital-based HIV clinics. Persons living with HIV(PLWH)/surrogate dyads were randomized to 2 weekly 60-minute sessions: ACP (1) ACP facilitated conversation, (2) advance directive completion; or Control (1) Developmental/relationship history, (2) Nutrition/Exercise. Growth Mixed Modeling was used for 18-month post-intervention analysis. FINDINGS 223 dyads (N = 449 participants) were enrolled. PLWH were 56% male, aged 22 to 77 years, and 86% African American. Surrogates were 56% female, aged 18 to 82 years, and 84% African American. Two latent classes (High vs. Low) of congruence growth trajectory were identified. ACP influenced the trajectory of outcome growth (congruence in all 5 AIDS related situations) by latent class. ACP dyads had a significantly higher probability of being in the High Congruence latent class compared to controls (52%, 75/144 dyads versus 27%, 17/62 dyads, p = 0.001). The probabilities of perfect congruence diminished at 3-months post-intervention but was then sustained. ACP had a significant effect (β = 1.92, p = 0.006, OR = 7.10, 95%C.I.: 1.729, 26.897) on the odds of being in the High Congruence class. CONCLUSION ACP had a significant effect on the trajectory of congruence growth over time. ACP dyads had 7 times the odds of congruence, compared to controls. Three-months post-intervention is optimal for booster sessions.
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Affiliation(s)
- Maureen E Lyon
- Division of Adolescent and Young Adult Medicine, 571630Children's National Hospital, Washington, District of Columbia (DC), USA.,Center for Translational Research/Children's Research Institute, Washington, DC, USA.,George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sarah Caceres
- Nova Southeastern University School of Nursing, Fort Lauderdale, FL, USA
| | - Rachel K Scott
- MedStar: Health Research Institute and Washington Hospital Center, Washington, DC, USA
| | - Debra Benator
- Washington DC Veterans Affairs Medical Center, Washington, DC, USA
| | - Linda Briggs
- Respecting Choices, Coalition to Transform Advance Care Innovations, Washington, DC, USA
| | | | - Lawrence J D'Angelo
- Division of Adolescent and Young Adult Medicine, 571630Children's National Hospital, Washington, District of Columbia (DC), USA
| | | | - Jichuan Wang
- Center for Translational Research/Children's Research Institute, Washington, DC, USA.,George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Division of Biostatistics & Study Methodology, Center for Translational Research/Children's Research Institute, Washington, DC, USA
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16
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Günther A, Schildmann J, in der Schmitten J, Schmid S, Weidlich-Wichmann U, Fischer M. Opportunities and Risks of Resuscitation Attempts in Nursing Homes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:757-763. [PMID: 33533330 PMCID: PMC7898050 DOI: 10.3238/arztebl.2020.0757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 02/19/2020] [Accepted: 06/03/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Data supporting decision-making regarding cardiopulmonary resuscitation (CPR) in German nursing homes is insufficient. METHODS A retrospective evaluation of pre-hospital CPR was carried out with data from the German Resuscitation Registry (Deutsches Reanimationsregister) for the years 2011-2018. Patients under age 65 were excluded, as were patients from districts in which long-term data was available for less than 60% of patients. Subgroups were analyzed based on age and certain prehospital situations; patients treated outside nursing homes were used for comparison. RESULTS The study group consisted of 2900 patients, whose mean age was 83.7 years (standard deviation, 7.5 years). 1766 (60.9%) were women and 1134 (39.1%) were men. 118 patients (4.0%) were discharged alive, including 64 (2.2%) with a cerebral performance category (CPC) of 1 or 2, 30 (1.0%) with an unknown CPC, and 24 (0.8%) with a CPC of 3 or 4. 902 patients (31.1%) died in the hospital, including five (0.2%) who died more than 30 days after resuscitation, 279 (9.6%) between 24 hours and 30 days, and 618 (21.3%) within 24 hours. 1880 patients (64.8%) died at the site of attempted resuscitation. In 1056 cases (36.4%), CPR was initiated before the arrival of the emergency medical services. In the "initially shockable" subgroup, 13 of 208 patients (6.3%) were discharged alive with a CPC of 1 or 2. CONCLUSION CPR can lead to a good neurological outcome in rare cases even when carried out in a nursing home. The large percentage of CPR attempts that were initiated only after a delay indicates that nursing home staff may often be uncertain how to proceed. Uncertainty among caregivers points to a potential for advance care planning.
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Affiliation(s)
- Andreas Günther
- Fire Department,City of Braunschweig and Department of Anesthesiology, Braunschweig Hospitals gGmbH
| | - Jan Schildmann
- Institute for the History and Ethics of Medicine, Medical Faculty, University of Halle-Wittenberg (Saale)
| | - Jürgen in der Schmitten
- Fire Department,City of Braunschweig and Department of Anesthesiology, Braunschweig Hospitals gGmbH
| | | | - Uta Weidlich-Wichmann
- Faculty of Public Health Services, Ostfalia University of Applied Sciences, Campus Wolfsburg
| | - Matthias Fischer
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy, Klinik am Eichert, Alb Fils Hospitals, Göppingen
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17
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Resick JM, Arnold RM, Sudore RL, Farrell D, Belin S, Althouse AD, Ferrell B, Hammes BJ, Chu E, White DB, Rak KJ, Schenker Y. Patient-centered and efficacious advance care planning in cancer: Protocol and key design considerations for the PEACe-compare trial. Contemp Clin Trials 2020; 96:106071. [PMID: 32739493 PMCID: PMC7510772 DOI: 10.1016/j.cct.2020.106071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/05/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Failure to deliver care near the end of life that reflects the needs, values and preferences of patients with advanced cancer remains a major shortcoming of our cancer care delivery system. METHODS A mixed-methods comparative effectiveness trial of in-person advance care planning (ACP) discussions versus web-based ACP is currently underway at oncology practices in Western Pennsylvania. Patients with advanced cancer and their caregivers are invited to enroll. Participants are randomized to either (1) in-person ACP discussions via face-to-face visits with a nurse facilitator following the Respecting Choices® Conversation Guide or (2) web-based ACP using the PREPARE for your care™ web-based ACP tool. The trial compares the effect of these two interventions on patient and family caregiver outcomes (engagement in ACP, primary outcome; ACP discussions; advance directive (AD) completion; quality of end-of-life (EOL) care; EOL goal attainment; caregiver psychological symptoms; healthcare utilization at EOL) and assesses implementation costs. Factors influencing ACP effectiveness are assessed via in-depth interviews with patients, caregivers and clinicians. DISCUSSION This trial will provide new and much-needed empirical evidence about two patient-facing ACP approaches that successfully overcome limitations of traditional written advance directives but entail very different investments of time and resources. It is innovative in using mixed methods to evaluate not only the comparative effectiveness of these approaches, but also the contexts and mechanisms influencing effectiveness. Data from this study will inform clinicians, payers and health systems seeking to adopt and scale the most effective and efficient ACP strategy in real-world oncology settings.
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Affiliation(s)
- Judith M Resick
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Robert M Arnold
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA; San Francisco Veterans Affairs Health Care System, SFVAMC 4150 Clement Street, #151R, San Francisco, CA 94121, USA.
| | - David Farrell
- People Designs, Inc., 1304 Broad Street, Durham, NC 27705, USA.
| | - Shane Belin
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Andrew D Althouse
- Center for Research on Health Care Data Center, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Suite 300, Pittsburgh, PA 15213, USA.
| | - Betty Ferrell
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope Medical Center, 1500 Duarte Road, Duarte, CA 91010, USA.
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, PO Box 258, Oregon, WI 53575-0258, USA.
| | - Edward Chu
- Department of Medicine, Division of Hematology-Oncology and Cancer Therapeutics Program, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Douglas B White
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, USA.
| | - Kimberly J Rak
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 3520 Fifth Ave, Suite100, Pittsburgh, PA 15213, USA.
| | - Yael Schenker
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
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18
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Silies K, Schnakenberg R, Berg A, Kirchner Ä, Langner H, Köberlein-Neu J, Meyer G, Hoffmann F, Köpke S. Process evaluation of a complex intervention to promote advance care planning in community-dwelling older persons (the STADPLAN study)-study protocol. Trials 2020; 21:653. [PMID: 32678005 PMCID: PMC7366302 DOI: 10.1186/s13063-020-04529-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 06/18/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Process evaluation addresses the implementation, mechanisms of impact, and context of participants in complex interventions. The STADPLAN study assesses the effects of conversations on advance care planning (ACP) led by trained nurse facilitators. The complex intervention consists of several components that may lead to various changes in attitude and behavior regarding personal ACP activities. With the process evaluation, we aim to assess how changes were achieved in the STADPLAN intervention. METHODS The planned process evaluation study will be conducted alongside a cluster-randomized controlled trial on ACP in home care services (HCS). Trained nurse facilitators will deliver the ACP intervention consisting of an information brochure and two ACP conversations. A logic model depicts the assumed change processes of the intervention: the educational program enables nurses to conduct ACP conversations with patients and their caregivers. Patients gain knowledge and reflect upon and engage in their own ACP. Caregivers better understand patients' wishes and feel reassured in their role as surrogates. Designation of a surrogate and communication on ACP are facilitated. We will assess the effects of the educational program with questionnaires and a focus group including all participating nurses. We will measure ACP engagement, and prevalence of advance directives in patients, and ask for their experiences with the intervention. We will conduct semi-structured interviews with caregivers about their expectations and experiences regarding ACP in general and the intervention. We will address context factors, e.g., basic characteristics of the HCS (such as ownership, number of clients, staff and qualification). Analysis will be based upon the logic model, integrating qualitative and quantitative data. DISCUSSION The comprehensive process evaluation will provide essential information on the feasibility of implementation strategies and the clinical relevance of a nurse-led ACP intervention in home care recipients and its generalizability and transferability to other settings. TRIAL REGISTRATION German Clinical Trials Register: DRKS00016886 . Registered retrospectively on June 4, 2019, first participant included on May 29, 2019.
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Affiliation(s)
- Katharina Silies
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.
| | - Rieke Schnakenberg
- Department for Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany.
| | - Almuth Berg
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Änne Kirchner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Henriette Langner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Rainer-Gruenter-Straße 21, 42119, Wuppertal, Germany
| | - Gabriele Meyer
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Falk Hoffmann
- Department for Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany
| | - Sascha Köpke
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.,Institute for Nursing Science, University of Cologne, Gleueler Straße 176 - 178, 50935, Köln, Germany
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Sex-Specific Differences in Hospital Transfers of Nursing Home Residents: Results from the HOspitalizations and eMERgency Department Visits of Nursing Home Residents (HOMERN) Project. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17113915. [PMID: 32492840 PMCID: PMC7312075 DOI: 10.3390/ijerph17113915] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/25/2020] [Accepted: 05/29/2020] [Indexed: 01/04/2023]
Abstract
Nursing home (NH) residents are often transferred to hospital (emergency department (ED) visits or hospital admissions) and this occurs more frequently in males. However, respective reasons are rather unclear. We conducted a multicenter prospective study in 14 northwest German NHs with 802 residents in which NH staff recorded anonymized data between March 2018 and July 2019 for each hospital transfer. Measures were analyzed using descriptive statistics and compared between sexes via univariate logistic regression analyses using mixed models with random effects. Eighty-eight planned transfers (53.5% hospital admissions, 46.5% ED visits) occurred as well as 535 unplanned transfers (63.1% hospital admissions, 36.9% ED visits). The two most common causes for unplanned transfers were deteriorations of health status (35.1%) and falls/accidents/injuries (33.5%). Male transferred residents were younger, more often married; their advance directives were more commonly not considered correctly and the NH staff identified more males nearing the end of life than females (52.9% vs. 38.2%). Only 9.2% of transfers were rated avoidable. For advance directive availability and NH staff’s perceptions on transfer conditions, we found marked inter-facility differences. There might be sociocultural factors influencing hospital transfer decisions of male and female nursing home residents and facility characteristics that may affect transfer policy.
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Collingridge Moore D, Payne S, Van den Block L, Ling J, Froggatt K. Strategies for the implementation of palliative care education and organizational interventions in long-term care facilities: A scoping review. Palliat Med 2020; 34:558-570. [PMID: 32009516 PMCID: PMC7222696 DOI: 10.1177/0269216319893635] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND The number of older people dying in long-term care facilities is increasing; however, care at the end of life can be suboptimal. Interventions to improve palliative care delivery within these settings have been shown to be effective in improving care, but little is known about their implementation. AIM The aim of this study was to describe the nature of implementation strategies and to identify facilitators and/or barriers to implementing palliative care interventions in long-term care facilities. DESIGN Scoping review with a thematic synthesis, following the ENTREQ guidelines. DATA SOURCES Published literature was identified from electronic databases, including MEDLINE, EMBASE, PsycINFO and CINAHL. Controlled, non-controlled and qualitative studies and evaluations of interventions to improve palliative care in long-term care facilities were included. Studies that met the inclusion criteria were sourced and data extracted on the study characteristics, the implementation of the intervention, and facilitators and/or barriers to implementation. RESULTS The review identified 8902 abstracts, from which 61 studies were included in the review. A matrix of implementation was developed with four implementation strategies (facilitation, education/training, internal engagement and external engagement) and three implementation stages (conditions to introduce the intervention, embedding the intervention within day-to-day practice and sustaining ongoing change). CONCLUSION Incorporating an implementation strategy into the development and delivery of an intervention is integral in embedding change in practice. The review has shown that the four implementation strategies identified varied considerably across interventions; however, similar facilitators and barriers were encountered across the studies identified. Further research is needed to understand the extent to which different implementation strategies can facilitate the uptake of palliative care interventions in long-term care facilities.
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Affiliation(s)
| | - Sheila Payne
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Lieve Van den Block
- VUB-UGhent End of Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Julie Ling
- European Association for Palliative Care, Vilvoorde, Belgium
| | - Katherine Froggatt
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
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Schnakenberg R, Silies K, Berg A, Kirchner Ä, Langner H, Chuvayaran Y, Köberlein-Neu J, Haastert B, Wiese B, Meyer G, Köpke S, Hoffmann F. Study on advance care planning in care dependent community-dwelling older persons in Germany (STADPLAN): protocol of a cluster-randomised controlled trial. BMC Geriatr 2020; 20:142. [PMID: 32303198 PMCID: PMC7164271 DOI: 10.1186/s12877-020-01537-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/25/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In Germany, advance care planning (ACP) was first introduced by law in 2015. However, ACP is still uncommon in Germany and only few people have advance directive forms. This study aims to evaluate an ACP program in care dependent community-dwelling persons, compared to optimised usual care. METHODS A cluster-randomised controlled trial of 12 months duration will be conducted in 3 German study sites comparing the pretested ACP-counselling offered by trained nurses with a control group receiving optimised usual care. Using external concealed randomisation, 16 home care services each will be included in the intervention and the control group (30 participants per cluster; n = 960). Eligibility criteria for patients are: ≥60 years, somehow care dependent, adequate German language skills, assumed life-expectancy of ≥4 weeks, and cognitive ability for participation. ACP will be delivered by trained nurse facilitators of the respective home care services and communication will include proxy decision-makers. The primary endpoint will be patient activation, assessed by the Patient Activation Measure (PAM-13). Secondary endpoints include ACP-engagement, proportion of prepared advance directives, number and duration of hospitalisations, quality of life as well as depression and anxiety. Further, comprehensive economic and process evaluations will be conducted. DISCUSSION STADPLAN is the first study in Germany that assesses an adapted ACP intervention with trained nurses in home care services and the first international study focusing on cost effectiveness of ACP in community-dwelling older persons. The results will help to improve the understanding and communicating of patients' preferences regarding medical treatment and care and thereby contribute to patients' autonomy. TRIAL REGISTRATION German Clinical Trials Register: DRKS00016886 (Date of registration: 04.06.2019).
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Affiliation(s)
- Rieke Schnakenberg
- Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Katharina Silies
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Lübeck, Germany
| | - Almuth Berg
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Änne Kirchner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Henriette Langner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Yuliya Chuvayaran
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | | | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Gabriele Meyer
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Sascha Köpke
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Lübeck, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Fassmer AM, Pulst A, Spreckelsen O, Hoffmann F. Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies. BMC FAMILY PRACTICE 2020; 21:29. [PMID: 32046652 PMCID: PMC7014634 DOI: 10.1186/s12875-020-01108-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023]
Abstract
Background Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement. Methods Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests. Results We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492). Conclusions A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.
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Affiliation(s)
- Alexander Maximilian Fassmer
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
| | - Alexandra Pulst
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany.,Health Sciences, University of Bremen, Bremen, Germany
| | - Ove Spreckelsen
- Division of General Practice, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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23
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Gilissen J, Pivodic L, Wendrich-van Dael A, Gastmans C, Vander Stichele R, Engels Y, Vernooij-Dassen M, Deliens L, Van den Block L. Implementing the theory-based advance care planning ACP+ programme for nursing homes: study protocol for a cluster randomised controlled trial and process evaluation. BMC Palliat Care 2020; 19:5. [PMID: 31915000 PMCID: PMC6950862 DOI: 10.1186/s12904-019-0505-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 12/10/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Research has highlighted the need for improving the implementation of advance care planning (ACP) in nursing homes. We developed a theory-based multicomponent ACP intervention (the ACP+ programme) aimed at supporting nursing home staff with the implementation of ACP into routine nursing home care. We describe here the protocol of a cluster randomised controlled trial (RCT) that aims to evaluate the effects of ACP+ on nursing home staff and volunteer level outcomes and its underlying processes of change. METHODS We will conduct a cluster RCT in Flanders, Belgium. Fourteen eligible nursing homes will be pair-matched and one from each pair will be randomised to either continue care and education as usual or to receive the ACP+ programme (a multicomponent programme which is delivered stepwise over an eight-month period with the help of an external trainer). Primary outcomes are: nursing home care staff's knowledge of, and self-efficacy regarding ACP. Secondary outcomes are: 1) nursing home care staff's attitudes towards ACP and ACP practices; 2) support staff's and volunteer's ACP practices and 3) support staff's and volunteers' self-efficacy. Measurements will be performed at baseline and eight months post-measurement, using structured self-reported questionnaires. A process evaluation will accompany the outcome evaluation in the intervention group, with measurements throughout and post-intervention to assess implementation, mechanisms of impact and context and will be carried out using a mixed-methods design. DISCUSSION There is little high-quality evidence regarding the effectiveness and underlying processes of change of ACP in nursing homes. This combined outcome and process evaluation of the ACP+ programme aims to contribute to building the necessary evidence to improve ACP and its uptake for nursing home residents and their family. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov (no. NCT03521206). Registration date: May 10, 2018. Inclusion of nursing homes started March, 2018. Hence, the trial was retrospectively registered but before end of data collection and analyses.
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Affiliation(s)
- Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Atlantic Fellow for Equity in Brain Health, Global Brain Health Institute (GBHI), UCSF & Trinity College Dublin, San Francisco, CA, USA. .,Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Jette, Belgium.
| | - Lara Pivodic
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Annelien Wendrich-van Dael
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 Box 7001, 3000, Leuven, Belgium
| | | | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Myrra Vernooij-Dassen
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Brussels, Belgium
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24
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Strautmann A, Allers K, Fassmer AM, Hoffmann F. Nursing home staff's perspective on end-of-life care of German nursing home residents: a cross-sectional survey. BMC Palliat Care 2020; 19:2. [PMID: 31900141 PMCID: PMC6942381 DOI: 10.1186/s12904-019-0512-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/26/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany. METHODS A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested. RESULTS 486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement. CONCLUSIONS Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.
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Affiliation(s)
- Anke Strautmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
- Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstr. 114-118, D-26129, Oldenburg, Germany.
| | - Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | | | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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25
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Gilissen J, Pivodic L, Wendrich-van Dael A, Gastmans C, Vander Stichele R, Van Humbeeck L, Deliens L, Van den Block L. Implementing advance care planning in routine nursing home care: The development of the theory-based ACP+ program. PLoS One 2019; 14:e0223586. [PMID: 31622389 PMCID: PMC6797173 DOI: 10.1371/journal.pone.0223586] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 09/24/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND While various initiatives have been taken to improve advance care planning in nursing homes, it is difficult to find enough details about interventions to allow comparison, replication and translation into practice. OBJECTIVES We report on the development and description of the ACP+ program, a multi-component theory-based program that aims to implement advance care planning into routine nursing home care. We aimed to 1) specify how intervention components can be delivered; 2) evaluate the feasibility and acceptability of the program; 3) describe the final program in a standardized manner. DESIGN To develop and model the intervention, we applied multiple study methods including a literature review, expert discussions and individual and group interviews with nursing home staff and management. We recruited participants through convenience sampling. SETTING AND PARTICIPANTS Management and staff (n = 17) from five nursing homes in Flanders (Belgium), a multidisciplinary expert group and a palliative care nurse-trainer. METHODS The work was carried out by means of 1) operationalization of key intervention components-identified as part of a previously developed theory on how advance care planning is expected to lead to its desired outcomes in nursing homes-into specific activities and materials, through expert discussions and review of existing advance care planning programs; 2) evaluation of feasibility and acceptability of the program through interviews with nursing home management and staff and expert revisions; and 3) standardized description of the final program according to the TIDieR checklist. During step 2, we used thematic analysis. RESULTS The original program with nine key components was expanded to include ten intervention components, 22 activities and 17 materials to support delivery into routine nursing home care. The final ACP+ program includes ongoing training and coaching, management engagement, different roles and responsibilities in organizing advance care planning, conversations, documentation and information transfer, integration of advance care planning into multidisciplinary meetings, auditing, and tailoring to the specific setting. These components are to be implemented stepwise throughout an intervention period. The program involves the entire nursing home workforce. The support of an external trainer decreases as nursing home staff become more autonomous in organizing advance care planning. CONCLUSIONS The multicomponent ACP+ program involves residents, family, and the different groups of people working in the nursing home. It is deemed feasible and acceptable by nursing home staff and management. The findings presented in this paper, alongside results of the subsequent randomized controlled cluster trial, can facilitate comparison, replicability and translation of the intervention into practice.
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Affiliation(s)
- Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lara Pivodic
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | | | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven (KUL), Brussels, Belgium
| | | | | | - Luc Deliens
- 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
| | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, and Department of Clinical Sciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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26
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Zhukovsky DS, Soliman PT, Mathew B, Mills S, Bodurka D, Frumovitz M, Meyer LA, Westin S, Nowitz M, Archie L, Fenton S, Lang K, Williams JL, Boving V, Bruera E. Systematic Approach to Selecting and Preparing a Medical Power of Attorney in the Gynecologic Oncology Center. J Oncol Pract 2019; 15:e1092-e1097. [PMID: 31613720 DOI: 10.1200/jop.19.00109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Advance care planning (ACP) supports national priorities of patient engagement, person-centered care, and safety. A systematic approach is uncommon in most care settings. Our institution offers all patients with cancer new to the institution an opportunity to select and prepare a medical decision maker (MDM) after social work counseling. The goals of this study were to determine the success of a systematic institutional process for selecting a prepared MDM. The primary objectives were that (1) 70% or more of new patients would have one or more documented social work ACP discussions by the third office visit within 4 months, and (2) there would be a two-fold increase in scanned medical power of attorney (MPOA) documents available in the electronic health record (EHR). The secondary objectives were (1) improved surrogate preparedness for medical decision making, and (2) to determine whether patients with metastatic disease demonstrated greater readiness for selection of an MDM than those with localized disease. MATERIALS AND METHODS We conducted a retrospective chart review of consecutive gynecology oncology outpatients. RESULTS Of 133 patients, 93 (70%) had metastatic disease. The median number of visits was two (one to three). Forty-seven patients (39.3%) met with social work by visit 3. Review of ACP notes suggested that most patients were in the early stages of selecting a prepared MDM. At visit 1, 39 (29.3%) reported having an advance directive document; 14 (10.5%) had an MPOA in the EHR. There was no increase by visit 3. Fewer patients with metastatic disease than those with localized cancer (32.3% v 67.5%; P = .001) had three visits; no other parameter, including presence of MPOA documents in the EHR, achieved statistical significance between groups. CONCLUSION Current processes fail to engage patients in selecting and preparing an MDM.
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Affiliation(s)
| | | | - Boby Mathew
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sarah Mills
- Seton Medical Center and University of Texas, Austin, TX
| | - Diane Bodurka
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Larissa A Meyer
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shannon Westin
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marisa Nowitz
- Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - LaShan Archie
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shauna Fenton
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kai Lang
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, TX
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27
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Chan CWH, Ng NHY, Chan HYL, Wong MMH, Chow KM. A systematic review of the effects of advance care planning facilitators training programs. BMC Health Serv Res 2019; 19:362. [PMID: 31174530 PMCID: PMC6555972 DOI: 10.1186/s12913-019-4192-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 05/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is the process of ongoing communication among patients, family and health care professionals regarding what plans for future care are preferred in the event that patients become unable to make their own decisions. Clinicians play an important role in ACP as both initiators and decision coaches. However, lack of training for clinicians has frequently been reported as the reason for low involvement in ACP discussions - hence the present review evaluates the effectiveness of ACP training programs for healthcare professionals to guide the development of novel training programs for them in the future. METHODS A literature search for intervention studies was conducted independently by two reviewers in July 2018. Participants included all healthcare professionals working with adult patients suffering from terminal illness. The primary outcomes were the professionals' knowledge of and attitudes towards ACP, and self-perceived competence in ACP conversations. The Effective Public Health Practice Project appraisal tool was used to examine the quality of the studies included. RESULTS A total of 4025 articles were identified, and ten eligible articles, covering 1081 participants, were included in the review. However, there is a lack of high quality randomized controlled trials of providing ACP training for nurses working in non-palliative care hospital settings. The overall quality of the intervention studies was moderate. All the studies included used instructional sessions in their interventions, while some contained group discussion, role-play and the use of advanced technology. The training programs increased the knowledge, attitudes towards shared decision-making, perceived communication skills, confidence, comfort and experiences concerned with discussing end-of-life (EOL) issues. Patient advocacy, job satisfaction and perceived level of adequate training for EOL care were improved. The use of 'decision aids' was rated as acceptable and clinically useful. CONCLUSIONS Training for healthcare professionals in ACP has positive effects on their knowledge, attitude and skills. The use of decision aids and advanced technology, instructional sessions with role play, training content focused on ACP communication skills and the needs and experience of patient in the ACP process, and a values-based ACP process are all those factors that made the ACP training programs effective.
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Affiliation(s)
- Carmen Wing Han Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F, Esther Lee Building, Shatin, NT, Hong Kong
| | - Nancy Hiu Yim Ng
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F, Esther Lee Building, Shatin, NT, Hong Kong.
| | - Helen Y L Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F, Esther Lee Building, Shatin, NT, Hong Kong
| | - Martin M H Wong
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F, Esther Lee Building, Shatin, NT, Hong Kong
| | - K M Chow
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F, Esther Lee Building, Shatin, NT, Hong Kong
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28
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Detering KM, Buck K, Ruseckaite R, Kelly H, Sellars M, Sinclair C, Clayton JM, Nolte L. Prevalence and correlates of advance care directives among older Australians accessing health and residential aged care services: multicentre audit study. BMJ Open 2019; 9:e025255. [PMID: 30647047 PMCID: PMC6340468 DOI: 10.1136/bmjopen-2018-025255] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES It is important that the outcomes of advance care planning (ACP) conversations are documented and available at the point of care. Advance care directives (ACDs) are a subset of ACP documentation and refer to structured documents that are completed and signed by competent adults. Other ACP documentation includes informal documentation by the person or on behalf of the person by someone else (eg, clinician, family). The primary objectives were to describe the prevalence and correlates of ACDs among Australians aged 65 and over accessing health and residential aged care services. The secondary aim was to describe the prevalence of other ACP documentation. DESIGN AND SETTING A prospective multicentre health record audit in general practices (n=13), hospitals (n=12) and residential aged care facilities (RACFs; n=26). PARTICIPANTS 503 people attending general practice, 574 people admitted to hospitals and 1208 people in RACFs. PRIMARY AND SECONDARY OUTCOME MEASURES Prevalence of one or more ACDs; prevalence of other ACP documentation. RESULTS 29.8% of people had at least one ACD on file. The majority were non-statutory documents (20.9%). ACD prevalence was significantly higher in RACFs (47.7%) than hospitals (15.7%) and general practices (3.2%) (p<0.001), and varied across jurisdictions. Multivariate logistic regression showed that the odds of having an ACD were positively associated with greater functional impairment and being in an RACF or hospital compared with general practice. 21.6% of people had other ACP documentation. CONCLUSIONS In this study, 30% of people had ACDs accessible and a further 20% had other ACP documentation, suggesting that approximately half of participants had some form of ACP. Correlates of ACD completion were greater impairment and being in an RACF or hospital. Greater efforts to promote and standardise ACDs across jurisdictions may help to assist older people to navigate and complete ACDs and to receive care consistent with their preferences. TRIAL REGISTRATION NUMBER ACTRN12617000743369.
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Affiliation(s)
- Karen M Detering
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Kimberly Buck
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Rasa Ruseckaite
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Helana Kelly
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Marcus Sellars
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Craig Sinclair
- Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia
| | - Josephine M Clayton
- Centre for Learning and Research in Palliative Care, Hammond Care, Greenwich Hospital and Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
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Lin CP, Evans CJ, Koffman J, Armes J, Murtagh FEM, Harding R. The conceptual models and mechanisms of action that underpin advance care planning for cancer patients: A systematic review of randomised controlled trials. Palliat Med 2019; 33:5-23. [PMID: 30362897 PMCID: PMC6291906 DOI: 10.1177/0269216318809582] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND: No systematic review has focused on conceptual models underpinning advance care planning for patients with advanced cancer, and the mechanisms of action in relation to the intended outcomes. AIM: To appraise conceptual models and develop a logic model of advance care planning for advanced cancer patients, examining the components, processes, theoretical underpinning, mechanisms of action and linkage with intended outcomes. DESIGN: A systematic review of randomised controlled trials was conducted, and was prospectively registered on PROSPERO. Narrative synthesis was used for data analysis. DATA SOURCES: The data sources were MEDLINE, CINAHL, PsycINFO, EMBASE, CENTRAL, PROSPERO, CareSearch, and OpenGrey with reference chaining and hand-searching from inception to 31 March 2017, including all randomised controlled trials with advance care planning for cancer patients in the last 12 months of life. Cochrane quality assessment tool was used for quality appraisal. RESULTS: Nine randomised controlled trials were included, with only four articulated conceptual models. Mechanisms through which advance care planning improved outcomes comprised (1) increasing patients' knowledge of end-of-life care, (2) strengthening patients' autonomous motivation, (3) building patients' competence to undertake end-of-life discussions and (4) enhancing shared decision-making in a trustful relationship. Samples were largely highly educated Caucasian. CONCLUSION: The use of conceptual models underpinning the development of advance care planning is uncommon. When used, they identify the individual behavioural change. Strengthening patients' motivation and competence in participating advance care planning discussions are key mechanisms of change. Understanding cultural feasibility of the logic model for different educational levels and ethnicities in non-Western countries should be a research priority.
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Affiliation(s)
- Cheng-Pei Lin
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Catherine J Evans
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,2 Sussex Community NHS Foundation Trust, Brighton, UK
| | - Jonathan Koffman
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Jo Armes
- 3 School of Health Sciences, University of Surrey, Guildford, UK
| | - Fliss E M Murtagh
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,4 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Richard Harding
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Schnakenberg R, Radbruch L, Kersting C, Frank F, Wilm S, Becka D, Weckbecker K, Bleckwenn M, Just JM, Pentzek M, Weltermann B. More counselling for end-of-life decisions by GPs with own advance directives: A postal survey among German general practitioners. Eur J Gen Pract 2018; 24:131-137. [PMID: 29547013 PMCID: PMC5917308 DOI: 10.1080/13814788.2017.1421938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although general practitioners (GPs) are among the preferred contact persons for discussing end-of-life issues including advance directives (ADs), there is little data on how GPs manage such consultations. OBJECTIVES This postal survey asked German GPs about their counselling for end-of-life decisions. METHODS In 2015, a two-sided questionnaire was mailed to 959 GPs. GPs were asked for details of their consultations on ADs: frequency, duration, template use, and whether they have own ADs. Statistical analysis evaluated physician characteristics associated with an above-average number of consultations on AD. RESULTS The participation rate was 50.3% (n = 482), 70.5% of the GPs were male; the average age was 54 years. GPs had an average of 18 years of professional experience, and 61.4% serve more than 900 patients per three months. Most (96.9%) GPs perform consultations on living wills (LW) and/or powers of attorney (PA), mainly in selected patients (72.3%). More than 20 consultations each on LWs and PAs are performed by 60% and 50% of GPs, respectively. The estimated mean duration of consultations was 21 min for LWs and 16 min for PAs. Predefined templates were used in 72% of the GPs, 50% of GPs had their ADs. A statistical model showed that GPs with ADs and/or a qualification in palliative medicine were more likely to counsel ≥20 patients per year for each document. CONCLUSION The study confirmed that nearly all German GPs surveyed provide counselling on ADs. Physicians with ADs counsel more frequently than those without such documents.
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Affiliation(s)
- Rieke Schnakenberg
- a Institute of General Practice and Family Medicine, Medical Faculty , University of Bonn , Bonn , Germany
| | - Lukas Radbruch
- b Department of Palliative Medicine , University Hospital Bonn , Bonn , Germany
| | - Christine Kersting
- c General Medicine , Teaching Area RWTH Aachen University , Aachen , Germany
| | - Friederike Frank
- d Institute of General Practice, Medical Faculty , Heinrich Heine University Düsseldorf , Düsseldorf , Germany
| | - Stefan Wilm
- e Department of General Practice, Medical Faculty , Ruhr University of Bochum , Bochum , Germany
| | - Denise Becka
- f Institute for General Medicine , University of Duisburg-Essen , Essen , Germany
| | - Klaus Weckbecker
- a Institute of General Practice and Family Medicine, Medical Faculty , University of Bonn , Bonn , Germany
| | - Markus Bleckwenn
- a Institute of General Practice and Family Medicine, Medical Faculty , University of Bonn , Bonn , Germany
| | - Johannes M Just
- a Institute of General Practice and Family Medicine, Medical Faculty , University of Bonn , Bonn , Germany
| | - Michael Pentzek
- e Department of General Practice, Medical Faculty , Ruhr University of Bochum , Bochum , Germany
| | - Birgitta Weltermann
- c General Medicine , Teaching Area RWTH Aachen University , Aachen , Germany
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[Desired place of death, living will and desired care at end of life: initial results of a survey of nursing home residents]. Z Gerontol Geriatr 2018; 52:582-588. [PMID: 30084032 DOI: 10.1007/s00391-018-1432-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 05/22/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND AND PURPOSE There is little information about the desired place of death of nursing home residents because they are usually not interviewed in population-based representative surveys. In preparation of support services for advance care planning the kind of care and support that nursing home residents desire needs to be systematically determined. METHOD From October 2016 to January 2017 the residents of 5 nursing homes, municipally owned by Würzburg, were interviewed face-to-face. RESULTS Of the residents 42.7% could not be interviewed due to cognitive limitations or dementia. The legal guardians of 63 residents declined participation in the study and 68 residents took part in the survey. Of the respondents 43 stated they wanted to pass away in the nursing home (63.2%). If interviewees had a person of trust or felt at home there, the number of those wanting to pass away in a nursing home was significantly higher. A total of 25 interviewees had either a living will, power of attorney for care, or a health care proxy (36.7%) and 55.3% had informed a person of trust in the nursing home about their desired care, usually a nurse (52.8%) or co-resident (36.1%). A total of 50.0% of respondents had informed their general practitioner and 23.5% had not spoken to anyone about their desired care. Especially nurses were specifically mentioned as the appropriate contact person to record desired care (70.4%). DISCUSSION Residents view their nursing home as the place for dying in a much more positive light compared to frequent discussions contrasting population surveys and actual places of death. End of life prearrangements should be designed as a dynamic process that include persons of trust, nurses and general practitioners.
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Allers K, Hoffmann F. Mortality and hospitalization at the end of life in newly admitted nursing home residents with and without dementia. Soc Psychiatry Psychiatr Epidemiol 2018; 53:833-839. [PMID: 29721593 DOI: 10.1007/s00127-018-1523-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/25/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE The proportion of deaths occurring in nursing homes is increasing and end of life hospitalizations in residents are common. This study aimed to obtain the time from nursing home admission to death and the frequency of hospitalizations prior to death among residents with and without dementia. METHODS This retrospective cohort study analyzed claims data of 127,227 nursing home residents aged 65 years and older newly admitted to a nursing home between 2010 and 2014. We analyzed hospitalizations during the last year of life and assessed mortality rates per 100 person-years. Factors potentially associated with time to death were analyzed in Cox proportional hazard models. RESULTS The median time from nursing home admission to death was 777 and 635 days in residents with and without dementia, respectively. Being male, older age and a higher level of care decreased the survival time. Sex and age had a higher influence on survival time in residents with dementia, whereas level of care was found to have a higher influence in residents without dementia. Half of the residents of both groups were hospitalized during the last month and about 37% during the last week before death. Leading causes of hospitalizations were infections (with dementia: 20.6% vs. without dementia: 17.2%) and cardiovascular diseases (with dementia: 16.6% vs. without dementia: 19.0%). CONCLUSIONS A high proportion of residents with and without dementia are hospitalized shortly before death. There should be an open debate about the appropriateness of hospitalizing nursing home residents especially those with dementia near death.
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Affiliation(s)
- Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Lin CP, Cheng SY, Chen PJ. Advance Care Planning for Older People with Cancer and Its Implications in Asia: Highlighting the Mental Capacity and Relational Autonomy. Geriatrics (Basel) 2018; 3:E43. [PMID: 31011081 PMCID: PMC6319225 DOI: 10.3390/geriatrics3030043] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/15/2018] [Accepted: 07/18/2018] [Indexed: 11/18/2022] Open
Abstract
With dramatically increasing proportions of older people, global ageing has remarkably influenced healthcare services and policy making worldwide. Older people represent the majority of patients with cancer, leading to the increasing demand of healthcare due to more comorbidities and inherent frailty. The preference of older people with cancer are often ignored, and they are considered incapable of making choices for themselves, particularly medical decisions. This might impede the provision of their preferred care and lead to poor healthcare outcomes. Advance care planning (ACP) is considered an effective intervention to assist older people to think ahead and make a choice in accordance with their wishes when they possess capacity to do so. The implementation of ACP can potentially lead to positive impact for patients and families. However, the assessment of mental capacity among older adults with cancer might be a crucial concern when implementing ACP, as loss of mental capacity occurs frequently during disease deterioration and functional decline. This article aims to answer the following questions by exploring the existing evidence. How does ACP develop for older people with cancer? How can we measure mental capacity and what kind of principles for assessment we should apply? What are the facilitators and barriers when implementing an ACP in this population? Furthermore, a discussion about cultural adaptation and relevant legislation in Asia is elucidated for better understanding about its cultural appropriateness and the implications. Finally, recommendations in relation to early intervention with routine monitoring and examination of capacity assessment in clinical practice when delivering ACP, reconciling patient autonomy and family values by applying the concept of relational autonomy, and a corresponding legislation and public education should be in place in Asia. More research on ACP and capacity assessment in different cultural contexts and policy frameworks is highlighted as crucial factors for successful implementation of ACP.
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Affiliation(s)
- Cheng-Pei Lin
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London SE5 9PJ, UK.
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei 100, Taiwan.
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Department of Division of Geriatrics and Gerontology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Palliative Care Centre, Chi-Mei Medical Centre, Tainan 710, Taiwan.
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Schuchter P, Heller A. The Care Dialog: the "ethics of care" approach and its importance for clinical ethics consultation. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2018; 21:51-62. [PMID: 28674939 PMCID: PMC5814518 DOI: 10.1007/s11019-017-9784-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Ethics consultation in institutions of the healthcare system has been given a standard form based on three pillars: education, the development of guidelines and concrete ethics consultation in case conferences. The spread of ethics committees, which perform these tasks on an organizational level, is a remarkable historic achievement. At the same time it cannot be denied that modern ethics consultation neglects relevant aspects of care ethics approaches. In our essay we present an "ethics of care" approach as well as an empirical pilot project-"Ethics from the bottom up"-which organizes ethics consultation based on this focus. Findings and philosophy of the project will be discussed as far as relevant for ethics consultation in the healthcare system.
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Affiliation(s)
- Patrick Schuchter
- Institute of Palliative Care and Organisational Ethics, IFF Faculty of Interdisciplinary Studies, Alpen-Adria Universität Klagenfurt | Wien | Graz, Schottenfeldgasse 29/4, 1070, Vienna, Austria.
| | - Andreas Heller
- Institute of Palliative Care and Organisational Ethics, IFF Faculty of Interdisciplinary Studies, Alpen-Adria Universität Klagenfurt | Wien | Graz, Schottenfeldgasse 29/4, 1070, Vienna, Austria
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Gilissen J, Pivodic L, Gastmans C, Vander Stichele R, Deliens L, Breuer E, Van den Block L. How to achieve the desired outcomes of advance care planning in nursing homes: a theory of change. BMC Geriatr 2018; 18:47. [PMID: 29444645 PMCID: PMC5813418 DOI: 10.1186/s12877-018-0723-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 01/23/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) has been identified as particularly relevant for nursing home residents, but it remains unclear how or under what circumstances ACP works and can best be implemented in such settings. We aimed to develop a theory that outlines the hypothetical causal pathway of ACP in nursing homes, i.e. what changes are expected, by means of which processes and under what circumstances. METHODS The Theory of Change approach is a participatory method of programme design and evaluation whose underlying intention is to improve understanding of how and why a programme works. It results in a Theory of Change map that visually represents how, why and under what circumstances ACP is expected to work in nursing home settings in Belgium. Using this approach, we integrated the results of two workshops with stakeholders (n = 27) with the results of a contextual analysis and a systematic literature review. RESULTS We identified two long-term outcomes that ACP can achieve: to improve the correspondence between residents’ wishes and the care/treatment they receive and to make sure residents and their family feel involved in planning their future care and are confident their care will be according to their wishes. Besides willingness on the part of nursing home management to implement ACP and act accordingly, other necessary preconditions are identified and put in chronological order. These preconditions serve as precursors to, or requirements for, accomplishing successful ACP. Nine original key intervention components with specific rationales are identified at several levels (resident/family, staff or nursing home) to target the preconditions: selection of a trainer, ensuring engagement by management, training ACP reference persons, in-service education for healthcare staff, information for staff, general practitioners, residents and their family, ACP conversations and documentation, regular reflection sessions, multidisciplinary meetings, and formal monitoring. ONCLUSIONS The Theory of Change map presented here illustrates a theory of how ACP is expected to work in order to achieve its desired long-term outcomes while highlighting organisational factors that potentially facilitate the implementation and sustainability of ACP. We provide the first comprehensive rationale of how ACP is expected to work in nursing homes, something that has been called for repeatedly.
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Affiliation(s)
- J. Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - L. Pivodic
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - C. Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35, Box 7001, 3000 Leuven, Belgium
| | - R. Vander Stichele
- Department of Pharmacology, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - L. Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - E. Breuer
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - L. Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
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MacKenzie MA, Smith-Howell E, Bomba PA, Meghani SH. Respecting Choices and Related Models of Advance Care Planning: A Systematic Review of Published Evidence. Am J Hosp Palliat Care 2017; 35:897-907. [PMID: 29254357 DOI: 10.1177/1049909117745789] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
All individuals should receive care consistent with their expressed preferences during serious and chronic illnesses. Respecting Choices (RC) is a well-known model of advance care planning intended to assist individuals consider, choose, and communicate these preferences to health-care providers. In this systematic review, we evaluated the published literature on the outcomes of the RC and derivative models utilizing criteria developed by the Cochrane Collaborative. Eighteen articles from 16 studies were included, of which 9 were randomized controlled trials, 6 were observational, and 1 was a pre-posttest study. Only 2 specifically included a minority population (African American). Fourteen were conducted in the United States, primarily in the Wisconsin/Minnesota region (n = 8). Seven studies examined the RC model, whereas 9 examined derivative models. There was significant heterogeneity of outcomes examined. We found that there is a low level of evidence that RC and derivative models increase the incidence and prevalence of Advance Directive and Physician Orders for Life-Sustaining Treatment completion. There is a high level of evidence that RC and derivative models increase patient-surrogate congruence in Caucasian populations. The evidence is mixed, inconclusive, and too poor in quality to determine whether RC and derivative models change the consistency of treatment with wishes and overall health-care utilization in the end of life. We urge further studies be conducted, particularly with minority populations and focused on the outcomes of preference-congruent treatment and health-care utilization.
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Affiliation(s)
| | | | - Patricia A Bomba
- 3 Geriatrics, Excellus BlueCross BlueShield and MedAmerica Insurance Company, Rochester, NY, USA
| | - Salimah H Meghani
- 2 School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Luck T, Rodriguez FS, Wiese B, van der Leeden C, Heser K, Bickel H, In der Schmitten J, Koenig HH, Weyerer S, Mamone S, Mallon T, Wagner M, Weeg D, Fuchs A, Brettschneider C, Werle J, Scherer M, Maier W, Riedel-Heller SG. Advance directives and power of attorney for health care in the oldest-old - results of the AgeQualiDe study. BMC Geriatr 2017; 17:85. [PMID: 28407800 PMCID: PMC5390475 DOI: 10.1186/s12877-017-0482-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 04/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Completion of advance directives (ADs) and power of attorney (POA) documents may protect a person's autonomy in future health care situations when the individual lacks decisional capacity. As such situations become naturally much more common in old age, we specifically aimed at providing information on (i) the frequency of ADs/POA in oldest-old individuals and (ii) factors associated with having completed ADs/POA. METHODS We analyzed data of oldest-old primary care patients (85+ years; including community-dwelling and institutionalized individuals) within the German AgeQualiDe study. Patients were initially recruited via their general practitioners (GPs). We calculated frequencies of ADs and POA for health care with 95% confidence intervals (CI) and used multivariable logistic regression analysis to evaluate the association between having ADs and POA and participants' socio-demographic, cognitive, functional, and health-related characteristics. RESULTS Among 868 GP patients participating in AgeQualiDe (response = 90.9%), n = 161 had dementia and n = 3 were too exhausted/ill to answer the questions. Out of the remaining 704 (81.1%) dementia-free patients (mean age = 88.7 years; SD = 3.0), 69.0% (95%-CI = 65.6-72.4) stated to having ADs and 64.6% (95%-CI = 61.1-68.2) to having a POA for health care. Individual characteristics did not explain much of the variability of the presence/absence of ADs and POA (regression models: Nagelkerke's R2 = 0.034/0.051). The most frequently stated reasons for not having ADs were that the older adults trust their relatives or physicians to make the right decisions for them when necessary (stated by 59.4% and 44.8% of those without ADs). Among the older adults with ADs, the majority had received assistance in its preparation (79.0%), most frequently from their children/grandchildren (38.3%). Children/grandchildren were also the most frequently stated group of designated persons (76.7%) for those with a POA for health care. CONCLUSIONS Our findings suggest a high dissemination of ADs and POA for health care in the oldest-old in Germany. Some adults without ADs/POA perhaps would have completed advance care documents, if they had had received more information and support. When planning programs to offer advanced care planning to the oldest old, it might be helpful to respond to these specific needs, and also to be sensitive to attitudinal differences in this target group.
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Affiliation(s)
- Tobias Luck
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany.
| | - Francisca S Rodriguez
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany.,LIFE - Leipzig Research Center for Civilization Diseases, Universität Leipzig, Leipzig, Germany.,Edward R. Roybal Institute on Aging, University of Southern California, Los Angeles, USA
| | - Birgitt Wiese
- Work Group Medical Statistics and IT-Infrastructure, Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Carolin van der Leeden
- Department of Primary Medical Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathrin Heser
- Department of Psychiatry, University of Bonn, Bonn, Germany
| | - Horst Bickel
- Department of Psychiatry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jürgen In der Schmitten
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Hans-Helmut Koenig
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Siegfried Weyerer
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Silke Mamone
- Work Group Medical Statistics and IT-Infrastructure, Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Tina Mallon
- Department of Primary Medical Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Wagner
- Department of Psychiatry, University of Bonn, Bonn, Germany.,DZNE, German Center for Neurodegenerative Diseases, Bonn, Germany
| | - Dagmar Weeg
- Department of Psychiatry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Angela Fuchs
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Brettschneider
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Werle
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Martin Scherer
- Department of Primary Medical Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Maier
- Department of Psychiatry, University of Bonn, Bonn, Germany.,DZNE, German Center for Neurodegenerative Diseases, Bonn, Germany
| | - Steffi G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
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Abstract
BACKGROUND Most patients in the last phase of life can be treated in the context of generalist palliative care, especially by general practitioners. In contrast to specialized palliative care, non-cancer patients predominate in this setting. OBJECTIVE The aim of this article is to review the literature and elaborate current topics for non-cancer patients at the end of life in primary palliative care. MATERIAL AND METHODS A literature search was carried out in the databases PubMed and Scopus from 2008 to 2013 followed by a qualitative content analysis according to the PRISMA statement. RESULTS A total of 127 articles could be included in the qualitative content analysis and the final review whereby four core topics were identified: (1) specific target groups (e.g. elderly patients, patients with advanced heart failure and pain), (2) collaboration of general practitioners with other physicians and health professions, (3) qualifications in palliative care and (4) provision of primary palliative care. Most articles found were related to the fourth topic and the subtopic of barriers and facilitators of palliative care. Insufficient coordination of the persons involved was a barrier often discussed. Advanced care planning including concrete aspects of palliative care at an early stage can be beneficial for both patients and professionals. CONCLUSION The current literature search elucidates the importance of optimizing the processes and structures in providing palliative care and the discussion of end of life issues at an early stage in general practice. Therefore, a structured identification of palliative care needs identified by appropriate assessment instruments is crucial.
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Survey on German Palliative Care Specialists' Experiences with Advance Directives. Pain Ther 2016; 6:17-28. [PMID: 27900726 PMCID: PMC5447540 DOI: 10.1007/s40122-016-0063-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Indexed: 11/13/2022] Open
Abstract
Introduction Advance directives (AD) play a central role in end-of-life treatments, intensive care, and palliative care. However, little is known about the experiences of healthcare professionals with ADs. This study reports on palliative care professionals’ views on advance directives (AD). Methods A questionnaire was handed out to attendants of a palliative care symposium. Results Complete answers were obtained from 126 physicians and 276 nurses. Almost all physicians and nurses had treated patients with an AD, and the majority more than 10 patients. The most frequent refusal by the patients was resuscitation (87.8%) followed by intensive care (79.1%), artificial ventilation, and nutrition. The most frequent wish was pain therapy (92.3%) followed by allowing the natural course of the illness (64.4%). The wish for hospice treatment (44.8%) or spiritual care (39.3%) was less frequent. Discussion The results hint at fears and deficits in the care of patients at the end of life. Often the quality of life and not the quantity of days remaining is in the center of a patient’s will and points to the growing importance of palliative care. Conclusion ADs are well established among palliative care professionals and regarded as helpful for patients at the end of life.
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Thoresen L, Lillemoen L. "I just think that we should be informed" a qualitative study of family involvement in advance care planning in nursing homes. BMC Med Ethics 2016; 17:72. [PMID: 27829409 PMCID: PMC5103414 DOI: 10.1186/s12910-016-0156-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 10/27/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND As part of the research project "End-of-life Communication in Nursing Homes. Patient Preferences and Participation", we have studied how Advance Care Planning (ACP) is carried out in eight Norwegian nursing homes. The concept of ACP is a process for improving patient autonomy and communication in the context of progressive illness, anticipated deterioration and end-of-life care. While an individualistic autonomy based attitude is at the fore in most studies on ACP, there is a lack of empirical studies on how family members' participation and involvement in ACP- conversations may promote nursing home patients' participation in decisions on future treatment and end-of-life care. Based on empirical data and family ethics perspectives, the purpose of this study is to add insights to the complexity of ACP-conversations and illuminate how a family ethics perspective may improve the quality of the ACP and promote nursing home patients' participation in advance care planning. METHODS Participant observations of ACP-conversations in eight nursing homes. The observations were followed by interviews with patients and relatives together on how they experienced being part of the conversation, and expressing their views on future medical treatment, hospitalization and end-of-life issues. RESULTS We found that the way nursing home patients and relatives are connected and related to each other, constitutes an intertwined unit. Further, we found that relatives' involvement and participation in ACP- conversations is significant to uncover, and give the nursing home staff insight into, what is important in the nursing home patient's life at the time. The third analytical theme is patients' and relatives' shared experiences of the dying and death of others. Drawing on past experiences can be a way of introducing or talking about death. CONCLUSIONS An individual autonomy approach in advance care planning should be complemented with a family ethics approach. To be open to family ethics when planning for the patient's future in the nursing home is to be open to diversity and nuances and to the significance of the patient's former life and experiences.
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Affiliation(s)
- Lisbeth Thoresen
- Centre for Medical Ethics and Department of Health Sciences, Institute of Health and Society, University of Oslo, Postboks 1130, Blindern, 0318 Oslo, Norway
| | - Lillian Lillemoen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Postboks 1130, Blindern, 0318 Oslo, Norway
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[Pre-operative documentation of individual in-patient therapy goals : A medical staff questionnaire]. Anaesthesist 2016; 65:499-506. [PMID: 27324155 DOI: 10.1007/s00101-016-0180-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/10/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Perioperative care demands consideration of individual treatment goals. We evaluated the attitudes of medical staff towards a short standardized advance directive (SSAD) as a means of improving patient-orientated care at the transition from operating theater to general or intensive care wards. METHOD Multicenter anonymized standardized multiple-choice questionnaire among physicians and nurses from various operative and anesthesiology departments. Questions addressing demographic parameters and attitudes towards advance directives in acute care settings (eleven 4‑stepped Likert items). Univariate analysis of group comparisons using the chi-square and Kruskal-Wallis rank-sum test. Multivariable analysis of significant differences employing ordinal logistic regression. RESULTS The overall return rate was 28.2 % (169 questionnaires). Of these, 19.5 % said that existing advance directives were regularly reassessed preoperatively. SSAD was expected to provide improved emergency care by 82.3 and 76.6 % thought that it would help to better focus intensive care resources according to patients' needs. DISCUSSION Our study shows the dilemma of insufficiently structured directives for changing treatment goals as well as a high number of legal procedures to obtain proxy decisions due to missing out-patient advance health planning. From a medical staff perspective there is strong support for the concept of SSAD based on medical, ethical, economic and organizational reasons.
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Geiger K, Schneider N, Bleidorn J, Klindtworth K, Jünger S, Müller-Mundt G. Caring for frail older people in the last phase of life - the general practitioners' view. BMC Palliat Care 2016; 15:52. [PMID: 27255464 PMCID: PMC4890268 DOI: 10.1186/s12904-016-0124-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 05/19/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Frail older people are an increasingly important group in primary care due to demographic change. For these patients, a palliative care approach may be useful to sustain the quality of life in the last phase of their lives. While general practitioners (GPs) play a key role in the primary care for older patients, general palliative care is still in its infancy and little is known in Germany about caring for frail older people towards the end of life. This study aims to explore the tasks and challenges regarding the care for frail older patients in the last phase of life from the GPs' point of view, and the latter's perception of their own role and responsibilities. METHODS Explorative qualitative study based on semi-structured in-depth interviews with 14 GPs from urban and rural regions in Lower Saxony, Germany. Analysis was carried out according to the principles of Grounded Theory. RESULTS The GPs' key commitment "caring for frail older patients until the end" as an integral part of primary care was worked out as a key category, flanked by central issues: "causal conditions and challenges," which include patients' preconditions and care needs as well as communication and cooperation aspects on the carers' level. "Barriers and facilitators within the health system" refers to prerequisites of the German healthcare system, such as high caseloads. Regarding "strategies to comply with this commitment", various self-developed strategies for the care of frail older people are presented, depending on the GPs' understanding of their professional role and individual circumstances. CONCLUSIONS The GPs show a strong commitment to caring for the frail older patients until the end of life. However, it is a challenging and complex task that requires significant time, which can take GPs to their limits. There is a great need to improve patient-and family-centered proactive communication, as well as interprofessional cooperation. Strengthening the team approach in primary care could relieve the burden on GPs, especially in rural areas, while simultaneously improving end-of-life care for their patients.
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Affiliation(s)
- Karin Geiger
- Hannover Medical School, Institute of General Practice, Hannover, Germany
| | - Nils Schneider
- Hannover Medical School, Institute of General Practice, Hannover, Germany.
| | - Jutta Bleidorn
- Hannover Medical School, Institute of General Practice, Hannover, Germany
| | | | - Saskia Jünger
- Hannover Medical School, Institute of General Practice, Hannover, Germany
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Klingler C, in der Schmitten J, Marckmann G. Does facilitated Advance Care Planning reduce the costs of care near the end of life? Systematic review and ethical considerations. Palliat Med 2016; 30:423-33. [PMID: 26294218 PMCID: PMC4838173 DOI: 10.1177/0269216315601346] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND While there is increasing evidence that Advance Care Planning has the potential to strengthen patient autonomy and improve quality of care near the end of life, it remains unclear whether it could also reduce net costs of care. AIM This study aims to describe the cost implications of Advance Care Planning programmes and discusses ethical conflicts arising in this context. DESIGN We conducted a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. DATA SOURCES We systematically searched the databases PubMed, NHS EED, EURONHEED, Cochrane Library and EconLit. We included empirical studies (no limitation to study type) that investigated the cost implications of Advance Care Planning programmes involving professionally facilitated end-of-life discussions. RESULTS AND DISCUSSION Seven studies met our inclusion criteria. Four of them used a randomised controlled design, one used a before-after design and two were observational studies. Six studies found reductions in costs of care ranging from USD1041 to USD64,827 per patient, depending on the study period and the cost measurement. One study detected no differences in costs. Studies varied considerably regarding the Advance Care Planning intervention, patient selection and costs measured which may explain some of the variations in findings. NORMATIVE APPRAISAL Looking at the impact of Advance Care Planning on costs raises delicate ethical issues. Given the increasing pressure to reduce expenditures, there may be concerns that cost considerations could unduly influence the sensitive communication process, thus jeopardising patient autonomy. Safeguards are proposed to reduce these risks. CONCLUSION The limited data indicate net cost savings may be realised with Advance Care Planning. Methodologically robust trials with clearly defined Advance Care Planning interventions are needed to make the costs and returns of Advance Care Planning transparent.
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Affiliation(s)
- Corinna Klingler
- Institute for Ethics, History and Theory of Medicine, Ludwig Maximilian University, Munich, Germany
| | - Jürgen in der Schmitten
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Georg Marckmann
- Institute for Ethics, History and Theory of Medicine, Ludwig Maximilian University, Munich, Germany
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Perkins GD, Griffiths F, Slowther AM, George R, Fritz Z, Satherley P, Williams B, Waugh N, Cooke MW, Chambers S, Mockford C, Freeman K, Grove A, Field R, Owen S, Clarke B, Court R, Hawkes C. Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04110] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundCardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.Aims and objectivesThis project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.MethodsA systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.ResultsThe literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.LimitationsThe variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.ConclusionThere is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.Future workRecommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.Study registrationThis study is registered as PROSPERO CRD42012002669.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Gavin D Perkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne-Marie Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Robert George
- Cicely Saunders Institute, King’s College London, London, UK
- Palliative Care, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - Zoe Fritz
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Barry Williams
- Patient and Relative Committee, The Intensive Care Foundation, London, UK
| | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew W Cooke
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sue Chambers
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Carole Mockford
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karoline Freeman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Amy Grove
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Richard Field
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sarah Owen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ben Clarke
- Medical School, University of Glasgow, Glasgow, UK
| | - Rachel Court
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Claire Hawkes
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Umgelter K, Anetsberger A, Blobner M, Kochs E. [Preoperative patient-oriented advance planning of emergency and intensive care treatment--Necessary or imposition? : Questionnaire survey]. Anaesthesist 2016; 65:107-14. [PMID: 26811949 DOI: 10.1007/s00101-015-0128-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/28/2015] [Accepted: 12/02/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Traditional advance directives can often not be satisfactorily implemented into patient care; therefore, patient-oriented decision-making prior to scheduled interventions and beyond the actual surgery is of particular importance. Data on inpatient advance care planning (ACP) in Germany are lacking. OBJECTIVES This proof-of-concept study was carried out to determine the needs of inpatients undergoing surgery for advance preoperative planning of emergency care and to assess potential discomfort caused by such a program. MATERIAL AND METHODS A voluntary and anonymous standardized questionnaire survey was carried out in scheduled surgery inpatients over 50 years old. Data collection was structured in a demographic part and statements dealing with preoperative advance planning of emergency care in hospital evaluated as Likert items. RESULTS Out of 579 patients (mean age 66 years, 51% male) 43% indicated a basic interest in being informed about advance planning of emergency care individually during the current hospital stay. Desire for patient self-determination represented an independent factor of information needs [p = 0.036, 95% confidence interval (95% CI) 0.027-0.793]. The survey was perceived as a burden by only 7.3% of patients. This perception was independently associated with less concern about perioperative complication risks (p = 0.008, 95% CI 0.144-0.975). CONCLUSION The results confirmed a substantial interest in patient-oriented advance planning of emergency care in a preoperative setting; however, no demographic group criteria for patients with information requirements could be defined. As the burden evoked by the topic is low, advance planning of emergency and intensive care treatment of inpatients undergoing surgery should be actively provided in the future.
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Affiliation(s)
- K Umgelter
- Klinik für Anaesthesiologie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - A Anetsberger
- Klinik für Anaesthesiologie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - M Blobner
- Klinik für Anaesthesiologie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - E Kochs
- Klinik für Anaesthesiologie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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Schröder L, Hommel G, Sahm S. Intricate decision making: ambivalences and barriers when fulfilling an advance directive. Patient Prefer Adherence 2016; 10:1583-9. [PMID: 27574407 PMCID: PMC4993391 DOI: 10.2147/ppa.s109040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite a recent statutory ruling stating the binding nature of advance directives (ADs), only a minority of the population has signed one. Yet, a majority deem it of utmost importance to ensure their wishes are followed through in case they are no longer able to decide. The reasons for this discrepancy have not yet been investigated sufficiently. PATIENTS AND METHODS This article is based on a survey of patients using a well-established structured questionnaire. First, patients were asked about their attitudes with respect to six therapeutic options at the end of life: intravenous fluids, artificial feeding, antibiotics, analgesia, chemotherapy/dialysis, and artificial ventilation; and second, they were asked about the negative effects related to the idea of ADs surveying their apprehensions: coercion to fulfill an AD, dictatorial reading of what had been laid down, and abuse of ADs. RESULTS A total of 1,260 interviewees completed the questionnaires. A significant percentage of interviewees were indecisive with respect to therapeutic options, ranging from 25% (analgesia) to 45% (artificial feeding). There was no connection to health status. Apprehensions about unwanted effects of ADs were widespread, at 51%, 35%, and 43% for coercion, dictatorial reading, and abuse, respectively. CONCLUSION A significant percentage of interviewees were unable to anticipate decisions about treatment options at the end of life. Apprehensions about negative adverse effects of ADs are widespread.
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Affiliation(s)
- Lars Schröder
- Department of Gynecology and Obstetrics, Center of Integrated Oncology, University Hospital Bonn, Bonn
- Correspondence: Lars Schröder, Department of Gynecology and Obstetrics, Center of Integrated Oncology, University Hospital Bonn, Sigmund-Freud Street 25, 53127 Bonn, Germany, Tel +49 151 1968 9224, Email
| | - Gerhard Hommel
- Institute of Medical Biometry, Epidemiology and Informatics, Johannes Gutenberg University, Mainz
| | - Stephan Sahm
- Department of Gastroenterology and Oncology, Ketteler Hospital, Offenbach
- Institute for Ethics and History of Medicine, Johann Wolfgang Goethe University, Frankfurt, Germany
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Leder N, Schwarzkopf D, Reinhart K, Witte OW, Pfeifer R, Hartog CS. The Validity of Advance Directives in Acute Situations. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:723-9. [PMID: 26568176 PMCID: PMC4647312 DOI: 10.3238/arztebl.2015.0723] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/24/2015] [Accepted: 06/24/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nearly every fourth person in Germany has an advance directive that is to be used in certain medical situations. It is questionable, however, whether advance directives truly influence important treatment decisions in the intensive care unit. We studied the extent to which doctors and patients' relatives agree on the applicability of advance directives in the acute setting. METHODS A prospective study was carried out by questionnaire among the physicians and relatives of 50 patients with advance directives who were hospitalized on four different multidisciplinary intensive care units. The answers of 25 residents in training, 14 senior physicians, and 19 relatives were analyzed both quantitatively and qualitatively. The extent of agreement was assessed by means of Gwet's AC1 with linear weighting. RESULTS In most of the advance directives, the conditions under which they were meant to apply were stated in broad, general terms in prewritten blocks of text. 23 of the 50 patients (46%) died. All relatives stated that they were very familiar with the patients' wishes; 18 of 19 were legally responsible for decision-making. In assessing whether the advance directive was applicable to the situation at hand, the strength of agreement between physicians and relatives as well as between the two groups of physicians was only fair and non-significant (0.35; 95% confidence interval [CI]: -0.01 to 0.71; p = 0.059 and 0.24; 95% CI: -0.03 to 0.50; p = 0.079). The relatives found the advance directives more useful than the doctors did (median, 5 vs. 3 [p = 0.018] on a Likert scale ranging from 0 [not useful at all] to 5 [very useful]) and favored their literal application (median, 5 vs. 4 [p = 0.018] on a Likert scale ranging from 0 [favoring the doctor's interpretation] to 5 [favoring literal application]). 30 days after the decision, 13 relatives (68%) felt that the patient's wishes had been fully complied with. CONCLUSION These groups' clearly differing assessments of the applicability of advance directives imply that the currently most common types of advance directive are not suitable for use in intensive care. In order to support patients' relatives in their role as surrogate participants in decision-making, improved advance directives should be developed, and their implementation should be incorporated into the training and continuing medical education of intensive-care physicians.
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Affiliation(s)
- Nadja Leder
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital
- Center for Sepsis Control and Care (CSCC), Jena University Hospital
| | | | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital
- Center for Sepsis Control and Care (CSCC), Jena University Hospital
| | - Otto W Witte
- Department of Neurology, Jena University Hospital
| | | | - Christiane S Hartog
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital
- Center for Sepsis Control and Care (CSCC), Jena University Hospital
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Schnakenberg R, Bleckwenn M, Just J. [Self determined planning at the end of life]. MMW Fortschr Med 2015; 157:52-54. [PMID: 26985510 DOI: 10.1007/s15006-015-3668-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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49
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Korfage IJ, Rietjens JAC, Overbeek A, Jabbarian LJ, Billekens P, Hammes BJ, Hansen-van der Meer E, Polinder S, Severijnen J, Swart SJ, Witkamp FE, van der Heide A. A cluster randomized controlled trial on the effects and costs of advance care planning in elderly care: study protocol. BMC Geriatr 2015; 15:87. [PMID: 26198573 PMCID: PMC4509612 DOI: 10.1186/s12877-015-0087-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/13/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Currently, health care and medical decision-making at the end of life for older people are often insufficiently patient-centred. In this trial we study the effects of Advance Care Planning (ACP), a formalised process of timely communication about care preferences at the end of life, for frail older people. METHODS/DESIGN We will conduct a cluster randomised controlled trial among older people residing in care homes or receiving home care in the Netherlands. The intervention group will receive the ACP program Respecting Choices® in addition to usual care. The control group will receive usual care only. Participants in both groups will fill out questionnaires at baseline and after 12 months. We hypothesize that ACP will lead to better patient activation in medical decision making and quality of life, while reducing the number of medical interventions and thus health care costs. Multivariate analysis will be used to compare differences between the intervention group and the control group at baseline and to compare differences in changes after 12 months following the inclusion. DISCUSSION Our study can contribute to more understanding of the effects of ACP on patient activation and quality of life in frail older people. Further, we will gain insight in the costs and cost-effectiveness of ACP. This study will facilitate ACP policy for older people in the Netherlands. TRIAL REGISTRATION Nederlands Trial Register: NTR4454.
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Affiliation(s)
- Ida J Korfage
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Judith A C Rietjens
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Anouk Overbeek
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Lea J Jabbarian
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
| | | | | | | | - Suzanne Polinder
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
| | | | | | - Frederika E Witkamp
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Agnes van der Heide
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
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Nauck F, Becker M, King C, Radbruch L, Voltz R, Jaspers B. To what extent are the wishes of a signatory reflected in their advance directive: a qualitative analysis. BMC Med Ethics 2014; 15:52. [PMID: 24981101 PMCID: PMC4083137 DOI: 10.1186/1472-6939-15-52] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 06/20/2014] [Indexed: 11/12/2022] Open
Abstract
Background Advance directives (ADs) are assumed to reflect the patients’ preferences, even if these are not clearly expressed. Research into whether this assumption is correct has been lacking. This study explores to what extent ADs reflect the true wishes of the signatories. Methods Semi-structured interviews (INT), pretest. Transcribed INT and the contents of ADs were inductively categorised (Mayring) and triangulated. Software: MAXQDA 2007. Participants: Patients receiving palliative care (PPC), healthy (H) and chronically ill (CI) individuals with an AD completed ≥3 months prior to recruitment. Results Between 08/2008 and 07/2009, 53 individuals (20 H, 17 CI, 16 PPC) were interviewed (mean age 63.2 years (55–70 years)), 34% male). Most important (in)consistencies between preferences as expressed in INT compared to ADs included preconditions for termination/rejection of life-sustaining measures, refusal of/demand for medical interventions and the nomination of proxies. Standardized AD forms were rarely tailored to the individual. We found a high tendency to use set phrases, such as want to die with dignity or do not want to suffer/vegetate. Likely events in the course of an existing progressive disease were not covered, even in ADs of PPC close to death. Conclusions Only some of the incongruities between verbally expressed preferences and the contents of the AD can be put down to use of standardized forms or lack of medical knowledge. Nevertheless, the non-involvement of a doctor in the process of making an AD must be seen as potentially problematic and seeking medical advice should be promoted by politics and physicians. Standardised forms should encourage amendments and present space for free text entries for all aspects covered. Set phrases need to be defined by the individual to enable them to be translated into a specific course of action.
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Affiliation(s)
| | | | | | | | | | - Birgit Jaspers
- Clinic for Palliative Medicine, University Medical Centre, Robert-Koch-Str, 40, 37075 Göttingen, Germany.
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