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Andrews N, Myall M. 'I don't think they really link together, do they?' An ethnography of multi-professional involvement in advance care planning in nursing homes. Age Ageing 2023; 52:afad234. [PMID: 38156974 PMCID: PMC10756180 DOI: 10.1093/ageing/afad234] [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: 02/02/2023] [Revised: 09/25/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Given the globally ageing population, care homes have an important role in delivering palliative and end-of-life care. Advance care planning (ACP) is promoted to improve the quality of end-of-life care in this setting. While many professionals can be involved in ACP, little is known about what influences multi-professional involvement and how multi-professional working impacts the ACP process in the UK. This study investigated multi-professional practice in relation to ACP in nursing homes. DESIGN AND METHODS An ethnography was undertaken in two UK nursing homes using multiple methods of data collection: observations, interviews and document review. Participants included the following: nursing home residents (n = 6), relatives (n = 4), nursing home staff (n = 19), and visiting health and social care professionals (n = 7). Analysis integrated thematic analysis, mapping of resident ACP trajectories and documentary analysis. FINDINGS This paper suggests that multi-professional and relatives' involvement in ACP was disjointed. Continuity and coordination were disrupted by misalignment of visiting professional and nursing home organisational structures. Findings show a 'knotworking' approach to teamwork and power imbalance between nursing home staff and visiting professionals, such as general practitioners. While residents wished their relatives to be involved in their ACP, this was not formally recognised, and limited support existed to facilitate their involvement. CONCLUSION The structure and organisation of multi-professional and relatives' involvement in ACP led to fragmentation of the process. This marginalised the voice of both the resident and nursing home staff, thereby limiting ACP as a tool to enhance quality of end-of-life care.
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Affiliation(s)
- Nicola Andrews
- School of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK
| | - Michelle Myall
- School of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK
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Moult A, Baker D, Twohig H, Missen M, Iqbal Z, Duffy H, Paskins Z. Applying the consolidated framework for implementation research to evaluate the community rapid intervention service. BMC Health Serv Res 2023; 23:844. [PMID: 37559064 PMCID: PMC10413526 DOI: 10.1186/s12913-023-09864-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Developed in 2019, the Community Rapid Intervention Service (CRIS) is a community intervention service aiming to prevent hospital admissions. CRIS provides a response within two hours to patients with sub-acute medical needs in their usual place of residence. This evaluation aimed to identify challenges and facilitators to implementation of the service, with a view to informing future service development, optimising patient care and disseminating learning to other areas looking to implement similar services. METHODS This study used the Consolidated Framework for Implementation Research (CFIR) as an evaluation framework. We conducted semi-structured interviews with local healthcare system leaders, clinicians that worked within the CRIS, and clinicians who interfaced with the CRIS. The CFIR was used to guide data collection and analysis. Two Community of Practice (CoP) meetings were held to gather stakeholders' perspectives of the evaluation. RESULTS Three key themes were identified from the analysis of 13 interviews: contextual factors influencing implementation, service identity and navigating complexity. Contextual factors such the influence of the Covid 19 pandemic upon health services and the expansion of the CRIS were discussed by participants. The adaptability of the service was deemed both a facilitator and challenge of implementation. Ways to build-on and improve the existing CRIS model were suggested. CONCLUSION This evaluation has shown that the CRIS may need to be redefined with clarity provided as to how the service interfaces with other urgent and planned care offered in acute, primary, community and social services. Structuring the evaluation around the CFIR was helpful in identifying facilitators and challenges that influenced the implementation of the CRIS.
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Affiliation(s)
- Alice Moult
- School of Medicine, Keele University, Newcastle-Under-Lyme, ST5 5BG, UK.
| | - Dereth Baker
- School of Medicine, Keele University, Newcastle-Under-Lyme, ST5 5BG, UK
| | - Helen Twohig
- School of Medicine, Keele University, Newcastle-Under-Lyme, ST5 5BG, UK
| | - Matthew Missen
- Midlands Partnership University NHS Foundation Trust, Trust Headquarters, Corporation St, Stafford, UK
| | - Zafar Iqbal
- Midlands Partnership University NHS Foundation Trust, Trust Headquarters, Corporation St, Stafford, UK
| | - Helen Duffy
- Midlands Partnership University NHS Foundation Trust, Trust Headquarters, Corporation St, Stafford, UK
| | - Zoe Paskins
- School of Medicine, Keele University, Newcastle-Under-Lyme, ST5 5BG, UK
- Haywood Academic Rheumatology Centre, Haywood Hospital, Midland Partnership University NHS Foundation Trust , ST5 5BG, Stafford, UK
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Pollock K, Caswell G, Turner N, Wilson E. The ideal and the real: Patient and bereaved family caregiver perspectives on the significance of place of death. DEATH STUDIES 2023; 48:312-325. [PMID: 37338854 PMCID: PMC10860700 DOI: 10.1080/07481187.2023.2225042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Home has become established as the preferred place of death within health policy and practice in the UK and internationally. However, growing awareness of the structured inequalities underpinning end-of-life care and the challenges for family members undertaking care at home raise questions about the nature of patient and public preferences and priorities regarding place of death and the feasibility of home management of the complex care needs at the end-of-life. This paper presents findings from a qualitative study of 12 patients' and 34 bereaved family caregivers' perspectives and priorities regarding place of death. Participants expressed complex and nuanced accounts in which place of death was not afforded an overarching priority. The study findings point to public pragmatism and flexibility in relation to place of death, and the misalignment of current policy with public priorities that are predominantly for comfort and companionship at the end-of-life, regardless of place.
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Affiliation(s)
- Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Glenys Caswell
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Nicola Turner
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK
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Islam Z, Pollock K, Patterson A, Hanjari M, Wallace L, Mururajani I, Conroy S, Faull C. Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-135. [PMID: 37464868 DOI: 10.3310/jvfw4781] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background This study explored whether or not, and how, terminally ill patients from ethnically diverse backgrounds and their family caregivers think ahead about deterioration and dying, and explored their engagement with health-care professionals in end-of-life care planning. Objective The aim was to address the question, what are the barriers to and enablers of ethnically diverse patients, family caregivers and health-care professionals engaging in end-of-life care planning? Design This was a qualitative study comprising 18 longitudinal patient-centred case studies, interviews with 19 bereaved family caregivers and 50 public and professional stakeholder responses to the findings. Setting The study was set in Nottinghamshire and Leicestershire in the UK. Results Key barriers - the predominant stance of patients was to live with hope, considering the future only in terms of practical matters (wills and funerals), rather than the business of dying. For some, planning ahead was counter to their faith. Health-care professionals seemed to feature little in people's lives. Some participants indicated a lack of trust and experienced a disjointed system, devoid of due regard for them. However, religious and cultural mores were of great importance to many, and there were anxieties about how the system valued and enabled these. Family duty and community expectations were foregrounded in some accounts and concern about being in the (un)care of strangers was common. Key enablers - effective communication with trusted individuals, which enables patients to feel known and that their faith, family and community life are valued. Health-care professionals getting to 'know' the person is key. Stakeholder responses highlighted the need for development of Health-care professionals' confidence, skills and training, Using stories based on the study findings was seen as an effective way to support this. A number of behavioural change techniques were also identified. Limitations It was attempted to include a broad ethnic diversity in the sample, but the authors acknowledge that not all groups could be included. Conclusions What constitutes good end-of-life care is influenced by the intersectionality of diverse factors, including beliefs and culture. All people desire personalised, compassionate and holistic end-of-life care, and the current frameworks for good palliative care support this. However, health-care professionals need additional skills to navigate complex, sensitive communication and enquire about aspects of people's lives that may be unfamiliar. The challenge for health-care professionals and services is the delivery of holistic care and the range of skills that are required to do this. Future work Priorities for future research: How can health professionals identify if/when a patient is 'ready' for discussions about deterioration and dying? How can discussions about uncertain recovery and the need for decisions about treatment, especially resuscitation, be most effectively conducted in a crisis? How can professionals recognise and respond to the diversity of faith and cultural practices, and the heterogeneity between individuals of beliefs and preferences relating to the end of life? How can conversations be most effectively conducted when translation is required to enhance patient understanding? Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. X. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Zoebia Islam
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Anne Patterson
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Matilda Hanjari
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Louise Wallace
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
| | - Irfhan Mururajani
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Christina Faull
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
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Zhu N, Yang L, Wang X, Tuo J, Chen L, Deng R, Kwan RYC. Experiences and perspectives of healthcare professionals implementing advance care planning for people suffering from life-limiting illness: a systematic review and meta-synthesis of qualitative studies. BMC Palliat Care 2023; 22:55. [PMID: 37149560 PMCID: PMC10163819 DOI: 10.1186/s12904-023-01176-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/24/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Life-limited patients may lose decision-making abilities during disease progression. Advance care planning can be used as a discussion method for healthcare professionals to understand patients' future care preferences. However, due to many difficulties, the participation rate of healthcare professionals in advance care planning is not high. AIM To explore the facilitators of and barriers to healthcare professionals' provision of advance care planning to life-limited patients to better implement it for this population. METHODS We followed ENTREQ and PRISMA to guide this study. We conducted a systematic search of PubMed, Web of Science, Embase, CINAHL, PsycINFO, CNKI, and SinoMed to include qualitative data on the experiences and perspectives of healthcare professionals in different professional fields in providing advance care planning for life-limited patients. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to assess the quality of the included studies. RESULTS A total of 11 studies were included. Two themes were identified: unsupported conditions and facilitative actions. Healthcare professionals regarded cultural concepts, limited time, and fragmented record services as obstacles to implementation. They had low confidence and were overly concerned about negative effects. They needed to possess multiple abilities, learn to flexibly initiate topics, and facilitate effective communication based on multidisciplinary collaboration. CONCLUSION Healthcare professionals need an accepting cultural environment to implement advance care planning, a sound legal system, financial support, and a coordinated and shared system to support them. Healthcare systems need to develop educational training programs to increase the knowledge and skills of healthcare professionals and to promote multidisciplinary collaboration to facilitate effective communication. Future research should compare the differences in the needs of healthcare professionals in different cultures when implementing advance care planning to develop systematic implementation guidelines in different cultures.
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Affiliation(s)
- Nanxi Zhu
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
- Nursing Department, Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, 519100, China
| | - Liu Yang
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
| | - Xianlin Wang
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
| | - Jinmei Tuo
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China
| | - Liuliu Chen
- School of Health, Zhuhai College of Science and Technology, Zhuhai, 519041, China
| | - Renli Deng
- Nursing Department, Affiliated Hospital of Zunyi Medical University, 121 Dalian Road, Zunyi City, Huichuan District, Guizhou Province, 563000, China.
- Nursing Department, Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, 519100, China.
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The experiences of adult patients, families, and healthcare professionals of CPR decision-making conversations in the United Kingdom: A qualitative systematic review. Resusc Plus 2023; 13:100351. [PMID: 36686325 PMCID: PMC9850060 DOI: 10.1016/j.resplu.2022.100351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/08/2023] Open
Abstract
Aim To conduct a qualitative systematic review on the experiences of patients, families, and healthcare professionals (HCPs) of CPR decision-making conversations in the United Kingdom (UK). Methods The databases PubMed, Embase, Emcare, CINAHL, and PsycInfo were searched. Studies published from 1 January 2012 describing experiences of CPR decision-making conversations in the UK were included. Included studies were critically appraised using the CASP tool. Thematic synthesis was conducted. Results From 684 papers identified, ten studies were included. Four key themes were identified:(i) Initiation of conversations - Key prompts for the discussion included clinical deterioration and poor prognosis. There are different perspectives about who should initiate conversations.(ii) Involvement of patients and families - HCPs were reluctant to involve patients who they thought would become distressed by the conversation, while patients varied in their desire to be involved. Patients wanted family support while HCPs viewed families as potential sources of conflict.(iii) Influences on the content of conversations - Location, context, HCPs' attitudes and emotions, and uncertainty of prognosis influenced the content of conversations.(iv) Conversation outcomes - Range of outcomes included emotional distress, sense of relief and value, disagreements, and incomplete conversations. Conclusions There is inconsistency in how these conversations occur, patients' desire to be involved, and between patients' and HCPs' views on the role of families in these conversations. CPR discussions raise ethical challenges for HCPs. HCPs need training and pastoral support in conducting CPR discussions. Patients and families need education on CPR recommendations and support after discussions.
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Mowbray FI, Jones A, Strum RP, Turcotte L, Foroutan F, de Wit K, Worster A, Griffith LE, Hebert P, Heckman G, Ko DT, Schumacher C, Gayowsky A, Costa AP. Prognosis of cardiac arrest in home care clients and nursing home residents: A population-level retrospective cohort study. Resusc Plus 2022; 12:100328. [DOI: 10.1016/j.resplu.2022.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/23/2022] [Accepted: 10/27/2022] [Indexed: 11/18/2022] Open
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Wilson E, Caswell G, Turner N, Pollock K. Talking about death and dying: Findings from deliberative discussion groups with members of the public. MORTALITY (ABINGDON, ENGLAND) 2022; 29:176-192. [PMID: 38293271 PMCID: PMC10824017 DOI: 10.1080/13576275.2022.2136515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Talking about death and dying is promoted in UK health policy and practice, from a perception that to do so encourages people to plan for their end of life and so increase their likelihood of experiencing a good death. This encouragement occurs alongside a belief that members of the public are reluctant to talk about death, although surveys suggest this is not the case. This paper describes findings from a research study in which people participated in deliberative discussion groups during which they talked about a range of topics related to death, including talking about death, the good death, choice and planning and compassionate communities. Here we report what they had to say in relation to talking about death and dying. We identified three themes: 1. The difference between talking about death as an abstract concept and confronting the certainty of death, 2. how death and dying presents issues for planning and responsibility, and 3. approaches to normalising death within society. For our participants, planning was considered most appropriate in relation to wills and funerals, while dying was considered too unpredictable to be easy to plan for; they had complex ideas about the value of talking about death and dying.
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Affiliation(s)
- Eleanor Wilson
- NCARE, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Glenys Caswell
- NCARE, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Nicola Turner
- NCARE, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Kristian Pollock
- NCARE, School of Health Sciences, University of Nottingham, Nottingham, UK
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Johansson T, Tishelman C, Eriksson LE, Cohen J, Goliath I. Use, usability, and impact of a card-based conversation tool to support communication about end-of-life preferences in residential elder care – a qualitative study of staff experiences. BMC Geriatr 2022; 22:274. [PMID: 35366816 PMCID: PMC8976536 DOI: 10.1186/s12877-022-02915-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 03/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Proactive conversations about individual preferences between residents, relatives, and staff can support person-centred, value-concordant end-of-life (EOL) care. Nevertheless, prevalence of such conversations is still low in residential care homes (RCHs), often relating to staff’s perceived lack of skills and confidence. Using tools may help staff to facilitate EOL conversations. While many EOL-specific tools are script-based and focus on identifying and documenting treatment priorities, the DöBra card tool is developed to stimulate reflection and conversation about EOL care values and preferences. In this study, we explore staff’s experiences of use, usability, and perceived impact of the DöBra cards in supporting discussion about EOL care in RCH settings.
Methods
This qualitative study was based on data from two participatory action research processes in which RCH staff tested and evaluated use of DöBra cards in EOL conversations. Data comprise 6 interviews and 8 group meetings with a total of 13 participants from 7 facilities. Qualitative content analysis was performed to identify key concepts in relation to use, usability, and impact of the DöBra cards in RCH practice.
Results
Based on participants’ experiences of using the DöBra cards as an EOL conversation tool in RCHs, we identified three main categories in relation to its usefulness. Outcomes of using the cards (1) included the outlining of content of conversations and supporting connection and development of rapport. Perceived impact (2) related to enabling openings for future communication and aligning care goals between stakeholders. Use and usability of the cards (3) were influenced by supporting and limiting factors on the personal and contextual level.
Conclusions
This study demonstrates how the DöBra cards was found to be useful by staff for facilitating conversations about EOL values, influencing both the content of discussion and interactions between those present. The tool encouraged reflection and interaction, which staff perceived as potentially helpful in building preparedness for future care-decision making. The combination of providing a shared framework and being adaptable in use appeared to be key features for the DöBra cards usability in the RCH setting.
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Bowers B, Pollock K, Barclay S. Unwelcome memento mori or best clinical practice? Community end of life anticipatory medication prescribing practice: A mixed methods observational study. Palliat Med 2022; 36:95-104. [PMID: 34493122 PMCID: PMC8796157 DOI: 10.1177/02692163211043382] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anticipatory medications are injectable drugs prescribed ahead of possible need for administration if distressing symptoms arise in the final days of life. Little is known about how they are prescribed in primary care. AIM To investigate the frequency, timing and recorded circumstances of anticipatory medications prescribing for patients living at home and in residential care. DESIGN Retrospective mixed methods observational study using General Practitioner and community nursing clinical records. SETTING/PARTICIPANTS 329 deceased adult patients registered with Eleven General Practitioner practices and two associated community nursing services in two English counties (30 most recent deaths per practice). Patients died from any cause except trauma, sudden death or suicide, between 4 March 2017 and 25 September 2019. RESULTS Anticipatory medications were prescribed for 167/329 (50.8%) of the deceased patients, between 0 and 1212 days before death (median 17 days). The likelihood of prescribing was significantly higher for patients with a recorded preferred place of death (odds ratio [OR] 34; 95% CI 15-77; p < 0.001) and specialist palliative care involvement (OR 7; 95% CI 3-19; p < 0.001). For 66.5% of patients (111/167) anticipatory medications were recorded as being prescribed as part of a single end-of-life planning intervention. CONCLUSION The variability in the timing of prescriptions highlights the challenges in diagnosing the end-of-life phase and the potential risks of prescribing far in advance of possible need. Patient and family views and experiences of anticipatory medication care, and their preferences for involvement in prescribing decision-making, warrant urgent investigation.
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Affiliation(s)
- Ben Bowers
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Kristian Pollock
- Nottingham Centre for the Advancement of Research into Supportive, Palliative and End of Life Care, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Armstrong-Buisseret L, Brittain C, Kai J, David M, Anstey Watkins J, Ozolins M, Jackson L, Abdali Z, Hepburn T, Griffiths F, Montgomery A, Daniels J, Manley A, Dean G, Ross JDC. Lactic acid gel versus metronidazole for recurrent bacterial vaginosis in women aged 16 years and over: the VITA RCT. Health Technol Assess 2022; 26:1-170. [DOI: 10.3310/zzkh4176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background
Bacterial vaginosis is a common and distressing condition associated with serious comorbidities. Antibiotic treatment is usually clinically effective in the short term, but recurrence is common and side effects can occur.
Objectives
The objective is to assess whether or not intravaginal lactic acid gel is clinically effective and cost-effective for treating recurrent bacterial vaginosis compared with oral metronidazole (Flagyl, Sanofi).
Design
This was an open-label, multicentre, parallel-arm, randomised (1 : 1) controlled trial.
Setting
This took place in one general practice and 19 sexual health centres in the UK.
Participants
Women aged ≥ 16 years with bacterial vaginosis symptoms and one or more episode(s) within the past 2 years took part.
Interventions
The interventions were 5 ml of intravaginal lactic acid gel taken once daily for 7 days (intervention) or 400-mg oral metronidazole tablets taken twice daily for 7 days (control).
Main outcome measures
The primary outcome was the resolution of bacterial vaginosis symptoms 14 days after randomisation. The secondary outcomes were time to first recurrence of symptoms; number of recurrences and treatment courses over 6 months; microbiological resolution on microscopy of vaginal smears at week 2; time to resolution of symptoms; tolerability, adherence and acceptability of the treatment; prevalence of concurrent sexually transmitted infections; quality of life; and cost-effectiveness.
Results
Recruitment stopped prior to reaching the target of 1900 participants on recommendation from the Data Monitoring Committee and Trial Steering Committee after a planned review of the results indicated that the research question had been answered. Overall, 518 participants were randomised and primary outcome data were available for 409 participants (79%; 204 in the metronidazole arm, 205 in the lactic acid gel arm). Participant-reported symptom resolution at week 2 was higher with metronidazole (143/204; 70%) than with lactic acid gel (97/205; 47%) (adjusted risk difference –23.2%, 95% confidence interval –32.3% to –14.0%). Recurrence in 6 months in a subset of participants who had initial resolution and were available for follow-up was similar across arms (metronidazole arm: 51/72, 71%; lactic acid gel arm: 32/46, 70%). A higher incidence of some side effects was reported with metronidazole than with lactic acid gel (nausea 32% vs. 8%; taste changes 18% vs. 1%; diarrhoea 20% vs. 6%, respectively). At week 2, the average cost per participant with resolved symptoms was £86.94 (metronidazole), compared with £147.00 (lactic acid gel). Some participants preferred using lactic acid gel even if they perceived it to be less effective than metronidazole.
Limitations
Loss to follow-up for collection of the primary outcome data was 21% and was similar in both arms. There is a risk of bias owing to missing outcome data at 3 and 6 months post treatment.
Conclusions
A higher initial response was seen with metronidazole than with lactic acid gel, but subsequent treatment failure was common with both. Lactic acid gel was less cost-effective than metronidazole. In general, women disliked taking repeated courses of metronidazole and preferred lactic acid gel, even when they were aware that it was less likely to provide symptom resolution. In the absence of effective curative therapy, further evaluation of non-antibiotic treatments to control the symptoms of recurrent bacterial vaginosis is required to improve quality of life for these patients. Further microbiological analysis of vaginal samples would be useful to identify additional factors affecting response to treatment.
Trial registration
Current Controlled Trials ISRCTN14161293.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Joe Kai
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Miruna David
- Clinical Microbiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jocelyn Anstey Watkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mara Ozolins
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Louise Jackson
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Zainab Abdali
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
| | - Alan Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alice Manley
- Department of Genitourinary Medicine, Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jonathan DC Ross
- Department of Genitourinary Medicine, Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Islam Z, Taylor L, Faull C. Thinking ahead in advanced illness: Exploring clinicians' perspectives on discussing resuscitation with patients and families from ethnic minority communities. Future Healthc J 2021; 8:e619-e624. [PMID: 34888453 DOI: 10.7861/fhj.2021-0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Evidence suggests that discussing resuscitation with patients and relatives from ethnic minority groups is problematic for healthcare professionals (HCPs), but there is limited evidence exploring these issues or offering guidance for HCPs in navigating these challenging discussions. This study explores the barriers and enablers to HCPs discussing deterioration and resuscitation decisions with patients and families from ethnic minority groups. Results Personal, cultural, religious/spiritual and health beliefs, emotions, and communication quality and skills were discussed. Participants described that the interaction between these factors as complex, impacting the way some patients and families responded to do not attempt cardiopulmonary resuscitation (DNACPR) orders and the particular challenges these pose. Conclusion Key barriers and enablers for healthcare professionals discussing resuscitation with patients and families from Black, Asian and minority ethnic communities were identified. The findings highlight areas of improvement for training, both relating to DNACPR discussions and 'cultural competence'.
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Affiliation(s)
- Zoebia Islam
- LOROS hospice, Leicester, UK, and honorary lecturer, University of Leicester, Leicester, UK
| | | | - Christina Faull
- LOROS hospice, Leicester, UK, and honorary professor, University of Leicester, Leicester, UK
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13
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Pollock K, Wilson E, Caswell G, Latif A, Caswell A, Avery A, Anderson C, Crosby V, Faull C. Family and health-care professionals managing medicines for patients with serious and terminal illness at home: a qualitative study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
More effective ways of managing symptoms of chronic and terminal illness enable patients to be cared for, and to die, at home. This requires patients and family caregivers to manage complex medicines regimens, including powerful painkillers that can have serious side effects. Little is known about how patients and family caregivers manage the physical and emotional work of managing medicines in the home or the support that they receive from health-care professionals and services.
Objective
To investigate how patients with serious and terminal illness, their family caregivers and the health-care professionals manage complex medication regimens and routines of care in the domestic setting.
Design
A qualitative study involving (1) semistructured interviews and group discussions with 40 health-care professionals and 21 bereaved family caregivers, (2) 20 patient case studies with up to 4 months’ follow-up and (3) two end-of-project stakeholder workshops.
Setting
This took place in Nottinghamshire and Leicestershire, UK.
Results
As patients’ health deteriorated, family caregivers assumed the role of a care co-ordinator, undertaking the everyday work of organising and collecting prescriptions and storing and administering medicines around other care tasks and daily routines. Participants described the difficulties of navigating a complex and fragmented system and the need to remain vigilant about medicines prescribed, especially when changes were made by different professionals. Access to support, resilience and coping capacity are mediated through the resources available to patients, through the relationships that they have with people in their personal and professional networks, and, beyond that, through the wider connections – or disconnections – that these links have with others. Health-care professionals often lacked understanding of the practical and emotional challenges involved. All participants experienced difficulties in communication and organisation within a health-care system that they felt was complicated and poorly co-ordinated. Having a key health professional to support and guide patients and family caregivers through the system was important to a good experience of care.
Limitations
The study achieved diversity in the recruitment of patients, with different characteristics relating to the type of illness and socioeconomic circumstances. However, recruitment of participants from ethnically diverse and disadvantaged or hard-to-reach populations was particularly challenging, and we were unable to include as many participants from these groups as had been originally planned.
Conclusions
The study identified two key and inter-related areas in which patient and family caregiver experience of managing medicines at home in end-of-life care could be improved: (1) reducing work and responsibility for medicines management and (2) improving co-ordination and communication in health care. It is important to be mindful of the need for transparency and open discussion about the extent to which patients and family caregivers can and should be co-opted as proto-professionals in the technically and emotionally demanding tasks of managing medicines at the end of life.
Future work
Priorities for future research include investigating how allocated key professionals could integrate and co-ordinate care and optimise medicines management; the role of domiciliary home care workers in supporting medicines management in end-of-life care; patient and family perspectives and understanding of anticipatory prescribing and their preferences for involvement in decision-making; the experience of medicines management in terminal illness among minority, disadvantaged and hard-to-reach patient groups; and barriers to and facilitators of increased involvement of community pharmacists in palliative and end-of-life care.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Glenys Caswell
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Asam Latif
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Alan Caswell
- Patient and Public Involvement Representative, Dementia, Frail Older and Palliative Care Patient and Public Involvement Advisory Group, University of Nottingham, Nottingham, UK
| | - Anthony Avery
- School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Claire Anderson
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Vincent Crosby
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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14
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Combes S, Forbes G, Gillett K, Norton C, Nicholson CJ. Development of a theory-based intervention to increase cognitively able frail elders' engagement with advance care planning using the behaviour change wheel. BMC Health Serv Res 2021; 21:712. [PMID: 34284759 PMCID: PMC8290869 DOI: 10.1186/s12913-021-06548-4] [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: 03/08/2021] [Accepted: 05/17/2021] [Indexed: 11/22/2022] Open
Abstract
Background Advance care planning (ACP) conversations support people to think about, discuss and document their beliefs, values and preferences regarding future care. This process means that should the person loose capacity in the future, care can be provided, consistent with their personal values and beliefs. The ACP process is particularly relevant for older people living with frailty (frail elders) as they are vulnerable to sudden deterioration. However, ACP is rarely undertaken by frail elders. The aim of this study was to develop an intervention to increase multidisciplinary health and social care professionals’ (H&SCPs) engagement of cognitively able, domestic-dwelling frail elders with ACP. Methods Intervention development was guided by the Medical Research Council framework for complex interventions and the Behaviour Change Wheel. Multiple methods were used to understand ACP barriers and enablers: a systematic integrative review, a survey (n = 73 H&SCPs), and semi-structured interviews (n = 10 frail elders, n = 8 family members). A conceptual model, developed from the integrative review, underpinned data collection for the survey and interviews. Synthesis of this data, including patient and public involvement, was then used to identify H&SCPs behaviours that needed to change for ACP to be implemented and decide content and implementation for the intervention. Results Following the Behaviour Change Wheel system, and based on the findings of the review, survey and interviews, the prototype intervention, Conversations on Living and Dying (CLaD), was developed. The CLaD prototype consisted of one 3.5-hour educational skills session for H&SCPs supported by a toolkit. Content focussed on the relevance of ACP for frail elders, experience of ACP by frail elders, and strategies H&SCPs could adopt to encourage frail elders’ engagement with ACP. Strategies include recognising the importance of relationships and living well now, preparing frail elders for ACP conversations and starting ACP early. Participants who took part in initial prototype refinement reported that the intervention helped them think differently about ACP and encouraged them to engage with frail elders. Conclusions The use of behavioural theory enabled the development of CLaD, an evidence-based, theory-driven, person-centred intervention to support ACP engagement with frail elders. While feasibility testing is required, initial prototype refinement demonstrated that H&SCPs found the intervention to be acceptable, engaging, and clinically valuable in their practice with frail elders and their families. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06548-4.
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Affiliation(s)
- S Combes
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK. .,St Christopher's Hospice, London, UK.
| | - G Forbes
- Centre for Behaviour Change, University College London, London, UK
| | - K Gillett
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - C Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - C J Nicholson
- St Christopher's Hospice, London, UK.,Faculty of Health and Medical Sciences, Surrey University, Guildford, UK
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15
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Bowers B, Barclay SS, Pollock K, Barclay S. GPs' decisions about prescribing end-of-life anticipatory medications: a qualitative study. Br J Gen Pract 2020; 70:e731-e739. [PMID: 32895243 PMCID: PMC7480177 DOI: 10.3399/bjgp20x712625] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/19/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND GPs have a central role in decisions about prescribing anticipatory medications to help control symptoms at the end of life. Little is known about GPs' decision-making processes in prescribing anticipatory medications, how they discuss this with patients and families, or the subsequent use of prescribed drugs. AIM To explore GPs' decision-making processes in the prescribing and use of anticipatory medications for patients at the end of life. DESIGN AND SETTING A qualitative interview study with GPs working in one English county. METHOD Semi-structured interviews were conducted with a purposive sample of 13 GPs. Interview transcripts were analysed inductively using thematic analysis. RESULTS Three themes were constructed from the data: something we can do, getting the timing right, and delegating care while retaining responsibility. Anticipatory medications were a tangible intervention GPs felt they could offer patients approaching death (something we can do). The prescribing of anticipatory medications was recognised as a harbinger of death for patients and their families. Nevertheless, GPs preferred to discuss and prescribe anticipatory medications weeks before death was expected whenever possible (getting the timing right). After prescribing medications, GPs relied on nurses to assess when to administer drugs and keep them updated about their use (delegating care while retaining responsibility). CONCLUSION GPs view anticipatory medications as key to symptom management for patients at the end of life. The drugs are often presented as a clinical recommendation to ensure patients and families accept the prescription. GPs need regular access to nurses and rely on their skills to administer drugs appropriately. Patients' and families' experiences of anticipatory medications, and their preferences for involvement in decision making, warrant urgent investigation.
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Affiliation(s)
- Ben Bowers
- Queen's Nurse, NIHR School for Primary Care Research PhD student
| | - Sam S Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Kristian Pollock
- Nottingham Centre for the Advancement of Research into Supportive, Palliative and End of Life Care, School of Health Sciences, University of Nottingham, Nottingham
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
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16
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Gerber K, Lemmon C, Williams S, Watt J, Panayiotou A, Batchelor F, Hayes B, Brijnath B. ‘There for me’: A qualitative study of family communication and decision-making in end-of-life care for older people. PROGRESS IN PALLIATIVE CARE 2020. [DOI: 10.1080/09699260.2020.1767437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Katrin Gerber
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | - Christel Lemmon
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | - Sue Williams
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | | | - Anita Panayiotou
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | - Frances Batchelor
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | | | - Bianca Brijnath
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
- Department of General Practice, Monash University, Melbourne, Australia
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17
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Hopkins SA, Lovick R, Polak L, Bowers B, Morgan T, Kelly MP, Barclay S. Reassessing advance care planning in the light of covid-19. BMJ 2020; 369:m1927. [PMID: 32423988 DOI: 10.1136/bmj.m1927] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Sarah A Hopkins
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Roberta Lovick
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Louisa Polak
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Ben Bowers
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Tessa Morgan
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Michael P Kelly
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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18
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Zwakman M, Pollock K, Bulli F, Caswell G, Červ B, van Delden JJM, Deliens L, van der Heide A, Jabbarian LJ, Koba-Čeh H, Lunder U, Miccinesi G, Arnfeldt CAM, Seymour J, Toccafondi A, Verkissen MN, Kars MC. Trained facilitators' experiences with structured advance care planning conversations in oncology: an international focus group study within the ACTION trial. BMC Cancer 2019; 19:1026. [PMID: 31672145 PMCID: PMC6822448 DOI: 10.1186/s12885-019-6170-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 09/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In oncology, Health Care Professionals often experience conducting Advance Care Planning (ACP) conversations as difficult and are hesitant to start them. A structured approach could help to overcome this. In the ACTION trial, a Phase III multi-center cluster-randomized clinical trial in six European countries (Belgium, Denmark, Italy, the Netherlands, Slovenia, United Kingdom), patients with advanced lung or colorectal cancer are invited to have one or two structured ACP conversations with a trained facilitator. It is unclear how trained facilitators experience conducting structured ACP conversations. This study aims to understand how facilitators experience delivering the ACTION Respecting Choices (RC) ACP conversation. METHODS A qualitative study involving focus groups with RC facilitators. Focus group interviews were recorded, transcribed, anonymized, translated into English, and thematically analysed, supported by NVivo 11. The international research team was involved in data analysis from initial coding and discussion towards final themes. RESULTS Seven focus groups were conducted, involving 28 of in total 39 trained facilitators, with different professional backgrounds from all participating countries. Alongside some cultural differences, six themes were identified. These reflect that most facilitators welcomed the opportunity to participate in the ACTION trial, seeing it as a means of learning new skills in an important area. The RC script was seen as supportive to ask questions, including those perceived as difficult to ask, but was also experienced as a barrier to a spontaneous conversation. Facilitators noticed that most patients were positive about their ACTION RC ACP conversation, which had prompted them to become aware of their wishes and to share these with others. The facilitators observed that it took patients substantial effort to have these conversations. In response, facilitators took responsibility for enabling patients to experience a conversation from which they could benefit. Facilitators emphasized the need for training, support and advanced communication skills to be able to work with the script. CONCLUSIONS Facilitators experienced benefits and challenges in conducting scripted ACP conversations. They mentioned the importance of being skilled and experienced in carrying out ACP conversations in order to be able to explore the patients' preferences while staying attuned to patients' needs. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number registry 63110516 ( ISRCTN63110516 ) per 10/3/2014.
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Affiliation(s)
- M Zwakman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - K Pollock
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - F Bulli
- Oncological network, research and prevention Institute - ISPRO, Florence, Italy
| | - G Caswell
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - B Červ
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - J J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - A van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - L J Jabbarian
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - H Koba-Čeh
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - U Lunder
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - G Miccinesi
- Oncological network, research and prevention Institute - ISPRO, Florence, Italy
| | - C A Møller Arnfeldt
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, The Research Unit, Copenhagen, Denmark
| | - J Seymour
- University of Sheffield, Sheffield, UK
| | - A Toccafondi
- Oncological network, research and prevention Institute - ISPRO, Florence, Italy
| | - M N Verkissen
- End-of-life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Ghent University, Brussels, Belgium
| | - M C Kars
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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19
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Lennard C. Best interest versus advance decisions to refuse treatment in advance care planning for neurodegenerative illness. ACTA ACUST UNITED AC 2019; 27:1261-1267. [PMID: 30457382 DOI: 10.12968/bjon.2018.27.21.1261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article describes the role of nurses assisting people with degenerative illness in advance care planning (ACP) for a time when they may lose decision-making capacity. It looks at the concept of advance decisions to refuse treatment (ADRT), as defined in the Mental Capacity Act 2005 , exploring the legal, ethical and philosophical ramifications of carrying out, or overriding, formerly expressed wishes of someone who has subsequently lost decision-making capacity. It uses an illustrative composite case study of an individual with Huntington's disease whose prognosis includes future deterioration in swallowing, together with consideration of whether to have or refuse a percutaneous endoscopic gastrostomy. The author, who as part of his role cares for people with neurodegenerative conditions, including Huntington's disease, discusses the difficulties and dilemmas that nurses experience with ADRTs, drawing on personal experience. He suggests that, rather than focusing on ADRTs, ACP may be most effective in preparing people and their surrogates to make real-time decisions, based on a shared understanding of the individual's values.
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Affiliation(s)
- Chris Lennard
- Registered mental health nurse, Pirton Grange Specialist Care Centre, Pirton, Worcestershire
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20
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Land V, Parry R, Pino M, Jenkins L, Feathers L, Faull C. Addressing possible problems with patients' expectations, plans and decisions for the future: One strategy used by experienced clinicians in advance care planning conversations. PATIENT EDUCATION AND COUNSELING 2019; 102:670-679. [PMID: 30528873 DOI: 10.1016/j.pec.2018.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 11/04/2018] [Accepted: 11/09/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Giving terminally ill people opportunities to participate in advance care planning involves tensions between: endorsing and supporting patients' expectations, plans and decisions, and addressing how realistic these are. The latter risks exerting undue pressure to change plans; undermining autonomy; jeopardising therapeutic relationships. Our objective is to describe how experienced hospice doctors raise potential/actual problems with patients' expectations, plans or decisions. METHODS Conversation analysis of video-recorded consultations between five UK hospice consultants, 37 patients and their companions. RESULTS Eleven episodes involving five doctors were found. In all of these we identified a 'Hypothetical Scenario Sequence' where doctors raise a hypothetical future scenario wherein current plans/expectations turn out to be problematic, then engage patients in discussing what could be done about this. We describe features of this sequence and how it can circumvent the risks of addressing problems with patients' expectations and plans. CONCLUSION Our research breaks new ground, showing that by treating expectations, plans and decisions as potentially not actually problematic, practitioners can recognise and support patients' preferences whilst preparing them for possible difficulties and inevitable uncertainties. PRACTICE IMPLICATIONS Where professionals judge it appropriate to raise problems about patients' preferences, plans and decisions, this sequence can manage the associated risks.
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Affiliation(s)
| | | | | | | | - Luke Feathers
- LOROS Hospice Care for Leicestershire and Rutland, and Medicine University Hospitals Leicester, UK
| | - Christina Faull
- LOROS Hospice Care for Leicestershire and Rutland, and Medicine University Hospitals Leicester, UK
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21
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Jung K, Sudat SEK, Kwon N, Stewart WF, Shah NH. Predicting need for advanced illness or palliative care in a primary care population using electronic health record data. J Biomed Inform 2019; 92:103115. [PMID: 30753951 PMCID: PMC6512802 DOI: 10.1016/j.jbi.2019.103115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Timely outreach to individuals in an advanced stage of illness offers opportunities to exercise decision control over health care. Predictive models built using Electronic health record (EHR) data are being explored as a way to anticipate such need with enough lead time for patient engagement. Prior studies have focused on hospitalized patients, who typically have more data available for predicting care needs. It is unclear if prediction driven outreach is feasible in the primary care setting. In this study, we apply predictive modeling to the primary care population of a large, regional health system and systematically examine the impact of technical choices, such as requiring a minimum number of health care encounters (data density requirements) and aggregating diagnosis codes using Clinical Classifications Software (CCS) groupings to reduce dimensionality, on model performance in terms of discrimination and positive predictive value. We assembled a cohort of 349,667 primary care patients between 65 and 90 years of age who sought care from Sutter Health between July 1, 2011 and June 30, 2014, of whom 2.1% died during the study period. EHR data comprising demographics, encounters, orders, and diagnoses for each patient from a 12 month observation window prior to the point when a prediction is made were extracted. L1 regularized logistic regression and gradient boosted tree models were fit to training data and tuned by cross validation. Model performance in predicting one year mortality was assessed using held-out test patients. Our experiments systematically varied three factors: model type, diagnosis coding, and data density requirements. We found substantial, consistent benefit from using gradient boosting vs logistic regression (mean AUROC over all other technical choices of 84.8% vs 80.7% respectively). There was no benefit from aggregation of ICD codes into CCS code groups (mean AUROC over all other technical choices of 82.9% vs 82.6% respectively). Likewise increasing data density requirements did not affect discrimination (mean AUROC over other technical choices ranged from 82.5% to 83%). We also examine model performance as a function of lead time, which is the interval between death and when a prediction was made. In subgroup analysis by lead time, mean AUROC over all other choices ranged from 87.9% for patients who died within 0 to 3 months to 83.6% for those who died 9 to 12 months after prediction time.
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Affiliation(s)
| | | | - Nicole Kwon
- Integrated Project Management, San Francisco, CA, USA
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22
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Zwakman M, Jabbarian LJ, van Delden JJM, van der Heide A, Korfage IJ, Pollock K, Rietjens JAC, Seymour J, Kars MC. Advance care planning: A systematic review about experiences of patients with a life-threatening or life-limiting illness. Palliat Med 2018; 32:1305-1321. [PMID: 29956558 PMCID: PMC6088519 DOI: 10.1177/0269216318784474] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Advance care planning is seen as an important strategy to improve end-of-life communication and the quality of life of patients and their relatives. However, the frequency of advance care planning conversations in practice remains low. In-depth understanding of patients' experiences with advance care planning might provide clues to optimise its value to patients and improve implementation. AIM To synthesise and describe the research findings on the experiences with advance care planning of patients with a life-threatening or life-limiting illness. DESIGN A systematic literature review, using an iterative search strategy. A thematic synthesis was conducted and was supported by NVivo 11. DATA SOURCES The search was performed in MEDLINE, Embase, PsycINFO and CINAHL on 7 November 2016. RESULTS Of the 3555 articles found, 20 were included. We identified three themes in patients' experiences with advance care planning. 'Ambivalence' refers to patients simultaneously experiencing benefits from advance care planning as well as unpleasant feelings. 'Readiness' for advance care planning is a necessary prerequisite for taking up its benefits but can also be promoted by the process of advance care planning itself. 'Openness' refers to patients' need to feel comfortable in being open about their preferences for future care towards relevant others. CONCLUSION Although participation in advance care planning can be accompanied by unpleasant feelings, many patients reported benefits of advance care planning as well. This suggests a need for advance care planning to be personalised in a form which is both feasible and relevant at moments suitable for the individual patient.
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Affiliation(s)
- M Zwakman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Marieke Zwakman, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Stratenum 6.131, PO Box 85500, 3508 GA Utrecht, The Netherlands.
| | - LJ Jabbarian
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - JJM van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - IJ Korfage
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - K Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - JAC Rietjens
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J Seymour
- School of Nursing and Midwifery, University of Sheffield, Sheffield, UK
| | - MC Kars
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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23
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Slyer JT, Archibald E, Moyo F, Truglio-Londrigan M. Advance care planning and anticipatory decision making in patients with Alzheimer disease. Nurse Pract 2018; 43:23-31. [PMID: 29757832 DOI: 10.1097/01.npr.0000532763.68509.e4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Early advance care planning and anticipatory decision making in the Alzheimer disease (AD) trajectory is a strategy NPs can incorporate to improve managing uncertainty around common decisions. This article explores decisions patients and caregivers face along the AD trajectory and provides resources for patients, caregivers, and NPs.
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Affiliation(s)
- Jason T Slyer
- Jason T. Slyer is a clinical assistant professor at Pace University, College of Health Professions, New York, N.Y., and an NP at Matrix Medical Network, New York, N.Y. Ella Archibald is a family NP at Hospital for Special Surgery, New York, N.Y. Fernea Moyo is an NP at New York Presbyterian Hospital, New York, N.Y. Marie Truglio-Londrigan is a professor at Pace University College of Health Professions, Lienhard School of Nursing, New York, N.Y
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Dixon J, Knapp M. Whose job? The staffing of advance care planning support in twelve international healthcare organizations: a qualitative interview study. BMC Palliat Care 2018; 17:78. [PMID: 29793469 PMCID: PMC5967099 DOI: 10.1186/s12904-018-0333-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 05/16/2018] [Indexed: 11/10/2022] Open
Abstract
Background ACP involving a facilitated conversation with a health or care professional is more effective than document completion alone. In policy, there is an expectation that health and care professionals will provide ACP support, commonly within their existing roles. However, the potential contributions of different professionals are outlined only broadly in policy and guidance. Research on opportunities and barriers for involving different professionals in providing ACP support, and feasible models for doing so, is currently lacking. Methods We identified twelve healthcare organizations aiming to offer system-wide ACP support in the United States, Canada, Australia and New Zealand. In each, we conducted an average 13 in-depth interviews with senior managers, ACP leads, dedicated ACP facilitators, physicians, nurses, social workers and other clinical and non-clinical staff. Interviews were analyzed thematically using NVivo software. Results Organizations emphasized leadership for ACP support, including strategic support from senior managers and intensive day-to-day support from ACP leads, to support staff to deliver ACP support within their existing roles. Over-reliance on dedicated facilitators was not considered sustainable or scalable. We found many professionals, from all backgrounds, providing ACP support. However, there remained barriers, particularly for facilitating ACP conversations. A significant barrier for all professionals was lack of time. Physicians sometimes had poor communication skills, misunderstood medico-legal aspects and tended to have conversations of limited scope late in the disease trajectory. However, they could also have concerns about the appropriateness of ACP conversations conducted by others. Social workers had good facilitation skills and understood legal aspects but needed more clinical support than nurses. While ACP support provided alongside and as part of other care was common, ACP conversations in this context could easily get squeezed out or become fragmented. Referrals to other professionals could be insecure. Team-based models involving a physician and a nurse or social worker were considered cost-effective and supportive of good quality care but could require some additional resource. Conclusions Effective staffing of ACP support is likely to require intensive local leadership, attention to physician concerns while avoiding an entirely physician-led approach, some additional resource and team-based frameworks, including in evolving models of care for chronic illness and end of life.
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Affiliation(s)
- Josie Dixon
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), Houghton Street, London, WC2A 2AE, UK.
| | - Martin Knapp
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), Houghton Street, London, WC2A 2AE, UK
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Fleming J, Calloway R, Perrels A, Farquhar M, Barclay S, Brayne C. Dying comfortably in very old age with or without dementia in different care settings - a representative "older old" population study. BMC Geriatr 2017; 17:222. [PMID: 28978301 PMCID: PMC5628473 DOI: 10.1186/s12877-017-0605-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 09/01/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Comfort is frequently ranked important for a good death. Although rising numbers of people are dying in very old age, many with dementia, little is known about symptom control for "older old" people or whether care in different settings enables them to die comfortably. This study aims to examine, in a population-representative sample, associations between factors potentially related to reported comfort during very old people's final illness: physical and cognitive disability, place of care and transitions in their final illness, and place of death. METHODS Retrospective analyses linked three data sources for n = 180 deceased study participants (68% women) aged 79-107 in a representative population-based UK study, the Cambridge City over-75s Cohort (CC75C): i) prospective in-vivo dementia diagnoses and cognitive assessments, ii) certified place of death records, iii) data from interviews with relatives/close carers including symptoms and "How comfortable was he/she in his/her final illness?" RESULTS In the last year of life 83% were disabled in basic activities, 37% had moderate/severe dementia and 45% minimal/mild dementia or cognitive impairment. Regardless of dementia/cognitive status, three-quarters died following a final illness lasting a week or longer. 37%, 44%, 13% and 7% of the deceased were described as having been "very comfortable", "comfortable", "fairly comfortable" or "uncomfortable" respectively during their final illness, but reported symptoms were common: distress, pain, depression and delirium or confusion each affected 40-50%. For only 10% were no symptoms reported. There were ≥4-fold increased odds of dying comfortably associated with being in a care home during the final illness, dying in a care home, and with staying in place (dying at what death certificates record as "usual address"), whether home or care home, compared with hospital, but no significant association with disability or dementia/cognitive status, regardless of adjustment. CONCLUSIONS These findings are consistent with reports that care homes can provide care akin to hospice for the very old and support an approach of supporting residents to stay in their care home or own home if possible. Findings on reported high prevalence of multiple symptoms can inform policy and training to improve older old people's end-of-life care in all settings.
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Affiliation(s)
- Jane Fleming
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| | - Rowan Calloway
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- North East Thames Foundation School, London, UK
| | - Anouk Perrels
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Faculty of Medicine, Vrije Universiteit, Amsterdam, Netherlands
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Stephen Barclay
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
- Primary Care Unit, Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
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Lazenby S, Edwards A, Samuriwo R, Riley S, Murray MA, Carson‐Stevens A. End-of-life care decisions for haemodialysis patients - 'We only tend to have that discussion with them when they start deteriorating'. Health Expect 2017; 20:260-273. [PMID: 26968338 PMCID: PMC5354044 DOI: 10.1111/hex.12454] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2016] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Haemodialysis patients receive very little involvement in their end-of-life care decisions. Issues relating to death and dying are commonly avoided until late in their illness. This study aimed to explore the experiences and perceptions of doctors and nurses in nephrology for involving haemodialysis patients in end-of-life care decisions. METHODS A semi-structured qualitative interview study with 15 doctors and five nurses and thematic analysis of their accounts was conducted. The setting was a large teaching hospital in Wales, UK. RESULTS Prognosis is not routinely discussed with patients, in part due to a difficulty in estimation and the belief that patients do not want or need this information. Advance care planning is rarely carried out, and end-of-life care discussions are seldom initiated prior to patient deterioration. There is variability in end-of-life practices amongst nephrologists; some patients are felt to be withdrawn from dialysis too late. Furthermore, the possibility and implications of withdrawal are not commonly discussed with well patients. Critical barriers hindering better end-of-life care involvement for these patients are outlined. CONCLUSIONS The study provides insights into the complexity of end-of-life conversations and the barriers to achieving better end-of-life communication practices. The results identify opportunities for improving the lives and deaths of haemodialysis patients.
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Affiliation(s)
- Sophia Lazenby
- Primary Care Patient Safety (PISA) Research GroupDivision of Population MedicineSchool of MedicineCardiff UniversityCardiffWalesUK
| | - Adrian Edwards
- Division of Population MedicineSchool of MedicineCardiff UniversityCardiffWalesUK
- Primary and Emergency Care Research (PRIME) Centre WalesCardiff UniversityCardiffWalesUK
| | - Raymond Samuriwo
- School of Healthcare SciencesCardiff UniversityCardiffWalesUK
- Cardiff Institute for Tissue Engineering and RepairCardiff UniversityCardiffWalesUK
- School of HealthcareUniversity of LeedsLeedsUK
| | | | - Mary Ann Murray
- Nursing Palliative Research and Education UnitFaculty of Health SciencesUniversity of OttawaOttawaONCanada
| | - Andrew Carson‐Stevens
- Primary and Emergency Care Research (PRIME) Centre WalesCardiff UniversityCardiffWalesUK
- Department of Family PracticeUniversity of British ColumbiaVancouverBCCanada
- Institute of Healthcare Policy and PracticeUniversity of the West of ScotlandPaisleyScotland
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