The Role of Advance Care Planning in Cancer Patient and Caregiver Grief Resolution: Helpful or Harmful?

Acceptability and usability of the Planning Advance Care Together (PACT) website for improving patients' engagement in advance care planning

Objectives

Most prior advance care planning (ACP) interventions lack integration of the social context of patients' ACP process, which patients indicate is critically important. The current study developed the Planning Advance Care Together (PACT) website to foster inclusion of loved ones in the ACP process.

Methods

To provide feedback about the PACT website, patients with advanced cancer (N = 11), their caregivers (N = 11), and experts (N = 10) participated in semi-structured interviews. Patients and caregivers also completed standardized ratings of acceptability and usability.

Results

Overall, patient (n = 11) and caregiver (n = 11) ratings of acceptability and usability of the website exceeded benchmark cut-offs (≥24 on the Acceptability E-Scale and ≥ 68 on the System Usability Scale). Patients, caregivers, and experts liked the topic of ACP but felt that it could be emotionally challenging. They recommended focusing more on planning and less on end of life. They appreciated being able to include loved ones and recommended adding resources for caregivers.

Conclusions

Study findings support the preliminary usability and acceptability of the PACT website. Findings will be used to inform a modified prototype of the PACT website that is interactive and ready for field testing with patients with advanced cancer and their loved ones.

Innovation

We utilized a novel application of the shared mind framework to support patients with advanced cancer in engaging their loved ones in the ACP process.

Development and refinement of a novel end-of-life planning website for patients with advanced cancer: a mixed methods approach

PURPOSE

Despite known benefits of planning for end-of-life, no digital tool exists to help patients with advanced cancer and their loved ones plan for death comprehensively. To address this unmet need, we developed a preliminary version of an innovative website to help patients with advanced cancer prepare for end-of-life tasks.

METHODS

Guided by the Obesity-Related Behavioral Intervention Trials (ORBIT) model for behavioral intervention development, patients with advanced cancer (n = 10) and their caregivers (n = 10) participated in a "Think Aloud" exercise and usability protocols to optimize the end-of-life planning website. The website was iteratively refined throughout the study in collaboration with the partnering company, Peacefully, Inc. Participants also completed the Acceptability E-Scale and System Usability Scale, with a priori benchmarks established for acceptability (scores of ≥ 24 on the Acceptability E-Scale) and usability (scores of ≥ 68 on the System Usability Scale).

RESULTS

Patients (N = 10) and caregivers (N = 10) completed usability testing. Patients were majority female (80%), White (100%), and had a mean age of 58 years. Caregivers (N = 10) were majority male (60%), spouse/partner (90%), White (90%), and had a mean age of 59 years. For patients, a priori hypotheses were met for both acceptability (mean score of 24.7, SD = 4.35) and usability (mean score of 73.8, SD = 6.15). For caregivers, acceptability was just below the cutoff (mean score of 22.9, SD = 4.07) and usability exceeded the cutoff (mean score of 70.0, SD = 8.42). Overall, patients and caregivers reported high levels of satisfaction and found the website helpful, with specific suggestions for changes (e.g., add more information about information security, improve text legibility).

CONCLUSIONS

The findings from this study will inform modifications to optimize an innovative website to support patients with advanced cancer to prepare holistically for end-of-life tasks.

Advance Care Planning conversations: What constitutes best practice and the way forward: Advance Care Planning-Gespräche: Was Best Practice ausmacht und wie es weitergehen kann

BACKGROUND

Advance Care Planning (ACP) conversations are a cornerstone of modern health care and need to be supported. However, research indicates that the uptake thereof is limited, regardless of various campaigns. ACP conversations are complex and specific elements thereof should be discussed at various timepoints during the illness trajectory.

OBJECTIVE

This narrative review delineates what ACP conversation should entail, and a way forward.

METHODS

A PEO (Population, Exposure, Outcome) search was performed using relevant keywords, and 615 articles were identified. Through screening and coding, this number was reduced to 24 articles. All the authors were involved in the final selection of the articles.

RESULTS

Various themes developed throughout the review which include timing early on in the disease trajectory; incorporating beliefs and culturally relevant contexts; conversations needing to be iterative and short; involving surrogates and family; applying various media formats.

DISCUSSION

ACP conversations are relevant. ACP is not static and needs to be dynamic as patients' illness trajectories and goals change. The care team needs to guard themselves against having ACP conversations to satisfy a metric and should instead be guided by the patient's expressed values and wishes. A system-wide operational plan will help alleviate common barriers in having appropriate ACP conversations.

Advance care planning in oncology: a scoping review and some recommendations

PURPOSE OF REVIEW

Cancer patients' communication with their relatives and healthcare professionals (HCPs) is essential for advance care planning (ACP). The purpose of this scoping review was to synthesize recent research findings about factors enabling cancer patients', their relatives', and physicians' communication about ACP, and to propose recommendations for future ACP implementation in cancer care.

RECENT FINDINGS

This review confirmed the importance of aspects of the cancer care context (i.e., culture) as ACP uptake-predisposing and -enabling factors. It highlighted the difficulty of determining who should initiate ACP discussion, with which patients and at what time-points. It also highlighted a lack of consideration for socioemotional processes in the study of ACP uptake despite evidence that cancer patients', relatives' and physicians' discomforts that arise from communication about end-of-life and the wish to safeguard each other are main obstacles to ACP implementation.

SUMMARY

Based on these recent findings, we propose an ACP communication model, developed with the consideration of factors reported to influence ACP uptake and communication in healthcare, and integrating socioemotional processes. The testing of the model may yield suggestions for innovative interventions that can support communication about ACP and promote a better uptake in clinical practice.

Advance Care Planning and Health-Related Quality of Life in Huntington Disease: Results from a Multicenter National Study

Objective:

With Huntington disease (HD), a fatal neurodegenerative disease where the prevalence of suicidal thoughts and behavior (STB) remains elevated as compared to other neurological disorders, it is unknown whether STB and health-related quality of life (HRQoL) affect plans for the end of life or more broadly, advance care planning (ACP). Conversely, it is unknown whether ACP would provoke future changes to STB and HRQoL. Therefore, we sought to evaluate whether STB and HRQoL patient-reported outcomes (PROs) contribute to ACP and whether ACP relates to changes in STB and HRQoL at 24 months.

Methods:

HD-validated clinician- and patient-assessments (i.e., HRQoL PROs) were obtained at baseline enrollment, 12 and 24 months through our multi-center study (HDQLIFE™) throughout the United States among people with premanifest, early-stage, and late-stage manifest HD. We used linear mixed-effects models to determine the relationships between STB and HRQoL at baseline and HDQLIFE End of Life Planning at follow-up. Separate linear mixed-effects models were used to assess the relationship between HDQLIFE End of Life Planning at baseline, and HRQoL and STB at 12 and 24 months. False discovery rate adjustments were used to account for multiple comparisons.

Results:

At baseline enrollment, STB and HRQoL were not related to HDQLIFE End of Life Planning at 12 or 24 months. Similarly, at baseline, HDQLIFE End of Life Planning demonstrated no association with STB or HRQoL at 12 or 24 months.

Interpretation:

STB and HRQoL PROs do not significantly affect patient engagement with ACP. Most importantly, engaging in ACP does not cause untoward effects on HRQoL or STB for this rare neurodegenerative disease where the lifetime prevalence of STB approaches 30%.

When Social Work Client Self-Determination Principle Meets Confucius Culture: A Living Will Decision-Making Case Study in China

Background. In western countries like the United States of America, living will is seen as a vehicle for achieving greater wisdom and skill in a fundamental aspect of health care and a civilized approach to mortality. However, the inception of living will in China emerged only a decade ago. Although, nowadays, Chinese medical social workers can provide living will service in health settings, their services are in a preliminary status. Objective. This exploratory case study aims to present an ethical dilemma and analyzes the reasons the social work client self-determination principle failed in living will decision-making in the oncology ward that has Confucius as a cultural context. Results. This case illustrates that the patient's family has the final say in living will decision-making. The social work principle of client self-determination exemplifies the difficulties of applying medical social work practices with living will to Chinese patients in hospital wards. Conclusions. Chinese patients and their families are still bound to Confucianism's long tradition. In China, individuals are still being defined by relationships, and the "self" exists only in a hierarchical interpersonal network known as the differential pattern. The Chinese people do not like to talk about death. Even in modern society, it will take time for the Chinese people to come to terms with the end-of-life planning with living will, mainly for cancer patients after diagnosis. Practice Implications. Future social work practices that implied living will similar to this case that has Confucius culture in the background should consider the cultural context where the social worker-client are situated and the types of social work values the profession hold.

“I wanna live and not think about the future” what place for advance care planning for people living with severe multiple sclerosis and their families? A qualitative study

Background

Little is known about how people with multiple sclerosis (MS) and their families comprehend advance care planning (ACP) and its relevance in their lives.

Aim

To explore under what situations, with whom, how, and why do people with MS and their families engage in ACP.

Methods

We conducted a qualitative study comprising interviews with people living with MS and their families followed by an ethical discussion group with five health professionals representing specialties working with people affected by MS and their families. Twenty-seven people with MS and 17 family members were interviewed between June 2019 and March 2020. Interviews and the ethical discussion group were audio-recorded and transcribed verbatim. Data were analysed using the framework approach.

Results

Participants’ narratives focused on three major themes: (i) planning for an uncertain future; (ii) perceived obstacles to engaging in ACP that included uncertainty concerning MS disease progression, negative previous experiences of ACP discussions and prioritising symptom management over future planning; (iii) Preferences for engagement in ACP included a trusting relationship with a health professional and that information then be shared across services. Health professionals’ accounts from the ethical discussion group departed from viewing ACP as a formal document to that of an ongoing process of seeking preferences and values. They voiced similar concerns to people with MS about uncertainty and when to initiate ACP-related discussions. Some shared concerns of their lack of confidence when having these discussions.

Conclusion

These findings support the need for a whole system strategic approach where information about the potential benefits of ACP in all its forms can be shared with people with MS. Moreover, they highlight the need for health professionals to be skilled and trained in engaging in ACP discussions and where information is contemporaneously and seamlessly shared across services.