Never the right time: advance care planning with frail and older people

The COVID-19 pandemic: A tipping point for advance care planning? Experiences of general practitioners

BACKGROUND

In 2020, the COVID-19 pandemic caused an acute risk of deterioration and dying for many, and an urgent need to start advance care planning.

AIM

To explore how general practitioners (GPs) experienced discussing values, goals and preferences with patients during COVID-19.

DESIGN AND SETTING

Qualitative research in general practice.

METHODS

Semi-structured interviews for which Dutch GPs were recruited via purposive sampling. Content analysis was used.

RESULTS

Fifteen GPs were interviewed. Six themes were identified: (i) urge of advance care planning, (ii) the GP's perceived role in it, (iii) preparations for it, (iv) (proactively) discussing it, (v) essentials for good communication and (vi) advance care planning in the (near) future. Calls for proactively discussing advance care planning in the media and in COVID-guidelines caused awareness of it's importance. GPs envisaged an important role for themselves in initiating it, especially with patients at risk to deteriorate or die from COVID-19. Timing advance care planning appeared difficult but crucial. The recommended digital way of communication was considered problematic due to missing nonverbal communication and difficulties in involving relatives. It was noted that admission to the ICU, which was hardly discussed before the COVID-19 pandemic, should remain a topic during advance care planning.

CONCLUSION

The COVID-19 pandemic brought advance care planning into a new light, GPs were more experienced with discussing it and patients were more aware of their frailty. Because of the nearing 'grey wave', advance care planning should remain top priority. Therefore, it should be central in GP and post-academic training.

Implementing advance care planning with community-dwelling frail elders requires a system-wide approach: An integrative review applying a behaviour change model

BACKGROUND

Facilitating advance care planning with community-dwelling frail elders can be challenging. Notably, frail elders' vulnerability to sudden deterioration leads to uncertainty in recognising the timing and focus of advance care planning conversations.

AIM

To understand how advance care planning can be better implemented for community-dwelling frail elders and to develop a conceptual model to underpin intervention development.

DESIGN

A structured integrative review of relevant literature.

DATA SOURCES

CINAHL, Embase, Ovid Medline, PsycINFO, Cochrane Library, and University of York Centre for Reviews and Dissemination. Further strategies included searching for policy and clinical documents, grey literature, and hand-searching reference lists. Literature was searched from 1990 until October 2018.

RESULTS

From 3043 potential papers, 42 were included. Twenty-nine were empirical, six expert commentaries, four service improvements, two guidelines and one theoretical. Analysis revealed nine themes: education and training, personal ability, models, recognising triggers, resources, conversations on death and dying, living day to day, personal beliefs and experience, and relationality.

CONCLUSION

Implementing advance care planning for frail elders requires a system-wide approach, including providing relevant resources and clarifying responsibilities. Early engagement is key for frail elders, as is a shift from the current advance care planning model focussed on future ceilings of care to one that promotes living well now alongside planning for the future. The proposed conceptual model can be used as a starting point for professionals, organisations and policymakers looking to improve advance care planning for frail elders.

Involvement of Japanese Care Managers and Social Workers in Advance Care Planning

Successful advance care planning relies heavily on effective communication between the elderly and their families, care managers, and social workers. However, care managers and social workers are often not adequately prepared to conduct such discussion. The aim of the present study was to identify the specific challenges facing Japanese care managers and social workers when involvement in advance care planning. Two focus group discussions were held between August and November 2017, involving eleven care managers and three social workers employed at two long-term care facilities actively pursuing advance care planning initiatives. Four main themes were identified, through content analysis, as barriers and facilitators: client readiness, communication, variation-rich client individuality, and difficult-to-explain end-of-life options. This study revealed the importance of building rapport with the residents and their families in order to assess their readiness to discuss care options and preferences. Obstacles included lack of medical knowledge of care managers and social workers. Study findings suggested that a multi-disciplinary team, facilitated by care managers and social workers, was fundamental to achieving the goals of advance care planning.

Frailty trajectories to identify end of life: a longitudinal population-based study

BACKGROUND

Timely recognition of the end of life allows patients to discuss preferences and make advance plans, and clinicians to introduce appropriate care. We examined changes in frailty over 1 year, with the aim of identifying trajectories that could indicate where an individual is at increased risk of all-cause mortality and may require palliative care.

METHODS

Electronic health records from 13,149 adults (cases) age 75 and over who died during a 1-year period (1 January 2015 to 1 January 2016) were age, sex and general practice matched to 13,149 individuals with no record of death over the same period (controls). Monthly frailty scores were obtained for 1 year prior to death for cases, and from 1 January 2015 to 1 January 2016 for controls using the electronic frailty index (eFI; a cumulative deficit measure of frailty, available in most English primary care electronic health records, and ranging in value from 0 to 1). Latent growth mixture models were used to investigate longitudinal patterns of change and associated impact on mortality. Cases were reweighted to the population level for tests of diagnostic accuracy.

RESULTS

Three distinct frailty trajectories were identified. Rapidly rising frailty (initial increase of 0.022 eFI per month before slowing from a baseline eFI of 0.21) was associated with a 180% increase in mortality (OR 2.84, 95% CI 2.34-3.45) for 2.2% of the sample. Moderately increasing frailty (eFI increase of 0.007 per month, with baseline of 0.26) was associated with a 65% increase in mortality (OR 1.65, 95% CI 1.54-1.76) for 21.2% of the sample. The largest (76.6%) class was stable frailty (eFI increase of 0.001 from a baseline of 0.26). When cases were reweighted to population level, rapidly rising frailty had 99.1% specificity and 3.2% sensitivity (positive predictive value 19.8%, negative predictive value 93.3%) for predicting individual risk of mortality.

CONCLUSIONS

People aged over 75 with frailty who are at highest risk of death have a distinctive frailty trajectory in the last 12 months of life, with a rapid initial rise from a low baseline, followed by a plateau. Routine measurement of frailty can be useful to support clinicians to identify people with frailty who are potential candidates for palliative care, and allow time for intervention.

Evaluating frailty scores to predict mortality in older adults using data from population based electronic health records: case control study

BACKGROUND

recognising that a patient is nearing the end of life is essential, to enable professional carers to discuss prognosis and preferences for end of life care.

OBJECTIVE

investigate whether an electronic frailty index (eFI) generated from routinely collected data, can be used to predict mortality at an individual level.

DESIGN

historical prospective case control study.

SETTING

UK primary care electronic health records.

SUBJECTS

13,149 individuals age 75 and over who died between 01/01/2015 and 01/01/2016, 1:1 matched by age and sex to individuals with no record of death in the same time period.

METHODS

two subsamples were randomly selected to enable development and validation of the association between eFI 3 months prior to death and mortality. Receiver operator characteristic (ROC) analyses were used to examine diagnostic accuracy of eFI at 3 months prior to death.

RESULTS

an eFI > 0.19 predicted mortality in the development sample at 75% sensitivity and 69% area under received operating curve (AUC). In the validation dataset this cut point gave 76% sensitivity, 53% specificity.

CONCLUSIONS

the eFI measured at a single time point has low predictive value for individual risk of death, even 3 months prior to death. Although the eFI is a strong predictor or mortality at a population level, its use for individuals is far less clear.

The frailest of the frail? Addressing the palliative care needs of frail older patients

Managing patients with frailty is an increasing element of acute hospital care, constituting around 40% of acute hospital inpatients. Up to half of these patients may be approaching the end of their life, and many also have repeated hospital admissions. We therefore undertook a quality improvement project to help us identify the prevalence of frail older inpatients approaching end of life and to better identify these patients in advance. We also developed and evaluated a pro forma to assist in initiating an advance care planning conversation with the patient and/or family. Fifty percent of our frail older inpatients were assessed as approaching end of life. Factors identifying older inpatients as more likely to die during the hospital admission included residence in a care home, two or more hospital admissions over the preceding 12 months, and a diagnosis of some form of dementia for more than 3 years. A novel goals and priorities of care (GPOC) document was found to support and guide palliative care conversations. Acute hospital care could be organised more effectively to recognise the potential need for palliative care in frail older patients. Identifying those at higher risk and using structured interviews and documentation is helpful, ultimately resulting in more appropriate care. Well-developed communication skills are needed for these complex care planning conversations.

[Healthcare preferences of the very elderly: A review]

The preferences of the very elderly are not taken into account in healthcare planning. For this reason, a medical literature review was performed in order to fill the gap in appropriate information on this issue. The majority of them think that they receive good healthcare. They favour building a trusting relationship, with the physician handling their decision-making. They also maximise their quality of life at the expense of quantity, and give great importance to comfort and safety. Most of them express the wish to be cared for and die at home. But when an acute event occurs, they want to be transferred to hospital. More explicit communication must be encouraged between very elderly patients, providers, and families to meet their subjective needs, through on-going discussions, focused on expected outcomes and patient care goals. A healthcare system designed to look after them should be based on individual and flexible care, with coordination between healthcare services. Such a healthcare system could enable a growing number of them to die in their preferred conditions.