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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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Hart M, Stepita R, Berall A, Sokolowski M, Karuza J, Katz P. Development of an Advance Care Planning Policy within an Evidenced-Based Evaluation Framework. Am J Hosp Palliat Care 2022; 39:1389-1396. [PMID: 35414245 DOI: 10.1177/10499091221077057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Background: As the population is aging and medical advancements enable people to live longer, advance care planning (ACP) becomes increasingly important in guiding future care decisions; however, they are often incomplete or absent from the patient chart. This study describes the development and implementation of an ACP policy in a post-acute care and long-term care setting using a systematic implementation framework. Methods: A process evaluation that parallels the Replicating Effective Programs (REP) framework was used to understand stakeholder experiences with ACP and identify gaps in practice. Physicians, multidisciplinary staff, patients, and substitute decision makers engaged in focus groups and interviews, and completed surveys. A retrospective chart review determined Plan for Life Sustaining Treatment (PLST) form completion rates. Results: Stakeholder feedback identified barriers and facilitators to ACP including a need for staff training, user-friendly resources, and standardization of ACP practice. The PLST form was developed and embedded in the electronic medical record, and had a 92% and an 87% PLST completion rate on 2 pilot units. Conclusion: The study showed the usefulness of the REP model in guiding the evaluation as an effective tool to enhance implementation practices and inform ACP policy development that can be replicated in other organizations.
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Affiliation(s)
| | | | - Anna Berall
- 7942Baycrest Health Sciences, Toronto, ONCanada
| | | | - Jurgis Karuza
- Department of Psychology, 12292Buffalo State University, Buffalo, NY, USA
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University
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Gaugler JE, Mitchell LL. Reimagining Family Involvement in Residential Long-Term Care. J Am Med Dir Assoc 2022; 23:235-240. [PMID: 34973167 PMCID: PMC8821144 DOI: 10.1016/j.jamda.2021.12.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 02/03/2023]
Abstract
Although descriptions of family involvement in residential long-term care (RLTC) are available in the scientific literature, how family involvement is optimized in nursing homes or assisted living settings remains underexplored. During the facility lockdowns and visitor restrictions of the COVID-19 pandemic, residents experienced social deprivation that may have resulted in significant and adverse health outcomes. As with so many other critical issues in RLTC, the COVID-19 pandemic has magnified the need to determine how families can remain most effectively involved in the lives of residents. This article seeks to better understand the state of the science of family involvement in RTLC and how the COVID-19 pandemic has expedited the need to revisit, and reimagine, family involvement in RLTC.
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Affiliation(s)
- Joseph E. Gaugler
- Division of Health Policy and Management, School of Public Health, University of Minnesota Twin Cities, Minneapolis, MN, USA
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Bp V, Mt W, Ee T. A Collaborative educational intervention to improve pre-clinical medical student confidence with Advance Care Planning (ACP). GERONTOLOGY & GERIATRICS EDUCATION 2021; 42:71-81. [PMID: 31056041 DOI: 10.1080/02701960.2019.1611570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Advance care planning (ACP) is an essential skill for clinicians, yet trainees feel inadequately prepared to conduct ACP discussions. Optimal teaching methods and timing are unknown. AIM We designed a curricular intervention to expose second-year medical students to the process of ACP, aiming to improve their ACP knowledge and confidence. DESIGN The intervention consisted of a case-based workshop facilitated by a physician experienced in ACP ("facilitated ACP workshop"), which was added to an existing multifaceted ACP curriculum (longitudinal senior mentor program including multiple visits with a volunteer older adult, completion of an electronic ACP learning module and reflective writing exercise). The control group received the existing ACP curriculum only, while the intervention group received the existing curriculum plus the facilitated ACP workshop. Both groups completed an ACP knowledge assessment and confidence survey at the conclusion of the curriculum. SETTING/PARTICIPANTS Two consecutive classes of second year medical students, single academic hospital. RESULTS No statistically significant differences in ACP knowledge or confidence were seen post-intervention. Overall confidence with ACP tasks remained relatively low despite a multifaceted ACP curriculum. CONCLUSIONS Future studies should investigate longitudinal, experiential ACP learning, and seek to optimize ACP teaching strategies and timing.
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Affiliation(s)
- Verdoorn Bp
- Division of Community Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Wingo Mt
- Division of Community Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Tung Ee
- Division of Community Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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A Multicenter Study to Identify Clinician Barriers to Participating in Goals of Care Discussions in Long-Term Care. J Am Med Dir Assoc 2019; 21:647-652. [PMID: 31672570 DOI: 10.1016/j.jamda.2019.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Long-term care (LTC) is an important setting for goals of care (GoC) discussions. Understanding clinician barriers to GoC discussions could identify opportunities for LTC-specific interventions to improve quantity and quality of GoC discussions in the context of serious illness. DESIGN A multicenter, cross-sectional survey study. SETTING AND PARTICIPANTS 1184 LTC clinicians from 34 Ontario LTC homes were invited to participate. MEASURES The questionnaire assessed (1) clinician barriers related to the LTC resident power of attorney (POA), the health care provider, and the health care system; (2) willingness to engage in GoC discussions; and (3) suggestions to address identified barriers. Responses were rated on a 7-point scale (1 = extremely unimportant/unwilling, 7 = extremely important/willing). A linear mixed-effects model determined significance between mean importance ratings for each barrier and the willingness to engage in GoC discussion between physicians and nurses. A simple content analysis was performed on written suggestions to address GoC discussion barriers. RESULTS The overall response rate was 49% (581/1184). The top 3 rated barriers were (1) POA's difficulty accepting their loved one's poor prognosis, (2) POA's difficulty understanding the limitations and complications of life-sustaining therapies, and (3) lack of adequate documentation of prior discussions with LTC resident or POA. Barriers related to the health care provider, and the health care system, were deemed statistically more important by nurses. LTC physicians were more willing to exchange information, be a decision coach, and participate in the final decision than nurses. Suggestions to improve GoC discussions include a dedicated team to have these conversations in LTC, and updating policies to mandate and standardize these conversations at all family meetings. CONCLUSIONS AND IMPLICATIONS This study has identified key LTC clinician-identified barriers to GoC discussions. Developing targeted interventions to these barriers could be the foundation for developing new interventions that support high-quality GoC discussions.
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CE: Original Research: Advance Care Planning: An Exploration of the Beliefs, Self-Efficacy, Education, and Practices of RNs and LPNs. Am J Nurs 2019; 118:26-32. [PMID: 30418182 DOI: 10.1097/01.naj.0000549664.43827.ce] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Objective: This study compared the advance care planning (ACP)-related beliefs, sense of self-efficacy, education, and practices of RNs and LPNs. METHODS Data were extrapolated from a larger multisite study that was conducted across seven counties in one midwestern state. The sample consisted of RNs and LPNs working in 29 urban skilled nursing facilities in zip code areas with greater than 10% African American residents. The survey tool, a self-administered written questionnaire, gathered data on participants' demographics and ACP-related beliefs, sense of self-efficacy, education, and practices. The two main outcome variables were the percentage of residents with whom a nurse discussed ACP and the timing of the most recent such discussion. RESULTS A total of 136 RNs and 178 LPNs completed the survey. Multivariate mixed-model analysis of the two main outcome variables showed that negative beliefs were not significantly associated with the percentage of residents with whom nurses discussed ACP but were significantly associated with the timing of the most recent ACP discussion. Having higher levels of ACP-related self-efficacy and education were significantly and positively associated with both outcome variables. RNs and LPNs did not differ significantly in their ACP-related beliefs, but RNs reported significantly higher levels of self-efficacy and education than LPNs did. CONCLUSIONS There has been a paucity of research comparing RNs and LPNs regarding their ACP practices in skilled nursing facilities. Better education and policies that empower nurses to take a more active role are critical to increasing conversations about ACP. Further research exploring how the complementary roles of RNs and LPNs can be used to improve ACP processes and inform ACP policies is needed.
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Lemon C, De Ridder M, Khadra M. Do Electronic Medical Records Improve Advance Directive Documentation? A Systematic Review. Am J Hosp Palliat Care 2018; 36:255-263. [PMID: 30165755 DOI: 10.1177/1049909118796191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Documentation rates of advance directives (ADs) remain low. Using electronic medical records (EMRs) could help, but a synthesis of evidence is currently lacking. OBJECTIVES To evaluate the evidence for using EMRs in documenting ADs and its implications for overcoming challenges associated with their use. DESIGN Systematic review of articles in English, published from inception of databases to December 2017. DATA SOURCES PubMed, PsycINFO, EMBASE, and CINAHL. METHODS/MEASUREMENTS Four databases were searched from inception to December 2017. Randomized and nonrandomized quantitative studies examining the effects of EMRs on creation, storage, or use of ADs were included. All featured an advance care planning process. Evidence was evaluated using the Cochrane Collaboration's risk assessment tool. RESULTS Fifteen studies were included: 1 randomized controlled trial, 1 randomized pilot, 4 pre-post studies, 4 cross-sectional studies, 1 retrospective cohort study, 1 historical control study, 1 retrospective observational study, 1 retrospective review, and 1 evaluation of an EMR feature. Seven studies showed that EMR-based reminders, AD templates, and decision aids can improve AD documentation rates. Three demonstrated that EMR search functions, decision aids, and automatic identification software can help identify patients who have or need ADs according to certain criteria. Five showed EMRs can create documentation challenges, including locating ADs, and making some patients more likely than others to have an AD. Most studies had an unclear or high risk of bias. CONCLUSIONS Limited evidence suggests EMRs could be used to help address AD documentation challenges but may also create additional problems. Stronger evidence is needed to more conclusively determine how EMR may assist in population approaches to improving AD documentation.
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Affiliation(s)
- Christopher Lemon
- University of Notre Dame Australia, Sydney, School of Medicine, Sydney, NSW, Australia
| | - Michael De Ridder
- Institute of Biomedical Engineering and Technology (BMET), The University of Sydney, Australia.,Nepean Telehealth Technology Centre, Sydney Medical School Nepean, The University of Sydney, Australia
| | - Mohamed Khadra
- Nepean Telehealth Technology Centre, Sydney Medical School Nepean, The University of Sydney, Australia.,Discipline of Surgery, Sydney Medical School Nepean, The University of Sydney, Australia
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Aultman J, Baughman KR, Ludwick R. A broader understanding of care managers' attitudes of advance care planning: A concurrent nested design. J Clin Nurs 2018; 27:3572-3582. [PMID: 29775994 DOI: 10.1111/jocn.14531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2018] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To examine barriers of advance care planning (ACP) experienced by care managers (CMs) through a mixed methods approach. A concurrent nested design was used to acquire a deeper understanding of ACP and to identify nuances between quantitative and qualitative data. BACKGROUND Past quantitative studies on providers have identified barriers related to time, culture, knowledge, responsibility and availability of legal documents. These barriers, and accompanying attitudes and feelings, have been taken at face value without rich qualitative data to identify under what conditions and to what extent a barrier impacts care. DESIGN A two-part multisite, mixed methods study was conducted using surveys and focus groups. METHODS Surveys were completed by 458 CMs at 10 Area Agencies on Aging and 62 participated in one of eight focus groups. Data were analysed using a concurrent nested design with individual data analysis and a merged data approach. RESULTS There were three main distinctions between the quantitative and qualitative data. First, while CMs reported on the survey that ACP was not too time consuming, focus group data revealed that time was an issue especially related to competing priorities. Second on the survey 60% of the CMS reported they had enough knowledge, but qualitative data revealed about more nuances. Last, the reported comfort levels in the quantitative data were less overt in the qualitative date where additional feelings and attitudes were revealed, for example, frustration with families, preferences for more physician involvement. CONCLUSIONS Care managers reported their attitudes about ACP, clarified through a rigorous mixed methods analysis. Care managers can successfully lead ACP discussions, but require further education, resources and team-based guidance. RELEVANCE TO CLINICAL PRACTICE Advance care planning is essential for reducing emotional, social and financial burdens associated with healthcare decision-making, and CMs can positively impact ACP discussions when appropriately supported by the clinical community. The many nuances in the ACP process that we found illustrate the need for ongoing discussions, education and research on this important topic.
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Affiliation(s)
- Julie Aultman
- Family and Community Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Kristin R Baughman
- Family and Community Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Ruth Ludwick
- College of Nursing, Kent State University, Kent, Ohio
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Flo E, Husebo BS, Bruusgaard P, Gjerberg E, Thoresen L, Lillemoen L, Pedersen R. A review of the implementation and research strategies of advance care planning in nursing homes. BMC Geriatr 2016; 16:24. [PMID: 26797091 PMCID: PMC4722739 DOI: 10.1186/s12877-016-0179-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 01/04/2016] [Indexed: 11/29/2022] Open
Abstract
Background Nursing home (NH) patients have complex health problems, disabilities and needs for Advance Care Planning (ACP). The implementation of ACP in NHs is a neglected research topic, yet it may optimize the intervention efficacy, or provide explanations for low efficacy. This scoping review investigates methods, design and outcomes and the implementation of ACP (i.e., themes and guiding questions, setting, facilitators, implementers, and promoters/barriers). Methods A systematic search using ACP MESH terms and keywords was conducted in CINAHL, Medline, PsychINFO, Embase and Cochrane libraries. We excluded studies on home-dwelling and hospital patients, including only specific diagnoses and/or chart-based interventions without conversations. Results Sixteen papers were included. There were large variations in definitions and content of ACP, study design, implementation strategies and outcomes. Often, the ACP intervention or implementation processes were not described in detail. Few studies included patients lacking decision-making capacity, despite the fact that this group is significantly present in most NHs. The chief ACP implementation strategy was education of staff. Among others, ACP improved documentation of and adherence to preferences. Important implementation barriers were non-attending NH physicians, legal challenges and reluctance to participate among personnel and relatives. Conclusion ACP intervention studies in NHs are few and heterogeneous. Variation in ACP definitions may be related to cultural and legal differences. This variation, along with sparse information about procedures, makes it difficult to collate and compare research results. Essential implementation considerations relate to the involvement and education of nurses, physicians and leaders.
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Affiliation(s)
- E Flo
- Centre for Elderly-and Nursing Home Medicine, Department of Global Public Health and Primary Care, University of Bergen, P.O. Box: 7200, Bergen, Norway.
| | - B S Husebo
- Centre for Elderly-and Nursing Home Medicine, Department of Global Public Health and Primary Care, University of Bergen, P.O. Box: 7200, Bergen, Norway.
| | - P Bruusgaard
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - E Gjerberg
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - L Thoresen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - L Lillemoen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - R Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
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Tung EE, Wieland ML, Verdoorn BP, Mauck KF, Post JA, Thomas MR, Bundrick JB, Jaeger TM, Cha SS, Thomas KG. Improved Resident Physician Confidence With Advance Care Planning After an Ambulatory Clinic Intervention. Am J Hosp Palliat Care 2013; 31:275-80. [DOI: 10.1177/1049909113485636] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Many primary care providers feel uncomfortable discussing end-of-life care. The aim of this intervention was to assess internal medicine residents’ advance care planning (ACP) practices and improve residents’ ACP confidence. Residents participated in a facilitated ACP quality improvement workshop, which included an interactive presentation and chart audit of their own patients. Pre- and postintervention surveys assessed resident ACP-related confidence. Only 24% of the audited patients had an advance directive (AD), and 28% of the ACP-documentation was of no clinical utility. Terminally ill patients (odds ratio 2.8, P < .001) were more likely to have an AD. Patients requiring an interpreter were less likely to have participated in ACP. Residents reported significantly improved confidence with ACP and identified important training gaps. Future studies examining the impact on ACP quality are needed.
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Affiliation(s)
- Ericka E. Tung
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark L. Wieland
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brandon P. Verdoorn
- Internal Medicine Residency Program, Mayo Graduate School of Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA
- Hematology and Oncology Fellowship Program, University of Colorado Health Sciences Center, Denver, CO, USA
| | - Karen F. Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jason A. Post
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Matthew R. Thomas
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - John B. Bundrick
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thomas M. Jaeger
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephen S. Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Kris G. Thomas
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Silvester W, Parslow RA, Lewis VJ, Fullam RS, Sjanta R, Jackson L, White V, Hudson R. Development and evaluation of an aged care specific Advance Care Plan. BMJ Support Palliat Care 2013; 3:188-95. [PMID: 23626906 PMCID: PMC3632978 DOI: 10.1136/bmjspcare-2012-000392] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objectives To report on the quality of advance care planning (ACP) documents in use in residential aged care facilities (RACF) in areas of Victoria Australia prior to a systematic intervention; to report on the development and performance of an aged care specific Advance Care Plan template used during the intervention. Design An audit of the quality of pre-existing documentation used to record resident treatment preferences and end-of-life wishes at participating RACFs; development and pilot of an aged care specific Advance Care Plan template; an audit of the completeness and quality of Advance Care Plans completed on the new template during a systematic ACP intervention. Participants and setting 19 selected RACFs (managed by 12 aged care organisations) in metropolitan and regional areas of Victoria. Results Documentation in use at facilities prior to the ACP intervention most commonly recorded preferences regarding hospital transfer, life prolonging treatment and personal/cultural/religious wishes. However, 7 of 12 document sets failed to adequately and clearly specify the resident's preferences as regards life prolonging medical treatment. The newly developed aged care specific Advance Care Plan template was met with approval by participating RACFs. Of 203 Advance Care Plans completed on the template throughout the project period, 49% included the appointment of a Medical Enduring Power of Attorney. Requests concerning medical treatment were specified in almost all completed documents (97%), with 73% nominating the option of refusal of life-prolonging treatment. Over 90% of plans included information concerning residents’ values and beliefs, and future health situations that the resident would find to be unacceptable were specified in 78% of completed plans. Conclusions Standardised procedures and documentation are needed to improve the quality of processes, documents and outcomes of ACP in the residential aged care sector.
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Affiliation(s)
- William Silvester
- Respecting Patient Choices, Austin Health, Heidelberg, Victoria, Australia
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