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Levi BH, Ekpa N, Lin A, Smith CW, Volpe RL. The Experience of Medical Scribing: No Disparities Identified. Adv Med Educ Pract 2024; 15:153-160. [PMID: 38476633 PMCID: PMC10929157 DOI: 10.2147/amep.s439826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/20/2023] [Indexed: 03/14/2024]
Abstract
Introduction The chronic failure to significantly increase the number of underrepresented minorities (URM) in medicine requires that we look for new mechanisms for channelling URM students through pre-medical education and into medical school. One potential mechanism is medical scribing, which involves a person helping a physician engage in real-time documentation in the electronic medical record. Methods As a precursor to evaluating this mechanism, this survey pilot study explored individuals' experiences working as a medical scribe to look for any differences related to URM status. Of 248 scribes, 159 (64% response rate) completed an online survey. The survey was comprised of 11 items: demographics (4 items), role and length of time spent as a scribe (2 items), and experience working as a scribe (5 items). Results The vast majority (>80%) of participants reported that working as a medical scribe gave them useful insight into being a clinician, provided valuable mentoring, and reinforced their commitment to pursue a career in medicine. The experiences reported by scribes who identified as URM did not differ from those reported by their majority counterparts. Discussion It remains to be seen whether medical scribing can serve as an effective pipeline for URM individuals to matriculate into medical school. But the present findings suggest that the experience of working as a medical scribe is a positive one for URM.
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Affiliation(s)
- Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Ndifreke Ekpa
- University of Houston, HCA Houston Healthcare Kingwood, Houston, TX, USA
| | - Andrea Lin
- Penn State College of Medicine, Hershey, PA, USA
| | | | - Rebecca L Volpe
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
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Levi BH, Dimmock AEF, Van Scoy LJ, Smith T, Kunzler B, Foy AJ, Badzek L, Green MJ. What Counts as a Surrogate Decision? Am J Hosp Palliat Care 2024; 41:125-132. [PMID: 36997165 PMCID: PMC10751970 DOI: 10.1177/10499091231168976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
When patients lose decision-making capacity, others must make surrogate decisions on their behalf. What counts as a surrogate decision might seem self-evident. But as clinician-researchers in the field of advance care planning, we have found that it is not always so clear-cut. In this paper, we describe how and why this is a matter of concern, a novel approach for assessing whether a surrogate decision occurred, and findings from this assessment.
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Affiliation(s)
- Benjamin H Levi
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Anne EF Dimmock
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Theresa Smith
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Bronson Kunzler
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Andrew J Foy
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Laurie Badzek
- Nursing Sciences Building University Park, Penn State College of Nursing, Hershey, PA, USA
| | - Michael J Green
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
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Rowe CJ, Nwaolu U, Salinas D, Hong J, Nunez J, Lansford JL, McCarthy CF, Potter BK, Levi BH, Davis TA. Inhibition of focal adhesion kinase 2 results in a macrophage polarization shift to M2 which attenuates local and systemic inflammation and reduces heterotopic ossification after polysystem extremity trauma. Front Immunol 2023; 14:1280884. [PMID: 38116014 PMCID: PMC10728492 DOI: 10.3389/fimmu.2023.1280884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Introduction Heterotopic ossification (HO) is a complex pathology often observed in combat injured casualties who have sustained severe, high energy polytraumatic extremity injuries. Once HO has developed, prophylactic therapies are limited outside of surgical excision. Tourniquet-induced ischemia injury (IR) exacerbates trauma-mediated musculoskeletal tissue injury, inflammation, osteogenic progenitor cell development and HO formation. Others have shown that focal adhesion kinase-2 (FAK2) plays a key role in regulating early inflammatory signaling events. Therefore, we hypothesized that targeting FAK2 prophylactically would mitigate extremity trauma induced IR inflammation and HO formation. Methods We tested whether the continuous infusion of a FAK2 inhibitor (Defactinib, PF-573228; 6.94 µg/kg/min for 14 days) can mitigate ectopic bone formation (HO) using an established blast-related extremity injury model involving femoral fracture, quadriceps crush injury, three hours of tourniquet-induced limb ischemia, and hindlimb amputation through the fracture site. Tissue inflammation, infiltrating cells, osteogenic progenitor cell content were assessed at POD-7. Micro-computed tomography imaging was used to quantify mature HO at POD-56. Results In comparison to vehicle control-treated rats, FAK2 administration resulted in no marked wound healing complications or weight loss. FAK2 treatment decreased HO by 43%. At POD-7, marked reductions in tissue proinflammatory gene expression and assayable osteogenic progenitor cells were measured, albeit no significant changes in expression patterns of angiogenic, chondrogenic and osteogenic genes. At the same timepoint, injured tissue from FAK-treated rats had fewer infiltrating cells. Additionally, gene expression analyses of tissue infiltrating cells resulted in a more measurable shift from an M1 inflammatory to an M2 anti-inflammatory macrophage phenotype in the FAK2 inhibitor-treated group. Discussion Our findings suggest that FAK2 inhibition may be a novel strategy to dampen trauma-induced inflammation and attenuate HO in patients at high risk as a consequence of severe musculoskeletal polytrauma.
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Affiliation(s)
- Cassie J. Rowe
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, Bethesda, MD, United States
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Uloma Nwaolu
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, Bethesda, MD, United States
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Daniela Salinas
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, Bethesda, MD, United States
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Jonathan Hong
- Center for Organogenesis Research and Trauma, University of Texas Southwestern, Dallas, TX, United States
| | - Johanna Nunez
- Center for Organogenesis Research and Trauma, University of Texas Southwestern, Dallas, TX, United States
| | - Jefferson L. Lansford
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, Bethesda, MD, United States
| | - Conor F. McCarthy
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, Bethesda, MD, United States
| | - Benjamin K. Potter
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, Bethesda, MD, United States
| | - Benjamin H. Levi
- Center for Organogenesis Research and Trauma, University of Texas Southwestern, Dallas, TX, United States
| | - Thomas A. Davis
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, Bethesda, MD, United States
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4
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Barnett WC, Panlilio CC, Mullins C, Levi BH, Humphreys KL. Identifying what works for whom: Implementation outcomes following iLookOut, a child abuse identification and referral training program. J Clin Transl Sci 2023; 7:e205. [PMID: 37830009 PMCID: PMC10565203 DOI: 10.1017/cts.2023.628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 08/16/2023] [Accepted: 09/05/2023] [Indexed: 10/14/2023] Open
Abstract
Introduction iLookOut, a web-based child abuse training for early childcare professionals (ECPs), has been shown to improve knowledge and attitudes related to correctly identifying and reporting suspected cases of child abuse. The overarching goal of the present study is to examine "what works for whom" for iLookOut in order to identify strategies for optimizing learner outcomes. Methods This prospective study enrolled 12,705 ECPs who completed iLookOut (November 2014-December 2018). We used structural equation models to test whether learner demographic and professional characteristics were differentially associated with implementation outcomes (i.e., acceptability and appropriateness) and whether these mediated subsequent indicators of training effectiveness (i.e., gains in knowledge). Results Consistent with previous research, individuals with lower baseline knowledge scores showed greater knowledge gains (β = -.57; p < .001). Greater knowledge gains were seen for learners who reported higher acceptability (β = .08; p < .001) or appropriateness (β = .14; p < .001). Implementation outcomes strongly associated with knowledge gains included acceptability for female learners and appropriateness for learners who had not completed high school or had >15 years of experience in childcare settings. Where mediation was found, for the majority of groups, appropriateness emerged as the driving mediator. Conclusion Implementation outcomes emerged as important drivers of knowledge change for most groups. The iLookOut Core Training's use of a multimedia learning environment, video-based storylines, and game-based techniques were endorsed by learners and correlated with increases in knowledge. Future work should explore why aspects of the iLookOut training are rated as less acceptable or appropriate by some groups and what changes would improve efficacy for low performing learners.
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Affiliation(s)
- Whitney C. Barnett
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Carlomagno C. Panlilio
- Department of Educational Psychology, Counseling, and Special Education, The Pennsylvania State University, State College, PA, USA
| | - Casey Mullins
- Department of Psychology, University of Miami, Coral Gables, FL, USA
| | - Benjamin H. Levi
- Department of Humanities and Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Kathryn L. Humphreys
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
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Kunzler BR, Smith TJ, Levi BH, Green MJ, Badzek L, Katsaros MG, Van Scoy LJ. The Value of Advance Care Planning for Spokespersons of Patients With Advanced Illness. J Pain Symptom Manage 2023; 65:471-478.e4. [PMID: 36690164 DOI: 10.1016/j.jpainsymman.2022.12.143] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/21/2023]
Abstract
CONTEXT Advance Care Planning (ACP) has fallen under scrutiny primarily because research has not consistently demonstrated patient-focused benefits. OBJECTIVES To better understand how spokespersons regard, engage with, and find value in ACP during decision-making for their loved ones. METHODS This qualitative analysis was part of a randomized controlled trial involving spokespersons of patients with advanced illness who had completed ACP. After making a medical decision on behalf of their loved one (or that loved one's death), semi-structured interviews explored spokespersons' experience of decision-making and if (and how) ACP played a role. Thematic analysis was conducted on interview transcripts. RESULTS From 120 interviews, five themes emerged: 1) Written advance directives (ADs) helped increase spokespersons' confidence that decisions were aligned with patient wishes (serving as a physical reminder of previous discussions and increasing clarity during decision-making and family conflict); 2) Iterative discussions involving ACP facilitated "In the moment" decision-making; 3) ADs and ACP conversations helped spokespersons feel more prepared for future decisions; 4) Spokespersons sometimes felt there was "no choice" regarding their loved one's medical care; and 5) Regrets and second-guessing were the most common negative emotions experienced by spokespersons. CONCLUSION Considering the recent debate about the utility of ACP and ADs, this analysis highlights the value of ACP for spokespersons involved in surrogate decision-making. Reframing the goals of ACP in terms of their benefit for spokespersons (and identifying appropriate outcome measures) may provide additional perspective on the utility of ACP.
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Affiliation(s)
| | - Theresa J Smith
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Pediatrics, Penn State College of Medicine (B.H.L.), Hershey, PA, USA
| | - Michael J Green
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Medicine, Penn State College of Medicine (M.J.G, L.J.V.S.), Hershey, PA, USA
| | - Laurie Badzek
- Penn State Ross and Carol Nese College of Nursing (L.B.), University Park, PA, USA
| | - Maria G Katsaros
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA
| | - Lauren J Van Scoy
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Medicine, Penn State College of Medicine (M.J.G, L.J.V.S.), Hershey, PA, USA; Department of Public Health Sciences, Penn State College of Medicine (L.J.V.S.), Hershey, PA, USA.
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Panlilio CC, Famularo L, Masters J, Dore S, Verdiglione N, Yang C, Lehman E, Hamm RM, Fiene R, Bard D, Kapp KM, Levi BH. Integrating Validity Evidence to Revise a Child Abuse Knowledge Test for Early Childhood Education Providers: A Mixed Methods Approach. Am J Eval 2022; 43:559-583. [PMID: 36507193 PMCID: PMC9733792 DOI: 10.1177/10982140211002901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Knowledge tests used to evaluate child protection training program effectiveness for early childhood education providers may suffer from threats to construct validity given the contextual variability inherent within state-specific regulations around mandated reporting requirements. Unfortunately, guidance on instrument revision that accounts for such state-specific mandated reporting requirements is lacking across research on evaluation practices. This study, therefore, explored how collection and integration of validity evidence using a mixed methods framework can guide the instrument revision process to arrive at a more valid program outcome measure.
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Affiliation(s)
- Carlomagno C. Panlilio
- Department of Educational Psychology, Counseling, and Special Education, The Pennsylvania State University, State College, PA, USA
| | | | | | - Sarah Dore
- Department of Humanities and Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Nicole Verdiglione
- Department of Humanities and Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Chengwu Yang
- Department of Epidemiology and Health Promotion, College of Dentistry, New York University, NY, USA
| | - Erik Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Robert M. Hamm
- Department of Family and Preventive Medicine, College of Medicine, The University of Oklahoma, Norman, OK, USA
| | - Richard Fiene
- Department of Human Development and Family Studies, The Pennsylvania State University, State College, PA, USA
- Department of Psychology, The Pennsylvania State University, State College, PA, USA
| | - David Bard
- Department of Pediatrics, College of Medicine, The University of Oklahoma, Norman, OK, USA
| | - Karl M. Kapp
- Department of Instructional Technology, Bloomsburg University, PA, USA
| | - Benjamin H. Levi
- Department of Humanities and Pediatrics, Penn State College of Medicine, Hershey, PA, USA
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Van Scoy LJ, Green MJ, Smith T, VanDyke E, Foy AJ, Badzek L, Levi BH. Conceptualization of Surrogate Decision-making Among Spokespersons for Chronically Ill Patients. JAMA Netw Open 2022; 5:e2245608. [PMID: 36480203 PMCID: PMC9856522 DOI: 10.1001/jamanetworkopen.2022.45608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE The value of advance care planning (ACP) has been the subject of recent debate because of mixed findings. This may be, in part, because trials presume that researchers and patient spokespersons share the same understanding of the role of a surrogate decision-maker. We explored how patient surrogates conceptualized and defined surrogate decision-making vs patient advocacy. Understanding how surrogates perceive their role in decision-making is important to avoid misinterpreting the effectiveness of ACP interventions. OBJECTIVE To understand how patient spokespersons distinguish surrogate decision-making from patient advocacy. DESIGN, SETTING, AND PARTICIPANTS This qualitative thematic analysis of a subsample of participants from a randomized clinical trial at a tertiary medical center was conducted from September 27, 2012, to June 30, 2021. Participants (n = 36) were the designated spokespersons of adult patients with severe illness who had made a surrogate decision on behalf of the patient since the last follow-up. Analysis was performed from March 21, 2021, to February 7, 2022. MAIN OUTCOMES AND MEASURES Semistructured interviews examined how patient spokespersons conceptualize differences between surrogate decision-making and advocacy. RESULTS The study included 36 patient spokespersons (32 women [88.9%]; mean [SD] age, 62.1 [11.8] years) and found substantial variability in how the spokespersons conceptualized what it means to make a surrogate decision for another. A total of 10 spokespersons (27.8%) did not distinguish surrogate decision-making from advocacy. There were 5 definitions for both surrogate decision-making and advocacy. The 3 most common definitions of surrogate decision-making were (1) acting as the final decision-maker (18 [50.0%]), (2) doing what is best for the patient (8 [22.2%]), and (3) making decisions on behalf of patients so that their wishes are respected (6 [16.7%]). The 3 most common definitions of advocacy were (1) doing what is best for the patient (8 [22.2%]), (2) respecting patients' wishes (6 [16.7%]), and (3) providing support to the patient (6 [16.7%]). The most common pairing of definitions by an individual spokesperson involved defining surrogate decision-making as being the final decision-maker, and defining advocacy as acting in the best interest of the patient (6 [16.7%]). CONCLUSIONS AND RELEVANCE This qualitative study found that many spokespersons perceive their roles as surrogate decision-makers differently than clinicians and researchers likely do, often conflating surrogacy with advocacy. These findings may help explain why researchers have found that ACP does not consistently improve traditional outcomes. If spokespersons do not distinguish surrogate decision-making from advocacy, then what is being reported by spokespersons and measured by clinicians and researchers may not accurately reflect the true association of ACP with outcomes.
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Affiliation(s)
- Lauren J. Van Scoy
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Michael J. Green
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania
| | - Theresa Smith
- Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania
| | - Erika VanDyke
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Andrew J. Foy
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Laurie Badzek
- Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park
| | - Benjamin H. Levi
- Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
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Berthold O, Clemens V, Levi BH, Jarczok M, Fegert JM, Jud A. Survey on Reporting of Child Abuse by Pediatricians: Intrapersonal Inconsistencies Influence Reporting Behavior More than Legislation. Int J Environ Res Public Health 2022; 19:15568. [PMID: 36497644 PMCID: PMC9738942 DOI: 10.3390/ijerph192315568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/14/2022] [Accepted: 11/18/2022] [Indexed: 06/17/2023]
Abstract
Background: Internationally, various laws govern reporting of child abuse to child protection services by medical professionals. Whether mandatory reporting laws are in place or not, medical professionals need internal thresholds for suspicion of abuse to even consider a report ("reasonable suspicion" in US law, "gewichtige Anhaltspunkte" in German law). Objective: To compare internal thresholds for suspicion of abuse among US and German pediatricians, i.e., from two countries with and without mandatory reporting laws. Participants and Setting: In Germany, 1581 pediatricians participated in a nationwide survey among child health professionals. In the US, a survey was mailed to all Pennsylvania pediatricians, and 1249 participated. Methods: Both samples were asked how high in their rank order of differential diagnoses child abuse would have to be when confronted with a child's injuries to qualify for reasonable suspicion/gewichtige Anhaltspunkte (differential diagnosis scale, DDS). In a second step, both had to mark a 10-point likelihood scale (0-100%) corresponding to reasonable suspicion/gewichtige Anhaltspunkte (estimated probability scale, EPS). Results: While for almost two-thirds of German pediatricians (62.4%), child abuse had to be among the top three differential diagnoses for gewichtige Anhaltspunkte, over half of the US respondents (48.1%) had a lower threshold for reasonable suspicion. On the estimated probability scale, over 65% in both samples indicated that the probability of abuse had to exceed 50% for reasonable suspicion/gewichtige Anhaltspunkte. There was great variability between the two countries. Conclusions: There are similar uncertainties in assessing cases of suspected child abuse in different legal systems. There is a need for debates on thresholds among medical professionals in both countries.
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Affiliation(s)
- Oliver Berthold
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
| | - Vera Clemens
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
| | - Benjamin H. Levi
- Departments of Humanities and Pediatrics, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA
| | - Marion Jarczok
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
| | - Jörg M. Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
| | - Andreas Jud
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
- School of Social Work, Lucerne University of Applied Sciences and Arts, Werftestrasse 1, 6002 Lucerne, Switzerland
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Van Scoy LJ, Bliton CF, Smith T, Badzek L, Green MJ, Levi BH, Foy AJ. Intrinsic Traits Such as Personality and Decision-Making Style are Predictive of Stress in Surrogate Decision-Makers. Am J Hosp Palliat Care 2022:10499091221135594. [PMID: 36266775 DOI: 10.1177/10499091221135594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Despite its prominence in psychology, little is known about how personality traits play a role in the stress experiences of surrogate decision-makers. We tested the hypothesis that intrinsic traits (personality and decision-making styles) would be related to surrogates' stress in order to learn whether screening or tailoring interventions based on personality traits could help support surrogate decision-makers. Methods: This pre-specified secondary analysis evaluated data from an interventional study with dyads of patients with advanced chronic illness and their spokespersons. Measures included stress after decision-making or patient death (Impact of Events-Revised), personality (Big Five Index; BFI) and decision-making style (maximization and regret scales). Multivariate linear regressions explored the impact of personality on the stress experience; linear regressions independently modeled the impact of maximization and regret on the stress experience. Results: Of 38 spokespersons, 89.5% were women, 97.4% non-Hispanic, and 29.0% had a college degree or higher. In univariate analyses, total stress was correlated with neuroticism (r = .56, P < .01), higher scores on the regret (r = .55, P < .01) and maximization (r = .48, P < .05). In adjusted models, BFI was significantly associated with total stress (R2 = 27.08, P = .02). However, only neuroticism was independently associated with total stress. Conclusions: Personality traits, particularly neuroticism, and decision-making styles predicted heightened stress in spokespersons of patients with advanced chronic illness. If ACP interventions are intended to reduce spokesperson stress, personality and decision-making style scales may help identify spokespersons most likely to benefit from ACP interventions.
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Affiliation(s)
- Lauren J Van Scoy
- Departments of Medicine, 12310Penn State College of Medicine, Hershey, PA, USA.,Department of Humanities, 12310Penn State College of Medicine, Hershey, PA, USA.,Department of Public Health Sciences, 12310Penn State College of Medicine, Hershey, PA, USA
| | - Chloe F Bliton
- Department of Psychology, Pennsylvania State University, State College, PA, USA
| | - Theresa Smith
- Department of Humanities, 12310Penn State College of Medicine, Hershey, PA, USA
| | - Laurie Badzek
- 15965Penn State Ross and Carol Nese College of Nursing, University Park, PA, USA
| | - Michael J Green
- Departments of Medicine, 12310Penn State College of Medicine, Hershey, PA, USA.,Department of Humanities, 12310Penn State College of Medicine, Hershey, PA, USA
| | - Benjamin H Levi
- Department of Humanities, 12310Penn State College of Medicine, Hershey, PA, USA.,Department of Pediatrics, 12310Penn State College of Medicine, Hershey, PA, USA
| | - Andrew J Foy
- Departments of Medicine, 12310Penn State College of Medicine, Hershey, PA, USA
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10
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Van Scoy LJ, Levi BH, Bramble C, Calo W, Chinchilli VM, Currin L, Grant D, Hollenbeak C, Katsaros M, Marlin S, Scott AM, Tucci A, VanDyke E, Wasserman E, Witt P, Green MJ. Comparing two advance care planning conversation activities to motivate advance directive completion in underserved communities across the USA: The Project Talk Trial study protocol for a cluster, randomized controlled trial. Trials 2022; 23:829. [PMID: 36180899 PMCID: PMC9523194 DOI: 10.1186/s13063-022-06746-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 09/13/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is a process involving conversations between patients, loved ones, and healthcare providers that consider patient preferences for the types of medical therapies received at the end of life. Underserved populations, including Black, Hispanic, rural, and low-income communities are less likely to engage in ACP than other communities, a health inequity that results in lower-quality care and reduced hospice utilization. The purpose of this trial is to compare efficacy of two interventions intended to motivate ACP (particularly advance directive completion) for those living in underserved communities. METHODS This 3-armed cluster, randomized controlled mixed methods design is being conducted in 75 community venues in underserved communities across the USA. The goal of the trial is to compare the efficacy of two interventions at motivating ACP. Arm 1 uses an end-of-life conversation game (Hello); Arm 2 uses a nationally utilized workshop format for ACP conversations (The Conversation Project); and Arm 3 uses an attention control game (TableTopics). Events are held in partnership with 75 local community-based host organizations and will involve 1500 participants (n=20 per event). The primary outcome is completion of a visually verified advance directive at 6 months post-event. Primary analyses compare efficacy of each intervention to each other and the control arm. Secondary mixed methods outcomes include (a) other ACP behaviors and engagement; (b) communication quality; (c) impact of sociocultural environment on ACP (via qualitative interviews); and (d) implementation and sustainability. Subgroup analyses examine outcomes for Black, Hispanic, and rural groups in particular. DISCUSSION This trial will add to the evidence base behind various conversational ACP interventions, examine potential mechanisms of action for such interventions, and provide qualitative data to better understand the sociocultural environment of how community-based ACP interventions are experienced by underserved populations. Results will also provide important data for future researchers to learn whether visual verification of advance directives is necessary or whether reliance on self-reported outcomes is of comparable value. Data from this study will inform ways to effectively motivate underserved communities to participate in advance care planning. TRIAL REGISTRATION ClinicalTrials.gov NCT04612738. Registered on October 12, 2020. All information from the WHO Trial Registration Data Set can be found within the protocol.
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Affiliation(s)
- Lauren J. Van Scoy
- Department of Medicine, Penn State College of Medicine, 500 University Dr., H-041, Hershey, PA 17033-0850 USA
- Department of Humanities, Penn State College of Medicine, 500 University Drive, Hershey, PA 17036 USA
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Academic Support Building, Suite 2200, Mail Code A210, Hershey, PA 17033 USA
| | - Benjamin H. Levi
- Department of Humanities, Penn State College of Medicine, 500 University Drive, Hershey, PA 17036 USA
- Department of Pediatrics, Penn State College of Medicine, Suite 4400, Mail Code A444, Hershey, PA 17033 USA
| | - Cindy Bramble
- Hospice Foundation of America, 1707 L St. NW, Suite 220, Washington, DC, 20036 USA
| | - William Calo
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Academic Support Building, Suite 2200, Mail Code A210, Hershey, PA 17033 USA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Academic Support Building, Suite 2200, Mail Code A210, Hershey, PA 17033 USA
| | - Lindsey Currin
- Hospice Foundation of America, 1707 L St. NW, Suite 220, Washington, DC, 20036 USA
| | - Denise Grant
- Hospice Foundation of America, 1707 L St. NW, Suite 220, Washington, DC, 20036 USA
| | - Christopher Hollenbeak
- Department of Health Policy and Administration, The Pennsylvania State University, 604E Donald H. Ford Bldg., University Park, PA 16802 USA
| | - Maria Katsaros
- Department of Medicine, Penn State College of Medicine, 500 University Dr., H-041, Hershey, PA 17033-0850 USA
| | - Sara Marlin
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Academic Support Building, Suite 2200, Mail Code A210, Hershey, PA 17033 USA
| | - Allison M. Scott
- Department of Communication, University of Kentucky, 275 Blazer Dining Hall, University of Kentucky, Lexington, KY 40506 USA
| | - Amy Tucci
- Hospice Foundation of America, 1707 L St. NW, Suite 220, Washington, DC, 20036 USA
| | - Erika VanDyke
- Department of Medicine, Penn State College of Medicine, 500 University Dr., H-041, Hershey, PA 17033-0850 USA
| | - Emily Wasserman
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Academic Support Building, Suite 2200, Mail Code A210, Hershey, PA 17033 USA
| | - Pamela Witt
- Department of Medicine, Penn State College of Medicine, 500 University Dr., H-041, Hershey, PA 17033-0850 USA
| | - Michael J. Green
- Department of Medicine, Penn State College of Medicine, 500 University Dr., H-041, Hershey, PA 17033-0850 USA
- Department of Humanities, Penn State College of Medicine, 500 University Drive, Hershey, PA 17036 USA
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11
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Van Scoy LJ, Scott AM, Green MJ, Witt PD, Wasserman E, Chinchilli VM, Levi BH. Communication Quality Analysis: A user-friendly observational measure of patient-clinician communication. Commun Methods Meas 2022; 16:215-235. [PMID: 37063460 PMCID: PMC10104441 DOI: 10.1080/19312458.2022.2099819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Communication Quality Analysis (CQA) is a rigorous transcript-based coding method for assessing clinical communication quality. We compared the resource-intensive transcript-based version with a streamlined real-time version of the method with respect to feasibility, validity, reliability, and association with traditional measures of communication quality. Simulated conversations between 108 trainees and 12 standardized patients were assessed by 7 coders using the two versions of CQA (transcript and real-time). Participants also completed two traditional communication quality assessment measures. Real-time CQA was feasible and yielded fair to excellent reliability, with some caveats that can be addressed in future work. CQA ratings were moderately correlated with traditional measures of communication quality, suggesting that CQA captures different aspects of communication quality than do traditional measures. Finally, CQA did not exhibit the ceiling effects observed in the traditional measures of communication quality. We conclude that real-time CQA is a user-friendly method for assessing communication quality that has the potential for broad application in training, research, and intervention contexts and may offer improvements to traditional, self-rated communication measures.
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Affiliation(s)
- Lauren Jodi Van Scoy
- Departments of Medicine, Penn State College of Medicine, Hershey, USA
- Department of Humanities, Penn State College of Medicine, Hershey, USA
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | - Allison M Scott
- Department of Communication; University of Kentucky, Lexington, USA
| | - Michael J. Green
- Departments of Medicine, Penn State College of Medicine, Hershey, USA
- Department of Humanities, Penn State College of Medicine, Hershey, USA
| | - Pamela D. Witt
- Departments of Medicine, Penn State College of Medicine, Hershey, USA
| | - Emily Wasserman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Hershey, USA
- Department of Pediatrics Penn State College of Medicine, Hershey, USA
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12
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Abstract
The purpose of this study was to determine whether statutory wording of child maltreatment mandated reporting legislation was associated with reporting patterns and substantiation of abuse across U.S. states and territories. Annual state averages for total referrals, referrals screened-out, referrals screened-in, referrals substantiated, and child population (all children in the U.S.; annual average = 74,457,928) were obtained from the 2010-2017 Child Maltreatment Reports. Odds ratios were calculated for: (1) two major statutory language frameworks (suspicion versus belief), (2) seven sub-categories (e.g., suspect, reasonably believe, etc.), and (3) universal mandated reporting (yes versus no). Use of suspicion (versus belief) was associated with higher rates of referrals made (OR = 1.13) and screened-in (OR = 1.13), but lower substantiation rates (OR = .92). States using universal mandated reporting (versus those who did not) had slightly lower rates of referrals (OR = .99), but higher rates of referrals screened-in (OR = 1.16) and substantiated (OR = 1.06). Differences in statutory wording are associated with variability in reports, suggesting the possibility that statutory wording is one factor involved with these differences. However, future research is needed to explore alternative contributing factors and/or explanations.
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Affiliation(s)
- Hannah A Piersiak
- Department of Psychology and Human Development, 5718Vanderbilt University, Nashville, TN, USA
| | - Benjamin H Levi
- Departments of Humanities and Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Kathryn L Humphreys
- Department of Psychology and Human Development, 5718Vanderbilt University, Nashville, TN, USA
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13
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Van Scoy LJ, Witt PD, Bramble C, Richardson C, Putzig I, Currin L, Wasserman E, Tucci A, Levi BH, Green MJ. Success of a Community-Based Delivery at Recruiting Individuals from Underserved Communities for an Observational Cohort Study of an Advance Care Planning Intervention. J Pain Symptom Manage 2022; 63:e149-e154. [PMID: 34662724 DOI: 10.1016/j.jpainsymman.2021.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Underserved and minority populations are often reluctant to engage in advance care planning and/or research often due to distrust in healthcare and/or research institutions. AIM To determine if use of a community-based delivery model can facilitate recruitment of individuals from underserved communities in research about advance care planning. DESIGN Recruitment data are presented from a prospective, mixed methods observational cohort study that examined the feasibility and preliminary efficacy of a community-based delivery model involving an end-of-life conversation game to motivate participants to complete advance care planning behaviors. Event attendance and research participation data are reported. SETTING/PARTICIPANTS Game events were held in community venues in 27 states across the US in 2018-2019. The model involved leveraging existing social networks to recruit attendees and research participants to community game day events. Attendees were eligible for research if they were adults who read/spoke English. RESULTS A total of 1,122 individuals attended events at 53 sites. Participants generally reported low income (48% reported $30,000 annual income). At sites with research assistants, there was a 90% consent rate (92% were Black). At community outreach sites, 45% agreed to a follow-up research phone call (49% were Black). CONCLUSIONS Use of the community-based delivery model successfully engaged undeserved communities in a research-based advance care planning related community outreach event. This model may be useful for overcoming underserved and minority populations' skepticism and distrust of healthcare and research that is a common barrier to progress in health agendas, especially advance care planning.
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Affiliation(s)
- Lauren Jodi Van Scoy
- Departments of Medicine (L.J.V.S., P.D.W, M.J.G.), Penn State College of Medicine, Hershey, Pennsylvania, USA; Department of Humanities (L.J.V.S., B.H.L., M.J.G.), Penn State College of Medicine, Hershey, Pennsylvania, USA; Department of Public Health Sciences (L.J.V.S., E.W.), Penn State College of Medicine, Hershey, Pennsylvania, USA.
| | - Pamela D Witt
- Departments of Medicine (L.J.V.S., P.D.W, M.J.G.), Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Cindy Bramble
- Hospice Foundation of America (C.B., C.R., I.P., L.C., A.T.), Washington, D.C., USA
| | | | - Irene Putzig
- Hospice Foundation of America (C.B., C.R., I.P., L.C., A.T.), Washington, D.C., USA
| | - Lindsey Currin
- Hospice Foundation of America (C.B., C.R., I.P., L.C., A.T.), Washington, D.C., USA
| | - Emily Wasserman
- Department of Public Health Sciences (L.J.V.S., E.W.), Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Amy Tucci
- Hospice Foundation of America (C.B., C.R., I.P., L.C., A.T.), Washington, D.C., USA
| | - Benjamin H Levi
- Department of Humanities (L.J.V.S., B.H.L., M.J.G.), Penn State College of Medicine, Hershey, Pennsylvania, USA; Department of Pediatrics, Penn State College of Medicine (B.H.L.), Hershey, Pennsylvania, USA
| | - Michael J Green
- Departments of Medicine (L.J.V.S., P.D.W, M.J.G.), Penn State College of Medicine, Hershey, Pennsylvania, USA; Department of Humanities (L.J.V.S., B.H.L., M.J.G.), Penn State College of Medicine, Hershey, Pennsylvania, USA
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14
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Kunzler BR, Foy AJ, Levi BH, Van Scoy LJ, Lehman EB, Smith TJ, Green MJ. Does Caregiver Participation in Advance Care Planning Using a Decision Support Tool Together With Patients Reduce Caregiver Strain, Burden and Anxiety Over Time? A Post-Hoc Analysis of a Randomized Controlled Trial. Am J Hosp Palliat Care 2021; 39:757-761. [PMID: 34414808 DOI: 10.1177/10499091211040233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
CONTEXT Surrogate decision makers experience significant amounts of anxiety, burden, and strain in their role as caregivers and decision makers for loved ones. OBJECTIVES To investigate longitudinally whether surrogate decision makers engaging in ACP together with their loved one reduces perceived anxiety, burden, and strain felt by surrogate decision makers. METHODS Post-hoc analysis of a randomized controlled trial evaluating caregivers' perceived self-efficacy to serve as surrogate decision makers. The trial employed a 2×2 study design of patient/caregiver dyads who engaged in advance care planning (ACP) using a standard living will form vs "Making Your Wishes Known" (MYWK), and having the patient engage in ACP alone vs together with the family caregiver. Surrogates completed validated survey instruments surveys longitudinally to compare levels of anxiety, burden, and strain. RESULTS 246 of 285 dyads completed the measures. No significant reductions in anxiety, burden, or strain were found longitudinally in surrogate decision makers using MYWK together with loved one's vs other control groups. Increases in strain and anxiety were seen across all study groups and increases in burden across 2/4 study groups. Strain and burden increased most in the MYWK Together arm (▴ = +2.22 and ▴ = +1.91 respectively). CONCLUSION Family caregivers who engaged in ACP together with patients using the decision support tool MYWK did not experience less strain, burden, or anxiety longitudinally compared to other study arms. These results may help inform the design of future studies and interventions that promote caregivers' involvement in ACP interventions.
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Affiliation(s)
| | - Andrew J Foy
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Theresa J Smith
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Michael J Green
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
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15
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Humphreys KL, Piersiak HA, Panlilio CC, Lehman EB, Verdiglione N, Dore S, Levi BH. A randomized control trial of a child abuse mandated reporter training: Knowledge and attitudes. Child Abuse Negl 2021; 117:105033. [PMID: 33901759 PMCID: PMC8360385 DOI: 10.1016/j.chiabu.2021.105033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/17/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Despite being well-positioned to identify maltreatment in the children that they provide care for and being legally required to report suspected child maltreatment, early childhood professionals (ECPs) make a limited proportion of reports to child protective services. It is critical to identify evidence-based interventions to improve the reporting practices of this group of mandated reporters allowing for the better protection of children from maltreatment. OBJECTIVE The goal of the present study was to determine if iLookOut, an online child abuse identification and reporting training for ECPs, results in differential gains in knowledge and attitudes towards child abuse and its reporting among ECPs, as compared to an online standard training. PARTICIPANTS AND SETTING Both interventions were completed online by participants recruited from licensed child care programs in Southern Maine from October 2017 to January 2020. Eligibility criteria included being at least 18 years of age, English-speaking, and working as paid or volunteer staff at a licensed child care program taking care of children 5 years of age or younger. Of the 1152 enrolled individuals, 1094 provided complete pre- and post-intervention data. METHODS A randomized controlled trial comparing iLookOut with an online standard training. RESULTS ECPs who completed iLookOut significantly outperformed those who completed Standard mandated reporter training in terms of both knowledge (d=1.09 vs. 0.67) and attitudes (d=0.67 vs. 0.54) relative to pre-test scores. CONCLUSIONS iLookOut is a promising candidate for widespread use in meeting the need for evidence-based training on child abuse and its reporting.
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Affiliation(s)
| | | | | | - Erik B Lehman
- Pennsylvania State College of Medicine, Hershey, PA, United States
| | | | - Sarah Dore
- Pennsylvania State College of Medicine, Hershey, PA, United States
| | - Benjamin H Levi
- Pennsylvania State College of Medicine, Hershey, PA, United States
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16
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Simmons DB, Levi BH, Green MJ, La IS, Lipnick D, Smith TJ, Thiede ER, Wiegand DL, Van Scoy L. What Surrogates Understand (and Don't Understand) About Patients' Wishes After Engaging Advance Care Planning: A Qualitative Analysis. Am J Hosp Palliat Care 2021; 39:427-432. [PMID: 34164999 DOI: 10.1177/10499091211026674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The goal of advance care planning (ACP) is to improve end-of-life decision-making for patients and their spokespersons, but multiple studies have failed to show substantial or consistent benefit from ACP. Understanding how and why ACP under-performs in the setting of complex medical decision-making is key to optimizing current, or designing new, ACP interventions. AIM To explore how ACP did or did not contribute to a spokespersons' understanding of patient wishes after engaging in ACP. DESIGN Thematic analysis of 200 purposively sampled interviews from a randomized control trial of an ACP decision aid. SETTING/PARTICIPANTS 200 dyads consisting of patients 18 years or older with advanced serious illness and their spokesperson at 2 tertiary care centers in Hershey, PA and Boston, MA. Participants were interviewed 1 month after completing ACP. RESULTS ACP helped participants: 1) express clear end-of-life wishes, 2) clarify values, and 3) recognize challenges associated with applying those wishes in complex situations. Shortcomings of ACP included 1) unknown prognostic information or quality-of-life outcomes to inform decision-making, 2) skepticism about patients' wishes, and 3) complicated emotions impacting end-of-life discussions. CONCLUSIONS Helping patients and their spokespersons better anticipate decision-making in the face of prognostic and informational uncertainty as well as the emotional complexities of making medical decisions may improve the efficacy of ACP interventions.
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Affiliation(s)
- David B Simmons
- Department of Pastoral Care, Penn State Milton S. Hershey Medical Center, Hershey, PA.,Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Benjamin H Levi
- Penn State College of Medicine, Hershey, PA.,Penn State Milton S. Hershey Medical Center, Hershey, PA.,Department of Humanities, Penn State College of Medicine, Hershey, PA.,Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Michael J Green
- Department of Medicine, Penn State College of Medicine, Hershey, PA.,Penn State College of Medicine, Hershey, PA.,Penn State Milton S. Hershey Medical Center, Hershey, PA.,Department of Humanities, Penn State College of Medicine, Hershey, PA
| | - In Seo La
- College of Nursing Science, Kyung Hee University, Seoul, South Korea
| | | | | | | | - Debra L Wiegand
- University of Maryland-Baltimore Department of Nursing, Baltimore, MD
| | - Lauren Van Scoy
- Department of Medicine, Penn State College of Medicine, Hershey, PA.,Penn State College of Medicine, Hershey, PA.,Penn State Milton S. Hershey Medical Center, Hershey, PA.,Department of Humanities, Penn State College of Medicine, Hershey, PA.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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17
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Levi BH, Mundy M, Palm C, Verdiglione N, Fiene R, Mincemoyer C. AN INTERACTIVE ONLINE LEARNING PROGRAM ON CHILD ABUSE AND ITS REPORTING. J Educ Online 2021; 18:https://www.thejeo.com/archive/archive/2021_182/levi_mundy_palm_verdiglione_fiene_mincemoyerpdf. [PMID: 34690610 PMCID: PMC8533645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
This article describes the content and pedagogical foundations of iLookOut for Child Abuse, an interactive, online learning program that was designed for early childhood professionals and others who provide childcare to young children. It also describes how an online intervention can address a complex social and behavioral issue--viz., how to identify and appropriately respond to concerns of possible child abuse.
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18
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Phillips TA, Foley KA, Levi BH, Jhaveri P, Chuang CH, Abdulahad D, Lehman E, Fogel BN. The Impact of Medical Scribes on Relative Value Units in a Pediatric Primary Care Practice. Acad Pediatr 2021; 21:542-547. [PMID: 32445825 DOI: 10.1016/j.acap.2020.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Our study assessed the impact of adding medical scribes to an academic pediatric primary practice by measuring the relationship between work relative value units (wRVUs) and use of the medical scribe. METHODS This is a retrospective comparative study on the effect of medical scribes on average wRVUs per patient encounter. wRVUs were abstracted from procedure codes in the billing system. RESULTS Six clinicians performed 2277 patient visits included in the study over 2 different time periods during 2017 and 2018. The first period was without the use of medical scribes and the second period included scribes. Average clinician wRVU production per visit increased by 7.68% (P < .001) with medical scribes over the previous period without them. CONCLUSIONS This study shows that scribes contribute to improving the wRVU per visit in a primary pediatric practice. This finding is consistent with other research showing that scribes help increase volume and improve wRVUs for specialists who perform complex procedures.
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Affiliation(s)
- Troy A Phillips
- Department of Learning and Performance Systems, Penn State University (TA Phillips), State College, Pa.
| | - Kasey A Foley
- Department of Communication Arts and Sciences, Penn State University (KA Foley), State College, Pa
| | - Benjamin H Levi
- Department of Pediatrics, Penn State College of Medicine (BH Levi, P Jhaveri, D Abdulahad, and BN Fogel), Hershey, Pa; Department of Humanities, Penn State College of Medicine (BH Levi), Hershey, Pa
| | - Pooja Jhaveri
- Department of Pediatrics, Penn State College of Medicine (BH Levi, P Jhaveri, D Abdulahad, and BN Fogel), Hershey, Pa; Penn State College of Medicine (P Jhaveri), Hershey, Pa
| | - Cynthia H Chuang
- Department of Medicine, Penn State College of Medicine (CH Chuang), Hershey, Pa; Department of Public Health Sciences, Penn State College of Medicine (CH Chuang and E Lehman), Hershey, Pa
| | - Denise Abdulahad
- Department of Pediatrics, Penn State College of Medicine (BH Levi, P Jhaveri, D Abdulahad, and BN Fogel), Hershey, Pa
| | - Erik Lehman
- Department of Public Health Sciences, Penn State College of Medicine (CH Chuang and E Lehman), Hershey, Pa
| | - Benjamin N Fogel
- Department of Pediatrics, Penn State College of Medicine (BH Levi, P Jhaveri, D Abdulahad, and BN Fogel), Hershey, Pa; Penn State College of Medicine (P Jhaveri), Hershey, Pa
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19
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Van Scoy LJ, Green MJ, Witt PD, Bramble C, Richardson C, Putzig I, Toyobo O, Wasserman E, Chinchilli VM, Tucci A, Levi BH. Low Skepticism and Positive Attitudes About Advance Care Planning Among African Americans: a National, Mixed Methods Cohort Study. J Gen Intern Med 2021; 36:705-712. [PMID: 32948953 PMCID: PMC7947044 DOI: 10.1007/s11606-020-06224-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND African Americans have low engagement in advance care planning (ACP). This has been attributed to healthcare distrust and skepticism about ACP. A better understanding of these attitudes is needed to address health disparities related to end-of-life care. OBJECTIVE To explore the ACP-related values and beliefs of diverse African American communities across the USA and then the perceived value of an inexpensive end-of-life conversational game. DESIGN Prospective, convergent, mixed methods cohort study involving fifteen underserved, African American communities across the USA. PARTICIPANTS Of the 428 who attended events at purposively sampled sites, 90% consented to the research; 37% participated in one of 15 focus groups (n = 141). INTERVENTION An end-of-life conversation game, played in groups of 4-6. MAIN MEASURES The validated, 7-item ACP values and beliefs questionnaire (scaled 7 = least skeptical, 49 = most skeptical) was administered pre-game. Post-game focus groups explored perceptions about ACP and the intervention. KEY RESULTS Participants had positive attitudes (low skepticism) about ACP with a median score of 12.00 (7.00, 20.00). Values and beliefs did not significantly differ by geographical region; however, rural areas were observed to be slightly more skeptical than urban areas (median score 14.00 vs. 11.00, p = 0.002). Themes from focus groups converged with survey data showing participants valued the ACP process and consider further engagement in ACP to be worthwhile. Subthemes emphasized the need for and value of ACP. CONCLUSIONS Skepticism about ACP may contribute to low rates of ACP engagement in underserved African American communities. The positive attitudes uncovered in our study either negate previous findings or suggest reduced skepticism. TRIAL REGISTRATION This study has been registered at clinicaltrials.gov ( NCT03456921 ).
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Affiliation(s)
- Lauren Jodi Van Scoy
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA.
- Department of Humanities, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA.
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA.
| | - Michael J Green
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
- Department of Humanities, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Pamela D Witt
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | | | | | - Irene Putzig
- Hospice Foundation of America, Washington, DC, USA
| | - Olubukola Toyobo
- Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Emily Wasserman
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Amy Tucci
- Hospice Foundation of America, Washington, DC, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
- Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
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Levi BH, Belser A, Kapp K, Verdiglione N, Mincemoyer C, Dore S, Keat J, Fiene R. iLookOut for Child Abuse: Conceptual and Practical Considerations in Creating an Online Learning Program to Engage Learners and Promote Behavior Change. Early Child Dev Care 2021; 191:535-544. [PMID: 34239220 PMCID: PMC8258631 DOI: 10.1080/03004430.2019.1626374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Benjamin H. Levi
- Departments of Humanities & Pediatrics; Penn State College of Medicine & Penn State Children’s Hospital; Hershey, Pennsylvania
| | - Andrew Belser
- Theatre Department; Penn State University; State College, Pennsylvania
| | - Karl Kapp
- Department of Humanities; Penn State College of Medicine; Hershey, Pennsylvania
| | - Nicole Verdiglione
- Department of Humanities; Penn State College of Medicine; Hershey, Pennsylvania
| | - Claudia Mincemoyer
- Emerita Professor; Extension Education Department, Penn State University, State College, Pennsylvania
| | - Sarah Dore
- Department of Humanities; Penn State College of Medicine; Hershey, Pennsylvania
| | - Jane Keat
- . Emerita Professor, Education Department, Penn State University, Middletown, Pennsylvania
| | - Richard Fiene
- Emeritus Professor, Departments of Psychology & Human Development, Penn State University; Elizabethtown, Pennsylvania; President, Research Institute for Key Indicators
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Thiede E, Levi BH, Lipnick D, Johnson R, Seo La I, Lehman EB, Smith T, Wiegand D, Green M, Van Scoy LJ. Effect of Advance Care Planning on Surrogate Decision Makers' Preparedness for Decision Making: Results of a Mixed-Methods Randomized Controlled Trial. J Palliat Med 2020; 24:982-993. [PMID: 33373538 DOI: 10.1089/jpm.2020.0238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Advance care planning (ACP) is intended to help patients and their spokespersons prepare for end-of-life decision making, yet little is known about what factors influence the extent to which spokespersons feel prepared for that role. Objective: To examine spokespersons' perceived preparedness for surrogate decision making after engaging in ACP. Design: Mixed methods experimental design with qualitative thematic analysis and data transformation (creating categorical data from rich qualitative data) of interviews collected during a randomized controlled trial (2012-2017). Setting/Participants: Two tertiary care medical centers (Hershey, PA and Boston, MA). Of 285 dyads (patients with advanced illness and their spokespersons) enrolled in the trial, 200 spokesperson interviews were purposively sampled and 198 included in the analyses. Main Outcomes and Measures: Interviews with spokespersons (four weeks post-intervention) explored spokespersons' perceived preparedness for surrogate decision making, occurrence of ACP conversations, and spokespersons' intentions regarding future surrogate decisions. Data transformation was used to categorize participants' responses into three categories: Very Prepared, Very Unprepared, or In Between Prepared and Unprepared. Themes and categories were compared across arms. Results: About 72.72% of spokespersons (144/198) reported being Very Prepared and 27.28% (54/198) reported being Very Unprepared or In Between with no differences in preparedness across study arms. Occurrence of post-intervention ACP conversations did not influence perceived preparedness; however, spokespersons who used an ACP decision aid reported more conversations. Four themes emerged to explain spokespersons' perceived preparedness: (1) perceptions about ACP; (2) level of comfort with uncertainty; (3) relational issues; and (4) personal characteristics. Regarding future intentions, it emerged that spokespersons believed their knowledge of patient wishes, as well as other personal, relational, situational, and emotional factors would influence their surrogate decisions. Conclusions: Factors extrinsic to specific ACP interventions influence how prepared spokespersons feel to act as spokespersons. Understanding these factors is important for understanding how to improve concordance between patients' stated end-of-life wishes and surrogate decisions. Trial Registration: NCT02429479.
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Affiliation(s)
- Elizabeth Thiede
- College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Benjamin H Levi
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Pediatrics, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Daniella Lipnick
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Rhonda Johnson
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - In Seo La
- School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - Erik B Lehman
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Theresa Smith
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Pediatrics, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Debra Wiegand
- School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - Michael Green
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Lauren Jodi Van Scoy
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
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Lipnick D, Green M, Thiede E, Smith TJ, Lehman EB, Johnson R, La IS, Wiegand D, Levi BH, Van Scoy LJ. Surrogate Decision Maker Stress in Advance Care Planning Conversations: A Mixed-Methods Analysis From a Randomized Controlled Trial. J Pain Symptom Manage 2020; 60:1117-1126. [PMID: 32645452 PMCID: PMC8109394 DOI: 10.1016/j.jpainsymman.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Spokespersons serving as surrogate decision makers for their loved ones report high levels of stress. Despite known benefits, advance care planning (ACP) conversations often do not occur. More information is needed to understand spokesperson stress during ACP. OBJECTIVES To explore if and how spokespersons perceive stress related to ACP conversations; compare factors related to stress; and assess whether ACP intervention impacted stress. METHODS Secondary and mixed-methods analysis with data transformation of semistructured interviews occurring during a 2 × 2 factorial (four armed) randomized controlled trial that compared standard online ACP to a comprehensive online ACP decision aid. Tools were completed by patients with advanced illness (n = 285) alone or with their spokesperson (n = 285). About 200 spokesperson interviews were purposively sampled from each of the four arms (50 per arm). RESULTS ACP conversations were reported as stressful by 54.41% (74 of 136) and nonstressful by 45.59% (62 of 136). Five themes impacting spokesperson stress were the nature of the relationship with their loved one; self-described personality and belief systems; knowledge and experience with illness and ACP conversations; attitude toward ACP conversations; and social support in caregiving and decision making. No significant differences in stress were associated with arm assignment. CONCLUSION Identifying what factors impact spokesperson stress in ACP conversations can be used to help design ACP interventions to more appropriately address the needs and concerns of spokespersons.
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Affiliation(s)
- Daniella Lipnick
- Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| | - Michael Green
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Elizabeth Thiede
- Penn State College of Nursing, University Park, Pennsylvania, USA
| | - Theresa J Smith
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Erik B Lehman
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Public Health Sciences at Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Rhonda Johnson
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - In Seo La
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Debra Wiegand
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Pediatrics, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Lauren J Van Scoy
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Public Health Sciences at Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Van Scoy LJ, Levi BH, Witt P, Bramble C, Richardson C, Putzig I, Levi AR, Wasserman E, Chinchilli V, Tucci A, Green MJ. Association of Participation in an End-of-Life Conversation Game With Advance Care Planning Behavior and Perspectives Among African American Individuals. JAMA Netw Open 2020; 3:e204315. [PMID: 32383747 PMCID: PMC7210487 DOI: 10.1001/jamanetworkopen.2020.4315] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Less than 25% of African American individuals have completed advance directives and are thus vulnerable to poor end-of-life care. Low-cost interventions are needed to increase engagement in advance care planning (ACP). OBJECTIVES To investigate whether an end-of-life conversation game motivates African American attendees to engage in ACP and to assess whether the game is well received and endorsed. EXPOSURES Attendance at an end-of-life conversation game (Hello) played in groups of 4 to 6 participants for 60 minutes. DESIGN, SETTING, AND PARTICIPANTS Prospective, mixed-methods cohort study conducted from 2018 to 2019 with a 3- to 11-month follow-up interview. Game events were held in 53 community venues across the US; 15 were purposively sampled for onsite research procedures. Of 428 attendees at purposively sampled sites, 386 (90%) consented to research procedures (6 attendees were removed from analysis for protocol deviation). Of 367 attendees who provided accurate contact information, 232 (63%) were contacted, and 220 were included in follow-up analyses. MAIN OUTCOMES AND MEASURES The primary outcome was advance directive completion rates after the intervention. Secondary outcomes included rates of other ACP behaviors, ACP engagement, conversation satisfaction and realism, and participants' Net Promoter Score (a measure of endorsement). Follow-up telephone interviews explored the game experience and relevant ACP behaviors of attendees. RESULTS Of 380 individuals who participated (mean [SD] age, 62.2 [13.8] years; 304 were female [80%], and 348 were [92%] African American), none withdrew because of an adverse event. After the intervention, 91 of 220 attendees (41%) completed a new advance directive; 176 of 220 attendees (80%) discussed end-of-life wishes with loved ones, and 214 of 219 attendees (98%) completed at least 1 ACP behavior. There was a moderate increase in the self-efficacy domain on the ACP Engagement Survey (mean [SD] change from before to after the game, 0.54 [0.98]; P < .001). The mean (SD) conversation satisfaction score was 6.21 (0.93) (range, 1-7, with 7 being highest satisfaction), and the overall Net Promoter Score was 57.89 (range, -100 to 100, with 100 being highest endorsement). Interviews revealed 5 themes about the game: (1) it was a useful forum for ACP; (2) it provided new information and perspective; (3) it was emotionally beneficial; (4) it increased appreciation for ACP; and (5) it empowered and motivated participants to perform ACP. Mixed-methods integration showed convergence across data sets. CONCLUSIONS AND RELEVANCE Among a nationwide sample of African American individuals, the end-of-life conversation game appeared to be well received and was associated with high rates of ACP behavior. This low-cost and scalable tool may help reduce health disparities associated with end-of-life care.
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Affiliation(s)
- Lauren Jodi Van Scoy
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Humanities, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Benjamin H. Levi
- Department of Humanities, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Pamela Witt
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | | | | | | | - A. Rose Levi
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Emily Wasserman
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Vernon Chinchilli
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Amy Tucci
- Hospice Foundation of America, Washington, DC
| | - Michael J. Green
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Humanities, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
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Green MJ, Van Scoy LJ, Foy AJ, Dimmock AEF, Lehman E, Levi BH. Patients With Advanced Cancer Choose Less Aggressive Medical Treatment on Vignettes After Using a Computer-Based Decision Aid. Am J Hosp Palliat Care 2019; 37:537-541. [PMID: 31830798 DOI: 10.1177/1049909119892596] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although patients often prefer less rather than more treatment at the end of life, in the absence of contrary instructions, the medical profession's de facto position is to treat aggressively. It is unknown whether a computer-based decision aid can affect treatment choices. METHODS Secondary analysis of a single-center, single-blind randomized controlled trial of an advance care planning (ACP) intervention among 200 patients with stage IV cancer. Participants were randomized to intervention (Making Your Wishes Known, a values-neutral, educational, computer-based decision aid) or control (standard living will + brochure). After reading a hypothetical clinical vignette, participants were asked whether they would want 11 medical/surgical treatments in that situation (dialysis, cardiopulmonary resuscitation [CPR], ventilator, feeding tube, etc). The median number of treatments wanted by participants was compared between groups, and logistic regression was used to compare between-group likelihood of not wanting each specific treatment. RESULTS The median number of treatments wanted was 1 in the intervention group versus 5 in the control (P < .001). For 6 of 11 treatments, the intervention group was significantly less likely than control to want aggressive treatment. Most notably, compared to control, intervention participants were less likely to want CPR (odds ratio [OR] = 0.31), short-term mechanical ventilation (OR = 0.34), short-term dialysis (OR = 0.38), surgery (OR = 0.37), and transfusion (OR = 0.21). CONCLUSIONS Individuals using an educational ACP decision aid were less likely to want aggressive medical treatment than those completing standard living wills. These findings have implications not only for how to respect patient's wishes but also potentially for reducing costs at the end of life.
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Affiliation(s)
- Michael J Green
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA.,Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA.,Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Andrew J Foy
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Anne E F Dimmock
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Erik Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
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Foy AJ, Levi BH, Van Scoy LJ, Bucher A, Dimmock A, Green MJ. Patient Preference to Accept Medical Treatment Is Associated with Spokesperson Agreement. Ann Am Thorac Soc 2019; 16:518-521. [PMID: 30714833 PMCID: PMC6441700 DOI: 10.1513/annalsats.201806-428rl] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - Anne Dimmock
- Penn State College of MedicineHershey, Pennsylvania
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Abstract
PURPOSE Advance directives (AD) have been heralded as vehicles to promote patient autonomy and have been decried as ineffective. Efforts to improve advance care planning (ACP) and AD documents are wide ranging but have not been prospectively studied. MATERIALS AND METHODS In an institutional review board-approved, single-blind, randomized, controlled trial, we compared an interactive, educational ACP decision aid to standard ACP among patients with advanced cancer. We hypothesized that use of the decision aid would increase physician awareness of patients' health care wishes and increase physician adherence to patients' end-of-life wishes compared with standard ACP. RESULTS A total of 200 patients were randomly assigned to two study arms. We analyzed data from medical records and interviews with physicians and family members for 121 patients who died by August 2016. No differences in physician awareness or adherence were found between the ACP decision aid and standard ACP groups. End-of-life treatment wishes and discussion of wishes were documented for 70% and 64% of the patients, respectively, but only 35% had an actual AD in the medical record. According to family members, end-of-life care was consistent with the patients' stated wishes 94% of the time. Similarly, according to physicians, it was consistent for 98%. However, according to AD documents, delivered care was consistent with desired care in only 65%. Considerably fewer patients than predicted died, and data from physicians were difficult to obtain. CONCLUSION ACP type did not influence documentation of patient wishes or end-of-life care received. Future prospective studies must account for challenges in prognostication and point-of-care data collection at the end of life.
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Affiliation(s)
- Jane R Schubart
- 1 The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Benjamin H Levi
- 1 The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Megan M Bain
- 1 The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Elana Farace
- 1 The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Michael J Green
- 1 The Pennsylvania State University, College of Medicine, Hershey, PA
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Schubart JR, Reading JM, Penrod J, Stewart RR, Sampath R, Lehmann LS, Levi BH, Green MJ. Family Caregivers' Characterization of Conversations Following an ACP Event. Am J Hosp Palliat Care 2018; 35:1161-1167. [PMID: 30071784 DOI: 10.1177/1049909118760302] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) has been shown to benefit patients and families, yet little is known about how an ACP event impacts communication and conversation about end-of-life treatment wishes and the content of such conversations between patients and family caregivers. OBJECTIVE To characterize post-ACP conversations regarding medical wishes between seriously ill patients and their family caregivers. PARTICIPANTS Patients with advanced illness and family caregivers. OUTCOME MEASURED Post-ACP conversations. DESIGN As part of a larger randomized controlled trial, dyads consisting of seriously ill patients and their identified family caregiver engaged in ACP and created an advance directive for the patient. Approximately 4 to 6 weeks later, semistructured interviews were conducted with the family caregivers to elucidate the subsequent communications regarding medical wishes. If the dyad did not have any conversations post-ACP, reasons and barriers were explored. RESULTS The majority of dyads (131/188, 69.7%) had 2 to 3 conversations lasting 3 to 5 minutes each in the weeks immediately following ACP. These conversations most commonly addressed general patient wishes about quality of life and specific medical treatments. The most common reasons for not having conversations were a general discomfort with the topic (13/57, 22.8%) and previously having discussed medical wishes (16/57, 28.1%). CONCLUSION The ACP events promote conversation regarding quality of life, general wishes at the end of life, and specific medical wishes. Barriers to conversation following ACP were similar to barriers to ACP in general, suggesting that a more intentional focus on addressing these barriers pre- and post-ACP may be necessary to improve communication.
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Affiliation(s)
- Jane R Schubart
- Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, PA, USA.,Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA.,Department of Medicine, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jean M Reading
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Janice Penrod
- College of Nursing, The Pennsylvania State University, University Park, PA, USA
| | - Renee R Stewart
- Department of Humanities, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Ramya Sampath
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Lisa S Lehmann
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.,National Center for Ethics in Health Care Veterans Health, Washington, DC, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Benjamin H Levi
- Department of Humanities, The Pennsylvania State University College of Medicine, Hershey, PA, USA.,10 Department of Pediatrics, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Michael J Green
- Department of Medicine, The Pennsylvania State University College of Medicine, Hershey, PA, USA.,Department of Humanities, The Pennsylvania State University College of Medicine, Hershey, PA, USA
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Stewart RR, Dimmock AEF, Green MJ, Van Scoy LJ, Schubart JR, Yang C, Farace E, Bascom R, Levi BH. An Analysis of Recruitment Efficiency for an End-of-Life Advance Care Planning Randomized Controlled Trial. Am J Hosp Palliat Care 2018; 36:50-54. [PMID: 29976075 DOI: 10.1177/1049909118785158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND: Optimizing recruitment efficiency is an important strategy to address the resource limitations that typically constrain clinical research. Surprisingly, little empiric data exist to guide research teams attempting to recruit a difficult population into similar studies. Our objective was to investigate factors associated with enrollment into an advance care planning interventional trial. METHODS: This study used secondary data of patients with advanced cancer receiving treatment at an academic medical center in central Pennsylvania who were referred to a randomized controlled trial of an advance care planning intervention. Enrolled participants were compared to nonparticipants with regard to age, gender, race, season of recruitment, elapsed time between recruitment stage, distance to study site, and number of recruitment calls. RESULTS: Of the 1988 patients referred, 200 participants were enrolled yielding a recruitment efficiency of 10%. Two-thirds of all enrolled participants were recruited with 1 or less phone calls, whereas only 5% were enrolled after 3 calls. There were no statistically significant differences in enrollment based on gender ( P = .88) or elapsed time between recruitment contacts ( P = .22). However, nonparticipants were slightly older ( P = .02). CONCLUSIONS: Our finding that individuals were more likely to enroll within the first 3 phone calls suggests that recruitment efforts should be focused on making initial contacts with potential participants, rather than continuing attempts to those who are unable to be contacted easily. Researchers could optimize their recruitment strategy by periodically performing similar analyses, comparing differences between participants and nonparticipants.
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Affiliation(s)
- Renee R Stewart
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Anne E F Dimmock
- 2 Division of Pulmonary, Department of Medicine, Allergy and Critical Care Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Michael J Green
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,3 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,2 Division of Pulmonary, Department of Medicine, Allergy and Critical Care Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Jane R Schubart
- 4 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,5 Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Chengwu Yang
- 6 Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York, NY, USA
| | - Elana Farace
- 4 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,7 Department of Neurosurgery, Penn State College of Medicine, Hershey, PA, USA
| | - Rebecca Bascom
- 2 Division of Pulmonary, Department of Medicine, Allergy and Critical Care Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Benjamin H Levi
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,8 Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
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Green MJ, Van Scoy LJ, Foy AJ, Stewart RR, Sampath R, Schubart JR, Lehman EB, Dimmock AEF, Bucher AM, Lehmann LS, Harlow AF, Yang C, Levi BH. A Randomized Controlled Trial of Strategies to Improve Family Members' Preparedness for Surrogate Decision-Making. Am J Hosp Palliat Care 2017; 35:866-874. [PMID: 29186982 DOI: 10.1177/1049909117744554] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate 2 strategies for preparing family members for surrogate decision-making. DESIGN A 2 × 2 factorial, randomized controlled trial testing whether: (1) comprehensive online advance care planning (ACP) is superior to basic ACP, and (2) having patients engage in ACP together with family members is superior to ACP done by patients alone. SETTING Tertiary care centers in Hershey, Pennsylvania, and Boston, Massachusetts. PARTICIPANTS Dyads of patients with advanced, severe illness (mean age 64; 46% female; 72% white) and family members who would be their surrogate decision-makers (mean age 56; 75% female; 75% white). INTERVENTIONS Basic ACP: state-approved online advance directive plus brochure. Making Your Wishes Known (MYWK): Comprehensive ACP decision aid including education and values clarification. MEASUREMENTS Pre-post changes in family member self-efficacy (100-point scale) and postintervention concordance between patients and family members using clinical vignettes. RESULTS A total 285 dyads enrolled; 267 patients and 267 family members completed measures. Baseline self-efficacy in both MYWK and basic ACP groups was high (90.2 and 90.1, respectively), and increased postintervention to 92.1 for MYWK ( P = .13) and 93.3 for basic ACP ( P = .004), with no between-group difference. Baseline self-efficacy in alone and together groups was also high (90.2 and 90.1, respectively), and increased to 92.6 for alone ( P = .03) and 92.8 for together ( P = .03), with no between-group difference. Overall adjusted concordance was higher in MYWK compared to basic ACP (85.2% vs 79.7%; P = .032), with no between-group difference. CONCLUSION The disconnect between confidence and performance raises questions about how to prepare family members to be surrogate decision-makers.
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Affiliation(s)
- Michael J Green
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Andrew J Foy
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,4 Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA, USA
| | - Renee R Stewart
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Ramya Sampath
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Jane R Schubart
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,6 Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Erik B Lehman
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Anne E F Dimmock
- 2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Ashley M Bucher
- 4 Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA, USA
| | - Lisa S Lehmann
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,7 National Center for Ethics in Health Care, Veterans Administration, Washington, DC, USA
| | - Alyssa F Harlow
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Chengwu Yang
- 8 Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York, NY, USA
| | - Benjamin H Levi
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,9 Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
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Van Scoy LJ, Reading JM, Hopkins M, Smith B, Dillon J, Green MJ, Levi BH. Community Game Day: Using an End-of-Life Conversation Game to Encourage Advance Care Planning. J Pain Symptom Manage 2017; 54:680-691. [PMID: 28743662 DOI: 10.1016/j.jpainsymman.2017.07.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Advance care planning (ACP) is an important process that involves discussing and documenting one's values and preferences for medical care, particularly end-of-life treatments. OBJECTIVES This convergent, mixed-methods study assessed whether an end-of-life conversation card game is an acceptable and effective means for performing ACP for patients with chronic illness and/or their caregivers when deployed in a community setting. METHODS Twenty-two games (n = 93 participants) were held in community settings surrounding Hershey, PA in 2016. Participants were recruited using random sampling from patient databases and also convenience sampling (i.e., flyers). Quantitative questionnaires and qualitative focus group interviews were administered to assess the game experience and subsequent performance of ACP behaviors. RESULTS Both quantitative and qualitative data found that Community Game Day was a well-received, positive experience for participants and 75% of participants performed ACP within three months post-intervention. CONCLUSIONS These findings suggest that using a conversation game during community outreach is a useful approach for engaging patients and caregivers in ACP. The convergence of quantitative and qualitative data strongly supports the continued investigation of the game in randomized controlled trials.
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Affiliation(s)
- Lauren J Van Scoy
- Department of Medicine and Humanities, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA.
| | - Jean M Reading
- Department of Medicine, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Margaret Hopkins
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Brandi Smith
- Department of Medicine, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Judy Dillon
- Department of Nursing, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Michael J Green
- Department of Medicine and Humanities, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Benjamin H Levi
- Department of Pediatrics and Humanities, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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Van Scoy LJ, Watson-Martin E, Bohr TA, Levi BH, Green MJ. End-of-Life Conversation Game Increases Confidence for Having End-of-Life Conversations for Chaplains-in-Training. Am J Hosp Palliat Care 2017; 35:592-600. [DOI: 10.1177/1049909117723619] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Lauren Jodi Van Scoy
- Department of Medicine and Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | | | - Tiffany A. Bohr
- Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Benjamin H. Levi
- Department of Pediatrics and Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Michael J. Green
- Department of Medicine and Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
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Mathews B, Yang C, Lehman EB, Mincemoyer C, Verdiglione N, Levi BH. Educating early childhood care and education providers to improve knowledge and attitudes about reporting child maltreatment: A randomized controlled trial. PLoS One 2017; 12:e0177777. [PMID: 28542285 PMCID: PMC5438118 DOI: 10.1371/journal.pone.0177777] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/02/2017] [Indexed: 01/21/2023] Open
Abstract
Early childhood care and education providers (CCPs) work with over 7 million young children. These children are vulnerable to physical, sexual and emotional abuse, and neglect. However, CCPs make less than 1% of all reports of suspected child abuse and neglect that are made to child protective services. CCPs are therefore an untapped resource in the public health response to child maltreatment. However, their knowledge and attitudes about duties to report child maltreatment are poorly understood. Moreover, no rigorous research has tested whether their knowledge and attitudes about reporting child maltreatment can be improved. These gaps in knowledge are important because knowledge of the duty and positive attitudes towards it produce more effective reporting, and little evidence exists about how to enhance cognitive and affective attributes. Using the CONSORT approach, we report a single-blind test-retest randomized controlled trial evaluating iLook Out for Child Abuse, a customized online educational intervention for CCPs to increase knowledge and attitudes towards the reporting duty. 762 participants were randomized with results analyzed for 741 participants (372 in the intervention group; 369 in the control). Knowledge of the reporting duty increased in the intervention group from 13.54 to 16.19 out of 21 (2.65 increase, 95% CI: (2.37, 2.93); large effect size 0.95, p < 0.001); the control group remained stable, moving from 13.54 to 13.59 (0.05 increase, 95% CI: (-0.12, 0.22); negligible effect size 0.03, p = 0.684). Attitudes were enhanced on all 13 items for the intervention group, remaining stable in the control, with significant differences between groups on all items (p < 0.05). Gains were largely sustained at four month follow-up. Findings support education for CCPs and other professions. Future research should also explore effects of education on reporting behavior. TRIAL REGISTRATION US National Institutes of Health NCT02225301.
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Affiliation(s)
- Ben Mathews
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD, Australia
| | - Chengwu Yang
- College of Medicine, Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, & Office for Scholarship in Learning and Education Research (OSLER), Penn State University, Hershey, PA, United States of America
| | - Erik B. Lehman
- College of Medicine, Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, Penn State University, Hershey, PA, United States of America
| | - Claudia Mincemoyer
- Department of Agricultural Economics, Sociology and Education, Penn State University, University Park, PA, United States of America
| | - Nicole Verdiglione
- Pediatric Clinical Research Office, Penn State Hershey Children's Hospital, Hershey, PA, United States of America
| | - Benjamin H. Levi
- College of Medicine, Department of Pediatrics, Penn State University, Hershey, PA, United States of America
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Van Scoy LJ, Scott AM, Reading JM, Chuang CH, Chinchilli VM, Levi BH, Green MJ. From Theory to Practice: Measuring end-of-life communication quality using multiple goals theory. Patient Educ Couns 2017; 100:909-918. [PMID: 28011081 DOI: 10.1016/j.pec.2016.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 11/17/2016] [Accepted: 12/14/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To describe how multiple goals theory can be used as a reliable and valid measure (i.e., coding scheme) of the quality of conversations about end-of-life issues. METHODS We analyzed conversations from 17 conversations in which 68 participants (mean age=51years) played a game that prompted discussion in response to open-ended questions about end-of-life issues. Conversations (mean duration=91min) were audio-recorded and transcribed. Communication quality was assessed by three coders who assigned numeric scores rating how well individuals accomplished task, relational, and identity goals in the conversation. RESULTS The coding measure, which results in a quantifiable outcome, yielded strong reliability (intra-class correlation range=0.73-0.89 and Cronbach's alpha range=0.69-0.89 for each of the coded domains) and validity (using multilevel nonlinear modeling, we detected significant variability in scores between games for each of the coded domains, all p-values <0.02). CONCLUSIONS Our coding scheme provides a theory-based measure of end-of-life conversation quality that is superior to other methods of measuring communication quality. PRACTICE IMPLICATIONS Our description of the coding method enables researches to adapt and apply this measure to communication interventions in other clinical contexts.
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Affiliation(s)
- L J Van Scoy
- Department of Medicine and Humanities, Penn State Milton S. Hershey Medical Center, United States.
| | - A M Scott
- Department of Communication, University of Kentucky, United States
| | - J M Reading
- Department of Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - C H Chuang
- Department of Medicine and Public Health Sciences, Penn State Milton S. Hershey Medical Center, United States
| | - V M Chinchilli
- Department of Public Health Sciences and Statistics, Penn State Milton S. Hershey Medical Center, United States
| | - B H Levi
- Department of Humanities and Pediatrics, Penn State Milton S. Hershey Medical Center, United States
| | - M J Green
- Department of Medicine and Humanities, Penn State Milton S. Hershey Medical Center, United States
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Levi BH, Simmons Z, Hanna C, Brothers A, Lehman E, Farace E, Bain M, Stewart R, Green MJ. Advance care planning for patients with amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2017. [PMID: 28631959 DOI: 10.1080/21678421.2017.1285317] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine whether an advance care planning (ACP) decision-aid could improve communication about end-of-life treatment wishes between patients with amyotrophic lateral sclerosis (ALS) and their clinicians. METHODS Forty-four patients with ALS (>21, English-speaking, without dementia) engaged in ACP using an interactive computer based decision-aid. Before participants completed the intervention, and again three months later, their clinicians reviewed three clinical vignettes, and made treatment decisions (n = 18) for patients. After patients indicated their agreement with the team's decisions, concordance was calculated. RESULTS The mean concordance between patient wishes and the clinical team decisions was significantly higher post-intervention (post = 91.9%, 95% CI = 87.8, 96.1, vs. pre = 52.4%, 95% CI = 41.9, 62.9; p <0.001). Clinical team members reported greater confidence that their decisions accurately represented each patient's wishes post-intervention (mean = 6.5) compared to pre-intervention (mean = 3.3, 1 = low, 10 = high, p <0.001). Patients reported high satisfaction (mean = 26.4, SD = 3.2; 6 = low, 30 = high) and low decisional conflict (mean = 28.8, SD = 8.2; 20 = low, 80 = high) with decisions about end-of-life care, and high satisfaction with the decision-aid (mean = 52.7, SD = 5.7, 20 = low, 60 = high). Patient knowledge regarding ACP increased post-intervention (pre = 47.8% correct responses vs. post = 66.3%; p <0.001) without adversely affecting patient anxiety or self-determination. CONCLUSION A computer based ACP decision-aid can significantly improve clinicians' understanding of ALS patients' wishes with regard to end-of-life medical care.
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Affiliation(s)
- Benjamin H Levi
- a Department of Humanities & Pediatrics , Penn State College of Medicine , Hershey , PA , USA
| | - Zachary Simmons
- b Department of Neurology , Penn State College of Medicine, ALS Clinic and Research Center , Hershey , PA , USA
| | | | - Allyson Brothers
- d Human Development and Family Studies , Colorado State University , Fort Collins , CO , USA
| | - Erik Lehman
- e Department of Public Health Sciences , Penn State College of Medicine , Hershey , PA , USA
| | - Elana Farace
- e Department of Public Health Sciences , Penn State College of Medicine , Hershey , PA , USA
| | - Megan Bain
- f Department of Humanities , Penn State College of Medicine , Hershey , PA , USA , and
| | - Renee Stewart
- f Department of Humanities , Penn State College of Medicine , Hershey , PA , USA , and
| | - Michael J Green
- g Department of Humanities & Medicine , Penn State College of Medicine , Hershey , PA , USA
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Van Scoy LJ, Reading JM, Scott AM, Chuang C, Levi BH, Green MJ. Exploring the Topics Discussed During a Conversation Card Game About Death and Dying: A Content Analysis. J Pain Symptom Manage 2016; 52:655-662. [PMID: 27650010 DOI: 10.1016/j.jpainsymman.2016.03.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/17/2016] [Accepted: 04/27/2016] [Indexed: 11/23/2022]
Abstract
CONTEXT Substantive discussions between loved ones are necessary for effective advance care planning. Although multiple tools are currently in use for promoting conversations, the content and clinical relevance of the conversations they stimulate is unknown. OBJECTIVE To describe the content and clinical relevance of conversations that occur during a nonfacilitated end-of-life conversation game. METHODS Using convenience sampling, we scheduled adult volunteers to participate in an end-of-life conversation game (2-6 individuals per game; n = 68). Participants discussed 20 questions about death, dying, or end-of-life issues. Games lasted up to two hours and were audio-recorded, transcribed, and analyzed using a conventional qualitative content analysis approach to identify emerging themes. RESULTS Participants (n = 68) were primarily Caucasian (94%), females (68%), with mean age of 51.3 years (SD 0.7). Seventeen games were analyzed. Four primary themes emerged during game conversations: 1) the importance of people, relationships, and the roles played during end-of-life decision making, 2) values, beliefs, and preferences related to end-of-life care and the dying period, 3) considerations about preparing for the aftermath of one's death, and 4) the relevance of stories or experiences for informing one's own end-of-life preferences. CONCLUSIONS Topics discussed during a nonfacilitated end-of-life conversation game are substantive and address important issues for advance care planning.
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Affiliation(s)
- Lauren Jodi Van Scoy
- Medicine and Humanities, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| | - Jean M Reading
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Allison M Scott
- Communication, University of Kentucky, Lexington, Kentucky, USA
| | - Cynthia Chuang
- Medicine and Public Health Sciences, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Benjamin H Levi
- Humanities and Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Michael J Green
- Medicine and Humanities, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Abstract
A great deal has been written about the ethics of organ transplantation. Much of it has (appropriately) concerned issues of policy—for example, how best to allocate scarce organs, avoid conflicts of interest, and increase the pool of potential donors. Although these discussions are important, they often fail to provide much context for applying relevant ethical precepts to the day-to-day activities of those directly involved in organ procurement. The purpose of this paper is to provide such a context by reviewing several key conceptual issues, drawing attention to various ethical and procedural distinctions, and offering some practical recommendations for addressing these issues with physicians and other healthcare providers.
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Affiliation(s)
- Benjamin H Levi
- Penn State Milton S. Hershey Medical Center, Hershey, Pa, USA
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Van Scoy LJ, Green MJ, Dimmock AE, Bascom R, Boehmer JP, Hensel JK, Hozella JB, Lehman EB, Schubart JR, Farace E, Stewart RR, Levi BH. High satisfaction and low decisional conflict with advance care planning among chronically ill patients with advanced chronic obstructive pulmonary disease or heart failure using an online decision aid: A pilot study. Chronic Illn 2016; 12:227-35. [PMID: 27055468 DOI: 10.1177/1742395316633511] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/08/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Many patients with chronic illnesses report a desire for increased involvement in medical decision-making. This pilot study aimed to explore how patients with exacerbation-prone disease trajectories such as advanced heart failure or chronic obstructive pulmonary disease experience advance care planning using an online decision aid and to compare whether patients with different types of exacerbation-prone illnesses had varied experiences using the tool. METHODS Pre-intervention questionnaires measured advance care planning knowledge. Post-intervention questionnaires measured: (1) advance care planning knowledge; (2) satisfaction with tool; (3) decisional conflict; and (4) accuracy of the resultant advance directive. Comparisons were made between patients with heart failure and chronic obstructive pulmonary disease. RESULTS Over 90% of the patients with heart failure (n = 24) or chronic obstructive pulmonary disease (n = 25) reported being "satisfied" or "highly satisfied" with the tool across all satisfaction domains; over 90% of participants rated the resultant advance directive as "very accurate." Participants reported low decisional conflict. Advance care planning knowledge scores rose by 18% (p < 0.001) post-intervention. There were no significant differences between participants with heart failure and chronic obstructive pulmonary disease. DISCUSSION Patients with advanced heart failure and chronic obstructive pulmonary disease were highly satisfied after using an online advance care planning decision aid and had increased knowledge of advance care planning. This tool can be a useful resource for time-constrained clinicians whose patients wish to engage in advance care planning.
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Affiliation(s)
- Lauren J Van Scoy
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Michael J Green
- Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania, USA Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Anne Ef Dimmock
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Rebecca Bascom
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - John P Boehmer
- Division of Cardiology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Jessica K Hensel
- Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Joshua B Hozella
- Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Jane R Schubart
- Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Elana Farace
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Renee R Stewart
- Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania, USA Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
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Van Scoy LJ, Green MJ, Reading JM, Scott AM, Chuang CH, Levi BH. Can Playing an End-of-Life Conversation Game Motivate People to Engage in Advance Care Planning? Am J Hosp Palliat Care 2016; 34:754-761. [PMID: 27406696 DOI: 10.1177/1049909116656353] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) involves several behaviors that individuals undertake to prepare for future medical care should they lose decision-making capacity. The goal of this study was to assess whether playing a conversation game could motivate participants to engage in ACP. METHODS Sixty-eight English-speaking, adult volunteers (n = 17 games) from communities around Hershey, Pennsylvania, and Lexington, Kentucky, played a conversation card game about end-of-life issues. Readiness to engage in 4 ACP behaviors was measured by a validated questionnaire (based on the transtheoretical model) immediately before and 3 months postgame and a semistructured phone interview. These behaviors were (1) completing a living will; (2) completing a health-care proxy; (3) discussing end-of-life wishes with loved ones; and (4) discussing quality versus quantity of life with loved ones. RESULTS Participants' (n = 68) mean age was 51.3 years (standard deviation = 0.7, range: 22-88); 94% of the participants were caucasian and 67% were female. Seventy-eight percent of the participants engaged in ACP behaviors within 3 months of playing the game (eg, updating documents, discussing end-of-life issues). Furthermore, 73% of the participants progressed in stage of change (ie, readiness) to perform at least 1 of the 4 behaviors. Scores on measures of decisional balance and processes of change increased significantly by 3 months postintervention. CONCLUSION This pilot study found that individuals who played a conversation game had high rates of performing ACP behaviors within 3 months. These findings suggest that using a game format may be a useful way to motivate people to perform important ACP behaviors.
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Affiliation(s)
- Lauren J Van Scoy
- 1 Department of Medicine and Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Michael J Green
- 1 Department of Medicine and Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jean M Reading
- 2 Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Allison M Scott
- 3 Department of Communication, University of Kentucky, Lexington, KY, USA
| | - Cynthia H Chuang
- 4 Department of Medicine and Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Benjamin H Levi
- 5 Department of Pediatrics and Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
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Van Scoy LJ, Reading JM, Scott AM, Green MJ, Levi BH. Conversation Game Effectively Engages Groups of Individuals in Discussions about Death and Dying. J Palliat Med 2016; 19:661-7. [PMID: 27022862 DOI: 10.1089/jpm.2015.0390] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Discussions about end-of-life (EOL) values, wishes, and beliefs are critical for effective advance care planning (ACP). New strategies are needed to engage individuals in EOL conversations. OBJECTIVE The study objective was to test the feasibility of using a conversation game to engage individuals in EOL discussions. METHODS This study used a mixed-methods approach. Participants played a conversation game that prompts players to answer and discuss 20 questions about death, dying, and EOL care. Participants completed pre- and postgame questionnaires and participated in postgame focus groups. Subjects were 70 healthy volunteers (18 groups of families, friends, or strangers). Demographics, emotional state, and perceived relational closeness were measured using preintervention questionnaires. Postintervention questionnaires measured conversation satisfaction, realism, self-rated quality, and emotional state. Postgame focus groups evaluated players' experiences playing the game. RESULTS Using a seven-point Likert scale (1 = low score, 7 = high score), players rated game conversations as satisfying (mean [M] = 6.1, SD = 0.9), realistic (M = 5.6, SD = 0.8), and of high quality (M = 5.7, SD = 0.9). There were no negative effects on emotional state immediately postgame (M = 1.3, SD = 0.5). A thematic analysis of participants' experiences (n = 55) revealed that (1) playing the game was an enjoyable, positive experience; (2) a game is a good framing for EOL discussions; and (3) there were mixed opinions about ideal game group composition. CONCLUSIONS This study established that healthy volunteers enjoyed engaging in a two-hour discussion about EOL issues when framed as a game. The game experience was a positive, satisfying, and enjoyable activity for participants. Further studies are needed to determine if health games can promote effective ACP.
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Affiliation(s)
- Lauren Jodi Van Scoy
- 1 Division of Pulmonary, Allergy, and Critical Care, Pennsylvania State University , Hershey, Pennsylvania
| | - Jean M Reading
- 1 Division of Pulmonary, Allergy, and Critical Care, Pennsylvania State University , Hershey, Pennsylvania
| | - Allison M Scott
- 2 Department of Communications, University of Kentucky , Lexington, Kentucky
| | - Michael J Green
- 3 Department of Humanities and Medicine, Pennsylvania State University , Hershey, Pennsylvania
| | - Benjamin H Levi
- 4 Department of Pediatrics and Humanities, College of Medicine, Pennsylvania State University , Hershey, Pennsylvania
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Schubart JR, Green MJ, Levi BH. Response to Letter "End-of-Life Preferences in Advanced Cancer Patients". J Palliat Med 2015; 19:7. [PMID: 26629733 DOI: 10.1089/jpm.2015.0467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jane R Schubart
- 1 Department of Surgery, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania.,2 Department of Public Health Sciences, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania
| | - Michael J Green
- 3 Department of Humanities, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania
| | - Benjamin H Levi
- 4 Department of Pediatrics and Humanities, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania
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Abstract
ACKNOWLEDGMENTS The authors wish to acknowledge the support and assistance of Dr. William Lawrence for his contribution to the M.A.UT model used in the decision aid, Making Your Wishes Known: Planning Your Medical Future (MYWK), Dr. Cheryl Dellasega for her leadership in focus group activities, Charles Sabatino for his review of legal aspects of MYWK, Dr. Robert Pearlman and his collaborative team for use of the advance care planning booklet "Your Life, Your Choices," Megan Whitehead for assistance in grant preparation and project organization, and the Instructional Media Development Center at the University of Wisconsin as well as JPL Integrated Communications for production and programming of MYWK. BACKGROUND For various cultural and historical reasons, African Americans are less likely than Caucasians to engage in advance care planning (ACP) for healthcare decisions. PURPOSE This pilot study tested whether an interactive computer program could help overcome barriers to effective ACP among African Americans. METHODS African American adults were recruited from traditionally Black churches to complete an interactive computer program on ACP, pre-/post-questionnaires, and a follow-up phone interview. RESULTS Eighteen adults (mean age =53.2 years, 83% female) completed the program without any problems. Knowledge about ACP significantly increased following the computer intervention (44.9% → 61.3%, p=0.0004), as did individuals' sense of self-determination. Participants were highly satisfied with the ACP process (9.4; 1 = not at all satisfied, 10 = extremely satisfied), and reported that the computer-generated advance directive accurately reflected their wishes (6.4; 1 = not at all accurate, 7 = extremely accurate). Follow-up phone interviews found that >80% of participants reported having shared their advance directives with family members and spokespeople. CONCLUSION Preliminary evidence suggests that an interactive computer program can help African Americans engage in effective advance care planning, including creating an accurate advance directive document that will be shared with loved ones.
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Affiliation(s)
- Sarah A Markham
- Department of Humanities, The Pennsylvania State University, College of Medicine
| | - Benjamin H Levi
- Department of Humanities, The Pennsylvania State University, College of Medicine
| | - Michael J Green
- Department of Humanities, The Pennsylvania State University, College of Medicine
| | - Jane R Schubart
- Departments of Surgery and Medicine, The Pennsylvania State University, College of Medicine.
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Dias MS, Boehmer S, Johnston-Walsh L, Levi BH. Defining 'reasonable medical certainty' in court: What does it mean to medical experts in child abuse cases? Child Abuse Negl 2015; 50:218-227. [PMID: 26589362 DOI: 10.1016/j.chiabu.2015.10.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/28/2015] [Accepted: 10/27/2015] [Indexed: 06/05/2023]
Abstract
Physicians and others who provide expert testimony in court cases involving alleged child abuse may be instructed to state their conclusions within a 'reasonable medical certainty' (RMC). However, neither judges nor jurors knows what degree of probability constitutes RMC for a given expert, nor whether different experts use different standards to formulate their opinions. We sought to better understand how experts define RMC in the context of court cases. An email survey was sent to members of six list-serves, representing four specialties, whose members testify in child abuse cases. Respondents were asked to define how RMC corresponded to (1) the numerical probability that abuse occurred, (2) the ordinal probability, and (3) how their determinations relate to common legal standards ('preponderance of the evidence', 'clear and convincing', and 'beyond a reasonable doubt'). Participants were also asked how comfortable they were in defining RMC; whether their definition changed according to the charges or type of proceeding; and how they would apply RMC to several hypothetical cases. The 294 list-serve participants who responded included child abuse pediatricians (46%), forensic pathologists (21%), pediatric neurosurgeons (15%), pediatric ophthalmologists (12%), and others (6%). Though 95% of respondents had testified in court, only 45% had received training in the definition of RMC. Only 37% were comfortable defining RMC. Although many responses were highly clustered and paired comparisons showed that 95% of participants' responses were internally consistent, there was variability in respondents' definitions of RMC. There is some variability in how child abuse expert witnesses define and use the term RMC; we provide suggestions about how to more accurately and transparently define RMC to ensure justice in these cases.
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Affiliation(s)
- Mark S Dias
- Department of Neurosurgery, Penn State Hershey Medical Center, USA; Department of Pediatrics, Penn State Hershey Medical Center, USA
| | - Susan Boehmer
- Department of Public Health Sciences, Penn State College of Medicine, USA
| | | | - Benjamin H Levi
- Department of Pediatrics, Penn State Hershey Medical Center, USA; Department of Humanities, Penn State College of Medicine, USA
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Schubart JR, Green MJ, Van Scoy LJ, Lehman E, Farace E, Gusani NJ, Levi BH. Advanced Cancer and End-of-Life Preferences: Curative Intent Surgery Versus Noncurative Intent Treatment. J Palliat Med 2015; 18:1015-8. [PMID: 26262942 DOI: 10.1089/jpm.2015.0021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND People with cancer face complex medical decisions, including whether to receive life-sustaining treatments at the end of life. It is not unusual for clinicians to make assumptions about patients' wishes based on whether they had previously chosen to pursue curative treatment. OBJECTIVE We hypothesized that cancer patients who initially underwent curative intent surgery (CIS) would prefer more aggressive end-of-life treatments compared to patients whose treatment was noncurative intent (non-CIT). METHODS This study was a retrospective review of data from a large, randomized controlled trial examining the use of an online decision aid for advance care planning, "Making Your Wishes Known" (MYWK), with patients who had advanced cancer. We reviewed patients' medical records to determine which patients underwent CIS versus non-CIT. In the parent trial, conducted at an academic medical center (2007-2012), 200 patients were enrolled with stage IV malignancy or other poor prognosis cancer. Patients' preferences for aggressive treatment were measured in two ways: using patient-selected General Wishes statements generated by the decision aid and patient-selected wishes for specific treatments under various hypothetical clinical scenarios (Specific Wishes). RESULTS We evaluated 79 patients. Of these, 48 had undergone initial CIS and 31 had non-CIT. Cancer patients who initially underwent CIS did not prefer more aggressive end-of-life treatments compared to patients whose treatment was non-CIT. CONCLUSIONS Clinicians should avoid assumptions about patients' preferences for life-sustaining treatment based on their prior choices for aggressive treatment.
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Affiliation(s)
- Jane R Schubart
- 1 Departments of Surgery and Public Health Sciences, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania
| | - Michael J Green
- 2 Department of Humanities, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania
| | - Lauren J Van Scoy
- 3 Department of Medicine, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania
| | - Erik Lehman
- 4 Department of Public Health Sciences, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania
| | - Elana Farace
- 4 Department of Public Health Sciences, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania
| | - Niraj J Gusani
- 5 Department of Surgery, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania
| | - Benjamin H Levi
- 6 Department of Pediatrics and Humanities, The Pennsylvania State University , College of Medicine, Hershey, Pennsylvania
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Green MJ, Schubart JR, Whitehead MM, Farace E, Lehman E, Levi BH. Advance Care Planning Does Not Adversely Affect Hope or Anxiety Among Patients With Advanced Cancer. J Pain Symptom Manage 2015; 49:1088-96. [PMID: 25542552 DOI: 10.1016/j.jpainsymman.2014.11.293] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 11/20/2014] [Accepted: 11/22/2014] [Indexed: 11/26/2022]
Abstract
CONTEXT Many physicians avoid advance care planning (ACP) discussions because they worry such conversations will lead to psychological distress. OBJECTIVES To investigate whether engaging in ACP using online planning tools adversely affects hope, hopelessness, or anxiety among patients with advanced cancer. METHODS Patients with advanced cancer and an estimated survival of two years or less (Intervention group) and a Control group were recruited at a tertiary care academic medical center (2007-2012) to engage in ACP using an online decision aid ("Making Your Wishes Known"). Pre/post and between-group comparisons were made, including hope (Herth Hope Index), hopelessness (Beck Hopelessness Scale), and anxiety (State Trait Anxiety Inventory). Secondary outcomes included ACP knowledge, self-determination, and satisfaction. RESULTS A total of 200 individuals completed the study. After engaging in ACP, there was no decline in hope or increase in hopelessness in either the Control or Intervention group. Anxiety was likewise unchanged in the Control group but decreased slightly in the Intervention group. Knowledge of ACP (% correct answers) increased in both the groups, but more so in the Intervention group (13% increase vs. 4%; P<0.01). Self-determination increased slightly in both groups, and satisfaction with the ACP process was greater (P<0.01) in the Intervention than Control group. CONCLUSION Engaging in ACP with online planning tools increases knowledge without diminishing hope, increasing hopelessness, or inducing anxiety in patients with advanced cancer. Physicians need not avoid ACP out of concern for adversely affecting patients' psychological well-being.
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Affiliation(s)
| | | | | | - Elana Farace
- Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Erik Lehman
- Penn State College of Medicine, Hershey, Pennsylvania, USA
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Schubart JR, Camacho F, Green MJ, Rush KA, Levi BH. Assessing the internal consistency and temporal stability of advance directives generated by an interactive, online computer program. BMJ Support Palliat Care 2015; 7:67-72. [PMID: 25743440 DOI: 10.1136/bmjspcare-2014-000814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/07/2015] [Accepted: 02/17/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Evaluate the internal consistency and temporal stability of advance directives (ADs) generated by an interactive, online computer program. METHODS 33 participants completed the program at three visits, 2 weeks apart. Agreement rates were calculated for the General Wishes component of the AD. The test-retest method was used to examine the temporal stability of the Specific Wish for Treatment component which contains five clinical scenarios. RESULTS General Wishes remained stable with 94% selecting the identical response at each visit. For the Specific Wish for Treatment scale, significant variations in test-retest correlations existed (ie, ρ=0.32-0.78, between time points 1 and 2); however within scenario, correlations did not significantly vary between time points. Temporal stability was lower in the Specific Wish for Treatment scale compared with General Wishes (average ρ=0.59, between time points 1 and 2; and ρ=0.75, between time points 2 and 3). CONCLUSIONS ADs generated by an online decision aid demonstrate good temporal stability, with highest stability for General Wishes and moderate stability for Specific Wish for Treatment regarding medical treatments in specific clinical scenarios. Internal consistency for wish for treatment across all time points and scenarios was high (Cronbach α>0.90).
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Affiliation(s)
- Jane R Schubart
- Departments of Surgery, Public Health Sciences, and Medicine, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Fabian Camacho
- Department of Public Health Sciences, University of Virginia, School of Medicine, Charlottesville, Virginia, USA
| | - Michael J Green
- Departments of Humanities and Medicine, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Kimberly A Rush
- Department of Pediatrics, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Benjamin H Levi
- Departments of Humanities and Pediatrics, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
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Volpe RL, Levi BH, Blackall GF, Green MJ. Ethics Pocket Cards: An Educational Tool for Busy Clinicians. The Journal of Clinical Ethics 2014. [DOI: 10.1086/jce201425208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Affiliation(s)
- Ian M Paul
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania2Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Benjamin H Levi
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania3Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania
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Volpe RL, Levi BH, Blackhall GF, Green MJ. Ethics pocket cards: an educational tool for busy clinicians. J Clin Ethics 2014; 25:148-151. [PMID: 24972065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The adage "an ounce of prevention is worth a pound of cure" is widely used in healthcare settings and can be applied to the work of institutional clinical ethics committees. The model of clinical ethics consultation, however, is inherently reactive: a crisis or question emerges, and ethics experts are called to help. In an effort to employ a proactive component to the model of clinical ethics consultation (as well as to standardize our educational interventions), we developed ethics pocket cards. The purpose of this article is to: (1) describe the rationale for using ethics pocket cards, (2) provide examples of our cards, and (3) begin a dialogue about the potential uses of ethics pocket cards. In doing so, we hope to explore how such portable, economical devices can advance the goals of ethics consultation as well as the educational aims of ethics committees.
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Affiliation(s)
- Rebecca L Volpe
- Clinical Ethics Consultation Service, Penn State College of Medicine, Milton S. Hersey Medical Center, Hershey, PA USA.
| | - Benjamin H Levi
- Department of Humanities, Department of Pediatrics, Penn State College of Medicine, Penn State Children's Hospital, Hershey, PA USA
| | - George F Blackhall
- Department of Pediatrics, Department of Humanities, Department of Psychiatry, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA USA
| | - Michael J Green
- Department of Humanities, Department of Medicine, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA USA
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Levi BH, Wilkes M, Der-Martirosian C, Latow P, Robinson M, Green MJ. An Interactive Exercise in Advance Care Planning for Medical Students. J Palliat Med 2013; 16:1523-7. [DOI: 10.1089/jpm.2013.0039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Benjamin H. Levi
- Departments of Humanities and Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - Michael Wilkes
- Office of the Dean, University of California, Davis, California
- School of Medicine, University of California, Davis, California
| | | | - Polly Latow
- Department of Internal Medicine, University of California, Davis, California
| | - Mark Robinson
- Department of Internal Medicine, University of California, Davis, California
| | - Michael J. Green
- Departments of Humanities and Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
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Schubart JR, Levi BH, Dellasega C, Whitehead M, Green MJ. Factors that affect decisions to receive (or not receive) life-sustaining treatment in advance care planning. J Psychosoc Nurs Ment Health Serv 2013; 52:38-44. [PMID: 24200911 DOI: 10.3928/02793695-20131028-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 08/07/2013] [Indexed: 11/20/2022]
Abstract
This study identifies factors that affect decisions people make regarding whether they want to receive life-sustaining treatment. It is an interpretive-descriptive study based on qualitative data from three focus groups (N = 23), representing a diverse population in central Pennsylvania. Study sites included a suburban senior center serving a primarily White, middle-class population; an urban senior center serving a frail, underserved, African American population; and a breast cancer support group. The most important factors affecting whether participants wished to receive life-sustaining medical treatment were prognosis, expected quality of life, burden to others, burden to oneself in terms of the medical condition and treatment, and effect on mental functioning and independence. Our findings contribute to the knowledge of the complex factors that influence how people make decisions about advance care planning and life-sustaining treatments. This understanding is critical if nurses are to translate the patient's goals, values, and preferences into an actionable medical plan.
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