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Experiences of Australian emergency doctors and nurses using advance care directives in the provision of care at the end of life. Emerg Med Australas 2024; 36:231-242. [PMID: 37940110 DOI: 10.1111/1742-6723.14343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/03/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE An advance care directive is a legal document outlining the wishes made by a person about treatment options. However, there is increasing evidence that an advance care directive that has previously been documented may not always benefit the current prognosis of the patient. Therefore, the aim of the present study was to explore the experiences of Australian emergency doctors and nurses concerning the use of previously documented advance care directives at the point of care for patients and their families. METHODS A qualitative study guided by a phenomenological interpretive approach was employed. Semi-structured interviews were conducted with ED doctors and nurses across Australia. Data were thematically analysed using a seven-stage data analysis framework. RESULTS An analysis of the interview data resulted in four major themes: (i) Benefits of Advance Care Directives; (ii) Knowledge and Awareness; (iii) Communication; and (iv) Availability of Advance Care Directive Information. CONCLUSIONS From the findings, advance care directives were believed to be beneficial in decision making when patients, families, and ED staff agreed with the decisions made. Advance care directives were often made a long time ago but were useful to start conversations around goals of care and end-of-life care relevant to the patient's current situation. Findings in the present study further reinforced that an advance care directive was beneficial when used alongside goals of care at the point of care in EDs.
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"Gives peace of mind" - Relatives' perspectives of end-of-life conversations. Palliat Support Care 2023:1-8. [PMID: 37982296 DOI: 10.1017/s1478951523001633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
OBJECTIVES Planning for end-of-life (EOL) and future treatment and care through advance care planning (ACP) is being increasingly implemented in different healthcare settings, and interest in ACP is growing. Several studies have emphasized the importance of relatives participating in conversations about wishes for EOL and being included in the process. Likewise, research has highlighted how relatives can be a valuable resource in an emergency setting. Although relatives have a significant role, few studies have investigated their perspectives of ACP and EOL conversations. This study explores relatives' experiences of the benefits and disadvantages of having conversations about wishes for EOL treatment. METHODS Semi-structured telephone interviews were held with 29 relatives who had participated in a conversation about EOL wishes with a patient and physician 2 years prior in a variety of Danish healthcare settings. The relatives were interviewed between September 2020 and June 2022. Content analysis was performed on the qualitative data. RESULTS The interviews revealed two themes: "gives peace of mind" and "enables more openness and common understanding of EOL." Relatives found that conversations about EOL could help assure that patients were heard and enhance their autonomy. These conversations relieved the relatives of responsibility by clarifying or confirming the patients' wishes, and they also made the relatives reflect on their own wishes for EOL. Moreover, they helped patients and relatives address other issues regarding EOL and made wishes more visible across settings. SIGNIFICANCE OF RESULTS The results indicate that conducting conversations about wishes for EOL treatment and having relatives participate in those conversations were perceived as beneficial for both relatives and patients. Involving relatives in ACP should be prioritized by physicians and healthcare personnel when holding conversations about EOL.
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Can Doctors Be Compelled to Prolong the Life of a Dying Patient? The Ongoing Medical, Legal and Social Issues. JOURNAL OF LAW AND MEDICINE 2023; 30:155-165. [PMID: 37271956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The law does not require health professionals to provide medical treatment that is of no benefit to the patient. Despite this, medical staff who are caring for patients at the end of their lives frequently experience pressure from the patients' families to prolong their lives. This article considers the Australian law relating to the right to demand treatment when a loved one is dying, and whether an increasing emphasis on shared decision-making has introduced uncertainty. It discusses factors that affect the application of the law, including widespread ignorance of the law, the difficulty of deciding whether a treatment is futile and the need to ration scarce health care resources. It also introduces the perspectives of three senior medical practitioners on disputes with families of dying patients. The article concludes that community education is needed on legal and medical issues at the end of life, including conversations about advance care directives.
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Facilitators and Barriers for Initiating Conversations About End of Life. Palliat Med Rep 2022; 3:296-307. [PMID: 36636612 PMCID: PMC9805848 DOI: 10.1089/pmr.2022.0042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 11/23/2022] Open
Abstract
Background Conducting a conversation about wishes for treatment at end of life (EOL) has been shown to improve EOL care for patients and relatives. Still, only a minority of physicians conduct the conversation, which might lead to unwanted interventions and treatments. Objectives The purpose of this survey was to examine which factors facilitate and hinder physicians across a wide range of health care facilities to initiate the conversation about wishes for treatment at EOL. Design A questionnaire survey based on a Delphi-developed questionnaire. Setting/Subjects The questionnaire was sent to both hospital physicians and general practitioners (GPs) in a Danish region. Results More than 3000 physicians were invited to participate in the survey. Of these, 782 responded, 622 working at a hospital department, and 160 from general practice clinics. Results showed that senior physicians, GPs, and physicians working in a medical department feel best equipped to conduct the conversation. Moreover, senior physicians pointed to their experience as physicians as being of great importance for conducting the conversation, whereas junior physicians found training in conducting the conversation as an important factor. Conclusion Our study indicates that different factors depending on the health care setting and the seniority of the physician facilitate or hinder physicians from conducting the conversation about wishes for treatment at EOL. Being aware of these differences and making a concerted effort depending on setting and seniority might help implement and conduct the conversation.
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Raising the Dead? Limits of CPR and Harms of Defensive Practices. Hastings Cent Rep 2022; 52:8-12. [PMID: 36537273 DOI: 10.1002/hast.1442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
We describe the case of an eighty-four-year-old man with disseminated lung cancer who had been receiving palliative care in the hospital and was found by nursing staff unresponsive, with clinically obvious signs of death, including rigor mortis. Because there was no documentation to the contrary, the nurses commenced cardiopulmonary resuscitation and called a code blue, resulting in resuscitative efforts that continued for around twenty minutes. In discussion with the hospital ethicist, senior nurses justified these actions, mainly citing disciplinary and medicolegal concerns. We argue that moral harms arise from CPR performed on a corpse and that legal concerns about failing to perform it are unfounded. We contend that such efforts are an unintended consequence of managerialist policies mandating do-not-resuscitate orders and advance care plans and of defensive practices that can value the interests of institutions and practitioners over those of patients. Health management teaching should include managerialism and its pitfalls, while clinician training should prioritize ethical reasoning and legal knowledge over defensive practice.
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Uptake of advance care planning and its circumstances: An nationwide survey in Australian general practice. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:1913-1923. [PMID: 34529292 DOI: 10.1111/hsc.13570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/04/2021] [Accepted: 09/03/2021] [Indexed: 06/13/2023]
Abstract
There are potential benefits associated with advance care planning (ACP), and general practitioners (GPs) are well placed to coordinate ACP initiatives with their patients. Few studies have reported on the uptake of different forms of advance care plan conducted by GPs and how this affects patients' place of death. The primary aims of the study were to examine uptake of verbal (conversations regarding care preferences) and written (documented care preferences) advance care plans and their associated factors from the perspective of Australian GPs. The secondary aim was to determine the impact of different types of advance care plans on place of death. Sixty-one GPs from three Australian states used a validated clinic-based data collection process to report on care provided for decedents in the last year of life, including provision of services, place of death, and uptake of ACP. We found that 58 (27.9%), 91 (43.7%) and 59 (28.4%) reported decedents had no advance care plans, verbal plans or written plans, respectively. There were increased uptake of both verbal plans (relative risk ratio [RRR] = 13.10, 95% confidence interval [CI]: 2.18-77.34) and written plans (RRR = 10.61, 95% CI: 1.72-65.57) if GPs foresaw the death for >90 days versus <7 days. Palliative care training history for GPs predicted uptake of verbal plans (RRR = 5.83, 95% CI: 1.46-31.93). Patients with verbal plans versus no plans were more likely to die at a private residence (odds ratio = 4.97, 95% CI: 1.32-18.63). Our findings suggest that expectation of death for at least three months prior to the event (where clinically possible) and palliative care training for GPs improve the uptake of ACP in general practice. Larger pragmatic trials are required to determine the impact of ACP on patients' place of death.
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Abstract
OBJECTIVES Palliative Medicine involvement in MICU patients have improved length of stay and mortality, but with varying effects on specific patient decision outcomes, such as, advance care planning. These studies have utilized Palliative Medicine later in the hospital or ICU course, with some evidence showing that earlier involvement resulted in better results. The purpose of this study was to evaluate the benefits of early (within 24 hours) palliative care consultation in medical ICU (MICU) patients to clinical and satisfaction outcomes. METHODS An unblinded randomized study performed in the MICU in one academic hospital in the USA. Ninety-one adult patients admitted to MICU received a Palliative care medicine consultation within 24 hours as the intervention. MEASUREMENTS AND RESULTS Ninety-one patients admitted to the MICU underwent randomization with 50 patients randomly assigned to receive Palliative Medicine consultation and 41 patients randomly assigned to receive standard-of-care based on predefined criteria. The median satisfaction score was 23 points higher for the patients in the intervention group (P < .001). The median length of MICU stay was 5 days shorter in the intervention group compared to the control group (95% CI; 1 day to 18 days, P = .018). Advance care planning was completed in the hospital for 34% of patients in the intervention arm and 12% of patients in the controls arm (absolute risk difference 22%, 95% CI 4% to 37%, P = .016). CONCLUSION Early Palliative Medicine consultation within 24 hours of MICU admission showed significant benefits to patients by improving satisfaction and decreasing length of stay. This study provides evidence that Palliative Medicine involvement earlier in the course of severe disease is important. Further studies in other types of intensive care units (neurological and Cardiovascular) are necessary to determine their impact.
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Exploring the Motivations for Completing Advance Care Directives: A Qualitative Study of Majority/Minority Israeli People Without Dementia. Front Psychiatry 2022; 13:864271. [PMID: 35360133 PMCID: PMC8964276 DOI: 10.3389/fpsyt.2022.864271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background Completing advance directives has been declared an essential instrument for preserving and respecting the autonomy and preferences for end-of-life care of people living with dementia. However, research deciphering the reasoning behind the decision to complete or not advance directives in the case of dementia remains limited, especially among people pertaining to different majority/minority groups. Objectives To explore the motivations of people without dementia in Israel to complete or not to complete advance directives and to compare these motivations among the majority veteran Jewish group, the minority Jewish Former Soviet Union immigrant group, and the minority Arab group. Methods This qualitative study used purposive sampling and focus groups with discussions elicited by a vignette. A total of 42 Israeli people without dementia participated in 6 focus groups: two with veteran Jews (n = 14), two with Jewish immigrants from the Former Soviet Union (n = 14), and two with Arabs (n = 14). The analysis followed recommended steps for thematic content analysis. Results Four overarching themes were identified: (1) the meaning of dementia-related advance directives, (2) motivations for willingness to complete advance directives, (3) motivations for not being willing to complete advance directives, and (4) ethical dilemmas. Some of the themes were common to all groups, while others were informed by the groups' unique characteristics. Participants displayed a lack of knowledge and misunderstanding about advance directives, and central concepts such as autonomy and competence. Furthermore, stigmatic images of dementia and of the person with the diagnosis were associated to participants' motivations to complete advance directives. Conclusions There is need to expand comparative research among culturally and socially similar and dissimilar groups within a country as well as between countries in order to better guide public health efforts to increase the rates of advance directives completion. Special attention should be paid to decreasing stigmatic beliefs and understanding unique cultural values and motivations.
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Advance care planning for older people in mainland China: An integrative literature review. Int J Older People Nurs 2021; 16:e12409. [PMID: 34291574 DOI: 10.1111/opn.12409] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recently, the attempts to promote advance care planning (ACP) and advance directives (ADs) have appeared in mainland China. However, anecdotal evidence suggests that the concept of ACP and ADs is not widely known to the public and healthcare professionals. AIM To examine and synthesise currently available research about ACP and ADs for older people in mainland China, and to discuss implications for future nursing practice and research. DESIGN An integrative literature review. METHODS A systematic search was conducted in seven English electronic databases (CINAHL, MEDLINE, ProQuest, Cochrane, JBI, Scopus and Wiley) and four Chinese electronic databases (CNKI, Wanfang, VIP and CBM). Eligible articles were critically appraised using the Mixed Methods Appraisal Tool (MMAT). FINDINGS From various groups including older people, families and healthcare professionals, low levels of knowledge and awareness about ACP and ADs are reported. Demographic characteristics such as age, gender, education and clinical conditions were related to positive or negative attitude towards ACP. The main reason people cited for being 'reluctant/fairly reluctant' to make an AD was that they were 'Not familiar with it'. CONCLUSIONS Given that older people showed positive attitudes towards ACP, policy support and practice guidelines about ADs and ACP are necessary to respect their wishes and to guide healthcare professionals in mainland China.
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Awareness and Attitudes towards Advance Care Directives (ACDs): An Online Survey of Portuguese Adults. Healthcare (Basel) 2021; 9:healthcare9060648. [PMID: 34072558 PMCID: PMC8227883 DOI: 10.3390/healthcare9060648] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/17/2021] [Accepted: 05/25/2021] [Indexed: 12/28/2022] Open
Abstract
(1) Background: Evidence shows that facilitated advance decisions can increase the number of meaningful and valid Advance Care Directives (ACDs) and improve the quality of care when End-Of-Life (EOL) is near. Little is known about the awareness and attitudes of Portuguese adults towards ACDs. The present study aims to assess the knowledge, attitudes, and preferences of a sample of Portuguese adults regarding EOL care decisions and ACDs. (2) Methods: A total of 1024 adults were assessed with an online cross-sectional survey collecting information on sociodemographic factors, knowledge, attitudes and preferences regarding advance decisions and EOL care. (3) Results: Participants had a mean age of 40.28 ± 11.41 years. Most were female and had a professional background related to healthcare. While 76.37% of participants had heard of ACDs, only a small percentage (2.34%) had actually ever made an ACD. Knowledge levels were weakly correlated with attitudes regarding ACDs (r = -0.344; p < 0.01). (4) Conclusions: Participants lacked a comprehensive understanding about ACDs, but revealed positive attitudes towards their use and usefulness. Further research can inform efforts to improve ACD engagement in this population. The discussion about ACDs should be part of health promotion education with a focus on planning for a comfortable and peaceful death.
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Role of Law in End-of-Life Decision-Making: Perspectives of Patients, Substitute Decision-Makers and Families. JOURNAL OF LAW AND MEDICINE 2021; 28:813-830. [PMID: 34369132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The law regulating medical end-of-life decisions aims to support patients to receive high-quality health care. It does so through ensuring treatment received reflects the person's wishes and values and protecting health professionals who provide adequate pain and symptom relief even if that treatment may coincidentally hasten death. However, good decision-making is predicated by those involved, including patients themselves and those supporting patients, being familiar with the law and the role it plays in the decision-making process. This article reports on a study exploring the role that law plays in end-of-life decision-making from the perspective of terminally-ill patients, their substitute decision-makers and family members. While participants' decision-making practices were often underpinned by a legal framework, the role of the law was largely invisible. Community education is needed for the public to know their legal rights and responsibilities, and to understand that the law plays a role in supporting end-of-life decision-making.
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Advance care planning in different settings for people with dementia: A systematic review and narrative synthesis. Palliat Support Care 2020; 17:707-719. [PMID: 31177997 DOI: 10.1017/s1478951519000257] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Advance care planning (ACP) is identified as being an important process for people with dementia. However, its efficacy for improving outcomes relevant for the individual, carers and the health system has yet to be established. AIM We conducted a systematic review with the aims of testing the efficacy of ACP for people with dementia and describing the settings and population in which it has been evaluated. METHODS A search was completed of electronic databases in August 2016. Articles were included if they described interventions aimed at increasing planning for future care of people with dementia, delivered to the person with dementia, their carers and/or health professionals. RESULTS Of 4,772 articles returned by searches, 30 met the inclusion criteria, testing interventions in nursing home (n= 16) community (n = 10) and acute care (n = 4) settings. Only 18 interventions directly involved the person with dementia, with the remainder focusing on surrogate decision-makers. In all settings, interventions were found effective in increasing ACP practice. In nursing homes, ACP was found to influence care and increase the concordance between end of life wishes and care provided. Interventions in the community were found to improve patient quality of life but were not shown to influence concordance. CONCLUSION Future research should focus on ways to involve people with dementia in decision-making through supported means.
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Advance care planning for vulnerable older adults within an Accountable Care Organization: study protocol for the IMPACT randomised controlled trial. BMJ Open 2019; 9:e032732. [PMID: 31843844 PMCID: PMC6924763 DOI: 10.1136/bmjopen-2019-032732] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Patients with multimorbidity plus additional impairments (eg, mobility limitations, disability, cognitive impairments or frailty) are at the highest risk for poor healthcare outcomes. Advanced care planning (ACP) provides patients and their surrogates the opportunity to discuss their goals, values and priorities for healthcare-particularly in the context of end-of-life care. ACP discussions promote more person-centred care; however, it is currently underused. There is a tremendous need for systematic, scalable approaches to individualised ACP that promotes patient and family engagement. Here we describe the study protocol for a randomised effectiveness trial of a nurse navigator and informatics intervention designed to improve the documentation and quality of ACP discussions. METHODS AND ANALYSIS This is a randomised, pragmatic, effectiveness trial; patients aged 65 years and older who have multimorbidity plus impairments in either physical function (eg, mobility limitations or disability) or cognition, and/or frailty within an affiliated Accountable Care Organization were eligible. The electronic health record was used to develop an automatic prescreening system for eligible patients (n=765) and participants were randomised in a 1:1 ratio to either the nurse navigator-led ACP pathway or usual care. Our primary outcomes are documentation of ACP discussions within the EHR along with the quality of ACP discussions. Secondary outcomes include a broad range of ACP actions (eg, usage of ACP billing codes, choosing a surrogate decision-maker and advance directive documentation). Outcomes will be measured over 12 months of follow-up. ETHICS AND DISSEMINATION This study has been approved by the appropriate Institutional Review Boards and is guided by input from patient and clinical advisory boards. The results of this study will inform a scalable solution to ACP discussions throughout our healthcare system and statewide. TRIALS REGISTRATION NUMBER NCT03609658.
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Doctors' perspectives on adhering to advance care directives when making medical decisions for patients: an Australian interview study. BMJ Open 2019; 9:e032638. [PMID: 31676659 PMCID: PMC6830700 DOI: 10.1136/bmjopen-2019-032638] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/27/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Advance care planning (ACP) assists people to identify their goals, values and treatment preferences for future care. Ideally, preferences are documented in an advance care directive (ACD) and used by doctors to guide medical decision-making should the patient subsequently lose their decision-making capacity. However, studies demonstrate that ACDs are not always adhered to by doctors in clinical practice. We aim to describe the attitudes and perspectives of doctors regarding ACD adherence and the utility of ACDs in clinical practice. DESIGN Face-to-face semistructured interviews were conducted using three case-based vignettes to explore doctors' decision-making and attitudes towards ACDs. Transcripts were analysed using a thematic analysis. SETTING Doctors from a variety of medical specialties and with varying experience levels were recruited from a large tertiary hospital in Melbourne, Australia. PARTICIPANTS A total of 21 doctors were interviewed, 48% female (10/21). Most (19/21) reported having experience using ACDs. RESULTS Four themes were identified: aligning with patient preferences (avoiding unwanted care, prioritising autonomy and anticipating family opposition), advocating best interests (defining futile care, relying on clinical judgement, rejecting unreasonable decisions and disregarding legal consequences), establishing validity (doubting rigour of the decision-making process, questioning patients' ability to understand treatment decisions, distrusting outdated preferences and seeking confirmation) and translating written preferences into practice (contextualising patient preferences, applying subjective terminology and prioritising emergency medical treatment). CONCLUSIONS ACDs provide doctors with opportunities to align patient preferences with treatment and uphold patient autonomy. However, doctors experience decisional conflict when attempting to adhere to ACDs in practice, especially when they believe that adhering to the ACD is not in the patients' best interests, or if they doubt the validity of the ACD. Future ACP programmes should consider approaches to improve the validity and applicability of ACDs. In addition, there is a need for ethical and legal education to support doctors' knowledge and confidence in ACP and enacting ACDs.
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Current practices, barriers and enablers for advance care planning among healthcare workers of aged care facilities in western New South Wales, Australia. Rural Remote Health 2018; 18:4714. [PMID: 30447659 DOI: 10.22605/rrh4714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Advance care planning (ACP) and advance care directives (ACDs) play a vital role in preparing for end-of-life care. However, current literature suggests that uptake of ACP and ACDs in rural Australia is low, which may contribute to lower quality care for the older rural population, as patients' end-of-life wishes may not be recognised and acknowledged. This study aims to provide a current perspective on the attitudes and practices of healthcare workers from residential aged care facilities towards ACP and ACDs in the central west, far west and Orana regions of New South Wales, Australia. METHODS This was a mixed-methods study incorporating anonymous survey and individual interviews. Healthcare workers from 12 residential aged care facilities within the studied region completed surveys (n=109). The 40-item survey assessed participant demographics, training and experience with ACP and ACD, attitudes towards ACP and ACDs, and barriers and facilitators towards the use of ACP and ACDs in their organisation. Five participants were interviewed to explore these issues in more depth. RESULTS Almost three-quarters (71%) of respondents thought that ACP is necessary while almost half (48%) were involved with >5 ACDs in the past 12 months. Formal training was seen as beneficial by most (81%) but the importance of practical experience was also acknowledged. No statistically significant differences were found in attitudes between those with 5 years of experience. Avoidance of unnecessary resuscitation was a consistent theme in all interviews and the potential of a nurse-led model of delivery was identified. Patient factors such as decreased capacity to make informed decisions were identified as barriers that could be circumvented by pre-emptive implementation of ACP discussion. The rural setting was identified as a facilitator due to a supportive community, which helped to mitigate barriers such as limited staffing. CONCLUSIONS Attitudes towards ACP in rural New South Wales are highly positive. The rural setting is a facilitator to ACP, and ACDs are approached in a multidisciplinary fashion. Further training is an identified need although on-the-ground experience may be more beneficial.
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Abstract
BACKGROUND: Advance care planning (ACP) often culminates in the completion of advance care directives (ACD), which is a written record of informed decisions specifying the type and extent of desired medical treatment. Documentation of ACD in nursing homes in the United States indicates a 60% to 70% completion rate. There are little data on the time at which ACD are completed in relation to when the resident was admitted to the nursing home facility. OBJECTIVE: To explore the success of advanced care planning at a large, rural long-term care (LTC) facility. METHODS: A descriptive approach, using a retrospective chart review, of 167 residents was used to examine resident completion of health-care system documents, legal documents, predisposing factors (resident demographics and psychosocial characteristics), and the actual process of ACP as defined by the rural LTC facility. RESULTS: This nursing home utilizes a document entitled resident preference for life-sustaining treatment (RPLST). For residents who do not have formal prepared advance directive documents, the RPLST serves to define resident and family choices for resuscitation and implementation of fluids, nutrition, medications, and antibiotics. The most striking finding was the completion rate of the RPLST within 100 days of being admitted to the nursing home. CONCLUSION: Documentation of end-of-life preferences within 10 days of admission was achieved through the incorporation of RPLST during the resident admission process.
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Discussing advance care planning: insights from older people living in nursing homes and from family members. Int Psychogeriatr 2018; 30:569-579. [PMID: 28988561 DOI: 10.1017/s1041610217001983] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED ABSTRACTBackground:Evidence concerning when and in which manner older people living in nursing homes (NHs) would prefer to discuss advance care planning (ACP) is still scarce. This study explored the attitudes of NH residents and family members toward ACP and their opinions as to the right time to broach the subject, the manner in which it should be approached, and the content of ACP. METHODS This was a qualitative study using face-to-face interviews with 30 residents (age range 66-94), and 10 family members from 4 Italian NHs. The interviews were analyzed using content analysis. RESULTS Three main themes were identified: (1) life in the NH, including thoughts about life in a nursing home, residents' concerns, wishes and fears, and communication barriers; (2) future plans and attitudes toward ACP, including attitudes toward planning for the future and plans already made, and attitudes toward and barriers against ACP; (3) contents and manner of ACP, including contents of ACP discussions, the right moment to introduce ACP, with whom it is better to discuss ACP, and attitudes toward advance directives. CONCLUSIONS ACP was a welcome intervention for the majority of participants, but an individualized assessment of the person's readiness to be involved in ACP is needed. For people with dementia, it is essential to identify the right time to introduce ACP before NH admission. Participants in our study suggested that ACP should include palliative care and practical issues, and that in the NH setting all staff and family members may have a valuable role in ACP.
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The South Australian Advance Care Directives Act 2013: How Has the Decision-Making Paradigm Changed? JOURNAL OF LAW AND MEDICINE 2018; 25:538-548. [PMID: 29978653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
This article analyses how the Advance Care Directives Act 2013 SA is changing the decision-making paradigm in health care and guardianship in South Australia. It examines the background to the legislation, the main areas that have been transformed by the Act and the amendments to associated legislation. The significant changes include an increased respect for autonomy and a presumption of decision-making capacity, a new paradigm of substitute decision-making, clarification of the decision-making hierarchy, and protections for medical practitioners who decline to give treatment that would have no benefit to a dying patient. Despite some difficulties implementing the new scheme, this article argues that the Act has introduced important changes and clarifications in the law that other States would do well to follow. When it is fully implemented, the Act will ensure that the wishes of patients are respected and that doctors can follow these wishes without fear of prosecution.
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Feasibility and acceptability of advance care planning in elderly Italian and Greek speaking patients as compared to English-speaking patients: an Australian cross-sectional study. BMJ Open 2015; 5:e008800. [PMID: 26319775 PMCID: PMC4554907 DOI: 10.1136/bmjopen-2015-008800] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To assess the feasibility and acceptability of facilitated advance care planning (ACP) discussions in elderly Italian and Greek-speaking inpatients compared to English-speaking inpatients. DESIGN, SETTING AND PARTICIPANTS This cross-sectional study with convenience sampling was conducted in Melbourne, Australia, and recruited hospital inpatients with medical decision-making capacity, aged 65 years or above, who spoke Greek (25 patients), Italian (24 patients) or English (63 patients). INTERVENTION Facilitated ACP was offered, aiming to assists patients to consider and discuss their goals, values, beliefs and future treatment wishes with their family and doctor; to help them consider how they would like healthcare decisions made in the future if they become unable to do this for themselves; and to complete advance care directives. MAIN OUTCOME MEASURES The completion of ACP discussions, their duration, advance care directive completion and utilisation of interpreters. RESULTS Of 112 patients, 109 (97%) had at least one discussion, 63 (54%) completed advance care directives, either nominating a substitute decision-maker, documenting their wishes or both, and 76 (68%) included family in discussions. The median duration of discussions for all patients was slightly more than 1 h, over two visits. There were no differences between the Greek-speaking and the Italian-speaking patients, or between the Non-English speaking and the English-speaking patients in any of these measures. Only 14 non-English speaking patients, (30%) utilised interpreters, but when utilised, patients were much more likely (p<0.005) to complete advance care directives. CONCLUSIONS Facilitated ACP in elderly Italian and Greek-speaking patients is feasible, acceptable and is similar to that for English-speaking patients.
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