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Malhotra C, Shafiq M, Batcagan-Abueg APM. What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials. BMJ Open 2022. [PMCID: PMC9301802 DOI: 10.1136/bmjopen-2021-060201] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives To conduct an up-to-date systematic review of all randomised controlled trials assessing efficacy of advance care planning (ACP) in improving patient outcomes, healthcare use/costs and documentation. Design Narrative synthesis conducted for randomised controlled trials. We searched electronic databases (MEDLINE/PubMed, Embase and Cochrane databases) for English-language randomised or cluster randomised controlled trials on 11 May 2020 and updated it on 12 May 2021 using the same search strategy. Two reviewers independently extracted data and assessed methodological quality. Disagreements were resolved by consensus or a third reviewer. Results We reviewed 132 eligible trials published between 1992 and May 2021; 64% were high-quality. We categorised study outcomes as patient (distal and proximal), healthcare use and process outcomes. There was mixed evidence that ACP interventions improved distal patient outcomes including end-of-life care consistent with preferences (25%; 3/12 with improvement), quality of life (0/14 studies), mental health (21%; 4/19) and home deaths (25%; 1/4), or that it reduced healthcare use/costs (18%; 4/22 studies). However, we found more consistent evidence that ACP interventions improve proximal patient outcomes including quality of patient–physician communication (68%; 13/19), preference for comfort care (70%; 16/23), decisional conflict (64%; 9/14) and patient-caregiver congruence in preference (82%; 18/22) and that it improved ACP documentation (a process outcome; 63%; 34/54). Conclusion This review provides the most comprehensive evidence to date regarding the efficacy of ACP on key patient outcomes and healthcare use/costs. Findings suggest a need to rethink the main purpose and outcomes of ACP. PROSPERO registration number CRD42020184080.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Mahham Shafiq
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
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Porter AS, Greenfield D. Letter to the Editor: Accounting for the Immeasurable: Broadening Our Valuation of Advanced Care Planning. J Palliat Med 2022; 25:1014-1015. [PMID: 35775894 DOI: 10.1089/jpm.2022.0150] [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)
- Amy S Porter
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Dana Greenfield
- Division of Palliative Care, University of California San Francisco Medical Center, San Francisco, California, USA
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153
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Pivodic L, Wendrich-van Dael A, Gilissen J, De Buyser S, Deliens L, Gastmans C, Vander Stichele R, Van den Block L. Effects of a theory-based advance care planning intervention for nursing homes: A cluster randomized controlled trial. Palliat Med 2022; 36:1059-1071. [PMID: 35769038 DOI: 10.1177/02692163221102000] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Indexed: 10/17/2022]
Abstract
BACKGROUND Uptake of advance care planning in routine nursing home care is low. Through extensive literature review, theoretical development, and stakeholder involvement, we developed the ACP+ intervention. AIMS To evaluate the effects of ACP+ on the knowledge and self-efficacy (confidence in own skills) of nursing home care staff concerning advance care planning. DESIGN Cluster randomized controlled trial, conducted between February 2018 and January 2019 (NCT03521206, clinicaltrials.gov). ACP+ is a multicomponent intervention aimed at training and supporting nursing home staff and management in implementing advance care planning in nursing home practice through a train-the-trainer approach over 8 months. Fourteen nursing homes were randomized using a matched-pairing strategy, seven received ACP+, seven followed usual practice. Analyses (intention-to-treat) involved linear mixed models. SETTING/PARTICIPANTS Nursing homes in Flanders (Belgium). RESULTS 694 of 1017 care staff (68% response rate) at baseline and 491 of 989 care staff (50%) post-intervention (8 months) returned questionnaires. Post-intervention, care staff's self-efficacy concerning advance care planning was significantly higher in the intervention than in the control group (baseline-adjusted mean difference 0.57; 95% CI 0.20-0.94; p = 0.003; Cohen's d = 0.30). Advance care planning knowledge (95% CI 0.95-1.15; p = 0.339; ratio: 1.04) did not differ significantly between groups. CONCLUSIONS The ACP+ intervention for nursing homes improved care staff's self-efficacy but not their knowledge concerning advance care planning. Considering the comprehensive and multi-component approach used, these effects were smaller than expected. Reasons for this may be related to the chosen follow-up period, outcomes and measurements, or to the intervention itself and its implementation.
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Affiliation(s)
- Lara Pivodic
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Brussels, Belgium
| | - Annelien Wendrich-van Dael
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Brussels, Belgium
| | - Joni Gilissen
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Brussels, Belgium.,Atlantic Fellows for Equity in Brain Health, Global Brain Health Institute, University California San Francisco, San Francisco, CA, USA
| | - Stefanie De Buyser
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Luc Deliens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | | | - Lieve Van den Block
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Brussels, Belgium
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154
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Needle JS, Friebert S, Thompkins JD, Grossoehme DH, Baker JN, Jiang J, Wang J, Lyon ME. Effect of the Family-Centered Advance Care Planning for Teens with Cancer Intervention on Sustainability of Congruence About End-of-Life Treatment Preferences: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2220696. [PMID: 35819787 PMCID: PMC9277499 DOI: 10.1001/jamanetworkopen.2022.20696] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE The effect of pediatric advance care planning (pACP) on the sustainability of end-of-life treatment preference congruence between adolescents with cancer and their families has not been examined. OBJECTIVE To evaluate the longitudinal efficacy of the Family-Centered Advance Care Planning for Teens with Cancer (FACE-TC) intervention to sustain adolescent-family congruence about end-of-life treatment preferences. DESIGN, SETTING, AND PARTICIPANTS This multisite, assessor-blinded, randomized clinical trial enrolled adolescents with cancer (aged 14-21 years) and their family members from 4 pediatric hospitals between July 16, 2016, and April 30, 2019. Participants were randomized 2:1 to FACE-TC (intervention group) or treatment as usual (control group) and underwent 5 follow-up visits over an 18-month postintervention period. Intention-to-treat analyses were conducted from March 9, 2021, to April 14, 2022. EXPOSURES Adolescent-family dyads randomized to the FACE-TC group received 3 weekly 60-minute sessions consisting of the discussion and/or completion of the Lyon Family-Centered Advance Care Planning Survey (session 1), Respecting Choices Next Steps pACP conversation (session 2), and Five Wishes advance directive (session 3). Dyads in the control group received treatment as usual. Both groups received pACP information. MAIN OUTCOMES AND MEASURES Congruence was measured by completion of the Statement of Treatment Preferences (a document that discusses 4 hypothetical clinical situations and treatment choices for each scenario: continue all treatments, stop all efforts to keep me alive, or unsure) after session 2 (time 1) and at 3 months (time 2), 6 months (time 3), 12 months (time 4), and 18 months (time 5) after intervention. The influence of FACE-TC on the trajectory of congruence over time was measured by longitudinal latent class analysis. RESULTS A total of 252 participants (126 adolescent-family dyads) were randomized. Adolescents (mean [SD] age, 17 [1.9] years) and family members (mean [SD] age, 46 [8.3] years) were predominantly female (72 [57%] and 104 [83%]) and White individuals (100 [79%] and 103 [82%]). There was an 83% (104 of 126) retention at the 18-month assessment. Two latent classes of congruence over time were identified: high-congruence latent class (69 of 116 [60%]) and low-congruence latent class (47 of 116 [41%]). The dyads in the FACE-TC group had a 3-fold odds of being in the high-congruence latent class (odds ratio [OR], 3.22; 95% CI, 1.09-9.57) compared with the control group. Statistically significant differences existed at 12 months (β [SE] = 1.17 [0.55]; P = .03]) but not at 18 months (OR, 2.08; 95% CI, 0.92-4.69). In the high-congruence latent class, good agreement (agreement on 2 or 3 of 4 situations) increased over 12 months. White adolescents and families had significantly greater odds of congruence than a small population of American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, or multiracial adolescents and families (OR, 3.97; 95% CI, 1.07-14.69). CONCLUSIONS AND RELEVANCE Results of this trial showed that, for those who received the FACE-TC intervention, the families' knowledge of their adolescents' end-of-life treatment preferences was sustained for 1 year, suggesting yearly follow-up sessions. Race and ethnicity-based differences in the sustainability of this knowledge reflect a difference in the effect of the intervention and require further study. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02693665.
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Affiliation(s)
- Jennifer Susan Needle
- Department of Pediatrics and Center for Bioethics, University of Minnesota, Minneapolis
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center, Akron Children’s Hospital, Akron, Ohio
- Rebecca D. Considine Research Institute, Akron Children’s Hospital, Akron, Ohio
| | - Jessica D. Thompkins
- Division of Allergy and Immunology, Children’s National Hospital, Washington, DC
| | - Daniel H. Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Akron Children’s Hospital, Akron, Ohio
- Rebecca D. Considine Research Institute, Akron Children’s Hospital, Akron, Ohio
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - JiJi Jiang
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Jichuan Wang
- Division of Biostatistics and Study Methodology, Center for Translational Research/Children’s National Research Institute, Children’s National Hospital, Washington, DC
- Center for Translational Research/Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - Maureen E. Lyon
- Center for Translational Research/Children’s National Research Institute, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
- Division of Adolescent and Young Adult Medicine, Children’s National Hospital, Washington, DC
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155
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Reich AJ, Perez S, Fleming J, Gazarian P, Manful A, Ladin K, Tjia J, Semco R, Prigerson H, Weissman JS, Candrian C. Advance Care Planning Experiences Among Sexual and Gender Minority People. JAMA Netw Open 2022; 5:e2222993. [PMID: 35857322 PMCID: PMC9301514 DOI: 10.1001/jamanetworkopen.2022.22993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Advance care planning (ACP) can promote patient-centered end-of-life (EOL) care and is intended to ensure that medical treatments are aligned with patient's values. Sexual and gender minority (SGM) people face greater discrimination in health care settings compared with heterosexual, cisgender people, but it is unknown whether such discrimination occurs in ACP and how it might affect the ACP experiences of SGM people. OBJECTIVES To increase understanding of barriers and facilitators of ACP facing SGM individuals. DESIGN, SETTING, AND PARTICIPANTS This mixed-methods national study of ACP included a telephone survey of self-identified SGM and non-SGM participants in a nationally representative sample drawn from a larger omnibus national panel by SSRS. Qualitative interviews were conducted with a subset of survey participants who identified as SGM. Data were collected from October 2020 to March 2021. EXPOSURES Self-identified SGM. MAIN OUTCOMES AND MEASURES The survey included 4 items from the validated ACP Engagement Survey, adapted to capture experiences of discrimination. Interviews asked about participants' experiences with ACP, including the appointment of medical decision-makers, sharing preferences, and experiences within the health care system more broadly. RESULTS A total of 603 adults participated in the survey, with 201 SGM individuals (mean [SD] age, 45.7 [18.7] years; 101 [50.2%] female; 22 [10.9%] Black, 37 [18.4%] Hispanic, and 140 [69.7%] White individuals) and 402 non-SGM individuals (mean [SD] age, 53.7 [19.2] years; 199 [49.5%] female; 35 [8.7%] Black, 41 [10.2%] Hispanic, and 324 [80.6%] White individuals). Regarding reasons for not completing ACP, SGM respondents, compared with non-SGM respondents, were more likely to say "I don't see the need" (72 [73.5%] vs 131 [57.2%], P = .006) and "I feel discriminated against by others" (12 [12.2%] vs 6 [2.6%], P < .001). Of 25 completed interviews among SGM participants, 3 main themes were identified: how fear and experiences of discrimination affect selection of clinicians and whether to disclose SGM identity; concerns about whether EOL preferences and medical decision-makers would be supported; and a preference to discuss EOL decisions and values outside of clinical settings. CONCLUSIONS AND RELEVANCE This study found that fear of disclosing sexual orientation or gender identity information and discrimination are important barriers to ACP for SGM in clinical settings, but discussions of preferences and values still occur between many SGM people and medical decision-makers. More SGM-specific patient-centered care might better support these discussions within the health care system. Furthermore, health systems can facilitate improved engagement by supporting clinician sensitivity training, including guidance on documentation and requirements.
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Affiliation(s)
- Amanda Jane Reich
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stephen Perez
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | | | | | | | - Keren Ladin
- Department of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Jennifer Tjia
- University of Massachusetts School of Medicine, Worcester
| | | | - Holly Prigerson
- Center for Research on End-of-Life Care, Weill Cornell School of Medicine, New York City, New York
| | - Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Carey Candrian
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
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156
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Dy SM, Scerpella DL, Cotter V, Colburn J, Roth DL, McGuire M, Giovannetti ER, Walker KA, Hussain N, Sloan DH, Boyd CM, Cockey K, Sharma N, Saylor MA, Smith KM, Wolff JL; SHARING Choices investigators. SHARING Choices: Design and rationale for a pragmatic trial of an advance care planning intervention for older adults with and without dementia in primary care. Contemp Clin Trials 2022; 119:106818. [PMID: 35690262 DOI: 10.1016/j.cct.2022.106818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/27/2022] [Accepted: 06/06/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Advance care planning (ACP) and involving family are particularly important in dementia, and primary care is a key setting. The purpose of this trial is to examine the impact and implementation of SHARING Choices, an intervention to improve communication for older adults with and without dementia through proactively supporting ACP and family engagement in primary care. METHODS We cluster-randomized 55 diverse primary care practices across two health systems to the intervention or usual care. SHARING Choices is a multicomponent intervention that aims to improve communication through patient and family engagement in ACP, agenda setting, and shared access to the patient portal for all patients over 65 years of age. The primary outcomes include documentation of an advance directive or medical orders for life-sustaining treatment in the electronic health record (EHR) at 12 months for all patients and receipt of potentially burdensome care within 6 months of death for the subgroup of patients with serious illness. We plan a priori sub-analysis for patients with dementia. Data sources include the health system EHRs and the Maryland health information exchange. We use a mixed-methods approach to evaluate uptake, fidelity and adaptation of the intervention and implementation facilitators and barriers. CONCLUSIONS This cluster-randomized pragmatic trial examines ACP with a focus on the key population of those with dementia, implementation in diverse settings and innovative approaches to trial design and outcome abstraction. Mixed-methods approaches enable understanding of intervention delivery and facilitators and barriers to implementation in rapidly changing health care systems. CLINICALTRIALS gov Identifier: NCT04819191.
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157
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Lam K, Haddock L, Yukawa M. More POLST forms are being completed in nursing homes, but is this meaningful? J Am Geriatr Soc 2022; 70:1950-1953. [PMID: 35642687 PMCID: PMC9283298 DOI: 10.1111/jgs.17904] [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] [Received: 03/26/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Kenneth Lam
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Short Term and Rehabilitation Unit, San Francisco Campus for Jewish Living, San Francisco, California, USA
| | - Lindsey Haddock
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Short Term and Rehabilitation Unit, San Francisco Campus for Jewish Living, San Francisco, California, USA
| | - Michi Yukawa
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Short Term and Rehabilitation Unit, San Francisco Campus for Jewish Living, San Francisco, California, USA
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158
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Uyeda AM, Curtis JR, Engelberg RA, Brumback LC, Guo Y, Sibley J, Lober WB, Cohen T, Torrence J, Heywood J, Paul SR, Kross EK, Lee RY. Mixed-methods evaluation of three natural language processing modeling approaches for measuring documented goals-of-care discussions in the electronic health record. J Pain Symptom Manage 2022; 63:e713-e723. [PMID: 35182715 PMCID: PMC9124686 DOI: 10.1016/j.jpainsymman.2022.02.006] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/05/2022] [Accepted: 02/07/2022] [Indexed: 01/02/2023]
Abstract
CONTEXT Documented goals-of-care discussions are an important quality metric for patients with serious illness. Natural language processing (NLP) is a promising approach for identifying goals-of-care discussions in the electronic health record (EHR). OBJECTIVES To compare three NLP modeling approaches for identifying EHR documentation of goals-of-care discussions and generate hypotheses about differences in performance. METHODS We conducted a mixed-methods study to evaluate performance and misclassification for three NLP featurization approaches modeled with regularized logistic regression: bag-of-words (BOW), rule-based, and a hybrid approach. From a prospective cohort of 150 patients hospitalized with serious illness over 2018 to 2020, we collected 4391 inpatient EHR notes; 99 (2.3%) contained documented goals-of-care discussions. We used leave-one-out cross-validation to estimate performance by comparing pooled NLP predictions to human abstractors with receiver-operating-characteristic (ROC) and precision-recall (PR) analyses. We qualitatively examined a purposive sample of 70 NLP-misclassified notes using content analysis to identify linguistic features that allowed us to generate hypotheses underpinning misclassification. RESULTS All three modeling approaches discriminated between notes with and without goals-of-care discussions (AUCROC: BOW, 0.907; rule-based, 0.948; hybrid, 0.965). Precision and recall were only moderate (precision at 70% recall: BOW, 16.2%; rule-based, 50.4%; hybrid, 49.3%; AUCPR: BOW, 0.505; rule-based, 0.579; hybrid, 0.599). Qualitative analysis revealed patterns underlying performance differences between BOW and rule-based approaches. CONCLUSION NLP holds promise for identifying EHR-documented goals-of-care discussions. However, the rarity of goals-of-care content in EHR data limits performance. Our findings highlight opportunities to optimize NLP modeling approaches, and support further exploration of different NLP approaches to identify goals-of-care discussions.
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Affiliation(s)
- Alison M Uyeda
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA
| | - J Randall Curtis
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Informatics (J.R.C., J.S., W.B.L.), University of Washington, Seattle, WA.
| | - Ruth A Engelberg
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Lyndia C Brumback
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biostatistics (L.C.B.), University of Washington, Seattle, WA
| | - Yue Guo
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biomedical Informatics and Medical Education (Y.G., W.B.L., T.C.), University of Washington, Seattle, WA
| | - James Sibley
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Informatics (J.R.C., J.S., W.B.L.), University of Washington, Seattle, WA
| | - William B Lober
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biomedical Informatics and Medical Education (Y.G., W.B.L., T.C.), University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Informatics (J.R.C., J.S., W.B.L.), University of Washington, Seattle, WA
| | - Trevor Cohen
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biomedical Informatics and Medical Education (Y.G., W.B.L., T.C.), University of Washington, Seattle, WA
| | - Janaki Torrence
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Joanna Heywood
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Sudiptho R Paul
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Erin K Kross
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Robert Y Lee
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
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Auriemma CL, O'Donnell H, Klaiman T, Jones J, Barbati Z, Akpek E, Halpern SD. How Traditional Advance Directives Undermine Advance Care Planning: If You Have It in Writing, You Do Not Have to Worry About It. JAMA Intern Med 2022; 182:682-684. [PMID: 35467697 PMCID: PMC9039829 DOI: 10.1001/jamainternmed.2022.1180] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This research explores the perspectives of seriously ill patients on the completion of documentation and the implementation of advance directives and advance care planning.
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Affiliation(s)
- Catherine L Auriemma
- Palliative and Advanced Illness Research Center (PAIR), University of Pennsylvania, Philadelphia.,Department of Medicine, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Helen O'Donnell
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Tamar Klaiman
- Palliative and Advanced Illness Research Center (PAIR), University of Pennsylvania, Philadelphia
| | - Julia Jones
- College of Arts and Sciences, University of Pennsylvania, Philadelphia
| | - Zoe Barbati
- Mixed Methods Research Laboratory, University of Pennsylvania, Philadelphia
| | - Eda Akpek
- Mixed Methods Research Laboratory, University of Pennsylvania, Philadelphia
| | - Scott D Halpern
- Palliative and Advanced Illness Research Center (PAIR), University of Pennsylvania, Philadelphia.,Department of Medicine, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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160
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Felde L, Wray CM. Hospital medicine and advanced care planning: Planting the seed for a value-based conversation. J Hosp Med 2022; 17:502-503. [PMID: 35612418 DOI: 10.1002/jhm.12840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Lanna Felde
- Division of Hospital Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Charlie M Wray
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Section of Hospital Medicine, San Francisco VA Health Care System, San Francisco, California, USA
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161
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Koffman J, Penfold C, Cottrell L, Farsides B, Evans CJ, Burman R, Nicholas R, Ashford S, Silber E. “I wanna live and not think about the future” what place for advance care planning for people living with severe multiple sclerosis and their families? A qualitative study. PLoS One 2022; 17:e0265861. [PMID: 35617268 PMCID: PMC9135191 DOI: 10.1371/journal.pone.0265861] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 03/08/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Little is known about how people with multiple sclerosis (MS) and their families comprehend advance care planning (ACP) and its relevance in their lives.
Aim
To explore under what situations, with whom, how, and why do people with MS and their families engage in ACP.
Methods
We conducted a qualitative study comprising interviews with people living with MS and their families followed by an ethical discussion group with five health professionals representing specialties working with people affected by MS and their families. Twenty-seven people with MS and 17 family members were interviewed between June 2019 and March 2020. Interviews and the ethical discussion group were audio-recorded and transcribed verbatim. Data were analysed using the framework approach.
Results
Participants’ narratives focused on three major themes: (i) planning for an uncertain future; (ii) perceived obstacles to engaging in ACP that included uncertainty concerning MS disease progression, negative previous experiences of ACP discussions and prioritising symptom management over future planning; (iii) Preferences for engagement in ACP included a trusting relationship with a health professional and that information then be shared across services. Health professionals’ accounts from the ethical discussion group departed from viewing ACP as a formal document to that of an ongoing process of seeking preferences and values. They voiced similar concerns to people with MS about uncertainty and when to initiate ACP-related discussions. Some shared concerns of their lack of confidence when having these discussions.
Conclusion
These findings support the need for a whole system strategic approach where information about the potential benefits of ACP in all its forms can be shared with people with MS. Moreover, they highlight the need for health professionals to be skilled and trained in engaging in ACP discussions and where information is contemporaneously and seamlessly shared across services.
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Affiliation(s)
- Jonathan Koffman
- Hull York Medical School, Wolfson Palliative Care Research Centre, Hull, United Kingdom
- King’s College London, Cicely Saunders Institute, London, United Kingdom
- * E-mail:
| | - Clarissa Penfold
- Hull York Medical School, Wolfson Palliative Care Research Centre, Hull, United Kingdom
| | | | - Bobbie Farsides
- Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Catherine J. Evans
- King’s College London, Cicely Saunders Institute, London, United Kingdom
| | - Rachel Burman
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Richard Nicholas
- United Kingdom Multiple Sclerosis Tissue Bank, Burlington Danes, Imperial College London, London, United Kingdom
| | - Stephen Ashford
- King’s College London, Cicely Saunders Institute, London, United Kingdom
- Regional Hyper-Acute Rehabilitation Unit, Northwick Park Hospital, North West University, Harrow, United Kingdom
| | - Eli Silber
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
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162
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Ninteau K, Bishop CE. Nursing Home Palliative Care during the Pandemic: Directions for the Future. Innov Aging 2022; 6:igac030. [PMID: 35832204 PMCID: PMC9273407 DOI: 10.1093/geroni/igac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Indexed: 11/15/2022] Open
Abstract
Background and Objectives Palliative care addresses physical, emotional, psychological, and spiritual suffering that accompanies serious illness. Emphasis on symptom management and goals of care is especially valuable for seriously ill nursing home residents. We investigated barriers to nursing home palliative care provision highlighted by the coronavirus disease 2019 (COVID-19) pandemic and the solutions nursing home staff used to provide care in the face of those barriers. Research Design and Methods For this descriptive qualitative study, seven Massachusetts nursing home directors of nursing were interviewed remotely about palliative care provision before and during the COVID-19 pandemic. Interview data were analyzed using thematic analysis. Results Before the pandemic, palliative care was delivered primarily by nursing home staff depending on formal and informal consultations from palliative care specialists affiliated with hospice providers. When COVID-19 lockdowns precluded these consultations, nursing staff did their best to provide palliative care, but were often overwhelmed by shortfalls in resources, resident decline brought on by isolation and COVID-19 itself, and a sense that their expertise was lacking. Advance care planning conversations focused on hospitalization decisions and options for care given resource constraints. Nevertheless, nursing staff discovered previously untapped capacity to provide palliative care on-site as part of standard care, building trust of residents and families. Discussion and Implications Nursing staff rose to the palliative care challenge during the COVID-19 pandemic, albeit with great effort. Consistent with prepandemic analysis, we conclude that nursing home payment and quality standards should support development of in-house staff capacity to deliver palliative care while expanding access to the formal consultations and family involvement that were restricted by the pandemic. Future research should be directed to evaluating initiatives that pursue these aims.
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Affiliation(s)
- Kacy Ninteau
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Christine E Bishop
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
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163
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Pyles O, Hritz CM, Gulker P, Straveler JD, Grudzen CR, Briggs C, Southerland LT. Locating Advance Care Planning Documents in the Electronic Health Record during Emergency Care. J Pain Symptom Manage 2022; 63:e489-e494. [PMID: 34896277 PMCID: PMC9199955 DOI: 10.1016/j.jpainsymman.2021.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 10/19/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
CONTEXT Emergency Departments (EDs) care for people at critical junctures in their illness trajectories, but Advanced Care Planning (ACP) seldom happens during ED visits. One barrier to incorporating patient goals into ED care may be locating ACP documents in the electronic health record (EHR). OBJECTIVES To determine the ease and accuracy of locating ACP documentation in the EHR during an ED visit. METHODS Academic ED with 82,000 visits per year. The EHR system includes a Storyboard with the patient's code status and a link to ACP documents. A real-time chart audit study was performed of ED patients who were either ≥65 years old or had a cancer diagnosis. Data elements included age, Emergency Severity Index, ACP document location(s) in the EHR, Storyboard accuracy, ED code status orders, and discussions of ACP or code status. RESULTS Of the 160 audited charts, 51 (32%) were for adults <65 years old with a cancer diagnosis. Code status was discussed and updated during the ED visit in 68% (n=108). ACP documents were found in 3 different EHR places. Only 30% (n=48) had ACP documents in the EHR, and of these (22%, n=13) were found in only one of the three EHR locations. The Storyboard was inaccurate for 5% (n=8). ED case managers frequently discussed APC documentation (78%, 43/55 charts). CONCLUSIONS Even under optimal conditions with social work availability, ACP documents are lacking for ED patients. Multiple potential locations of ACP documents and inaccurate linkage to the Storyboard are potentially addressable barriers to ACP conversations.
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Affiliation(s)
- Olivia Pyles
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Christopher M Hritz
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Peg Gulker
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Jansi D Straveler
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Corita R Grudzen
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Cole Briggs
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Lauren T Southerland
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA.
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Case AA, Epstein AS, Gustin JL. Advance care planning imperative: High-quality patient-centred goals of care. BMJ Support Palliat Care 2022; 12:407-409. [PMID: 35477675 DOI: 10.1136/bmjspcare-2022-003677] [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] [Received: 04/03/2022] [Accepted: 04/12/2022] [Indexed: 11/03/2022]
Abstract
Advance care planning (ACP) discussions aim to ensure goal-concordant care for patients with serious illness, throughout treatment and especially at the end of life. But recent literature has forced the field of palliative care to wrestle with the definition and impact of ACP. Are ACP discussions worthwhile? Is there a difference between ACP discussions early in a patient's illness versus discussions occurring later when a concrete medical care decision must be made? Here, we identify elements needed to answer these questions and describe how a multisite initiative will elucidate the value of discussing and documenting what matters most to patients.
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Affiliation(s)
- Amy Allen Case
- Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | | | - Jillian L Gustin
- Division of Palliative Medicine, Arthur G James Cancer Hospital and Richard J Solove Research Institute, The Ohio State University College of Medicine, Columbus, Ohio, USA
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165
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McCreedy EM, Yang X, Mitchell SL, Gutman R, Teno J, Loomer L, Moyo P, Volandes A, Gozalo PL, Belanger E, Ogarek J, Mor V. Effect of advance care planning video on do-not-hospitalize orders for nursing home residents with advanced illness. BMC Geriatr 2022; 22:298. [PMID: 35392827 PMCID: PMC8991654 DOI: 10.1186/s12877-022-02970-3] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of the study is to evaluate the effect of an Advance Care Planning (ACP) Video Program on documented Do-Not-Hospitalize (DNH) orders among nursing home (NH) residents with advanced illness. METHODS Secondary analysis on a subset of NHs enrolled in a cluster-randomized controlled trial (41 NHs in treatment arm implemented the ACP Video Program: 69 NHs in control arm employed usual ACP practices). Participants included long (> 100 days) and short (≤ 100 days) stay residents with advanced illness (advanced dementia or cardiopulmonary disease (chronic obstructive pulmonary disease or congestive heart failure)) in NHs from March 1, 2016 to May 31, 2018 without a documented Do-Not-Hospitalize (DNH) order at baseline. Logistic regression with covariate adjustments was used to estimate the impact of the resident being in a treatment versus control NH on: the proportion of residents with new DNH orders during follow-up; and the proportion of residents with any hospitalization during follow-up. Clustering at the facility-level was addressed using hierarchical models. RESULTS The cohort included 6,117 residents with advanced illness (mean age (SD) = 82.8 (8.4) years, 65% female). Among long-stay residents (n = 3,902), 9.3% (SE, 2.2; 95% CI 5.0-13.6) and 4.2% (SE, 1.1; 95% CI 2.1-6.3) acquired a new DNH order in the treatment and control arms, respectively (average marginal effect, (AME) 5.0; SE, 2.4; 95% CI, 0.3-9.8). Among short-stay residents with advanced illness (n = 2,215), 8.0% (SE, 1.6; 95% CI 4.6-11.3) and 3.5% (SE 1.0; 95% CI 1.5-5.5) acquired a new DNH order in the treatment and control arms, respectively (AME 4.4; SE, 2.0; 95% CI, 0.5-8.3). Proportion of residents with any hospitalizations did not differ between arms in either cohort. CONCLUSIONS Compared to usual care, an ACP Video Program intervention increased documented DNH orders among NH residents with advanced disease but did not significantly reduce hospitalizations. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02612688 .
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Affiliation(s)
- Ellen M McCreedy
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA. .,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.
| | - Xiaofei Yang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St, Boston, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Joan Teno
- Oregon Health Sciences University School of Medicine, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business and Economics, University of Minnesota Duluth, 1518 Kirby Dr, Duluth, MN, 55806, USA
| | - Patience Moyo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Angelo Volandes
- Section of General Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Emmanuelle Belanger
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Jessica Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
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Lee RY, Kross EK, Downey L, Paul SR, Heywood J, Nielsen EL, Okimoto K, Brumback LC, Merel SE, Engelberg RA, Curtis JR. Efficacy of a Communication-Priming Intervention on Documented Goals-of-Care Discussions in Hospitalized Patients With Serious Illness: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e225088. [PMID: 35363271 PMCID: PMC8976242 DOI: 10.1001/jamanetworkopen.2022.5088] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 11/14/2022] Open
Abstract
IMPORTANCE High-quality goals-of-care communication is critical to delivering goal-concordant, patient-centered care to hospitalized patients with chronic life-limiting illness. However, implementation and documentation of goals-of-care discussions remain important shortcomings in many health systems. OBJECTIVE To evaluate the efficacy, feasibility, and acceptability of a patient-facing and clinician-facing communication-priming intervention to promote goals-of-care communication for patients hospitalized with serious illness. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial enrolled patients from November 6, 2018, to February 18, 2020. The setting was 2 hospitals in an academic health care system in Seattle, Washington. Participants included hospitalized adults with chronic life-limiting illness, aged 65 years or older and with markers of frailty, or aged 80 years or older. Data analysis was performed from August 2020 to August 2021. INTERVENTION Patients were randomized to usual care with baseline questionnaires (control) vs the Jumpstart communication-priming intervention. Patients or surrogates in the intervention group and their clinicians received patient-specific Jumpstart Guides populated with data from questionnaires and the electronic health records (EHRs) that were designed to prompt and guide a goals-of-care discussion. MAIN OUTCOMES AND MEASURES The primary outcome was EHR documentation of a goals-of-care discussion between randomization and hospital discharge. Additional outcomes included patient-reported or surrogate-reported goals-of-care discussions, patient-reported or surrogate-reported quality of communication, and intervention feasibility and acceptability. RESULTS Of 428 eligible patients, this study enrolled 150 patients (35% enrollment rate; mean [SD] age, 59.2 [13.6] years; 66 women [44%]; 132 [88%] by patient consent and 18 [12%] by surrogate consent). Seventy-five patients each were randomized to the intervention and control groups. Compared with the control group, the cumulative incidence of EHR-documented goals-of-care discussions between randomization and hospital discharge was higher in the intervention group (16 of 75 patients [21%] vs 6 of 75 patients [8%]; risk difference, 13% [95% CI, 2%-24%]; risk ratio, 2.67 [95% CI, 1.10-6.44]; P = .04). Patient-reported or surrogate-reported goals-of-care discussions did not differ significantly between groups (30 of 66 patients [45%] vs 36 of 66 patients [55%]), although the intrarater consistency of patient and surrogate reports was poor. Patient-rated or surrogate-rated quality of communication did not differ significantly between groups. The intervention was feasible and acceptable to patients, surrogates, and clinicians. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, a patient-facing and clinician-facing communication priming intervention for seriously ill, hospitalized patients promoted EHR-documented goals-of-care discussions before discharge with good feasibility and acceptability. Communication-priming interventions should be reexamined in a larger randomized clinical trial to better understand their effectiveness in the inpatient setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03746392.
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Affiliation(s)
- Robert Y. Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Lois Downey
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Sudiptho R. Paul
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- University of Washington School of Medicine, Seattle
| | - Joanna Heywood
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Elizabeth L. Nielsen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Kelson Okimoto
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- Department of Family Medicine, University of Washington, Seattle
| | - Lyndia C. Brumback
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Susan E. Merel
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
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Haverfield MC, Garcia A, Giannitrapani KF, Walling A, Rigdon J, Bekelman DB, Lo N, Lehmann LS, Jacobs J, Festa N, Lorenz KA. Goals of Care Documentation: Insights from A Pilot Implementation Study. J Pain Symptom Manage 2022; 63:485-494. [PMID: 34952172 DOI: 10.1016/j.jpainsymman.2021.12.023] [Citation(s) in RCA: 2] [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: 07/13/2021] [Revised: 12/11/2021] [Accepted: 12/16/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The Life Sustaining Treatment Decision Initiative is a national effort by the Veterans Health Administration to ensure goals of care documentation occurs among all patients at high risk of life-threatening events. OBJECTIVES Examine likelihood to receive goals of care documentation and explore associations between documentation and perceived patient care experience at the individual and site level. METHODS Retrospective, quality improvement analysis of initiative pilot data from four geographically diverse Veterans Affairs (VA) sites (Fall 2014-Winter 2016) before national roll-out. Goals of care documentation according to gender, marital status, urban/rural status, race/ethnicity, age, serious health condition, and Care Assessment Needs scores. Association between goals of care documentation and perceived patient care experience analyzed based on Bereaved Family Survey outcomes of overall care, communication, and support. RESULTS Veterans were more likely to have goals of care documentation if widowed, urban residents, and of white race. Patients older than 65-years and those with a higher Care Assessment Needs score were twice as likely as a frail patient to have goals of care documented. One pilot site demonstrated a positive association between documentation and perceived support. Pilot site was a statistically significant predictor of the occurrence of goals of care documentation and Bereaved Family Survey scores. CONCLUSION Older and seriously ill patients were most likely to have goals of care documented. Association between a documented goals of care conversation and perceived patient care experience were largely unsupported. Site-level largely contributed to understanding the likelihood of documentation and care experience.
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Affiliation(s)
- Marie C Haverfield
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA; Department of Communication Studies, San José State University, San Jose, California, USA.
| | - Ariadna Garcia
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA; School of Medicine, Stanford University, Stanford, California, USA
| | - Karleen F Giannitrapani
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA; School of Medicine, Stanford University, Stanford, California, USA
| | - Anne Walling
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Joseph Rigdon
- Wake Forest School of Medicine, Department of Biostatistics and Data Science, Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - David B Bekelman
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado, USA; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Natalie Lo
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA
| | - Lisa S Lehmann
- Veterans Affairs New England Healthcare System, Bedford, Massachusetts, USA
| | - Josephine Jacobs
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA
| | - Natalia Festa
- Yale New Haven Hospital, Department of Internal Medicine, Section of Geriatrics, New Haven, Connecticut, USA
| | - Karl A Lorenz
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA; School of Medicine, Stanford University, Stanford, California, USA
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168
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Nakagawa S, Blinderman CD. Advancing goals and values, not advance care planning. J Am Geriatr Soc 2022; 70:1895-1897. [PMID: 35332525 DOI: 10.1111/jgs.17758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/05/2022] [Accepted: 03/12/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Shunichi Nakagawa
- Adult Palliative Care Services, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Craig D Blinderman
- Adult Palliative Care Services, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
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169
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Affiliation(s)
- Alexander K. Smith
- Division of Geriatrics, Department of Medicine University of California, San Francisco San Francisco VA Medical Center
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170
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Gonella S, Di Giulio P, Antal A, Cornally N, Martin P, Campagna S, Dimonte V. Challenges Experienced by Italian Nursing Home Staff in End-of-Life Conversations with Family Caregivers during COVID-19 Pandemic: A Qualitative Descriptive Study. Int J Environ Res Public Health 2022; 19:2504. [PMID: 35270195 DOI: 10.3390/ijerph19052504] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/18/2022] [Accepted: 02/20/2022] [Indexed: 12/29/2022]
Abstract
End-of-life conversations are among the most challenging of all communication scenarios and on the agenda of several healthcare settings, including nursing homes (NHs). They may be also difficult for experienced healthcare professionals (HCPs). This study explores the difficulties experienced by Italian NH staff in end-of-life conversations with family caregivers (FCs) during COVID-19 pandemic to uncover their educational needs. A qualitative descriptive study based on inductive thematic analysis was performed. Twenty-one HCPs across six Italian NHs were interviewed. Four themes described their experiences of end-of-life conversations: (1) communicating with FCs over the overall disease trajectory; (2) managing challenging emotions and situations; (3) establishing a partnership between HCPs and FCs; (4) addressing HCPs' communication skills needs. HCPs had to face multiple challenging situations that varied across the care period as well as complex emotions such as anxiety, guilt, uncertainty, fear, anger, or suffering, which required tailored answers. COVID-19 pandemic increased FCs' aggressive behaviors, their distrust, and uncertainty due to visitation restrictions. HCPs had to overcome this by developing a set of strategies, including adoption of an active-listening approach, supportive communication, and explicit acknowledgement of FCs' emotions. Since communication needs were mostly practical in nature, HCPs valued practical communication training.
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171
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife Marcus Institute for Aging Research, Boston, Massachusetts
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172
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Affiliation(s)
- Jeff Myers
- Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada
| | - Leah Steinberg
- Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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173
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Affiliation(s)
- Michael J Rigby
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Tosha B Wetterneck
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - George M Lange
- Honoring Choices Wisconsin, Wisconsin Medical Society, Madison
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174
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Susan E Hickman
- School of Nursing, Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis
| | - Anne M Walling
- Division of General Internal Medicine, Health Services Research, University of California, Los Angeles
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175
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Affiliation(s)
| | - Diane E Meier
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert M Arnold
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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176
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Gotanda H, Walling AM, Reuben DB, Lauzon M, Tsugawa Y. Trends in advance care planning and end-of-life care among persons living with dementia requiring surrogate decision-making. J Am Geriatr Soc 2022; 70:1394-1404. [PMID: 35122231 PMCID: PMC9106854 DOI: 10.1111/jgs.17680] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/21/2021] [Accepted: 01/08/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Previous studies have demonstrated positive impacts of advance care planning (ACP) on end-of-life (EOL) care. We sought to examine trends in ACP and EOL care intensity among persons living with dementia who required surrogate decision-making in their final days of life. METHODS We analyzed the participants of the Health and Retirement Study (HRS), a nationally representative longitudinal panel study of U.S. residents, with dementia 70 years and older who required surrogate decision-making in the final days of life and died between 2000 and 2014. Based on surrogate reports after the death of a participant, our study measured the completion of three specific types of patient-engaged ACP (written EOL care instructions, assignment of a durable power of attorney for healthcare, patient engagement in EOL care discussions) and four measures of EOL care in the final days of life (death in hospital, receipt of life-prolonging treatments, limiting or withholding certain treatments, and receipt of comfort-oriented care). All analyses accounted for the complex survey design of HRS. RESULTS Among 870 adults (weighted N = 2,812,380) with dementia who died in 2000-2014 and required surrogate decision-making at EOL, only 34.8% of patients participated in all three aspects of ACP, and there was not a significant increase in ACP completion between 2000 and 2014. The receipt of life-prolonging treatments in the final days of life has increased over time (adjusted change per year, 1.4 percentage points [pp]; 95% CI, 0.5 to 2.2 pp; P-for-trend = 0.002), while the percentage of death in hospital, limiting or withholding certain treatments, or comfort-oriented care did not change. CONCLUSIONS Our findings suggest that the rates of ACP completion have not increased over time despite its potential benefits and life-prolonging treatments are still common among PLWD who require surrogate decision-making, a population who might benefit greatly from early ACP.
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Affiliation(s)
- Hiroshi Gotanda
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Marie Lauzon
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
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177
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Affiliation(s)
- Catherine L Auriemma
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Department of Medicine, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA
| | - Nwamaka D Eneanya
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Department of Medicine, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA
| | - Katherine R Courtright
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Department of Medicine, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA
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178
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Affiliation(s)
- Juliet Jacobsen
- Harvard Medical School, Boston, Massachusetts
- Lund University Institute for Palliative Care, Lund, Sweden
| | - Rachelle Bernacki
- Harvard Medical School, Boston, Massachusetts
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joanna Paladino
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
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179
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Alzayer H, Geraghty AM, Sebastian KK, Panesar H, Reddan DN. Dialysis Patients’ Preferences on Resuscitation: A Cross-Sectional Study Design. Can J Kidney Health Dis 2022; 9:20543581221113383. [PMID: 35923181 PMCID: PMC9340425 DOI: 10.1177/20543581221113383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/08/2022] [Indexed: 11/30/2022] Open
Abstract
Background: End-stage kidney disease is associated with a 10- to 100-fold increase in
cardiovascular mortality compared with age-, sex-, and race-matched
population. Cardiopulmonary resuscitation (CPR) in this cohort has poor
outcomes and leads to increased functional morbidity. Objective: The aim of this study is to assess patients’ preferences toward CPR and
advance care planning (ACP). Design: cross-sectional study design. Setting: Two outpatient dialysis units. Patients: Adults undergoing dialysis for more than 3 months were included. Exclusion
criteria were severe cognitive impairment or non-English-speaking
patients. Measurements: A structured interview with the use of Willingness to Accept Life-Sustaining
Treatment (WALT) tool. Methods: Demographic data were collected, and baseline Montreal Cognitive Assessment,
Patient Health Questionnaire–9, Duke Activity Status Index, Charlson
comorbidity index, and WALT instruments were used. Descriptive analysis,
chi-square, and t test were performed along with
probability plot for testing hypotheses. Results: Seventy participants were included in this analysis representing a 62.5%
response rate. There was a clear association between treatment burden,
anticipated clinical outcome, and the likelihood of that outcome with
patient preferences. Low-burden treatment with expected return to baseline
was associated with 98.5% willingness to accept treatment, whereas
high-burden treatment with expected return to baseline was associated with
94.2% willingness. When the outcome was severe functional or cognitive
impairment, then 45.7% and 28.5% would accept low-burden treatment,
respectively. The response changed based on the likelihood of the outcome.
In terms of resuscitation, more than 75% of the participants would be in
favor of receiving CPR and mechanical ventilation at their current health
state. Over 94% of patients stated they had never discussed ACP, whereas
59.4% expressed their wish to discuss this with their primary
nephrologist. Limitations: Limited generalizability due to lack of diversity. Unclear decision stability
due to changes in health status and patients’ priorities. Conclusions: ACP should be incorporated in managing chronic kidney disease (CKD) to
improve communication and encourage patient involvement.
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Affiliation(s)
- Husam Alzayer
- Department of Nephrology, University Hospital Galway, Ireland
- Royal College of Surgeons in Ireland, Dublin
| | | | - Kuruvilla K. Sebastian
- Department of Renal Medicine, Cork University Hospital, Ireland
- Department of Medicine, National University of Ireland, Galway
- Royal College of Physicians of Ireland, Dublin
| | - Hardarsh Panesar
- Department of Renal Medicine, Cork University Hospital, Ireland
- Western University, London, ON, Canada
| | - Donal N. Reddan
- Department of Nephrology, University Hospital Galway, Ireland
- Royal College of Physicians of Ireland, Dublin
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180
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Lattimer TA, Tenzek KE, Ophir Y, Sullivan SS. Exploring Online Twitter Conversations surrounding National Healthcare Decisions Day and Advance Care Planning from a Socio-Cultural Perspective: A Computational Mixed-Methods Analysis (Preprint). JMIR Form Res 2021; 6:e35795. [PMID: 35416783 PMCID: PMC9047726 DOI: 10.2196/35795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/07/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Within the cultures and societies of the United States, topics related to death and dying continue to be taboo, and as a result, opportunities for presence and engagement during the end of life, which could lead to a good death, are avoided. Several efforts have been made to help people engage in advance care planning (ACP) conversations, including completing advance care directives so that they may express their goals of care if they become too sick to communicate their wishes. A major effort in the United States toward encouraging such challenging discussions is the annual celebration of the National Healthcare Decisions Day. Objective This study aimed to explore ACP from a sociocultural perspective by using Twitter as a communication tool. Methods All publicly available tweets published between August 1, 2020, and July 30, 2021 (N=9713) were collected and analyzed using the computational mixed methods Analysis of Topic Model Network approach. Results The results revealed that conversations driven primarily by laypersons (7107/7410, 95.91% of tweets originated from unverified accounts) surrounded the following three major themes: importance and promotion, surrounding language, and systemic issues. Conclusions On the basis of the results, we argue that there is a need for awareness of the barriers that people may face when engaging in ACP conversations, including systemic barriers, literacy levels, misinformation, policies (including Medicare reimbursements), and trust among health care professionals, in the United States. This is incredibly important for clinicians and scholars worldwide to be aware of as we strive to re-envision ACP, so that people are more comfortable engaging in ACP conversations. In terms of the content of tweets, we argue that there is a chasm between the biomedical and biopsychosocial elements of ACP, including patient narratives. If used properly, Twitter conversations and National Health Care Decision Day hashtags could be harnessed to serve as a connecting point among organizations, physicians, patients, and family members to lay the groundwork for the trajectory toward a good death.
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Affiliation(s)
- Tahleen A Lattimer
- Department of Communication, University at Buffalo, SUNY, East Amherst, NY, United States
| | - Kelly E Tenzek
- Department of Communication, University at Buffalo, SUNY, East Amherst, NY, United States
| | - Yotam Ophir
- Department of Communication, University at Buffalo, SUNY, East Amherst, NY, United States
| | - Suzanne S Sullivan
- School of Nursing, University at Buffalo, SUNY, East Amherst, NY, United States
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181
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Allsop MJ, Chumbley K, Birtwistle J, Bennett MI, Pocock L. Building on sand: digital technologies for care coordination and advance care planning. BMJ Support Palliat Care 2021; 12:194-197. [PMID: 34876456 DOI: 10.1136/bmjspcare-2021-003304] [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] [Received: 07/28/2021] [Accepted: 11/21/2021] [Indexed: 11/03/2022]
Abstract
Approaches using digital technologies to support advance care planning (ACP) and care coordination are being used in palliative and end of life care. While providing opportunities to facilitate increases in the completeness, sharing and availability of care plans, the evidence base underpinning their use remains limited. We outline an approach that continues to be developed in England; Electronic Palliative Care Coordination Systems (EPaCCS). Stages governing their optimal use are outlined alongside unanswered questions with relevance across technology-mediated approaches to ACP. Research has a critical role in determining if technology-mediated approaches to ACP, such as EPaCCS, could be useful tools to support the delivery of care for patients with chronic and progressive illnesses.
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Affiliation(s)
- Matthew John Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Karen Chumbley
- North East Essex Health and Wellbeing Alliance, Colchester, UK
| | - Jacqueline Birtwistle
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Lucy Pocock
- Centre for Academic Primary Care, University of Bristol Medical School, Bristol, UK
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182
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Breslin L, Connolly E, Purcell R, Lavan A, Kenny RA, Briggs R. What factors are associated with advance care planning in community-dwelling older people? Data from TILDA. Eur Geriatr Med 2021; 13:285-289. [PMID: 34826110 DOI: 10.1007/s41999-021-00593-2] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/16/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess advance care planning (ACP) in a large population-representative sample of older people. METHODS At Wave 4 of the Irish Longitudinal Study on Ageing, participants were asked: Have you made your wishes/preferences known about the kind of care that you would like to receive in the event of serious illness? RESULTS One quarter (1153/4831) had discussed ACP. Of those, 90% had discussed with family/friends, 10% documented ACP in writing, while 2% had discussed with a healthcare professional. Age ≥ 80 years [OR 1.63 (1.31-2.02)], female sex [OR 1.58 (1.37-1.83)], higher educational attainment [OR 1.42 (1.18-1.71)], poorer self-rated health [OR 1.67 (1.06-2.62)] and lower levels of religiosity [OR 1.50 (1.02-2.19)] were independently associated with ACP. CONCLUSION Only one in four older people had discussed ACP informally, while less than 3% have ACP documented in writing. Further work is required to educate the public and healthcare professionals regarding treatment choices at end-of-life.
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Affiliation(s)
- Laura Breslin
- Mercer's Institute for Successful Ageing, St James's Hospital, James's St, Dublin 8, Ireland
| | - Eimear Connolly
- Mercer's Institute for Successful Ageing, St James's Hospital, James's St, Dublin 8, Ireland
| | - Roisin Purcell
- Mercer's Institute for Successful Ageing, St James's Hospital, James's St, Dublin 8, Ireland.,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
| | - Amanda Lavan
- Mercer's Institute for Successful Ageing, St James's Hospital, James's St, Dublin 8, Ireland.,The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin 1, Ireland.,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
| | - Rose Anne Kenny
- Mercer's Institute for Successful Ageing, St James's Hospital, James's St, Dublin 8, Ireland.,The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin 1, Ireland.,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
| | - Robert Briggs
- Mercer's Institute for Successful Ageing, St James's Hospital, James's St, Dublin 8, Ireland. .,The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin 1, Ireland. .,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland.
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183
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Back AL, Warner MR, Beard KM, Goodnow MH, Constans LA, McCabe PJ. Use of Messaging Principles to Design a Facebook Ad Promoting Public Engagement in Serious Illness Care for National Healthcare Decisions Day. J Palliat Med 2021; 24:1762-1765. [PMID: 34668792 DOI: 10.1089/jpm.2021.0346] [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: 11/12/2022] Open
Abstract
Public hesitation to engage in advance care planning, consultation with palliative care, and admission to hospice is a significant barrier to improving patient outcomes. In previous study, we derived five empirically supported messaging principles, and in this project we used these messaging principles to design, place, and analyze a 60-second video for the Oregon Coalition for Living Well with Serious Illness. The video was scripted to emphasize a single message that had emerged from the empirical research: that "you should have a say in your care." We deliberately did not use the term "advance care planning" because our prior focus groups showed that most consumers did not use this term. The marketing plan for the resulting video on Facebook included a paid sponsorship of the full-length video through a Facebook boosted post, and three 10-second ads featuring key lines from the video that tested different elaborations of the central message. Facebook Analytics indicated that the 60-second video was viewed 67,650 times in the week it was promoted. The three 10-second ads, which showed selected moments from the full-length video, were viewed a total of 253,087 times. Of the three 10-second ads, the one emphasizing "What matters to me is being near my family" (65% of clicks) strongly outperformed "I don't want to go out on a machine" and "I've heard so many medical horror stories" (35% for both messages combined) as messages that persuaded viewers to click through the ad to the website. Use of the messaging principles to guide the design and marketing of this Facebook ad shows that (1) the public is interested in serious illness care, (2) that targeted social media can be used to reach a defined public audience, and that (3) this public messaging strategy can be implemented at relatively low cost.
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Affiliation(s)
- Anthony L Back
- Department of Medicine, University of Washington, Seattle, Washington, USA
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