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Beltran SJ, Molina O, Chapple R. Enhancing End-of-Life Care Knowledge Among Older Spanish-Speaking Adults: Results From a Pilot Educational Intervention on Advance Care Planning and Care Options. Am J Hosp Palliat Care 2024:10499091241246057. [PMID: 38621826 DOI: 10.1177/10499091241246057] [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: 04/17/2024] Open
Abstract
BACKGROUND Disparities in advance care planning (ACP) among older Latinos necessitate targeted interventions to enhance engagement and knowledge in end-of-life care. This study aimed to evaluate the effectiveness of a resource-efficient, culturally tailored educational intervention in improving ACP readiness and knowledge among older Latino adults in the community. METHODS A quasi-experimental pretest-posttest design was used to assess the impact of the intervention. The study involved community-dwelling older Latinos (aged 61-94) in the U.S. attending community wellness centers. Measures included participants' knowledge of ACP, care options, familiarity with hospice and palliative care, and attitudes toward hospice, assessed using pre- and post-intervention surveys. RESULTS Statistically significant improvements were observed in ACP knowledge, understanding of care options, and attitudes towards hospice and palliative care post-intervention. Demographic factors influenced knowledge scores, with no significant gender differences in the intervention's efficacy. CONCLUSIONS The educational intervention effectively enhanced end-of-life care planning readiness and knowledge among older Latinos. The study highlights the potential for sustainable, accessible, and culturally sensitive educational strategies to reduce disparities in ACP knowledge and possibly engagement.
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Affiliation(s)
- Susanny J Beltran
- School of Social Work, University of Central Florida, Orlando, FL, USA
| | - Olga Molina
- School of Social Work, University of Central Florida, Orlando, FL, USA
| | - Reshawna Chapple
- School of Social Work, University of Central Florida, Orlando, FL, USA
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Bobier C, Reinhardt N, Pawlowski K. Animal rights, animal research, and the need to reimagine science. New Bioeth 2024; 30:63-76. [PMID: 38182130 DOI: 10.1080/20502877.2023.2300232] [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: 01/07/2024]
Abstract
What would it look like for researchers to take non-human animal rights seriously? Recent discussions foster the impression that scientific practice needs to be reformed to make animal research ethical: just as there is ethically rigorous human research, so there can be ethically rigorous animal research. We argue that practically little existing animal research would be ethical and that ethical animal research is not scalable. Since animal research is integral to the existing scientific paradigm, taking animal rights seriously requires a radical, wholesale reimagining of science.Trial registration: ClinicalTrials.gov identifier: NCT05340426.
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Affiliation(s)
- Christopher Bobier
- Department of Theology & Philosophy, Saint Mary's University of Minnesota, Winona, MN, USA
| | - Noah Reinhardt
- Business Department, University of Mary, Bismarck, ND, USA
| | - Kate Pawlowski
- Public Health, Saint Mary's University of Minnesota, Winona, MN, USA
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Levi BH, Dimmock AEF, Van Scoy LJ, Smith T, Kunzler B, Foy AJ, Badzek L, Green MJ. What Counts as a Surrogate Decision? Am J Hosp Palliat Care 2024; 41:125-132. [PMID: 36997165 PMCID: PMC10751970 DOI: 10.1177/10499091231168976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
When patients lose decision-making capacity, others must make surrogate decisions on their behalf. What counts as a surrogate decision might seem self-evident. But as clinician-researchers in the field of advance care planning, we have found that it is not always so clear-cut. In this paper, we describe how and why this is a matter of concern, a novel approach for assessing whether a surrogate decision occurred, and findings from this assessment.
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Affiliation(s)
- Benjamin H Levi
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Anne EF Dimmock
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Theresa Smith
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Bronson Kunzler
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Andrew J Foy
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Laurie Badzek
- Nursing Sciences Building University Park, Penn State College of Nursing, Hershey, PA, USA
| | - Michael J Green
- Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA
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Malhotra C, Huynh VA, Shafiq M, Batcagan-Abueg APM. Advance care planning and caregiver outcomes: intervention efficacy - systematic review. BMJ Support Palliat Care 2024; 13:e537-e546. [PMID: 35788465 DOI: 10.1136/spcare-2021-003488] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 06/13/2022] [Indexed: 11/04/2022]
Abstract
CONTEXT Caregivers make difficult end-of-life (EOL) decisions for patients, often adversely affecting their own psychological health. Understanding whether advance care planning (ACP) interventions benefit caregivers can enable healthcare systems to use these approaches to better support them. OBJECTIVE We conducted a systematic review and meta-analysis to identify and quantify the impacts of ACP interventions on caregiver outcomes. METHODS We searched MEDLINE, Embase and Cochrane databases for English-language randomised or cluster randomised controlled trials (RCTs) published until May 2021. Two reviewers independently assessed methodological quality using the Physiotherapy Evidence-Based Database Scale. We conducted a narrative synthesis for each outcome. Difference between arms with a p value of <0.05 was considered statistically significant. RESULTS Of the 3487 titles reviewed, 35 RCTs met eligibility; 68.6% were rated high quality. Included RCTs were heterogeneous in intervention characteristics, setting and disease. Meta-analysis of 17 RCTs showed that ACP had large and significant improvement in congruence in EOL care preferences between caregivers and patients (standardised mean difference 0.73, 95% CI 0.42 to 1.05). The effect of ACP on this outcome, however, declined over time. We also found some evidence that ACP improved bereavement outcomes (three of four RCTs), satisfaction with care quality/communication (four of the six RCTs), reduced decisional conflict (two of the two RCTs) and burden (one RCT). No study showed that mental health of caregivers were adversely affected. CONCLUSION The review provides most comprehensive evidence about the efficacy of ACP on caregiver outcomes. Findings suggest some evidence of benefit of ACP on caregiver outcomes.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Vinh Anh Huynh
- 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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Steinberg A, Fischhoff B. Cognitive Biases and Shared Decision Making in Acute Brain Injury. Semin Neurol 2023; 43:735-743. [PMID: 37793424 DOI: 10.1055/s-0043-1775596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, Neurology, and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
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Gazaway S, Wells RD, Azuero A, Pisu M, Guastaferro K, Rini C, Taylor R, Reed RD, Harrell ER, Bechthold AC, Bratches RW, McKie P, Lowers J, Williams GR, Rosenberg AR, Bakitas MA, Kavalieratos D, Dionne-Odom JN. Decision support training for advanced cancer family caregivers: Study protocol for the CASCADE factorial trial. Contemp Clin Trials 2023; 131:107259. [PMID: 37286131 PMCID: PMC10527385 DOI: 10.1016/j.cct.2023.107259] [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: 03/27/2023] [Revised: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Patients with advanced cancer face numerous decisions when diagnosed and often receive decision support from family caregivers. The CASCADE (CAre Supporters Coached to be Adept DEcision partners) factorial trial intervention aims to train caregivers in skills to provide effective decision support to patients and identify most effective intervention components. METHODS This is a 2-site, single-blind, 24 factorial trial to test components of the CASCADE decision support training intervention for family caregivers of patients with newly-diagnosed advanced cancer delivered by specially-trained, telehealth, palliative care lay coaches over 24 weeks. Family caregivers (target N = 352) are randomly assigned to one of 16 combinations of four components with two levels each: 1) psychoeducation on effective decision partnering principles (1 vs. 3 sessions); 2) decision support communication training (1 session vs. none); 3) Ottawa Decision Guide training (1 session vs. none) and 4) monthly follow-up (1 call vs. calls for 24 weeks). The primary outcome is patient-reported decisional conflict at 24 weeks. Secondary outcomes include patient distress, healthcare utilization, caregiver distress, and quality of life. Mediators and moderators (e.g., sociodemographics, decision self-efficacy, social support) will be explored between intervention components and outcomes. Results will be used to build two versions of CASCADE: one with only effective components (d ≥ 0.30) and another optimized for scalability and cost. DISCUSSION This protocol describes the first factorial trial, informed by the multiphase optimization strategy, of a palliative care decision-support intervention for advanced cancer family caregivers and will address the field's need to identify effective components that support serious illness decision-making. TRIAL REGISTRATION NCT04803604.
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Affiliation(s)
- Shena Gazaway
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Rachel D Wells
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Maria Pisu
- Division of Preventive Medicine, UAB Heersink School of Medicine, Birmingham, AL, USA
| | - Kate Guastaferro
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, USA
| | - Christine Rini
- Cancer Survivorship Institute, Feinberg School of Medicine, Northwestern University, Evanston, IL, USA
| | - Richard Taylor
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Rhiannon D Reed
- Division of Transplantation, Department of Medicine, UAB, Birmingham, AL, USA
| | - Erin R Harrell
- Department of Psychology, University of Alabama, Tuscaloosa, AL, USA
| | - Avery C Bechthold
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Reed W Bratches
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Peg McKie
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Jane Lowers
- Division of Palliative Medicine, Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Abby R Rosenberg
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA, USA
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Martins CS, Cadavez E, Nunes R. Advance directives in palliative care-a new tool to improve the communication between patients and caregivers? Int J Palliat Nurs 2023; 29:344-349. [PMID: 37478063 DOI: 10.12968/ijpn.2023.29.7.344] [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: 07/23/2023]
Abstract
BACKGROUND In palliative care, caregivers frequently act as surrogate decision-makers, but their knowledge of patients' preferences for end-of-life care is sometimes scarce and incorrect. Advance Directives might be a powerful communication tool to promote the dialogue between patients and caregivers. AIMS This work aims to find evidence supporting the use of the Advance Directives documents by health practitioners as a communication tool to improve caregivers' capacity as health surrogates in palliative care. METHODS A literature review was conducted in four databases-Medline, Web of Science, Scopus, and Cochrane to identify studies published until February 27th, 2021, analysing advance directive's use as a communication tool between palliative patients and their caregivers. FINDINGS Of the 1251 papers screened, only one article met the defined criteria, presenting results statistically favourable to advance directive's use, although with the risk of significant bias. CONCLUSIONS Although the results seem promising, more studies are needed to validate this strategy scientifically.
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Affiliation(s)
- Catarina Sampaio Martins
- Anesthesiology Consultant and Palliative Care Medical Doctor, Palliative Medicine Service of Centro Hospitalar de Tràs-os-Montes e Alto Douro, Portugal
| | - Emanuel Cadavez
- Oncology Resident Medical Doctor, Oncology Service of Centro Hospitalar de Tràs-os-Montes e Alto Douro, Portugal
| | - Rui Nunes
- Professor, Faculty of Medicine, MEDCIDS-Department of Community Medicine, Information and Decision in Health, University of Porto, Portugal
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Yeung CCY, Ho KHM, Chan HYL. A dyadic advance care planning intervention for people with early-stage dementia and their family caregivers in a community care setting: a feasibility trial. BMC Geriatr 2023; 23:115. [PMID: 36859250 PMCID: PMC9979490 DOI: 10.1186/s12877-023-03815-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/09/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Advance care planning (ACP) is highly relevant for people with early-stage dementia to communicate their care preferences for serious illness conditions with their family caregivers before they become mentally incapacitated. METHODS A multi-centre, quasi-experimental study was conducted to test the feasibility and acceptability of a theory-guided, dyadic ACP intervention ('Have a Say' programme) among participants with early-stage dementia-family caregiver dyads. The feasibility of the trial design, intervention procedures, subject recruitment and retention, and study instruments were assessed. Study outcomes were measured at baseline (T0), immediately after the intervention (T1), and at 1 month (T2) and 3 months post-intervention (T3). Acceptability of the intervention was determined by the satisfaction score, completion rate and qualitative interviews as process evaluation with a purposive sample of participants and ACP facilitators. Generalised estimating equations were performed to examine differential changes between groups over time, with covariates adjusted. RESULTS Subject recruitment from five elderly community centres yielded a recruitment rate of 60% and resulted in 36 client-caregiver dyads. The intervention was acceptable to the dyads, with a mean satisfaction score of 4.4 out of 5 and completion rate of 94.4%. The attrition rates at T1, T2, and T3 were 8.3%, 13.9%, and 19.4%, respectively. The intervention group reported a significantly greater improvement in the readiness for ACP at T1, self-efficacy for ACP at T3, and dyadic concordance on end-of-life care preferences at all time points than the control group, but not on depressive symptoms. Family caregivers in the intervention group reported a significantly higher caregiving burden at T2 than the control group. The qualitative findings revealed that triadic involvement of and trusting relationships among the dyads and ACP facilitators, and documentation of clients' views are the programme strengths, while the structured format and discussion about medical issues posed implementation challenges. CONCLUSIONS This ACP intervention and trial design were feasible and acceptable to the dyads. Several refinements were identified, including adding a nurse-led group-based session for information giving, allowing flexibility in arrangement, and adding measure of ACP engagement of family caregivers. A rigorous trial to test the effects of the ACP intervention is warranted. TRIAL REGISTRATION Retrospectively registered on 14/08/2020 at clinicaltrials.gov (Identifier: NCT04513106).
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Affiliation(s)
- Cheryl Chi-Yan Yeung
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6-8/F, Esther Lee Building, Shatin, Hong Kong SAR, China
| | - Ken Hok-Man Ho
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6-8/F, Esther Lee Building, Shatin, Hong Kong SAR, China
| | - Helen Yue-Lai Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6-8/F, Esther Lee Building, Shatin, Hong Kong SAR, China.
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Ke LS, Cheng HC, Liu CL, Ku YC, Lee MJ, Lin YL, Huang HY. Taiwanese Older Adults Prefer to Use Antibiotics and Intravenous Infusion at the End of Life based on a Cartoon Version of the Life Support Preferences Questionnaire. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3430. [PMID: 36834122 PMCID: PMC9959590 DOI: 10.3390/ijerph20043430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
Asians believe discussing death-related topics is inauspicious and may bring bad luck. It is critical to explore the end-of-life care preferences of the Asian elderly with less-threatening tools. The study examined older adults' preferences regarding end-of-life treatments by applying a cartoon version of the Life Support Preferences Questionnaire (LSPQ). A cross-sectional survey was conducted to understand older adults' preferences for end-of-life treatments. A total of 342 older adults participated in the study, comprising 268 elderly patients from a veterans hospital located in northern Taiwan and 74 elderly family members of the patients. Regardless of scenario, cardiopulmonary resuscitation (CPR) had the lowest score, indicating that older adults considered it a less desirable medical treatment. By contrast, antibiotics and intravenous infusions had the highest scores, indicating that older adults tended to prefer them. End-of-life care preferences were significantly different in genders. CPR and surgical preferences of older adults differed significantly with education level. Different demographic characteristics had different end-of-life treatment preferences, and future research may develop advance care planning programs for different attributes. This cartoon version of the LSPQ can help healthcare professionals to understand older adults' preferences for end-of-life care and warrants further empirical research.
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Affiliation(s)
- Li-Shan Ke
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei 112, Taiwan
| | - Hui-Chuan Cheng
- Department of Nursing, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Chien-Liang Liu
- Department of Neurology, Taipei City Hospital, Taipei 110, Taiwan
| | - Yu-Chen Ku
- Department of Nursing, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Ming-Ju Lee
- Department of Nursing, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Yin-Ling Lin
- Department of Nursing, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Hsiu-Ying Huang
- Department of Nursing, Taipei Veterans General Hospital, Taipei 112, Taiwan
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Koenig JFL, Asendorf T, Simon A, Bleckmann A, Truemper L, Wulf G, Overbeck TR. "SpezPat"- common advance directives versus disease-centred advance directives: a randomised controlled pilot study on the impact on physicians' understanding of non-small cell lung cancer patients' end-of-life decisions. BMC Palliat Care 2022; 21:167. [PMID: 36167565 PMCID: PMC9516789 DOI: 10.1186/s12904-022-01057-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 09/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The advance directive represents patients' health care choices and fosters patients' autonomy. Nevertheless, understanding patients' wishes based on the information provided in advance directives remains a challenge for health care providers. Based on the ethical premises of positive obligation to autonomy, an advanced directive that is disease-centred and details potential problems and complications of the disease should help health care providers correctly understand patients' wishes. To test this hypothesis, a pilot-study was conducted to investigate whether physicians could make the correct end-of-life decision for their patients when patients used a disease-centred advance directive compared to a common advance directive. MATERIAL AND METHODS: A randomised, controlled, prospective pilot study was designed that included patients with non-small cell lung cancer (NSCLC) stage VI from the Department of Haematology and Medical Oncology, University Medical Centre, Goettingen. Patients were randomised into intervention and control groups. The control group received a common advance directive, and the intervention group received a disease-centred advance directive. Both groups filled out their advance directives and returned them. Subsequently, patients were asked to complete nine medical scenarios with different treatment decisions. For each scenario the patients had to decide whether they wanted to receive treatment on a 5-point Likert scale. Four physicians were given the same scenarios and asked to decide on the treatment according to the patients' wishes as stated in their advance directives. The answers by patients and physicians were then compared to establish whether physicians had made the correct assumptions. RESULTS Recruitment was stopped prior to reaching anticipated sample target. 15 patients with stage IV NSCLC completed the study, 9 patients were randomised into the control group and 6 patients in the intervention group. A total of 135 decisions were evaluated. The concordance between physicians' and patients' answers, was 0.83 (95%-CI 0.71-0.91) in the intervention group, compared to 0.60 (95%-CI 0.48-0.70) in the control group, and the difference between the two groups was statistically significant (p = 0.005). CONCLUSION This pilot study shows that disease-centred advance directives help physicians understand their NSCLC patients' wishes more precisely and make treatment choices according to these wishes. TRIAL REGISTRATION The study is registered at the German Clinical Trial Register (no. DRKS00017580, registration date 27/08/2019).
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Affiliation(s)
- Julia Felicitas Leni Koenig
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany.
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Centre, Von-Siebold-Str. 3, Goettingen, Germany
| | - Alfred Simon
- Academy of Ethics in Medicine, Robert-Koch-Str. 40, Goettingen, Germany
| | - Annalen Bleckmann
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany.,Department of Medicine A; Hematology, Oncology and Pneumology, University Hospital Muenster; Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Lorenz Truemper
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany
| | - Gerald Wulf
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany
| | - Tobias R Overbeck
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany
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Noerup ES, Skorstengaard MH, Jensen AB, Guldin MB, Neergaard MA. Does advance care planning affect relatives’ healthcare-seeking behaviour? PROGRESS IN PALLIATIVE CARE 2022. [DOI: 10.1080/09699260.2022.2119326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
| | | | | | - Mai-Britt Guldin
- The Danish Knowledge Centre for Rehabilitation and Palliative Care, Nyborg, Denmark
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Soofi H. Respect for Autonomy and Dementia Care in Nursing Homes: Revising Beauchamp and Childress's Account of Autonomous Decision-Making. JOURNAL OF BIOETHICAL INQUIRY 2022; 19:467-479. [PMID: 35749025 PMCID: PMC9463234 DOI: 10.1007/s11673-022-10195-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 02/14/2022] [Indexed: 05/26/2023]
Abstract
Specifying the moral demands of respect for the autonomy of people with dementia (PWD) in nursing homes (NHs) remains a challenging conceptual task. These challenges arise primarily because received notions of autonomous decision-making and informed consent do not straightforwardly apply to PWD in NHs. In this paper, I investigate whether, and to what extent, the influential account of autonomous decision-making and informed consent proposed by Beauchamp and Childress has applicability and relevance to PWD in NHs. Despite its otherwise practical orientation and suitability for acute care settings, I identify three problems with this account when applied to PWD in NHs. These problems include (1) intentionality as an all-or-nothing condition of autonomous decision-making, (2) construing consent as one-off authorization, and (3) unresolved ambiguities around the primacy of precedent autonomy over best interest considerations. To address these problems, I propose and defend a number of revisions to Beauchamp and Childress's account. First, I suggest that we consider intentionality as a non-binary criterion of autonomous decision-making. Second, I argue for a model of process consent to overcome the moral inadequacy of construing consent as one-off authorization in NHs. And, to overcome the third problem, I suggest accounting for both precedent and extant autonomy of PWD, considering mandates of precedent autonomy not as prescriptive but as informative, and drawing a less rigid distinction between autonomy considerations and best interest judgements. I conclude that this revised version of Beauchamp and Childress's account fares better than the original version in capturing relevant autonomy considerations to care for PWD in NHs.
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Affiliation(s)
- Hojjat Soofi
- Department of Clinical Medicine, Macquarie University, Level 1, 75 Talavera Rd, Macquarie Park, NSW, 2113, Australia.
- Department of Philosophy, Macquarie Univesity, Levels 6, 25B Wally's Walk, Macquarie Park, NSW, 2109, Australia.
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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: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [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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The Association Between Mild Cognitive Impairment Diagnosis and Patient Treatment Preferences: a Survey of Older Adults. J Gen Intern Med 2022; 37:1925-1934. [PMID: 33963503 PMCID: PMC9198187 DOI: 10.1007/s11606-021-06839-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 03/25/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Older patients (65+) with mild cognitive impairment (MCI) receive less guideline-concordant care for cardiovascular disease (CVD) and other conditions than patients with normal cognition (NC). One potential explanation is that patients with MCI want less treatment than patients with NC; however, the treatment preferences of patients with MCI have not been studied. OBJECTIVE To determine whether patients with MCI have different treatment preferences than patients with NC. DESIGN Cross-sectional survey conducted at two academic medical centers from February to December 2019 PARTICIPANTS: Dyads of older outpatients with MCI and NC and patient-designated surrogates. MAIN MEASURES The modified Life-Support Preferences-Predictions Questionnaire score measured patients' preferences for life-sustaining treatment decisions in six health scenarios including stroke and acute myocardial infarction (range, 0-24 treatments rejected with greater scores indicating lower desire for treatment). KEY RESULTS The survey response rate was 73.4%. Of 136 recruited dyads, 127 (93.4%) completed the survey (66 MCI and 61 NC). The median number of life-sustaining treatments rejected across health scenarios did not differ significantly between patients with MCI and patients with NC (4.5 vs 6.0; P=0.55). Most patients with MCI (80%) and NC (80%) desired life-sustaining treatments in their current health (P=0.99). After adjusting for patient and surrogate factors, the difference in mean counts of rejected treatments between patients with MCI and patients with NC was not statistically significant (adjusted ratio, 1.08, 95% CI, 0.80-1.44; P=0.63). CONCLUSION We did not find evidence that patients with MCI want less treatment than patients with NC. These findings suggest that other provider and system factors might contribute to patients with MCI getting less guideline-concordant care.
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Howard D, Rivlin A, Candilis P, Dickert NW, Drolen C, Krohmal B, Pavlick M, Wendler D. Surrogate Perspectives on Patient Preference Predictors: Good Idea, but I Should Decide How They Are Used. AJOB Empir Bioeth 2022; 13:125-135. [PMID: 35259317 PMCID: PMC9761590 DOI: 10.1080/23294515.2022.2040643] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Current practice frequently fails to provide care consistent with the preferences of decisionally-incapacitated patients. It also imposes significant emotional burden on their surrogates. Algorithmic-based patient preference predictors (PPPs) have been proposed as a possible way to address these two concerns. While previous research found that patients strongly support the use of PPPs, the views of surrogates are unknown. The present study thus assessed the views of experienced surrogates regarding the possible use of PPPs as a means to help make treatment decisions for decisionally-incapacitated patients. This qualitative study used semi-structured interviews to determine the views of experienced surrogates [n = 26] who were identified from two academic medical centers and two community hospitals. The primary outcomes were respondents' overall level of support for the idea of using PPPs and the themes related to their views on how a PPP should be used, if at all, in practice. Overall, 21 participants supported the idea of using PPPs. The remaining five indicated that they would not use a PPP because they made decisions based on the patient's best interests, not based on substituted judgment. Major themes which emerged were that surrogates, not the patient's preferences, should determine how treatment decisions are made, and concern that PPPs might be used to deny expensive care or be biased against minority groups. Surrogates, like patients, strongly support the idea of using PPPs to help make treatment decisions for decisionally-incapacitated patients. These findings provide support for developing a PPP and assessing it in practice. At the same time, patients and surrogates disagree over whose preferences should determine how treatment decisions are made, including whether to use a PPP. These findings reveal a fundamental disagreement regarding the guiding principles for surrogate decision-making. Future research is needed to assess this disagreement and consider ways to address it. Supplemental data for this article is available online at.
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Affiliation(s)
- Dana Howard
- Center for Bioethics, Ohio State University, Columbus, OH, USA
| | | | | | | | | | - Benjamin Krohmal
- John J. Lynch MD Center for Ethics, MedStar Washington Hospital Center, Washington, DC, USA.,Emergency Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | | | - David Wendler
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, USA
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16
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Vitcov GG, Santulli RB. Video Messages: A Tool to Improve Surrogate Decision Making. THE JOURNAL OF CLINICAL ETHICS 2022. [DOI: 10.1086/jce2022331036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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17
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Abstract
The palliative care needs of inpatients with neurologic illness are varied, depending on diagnosis, acuity of illness, available treatment options, prognosis, and goals of care. Inpatient neurologists ought to be proficient at providing primary palliative care and effective at determining when palliative care consultants are needed. In the acute setting, palliative care should be integrated with lifesaving treatments using a framework of determining goals of care, thoughtfully prognosticating, and engaging in shared decision-making. This framework remains important when aggressive treatments are not desired or not available, or when patients are admitted to the hospital for conditions related to advanced stages of chronic neurologic disease. Because prognostic uncertainty characterizes much of neurology, inpatient neurologists must develop communication strategies that account for uncertainty while supporting shared decision-making and allowing patients and families to preserve hope. In this article, we illustrate the approach to palliative care in inpatient neurology.
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Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, San Francisco, California
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Jo M, Park M, Park EJ, Choi JY. The Acceptability and Effect of a Communication-Based Advance Care Planning Program for Older Adults. J Hosp Palliat Nurs 2021; 23:375-385. [PMID: 34185729 DOI: 10.1097/njh.0000000000000762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study was a preliminary study that assessed the acceptability of a communication-based advance care planning (ACP) intervention for older adults to improve decision making for treatment at the end of life. Twenty dyads were recruited, including patients who were older than 65 years and registered in a home health care center of a teaching hospital in South Korea and their surrogates. The intervention is a patient-centered ACP program with surrogates and a structured and guided discussion by home health care nurses as the trained interventionists. The acceptability of the intervention was assessed by a mixed method including a survey and a structured interview with participants. Findings in this study indicate that recruiting older adults with chronic diseases and their surrogates in a home health care center and conducting the intervention by home health care nurses is feasible. In addition, the outcomes of this study suggest that the intervention may have a potential impact on end-of-life care decision making for older adults in South Korea. A larger-scale trial is required to determine the effects of the ACP program when implemented with various groups. This study suggests that older adults need an ACP program as part of routine care.
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Park M, Park EJ, Jo M, Ahn J. Feasibility of an Advance Care Planning Program (ACP) for Korean Community-Dwelling Older Adults and ACP Training of Advance Practice Nurses. J Community Health Nurs 2021; 38:179-192. [PMID: 34148432 DOI: 10.1080/07370016.2021.1932963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This study aimed to develop a locally suitable advance care planning (ACP) program for older community-dwelling adults and a training program for nurse facilitators in Korea, and to evaluate their feasibility from the facilitators' experiences. This was a mixed methods pilot study that assessed the feasibility of an ACP program by analyzing survey, checklist, and focus group interview data. The ACP program was named CLOSE (Communicating and Listening to Our Seniors' voices about End-of-life care). Home health care nurses (N = 9) participated in this study. The participants reported that CLOSE was applicable to older community-dwelling adults and the training program was useful for increasing facilitator competency. We suggest some lessons from this pilot study that can be used to improve the ACP program and encourage community health nurses to participate in ACP as facilitators.
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Affiliation(s)
- Mihyun Park
- Department of Health System, College of Nursing, the Catholic University of Korea, Seoul, South Korea
| | - Eun-Jun Park
- Department of Nursing, Konkuk University, Chungju, South Korea
| | - Minjeong Jo
- Department of Clinical Nursing, College of Nursing, the Catholic University of Korea, Seoul, South Korea
| | - Jinhee Ahn
- Maumahn Healing & Communication, Seoul, South Korea
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20
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Abstract
Advance directives entail a refusal expressed by a still-healthy patient. Three consequences stem from that fact: (a) advance refusal is unspecific, since it is impossible to predict what the patient's conditions and the risk-benefit ratio may be in the foreseeable future; (b) those decisions cannot be as well informed as those formulated while the disease is in progress; (c) while both current consent and refusal can be revoked as the disease unfolds, until the treatment starts out, advance directives become effective when the patient becomes incapable or unconscious; such decisions can therefore not be revoked at any stage of the disease. Therefore, advance directives are binding for doctors only at the stage of advance treatment planning, i.e., only if they refer to an illness already in progress.
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21
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Ke LS, Hu WY, Chen CY, Liu CY, Chiu TY. A quasi-experimental evaluation of advance care planning improves consistency between elderly individuals and their surrogates regarding end-of-life care preferences: Development and application of a decision aid with cartoon pictures. PATIENT EDUCATION AND COUNSELING 2021; 104:815-825. [PMID: 33010998 DOI: 10.1016/j.pec.2020.09.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/10/2020] [Accepted: 09/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE This study sought to develop a decision aid with cartoon pictures and evaluate its effectiveness in increasing consistency between elderly individuals and their surrogates regarding end-of-life care. METHODS A pre-post quasi-experimental design was adopted using the Life Support Preferences Questionnaire. The intervention had two components: (1) increasing participants' knowledge of medical treatments related to end-of-life care, and (2) sharing their end-of-life wishes. The experimental group received an intervention, whereas the control group received usual care. RESULTS A total of 110 participants in 55 pairs of elderly individuals with average aged 86.4 and their surrogates (27 in the experimental group, 28 in the control group) were recruited from a veterans hospital in northern Taiwan. Nearly 90 % of elderly individuals were male. The multiple linear regression showed that the inconsistent gap between elderly individuals and their surrogates in the experimental group decreased 12 points than the control group after controlling the covariances (B = -12.116, p = 0.032). CONCLUSION The intervention improved the consistency between elderly individuals and their surrogates regarding end-of-life care. PRACTICE IMPLICATIONS A decision aid with cartoon pictures may support the discussion of end-of-life care in older Asian populations.
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Affiliation(s)
- Li-Shan Ke
- National Taipei University of Nursing and Health Sciences, School of Nursing, Taipei, Taiwan; Taipei Veterans General Hospital, Department of Nursing, Taipei, Taiwan; National Taiwan University, College of Medicine, School of Nursing, Taipei, Taiwan.
| | - Wen-Yu Hu
- National Taiwan University, College of Medicine, School of Nursing, Taipei, Taiwan; National Taiwan University Hospital, Department of Nursing, Taipei, Taiwan
| | - Ching-Yu Chen
- National Taiwan University, College of Medicine, Taipei, Taiwan; National Taiwan University Hospital, Department of Family Medicine, Taipei, Taiwan
| | - Chieh-Yu Liu
- National Taipei University of Nursing and Health Sciences, Department of Speech Language Pathology and Audiology, Taipei, Taiwan
| | - Tai-Yuan Chiu
- National Taiwan University, College of Medicine, Taipei, Taiwan; National Taiwan University Hospital, Department of Family Medicine, Taipei, Taiwan
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22
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Lank RJ, Shafie-Khorassani F, Zhang X, Ortiz C, Kim S, Case E, Creutzfeldt CJ, Morgenstern LB, Zahuranec DB. Advance Care Planning and Transitions to Comfort Measures after Stroke. J Palliat Med 2020; 24:1191-1196. [PMID: 33370167 DOI: 10.1089/jpm.2020.0587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Advance care planning (ACP) is recommended to align treatment with patient goals, although there has been little study of the impact of ACP on in-hospital stroke treatment. Objective: To examine the association between ACP and transitions to comfort measures after stroke. Design: Prospective cohort study. Setting/Subjects: Hospitalized stroke patients 45 years and older and surrogate decision makers from a population-based study in Corpus Christi, TX. Measurements: Surrogates were interviewed to assess presence of patient prestroke ACP, categorized as none, informal conversations only, or formal documentation. Patient records were reviewed for time from admission to transition to comfort measures only (CMO) (defined as in-hospital comfort measures or discharge with hospice services). Cox proportional-hazards models assessed the relationship between ACP and time to transition to CMO. Results: Of 148 included stroke patients, 37% transitioned to CMO (median time five days). For ACP, 44% had only informal conversations, 38% had formal documentation (98% of which also reported informal conversations), and 18% had neither. After adjustment for age, severity, and baseline disability, informal conversations alone (hazard ratio [HR] 3.55; 95% confidence interval [CI]: 1.35-9.33) and formal documentation (HR 2.85; 95% CI: 1.05-7.72) were associated with earlier transition to comfort measures compared to no ACP. There was no difference between formal documentation and informal conversations on time to comfort measures (HR 0.80, 95% CI: 0.40-1.63). Conclusions: There was no additional association of formal ACP documentation over informal conversations on time to transition to comfort measures after stroke. Further study of formal ACP is warranted.
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Affiliation(s)
- Rebecca J Lank
- Stroke Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Fatema Shafie-Khorassani
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Xingyu Zhang
- Department of Systems, Populations and Leadership, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Carmen Ortiz
- Stroke Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Sehee Kim
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin Case
- Department of Epidemiology, School of Public Health University of Michigan, Ann Arbor, Michigan, USA
| | | | - Lewis B Morgenstern
- Stroke Program, University of Michigan, Ann Arbor, Michigan, USA.,Department of Epidemiology, School of Public Health University of Michigan, Ann Arbor, Michigan, USA
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23
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Lipnick D, Green M, Thiede E, Smith TJ, Lehman EB, Johnson R, La IS, Wiegand D, Levi BH, Van Scoy LJ. Surrogate Decision Maker Stress in Advance Care Planning Conversations: A Mixed-Methods Analysis From a Randomized Controlled Trial. J Pain Symptom Manage 2020; 60:1117-1126. [PMID: 32645452 PMCID: PMC8109394 DOI: 10.1016/j.jpainsymman.2020.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Spokespersons serving as surrogate decision makers for their loved ones report high levels of stress. Despite known benefits, advance care planning (ACP) conversations often do not occur. More information is needed to understand spokesperson stress during ACP. OBJECTIVES To explore if and how spokespersons perceive stress related to ACP conversations; compare factors related to stress; and assess whether ACP intervention impacted stress. METHODS Secondary and mixed-methods analysis with data transformation of semistructured interviews occurring during a 2 × 2 factorial (four armed) randomized controlled trial that compared standard online ACP to a comprehensive online ACP decision aid. Tools were completed by patients with advanced illness (n = 285) alone or with their spokesperson (n = 285). About 200 spokesperson interviews were purposively sampled from each of the four arms (50 per arm). RESULTS ACP conversations were reported as stressful by 54.41% (74 of 136) and nonstressful by 45.59% (62 of 136). Five themes impacting spokesperson stress were the nature of the relationship with their loved one; self-described personality and belief systems; knowledge and experience with illness and ACP conversations; attitude toward ACP conversations; and social support in caregiving and decision making. No significant differences in stress were associated with arm assignment. CONCLUSION Identifying what factors impact spokesperson stress in ACP conversations can be used to help design ACP interventions to more appropriately address the needs and concerns of spokespersons.
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Affiliation(s)
- Daniella Lipnick
- Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| | - Michael Green
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Elizabeth Thiede
- Penn State College of Nursing, University Park, Pennsylvania, USA
| | - Theresa J Smith
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Erik B Lehman
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Public Health Sciences at Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Rhonda Johnson
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - In Seo La
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Debra Wiegand
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Pediatrics, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Lauren J Van Scoy
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Public Health Sciences at Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Blackstone E, Daly BJ, Griggins C. Making Medical Decisions for Incapacitated Patients Without Proxies: Part II. HEC Forum 2020; 32:47-62. [PMID: 31691879 PMCID: PMC7223299 DOI: 10.1007/s10730-019-09388-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
In the United States, there is no consensus about who should make decisions in acute but non-emergent situations for incapacitated patients who lack surrogates. For more than a decade, our academic medical center has utilized community volunteers from the hospital ethics committee to engage in shared decision-making with the medical providers for these patients. In order to add a different point of view and minimize conflict of interest, the volunteers are non-clinicians who are not employed by the hospital. Using case examples and interviews with the community members, this paper describes how the protocol has translated into practice over the years since its inception. Members reported comfort with the role as well as satisfaction with the thoroughness of their discussions with the medical team. They acknowledged feelings of moral uncertainty, but expressed confidence in the process. Questions raised by the experience are discussed. Overall, the protocol has provided oversight, transparency, and protection from conflict of interest to the decision-making process for this vulnerable patient population.
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Affiliation(s)
- Eric Blackstone
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106-4904, USA.
| | - Barbara J Daly
- Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106-4904, USA
| | - Cynthia Griggins
- Department of Neurology, Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH, 44106, USA
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Spalding R. Accuracy in Surrogate End-of-Life Medical Decision-Making: A Critical Review. Appl Psychol Health Well Being 2020; 13:3-33. [PMID: 32829505 DOI: 10.1111/aphw.12221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/14/2020] [Accepted: 07/14/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Increasing age is accompanied by a greater need for medical decisions, due in part to age-related increases in chronic disease and disability. In later life, medical decisions about end-of-life care in particular are likely. However, a significant percentage of these decisions are made by surrogate decision-makers. "Surrogates" are most often instructed to use the substituted judgment standard and make decisions that patients would choose if they were able. Whether surrogates make decisions that adequately match patients' preferences is a concern. Surrogates are generally poor predictors of patient preferences (Shalowitz et al., 2006). However, no critical review of this literature has yet been published. METHOD A critical review was conducted to summarise and provide a methodological critique of 25 studies. RESULTS These studies generally concur that patient-surrogate agreement on medical decisions is poor. However, this conclusion is qualified by inconsistencies in methodological quality and the potentially limited generalisability of these findings. CONCLUSIONS Clinical research incorporating standardised hypothetical decision-making protocols, as well as triangulated data collection methods, would bolster confidence in future findings. Investigations prioritising the surrogate decision-making process, rather than solely the decisional outcome, could better identify ways to improve the decision-making process for incapacitated patients.
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26
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Xie B, Tao C, Li J, Hilsabeck RC, Aguirre A. Artificial Intelligence for Caregivers of Persons With Alzheimer's Disease and Related Dementias: Systematic Literature Review. JMIR Med Inform 2020; 8:e18189. [PMID: 32663146 PMCID: PMC7471889 DOI: 10.2196/18189] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/20/2020] [Accepted: 06/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Artificial intelligence (AI) has great potential for improving the care of persons with Alzheimer's disease and related dementias (ADRD) and the quality of life of their family caregivers. To date, however, systematic review of the literature on the impact of AI on ADRD management has been lacking. OBJECTIVE This paper aims to (1) identify and examine literature on AI that provides information to facilitate ADRD management by caregivers of individuals diagnosed with ADRD and (2) identify gaps in the literature that suggest future directions for research. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic literature reviews, during August and September 2019, we performed 3 rounds of selection. First, we searched predetermined keywords in PubMed, Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, PsycINFO, IEEE Xplore Digital Library, and the ACM Digital Library. This step generated 113 nonduplicate results. Next, we screened the titles and abstracts of the 113 papers according to inclusion and exclusion criteria, after which 52 papers were excluded and 61 remained. Finally, we screened the full text of the remaining papers to ensure that they met the inclusion or exclusion criteria; 31 papers were excluded, leaving a final sample of 30 papers for analysis. RESULTS Of the 30 papers, 20 reported studies that focused on using AI to assist in activities of daily living. A limited number of specific daily activities were targeted. The studies' aims suggested three major purposes: (1) to test the feasibility, usability, or perceptions of prototype AI technology; (2) to generate preliminary data on the technology's performance (primarily accuracy in detecting target events, such as falls); and (3) to understand user needs and preferences for the design and functionality of to-be-developed technology. The majority of the studies were qualitative, with interviews, focus groups, and observation being their most common methods. Cross-sectional surveys were also common, but with small convenience samples. Sample sizes ranged from 6 to 106, with the vast majority on the low end. The majority of the studies were descriptive, exploratory, and lacking theoretical guidance. Many studies reported positive outcomes in favor of their AI technology's feasibility and satisfaction; some studies reported mixed results on these measures. Performance of the technology varied widely across tasks. CONCLUSIONS These findings call for more systematic designs and evaluations of the feasibility and efficacy of AI-based interventions for caregivers of people with ADRD. These gaps in the research would be best addressed through interdisciplinary collaboration, incorporating complementary expertise from the health sciences and computer science/engineering-related fields.
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Affiliation(s)
- Bo Xie
- School of Nursing, The University of Texas at Austin, Austin, TX, United States
- School of Information, The University of Texas at Austin, Austin, TX, United States
| | - Cui Tao
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Juan Li
- Department of Computer Science, North Dakota State University, Fargo, ND, United States
| | - Robin C Hilsabeck
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, TX, United States
| | - Alyssa Aguirre
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, TX, United States
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Abstract
Critical care clinicians strive to reverse the disease process and are frequently faced with difficult end-of-life (EoL) situations, which include transitions from curative to palliative care, avoidance of disproportionate care, withholding or withdrawing therapy, responding to advance treatment directives, as well as requests for assistance in dying. This article presents a summary of the most common issues encountered by intensivists caring for patients around the end of their life. Topics explored are the practices around limitations of life-sustaining treatment, with specific mention to the thorny subject of assisted dying and euthanasia, as well as the difficulties encountered regarding the adoption of advance care directives in clinical practice and the importance of integrating palliative care in the everyday practice of critical-care physicians. The aim of this article is to enhance understanding around the complexity of EoL decisions, highlight the intricate cultural, religious, and social dimensions around death and dying, and identify areas of potential improvement for individual practice.
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Affiliation(s)
- Victoria Metaxa
- Critical Care Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
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28
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What would people think? Perceived social norms, willingness to serve as a surrogate, and end-of-life treatment decisions. Palliat Support Care 2020; 19:46-54. [PMID: 32665048 DOI: 10.1017/s1478951520000401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Population aging has increased the prevalence of surrogate decision making in healthcare settings. However, little is known about factors contributing to the decision to become a surrogate and the surrogate medical decision-making process in general. We investigated how intrapersonal and social-contextual factors predicted two components of the surrogate decision-making process: individuals' willingness to serve as a surrogate and their tendency to select various end-of-life treatments, including mechanical ventilation and palliative care options. METHOD An online sample (N = 172) of adults made hypothetical surrogate decisions about end-of-life treatments on behalf of an imagined person of their choice, such as a parent or spouse. Using self-report measures, we investigated key correlates of willingness to serve as surrogate (e.g., decision-making confidence, willingness to collaborate with healthcare providers) and choice of end-of-life treatments. RESULTS Viewing service as a surrogate as a more typical practice in healthcare was associated with greater willingness to serve. Greater decision-making confidence, greater willingness to collaborate with patients' physicians, and viewing intensive, life-sustaining end-of-life treatments (e.g., mechanical ventilation) as more widely accepted were associated with choosing more intensive end-of-life treatments. SIGNIFICANCE OF RESULTS The current study's consideration of both intrapersonal and social-contextual factors advances knowledge of two key aspects of surrogate decision making - the initial decision to serve as surrogate, and the surrogate's selection of various end-of-life treatment interventions. Providers can use information about the role of these factors to engage with surrogates in a manner that better facilitates their decision making. For instance, providers can be sensitive to potential cultural differences in surrogate decision-making tendencies or employing decision aids that bolster surrogates' confidence in their decisions.
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Rolnick JA, Oredeko F, Cooney-Zingman E, Asch DA, Halpern SD. Comparison of Web-Based and Paper Advance Directives: A Pilot Randomized Clinical Trial. Am J Hosp Palliat Care 2020; 38:230-237. [PMID: 32648476 DOI: 10.1177/1049909120940210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Digital tools to document care preferences in serious illnesses are increasingly common, but their impact is unknown. We developed a web-based advance directive (AD) featuring (1) modular content eliciting detailed care preferences, (2) the ability to electronically transmit ADs to the electronic health record (EHR), and (3) use of nudges to promote document transmission and sharing. OBJECTIVE To compare a web-based, EHR-transmissible AD to a paper AD. METHODS Patients with gastrointestinal and lung malignancies were randomized to the web or paper AD. The primary outcome was the proportion of patients with newly documented advance care plans in the EHR at 8 weeks. Secondary outcomes assessed through an e-mail survey included the change in satisfaction with end-of-life plans, AD acceptability, and self-reported sharing with a surrogate. RESULTS Ninety-one participants were enrolled: 46 randomly allocated to the web AD and 45 to paper. Thirteen patients assigned to web AD (28%) had new documentation versus 7 (16%) assigned to paper (P = .14). Adjusted for demographic factors and primary diagnosis, the odds ratio of new documentation with web AD was 3.7 (95% CI: 0.8-17.0, P = .10). Satisfaction with advance care planning and AD acceptability were high in both groups and not significantly different. Among patients completing web ADs, 79% reported sharing plans with their caregivers, compared with 65% of those completing paper ADs (P = .40). CONCLUSION Web-based ADs hold promise for promoting documentation and sharing of preferences, but larger studies are needed to quantify effects on these intermediate end points and on patient-centered outcomes.
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Affiliation(s)
- Joshua A Rolnick
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,National Clinician Scholars Program, 14640University of Pennsylvania, PA, USA
| | - Francisca Oredeko
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth Cooney-Zingman
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Center for Health Care Innovation, Penn Medicine, Philadelphia PA, USA
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Sellars M, Detering KM, Sinclair C, White BP, Buck K, Ruseckaite R, Clayton JM, Nolte L. Personal and Interpersonal Factors and Their Associations With Advance Care Planning Documentation: A Cross-sectional Survey of Older Adults in Australia. J Pain Symptom Manage 2020; 59:1212-1222.e3. [PMID: 31899284 DOI: 10.1016/j.jpainsymman.2019.12.371] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 11/23/2022]
Abstract
CONTEXT Personal and interpersonal factors may be influential in a person's decision to engage in advance care planning (ACP), including completion of ACP documentation. OBJECTIVES To conduct a cross-sectional survey of older adults accessing Australian general practices, hospitals, and residential aged care facilities, with the aim of describing associations between personal and interpersonal factors and self-reported ACP documentation completion. METHODS Eligible participants included in a national health record audit were approached to complete a survey measuring demographic and health characteristics, preferences for care, worries about the future, and experiences talking with others about ACP and completing ACP documentation. RESULTS Of 1082 people eligible to participate in the survey, 507 completed the survey (response rate = 47%; median age 82 years) and 54% (n = 272) reported having completed ACP documentation. Having ever discussed ACP with other people (anyone) or a doctor were both significant predictors of ACP documentation completion, whereas having previously spoken specifically to a partner about ACP, currently living with children compared to living alone, and being aged 55-69 versus 90-99 years were associated with reduced odds of ACP documentation completion. CONCLUSION Approximately half the participants reported having completed ACP documentation. The strongest predictor of ACP documentation completion was having spoken to anyone about ACP followed by having spoken to a doctor about ACP. These findings suggest that discussions about ACP are an important part of the process of completing ACP documentation.
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Affiliation(s)
- Marcus Sellars
- Advance Care Planning Australia, Austin Health, Melbourne, Australia; Kolling Institute, Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia.
| | - Karen M Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Craig Sinclair
- Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney, Australia; Neuroscience Research Australia, Sydney, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Australia
| | - Kimberly Buck
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Rasa Ruseckaite
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Josephine M Clayton
- Kolling Institute, Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia; HammondCare Centre for Learning & Research in Palliative Care, Greenwich Hospital and University of Sydney, Sydney, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
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Breaking Down Silos: Consensus-Based Recommendations for Improved Content, Structure, and Accessibility of Advance Directives in Emergency and Out-of-Hospital Settings. J Palliat Med 2020; 23:379-388. [DOI: 10.1089/jpm.2019.0087] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Advance Care Planning to Improve End-of-Life Decision-Making Consistency between Older People and Their Surrogates in Taiwan. J Palliat Med 2020; 23:325-336. [DOI: 10.1089/jpm.2019.0277] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Aloiau A, Benton MJ, Mouchawar A, Segal DL. Impact of end-of-life planning on surrogate decision-maker anxiety in the US. Int J Palliat Nurs 2020; 26:75-82. [PMID: 32125916 DOI: 10.12968/ijpn.2020.26.2.75] [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: 11/11/2022]
Abstract
At the end of life, hospice patients frequently rely on surrogate decision makers (SDMs) for healthcare decisions, which creates anxiety among SDMs. This project evaluated whether an educational intervention to create a plan of care for hospice patients would reduce anxiety among SDMs. Before the intervention, immediately after the intervention, and 2 weeks following the intervention SDM anxiety was measured with the Geriatric Anxiety Scale, State Trait Anxiety Inventory-State Anxiety Scale, and one question about decision-making anxiety. Twelve patients (80±14.7 years) and 18 SDMs (60±12.9 years) completed the intervention. Immediately after the intervention SDMs showed a significant decrease (P=0.003) in anxiety. When anxiety was measured 2 weeks post-intervention, anxiety had increased again, and was no longer significantly different from pre-intervention levels. This project demonstrated that an educational intervention in the hospice setting can be effective in creating a short-term decrease to SDM anxiety levels.
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Affiliation(s)
| | | | - Alan Mouchawar
- Director Cardiac Anesthesia, Newport Harbor Anesthesia Consultants
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Jutkowitz E, Van Houtven CH, Plassman BL, Mor V. Willingness to Undergo a Risky Treatment to Improve Cognition Among Persons With Cognitive Impairment Who Received an Amyloid PET Scan. Alzheimer Dis Assoc Disord 2020; 34:1-9. [PMID: 31414990 PMCID: PMC7015762 DOI: 10.1097/wad.0000000000000338] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate determinants of willingness to accept a treatment to return memory to normal among persons with cognitive impairment who received an amyloid positron emission tomography (PET) scan and their care partner and discordance in risk taking. METHODS Using data from CARE-IDEAS (n=1872 dyads), a supplement of the Imaging Dementia-Evidence for Amyloid Scanning study, we predicted scan recipient's willingness to accept a risky treatment, the risk care partners believed their care recipient would accept, and discordance in these perceptions. RESULTS Scan recipients were willing to accept a treatment with a 27.94% (SD=34.36) risk of death. Care partners believed their care recipient would accept a 29.68% (SD=33.74) risk of death; thus, overestimating risk acceptance by 1.74 (SD=41.88) percentage points. A positive amyloid PET scan was associated with willingness to accept greater risk. Poorer functioning of the care recipient was associated with care partners believing their care recipient would accept more risk. The amyloid PET scan result was not significantly associated with discordance, but poorer functioning of the care recipient resulted in care partners overestimating risk. CONCLUSIONS Scan recipients were willing to accept a treatment with a high risk of death. Discordance was affected by scan recipient's having poorer functioning.
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Affiliation(s)
- Eric Jutkowitz
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
- Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, RI
| | - Courtney Harold Van Houtven
- Durham ADAPT COIN, HSR&D, Durham VAMC
- Department of Population Health Sciences, Duke University School of Medicine
| | - Brenda L. Plassman
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine
- Department of Neurology, Duke University School of Medicine
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
- Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, RI
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Yamaguchi H, Sato K, Kawahito K, Miyatake A, Kondo K, Inaba K, Inaba K, Kawaminami S, Tabata R, Yuasa S, Okura Y, Tuchiya A, Suzuki Y, Tani K. Japanese elderly individuals wish for enteral tube feeding more strongly for their parents than for themselves. THE JOURNAL OF MEDICAL INVESTIGATION 2019; 66:258-263. [PMID: 31656285 DOI: 10.2152/jmi.66.258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
[Introduction] The purpose of this study was to investigate the differences in the preference of enteral tube feeding between elderly inhabitants of Mugi town, Tokushima Prefecture, Japan, and their parents in various physical conditions. [Methods] This population-based questionnaire survey studied 300 randomly selected participants aged 65-80 years. Respondents were to consider a situation where eating was difficult, and were questioned on their desire for tube feeding, using a visual analogue scale (VAS) ranging from "do not want tube feeding (0)" to "want tube feeding (100)." [Results] Valid responses of 103 (34.4%) participants were analyzed. Under conditions of being "healthy," "bedridden," "with dementia," and "bedridden and with dementia," the median (IQR) of the VAS values for the desire for tube feeding were 31.8 (3.3 to 83.8), 19.3 (2.4 to 52.3), 5.2 (0.7 to 18.9), 4.0 (0.3 to 15.2) for respondents and 55.2 (11.6 to 92.2), 48.7 (5.5 to 85.5), 9.0 (1.2 to 46.8), 5.1 (0.1 to 36.5) for parents, respectively. The VAS values for the parents were significantly higher (p=0.001, 0.002, 0.001, and 0.01, respectively for the four conditions described) for the same items. [Conclusion] Surrogate decisions made by family members often differ from what the patients would have desired. J. Med. Invest. 66 : 258-263, August, 2019.
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Affiliation(s)
- Harutaka Yamaguchi
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Koj Sato
- Medical student, Tokushima University, Tokushima, Japan
| | | | | | | | - Keisuke Inaba
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kaori Inaba
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shingo Kawaminami
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Ryo Tabata
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shino Yuasa
- Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Yoshihiro Okura
- Department of General Medicine and Primary Care, Tokushima University Hospital, Tokushima, Japan
| | - Atsushi Tuchiya
- Department of Civil and Environmental Studies, Tokushima University Graduate School of Integrated Arts and Sciences, Tokushima, Japan
| | - Yoshihiro Suzuki
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kenji Tani
- Department of General Medicine and Primary Care, Tokushima University Hospital, Tokushima, Japan
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Abstract
This review proposes that the end of life is a uniquely contemporary life course stage. Epidemiologic, technological, and cultural shifts over the past two centuries have created a context in which dying has shifted from a sudden and unexpected event to a protracted, anticipated transition following an incurable chronic illness. The emergence of an end-of-life stage lasting for months or even years has heightened public interest in enhancing patient well-being, autonomy, and the receipt of medical care that accords with patient and family members' wishes. We describe key components of end-of-life well-being and highlight socioeconomic and race disparities therein, drawing on fundamental cause theory. We describe two practices that are critical to end-of-life well-being (advance care planning and hospice) and identify limitations that may undermine their effectiveness. We conclude with recommendations for future sociological research that could inform practices to enhance patient and family well-being at the end of life.
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Affiliation(s)
- Deborah Carr
- Department of Sociology, Boston University, Boston, Massachusetts 02215, USA
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Ellis EM, Barnato AE, Chapman GB, Dionne-Odom JN, Lerner JS, Peters E, Nelson WL, Padgett L, Suls J, Ferrer RA. Toward a Conceptual Model of Affective Predictions in Palliative Care. J Pain Symptom Manage 2019; 57:1151-1165. [PMID: 30794937 DOI: 10.1016/j.jpainsymman.2019.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/24/2019] [Accepted: 02/10/2019] [Indexed: 10/27/2022]
Abstract
CONTEXT Being diagnosed with cancer often forces patients and families to make difficult medical decisions. How patients think they and others will feel in the future, termed affective predictions, may influence these decisions. These affective predictions are often biased, which may contribute to suboptimal care outcomes by influencing decisions related to palliative care and advance care planning. OBJECTIVES This study aimed to translate perspectives from the decision sciences to inform future research about when and how affective predictions may influence decisions about palliative care and advance care planning. METHODS A systematic search of two databases to evaluate the extent to which affective predictions have been examined in the palliative care and advance care planning context yielded 35 relevant articles. Over half utilized qualitative methodologies (n = 21). Most studies were conducted in the U.S. (n = 12), Canada (n = 7), or European countries (n = 10). Study contexts included end of life (n = 10), early treatment decisions (n = 10), pain and symptom management (n = 7), and patient-provider communication (n = 6). The affective processes of patients (n = 20), caregivers (n = 16), and/or providers (n = 12) were examined. RESULTS Three features of the palliative care and advance care planning context may contribute to biased affective predictions: 1) early treatment decisions are made under heightened emotional states and with insufficient information; 2) palliative care decisions influence life domains beyond physical health; and 3) palliative care decisions involve multiple people. CONCLUSION Biases in affective predictions may serve as a barrier to optimal palliative care delivery. Predictions are complicated by intense emotions, inadequate prognostic information, involvement of many individuals, and cancer's effect on non-health life domains. Applying decision science frameworks may generate insights about affective predictions that can be harnessed to solve challenges associated with optimal delivery of palliative care.
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Affiliation(s)
- Erin M Ellis
- National Cancer Institute, Bethesda, Maryland, USA.
| | | | | | | | | | | | | | - Lynne Padgett
- Washington D.C. Veteran's Affairs Medical Center, Washington, District of Columbia, USA
| | - Jerry Suls
- National Cancer Institute, Bethesda, Maryland, USA
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Maldonado LY, Goodson RB, Mulroy MC, Johnson EM, Reilly JM, Homeier DC. Wellness in Sickness and Health (The W.I.S.H. Project): Advance Care Planning Preferences and Experiences Among Elderly Latino Patients. Clin Gerontol 2019; 42:259-266. [PMID: 29206578 DOI: 10.1080/07317115.2017.1389793] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess advance care planning (ACP) preferences, experiences, and comfort in discussing end-of-life (EOL) care among elderly Latinos. METHODS Patients aged 60 and older from the Los Angeles County and University of Southern California (LAC+USC) Medical Center Geriatrics Clinic (n = 41) participated in this intervention. Trained staff conducted ACP counseling with participants in their preferred language, which included: (a) pre-counseling survey about demographics and EOL care attitudes, (b) discussion of ACP and optional completion of an advance directive (AD), and (c) post-session survey. RESULTS Patients were primarily Spanish speaking with an average of 2.7 chronic medical conditions. Most had not previously documented (95%) or discussed (76%) EOL wishes. Most were unaware they had control over their EOL treatment (61%), but valued learning about EOL options (83%). Post-counseling, 85% reported comfort discussing EOL goals compared to 66% pre-session, and 88% elected to complete an AD. Nearly half of patients reported a desire to discuss EOL wishes sooner. CONCLUSIONS Elderly Latino patients are interested in ACP, given individualized, culturally competent counseling in their preferred language. CLINICAL IMPLICATIONS Patients should be offered the opportunity to discuss and document EOL wishes at all primary care appointments, regardless of health status. Counseling should be completed in the patient's preferred language, using culturally competent materials, and with family members present if this is the patient's preference. Cultural-competency training for providers could enhance the impact of EOL discussions and improve ACP completion rates for Latino patients.
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Affiliation(s)
- Lauren Y Maldonado
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA
| | - Ruth B Goodson
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA
| | - Matthew C Mulroy
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA
| | - Emily M Johnson
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA.,b Department of Family Medicine, LAC+USC Medical Center , Los Angeles , California , USA
| | - Jo M Reilly
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA.,b Department of Family Medicine, LAC+USC Medical Center , Los Angeles , California , USA
| | - Diana C Homeier
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA.,c Department of Family Medicine and Geriatrics Clinic, LAC+USC Medical Center , Los Angeles , California , USA
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Toller CAS, Budge MM. Compliance with and Understanding of Advance Directives among Trainee Doctors in the United Kingdom. J Palliat Care 2019. [DOI: 10.1177/082585970602200303] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim To investigate doctors’ response to and understanding of the legal status of advance directives. Methods A vignette-based study administered at palliative medicine, oncology, general practice, and geriatric medicine specialist registrar meetings (United Kingdom). Respondents determined the treatment to provide for a Patient presenting with a myocardial infarction with or without an advance directive requesting maximum therapy. Results Response rate 77% (43/56). Twenty-five percent (10/40) of respondents increased the care that they would provide in response to the advance directive (p=0.004); 77% (33/43) support /strongly support use of advance directives; 51% (22/43) did not know the legal status of advance directives; 44% found that their medical school education was not an important influence on their decision making. Conclusions Advance directives requesting treatment can increase the level of care provided by the physician, however, most trainees chose a level of care different from that in the advance directive. Confusion exists among doctors about the legal status of advance directives, which limits their usefulness. Medical education needs to be improved to train doctors to deal with advance directives.
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Affiliation(s)
| | - Marc M. Budge
- University of Canberra, Canberra, Australian Capital Territory, Australia
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Dionne-Odom JN, Ejem D, Wells R, Barnato AE, Taylor RA, Rocque GB, Turkman YE, Kenny M, Ivankova NV, Bakitas MA, Martin MY. How family caregivers of persons with advanced cancer assist with upstream healthcare decision-making: A qualitative study. PLoS One 2019; 14:e0212967. [PMID: 30865681 PMCID: PMC6415885 DOI: 10.1371/journal.pone.0212967] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/12/2019] [Indexed: 12/27/2022] Open
Abstract
Aims Numerous healthcare decisions are faced by persons with advanced cancer from diagnosis to end-of-life. The family caregiver role in these decisions has focused on being a surrogate decision-maker, however, little is known about the caregiver’s role in supporting upstream patient decision-making. We aimed to describe the roles of family caregivers in assisting community-dwelling advanced cancer patients with healthcare decision-making across settings and contexts. Methods Qualitative study using one-on-one, semi-structured interviews with community-dwelling persons with metastatic cancer (n = 18) and their family caregivers (n = 20) recruited from outpatient oncology clinics of a large tertiary care academic medical center, between October 2016 and October 2017. Transcribed interviews were analyzed using a thematic analysis approach. Findings Caregivers averaged 56 years and were mostly female (95%), white (85%), and the patient’s partner/spouse (70%). Patients averaged 58 years and were mostly male (67%) in self-reported “fair” or “poor” health (50%) with genitourinary (33%), lung (17%), and hematologic (17%) cancers. Themes describing family member roles in supporting patients’ upstream healthcare decision-making were: 1) seeking information about the cancer, its trajectory, and treatments options; 2) ensuring family and healthcare clinicians have a common understanding of the patient’s treatment plan and condition; 3) facilitating discussions with patients about their values and the framing of their illness; 5) posing “what if” scenarios about current and potential future health states and treatments; 6) addressing collateral decisions (e.g., work arrangements) resulting from medical treatment choices; 6) originating healthcare-related decision points, including decisions about seeking emergency care; and 7) making healthcare decisions for patients who preferred to delegate healthcare decisions to their family caregivers. Conclusions These findings highlight a previously unreported and understudied set of critical decision partnering roles that cancer family caregivers play in patient healthcare decision-making. Optimizing these roles may represent novel targets for early decision support interventions for family caregivers.
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Affiliation(s)
- J. Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- * E-mail:
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Rachel Wells
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Amber E. Barnato
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, United States of America
| | - Richard A. Taylor
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Gabrielle B. Rocque
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Yasemin E. Turkman
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Matthew Kenny
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Nataliya V. Ivankova
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Marie A. Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Michelle Y. Martin
- Center for Innovation in Health Equity Research, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
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Leung DYP, Chan HYL, Yau SZM, Chiu PKC, Tang FWK, Kwan JSK. A video‐supported nurse‐led advance care planning on end‐of‐life decision‐making among frail older patients: Protocol for a randomized controlled trial. J Adv Nurs 2019; 75:1360-1369. [DOI: 10.1111/jan.13959] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/10/2018] [Accepted: 11/20/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | - Helen Yue Lai Chan
- Nethersole School of Nursing The Chinese University of Hong Kong Hong Kong
| | - Susan Zi May Yau
- Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong
| | | | - Fiona Wing Ki Tang
- Nethersole School of Nursing The Chinese University of Hong Kong Hong Kong
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Sulmasy DP. Ethics and Evidence. THE JOURNAL OF CLINICAL ETHICS 2019. [DOI: 10.1086/jce2019301056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Harrison Dening K, Sampson EL, De Vries K. Advance care planning in dementia: recommendations for healthcare professionals. Palliat Care 2019; 12:1178224219826579. [PMID: 30833812 PMCID: PMC6393818 DOI: 10.1177/1178224219826579] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 11/17/2022] Open
Abstract
The process of advance care planning in dementia is far from straightforward; as dementia progresses, the ability to consider future thoughts and actions becomes compromised, thus affecting decision-making abilities. Family carers find themselves increasingly in a position where they need to inform, or directly make, decisions on behalf of the person with dementia. This article discusses the context and importance of a palliative care approach and recommends rationales and strategies for healthcare professionals to support families affected by dementia to better plan for their future care.
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Affiliation(s)
- Karen Harrison Dening
- Research & Publications, Dementia UK, London, UK; School of Nursing and Midwifery, De Montfort University, Leicester, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Kay De Vries
- School of Nursing and Midwifery, De Montfort University, Leicester, UK
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Xie B, Champion JD, Kwak J, Fleischmann KR. Mobile Health, Information Preferences, and Surrogate Decision-Making Preferences of Family Caregivers of People With Dementia in Rural Hispanic Communities: Cross-Sectional Questionnaire Study. J Med Internet Res 2018; 20:e11682. [PMID: 30530450 PMCID: PMC6305885 DOI: 10.2196/11682] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Mobile health (mHealth) technology holds promise for promoting health education and reducing health disparities and inequalities in underserved populations. However, little research has been done to develop mHealth interventions for family caregivers of people with dementia, particularly those in rural Hispanic communities, who often serve as surrogate decision makers for their relatives with dementia. OBJECTIVE As part of a larger project to develop and test a novel, affordable, and easy-to-use mHealth intervention to deliver individually tailored materials in rural Hispanic communities, in this pilot study, we aimed to examine (1) characteristics of people with dementia and their family caregivers in rural Hispanic communities, (2) caregivers' preferences for types and amounts of health information and participation in surrogate decision making, and (3) caregivers' mobile device usage and their desire for receiving information via mobile devices. METHODS This was a cross-sectional survey. A convenience sample of 50 caregivers of people with dementia was recruited from rural health care facilities in Southwest Texas during 3 weeks of April 2017 to May 2017 via word-of-mouth and flyers posted at the facilities. RESULTS More women than men were in the patient group (χ21=17.2, P<.001) and in the caregiver group (χ21=22.2, P<.001). More patients were on Medicare and Medicaid; more caregivers had private insurance (P<.001 in all cases). Overall, 42% of patients did not have a power of attorney for their health care; 40% did not have a living will or advance directive. Caregivers were interested in receiving all types of information and participating in all types of decisions, although on subscales for diagnosis, treatment, laboratory tests, self-care, and complementary and alternative medicine, their levels of interest for decision-making participation were significantly lower than those for receiving information. On the psychosocial subscale, caregivers' desire was greater for surrogate decision-making participation than for information. Caregivers did not differ in their interests in information and participation in decision making on the health care provider subscale. All but 1 caregiver (98%) owned a mobile phone and 84% had a smartphone. Two-thirds wanted to receive at least a little dementia-related information via a smartphone or tablet. The amount of dementia-related information caregivers wanted to receive via a mobile device was significantly greater for women than for men (U=84.50, P=.029). Caregivers who owned a tablet were more likely to want to receive dementia-related information via a mobile device than those who did not own a tablet (U=152.0, P=.006). CONCLUSIONS Caregivers in rural Hispanic communities were interested in receiving a wide range of information as well as participating in making decisions for their relatives with dementia. There is much need for effective mHealth interventions that can provide information tailored to the needs and preferences of these caregivers.
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Affiliation(s)
- Bo Xie
- School of Nursing, The University of Texas at Austin, Austin, TX, United States
- School of Information, The University of Texas at Austin, Austin, TX, United States
| | | | - Jung Kwak
- School of Nursing, The University of Texas at Austin, Austin, TX, United States
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Memory of Medical Scenarios for End-of-Life Support Preferences. SPANISH JOURNAL OF PSYCHOLOGY 2018; 21:E56. [PMID: 30468141 DOI: 10.1017/sjp.2018.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We studied memory of health scenarios for end-of-life support decisions and stability of life support preferences. Psychology students (n = 36, age M = 27.25, SD = 6.21, 64% females) were administered the Life Support Preferences Questionnaire to assess their memory of six medical scenarios with different prognoses, care treatment, and end-of-life support choices. Recall, recognition, confidence and decision stability were assessed immediately and one month later. Correct recall decreased and incorrect recall increased from immediate to long-term recall, F(2, 68) = 74.38, p < .001, η2p = .69. In recall, participants spontaneously gave false information consistent with prior knowledge of illnesses and medical scenarios. Participants who had suffered a disease or serious accident did worse on correct recall, F(1, 34) = 6.59, p = .015, η2p = .16, and had more errors, F(1, 34) = 4.68, p = .038, η2p = .12, than participants who had not. In the recognition test there were no differences between hits and false alarms, showing the difficulty in discriminating between true and false contents. Confidence was greater for hits than for false alarms, F(1, 34) = 10.86, p = .002, η2p = .24, but this subjective measure did not seem to be a good predictor of accuracy because confidence was greater than the mean value for hits (p = .001, d = 1.74) and for false alarms (p = .001, d = 0.96). Long-term memory was quite poor and biased, but life support preferences did not change much.
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Should capacity assessments be performed routinely prior to discussing advance care planning with older people? Int Psychogeriatr 2018; 30:1243-1250. [PMID: 29335033 DOI: 10.1017/s1041610217002836] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED ABSTRACTBackground:People with dementia receive worse end of life care compared to those with cancer. Barriers to undertaking advanced care planning (ACP) in people with dementia include the uncertainty about their capacity to engage in such discussions. The primary aim of this study was to compare the Advance Care Planning-Capacity Assessment Vignette tool (ACP-CAV) with a semi-structured interview adapted from the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). The secondary aim was to identify demographic and cognitive functioning variables that may predict whether a person has capacity to discuss ACP. METHODS 32 older people (mean age = 84.1) with a Mini-Mental State Examination of 24 or above were recruited from two retirement villages in Auckland. Participants also completed Trail Making Test Part A & Part B and Geriatric Depression Scale (GDS-15) before undertaking the two capacity assessments that were video recorded to enable further analysis by four independent old age psychiatrists. RESULTS Using the MacCAT-T as the gold standard, over half (53.1%) of the participants were considered as lacking in capacity to engage in ACP. Participants struggled with the "Understanding ACP" domain the most. Capacity was not predictable by any of the demographic or cognitive functioning variables. When compared to the gold standard, ACP-CAV was accurate in assessing capacity in 68.8% of the cases. CONCLUSION Clinicians should routinely explain ACP to older people and ensure they fully understand it prior to an ACP discussion. If there is any concern about their understanding, further exploration and documentation of their capacity using the capacity assessment framework would be necessary. However, capacity assessment is a complex iterative process that does not easily lend itself to screening methodology and requires a high level of clinical judgment.
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Chan HYL, Ng JSC, Chan KS, Ko PS, Leung DYP, Chan CWH, Chan LN, Lee IFK, Lee DTF. Effects of a nurse-led post-discharge advance care planning programme for community-dwelling patients nearing the end of life and their family members: A randomised controlled trial. Int J Nurs Stud 2018; 87:26-33. [PMID: 30048916 DOI: 10.1016/j.ijnurstu.2018.07.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/13/2018] [Accepted: 07/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although evidence increasingly demonstrates the effects of advance care planning, the relevant studies are of questionable quality, and lack consensus regarding when and with whom to initiate the conversation. OBJECTIVE To examine the effects of a structured, nurse-led post-discharge advance care planning programme on congruence between the end-of-life care preferences of the patient and family members, decisional conflicts and the documentation of care preferences. DESIGN A two-arm parallel-group randomised controlled trial. PARTICIPANTS A total of 230 dyads comprising community-dwelling patients screened by the Gold Standards Framework Prognostic Indicator Guidance and their designated family members. METHODS Patients in the experimental group participated in a structured advance care planning programme administered by a trained nurse during three weekly home visits following hospital discharge. In contrast, the post-discharge home visits provided to the control group focused on self-care management as attention control. The study outcomes were the dyadic congruence regarding end-of-life care preferences, the patients' level of decisional conflict regarding end-of-life decision-making and the documentation of these preferences at baseline and 1 and 6 months after enrolment. Generalised estimating equation models were used to compare changes in the outcomes between the groups across time. RESULTS At baseline, few participants had ever heard of advance directives (12/460, 2.6%) and few patients had ever discussed end-of-life issues with family members (34/230, 14.8%). After six months, the experimental group exhibited a greater increase in dyadic congruence regarding various end-of-life care preferences than the control group (Ps < 0.04). The experimental group also exhibited a greater improvement in decisional conflict at 6 months relative to the control group (P = 0.003). However, the groups did not differ significantly in terms of changes in any outcomes after one month. The experimental group had significantly higher rates of completion of advance directives and electronic medical record documentation of do-not-attempt cardiopulmonary resuscitation orders than the control group. CONCLUSIONS This study showed that a nurse-led structured advance care planning programme could effectively improve dyadic congruence regarding end-of-life care preferences, reduce patients' decisional conflict and increase the documentation of care preferences. The findings underscored the importance of supporting nurses to introduce advance care planning at an earlier time that enable patients with sufficient time to contemplate end-of-life issues, empower patients to deliberate their choices and engage patients and their family members in open discussion.
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Affiliation(s)
- Helen Yue-Lai Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong.
| | | | | | | | | | - Carmen Wing-Han Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong
| | | | - Iris Fung-Kam Lee
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong
| | - Diana Tze-Fan Lee
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong
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Bravo G, Sene M, Arcand M, Hérault É. Effects of advance care planning on confidence in surrogates' ability to make healthcare decisions consistent with older adults' wishes: Findings from a randomized controlled trial. PATIENT EDUCATION AND COUNSELING 2018; 101:1256-1261. [PMID: 29452728 DOI: 10.1016/j.pec.2018.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 01/08/2018] [Accepted: 02/07/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate how confidence in surrogates' ability to make consistent decisions in the future change over time, in the context of an ACP intervention that did not improve surrogates' ability to predict an older adult's hypothetical treatment preferences. METHODS The study involved 235 older adults and surrogates, randomly allocated to an ACP or control intervention. At baseline, end of intervention, and six months later, participants were asked how confident they were in the surrogate making decisions in the future that would match the older adult's wishes. RESULTS By the end of the intervention, confidence had increased among older adults and surrogates involved in ACP (OR = 3.1 and 5.8 respectively, p < 0.001), while less change occurred among controls. Over the following six months, confidence remained stable among older adults but decreased among surrogates (OR = 0.5, p = 0.005). CONCLUSION ACP increases confidence in surrogates' ability to make consistent decisions, which may lighten the burden of substitute decision making. Efforts to improve substitute decision-making must continue so that participants' confidence is not based on the mistaken assumption that surrogates can make consistent decisions. PRACTICE IMPLICATIONS Professionals involved in ACP should inform participants that confidence in the surrogate may increase in the absence of enhanced predictive ability.
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Affiliation(s)
- Gina Bravo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada; Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada.
| | - Modou Sene
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
| | - Marcel Arcand
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada; Department of Family Medicine, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Élodie Hérault
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
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Cole J, Kiriaev O, Malpas P, Cheung G. 'Trust me, I'm a doctor': a qualitative study of the role of paternalism and older people in decision-making when they have lost their capacity. Australas Psychiatry 2017; 25:549-553. [PMID: 28990400 DOI: 10.1177/1039856217734741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this study was to explore whether older people want their doctors to make treatment decisions on their behalf when they no longer have capacity to do so, and their reasons for these preferences. METHOD A convenience sample of older people from two retirement villages were interviewed and asked to respond to a hypothetical vignette. Their responses were analysed using qualitative thematic methodology. RESULTS Thirty-seven people (56.8% female; mean age = 83.9 years; mean Mini Mental State Examination = 26.5) participated; 73.0% indicated that they would want their doctor to make treatment decisions on their behalf. Three key themes emerged: 1) trust in the doctor-patient relationship; 2) doctor-derived factors: knowledge and expertise, professionalism, role and responsibility; 3) patient-derived factors: vulnerability, dependence and reliance, compromised autonomy. CONCLUSION Our findings suggest that the paternalistic model within medical care can be an expectation of some older patients and if taking a paternalistic approach we should not underestimate the trust and power that is imparted to us.
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Affiliation(s)
- Joanne Cole
- Specialist Psychiatrist, Pennine Care NHS Foundation Trust, Stockport, UK
| | - Oleg Kiriaev
- Specialist Geriatrician, Mental Health Services for Older People, Auckland District Health Board, Auckland, New Zealand
| | - Phillipa Malpas
- Senior Lecturer in Clinical Medical Ethics, Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Gary Cheung
- Senior Lecturer in Psychiatry, Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
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Sulmasy DP, Hughes MT, Yenokyan G, Kub J, Terry PB, Astrow AB, Johnson JA, Ho G, Nolan MT. The Trial of Ascertaining Individual Preferences for Loved Ones' Role in End-of-Life Decisions (TAILORED) Study: A Randomized Controlled Trial to Improve Surrogate Decision Making. J Pain Symptom Manage 2017; 54:455-465. [PMID: 28712987 PMCID: PMC5632104 DOI: 10.1016/j.jpainsymman.2017.07.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/02/2017] [Accepted: 07/06/2017] [Indexed: 11/23/2022]
Abstract
CONTEXT Patients with terminal illnesses often require surrogate decision makers. Prior research has demonstrated high surrogate stress, and that despite standards promoting substituted judgment, most patients do not want their surrogates to make pure substituted judgments for them. It is not known how best to help loved ones fulfill the surrogate role. OBJECTIVES To test the effectiveness of an intervention to help surrogate decision makers. METHODS One hundred sixty-six patients (41% with amyotrophic lateral sclerosis and 59% with gastrointestinal cancers) and their surrogates at two university medical centers were randomized to an intensive nurse-directed discussion of the end-of-life decision control preferences of the patient (TAILORED) or a discussion of nutrition (CONTROL); 163 completed baseline interviews and underwent the intervention. RESULTS Twelve patients died during follow-up and 137 dyads completed the study. Post-intervention, using all available data, TAILORED patients and surrogates became more likely to endorse mutual surrogate decision making, that is, a balance of their own wishes and what the surrogate thinks best (adjusted odds compared with baseline for patients = 1.78, P = 0.04; adjusted odds for surrogates = 2.05, P = 0.03). CONTROL patients became 40% less likely to endorse mutual surrogate decision making (P = 0.08), and CONTROL surrogates did not change significantly from baseline (adjusted odds = 1.44, P = 0.28). Stress levels decreased for TAILORED surrogates (impact of events scale = 23.1 ± 14.6 baseline, 20.8 ± 15.3 f/u, P = 0.046), but not for CONTROL (P = 0.85), and post-intervention stress was lower for TAILORED than CONTROL (P = 0.04). Surrogates' confidence was uniformly high at baseline and did not change. Caregiver burden (Zarit) increased from 12.5 ± 6.5 to 14.7 ± 8.1 for TAILORED (P < 0.01), while not changing for CONTROL, yet satisfaction with involvement in decision making was higher at follow-up for TAILORED than for CONTROL (71% vs. 52%, P = 0.03). CONCLUSION TAILORED patients and surrogates who completed the study adopted a more mutual decision-making style, balancing their own wishes with what the surrogate thinks would be best for them. Surrogates reported less stress and more satisfaction. Confidence was high at baseline and did not change. There was a modest increase in caregiver burden. These findings suggest that interventions like TAILORED might positively impact surrogate decision making.
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Affiliation(s)
| | | | | | - Joan Kub
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Grace Ho
- Johns Hopkins University, Baltimore, Maryland
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