Advance-care-planning and end-of-life discussions in the perioperative period: a review of healthcare professionals' knowledge, attitudes, and training

Views of health care professionals on the implementation of preoperative advance care planning in older patients with head and neck cancer: Q methodology

Objective

To investigate the views of health care professionals in a head and neck surgical department toward the implementation of advance care planning prior to surgery for older patients with head and neck cancer.

Method

Q methodology was used to explore and analyze participants' views by combining quantitative and qualitative methods. Participants were asked to rank 35 Q statements generated via semi-structured interviews and a literature review and to explain the reasons for their ranking in subsequent interviews. The data was then analyzed and used to develop a factor series to illustrate participants' views.

Results

This study surveyed 15 health care professionals, including eight doctors and seven nurses. The views of health care professionals toward preoperative implementation of advance care planning discussions were varied and could be categorized into three types: defending the autonomy of patients, patients' knowledge and the Chinese traditional cultural context hinder the implementation of preoperative advance care planning, and lack of confidence in performing preoperative advance care planning.

Conclusions

Although the health care professionals in the head and neck surgical department in this study recognized the benefits of preoperative discussions regarding advance care planning, patients' knowledge level, traditional Chinese values, inadequate capacity among health care professionals, and unsound legal policies have caused these professionals to have misgivings about preoperative counseling and discussing advance care planning with patients. Further studies should be conducted, and strategies to overcome barriers to discussions of preoperative advance care planning should be developed.

Experiences with targeting inpatient advance care planning for emergency general surgery patients: A resident-led quality improvement project

BACKGROUND

For patients who may permanently or temporarily lose their ability to communicate preferences, advance care planning is a critical mechanism to guide medical decision-making but is currently underused among surgical patients.

METHODS

A resident-led quality improvement project, including education and performance measurement, was conducted on an emergency general surgery service to increase the completion of inpatient advance care planning notes using a specialized template in the electronic health record. Advance care planning documentation was defined as either preadmission advance care planning documentation (eg, advance directive) or inpatient advance care planning (use of the electronic health record template). Data from patients admitted to the emergency general surgery service for 12+ hours were analyzed, and baseline data (July 2020 to June 2021) were compared with data from the intervention period (July 2021 to June 2022). The chart review evaluated the content of the inpatient advance care planning documentation from the intervention period.

RESULTS

The frequency of inpatient advance care planning documentation increased (9.3%, n = 56 to 16.6%, n = 92, P < .001) with a greater contribution of inpatient advance care planning notes by the surgery team (16.7% to 55.4%) in the intervention period. Content analysis indicated that 79.0% of inpatient advance care planning notes listed preferences for life-sustaining therapy, 78.3% listed surrogacy, 57.3% listed overall health goals, and 50.3% listed treatment goals specific to the surgical encounter.

CONCLUSION

Although a resident-led quality improvement project contributed to greater adoption of standardized inpatient advance care planning documentation on an emergency general surgery service, progress was slow, and integration into standard work was not achieved. Future efforts are needed to better understand the integration of essential advance care planning elements into workflows and to establish inclusive educational programming to prepare all team members for conducting and documenting advance care planning conversations.

Amputation and advance care plans: An observational study exploring decision making and long-term outcomes in a vascular centre

BACKGROUND

Half of those undergoing major lower limb amputation for peripheral arterial disease die within 1 year. Advance care planning reduces days in hospital and increases the chance of dying in a preferred place.

AIM

To investigate the prevalence and content of advance care planning for people having a lower limb amputation due to acute or chronic limb-threatening ischaemia or diabetes. Secondary aims were to explore its association with mortality, and length of hospital stay.

DESIGN

A retrospective observational cohort study. The intervention was advance care planning.

SETTING/PARTICIPANTS

Patients admitted to the South West England Major Arterial Centre between 1 January 2019 and 1 January 2021 who received unilateral or bilateral below, above, or through knee amputation due to acute or chronic limb-threatening ischaemia or diabetes.

RESULTS

116 patients were included in the study. 20.7% (n = 24) died within 1 year. 40.5% (n = 47) had an advance care planning discussion of which all included cardiopulmonary resuscitation decisions with few exploring other options. Patients who were more likely to have advance care planning discussions were ≥75 years (aOR = 5.58, 95%CI 1.56-20.0), female (aOR = 3.24, 95%CI 1.21-8.69), and had multimorbidity (Charlson Comorbidity Index ≥5, aOR = 2.97, 95%CI 1.11-7.92). Discussions occurred more often in the emergency pathway and were predominantly initiated by physicians. Advance care planning was associated with increased mortality (aHR = 2.63, 95%CI 1.01, 5.02) and longer hospital stay (aHR = 0.52, 95%CI 0.32-0.83).

CONCLUSIONS

Despite a high risk of death for all patients in the months following amputation, advance care planning occurred in fewer than half of people and mostly focused on resuscitation.

"I Wish Someone had Asked Me Earlier"-Perspectives on Advance Care Planning in Surgery

Recent controversy has called into question the meaning and clinical utility of Advance Care Planning (ACP), however data have consistently shown potential benefit to patients and their surrogate decision makers. We present the concept of surgery-specific advance care planning and a structured, scalable approach to integrating it into clinical practice.

Indicators and predictors modifiable by the nursing department during the preoperative period: A scoping review

AIM AND OBJECTIVES

The aim of this study is to identify preoperative indicators and/or predictors of complications or inefficiencies in the surgical process that can be modified within nursing practice.

BACKGROUND

Due to rapid sociodemographic and technological change, the global demand for surgical attention is rising exponentially, requiring new strategies for optimisation and sustainability in perioperative care.

DESIGN

We conduced the scoping review using the methodology recommended by the Joanna Briggs Institute supported with The PAGER framework and guided by the PRISMA-ScR Checklist.

METHODS

Four databases (CINAHL, MEDLINE, SCOPUS and PUBMED) were examined to extract relevant published results for elective surgery on adult patients during the period 2011-2021. This process identified 609 records. Exclusion criteria were applied, and the sample was then evaluated with the Quality Assessment Tool for Studies with Diverse Designs (QATSDD), after which 15 studies remained.

RESULTS

The following preoperative indicators and/or predictors were considered: (1) Anxiety; (2) Pain; (3) Health education, knowledge and training; (4) Satisfaction; (5) Management/organisation (including costs, resources used/available, organisational issues, hospital stay (preoperative), standardisation and protocolisation.

CONCLUSION

The identification of five indicators and/or predictors of complications or inefficiencies in the surgical process, which can be modified by nursing, allows the effective application of interventions in the preoperative phase, optimising care and improving health outcomes.

RELEVANCE TO CLINICAL PRACTICE

The development and implementation of specific nursing skills in the preoperative phase are essential to optimise the surgical process.

Crucial Conversations for High-Risk Populations before Surgery: Advance Care Planning in a Preoperative Setting

Background: High-risk patients undergoing elective surgery are at risk for perioperative complications, including readmissions and death. Advance care planning (ACP) may allow for preparation for such events.

Objectives: (1) To assess the completion rate of advance directives (ADs) and their association with one year readmissions and mortality (2) to examine clinical events for decedents.

Design: This is an observational cohort study conducted through chart review.

Setting/Subjects: Subjects were 400 patients undergoing preoperative evaluation for elective surgery at two hospitals in the United States.

Measurements: The prevalence of ADs at the time of surgery and at one year, readmissions, and mortality at one year were determined.

Results: Three-hundred ninety patients were included. In total, 102 (26.4%) patients were readmitted, yet did not complete an AD. Seventeen (4.4%) patients filed an AD during follow-up. Nineteen patients died and mortality rate was 4.9%. There was a significant association between completing an AD before death. Of the decedents, seven (37%) underwent resuscitation, but only four had ADs.

Conclusions: Many high-risk surgical patients would benefit from ADs before clinical decline. Preoperative clinics present a missed opportunity to ensure ACP occurs before complications arise.

The Role of Anesthesiologists in Perioperative Limitation of Potentially Life-Sustaining Medical Treatments: A Narrative Review and Perspective

No patient arrives at the hospital to undergo general anesthesia for its own sake. Anesthesiology is a symbiont specialty, with the primary mission of preventing physical and psychological pain, easing anxiety, and shepherding physiologic homeostasis so that other care may safely progress. For most elective surgeries, the patient-anesthesiologist relationship begins shortly before and ends after the immediate perioperative period. While this may tempt anesthesiologists to defer goals of care discussions to our surgical or primary care colleagues, we have both an ethical and a practical imperative to share this responsibility. Since the early 1990s, the American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA), and the Association of Perioperative Registered Nurses (AORN) have mandated a "required reconsideration" of do-not-resuscitate (DNR) orders. Key ethical considerations and guiding principles informing this "required reconsideration" have been extensively discussed in the literature and include respect for patient autonomy, beneficence, and nonmaleficence. In this article, we address how well these principles and guidelines are translated into daily clinical practice and how often anesthesiologists actually discuss goals of care or potential limitations to life-sustaining medical treatments (LSMTs) before administering anesthesia or sedation. Having done so, we review how often providers implement goal-concordant care, that is, care that reflects and adheres to the stated patient wishes. We conclude with describing several key gaps in the literature on goal-concordance of perioperative care for patients with limitations on LSMT and summarize novel strategies and promising efforts described in recent literature to improve goal-concordance of perioperative care.

Determining Goals of Care During the COVID-19 Pandemic: A Virtual Course for Emergency Medicine Residents

Background Patients' goals of care (GOC), which direct end-of-life clinical decision-making, should be established in conjunction with their primary physician when they are well. However, these discussions are often left for when critical intervention is needed in the Emergency Department, and this has been exacerbated in the new context of the current coronavirus disease 2019 pandemic. Establishing effective, formal training for Emergency Medicine (EM) residents to successfully carry out these conversations and potentially improve patient care is needed. Methodology A physician dual-certified in Emergency Medicine and Palliative Care developed a virtual course on best practices in determining GOC for EM residents. It occurred for one hour during resident didactic conference and all residents who attended were included. A survey was sent to all participants to assess the success of the course's content and method of delivery. Results Of the 39 residents who participated, 18 (46%) completed the survey. The majority (94%) agreed the course helped close knowledge gaps and increased comfort in carrying out these discussions and 100% planned to incorporate these learning points into practice. A smaller majority (61%) thought the virtual platform was an effective method of delivery and 61% felt the breakout rooms helped with learning retention. Open-ended comments reflected learners' desire for more of this content, suggestions to augment with simulation, as well as technical difficulties experienced. Conclusions This course helped EM residents identify and close knowledge gaps in determining patients' GOC who plan to incorporate what they learned into their clinical practice. Next steps in validating the course include seeking more pointed feedback of the virtual format and assessing its effects over broader audiences after making feedback-focused adjustments to its content and delivery.

Recognising the elephant in the room: Foundation doctors and anticipatory care planning

Anticipatory/advance care planning (ACP) conversations are often known to be challenging and should be undertaken sensitively. A qualitative service evaluation was undertaken with the elderly care department at The Leeds Teaching Hospitals NHS Trust by medical students to explore the thoughts and experiences of foundation doctors. ACP discussions include consideration of future treatment options and preferences; however, foundation doctors were not confident to discuss issues beyond resuscitation status. The key themes identified include understanding of and confidence in ACP, variation across specialty and medical educational needs. The analysis highlights a further need for qualitative research into prevalent attitudes towards ACP discussions across the range of specialties.

Development and psychometric properties of the general public's attitudes toward advance care directives scale in Portugal

Background: To date, no instrument in Portugal has evaluated the attitudes of the population about advance care directives. This paper describes the development and testing of the General Public's Attitudes Toward Advance Care Directives (GPATACD) Scale. Design and Methods: Methodological study. The development of the instrument was based on a literature review, updated in 2018. Face and content validity were verified by an expert panel and piloted among six participants. Data were collected in an online survey of 1024 Portuguese adults. The obtained data were analyzed using Varimax rotation, while the reliability was evaluated by calculating Cronbach's alpha. Results: The scale achieves good Item-Content Validity Index (I-CVI) values, between 0.89 and 1.00, and scale-CVI values of 0.91. A principal component analysis generated four dimensions with 26 items as a final scale, with overall Cronbach's alpha of 0.848. Conclusions: The findings demonstrate that the scale is valid and reliable as a vehicle for assessment of the general public's attitudes toward advance care directives.

Emergency Healthcare Providers' Knowledge about and Attitudes toward Advance Directives: A Cross-Sectional Study between Nurses and Emergency Medical Technicians at an Emergency Department

This study aimed to explore and compare knowledge levels about advance directives (ADs) and life-sustaining treatment (LST) plans in end-of-life patients between emergency nurses and emergency medical technicians (EMTs). Using a cross-sectional study design and convenience sampling, 96 nurses and 68 EMTs were recruited from 12 emergency medical centers. A survey on knowledge about and attitudes toward ADs was performed using both online and offline methods between November and December 2019. Emergency healthcare providers were conceptually knowledgeable regarding ADs and LST, although approximately half or fewer had knowledge about ADs (such as the legal process for preparation, family or healthcare providers’ role, and the healthcare proxy). The knowledge levels of nurses and EMTs were moderate. Nurses had significantly greater knowledge relative to EMTs about ADs and LST. Positive attitudes of emergency healthcare providers were also moderately low, with nurses having less positive views than EMTs. Significant differences regarding ADs were found, with younger emergency healthcare providers having fewer career years, no personal end-of-life experiences, and less need for ADs having less knowledge. Emergency healthcare providers’ knowledge about and attitudes toward ADs were moderately low, with EMTs demonstrating a greater knowledge deficit and nurses exhibiting lower positive attitudes. Younger and novice providers had lower knowledge, but younger providers had more positive attitudes, implying that professional education and training should begin early in their careers to enhance their confidence for emergency delivery of advanced care planning.

Chronic and Sudden Serious Illness, COVID-19, and Decision-Making Capacity: Integrating Advance Care Planning Into the Preoperative Checklist for Elective Surgery

Advance Care Planning (ACP) includes anticipating future medical decisions and designating a medical decision maker in the event of losing the capacity to make one’s own medical decisions. Many advantages can be seen to doing ACP before a crisis as well as revisiting these discussions over time as circumstances change. This case presentation is of a 74-year-old woman with multiple medical problems who had ACP discussions in the context of proposed surgery for colon cancer. These conversations highlight the elements of high-quality ACP and the importance of learning what patients mean when they employ phrases commonly referenced in these conversations. The planned surgery was delayed by the COVID-19 pandemic but the discussions helped to guide decision-making when the patient became critically ill with COVID-19.

Self-Perceived Knowledge and Comfort Discussing Palliative Care and End-of-Life Issues among Professionals Managing Neuroinflammatory Diseases

Background: The growing trend in providing palliative care and end-of-life services has dictated that healthcare providers be adequately trained to care for people with serious illnesses, such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). These progressive inflammatory diseases lead to physical, cognitive and emotional deficits and have exceptionally high care demands leading to high levels of distress. Because the impact on the delivery of patient care is influenced by the specialists' knowledge and comfort discussing end-of-life issues, it is concerning that interventions to address unmet palliative care needs in MS and NMOSD rarely include clinician-patient dyads. Objectives: To evaluate the neurology clinicians' knowledge and level of comfort discussing palliative care and end-of-life issues. Design: A cross sectional survey was conducted. The statistical analyses included frequencies, chi square statistics and logistic regression. Setting/Subjects: 414 MS specialists answered an online anonymous survey. The survey was conducted using email distributions to MS professionals through the Consortium of MS Centers (CMSC), the International Organization of MS Nurses (IOMSN) and the UK Nurses' MS Organization. Measurement: The "End of Life Professional Caregiver Survey" (EPCS) was used to collect data. Results: The majority of the multidisciplinary professionals were female, white, nurses, and older than 40 years of age. 41% had their own advance directives and 57.6% had end-of-life basic training. There was a statistically significant association between end-of-life training or having advance directives and comfort discussing palliative care and end of life issues. Professionals that had basic end-of-life training and their own advance directives had higher comfort discussing code status, specific end-of-life issues, and advance directive planning. Conclusions: Basic end-of-life training and having advance directives among MS professionals were associated with better communication of palliative care and end-of-life domains with patients and their care partners.

The Challenge of Perioperative Advance Care Planning

As our population ages, there will be an increasing number of patients with life-limiting disease who may be referred for major elective surgery and more pressingly may present acutely, requiring major emergency surgical intervention. Owing to the high risk of perioperative and postoperative complications associated this group of patients, it is paramount that specific advance care planning that encompasses a patient's goals of care and resuscitative status be clarified before undergoing surgery in this acute period. In doing so, this will lead to a better quality of life for patients with a limited trajectory and allow for more informed decisions to be made about their health care. Furthermore, it will help to prevent futile and inappropriate treatments that do not respect a patient's wishes and their clinical status. In this case discussion, we explore the key themes about the challenge of perioperative advance care planning for patients with life-limiting disease and provide a framework to help guide conversation in this crucial period.

Recurrent oral squamous cell carcinoma-incorporating advance care planning in education and practice

This reflection describes a life-limiting case of oral squamous cell carcinoma (SCC) that required thoughtful management facilitated by an advance care plan (ACP). A 70-year-old female was diagnosed with a T4aN2bM0 biopsy-proven invasive, well-differentiated keratinizing SCC. Surgical wide-local excision included teeth #11-16 with left unilateral neck dissection, levels I-V. She was rehabilitated with maxillary obturator prosthesis and underwent chemoradiation therapy. Her course was complicated by dysphagia and trismus. She experienced multiple recurrences. At a certain point, negative margins could not be achieved without facial disfigurement. The patient, her husband, and providers decided together that further management would be palliative. Before the additional surgical procedures, she communicated a thorough ACP with her husband and providers who were prepared to facilitate difficult care decisions on her behalf. The patient passed away at home with hospice care at the age of 74. This motivated patient with oral SCC and impactful postmanagement complications appreciated the clarity of an ACP. Her values and goals of care were incorporated with ongoing communication and documentation of this plan, which was instrumental in facilitating her person-centered care. The providers apply lessons learned here in future practice and education of residents and students.