1
|
Moy JX, Law AC, Stalter LN, Peliska MD, Palmer G, Hanlon BM, Mortenson S, Viglianti EM, Wiegmann DA, Kruser JM. Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study. Crit Care Explor 2024; 6:e1148. [PMID: 39283228 DOI: 10.1097/cce.0000000000001148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2024] Open
Abstract
IMPORTANCE A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use. OBJECTIVES To characterize TLT use in patients with acute respiratory failure (ARF). DESIGN, SETTING, AND PARTICIPANTS Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours. MAIN OUTCOMES AND MEASURES Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record. RESULTS Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01). CONCLUSIONS AND RELEVANCE In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use.
Collapse
Affiliation(s)
- Joy X Moy
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Anica C Law
- Department of Medicine, Pulmonary, Allergy, Sleep & Critical Care Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Lily N Stalter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michael D Peliska
- Department of Medicine, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Geralyn Palmer
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Bret M Hanlon
- Department of Biostatistics & Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sean Mortenson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Elizabeth M Viglianti
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Douglas A Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI
| | - Jacqueline M Kruser
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, University of Wisconsin School of Medicine and Public Health, Madison, WI
| |
Collapse
|
2
|
Khemai C, Leão DLL, Janssen DJA, Schols JMGA, Meijers JMM. Interprofessional collaboration in palliative dementia care. J Interprof Care 2024; 38:675-694. [PMID: 38757957 DOI: 10.1080/13561820.2024.2345828] [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] [Received: 05/04/2022] [Accepted: 04/16/2024] [Indexed: 05/18/2024]
Abstract
Interprofessional collaboration (IPC) is essential for high-quality palliative care (PC) for persons with dementia. The aim of this scoping review was to identify IPC approaches in palliative dementia care and explore the elements constituting these approaches. We performed a search in PubMed, CINAHL, and PsychINFO using the Joanna Briggs Institute Reviewers' manual and PRISMA guidelines, and conducted content analysis of the included articles. In total, 28 articles were included, which described 16 IPC approaches in palliative dementia care. The content analysis revealed three overall elements of these approaches: 1) collaborative themes, 2) collaborative processes, and 3) resources facilitating collaboration. Frequently reported collaborative themes embraced pain management and providing care in the dying phase. These themes were addressed through intertwined collaborative processes including communication, coordination, assessing and monitoring, and reflecting and evaluating. To ensure optimal IPC in palliative dementia care, various resources were required, such as PC knowledge, skills to manage symptoms, skills to communicate with collaborators, and a facilitating environment. In conclusion, the identified IPC approaches in palliative dementia care involve diverse collaborating professionals who mainly manage symptoms, prepare for the dying phase and require material and immaterial resources to enable optimal IPC in palliative dementia care.
Collapse
Affiliation(s)
- C Khemai
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - D L L Leão
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - D J A Janssen
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
- Department of Research and Development, Ciro, Horn, the Netherlands
| | - J M G A Schols
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - J M M Meijers
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
- Zuyderland Care, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| |
Collapse
|
3
|
Kruser JM, Nadig NR, Viglianti EM, Clapp JT, Secunda KE, Halpern SD. Time-Limited Trials for Patients With Critical Illness: A Review of the Literature. Chest 2024; 165:881-891. [PMID: 38101511 PMCID: PMC11243441 DOI: 10.1016/j.chest.2023.12.014] [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: 07/28/2023] [Revised: 11/08/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023] Open
Abstract
TOPIC IMPORTANCE Since the 1990s, time-limited trials have been described as an approach to navigate uncertain benefits and limits of life-sustaining therapies in patients with critical illness. In this review, we aim to synthesize the evidence on time-limited trials in critical care, establish what is known, and highlight important knowledge gaps. REVIEW FINDINGS We identified 18 empirical studies and 15 ethical analyses about time-limited trials in patients with critical illness. Observational studies suggest time-limited trials are part of current practice in ICUs in the United States, but their use varies according to unit and physician factors. Some ICU physicians are familiar with, endorse, and have participated in time-limited trials, and some older adults appear to favor time-limited trial strategies over indefinite life-sustaining therapy or care immediately focused on comfort. When time-limited trials are used, they are often implemented incompletely and challenged by systematic barriers (eg, continually rotating ICU staff). Predictive modeling studies support prevailing clinical wisdom that prognostic uncertainty decreases over time in the ICU for some patients. One study prospectively comparing usual ICU care with an intervention designed to support time-limited trials yielded promising preliminary results. Ethical analyses describe time-limited trials as a pragmatic approach within the longstanding discussion about withholding and withdrawing life-sustaining therapies. SUMMARY Time-limited trials are endorsed by physicians, align with the priorities of some older adults, and are part of current practice. Substantial efforts are needed to test their impact on patient-centered outcomes, improve their implementation, and maximize their potential benefit.
Collapse
Affiliation(s)
- Jacqueline M Kruser
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Nandita R Nadig
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth M Viglianti
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Justin T Clapp
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Katharine E Secunda
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott D Halpern
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA; Palliative and Advanced Illness Research (PAIR) Center, Philadelphia, PA
| |
Collapse
|
4
|
Gaster B, Pope TM. Guiding the Future: Rethinking the Role of Advance Directives in the Care of People with Dementia. Hastings Cent Rep 2024; 54 Suppl 1:S33-S39. [PMID: 38382035 DOI: 10.1002/hast.1553] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
When people lose capacity to make a medical decision, the standard is to assess what their preferences would have been and try to honor their wishes. Dementia raises a special case in such situations, given its long, progressive trajectory during which others must make substituted judgments. The question of how to help surrogates make better-informed decisions has led to the development of dementia-specific advance directives, in which people are given tools to help them communicate what their preferences are while they are still able. Such directives allow the perspective of the person to play a clearer role in guiding decisions about their care. Dementia directives can never serve as rigid algorithms. Rather, they can be used to help inform conversations, to help surrogates make decisions that are better aligned with the preferences the person would have had. This essay lays out the proposed utility of dementia-specific directives and addresses some of the criticisms raised about them.
Collapse
|
5
|
Gotanda H, Zhang JJ, Reuben DB, Walling AM, Xu H, Jena AB, Gross N, Tsugawa Y. Association between physicians' geriatric training and patterns of end-of-life care delivered to persons with dementia. J Am Geriatr Soc 2023; 71:3457-3466. [PMID: 37470082 PMCID: PMC10799178 DOI: 10.1111/jgs.18510] [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: 12/20/2022] [Revised: 04/24/2023] [Accepted: 06/25/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Geriatric training is designed to prepare physicians to meet the complex needs of older adults, including persons with dementia at the end-of-life (EOL) stage. We sought to compare patterns of EOL care delivered to persons with dementia between physicians with versus without geriatric training. METHODS We conducted a cross-sectional study of a 20% random sample of fee-for-service Medicare beneficiaries with dementia who died in 2016-2018 (n = 99,631). We attributed beneficiaries to a physician who had the largest number of primary care visits during the last 6 months of life and determined whether the physician was trained in geriatrics. Our outcome measures included: (i) advance care planning (ACP) and palliative care (e.g., ACP, hospice enrollment in the last 90 days of life), and (ii) high-intensity EOL care (e.g., emergency department visits or hospital admissions in the last 30 days of life). RESULTS Beneficiaries with dementia under the care of physicians with geriatric training had a higher proportion of ACP (adjusted proportion, 15.8% vs. 13.0%; p < 0.001 after accounting for multiple comparisons), palliative care counseling (22.4% vs. 20.9%; p = 0.01), and hospice enrollment (63.7% vs. 60.6%; p < 0.001). Geriatric training was also associated with a lower proportion of emergency department visits (55.1% vs. 59.1%; p < 0.001), hospital admissions (48.8% vs. 52.3%; p < 0.001), ICU admissions (24.9% vs. 27.4%; p < 0.001), use of mechanical ventilation (11.2% vs. 13.0%; p < 0.001), and use of cardiopulmonary resuscitation (2.1% vs. 2.4%; p = 0.03) in the last 30 days of life. There was no evidence that the placement of feeding tubes differed between the two groups. CONCLUSIONS Physicians' geriatric training was associated with the receipt of more ACP and palliative care and less intensive EOL care among persons with dementia. Provision of geriatric training for physicians may have the potential to improve the quality of EOL care delivered to persons with dementia.
Collapse
Affiliation(s)
- Hiroshi Gotanda
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jessica J. Zhang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Anupam B. Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| |
Collapse
|
6
|
Mattos MK, Gibson JS, Wilson D, Jepson L, Ahn S, Williams IC. Shared decision-making in persons living with dementia: A scoping review. DEMENTIA 2023; 22:875-909. [PMID: 36802973 PMCID: PMC10866150 DOI: 10.1177/14713012231156976] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Evidence supports that older adults with cognitive impairment can reliably communicate their values and choices, even as cognition may decline. Shared decision-making, including the patient, family members, and healthcare providers, is critical to patient-centered care. The aim of this scoping review was to synthesize what is known about shared decision-making in persons living with dementia. A scoping review was completed in PubMed, CINAHL, and Web of Science. Keywords included content areas of dementia and shared decision-making. Inclusion criteria were as follows: description of shared or cooperative decision making, cognitively impaired patient population, adult patient, and original research. Review articles were excluded, as well as those for which the formal healthcare provider was the only team member involved in the decision-making (e.g., physician), and/or the patient sample was not cognitively impaired. Systematically extracted data were organized in a table, compared, and synthesized. The search yielded 263 non-duplicate articles that were screened by title and abstract. Ninety-three articles remained, and the full text was reviewed; 32 articles were eligible for this review. Studies were from across Europe (n = 23), North America (n = 7), and Australia (n = 2). The majority of the articles used a qualitative study design, and 10 used a quantitative study design. Categories of similar shared decision-making topics emerged, including health promotion, end-of-life, advanced care planning, and housing decisions. The majority of articles focused on shared decision-making regarding health promotion for the patient (n = 16). Findings illustrate that shared decision-making requires deliberate effort and is preferred among family members, healthcare providers, and patients with dementia. Future research should include more robust efficacy testing of decision-making tools, incorporation of evidence-based shared decisionmaking approaches based on cognitive status/diagnosis, and consideration of geographical/cultural differences in healthcare delivery systems.
Collapse
Affiliation(s)
| | | | - Dan Wilson
- Health Sciences Library, 2358University of Virginia, USA
| | - Laura Jepson
- School of Nursing, 2358University of Virginia, USA
| | - Soojung Ahn
- School of Nursing, Vanderbilt University, USA
| | | |
Collapse
|
7
|
Tjia J, D’Arcangelo N, Carlston D, Bronzi O, Gazarian P, Reich A, Porteny T, Gonzales K, Perez S, Weissman JS, Ladin K. US clinicians' perspectives on advance care planning for persons with dementia: A qualitative study. J Am Geriatr Soc 2023; 71:1473-1484. [PMID: 36547969 PMCID: PMC10175113 DOI: 10.1111/jgs.18197] [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: 09/30/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although advance care planning (ACP) for persons with dementia (PWD) can promote patient-centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians. METHODS Qualitative study using semi-structured interviews (August 2018-December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision-making was approached, and how decision-making capacity was assessed. RESULTS Of 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as possible with PWD. Three themes emerged: value of early ACP preserves PWD's autonomy in cases of differing PWD carepartner values, acute medical crises, and clinician paternalism; barriers to ACP with PWD including the dynamic and subjective assessment of patient decision-making capacity, inconsistent awareness of cognitive impairment by clinicians, and the need to balance patient and family carepartner involvement; and strategies to support ACP include clarifying clinicians' roles in ACP, standardizing clinicians' approach to PWD and their carepartners, and making time for ACP and decision-making assessments that allow PWD and carepartner involvement regardless of the patients' capacity. CONCLUSIONS Clinicians found early ACP for PWD valuable in promoting patient-centered care among an at-risk population. In sharing their perspectives on conducting ACP for PWD, clinicians described challenges that are amenable to changes in training, workflow, and material support for clinician time. Clinical practices need sustainable scheduling and financial support models.
Collapse
Affiliation(s)
- Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Noah D’Arcangelo
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
| | - Daniel Carlston
- Columbia Law School, New York, NY
- College of Nursing and Health Sciences, University of Massachusetts Boston, MA
| | - Olivia Bronzi
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
| | - Priscilla Gazarian
- College of Nursing and Health Sciences, University of Massachusetts Boston, MA
| | - Amanda Reich
- Center for Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Thalia Porteny
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY
| | - Kristina Gonzales
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
| | - Stephen Perez
- Center for Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
| |
Collapse
|
8
|
Bartley MM, Manggaard JM, Fischer KM, Holland DE, Takahashi PY. Dementia Care in the Last Year of Life: Experiences in a Community Practice and in Skilled Nursing Facilities. J Palliat Care 2023; 38:135-142. [PMID: 36148476 PMCID: PMC10026163 DOI: 10.1177/08258597221125607] [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: 11/16/2022]
Abstract
OBJECTIVE People living with dementia often have high care needs at the end-of-life. We compared care delivery in the last year of life for people living with dementia in the community (home or assisted living facilities [ALFs]) versus those in skilled nursing facilities (SNFs). METHODS A retrospective study was performed of older adults with a dementia diagnosis who died in the community or SNFs from 2013 through 2018. Primary outcomes were numbers of hospitalizations and emergency department visits in the last year of life. Secondary outcomes were completed advance care plans, hospice enrollment, time in hospice, practitioner visits, and intensive care unit admissions. RESULTS Of 1203 older adults with dementia, 622 (51.7%) lived at home/ALFs; 581 (48.3%) lived in SNFs. At least 1 hospitalization was recorded for 70.7% living at home/ALFs versus 50.8% in SNFs (P < .001), similar to percentages of emergency department visits (80.2% vs 58.0% of the home/ALF and SNF groups, P < .001). SNF residents had more practitioner visits than home/ALF residents: median (IQR), 9.0 (6.0-12.0) versus 5.0 (3.0-9.0; P < .001). No advance care plan was documented for 12.2% (n = 76) of the home/ALF group versus 4.6% (n = 27) of the SNF group (P < .001). Nearly 57% of SNF residents were enrolled in hospice versus 68.3% at home/ALFs (P < .001). The median time in hospice was 26.5 days in SNFs versus 30.0 days at home/ALFs (P = .67). CONCLUSIONS Older adults with dementia frequently receive acute care in their last year of life. Hospice care was more common for home/ALF residents. Time in hospice was short.
Collapse
Affiliation(s)
- Mairead M Bartley
- Division of Community Internal Medicine, 384842Mayo Clinic, Rochester, MN, USA
| | | | - Karen M Fischer
- Division of Clinical Trials and Biostatistics, 384842Mayo Clinic, Rochester, MN, USA
| | - Diane E Holland
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 384842Mayo Clinic, Rochester, MN, USA
| | - Paul Y Takahashi
- Division of Community Internal Medicine, 384842Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
9
|
Volle D. Dementia Care at the End of Life: A Clinically Focused Review. Am J Geriatr Psychiatry 2023; 31:291-303. [PMID: 36456444 DOI: 10.1016/j.jagp.2022.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
With the geriatric population in the United States growing rapidly, the prevalence of dementia is expected to rise concomitantly. As dementia is an invariably progressive and terminal illness, planning for and managing end of life care in dementia is an important part of the overall process of dementia care. Unfortunately, this is often neglected outside of formal palliative and hospice medicine training programs and geriatric psychiatrists are left without preparation on how to manage, as well as counsel patients and families on, this important phase of dementia care. This review aims to explore the potential contributors to this historic disparity in geriatric education and care delivery, as well as its impact, while also attempting to shift the field's focus toward a palliative approach to dementia care. To begin to accomplish this, this review explores the natural illness history/disease trajectory of the various dementing illnesses, as well as the topic of prognostication as it pertains to the end of life for patients with dementia and how this information can be used in advanced care planning and symptom management.
Collapse
Affiliation(s)
- Dax Volle
- Department of Psychiatry (DV), Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| |
Collapse
|
10
|
Factors associated with the intention to engage in care planning among persons with mild cognitive impairment and dementia. Geriatr Nurs 2023; 50:143-151. [PMID: 36780712 DOI: 10.1016/j.gerinurse.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 02/13/2023]
Abstract
This study examined factors associated with the intention to engage in advance care planning among persons with cognitive impairment. This cross-sectional study recruited 116 persons with cognitive impairment by convenience sampling from two teaching hospitals in Northern Taiwan from November 1, 2018, to December 31, 2020. Fewer than 50% of the participants intended to engage in advance care planning, and less than 10% signed the living will for hospice and palliative care. Multivariate linear regression determined factors influencing advance care planning intention included education level, a proxy signed do-not-resuscitate document, belief that family members would provide a signed do-not-resuscitate at their end-of-life, and necessity of explaining future care in advance. It is recommended to popularize advance care planning education and ensure the rights of persons with cognitive impairment to enable them to fully participate in their own care plans through family-centered advance care planning.
Collapse
|
11
|
Dassel KB, Iacob E, Utz RL, Supiano KP, Fuhrmann H. Promoting Advance Care Planning for Persons with Dementia: Study Protocol for the LEAD (Life-Planning in Early Alzheimer's and Other Dementias) Clinical Trial. OBM INTEGRATIVE AND COMPLIMENTARY MEDICINE 2023; 8:26. [PMID: 37859668 PMCID: PMC10586385 DOI: 10.21926/obm.icm.2301004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Due to the insidious progression of Alzheimer's disease and related dementias (ADRD), surrogate decision-makers typically make medical and long-term-care decisions for a care recipient, most often a family care partner. Unfortunately, many care recipient/care partner dyads have failed to engage in advance care planning or have lost the opportunity to do so due to the cognitive decline of the care recipient. To address this need, our team created a validated dementia-focused advance care planning tool known as the LEAD Guide (Life-Planning in Early Alzheimer's and Other Dementias). With funding from the National Alzheimer's Association and in consultation with our community advisory board, we developed a preliminary web-based intervention. This intervention integrates the LEAD Guide with self-paced educational modules that lead dyads through conversations and dementia-focused advance care planning processes. In this concept paper, we describe the aims of our funded R01 clinical trial (National Institute on Aging), where we aim to refine our preliminary web-based platform for use in a 5-month mixed-method NIH Stage-1 behavioral intervention. Using a sample of diverse community-based ADRD dyads (n = 60), we aim to: 1) describe the acceptability, usability, and feasibility of the intervention, 2) assess the initial efficacy of the intervention on the primary outcome (decision-making self-efficacy), and secondary outcomes (relationship quality, subjective well-being, anxiety) as perceived by both the care recipient and the care partner, and 3) examine advance care planning congruence as a mechanism of action. The LEAD clinical trial addresses public health challenges by guiding and supporting families through challenging advance care planning conversations, facilitating the transfer of knowledge regarding care preferences and values from the care recipient to the care partner, with the ultimate goal of improving the quality of life for both individuals with ADRD and their care partners.
Collapse
Affiliation(s)
- Kara B. Dassel
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
| | - Eli Iacob
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
| | - Rebecca L. Utz
- University of Utah, College of Social and Behavioral Sciences, 260 South Central Campus Drive, Salt Lake City, UT, USA
| | | | - Hollie Fuhrmann
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
| |
Collapse
|
12
|
Sussman T, Tétrault B. "People are more afraid of a dementia diagnosis than of death": The challenges of supporting advance care planning for persons with dementia in community settings. FRONTIERS IN DEMENTIA 2022; 1:1043661. [PMID: 39081479 PMCID: PMC11285647 DOI: 10.3389/frdem.2022.1043661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/05/2022] [Indexed: 08/02/2024]
Abstract
Improving early uptake of advance care planning (ACP) for persons with dementia and their families requires that staff in community-based settings feel armed and equipped to encourage and support this process. Yet few studies have explored whether staff within non-medical environments feel prepared to support early ACP engagement for persons with early-stage dementia and their families. Our qualitative interpretivist study aimed to fill this gap by facilitating, transcribing and thematically analyzing deliberations from three focus groups with 17 community-based staff. Our findings revealed four key barriers to ACP activation in community settings: (1) the stigma associated with the condition; (2) lack of knowledge about end-of-life concerns for persons with dementia; (3) uncertainties about managing complex family dynamics and (4) worries that opening up conversations about future care may lead to the expression of wishes that could not be actualized (e.g., dying at home). Our findings further revealed that ACP engagement was facilitated when staff expressed confidence in their capacities to gauge readiness, viewed themselves as guides rather than experts and had access to resources to supplement their knowledge. Reflexive training opportunities and access to materials and resources around end-of-life care for persons with dementia, could equip staff in these non-medical settings with the skills to engage in ongoing dialogue about future care issues with persons living with dementia and their families.
Collapse
Affiliation(s)
- Tamara Sussman
- School of Social Work, McGill University, Montreal, QC, Canada
| | | |
Collapse
|
13
|
Sullivan SS, Bo W, Li CS, Xu W, Chang YP. Predicting Hospice Transitions in Dementia Caregiving Dyads: An Exploratory Machine Learning Approach. Innov Aging 2022; 6:igac051. [PMID: 36452051 PMCID: PMC9701063 DOI: 10.1093/geroni/igac051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Indexed: 10/19/2023] Open
Abstract
Background and Objectives Hospice programs assist people with serious illness and their caregivers with aging in place, avoiding unnecessary hospitalizations, and remaining at home through the end-of-life. While evidence is emerging of the myriad of factors influencing end-of-life care transitions among persons living with dementia, current research is primarily cross- sectional and does not account for the effect that changes over time have on hospice care uptake, access, and equity within dyads. Research Design and Methods Secondary data analysis linking the National Health and Aging Trends Study to the National Study of Caregiving investigating important social determinants of health and quality-of-life factors of persons living with dementia and their primary caregivers (n = 117) on hospice utilization over 3 years (2015-2018). We employ cutting-edge machine learning approaches (correlation matrix analysis, principal component analysis, random forest [RF], and information gain ratio [IGR]). Results IGR indicators of hospice use include persons living with dementia having diabetes, a regular physician, a good memory rating, not relying on food stamps, not having chewing or swallowing problems, and whether health prevents them from enjoying life (accuracy = 0.685; sensitivity = 0.824; specificity = 0.537; area under the curve (AUC) = 0.743). RF indicates primary caregivers' age, and the person living with dementia's income, census division, number of days help provided by caregiver per month, and whether health prevents them from enjoying life predicts hospice use (accuracy = 0.624; sensitivity = 0.713; specificity = 0.557; AUC = 0.703). Discussion and Implications Our exploratory models create a starting point for the future development of precision health approaches that may be integrated into learning health systems that prompt providers with actionable information about who may benefit from discussions around serious illness goals-for-care. Future work is necessary to investigate those not considered in this study-that is, persons living with dementia who do not use hospice care so additional insights can be gathered around barriers to care.
Collapse
Affiliation(s)
| | - Wei Bo
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Chin-Shang Li
- School of Nursing, University at Buffalo, Buffalo, New York, USA
| | - Wenyao Xu
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Yu-Ping Chang
- School of Nursing, University at Buffalo, Buffalo, New York, USA
| |
Collapse
|
14
|
Brungardt A, Cassidy J, LaRoche A, Dulaney S, Sawyer RJ, Possin KL, Lum HD. End-of-Life Experiences Within a Dementia Support Program During COVID-19: Context and Circumstances Surrounding Death During the Pandemic. Am J Hosp Palliat Care 2022:10499091221116140. [PMID: 35848399 PMCID: PMC9294611 DOI: 10.1177/10499091221116140] [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] [Indexed: 11/15/2022] Open
Abstract
Background: Persons with dementia (PWD) and their caregivers are uniquely impacted by the COVID-19 pandemic, including higher risk of mortality for PWD. Objectives: To describe the context and circumstances of deaths of PWD within a dementia support program during the COVID-19 pandemic. Design: Retrospective data collection of PWD deaths between March 1, 2020 and February 28, 2021. Setting/Subjects: Decedents enrolled in Care Ecosystem, a multidisciplinary team model for dementia care at University of California San Francisco, Ochsner Health, and UCHealth. Measurements: Using mixed methods, we analyzed data using descriptive measures and team-based thematic analysis to understand the end-of-life (EOL) experience of PWD-caregiver dyads. Results: Twenty-nine PWD died across three sites. Almost half (45%) were between ages 70-79 and 12 (41%) were women. Eighteen (62%) died at a private residence; two died in the hospital. Hospice was involved for 22 (76%) patients. There were known causes of death for 15 (53%) patients. Only two deaths were directly related to COVID-19 infection. Social isolation was perceived to have a high or very high impact for 12 (41%) decedents. Four qualitative themes were identified: (1) isolation due to the pandemic, (2) changes in use of dementia supports and resources, (3) impact on goals of care decisions, and (4) communication challenges for EOL care coordination. Conclusion: Among PWD and caregivers enrolled in a dementia support program, the COVID-19 pandemic had direct and indirect influences on mortality and EOL experiences of PWD. Caregivers' experiences of caring, decision making, and bereavement were also affected.
Collapse
Affiliation(s)
- Adreanne Brungardt
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, 129263University of Colorado, Aurora, CO, USA
| | - Jessica Cassidy
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, 129263University of Colorado, Aurora, CO, USA
| | - Ashley LaRoche
- Department of Neurology, 604328Ochsner Health, New Orleans, LA, USA
| | - Sarah Dulaney
- Memory and Aging Center, Department of Neurology, 271696University of California, San Francisco, San Francisco, CA, USA
| | - R John Sawyer
- Department of Neurology, 604328Ochsner Health, New Orleans, LA, USA
| | - Katherine L Possin
- Memory and Aging Center, Department of Neurology, 271696University of California, San Francisco, San Francisco, CA, USA.,Global Brain Health Institute, 271696University of California, San Francisco, San Francisco, CA, USA; The Trinity College of Dublin, Dublin, Ireland
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, 129263University of Colorado, Aurora, CO, USA
| |
Collapse
|
15
|
Review of Religious Variables in Advance Care Planning for End-of-Life Care: Consideration of Faith as a New Construct. Am J Geriatr Psychiatry 2022; 30:747-758. [PMID: 34972634 DOI: 10.1016/j.jagp.2021.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/30/2021] [Accepted: 11/30/2021] [Indexed: 12/28/2022]
Abstract
Religion and spirituality have long been considered important social determinants of human health, and there exists an extensive body of research to support such. End-of-life (EOL) may raise complex questions for individuals about religious and spiritual (R/S) values guiding advance care planning (ACP) and EOL care decisions, including the provision of spiritual care. This commentary will review the history and current national trends of ACP activities for EOL, principally within the United States. It will describe the relationship of religious variables and the attributes of selected research instruments used to study religious variables on ACP and EOL preferences. The review also summarizes unique ACP challenges for patients with neurocognitive disorders and severe mental illness. Findings disclose that higher levels of religiosity, reliance on religious coping, conservative faith traditions, and "belief in God's control over life's length and divine intervention have lower levels of ACP and more intensive EOL care preferences, although the provision of spiritual spiritual care at EOL mitigates intensive EOL care. Based upon the curated evidence, we propose an epistemological justification to consider "faith" as a separately defined religious variable in future ACP and EOL research. This review is relevant to geriatric psychiatrists and gerontological health care professionals, as they may be part of multidisciplinary palliative care teams; provide longitudinal care to patients with neurocognitive disorders and severe mental illness; and may provide diagnostic, emotional, and therapeutic services for patients and families who may struggle with EOL care decisions.
Collapse
|
16
|
Visser M, Smaling HJA, Parker D, van der Steen JT. How Do We Talk With People Living With Dementia About Future Care: A Scoping Review. Front Psychol 2022; 13:849100. [PMID: 35496203 PMCID: PMC9039178 DOI: 10.3389/fpsyg.2022.849100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
A diagnosis of dementia often comes with difficulties in understanding a conversational context and expressing how one feels. So far, research on how to facilitate advance care planning (ACP) for people with dementia focused on defining relevant themes and topics for conversations, or on how to formalize decisions made by surrogate decision makers, e.g., family members. The aim of this review is to provide a better scope of the existing research on practical communication aspects related to dementia in ACP conversations. In November 2020, seven databases were searched to select papers for inclusion (Proquest, Medline, Embase, Scopus, Psycinfo, Amed, and Cinahl). This search was updated in December 2021. The search strategy consisted of three tiers (related terms to "dementia," "communication" and "ACP"), intersected by using the Boolean term "AND," and resulted in 787 studies. Two researchers followed explicit criteria for two sequential levels of screening, based on titles and abstracts and full papers. A total of 22 studies were included for data analysis. Seven topics (i.e., importance of having ACP conversations, knowledge gap, inclusion of people with dementia in ACP conversations, policy vs. practice, adapting to cognitive changes, adapting to psychosocial changes, and adapting to emotional changes) emerged clustered around two themes (i.e., communicating with people with dementia in ACP, and changes in communication due to dementia). This scoping review provides practical suggestions for healthcare professionals to improve ACP communication and uncovered gaps in research on communication aspects related to dementia in ACP conversations, such as non-verbal behavior, timing and implementation, and personal preferences.
Collapse
Affiliation(s)
- Mandy Visser
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Hanneke J A Smaling
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands.,University Network for the Care Sector Zuid-Holland, Leiden University Medical Center, Leiden, Netherlands
| | - Deborah Parker
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| |
Collapse
|
17
|
Naasan G, Boyd ND, Harrison KL, Garrett SB, D'Aguiar Rosa T, Pérez-Cerpa B, McFarlane S, Miller BL, Ritchie CS. Advance Directive and POLST Documentation in Decedents With Dementia at a Memory Care Center: The Importance of Early Advance Care Planning. Neurol Clin Pract 2022; 12:14-21. [PMID: 36157620 PMCID: PMC9491507 DOI: 10.1212/cpj.0000000000001123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/06/2021] [Indexed: 02/03/2023]
Abstract
Background and Objectives To determine the frequency of and challenges to documentation of advance care planning (ACP) in people with dementia, we conducted a chart review of 746 deceased patients seen at a tertiary memory care center between 2012 and 2017. Methods The rates of documented advance directives (ADs), Physician Order for Life-Sustaining Treatment (POLST), and Do Not Resuscitate (DNR) status were calculated from review of institutional electronic health records. Regression analysis was used to determine associations between ACP documentation and patient characteristics. Results At the time of death, approximately half of the patients had a documented AD and/or DNR status and 37% had a documented POLST; 30% of patients did not have any ACP documentation. Whereas most of the ADs were documented more than 5 years before time of death, POLST and DNR status were documented more frequently within 2 years of time of death. People who presented to clinic at a younger age and who primarily spoke English were more likely to have documented ADs. People living in zip codes with lower household incomes were 2-4.5 times less likely to have a POLST or DNR documentation. Discussion ACP is underutilized in people with dementia, even among those seen in a specialty memory care center. ACP should be introduced early on for people with dementia to ensure patients have a voice in their care.
Collapse
|
18
|
Lemos Dekker N, Bolt SR. Relating to the end of life through advance care planning: Expectations and experiences of people with dementia and their family caregivers. DEMENTIA 2022; 21:918-933. [PMID: 34978465 PMCID: PMC8996290 DOI: 10.1177/14713012211066370] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Dementia is widely considered a progressive condition associated with changes in
cognitive capacities, which promotes the idea that people with dementia need to
anticipate end-of-life care preferences. There is a growing body of interventions meant
to support advance care planning (ACP) for people with dementia and their families.
However, a deeper understanding of their experiences and expectations regarding planning
the end of life is needed to inform ethically sound and person-centered ACP. This study
explores how end-of-life care planning for people with dementia is experienced and
perceived in practice. Methods We conducted a secondary analysis of qualitative data from in-depth interviews and
ethnographic fieldwork. Participants included people with dementia living in the
community or in nursing homes, family caregivers, and professional caregivers. During
reflective sessions, the researchers moved back and forth between their original data
and overarching topics related to ACP. Both performed deductive coding to filter
relevant information from their data. Ongoing discussions allowed for the fine-tuning of
themes. Results End-of-life care planning for people with dementia can encompass a paradox of control.
While it may foster a sense of being in control, it may also feel like relinquishing
control over future situations. It raises concerns regarding responsibility, as present,
former and future wishes may not align. Family caregivers are often responsible for
concrete end-of-life decision-making, prompting them to weigh previous wishes against
present situations. Further, people with dementia may wish to focus on the present and
distance themselves from the future. Discussion Advance decisions about end-of-life care are often decontextualized and people may find
it difficult to oversee their future conditions and preferences. The widely recognized
purpose of ACP to exert control over end-of-life care may need revision to match the
needs of people with dementia while they are coping with their condition and an
uncertain future.
Collapse
Affiliation(s)
- Natashe Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Leiden, the Netherlands
| | - Sascha R Bolt
- TRANZO Tilburg School of Social and Behavioral Sciences, Tilburg University;, Tilburg, the Netherlands Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Living Lab in Ageing and Long-Term Care, 5211Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
19
|
Ma H, Kiekhofer RE, Hooper SM, Dulaney S, Possin KL, Chiong W. Goals of Care Conversations and Subsequent Advance Care Planning Outcomes for People with Dementia. J Alzheimers Dis 2021; 83:1767-1773. [PMID: 34459407 DOI: 10.3233/jad-210720] [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: 10/20/2022]
Abstract
BACKGROUND Advance care planning has been shown to improve end of life decision-making for people with dementia. However, the impact of goals of care conversations between people with dementia and their caregivers has not been characterized. OBJECTIVE In this study, we evaluate the association between goals of care conversations and advance care planning outcomes. METHODS Retrospective advance care planning measures were collected via a questionnaire administered to 166 caregivers after the death of the person with dementia for whom they provided care. RESULTS At time of death, the majority of decedents with dementia had advance directives, health care agents, and previous goals of care conversations with their caregiver. Goals of care conversations were significantly associated with the perceived usefulness of advance directives, the perceived adherence to advance directives, and decedent dying at their desired place of death, but not with disagreements around end-of-life care. CONCLUSION Our findings suggest that goals of care conversations are an important component of advance care planning. These findings support the development of interventions that facilitate such conversations between people with dementia and their caregivers.
Collapse
Affiliation(s)
- Heather Ma
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Rachel E Kiekhofer
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, CA, USA
| | - Sarah M Hooper
- UCSF/UC Consortium on Law, Science & Health Policy, UC Hastings College of the Law, San Francisco, San Francisco, CA, USA
| | - Sarah Dulaney
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, CA, USA
| | - Katherine L Possin
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, CA, USA.,Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Winston Chiong
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
20
|
Exploring Differential Perceptions and Barriers to Advance Care Planning in Dementia among Asian Patient-Caregiver Dyads-A Mixed-Methods Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137150. [PMID: 34281087 PMCID: PMC8297379 DOI: 10.3390/ijerph18137150] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/28/2021] [Accepted: 07/01/2021] [Indexed: 12/17/2022]
Abstract
A parallel mixed-methods study on 20 patient–caregiver dyads in an Asian population was conducted to explore the differential perceptions and barriers to ACP in dementia. We recruited English-speaking patients with mild dementia and their caregivers. A trained ACP facilitator conducted ACP counseling. Patient–caregiver dyads completed pre–post surveys and participated in post-counseling qualitative interviews. We used mixed-methods analysis to corroborate the quantitative and qualitative data. Differential perceptions of ACP were reported among dyads, with caregivers less inclined for further ACP discussions. Post-ACP counseling, caregivers were significantly more likely to acknowledge barriers to ACP discussions than patients (57.9% versus 10.5%, p = 0.005). Thematic analysis of the interview transcripts revealed four themes around barriers to ACP: patient-related factors (transference of decision making, poor cognition and lack of understanding, and dis-inclination to plan for the future), caregiver-related factors (perceived negative impact on the patient, caregiver discomfort, and confidence in congruent decision making), socio-cultural factors (taboos, superstitions, and religious beliefs), and the inappropriate timing of discussions. In a collectivist Asian culture, socio-cultural factors pose important barriers, and a family-centric approach to initiation of ACP may be the first step towards engagement in the ACP process. For ACP in dementia to be effective for patients and caregivers, these discussions should be culturally tailored and address patient, caregiver, socio-cultural, and timing barriers.
Collapse
|
21
|
Bryant J, Sellars M, Waller A, Detering K, Sinclair C, Ruseckaite R, White B, Nolte L. Advance care planning participation by people with dementia: a cross-sectional survey and medical record audit. BMJ Support Palliat Care 2021; 12:bmjspcare-2020-002550. [PMID: 33658249 PMCID: PMC9380490 DOI: 10.1136/bmjspcare-2020-002550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To describe among individuals with dementia: (1) self-reported awareness of, and engagement in, advance care planning; (2) presence of advance care planning documentation in the health record and (3) concordance between self-reported completion of advance care planning and presence of documentation in the health record. METHODS An Australian prospective multicentre audit and cross-sectional survey. Individuals diagnosed with dementia who were able to speak English and were judged by a healthcare provider as having decision-making capacity were recruited from self-selected hospitals, residential aged care facilities and general practices across Australia. RESULTS Fifty-two people with dementia completed surveys and were included. Overall, 59.6% of participants had heard about advance care planning and 55.8% had discussed advance care planning with someone, most often a family member (48.1%). While 38.5% of participants had appointed a medical substitute decision maker, only 26.9% reported that they had written down their values and preferences for future care. Concordance between self-reported completion of advance care planning and presence of documentation in the health record was low (56.8%, κ=0.139; 57.7%, κ=0.053). CONCLUSION Effective models that promote discussion, documentation and accessible storage of advance care planning documents for people with dementia are needed.
Collapse
Affiliation(s)
- Jamie Bryant
- Health Behaviour Research Collaborative,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- School of Medicine and Public Health, Health Behaviour Research Collaborative, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Marcus Sellars
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| | - Amy Waller
- Health Behaviour Research Collaborative,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- School of Medicine and Public Health, Health Behaviour Research Collaborative, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Karen Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Craig Sinclair
- Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney, New South Wales, Australia
- Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Rasa Ruseckaite
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Ben White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| |
Collapse
|
22
|
Sussman T, Pimienta R, Hayward A. Engaging persons with dementia in advance care planning: Challenges and opportunities. DEMENTIA 2020; 20:1859-1874. [PMID: 33290098 DOI: 10.1177/1471301220973059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This study reports findings from a series of focus groups with persons with dementia and family caregivers intended to explore: (1) perceptions of and experiences with advance care planning (ACP); (2) concerns related to future care including, but not limited to, end-of-life care; and (3) practices that may support positive engagement with ACP. A total of 18 participants including 10 persons with dementia and eight family caregivers participated in five focus groups held in two urban cities in Canada. All focus group deliberations were audio recorded, transcribed verbatim, and analyzed in five stages using a semantic thematic approach. All participants expressed some form of engagement in ACP, but understandings were limited and divergence was expressed regarding the timing of more expansive conversations about future care. Although some persons with dementia were ready to engage in future care discussions, most preferred focusing on the present and suggested their families did not require direction. This placed families in the complex dilemma of protecting their loved ones while compromising their own needs for dialogue. Although individually focused models of ACP engagement hold promise for those persons with dementia ready to engage in future planning, our findings suggest that early engagement of families in the reflective process may go a long way in supporting ACP activation. Our findings further suggest that persons with dementia who do not have close family/friends may require extensive ACP encouragement and support from service providers.
Collapse
Affiliation(s)
- Tamara Sussman
- School of Social Work, 5620McGill University, Montreal, Quebec, Canada
| | - Rebecca Pimienta
- School of Social Work, 5620McGill University, Montreal, Quebec, Canada
| | - April Hayward
- Special Care Counselling, 91424Vanier College, Montreal, Quebec, Canada
| |
Collapse
|
23
|
McDermott CL, Engelberg RA, Khandelwal N, Steiner JM, Feemster LC, Sibley J, Lober WB, Curtis JR. The Association of Advance Care Planning Documentation and End-of-Life Healthcare Use Among Patients With Multimorbidity. Am J Hosp Palliat Care 2020; 38:954-962. [PMID: 33084357 DOI: 10.1177/1049909120968527] [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: 11/17/2022] Open
Abstract
PURPOSE Multimorbidity is associated with increased intensity of end-of-life healthcare. This association has been examined by number but not type of conditions. Our purpose was to understand how intensity of care is influenced by multimorbidity within specific chronic conditions to provide guidance for interventions to improve end-of-life care for these patients. METHODS We identified adults cared for in a multihospital healthcare system who died between 2010-2017. We categorized patients by 4 primary chronic conditions: heart failure, pulmonary disease, renal disease, or dementia. Within each condition, we examined the effect of multimorbidity (presence of 4 or more chronic conditions) on hospital and ICU admission in the last 30 days of life, in-hospital death, and advance care planning (ACP) documentation >30 days before death. We performed logistic regression to estimate associations between multimorbidity and end-of-life care utilization, stratified by the presence or absence of ACP documentation. RESULTS ACP documentation >30 days before death was associated with lower odds of in-hospital death for all 4 conditions both in patients with and without multimorbidity. With the exception of patients with renal disease without multimorbidity, we observed lower odds of hospitalization and ICU admission for all patients with ACP >30 days before death. CONCLUSIONS Patients with dementia and multimorbidity had the highest odds of high-intensity end-of-life care. For patients with dementia, heart failure, or pulmonary disease, ACP documentation >30 days before death was associated with lower likelihood of in-hospital death, hospitalization, and ICU use at end-of-life, regardless of multimorbidity.
Collapse
Affiliation(s)
- Cara L McDermott
- Division of Pulmonary, Critical Care and Sleep Medicine, 7284University of Washington, Seattle, WA, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, 7284University of Washington, Seattle, WA, USA
| | - Nita Khandelwal
- Division of Anesthesiology and Pain Medicine, 7284University of Washington, Seattle, WA, USA
| | - Jill M Steiner
- Division of Cardiology, 7284University of Washington, Seattle, WA, USA
| | - Laura C Feemster
- Division of Pulmonary, Critical Care and Sleep Medicine, 7284University of Washington, Seattle, WA, USA.,VA Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
| | - James Sibley
- Department of Biobehavioral Nursing and Health Informatics, 7284University of Washington, Seattle, WA, USA
| | - William B Lober
- Department of Biobehavioral Nursing and Health Informatics, 7284University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, 7284University of Washington, Seattle, WA, USA
| |
Collapse
|
24
|
Cheng SY, Lin CP, Chan HYL, Martina D, Mori M, Kim SH, Ng R. Advance care planning in Asian culture. Jpn J Clin Oncol 2020; 50:976-989. [PMID: 32761078 DOI: 10.1093/jjco/hyaa131] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 07/20/2020] [Indexed: 11/14/2022] Open
Abstract
Ageing has been recognized as one of the most critically important health-care issues worldwide. It is relevant to Asia, where the increasing number of older populations has drawn attention to the paramount need for health-care investment, particularly in end-of-life care. The advocacy of advance care planning is a mean to honor patient autonomy. Since most East Asian countries are influenced by Confucianism and the concept of 'filial piety,' patient autonomy is consequently subordinate to family values and physician authority. The dominance from family members and physicians during a patient's end-of-life decision-making is recognized as a cultural feature in Asia. Physicians often disclose the patient's poor prognosis and corresponding treatment options to the male, family member rather to the patient him/herself. In order to address this ethical and practical dilemma, the concept of 'relational autonomy' and the collectivism paradigm might be ideally used to assist Asian people, especially older adults, to share their preferences on future care and decision-making on certain clinical situations with their families and important others. In this review article, we invited experts in end-of-life care from Hong Kong, Indonesia, Japan, South Korea, Singapore and Taiwan to briefly report the current status of advance care planning in each country from policy, legal and clinical perspectives. According to the Asian experiences, we have seen different models of advance care planning implementation. The Asian Delphi Taskforce for advance care planning is currently undertaken by six Asian countries and a more detailed, culturally sensitive whitepaper will be published in the near future.
Collapse
Affiliation(s)
- Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Cheng-Pei Lin
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Helen Yue-Lai Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Central Ave, Hong Kong
| | - Diah Martina
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Division of Psychosomatic and Palliative Medicine, Department of Internal Medicine Universitas Indonesia, Jakarta Pusat, Indonesia
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Sun-Hyun Kim
- Department of Family Medicine, International St. Mary's Hospital, College of Medicine, Catholic Kwandong University, Incheon, Republic of Korea
| | - Raymond Ng
- Department of Palliative Medicine, Tan Tock Seng Hospital, Jln Tan Tock Seng, Singapore
| |
Collapse
|
25
|
Harrison KL, Allison TA, Garrett SB, Thompson N, Sudore RL, Ritchie CS. Hospice Staff Perspectives on Caring for People with Dementia: A Multisite, Multistakeholder Study. J Palliat Med 2020; 23:1013-1020. [PMID: 32130076 PMCID: PMC7404831 DOI: 10.1089/jpm.2019.0565] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2020] [Indexed: 01/03/2023] Open
Abstract
Background: In the United States, 45% of people enrolled in hospice have dementia. We know little about how hospice professionals facilitate preference-aligned end-of-life care for people with dementia (PWD) and their families. Objective: To examine hospice stakeholders' perspectives on caring for PWD and their families. Design: Multisite qualitative study using semi-structured interviews with interdisciplinary hospice clinicians, leaders, and administrators. The interdisciplinary team used the constant comparative method to identify, code, and characterize relevant themes. Setting/participants: Four geographically distinct nonprofit U.S. hospice organizations. Fifty-one hospice employees: 61% clinical staff, 25% executive leaders, and 14% administrators. Measurements: Interview domains included participants' practices of engaging patients/families in discussions of preferences for end-of-life care and professional opinions of changes over time. Cross-topic probes focused on delivering hospice care to PWD and their proxies/families. Results: Four themes regarding caring for PWD in hospice. (1) Dementia prevalence in hospice is increasing and some hospices are developing programs to accommodate specific needs. (2) Setting impacts discussions of preferences and care decisions. (3) Caring for PWD on hospice poses unique challenges caused by (i) perceptions that dementia is not terminal, (ii) a lack of advance care planning discussions before hospice admission, and (iii) proxy decision-makers who were inadequately prepared for their role. (4) Hospice regulatory and policy changes disproportionately impact PWD. Conclusions: Hospice professionals perceive increasing demand for, and multilevel challenges to, caring for PWD. Clinicians "upstream" from hospice may help by engaging patients and proxies in discussions of preferences for end-of-life care and providing anticipatory guidance.
Collapse
Affiliation(s)
- Krista L. Harrison
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Theresa A. Allison
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Sarah B. Garrett
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Nicole Thompson
- Osher Center for Integrative Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Christine S. Ritchie
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Campus for Jewish Living, San Francisco, California, USA
| |
Collapse
|
26
|
Wendrich-van Dael A, Bunn F, Lynch J, Pivodic L, Van den Block L, Goodman C. Advance care planning for people living with dementia: An umbrella review of effectiveness and experiences. Int J Nurs Stud 2020; 107:103576. [DOI: 10.1016/j.ijnurstu.2020.103576] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 11/26/2022]
|
27
|
Sulmasy DP. We Need More Wisdom, Not More Paper: A Reply to Merel and Gaster. J Am Geriatr Soc 2020; 68:1609-1610. [PMID: 32374411 DOI: 10.1111/jgs.16494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 03/19/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Daniel P Sulmasy
- Departments of Medicine and Philosophy, Georgetown University, Washington, DC, USA
| |
Collapse
|
28
|
Merel SE, Gaster B. Advance Directives for Dementia Can Elicit Preferences to Improve Patient Care. J Am Geriatr Soc 2020; 68:1606-1608. [DOI: 10.1111/jgs.16492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Susan E. Merel
- Division of General Internal Medicine, Department of MedicineUniversity of Washington Seattle Washington USA
| | - Barak Gaster
- Division of General Internal Medicine, Department of MedicineUniversity of Washington Seattle Washington USA
| |
Collapse
|
29
|
Pettigrew C, Brichko R, Black B, O’Connor MK, Austrom MG, Robinson MT, Lindauer A, Shah RC, Peavy GM, Meyer K, Schmitt FA, Lingler JH, Domoto-Reilly K, Farrar-Edwards D, Albert M. Attitudes toward advance care planning among persons with dementia and their caregivers. Int Psychogeriatr 2020; 32:585-599. [PMID: 31309906 PMCID: PMC6962575 DOI: 10.1017/s1041610219000784] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To examine factors that influence decision-making, preferences, and plans related to advance care planning (ACP) and end-of-life care among persons with dementia and their caregivers, and examine how these may differ by race. DESIGN Cross-sectional survey. SETTING 13 geographically dispersed Alzheimer's Disease Centers across the United States. PARTICIPANTS 431 racially diverse caregivers of persons with dementia. MEASUREMENTS Survey on "Care Planning for Individuals with Dementia." RESULTS The respondents were knowledgeable about dementia and hospice care, indicated the person with dementia would want comfort care at the end stage of illness, and reported high levels of both legal ACP (e.g., living will; 87%) and informal ACP discussions (79%) for the person with dementia. However, notable racial differences were present. Relative to white persons with dementia, African American persons with dementia were reported to have a lower preference for comfort care (81% vs. 58%) and lower rates of completion of legal ACP (89% vs. 73%). Racial differences in ACP and care preferences were also reflected in geographic differences. Additionally, African American study partners had a lower level of knowledge about dementia and reported a greater influence of religious/spiritual beliefs on the desired types of medical treatments. Notably, all respondents indicated that more information about the stages of dementia and end-of-life health care options would be helpful. CONCLUSIONS Educational programs may be useful in reducing racial differences in attitudes towards ACP. These programs could focus on the clinical course of dementia and issues related to end-of-life care, including the importance of ACP.
Collapse
Affiliation(s)
- Corinne Pettigrew
- Department of Neurology, Johns Hopkins School of Medicine, 1620 McElderry St., Baltimore, MD, 21205, USA
| | - Rostislav Brichko
- Department of Neurology, Johns Hopkins School of Medicine, 1620 McElderry St., Baltimore, MD, 21205, USA
| | - Betty Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5300 Alpha Commons Dr., Baltimore, MD 21224, USA
| | - Maureen K. O’Connor
- Department of Neurology, Boston University School of Medicine, 72 East Concord St., B-7800, Boston, MA 02118, USA
| | - Mary Guerriero Austrom
- Department of Psychiatry, Indiana University School of Medicine, 355 W. 16 St., Goodman Hall, Suite 2800, Indianapolis, IN 46202, USA
| | - Maisha T. Robinson
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
| | - Allison Lindauer
- Department of Neurology, Layton Aging and Alzheimer’s Disease Center, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR 97239, USA
| | - Raj C. Shah
- Department of Family Medicine and the Rush Alzheimer’s Disease Center, Rush University Medical Center, 1750 W. Harrison Street., Suite 1000, Chicago, IL 60612, USA
| | - Guerry M. Peavy
- Department of Neurosciences, University of California, San Diego School of Medicine, 9444 Medical Center Drive, Suite 1-100, La Jolla, CA 92037, USA
| | - Kayla Meyer
- Department of Neurology, University of Kansas Medical Center, 4350 Shawnee Mission Parkway, MS 6002, Fairway, KS 66205, USA
| | - Frederick A. Schmitt
- Department of Neurology & Sanders-Brown Center on Aging, University of Kentucky, 800 South Limestone St., Lexington, KY 40536, USA
| | - Jennifer H. Lingler
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, 415 Victoria Hall, 3500 Victoria St., Pittsburgh, PA 15261, USA
| | - Kimiko Domoto-Reilly
- Department of Neurology, University of Washington, 325 9th Ave., 3 Floor West Clinic, Seattle, WA 98104, USA
| | - Dorothy Farrar-Edwards
- Department of Kinesiology-Occupational Therapy, University of Wisconsin Madison School of Education, 2170 Medical Sciences Center, 1300 University Ave., Madison, WI 53706, USA
| | - Marilyn Albert
- Department of Neurology, Johns Hopkins School of Medicine, 1620 McElderry St., Baltimore, MD, 21205, USA
| |
Collapse
|
30
|
Phenwan T, Sixsmith J, McSwiggan L, Buchanan D. A narrative review of facilitating and inhibiting factors in advance care planning initiation in people with dementia. Eur Geriatr Med 2020; 11:353-368. [PMID: 32297272 PMCID: PMC7280342 DOI: 10.1007/s41999-020-00314-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/19/2020] [Indexed: 12/16/2022]
Abstract
Aim To identify and assess factors that affect the decisions to initiate advance care planning (ACP) amongst people living with dementia (PwD). Findings All articles included for the analysis came from countries that have supportive regulations and guidelines for ACP.
ACP initiation amongst PwD is a complex decision that involves several stakeholders who have different knowledge and attitudes of ACP. Message More research is required on ACP education, initiation timing given the disease trajectory, and changing family dynamics overtime. Electronic supplementary material The online version of this article (10.1007/s41999-020-00314-1) contains supplementary material, which is available to authorized users. Purpose of the review To identify and assess factors that affect the decisions to initiate advance care planning (ACP) amongst people living with dementia (PwD). Methods A narrative review was conducted. A keyword search of Medline, CINAHL PsycINFO, and Web of Sciences databases produced 22,234 articles. Four reviewers independently applying inclusion/exclusion criteria resulted in 39 articles. Discrepancies were settled in discussion. Results Twenty-eight primary studies and eleven review articles remained. Narrative analysis generated five categories of facilitating and inhibitory factors: people with dementia, family orientation, healthcare professionals (HCP), systemic and contextual factors, and time factors. Key facilitators of ACP initiation were (i) healthcare settings with supportive policies and guidelines, (ii) family members and HCPs who have a supportive relationship with PwD, and (iii) HCPs who received ACP education. Key inhibitors were: (i) lack of knowledge about the dementia trajectory in stakeholders, (ii) lack of ACP knowledge, and (iii) unclear timing to initiate an ACP. Conclusion This review highlighted the main challenges associated with optimal ACP initiation with PwD. To encourage effective ACP initiation with PwD, succinct policies and guidelines for clinical commissioners are needed. ACP also needs to be discussed with family members in an informal, iterative manner. More research is required on initiation timing given the disease trajectory and changing family dynamics. Electronic supplementary material The online version of this article (10.1007/s41999-020-00314-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Tharin Phenwan
- School of Nursing and Health Sciences, University of Dundee, Dundee, UK.
| | - Judith Sixsmith
- School of Nursing and Health Sciences, University of Dundee, Dundee, UK
| | - Linda McSwiggan
- School of Nursing and Health Sciences, University of Dundee, Dundee, UK
| | - Deans Buchanan
- NHS Tayside and Dundee Health and Social Care Partnership, Dundee, UK.,School of Medicine, University of Dundee, Dundee, UK.,Tayside Palliative and End of Life Care Managed Care Network, Tayside, UK
| |
Collapse
|
31
|
Factors Associated With Life Discussions Among Friends and Family in Japanese Depopulated Areas. J Hosp Palliat Nurs 2020; 22:159-165. [PMID: 31996586 DOI: 10.1097/njh.0000000000000633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advance care planning is spreading globally, but it is still a difficult task for healthy, community-dwelling Japanese residents. In Japan, it is called "life discussion," and the first step is a discussion on goals, values, and preferences of medical care among family or other close persons, as knowledge on this topic is limited. This study aimed to explore the factors associated with the degree of engagement in life discussions among friends and family in depopulated areas. In 2 areas of Japan, 2466 individuals (aged 40-79 years) participated in this survey. Health/life habits, such as collecting health information and participating in some community activities, were significantly associated with the discussions more than attitude to medical/long-term care and community. Additionally, it was discussed how local governments could intervene to encourage advance care planning in depopulated areas. In conclusion, health habits or attitudes for care such as preference and desire for care among community-dwelling adults were associated with engaging in the discussions. It was proposed that local governments should motivate individuals to consider end-of-life experiences from a first-person perspective for creating advance care planning directives, and nurses could facilitate the discussion when death is imminent.
Collapse
|
32
|
Hickman SE, Unroe KT, Ersek M, Stump TE, Tu W, Ott M, Sachs GA. Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents. J Am Geriatr Soc 2019; 67:1649-1655. [DOI: 10.1111/jgs.15927] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/19/2019] [Accepted: 03/19/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Susan E. Hickman
- Department of Community Health Systems, School of Nursing Indiana University Indianapolis Indiana
- RESPECT (Research in Palliative and End‐of‐Life Communication and Training) Signature Center Indiana University Purdue University Indianapolis Indianapolis Indiana
| | - Kathleen T. Unroe
- RESPECT (Research in Palliative and End‐of‐Life Communication and Training) Signature Center Indiana University Purdue University Indianapolis Indianapolis Indiana
- Division of General Internal Medicine and Geriatrics, School of Medicine Indiana University Indianapolis Indiana
- Center for Aging Research, Regenstrief Institute Indianapolis Indiana
| | - Mary Ersek
- Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center Philadelphia Pennsylvania
- Biobehavioral Health Sciences, School of Nursing University of Pennsylvania Philadelphia Pennsylvania
| | - Timothy E. Stump
- Division of General Internal Medicine and Geriatrics, School of Medicine Indiana University Indianapolis Indiana
- Department of Biostatistics School of Medicine, Indiana University Indianapolis Indiana
| | - Wanzhu Tu
- Division of General Internal Medicine and Geriatrics, School of Medicine Indiana University Indianapolis Indiana
- Center for Aging Research, Regenstrief Institute Indianapolis Indiana
- Department of Biostatistics School of Medicine, Indiana University Indianapolis Indiana
| | - Monica Ott
- Division of General Internal Medicine and Geriatrics, School of Medicine Indiana University Indianapolis Indiana
| | - Greg A. Sachs
- RESPECT (Research in Palliative and End‐of‐Life Communication and Training) Signature Center Indiana University Purdue University Indianapolis Indianapolis Indiana
- Division of General Internal Medicine and Geriatrics, School of Medicine Indiana University Indianapolis Indiana
- Center for Aging Research, Regenstrief Institute Indianapolis Indiana
| |
Collapse
|
33
|
Cotter VT, Hasan MM, Ahn J, Budhathoki C, Oh E. A Practice Improvement Project to Increase Advance Care Planning in a Dementia Specialty Practice. Am J Hosp Palliat Care 2019; 36:831-835. [DOI: 10.1177/1049909119841544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study was conducted to enhance the rate of advance care planning (ACP) conversations and documentation in a dementia specialty practice by increasing physician knowledge, attitudes, and skills. We used a pre- and postintervention paired design for physicians and 2 independent groups for patients. The ACP dementia educational program encompassed 3 objectives: (1) to understand the relevance of ACP to the dementia specialty practice, (2) to provide a framework to discuss ACP with patients and caregivers, and (3) to discuss ways to improve ACP documentation and billing in the electronic medical record. A 10-item survey was utilized pre- and posteducational intervention to assess knowledge, attitudes, and skill. The prevalence of ACP documentation was assessed through chart review 3 months pre- and postintervention. The educational intervention was associated with increased confidence in ability to discuss ACP ( P = .033), belief that ACP improves outcomes in dementia ( P = .035), knowledge about ACP Medicare billing codes and requirements ( P = .002), and belief that they have support from other personnel to implement ACP ( P = .017). In 2 independent groups of patients with dementia, documentation rates of an advance directive increased from 13.6% to 19.7% ( P = .045) and the Medical Order for Life-Sustaining Treatment (MOLST) increased from 11.0% to 19.0% ( P = .006). The MOLST documentation in 2 independent groups of patients with nondementia increased from 7.3% to 10.7% ( P = .046). Continuing efforts to initiate educational interventions are warranted to increase the effectiveness ACP documentation and future care of persons with dementia.
Collapse
Affiliation(s)
| | | | - Jheesoo Ahn
- Johns Hopkins School of Nursing, Baltimore, MD, USA
| | | | - Esther Oh
- Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| |
Collapse
|
34
|
Jennings LA, Turner M, Keebler C, Burton CH, Romero T, Wenger NS, Reuben DB. The Effect of a Comprehensive Dementia Care Management Program on End-of-Life Care. J Am Geriatr Soc 2019; 67:443-448. [PMID: 30675898 PMCID: PMC9859712 DOI: 10.1111/jgs.15769] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/24/2018] [Accepted: 10/24/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND/OBJECTIVES Although Alzheimer disease and other dementias are life limiting, only a minority of these patients or their proxy decision makers participate in advance care planning. We describe end-of-life care preferences and acute care and hospice use in the last 6 months of life for persons enrolled in a comprehensive dementia care management program. DESIGN Observational, retrospective cohort. SETTING Urban, academic medical center. PARTICIPANTS A total of 322 persons enrolled in dementia care management after July 1, 2012, who died before July 1, 2016. INTERVENTION Dementia care comanagement model using nurse practitioners partnered with primary care providers and community organizations to provide comprehensive dementia care, including advance care planning. MEASUREMENTS Advance care preferences, use of Physician Orders for Life Sustaining Treatment (POLST), hospice enrollment, and hospitalizations and emergency department (ED) visits in the last 6 months of life obtained from electronic health record data. RESULTS Nearly all decedents (99.7%, N = 321) had a goals-of-care conversation documented (median = 3 conversations; interquartile range = 2-4 conversations), and 64% had advance care preferences recorded. Among those with recorded preferences, 88% indicated do not resuscitate, 48% limited medical interventions, and 35% chose comfort-focused care. Most patients (89%) specified limited artificial nutrition, including withholding feeding tubes. Over half (54%) had no hospitalizations or ED visits in the last 6 months of life, and intensive care unit stays were rare (5% of decedents). Overall, 69% died on hospice. Decedents who had completed a POLST were more likely to die in hospice care (74% vs 62%; P = .03) and die at home (70% vs 59%; P = .04). CONCLUSIONS Enrollees in a comprehensive dementia care comanagement program had high engagement in advance care planning, high rates of hospice use, and low acute care utilization near the end of life. Wider implementation of such programs may improve end-of-life care for persons with dementia. J Am Geriatr Soc 67:443-448, 2019.
Collapse
Affiliation(s)
- Lee A. Jennings
- Reynolds Department of Geriatric Medicine, University of Oklahoma Health Sciences Center
| | - Maurice Turner
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School Medicine, University of California, Los Angeles
| | - Chandra Keebler
- Division of Geriatrics and Supportive Care, Kaiser Permanente, Vallejo, California
| | - Carl H. Burton
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School Medicine, University of California, Los Angeles
| | - Tahmineh Romero
- Statistics Core, David Geffen School of Medicine, University of California, Los Angeles
| | - Neil S. Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - David B. Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School Medicine, University of California, Los Angeles
| |
Collapse
|