Advance Care Planning in Serious Illness: A Narrative Review

Family-Integrated Advance Care Planning for Cancer Patients: A Mixed-Methods Feasibility Study

CONTEXT

Advance care planning programs which focus on facilitating conversations among families are scant. We developed a family-integrated Serious Illness Conversation Guide (SICG-Fam).

OBJECTIVES

This study aims to examine the ability and acceptability of the SICG-Fam for advanced cancer patients, family members and physicians in Japan.

METHODS

Trained physicians provided their patients and family members with serious illness conversations using the SICG-Fam. Data regarding ability and acceptability were collected through questionnaires and semi-structured interviews with patients, family members and physicians. Descriptive statistics and thematic analyses were conducted for data analysis.

RESULTS

From February to May 2023, 10 physicians and 22 dyads comprising 22 patients and 24 family members participated. Physicians had a median of 19 years' experience. Each item in the SICG-Fam was delivered by physicians in 18-22 of all the 22 conversations. Patients and family members, except for one family member, judged the conversation as being helpful to discuss their respective views on patients' wishes. Two patients and four family members evaluated the conversation as distressing. Family context, including family relationships, and how physicians engage with them, including supportive attitudes and encouraging patients and family members to express their views, affected the perceived helpfulness of the conversation.

CONCLUSION

The SICG-Fam was delivered by physicians and accepted by patients and family members. However, how physicians consider the family perception of the conversation may mitigate potential patient and family member distress. Future studies should focus on further refining the intervention to address the identified challenges and rigorously investigate the effectiveness of this approach.

Effects of advance care planning for patients with advanced cancer: A meta-analysis of randomized controlled studies

BACKGROUND

Patients with advanced cancer often have to make difficult end-of-life decisions, which are closely associated with their access to anticipated care after loss of mental capacity. Advance care planning, an approach of discussing, documenting, and deciding on end-of-life preferences, helps with better decision-making. However, despite being recommended for oncology care, its efficacy for patients with advanced cancer remains unclear.

OBJECTIVE

To explore the effects of advance care planning in patients with advanced cancer.

DESIGN

Systematic review and meta-analysis.

METHODS

Twelve electronic databases, including Embase, Medline, the Cochrane Central Register of Controlled Trials, PsycINFO, Web of Science, CINAHL complete, CBM, CNKI, VIP, Wanfang, Google Scholar and Proguest Dissertations and Theses, were searched from inception to December 2024. The Cochrane Risk of Bias Tool 2.0 was used to evaluate the quality of the included studies. Meta-analysis was performed with R software, and outcomes not amenable to meta-analysis were narratively synthesized.

RESULTS

Fourteen studies were included. The results of the meta-analysis implied that advance care planning significantly improved the completion of advance directives (OR = 7.93, 95 % CI: 2.76-22.77, P = 0.0001) and palliative care utilization (OR = 1.39, 95 % CI: 1.08-1.78, P = 0.0009). Anxiety (SMD = -0.14, 95 % CI: -0.52-0.23, P = 0.45), depression (SMD = -0.10, 95 % CI: -0.55-0.34, P = 0.66), decisional conflicts (MD = -1.25, 95 % CI: -3.67-1.18, P = 0.31), patient satisfaction (SMD = 0.19, 95 % CI: -0.23-0.70, P = 0.47), and quality of life (SMD = 0.32, 95 % CI: -0.83-1.48, P = 0.58) were not improved. In the narrative synthesis, dignity was enhanced, but the effects of concordance between actual care received and preferences were inconsistent. In general, existing advance care planning is primarily delivered in a face-to-face format in hospitals and focuses on older patients.

CONCLUSIONS

Advance care planning may have desirable impacts on improving the completion of advance directives and palliative care utilization for patients with advanced cancer. It was not effective in improving anxiety, depression, decisional conflicts, patient satisfaction, and quality of life. The effects of dignity and care concordance need to be further validated. Young patient-specific, digital technology-based, and in-home advance care planning is encouraged, and the optimal timing of interventions also needs to be clarified.

Impact of a team-based versus individual clinician-focused training approach on primary healthcare professionals' intention to have serious illness conversations with patients: A theory-informed process evaluation embedded within a cluster randomized trial

BACKGROUND

Cluster randomized trials (cRTs) on the effectiveness of training programs face complex challenges when conducted in real-world settings. Process evaluations embedded within cRTs can help explain their results by exploring possible causal mechanisms impacting training effectiveness.

OBJECTIVE

To conduct a process evaluation embedded within a cRT by comparing the impact of team-based vs. individual clinician-focused SICP training on primary healthcare professionals' (PHCPs) intention to have serious illness conversations with patients.

METHODS

The cRT involved 45 primary care practices randomized into a team-based (intervention) or individual clinician-focused (comparator) training program and measured primary outcomes at the patient level: days at home and goals of care. To perform this theory-informed mixed-methods process evaluation embedded within the cRT, a different outcome was measured at the level of the PHCPs, namely, PHCPs' intention to have serious illness conversations with patients as measured with CPD-Reaction. Barriers and facilitators to implementing the conversations were identified through open-ended questions and analyzed using the Theoretical Domains Framework. The COM-B framework was used to triangulate data. Results were reported using the CONSORT and GRAMMS reporting guidelines.

RESULTS

Of 535 PHCPs from 45 practices, 373 (69.7%) fully completed CPD-Reaction (30.8% between 25-34 years old; 78.0% women; 54.2% had a doctoral degree; 50.1% were primary care physicians). Mean intention scores for the team-based (n = 223) and individual clinician-focused arms (n = 150) were 5.97 (standard error (SE): 0.11) and 6.42 (SE: 0.13), respectively. Mean difference between arms was 0.0 (95% CI -0.29; 0.30; p = 0.99) after adjusting for age, education and profession. The team-based arm reported barriers with communication, workflow, and more discomfort in having serious illness conversations with patients.

CONCLUSIONS

Team-based training did not outperform individual clinician-focused in influencing PHCPs' intention to have serious illness conversations. This process evaluation suggests that team-based training could improve intervention effectiveness by focusing on interprofessional communication, better organized workflows, and better support and training for non-clinician team members. Registration: ClinicalTrials.gov (ID: NCT03577002).

Facilitated Versus Patient-Directed Advance Care Planning Among Patients With Advanced Cancer: A Randomized Clinical Trial

PURPOSE

Guidelines recommend advance care planning (ACP) to improve patient-centered care near the end of life (EOL), but the optimal approach is unknown. This single-blind, patient-level, randomized comparative effectiveness trial compared two patient-facing ACP interventions that are widely used but differ in costs and complexity.

METHODS

Adult patients with advanced solid tumors and their caregivers were recruited from academic and community oncology clinics. Participants were randomly assigned to facilitated ACP using trained nurse facilitators versus patient-directed ACP using written and web-based tools. The primary outcome was patient-reported ACP engagement (assessed at baseline and 12 weeks using a 15-item validated survey; range, 0-5; higher scores indicate higher engagement). Secondary outcomes included advance directive completion and communication about EOL wishes.

RESULTS

A total of 400 patients enrolled (mean [SD] age, 67.9 [10.5] years; 192 women [48%]). At 12 weeks, patients in the facilitated versus patient-directed group reported higher ACP engagement (4.34 [0.78] v 4.08 [0.82]; adjusted mean difference, 0.25 [95% CI, 0.1 to 0.4]; P = .0014) and higher odds of completing an advance directive (74.8% v 60.6%; OR, 2.52 [95% CI, 1.27 to 5.0]; P = .008). There were no significant differences between the facilitated and patient-directed groups in the odds of having a conversation about EOL wishes with family or friends (88.9% v 88%; OR, 1.13 [95% CI, 0.5 to 2.6]; P = .76) or physicians (49.6% v 40.6%; OR, 1.53 [95% CI, 0.9 to 2.7]; P = .13), and all ACP behaviors increased significantly from baseline in both groups.

CONCLUSION

Facilitated ACP resulted in greater increases in ACP engagement and advance directive completion than patient-directed written and web-based materials. Although some patients with advanced cancer may engage in self-directed ACP, some may need additional facilitator support.

Advance Care Planning Before and After In-Hospital Cardiac Arrest

Objective: In-hospital cardiac arrest (IHCA) is a common event with high morbidity and mortality. This study seeks to evaluate advance care planning (ACP) among hospitalized patients who experienced IHCA. Design: Single center retrospective cohort study. Measurement and Main Results: The primary objective was to compare whether certain clinical characteristics are associated with a physician's likelihood of having an ACP discussion with patients who subsequently have IHCA. We found that older age, White race, and higher GO-FAR score were associated with increased ACP documentation. In multivariate regression modeling, numerically higher GO-FAR score, ICU patients, hospitalization for ≥7 days, and having a normal mental status were consistently associated with ACP documentation (OR ∼2 for all). There was a persistent trend, significant in some models, to lower likelihood of ACP documentation for non-White patients. Among patients who had predicted low-to-very low likelihood of IHCA survival, most (56%) had no ACP documentation prior to IHCA. Conclusions: We found that the factors associated with an increased likelihood of ACP were age, ICU location, longer LOS prior to IHCA, higher GO-FAR score and normal mental status before IHCA. There was a worrying trend toward lower rates of ACP documentation among non-White patients. The overall rate of completion of ACP was low in patients with poor predicted IHCA outcomes. Ongoing efforts should continue to engage all patients in ACP irrespective of demographics, and there may be a role for utilizing standardized prognostication models to encourage ACP.

Integration of Psychiatric Advance Directives Into the Patient-Accessible Electronic Health Record: Exploring the Promise and Limitations

Psychiatric advance directives (PAD), also known as advance statements or advance choice documents, are legal documents that enable people with mental health conditions to specify their treatment preferences in advance for possible future crises. Subtypes of PADs include crisis cards, joint crisis plans, and self-binding directives (also known as Ulysses contracts). These instruments are intended to improve service user involvement and need orientation in the care of mental crises and to avoid traumatization through unwanted treatment. The existing evidence suggests that people who complete a PAD tend to work more cooperatively with their clinician and experience fewer involuntary hospital admissions. Nevertheless, PADs have not been successfully mainstreamed into care due to multiple barriers to the implementation of PADs, mainly around the completion of PADs and their accessibility and use in crises. The reasons for this include the lack of support in the completion process and acceptance problems, especially on the part of professionals. The research to date primarily recommends support for service users from facilitators, such as peer support workers, and training for all stakeholders. In this article, we argue that while these approaches can help to solve completion and acceptance challenges, they are not sufficient to ensure access to PADs in crises. To ensure accessibility, we propose digital PADs, which offer considerable potential for overcoming these aforementioned barriers. Embedded in national health data infrastructures, PADs could be completed and accessed by service users themselves, possibly with the support of facilitators, and retrieved by any clinic in an emergency. We highlight the strengths and limitations of digital PADs and point out that the proposed solutions must be developed collaboratively and take into account digital inequalities to be effective support for people with serious mental health conditions.

Coming to terms with dying: Advance care planning as a conduit between clinicians, patients, and conversations about death and dying - a qualitative interview study

BACKGROUND

Advance care planning discussions exploring future care and support needs can be beneficial to people with advanced illness. While research has focussed on barriers, outcomes, and completion, little is known about how discussions influence thoughts, feelings, and behaviours.

AIM

To explore experiences of advance care planning for people with incurable life-limiting illnesses, to understand the impact of discussions on individuals, and factors influencing psychological responses.

DESIGN

Semi-structured qualitative interviews were conducted. Data were analysed using framework analysis. Reflexive journalling and discussion of coding framework and themes supported rigour.

SETTING/PARTICIPANTS

Twenty purposively sampled adults receiving hospice care, aged 30-93 with cancer (n = 15) and non-cancer (n = 5) diagnoses were interviewed.

RESULTS

Advance care planning elicits multiple complex thoughts, emotions, and behaviours, with responses ranging from the procedural to the profound. Discussions empowered and instilled confidence, promoted openness with relatives, encouraged people to make the most of their time remaining, and sometimes contributed to coming to terms with their mortality. Factors influencing experiences of discussions reflected the complexity and diversity in participants' lives, personalities, and life experiences, with discussions exposing the realities of living with terminal illness.

CONCLUSION

Individuals' unique lives and experiences shape their responses to, and the impact of advance care planning on how they think, feel and behave. Advance care planning is not simply a means to document end-of-life care preferences, but can empower and instil confidence in patients, and may form part of the process of coming to terms with mortality, allowing clinicians to shift focus from process-related outcomes.

Prognostic Awareness and Knowledge of Acute Exacerbation in Patients Dying with Interstitial Lung Disease: A Nationwide Survey

Rationale: Accurate prognostic awareness (PA) and knowledge of the disease are critical for decision-making regarding treatment options, advance care planning, and end-of-life care. However, they have not been investigated in patients with interstitial lung disease (ILD). Objectives: To determine the prevalence of patients with ILD who have accurate PA and/or knowledge of acute exacerbation and whether accurate PA is associated with end-of-life medical interventions and quality of dying and death. Methods: Through a nationwide bereavement survey, we examined the prevalence of accurate PA and knowledge of acute exacerbation (AE) in patients with ILD who died in acute general hospitals between January 2018 and February 2020. Patients' PA and knowledge were assessed from the perspective of the bereaved. We also quantified the quality of dying and death from the perspective of the bereaved using three scales-the Good Death Inventory, the Quality of Dying and Death questionnaire, and the single-item Quality of Dying and Death overall score-and obtained information on end-of-life interventions from the electronic medical record. We examined the associations of accurate PA with end-of-life interventions and quality of dying and death. Results: A total of 296 patients whose caregivers completed questionnaires were analyzed. One hundred sixty-three patients (55.1%; 95% confidence interval [CI], 49.2-60.8%) who died of ILD had accurate PA, and 138 (46.9%; 95% CI, 41.1-52.8%) recognized that their disease could have AE. Multivariate regression analysis showed that accurate PA was associated with significantly fewer intensive care unit deaths (odds ratio, 0.28; 95% CI, 0.10-0.82; P = 0.02). Patients with accurate PA had better quality of dying and death on all three scales. Conclusions: Approximately half of the patients who died of ILD did not recognize that their disease could lead to death or AE. The lower number of intensive care unit deaths and better quality of dying and death in patients with accurate PA suggest the potential benefits of obtaining accurate PA in patients with ILD.

Chronic obstructive pulmonary disease: A narrative synthesis of its hallmarks for palliative care clinicians

Chronic obstructive pulmonary disease (COPD) is a life-limiting condition and the third leading cause of death worldwide. People with COPD experience physical and psychological symptoms and functional limitations that impair their quality of life. Their caregivers face adverse clinical outcomes due to personal, social, and financial demands. As such, recent emphasis has been placed on early referral to palliative care services to enhance prognostic awareness, clarify goals of care, and manage symptoms. In this narrative synthesis of key aspects of COPD care, we propose practical, evidence-based strategies to integrate palliative care principles with conventional disease-directed treatments throughout the illness trajectory. We emphasize the importance of equipping clinicians caring for people with COPD with a thorough understanding of both the inherent disease complexities and the cornerstones of its multimodal management, including palliative care, to address the unique psychosocial and physical needs of this patient population.

Development of an Interprofessional Clinician Training in Pediatric Serious Illness Communication

Background: Early advance care planning (ACP) is associated with improved outcomes in pediatrics, yet few rigorously developed curricula exist to train interprofessional clinicians in ACP communication. Objectives: To develop, pilot and evaluate an evidence-based virtual clinician training in a pediatric serious illness communication program (PediSICP) to facilitate ACP. Primary outcomes were learner self-assessment of skills attainment and training program satisfaction. Methods: We developed an interactive, skills-based three-hour synchronous online clinician training program using Kern's Six-Step Curriculum Design, incorporating didactic and simulated patient encounters with a trained actor. Specific, measurable cognitive and behavioral learning objectives were to improve knowledge of the evidence-based benefits of ACP, to describe the PediSICP framework, and to improve practice by demonstrating a simulated ACP conversation using a goals and values approach. Sub-objectives include responding to emotion and sharing prognosis using "wish/worry" statements. Results: We conducted 10 virtual trainings from April to December 2021, each with 2-8 participants (n = 40), including 27 physicians, 7 nurse practitioners, 5 nurses, and 1 respiratory therapist from critical care, cardiology, pulmonary, and complex care; 62.5% reported no prior formal ACP communication training. Following training, 97% of participants were highly satisfied with training quality, and 100% endorsed that they would recommend it to colleagues. Additionally, clinician self-reported comfort discussing fundamental elements of ACP significantly increased following the training. Conclusion: Teaching ACP communication virtually to pediatric interprofessional clinicians is both feasible and acceptable, with improvements described in self-reported knowledge and comfort discussing elements of ACP. Future research will test the efficacy of PediSICP to facilitate longitudinal ACP.

Experiences of using the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) in English general practice: a qualitative study among key primary health and social care professionals, patients, and their relatives

BACKGROUND

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) has been implemented in many areas of the UK. It is unclear how ReSPECT is used in primary and community care settings.

AIM

To investigate how the ReSPECT process is understood and experienced in the community by clinicians, social care staff, patients, their relatives, and identify obstacles and enablers to its implementation.

DESIGN AND SETTING

A qualitative interview and focus-group study across 13 general practices in three areas of England, between January and December 2022.

METHOD

We interviewed GPs, specialist nurses, patients and relatives, and senior care home staff. Focus groups were conducted with community nurses, paramedics, and home care workers. Questions focused on understanding experiences of, and engagement with, ReSPECT. We analysed data using thematic analysis and a coding framework drawn from normalisation process theory.

RESULTS

Participants included n = 21 GPs, n = 5 specialist nurses, n = 9 patients, n = 7 relatives, n = 31 care home staff, n = 9 community nurses, n = 7 home care workers, and n = 2 paramedics. Participants supported ReSPECT, regarding it as a tool to facilitate person-centred care. GPs faced challenges in timing the introduction of ReSPECT and ensuring sufficient time to complete plans with patients. ReSPECT conversations worked best when there was a trusting relationship between the clinician and the patient (and their family). Anticipating future illness trajectories was difficult, yet plans were rarely reviewed. Interpreting recommendations in emergencies was challenging.

CONCLUSION

The ReSPECT process has not translated as well as expected in the community setting. A revised approach is needed to address the challenges of implementation in this context.

Fragmented care in lupus: Patient experiences and insights

Background

Systemic lupus erythematosus (SLE) is a complex autoimmune disease requiring interprofessional collaborative care because of its varied manifestations. This study explores the experiences of individuals living with SLE regarding the communication and collaboration among their healthcare providers.

Objectives

This study aimed to explore the communication dynamics that shape treatment experiences and well-being in SLE care.

Method

A qualitative multiple case study design was used, with thematic analysis of semi-structured interviews from six people living with SLE.

Results

Three primary themes emerged: the necessity of cohesive healthcare teams, the centrality of client-centred care and the significant challenges posed by fragmented healthcare systems.

Conclusion

The study highlights the need for integrated care models to enhance communication and coordination among healthcare providers.

Contribution

This research adds empirical insights into the communication dynamics within medical teams managing SLE, advocating for client-centred and systemic improvements in care coordination.

Advance Care Planning in Palliative Care in Asia: Barriers and Implications

Advance care planning (ACP) in palliative care is essential for patient autonomy and quality of dying. This review explores ACP practices in South Korea, Japan, and Taiwan, highlighting how legislation and cultural values shape those practices. In these three sectors, which are influenced by Confucian values, family involvement plays a significant role in decision-making. In South Korea, the Life-Sustaining Treatment Decisions Act made ACP processes mandatory at all healthcare institutions and rapidly created advance directive registration agencies nationwide, with a national web-based system for legal documentation. The Act's narrow focus on terminal illness and dying phase may inadvertently delay end-of-life discussions. A broader social consensus is needed to allocate end-of-life care resources in a way that reflects patients' and families' wishes. Japan's family-based approach highlights relational autonomy, with ACP timing varying and no formal legal frameworks for advance directives. Expanded palliative care, ACP guidelines, systemic support, and public awareness drive progress in Japan. Taiwan's two relevant legislative frameworks-the Hospice Palliative Care Act and Patient Right to Autonomy Act-expand palliative care services for terminal illnesses and non-cancer diseases such as severe dementia, irreversible coma, and a persistent vegetative state. Misunderstandings of ACP and family-led decision-making may hinder ACP uptake. ACP referral based on patient care needs rather than terminal diagnoses is suggested. Overcoming common barriers in Asia necessitates open dialogues about death and public education. A standardized legal framework and comprehensive training for healthcare providers are equally important. Further international collaboration will suggest culturally sensitive ACP conversations across Asia.

Mortality Review Committee: Understanding Inpatient and 30-Day Mortality at a Comprehensive Cancer Center

Background: The Triple Aim of health care involves the simultaneous pursuit of improving the individual experience of care, population health, and reducing per capita costs of care. Our institution established a Mortality Review Committee (MRC) to review instances of inpatient mortality as part of continuing quality improvement with the goal of improving goal concordant care. In this article, we report the experience of MRC. Measures/Interventions: In April 2022, an MRC was formed to evaluate inpatient and 30-day hospital mortality mortalities at our institution. The committee was formed with representation across the entire medical staff. The primary feature of each review was to characterize if the episode of care surrounding the mortality had a learning and/or improvement opportunity associated with the episode of care. Opportunities included improvements in documentation, communication between patients and/or care team, medically futile treatments or procedures, and consideration of interventions, adverse medical and surgical complications. Results: Patients with goals of care (GOC) discussion or palliative care visit prior to admission were significantly less likely to have a learning opportunity (29% vs. 51%, p < 0.001) and (37% vs. 48%, p < 0.001), respectively. The frequency of GOC conversations remained stable throughout the course of this intervention, although an increase in hospice referrals ensued. Discussion: The MRC promoted open conversation across an interdisciplinary team to understand how the health system could have better served patients who experienced hospital associated mortality. These meetings frequently gravitated toward documentation and communication with a particular focus on earlier GOC discussions and shared decision making across a patient's disease course. Our MRC committee has helped foster a cultural shift of the integration of advanced care/end of life planning at earlier stages of patients' treatment courses.

Culturally Adapted RN-MD Collaborative SICP-Based ACP: Feasibility RCT in Advanced Cancer Patients

CONTEXT

Cultural adaptation is essential for optimizing programs centered around autonomy, such as the Serious Illness Care Program (SICP), especially for populations valuing family-involved decision-making.

OBJECTIVES

We aimed to evaluate the feasibility and efficacy of a culturally adapted SICP-based nurse-physician collaborative Advance Care Planning (ACP) intervention tailored for patients with advanced cancer who prefer family-involved decision-making.

METHODS

Oncology nurses, extensively trained and closely collaborating with physicians, conducted structured discussions with patients in the intervention group. The culturally adapted SICP-based ACP intervention was supplemented with trust-building, family involvement, and understanding of patient values. Primary inclusion criteria included patients within six weeks of initiating first-line palliative chemotherapy. Primary endpoints were achieving a 70% completion rate and assessing spiritual well-being (FACIT-Sp) at six months. Secondary endpoints included anxiety (GAD-7), depression (PHQ-9), quality of life (QOL) (CoQoLo), and ACP progress (ACP Engagement Scale) at the same interval.

RESULTS

Forty-one patients (67.2%) completed the six-month follow-up, falling short of the targeted completion rate. The least-squares mean change from baseline in spiritual well-being at six months was 3.00 in the intervention group and -2.22 in the standard care group (difference, 5.22 points; 95% confidence interval, 1.38-9.06; P = 0.009). Similar superiority of the intervention was observed in QOL and ACP progress.

CONCLUSION

Despite not meeting the targeted completion rate, the intervention group demonstrated enhanced spiritual well-being, QOL, and ACP progress. Our findings suggest revisions to the intervention manual to improve feasibility and to progress to an efficacy-focused randomized controlled trial.

Cross-disciplinary advance care planning in oncology and palliative care amidst a pandemic: a best practice implementation project

INTRODUCTION

Advance care planning (ACP) ensures that patients receive medical care aligned with their values, goals, and preferences, especially regarding end-of-life decisions in serious chronic illnesses.

OBJECTIVE

This project aimed to introduce and promote evidence-based ACP in oncology and palliative care at a midsized hospital near Berlin, Germany, during the COVID-19 pandemic.

METHODS

This project was guided by the JBI Evidence Implementation Framework and used a mixed methods audit cycle. A baseline audit was conducted using qualitative interviews and workshops with representatives from all the health care disciplines involved in oncology and palliative care at the hospital. The findings were compared with eight best practice recommendations. Targeted strategies aimed at the key stakeholders involved in ACP practice were then implemented. Finally, a semi-quantitative questionnaire was used in a follow-up audit with the same participants as in the baseline audit.

RESULTS

The baseline audit revealed a high level of familiarity with the concept of ACP. However, there was a lack of a uniformly accepted definition and understanding of ACP among the health care professionals, leading to a lack of coordination in task distribution. The follow-up audit revealed improvements with regard to education and training in ACP (Criterion 1: 50% to 100%) and organizational support to facilitate ACP conversations (Criterion 3: 87.5% to 100%). Other audit criteria compliance rates remained unchanged.

CONCLUSION

Clinical education and team-based process analysis can facilitate ACP implementation across disciplines in oncology and palliative care facilities. However, the project did not succeed in implementing lasting changes in clinical processes and best practice ACP due to the COVID-19 pandemic. Such an endeavor would demand considerable resources and time, both of which were constrained during the pandemic.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A236.

Sharing health care wishes among older adults with cognitive impairment in primary care: Results from a randomized controlled trial

INTRODUCTION

Best practices for conducting advance care planning (ACP) among persons with cognitive impairment exist, but evidence-based models are lacking for the primary care setting.

METHODS

We tested a remote multicomponent ACP model (SHARE) versus minimally enhanced usual care in 273 person-family dyads from eight primary care practices.

RESULTS

Mean patient age was 88.0 years, 85 (31.1%) were Black/Latino; 189 (69.2%) had moderate-to-severe cognitive impairment. Most (101/145; 69.6%) intervention dyads engaged in ACP. At follow-up, no treatment effect was observed for care partner-reported quality of communication about end-of-life care at 6 or 12 months, but intervention patients reported better quality of communication about end-of-life care at 12 months. Intervention care partners and patients reported greater readiness to engage in ACP at 6 and 12 months, respectively, and increased completion of key aspects of ACP.

DISCUSSION

SHARE supported key aspects of ACP processes and communication about end-of-life care.

HIGHLIGHTS

Primary care-based models of ACP for persons with dementia are lacking. Involving persons with cognitive impairment in remote ACP is feasible with care partner involvement. Results indicate benefit for aspects of ACP processes and communication about end-of-life care.

Promoting serious illness conversations in primary care through telehealth among persons living with cognitive impairment

BACKGROUND

serious illness conversations (SIC), particularly for persons living with cognitive impairment (PLCI), inconsistently happen in primary care. Pragmatic, scalable strategies are needed to promote SIC for PLCI.

DESIGN

Pragmatic, prospective single-arm pilot study that occurred between July 1, 2021 and May 30, 2022 across seven primary care practices in North Carolina.

PARTICIPANTS

Community-dwelling patients aged 65 and older with known or probable mild cognitive impairment or dementia (with decision-making capacity) and their care partners (if available).

INTERVENTION

SIC telehealth intervention (TeleVoice) via video or telephone to assist PLCI in discussing their current goals, values, and future medical preferences, while facilitating documentation within the EHR.

MAIN OUTCOMES

Main feasibility outcomes included reach/enrollment, intervention completion, and adoption rates at the clinic and provider level. Primary effectiveness outcomes included SIC documentation and quality within the EHR and usage of advance care planning billing (ACP) codes.

RESULTS

Of the 163 eligible PLCI approached, 107 (66%) enrolled (mean age 83.7 years, 68.2% female, 16.8% Black, 22% living in a geographic area of high socioeconomic disadvantage) and 81 (76%) completed the SIC telehealth intervention; 45 care partners agreed to participate (mean age 71.5 years, 80% female). Adoption at clinic level was 50%, while 75% of providers within these clinics participated. Among PLCI that completed the intervention, SIC documentation and usage of ACP billing codes was 100% and 96%, respectively, with 96% (n = 78) having high-quality SIC documentation. No significant differences were observed between telephone and video visits.

CONCLUSION

These findings provide preliminary evidence to support the feasibility of conducting SICs through telehealth to specifically meet the needs of community-dwelling PLCI. Further investigation of the sustainability of the intervention and its long-term impact on patient and caregiver outcomes is needed.

Acknowledgement and use of advance care directives and goals of care by emergency department staff: a mixed method post intervention study

INTRODUCTION

Advance Care Planning (ACP) refers to a process that includes Advance Care Directives (ACD) and Goals of Care (GOC), a practice widely used for over three decades. Following the findings of an audit and a cross-sectional study in 2019 and 2021 respectively, we implemented several educational and other interventional strategies aimed at enhancing staff awareness and emphasizing the importance of recognizing and documenting of ACD/GOC. The aim of this study was to evaluate the acknowledgement and use of ACD and GOC by Emergency Department (ED) staff following these interventions.

METHOD

We used a mixed methods approach, incorporating both observational and cross-sectional designs with reflexive thematic analysis. Data extraction for the observational study took place between 1st April and 30th June 2023 focusing on a target population of randomly sampled adults aged ≥ 65 years. Demographics and other ACD and GOC related patients' clinical data were collected. Data collection for the cross-sectional study occurred between 19th July and 13th September 2023 targeting all ED staff. Information gathered included demographics, awareness about ACD and GOC, including storage location and implementation, as well as knowledge of Medical Treatment decision Makers (MTDM), a jurisdictional term identifying a person legally appointed to make healthcare decisions on behalf of someone who lacks decision-making capacity and other Victorian State legislative requirements were collected.

RESULTS

In the observational period, 22,335 patients attended the ED and 19% (n = 6546) qualified for inclusion from which a sample of 308 patients were randomly extracted. We found ACD documents were noted in the medical records of 6.5% of the sample, fewer than 8% identified in our previous study. There was no correlation between ACD record availability and age (p = 0.054; CI ranging from - 0.065 to 7.768). The response rate for the cross-sectional survey was 12% (n = 340) in contrast to earlier study with 28% (n = 476) respondents. Staff knowledge and familiarity with ACD was 25% and GOC 45%.

CONCLUSION

After implementing interventions in staff education and ACP awareness, we found that ACD documentation did not improve. However, GOC documentation increased in the context of heightened institutional awareness and integration into the Electronic Medical Records (EMR).

A Survey of State Correctional Health Care Providers on Advance Care Planning: Opportunity for Collaboration With Corrections

Prison populations are rapidly aging. Persons in prison age quicker and suffer more chronic illness and disability than their nonincarcerated peers, posing challenges to caring for prisoners who are chronically ill and dying. The goal of our study was to describe state prisons' practices and policies addressing persons in prison with advanced chronic and life limiting illness through a national web-based survey of state-level prison health care professionals. In particular, we focused on advanced care planning, use of health care directives, decision-making about goals of care, including life sustaining treatments, The response rate was 22% for a sample size 152 completed surveys. The average age of respondent was 52 years; majority were female and Caucasian, and had worked in corrections more than 8 years. Nearly half were registered nurses. Most reported their prison did not have a dedicated end-of-life care program and only 11% offered a peer-care program. However, two-thirds indicated their facility provided the opportunity to designate a health care agent with physicians most likely responsible for facilitating completion of a health care directive. It is evident the care of persons aging and dying in prison is complex and requires further investigation addressing staff and prison population education, ethics guidelines for care, compassionate release, and advance care planning. This study suggests that hospice and palliative care professionals could collaborate with corrections professionals and national organizations to provide innovative education and support to enhance the humane care of this vulnerable population.

The Sowers of Seeds: A Qualitative Analysis of the Role of Palliative Care Educators in Facilitating Goals-of-Care Conversations and Palliative Care Referrals

BACKGROUND

Optimal care for seriously ill and older patients often involves advance care planning (ACP), goals-of-care (GOC) conversations, and specialty palliative care consultation, three sometimes overlapping, yet distinct practices. Insufficient staffing and investment in these areas have limited their availability.

OBJECTIVES

We explored the facilitators and barriers to successful implementation of the VIDEO-PCE trial. The intervention aimed to increase patient engagement in ACP, GOC, and by establishing Palliative Care Educators, a new clinical role integrated into existing hospital wards.

DESIGN

This qualitative interview study employed a semi-structured interview guide tailored to the interviewee's clinical role. The interviews elicited perceptions of the facilitators and barriers to integration of palliative care educators (PCEs) into existing workflows. We developed deductive codes a priori and inductive codes as we coded interview transcripts.

SETTING/SUBJECTS

Medical/surgical floor clinical colleagues, palliative care team members, and PCEs from both participating sites were interviewed.

RESULTS

Twenty-four individuals were interviewed (12 clinical staff of medical and surgical wards, seven palliative care team members, and five PCEs). Four themes were identified: (1) The work completed by the PCEs provided a foundation for future palliative care involvement; (2) Constituting the new role in practice required revision and creativity; (3) Communication was important to providing continuity of care; and (4) Establishing trust catalyzed the acceptance of the role.

CONCLUSION

The creation and implementation of a new role within existing clinical workflows posed some challenges but were felt to relieve staff from some work burden and allow more patients to engage in ACP and GOC conversations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04857060.

Natural Language Processing to Identify Home Health Care Patients at Risk for Becoming Incapacitated With No Evident Advance Directives or Surrogates

OBJECTIVES

Home health care patients who are at risk for becoming Incapacitated with No Evident Advance Directives or Surrogates (INEADS) may benefit from timely intervention to assist them with advance care planning. This study aimed to develop natural language processing algorithms for identifying home care patients who do not have advance directives, family members, or close social contacts who can serve as surrogate decision-makers in the event that they lose decisional capacity.

DESIGN

Cross-sectional study of electronic health records.

SETTING AND PARTICIPANTS

Patients receiving post-acute care discharge services from a large home health agency in New York City in 2019 (n = 45,390 enrollment episodes).

METHODS

We developed a natural language processing algorithm for identifying information documented in free-text clinical notes (n = 1,429,030 notes) related to 4 categories: evidence of close relationships, evidence of advance directives, evidence suggesting lack of close relationships, and evidence suggesting lack of advance directives. We validated the algorithm against Gold Standard clinician review for 50 patients (n = 314 notes) to calculate precision, recall, and F-score.

RESULTS

Algorithm performance for identifying text related to the 4 categories was excellent (average F-score = 0.91), with the best results for "evidence of close relationships" (F-score = 0.99) and the worst results for "evidence of advance directives" (F-score = 0.86). The algorithm identified 22% of all clinical notes (313,290 of 1,429,030) as having text related to 1 or more categories. More than 98% of enrollment episodes (48,164 of 49,141) included at least 1 clinical note containing text related to 1 or more categories.

CONCLUSIONS AND IMPLICATIONS

This study establishes the feasibility of creating an automated screening algorithm to aid home health care agencies with identifying patients at risk of becoming INEADS. This screening algorithm can be applied as part of a multipronged approach to facilitate clinician support for advance care planning with patients at risk of becoming INEADS.

Top Ten Tips Palliative Care Clinicians Should Know About End-of-Life Doulas

Palliative care has made great strides in improving the lives of people living with serious illness, with an empirical premise for increasing quality, and sometimes quantity of life. Yet in some cases, there exist gaps that impede the ability of palliative care clinicians to truly advocate, procure, and provide the comprehensive services needed for patients, family caregivers, and communities, particularly in the contexts of caring for marginalized populations and working in under-resourced practice settings. The end-of-life doula role has emerged over the last decade and the availability of trained doulas in the community has burgeoned. An end-of-life doula is a nonmedical, holistic support person who provides education, guidance, emotional, spiritual, and practical support to persons and families navigating serious and terminal illness, ideally early in the disease process, throughout the time surrounding death, and during bereavement. A pervasive Western culture of avoiding the subject of death means that we, as a society, often do not know or remember how to navigate the journey of end of life in a way that is caring, compassionate, skilled, holistic, and centered on the needs and worldview of the dying one. The ten tips provided here can guide palliative care clinicians to leverage collaboration with trusted, community-based end-of-life doulas to ensure comprehensive and people-centered palliative care.

Content Analysis of Serious Illness Conversation Documentation: Structured vs. Free-Text Information

CONTEXT

Clear, accessible, and thorough documentation of serious illness conversations helps ensure that critical information patients share with clinicians is reflected in their future care.

OBJECTIVES

We sought to characterize and compare serious illness conversations recorded two different ways in the electronic health record to better understand patterns of serious illness conversation documentation.

METHODS

We performed content analysis of serious illness conversations documented in the electronic health record, whether documented via structured tab or free-text clinical notes, for patients (n=150) with advanced cancer who started a treatment associated with a poor prognosis between October 2020 and June 2022. A multidisciplinary team iteratively developed a codebook to classify serious illness conversation content (e.g., goals/hopes) on a preliminary sample (n=30), and two researchers performed mixed deductive-inductive coding on the remaining data (n=120). We reviewed documentation from 34 patients with serious illness conversations documentation in the structured tab only, 43 with documentation in only free-text clinical notes, and 44 with documentation of both types. We then compared content between documentation types.

RESULTS

Information documented more frequently in structured tabs included fears/worries and illness understanding; clinical notes more often included treatment preferences, deliberations surrounding advance directives, function, and trade-offs. Qualitative insights highlight a range of length and detail across documentation types, and suggest notable authorship by palliative and social work clinicians.

CONCLUSION

How serious illness conversations are documented in the electronic health record may impact the content captured. Future quality improvement efforts should seek to consolidate documentation sources to improve care and information retention.

Readiness for advance care planning and related factors in the general population: a cross sectional study in Iran

CONTEXT

Advance Care Planning (ACP), as a process for expressing and recording patients' preferences about end-of-life care, has received increasing attention in recent years. However, implementing ACP has been challenging in Iran.

OBJECTIVES

To assess the readiness for advance care planning and related factors in the general population of Iran.

METHODS

This cross-sectional study was conducted on the general population of Iran in 2022. The data was collected using demographic information questionnaire and The RACP Scale. The purpose and methodology of the research was explained to all participants, and upon their agreement an informed consent was obtained. Participants were invited to fill out the questionnaires wherever is more convenient for them, either alone or if needed, with the help of the researcher to protect their privacy. Chi-square, fisher exact test and multiple logistic Regression model were used to assess the effective factors on the RACP. The data were analyzed by SPSS software version 26.

RESULTS

A total of 641 people with an average age of 36.85 ± 12.05 years participated in this study. Of those, 377 (58.8%) had high RACP. The logistics model showed an association between the chance of readiness for receiving ACP with participants' education level, such that the chance of readiness in those with Master's or Ph.D. degrees was three times higher than those with a diploma (p = 0.00, OR:3.178(1.672, 6.043)). However, the chances of readiness in those with bachelor's degrees was not significantly different from those with a diploma (p = 0.936, OR: 0.984 (0.654, 1.479)). Moreover, the chance of readiness was 1.5 higher in participants over 40 years of age compared with participants under the age of 40 (P = 0.01, OR: 1.571(1.10, 2.23)).

CONCLUSION

According to the findings of this study, it can be concluded that there is a relatively RACP among people in Iranian society. The readiness of individuals for ACP increases by their age and education level. Therefore, by holding appropriate training intervention, we can increase the readiness of the public for ACP to improve their end-of-life outcome.

Experiences with implementing advance care planning (ACP-GP) in Belgian general practice in the context of a cluster RCT: a process evaluation using the RE-AIM framework

BACKGROUND

General practice is often recommended as an ideal setting to initiate advance care planning (ACP), but uptake of ACP in this setting is low. ACP-GP is a complex intervention to facilitate ACP for patients with chronic, life-limiting illness in Belgian general practice. It aims to increase patient ACP engagement and general practitioner (GP) ACP self-efficacy. In a cluster-randomized controlled trial, the intervention was not superior to control in increasing these outcomes. A parallel process evaluation aimed to enhance understanding of how the intervention was implemented, and which factors might have influenced trial results.

METHODS

We conducted a mixed-methods process evaluation following the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data sources include recruitment and implementation monitoring, questionnaires for patients and GPs, and semi-structured (focus group) interviews with patients and GPs. Questionnaire data were analyzed descriptively. Qualitative data were first analyzed inductively; themes were then assigned deductively to RE-AIM dimensions.

RESULTS

Thirty-five GPs and 95 patients were recruited to the trial; GP reach was low. Sixteen GPs and 46 patients provided questionnaire data at 3 months post-baseline; qualitative data were transcribed for 14 GPs and 11 patients. Adoption of intervention components was moderate to good, with the exception of the documentation template for GPs. Interviews revealed varying patient attitudes towards ACP, but patients nonetheless emphasized that conversations made them feel reassured. GPs especially valued a positive framing of ACP. When adopted, the intervention was well-implemented and participant satisfaction was high. However, intention for maintenance was moderate, with GPs raising questions of how to sustainably implement ACP conversations in the future.

CONCLUSIONS

Implementing the complex ACP-GP intervention in general practice is feasible, and can be successful. However, the implementation process is challenging and the sustainability is suboptimal. Our findings will guide future research and recommendations for facilitating and implementing ACP in general practice.

TRIAL REGISTRATION

ISRCTN12995230; prospectively registered on 19/06/2020.

Effect of a person-centred goals-of-care form and clinical communication training on shared decision-making and outcomes in an acute hospital: a prospective longitudinal interventional study

BACKGROUND

Patients with a life-limiting illness (LLI) requiring hospitalisation have a high likelihood of deterioration and 12-month mortality. To avoid non-aligned care, we need to understand our patients' goals and values.

AIM

To describe the association between the implementation of a shared decision-making (SDM) programme and documentation of goals of care (GoC) for hospitalised patients with LLI.

METHODS

A prospective longitudinal interventional study of patients admitted to acute general medicine wards in an Australian tertiary hospital over 5 years was conducted. A SDM programme with a new GoC form, communication training and clinical support was implemented. The primary outcome was the proportion of patients with a documented person-centred GoC discussion (PCD). Clinical outcomes included hospital utilisation and 90-day mortality.

RESULTS

1343 patients were included. The proportion of patients with PCDs increased from 0% to 35.4% (adjusted odds ratio (aOR), 2.38; 95% confidence interval (CI), 2.01-2.82; P < 0.001). During this time, median hospital length of stay decreased from 8 days (interquartile range (IQR), 4-14) to 6 days (IQR, 3-11) (adjusted estimate effect, -0.38; 95% CI, -0.64 to -0.11; P = 0.005) and rapid response team activation from 28% to 13% (aOR, 0.87; 95% CI, 0.78-0.97; P value = 0.01). Documented treatment preference of high-dependency unit care decreased from 39.7% to 24.4% (aOR, 0.81; 95% CI, 0.73-0.89; P value < 0.001), and ward-based care increased from 31.9% to 55.1% (aOR, 1.24; 95% CI, 1.14-1.36; P value < 0.001).

CONCLUSION

The implementation of a SDM programme was associated with increased documentation of person-centred GoC, changed patient treatment preference to lower intensity care and reduced hospital utilisation.

Feasibility of a Serious Illness Communication Program for Pediatric Advance Care Planning

Importance

Pediatric advance care planning (ACP), which aims to ensure care is aligned with family goals and values, is associated with better end-of-life outcomes; however, ACP in pediatrics remains uncommon.

Objectives

To determine the feasibility and acceptability of the Pediatric Serious Illness Communication Program (PediSICP) and explore family-centered outcomes.

Design, Setting, and Participants

This cohort study was a single-group pilot study of the PediSICP in adolescents and young adults (AYAs; age ≥13 y) with serious illness, parents of seriously ill children, and interprofessional clinicians from April 2021 to March 2023 in a quaternary care pediatric hospital. Duration of follow-up was 1 month. Data were analyzed from January 2022 to March 2023.

Exposure

The PediSICP includes clinician training preceding an ACP communication occasion supported by communication guides and a template for electronic medical record documentation.

Main Outcomes and Measures

Outcomes of interest were parent, patient, and clinician experiences with and perceptions of the PediSICP. Feasibility was defined a priori as at least 70% clinician intervention completion rates.

Results

A total of 10 virtual trainings were conducted among 40 clinicians, including 27 physicians, 7 nurse practitioners, 5 nurses, and 1 respiratory therapist, and 30 trained clinicians (75%) conducted and documented 42 ACP conversations with 33 parents (median [IQR] age, 43 [35-51] years; 25 [76%] female) and 5 AYAs (median [IQR] age, 19 [17-19] years; 3 [60%] female) who completed the intervention. The median (IQR) conversation duration was 27 (10-45) minutes. Most clinicians (29 clinicians [97%]) agreed that they felt prepared for the conversation, and all clinicians recommended the PediSICP. Parents reported participation was worthwhile (27 parents [84%]), they felt listened to (31 parents [94%]), and would recommend the PediSICP (28 parents [85%]). Parents endorsed higher therapeutic alliance after the PediSICP intervention compared with before (The Human Connection scale mean [SD] score, 57.6 [6.4] vs 55.3 [7.8]; P = .03) and decreased anxiety immediately after the intervention (Generalized Anxiety Disorder-7-item mean [SD] score, 10.1 [7.3] vs 8.4 [6.9]; P = .003), which persisted at the 1-month follow-up (mean [SD] score, 7.7 [6.8]; P = .03).

Conclusions and Relevance

This pilot cohort study found that the PediSICP was feasible, acceptable, and highly valued by clinicians and parents of children with serious illness. These findings suggest that the PediSICP may empower interprofessional clinicians and improve ACP with families of children and AYAs who are seriously ill.

Development and perception of surgery-specific goals of care discussions in the preoperative setting: A learning pilot

BACKGROUND

Goals of care discussions are infrequently documented in the preoperative period. Furthermore, documentation does not consistently address what matters most to patients, although patient values (PV) are central to person-centered care.

METHODS

A multidisciplinary working group was formed. An electronic note comprised of (1) topics of discussion, (2) PV, and (3) advance care planning (ACP), was created and embedded into existing note templates for Gynecologic Surgical Oncology. Surgeons and advanced practice providers (APPs) were educated to conduct and document these conversations in preoperative clinic for patients undergoing cancer surgery for a pilot period. Data were collected regarding usage of the template. Focus groups with surgeons, APPs, and patients were conducted. Qualitative analysis was performed on transcripts.

RESULTS

During the pilot, 7 surgeon/APP teams utilized the template on a total of 55 notes. Average number of notes completed per surgeon was 7.8 (SD 8.5). Forty-six notes (84%) included topics of discussion, 15 (27%) included PV, 4 (7%) included ACP. Qualitative analysis of focus group transcripts revealed that clinicians and patients perceived the initiative to be useful and important, although implementation barriers were identified.

CONCLUSION

Creating a surgery-specific GOC template is feasible. Iterative revisions are needed to increase utility in clinic workflows.

Co-designing strategies to improve advance care planning among people from culturally and linguistically diverse backgrounds with cancer: iCanCarePlan study protocol

BACKGROUND

Advance care planning (ACP) describes the process of supporting individuals at any age or stage of health to consider and share their personal values, life goals, and preferences regarding future health care. Engaging in ACP is associated with better-quality of care in which people receive care in lines with their wishes, values and preferences. Direct translations of ACP guides and resources do not attend to the considerable inter- and intra-ethnic variations in cultural and religious or spiritual beliefs that shape preferences among people from culturally and linguistically diverse (CALD) backgrounds. ICanCarePlan is a three-year project that aims to determine the prevalence of ACP documentation among people from CALD backgrounds with cancer, identify resources available and their use to support ACP among CALD communities, identify barriers and facilitators of person-centred ACP, and to develop, through co-design with consumers and clinicians, approaches that enhance the process ACP for people from CALD backgrounds.

METHOD

A mixed-method sequential approach will be used comprising of four studies. Study one is retrospective medical record review of approximately 1500 medical records to establish the prevalence of ACP documentation among CALD patient records in cancer services. Study two is a document analysis synthesising the resources available in the Australian health system to support ACP. Study three is a qualitative study with healthcare staff and consumers to explore barriers and enablers of person-centred ACP. Evidence generated from studies one to three will inform the conduct of co-design with stakeholders to develop approaches to improve ACP processes among CALD communities. Language, technical and financial support for meaningful involvement with consumers from CALD backgrounds throughout this project is outlined. A plan for distress management is also made due to sensitive nature of the topic. The research project has also established a project steering group consisting of three consumer members who are from CALD backgrounds.

DISCUSSION

The project will address a national priority issue for a growing population of CALD communities in Australia. The project will provide novel evidence of ACP among CALD communities and novel strategies developed with stakeholders to enhance uptake and experiences of ACP.

Looking Beyond Mortality Prediction: Primary Care Physician Views of Patients' Palliative Care Needs Predicted by a Machine Learning Tool

OBJECTIVES

 To assess primary care physicians' (PCPs) perception of the need for serious illness conversations (SIC) or other palliative care interventions in patients flagged by a machine learning tool for high 1-year mortality risk.

METHODS

 We surveyed PCPs from four Brigham and Women's Hospital primary care practice sites. Multiple mortality prediction algorithms were ensembled to assess adult patients of these PCPs who were either enrolled in the hospital's integrated care management program or had one of several chronic conditions. The patients were classified as high or low risk of 1-year mortality. A blinded survey had PCPs evaluate these patients for palliative care needs. We measured PCP and machine learning tool agreement regarding patients' need for an SIC/elevated risk of mortality.

RESULTS

 Of 66 PCPs, 20 (30.3%) participated in the survey. Out of 312 patients evaluated, 60.6% were female, with a mean (standard deviation [SD]) age of 69.3 (17.5) years, and a mean (SD) Charlson Comorbidity Index of 2.80 (2.89). The machine learning tool identified 162 (51.9%) patients as high risk. Excluding deceased or unfamiliar patients, PCPs felt that an SIC was appropriate for 179 patients; the machine learning tool flagged 123 of these patients as high risk (68.7% concordance). For 105 patients whom PCPs deemed SIC unnecessary, the tool classified 83 as low risk (79.1% concordance). There was substantial agreement between PCPs and the tool (Gwet's agreement coefficient of 0.640).

CONCLUSIONS

 A machine learning mortality prediction tool offers promise as a clinical decision aid, helping clinicians pinpoint patients needing palliative care interventions.

Integrating Palliative Care Into the Management of Genitourinary Malignancies

Palliative care (PC) plays a critical role in managing the difficulties associated with genitourinary malignancies. Its primary aim is to improve the overall health of patients, provide support to both patients and their caregivers, and help individuals to navigate the complex decisions about treatment and end-of-life care. PC takes a holistic approach to patient care, recognizing that genitourinary malignancies affect multiple aspects of a person's life. By addressing physical, emotional, social, and spiritual needs, PC aims to provide comprehensive support that is consistent with the patient's values and preferences. The goal is to optimize comfort, minimize distress, and enhance the patient's quality of life throughout the course of the illness. PC is not a one-off intervention, but an ongoing source of support. This article aims to provide a thorough overview of the critical elements involved in addressing the challenges posed by genitourinary cancers, emphasizing the importance of palliative interventions. We will highlight the multifaceted aspects of care and explore strategies to optimize the overall well-being of patients throughout the course of treatment for genitourinary malignancies.

The PACT Project: Feasibility of a Multidisciplinary, Multi-Faceted Intervention to Promote Goals of Care Conversations

BACKGROUND

Patients living with serious illness generally want their physicians to facilitate Goals of Care conversations (GoCc), yet physicians may lack time and skills to engage in these conversations in the outpatient setting. The problem may be addressed by supporting multiple members of the clinical team to facilitate GoCc with the patient while admitted to the hospital.

METHODS

A multi-modal training and mentored implementation program was developed. A group of 10 hospitals were recruited to participate. Each hospital selected a primary inpatient unit on which to start the intervention, then expanded to a secondary unit later in the project. The number of trained facilitators (champions) and the number of documented GoCc were tracked over time.

RESULTS

Nine of 10 hospitals completed the 3-year project. Most of the units were general medical-surgical units. Forty-eight champions were trained at the kick-off conference, attended primarily by nurses, physicians, and social workers. By the end of the project, 153 champions had been trained. A total of 51 087 patients were admitted to PACT units with 85.4% being screened for eligibility. Of the patients who were eligible, over 68% had documented GoCc.

CONCLUSION

A multifaceted quality improvement intervention focused on serious illness communication skills can support a diverse clinical workforce to facilitate inpatient GoCc over time.

What Clinicians and Researchers Should Know About the Evolving Field of Advance Care Planning: a Narrative Review

Advance care planning (ACP) has been recognized as crucial by patients, families, and clinicians; however, different definitions and measurements have led to inconsistencies in practice and mixed evidence in the literature. This narrative review explores ACP's evolution, innovations, and outcomes using thematic analysis to synthesize data from randomized controlled trials, reviews, and editorials. Key findings include (1) ACP has evolved over the past several decades from a sole focus on code status and advance directive (AD) forms to a continuum of care planning over the life course focused on tailored preparation for patients and surrogate decision-makers and (2) ACP measurement has evolved from traditional outcome metrics, such as AD completion, to a comprehensive outcomes framework that includes behavior change theory, systems, implementation science, and a focus on surrogate outcomes. Since the recent development of an ACP consensus definition and outcomes framework, high-quality trials have reported mainly positive outcomes for interventions, especially for surrogates, which aligns with the patient desire to relieve decision-making burden for loved ones. Additionally, measurement of "clinically meaningful" ACP information, including documented goals of care discussions, is increasingly being integrated into electronic health records (EHR), and emerging, real-time assessments and natural language processing are enhancing ACP evaluation. To make things easier for patients, families, and care teams, clinicians and researchers can use and disseminate these evolved definitions; provide patients validated, easy-to-use tools that prime patients for conversations and decrease health disparities; use easy-to-access clinician training and simple scripts for interdisciplinary team members; and document patients' values and preferences in the medical record to capture clinically meaningful ACP so this information is available at the point of care. Future efforts should focus on efficient implementation, expanded reimbursement options, and seamless integration of EHR documentation to ensure ACP's continued evolution to better serve patients and their care partners.

Adolescents and young adults with cancer conversations following participation in an advance care planning video pilot

PURPOSE

Advance care planning (ACP) discussions can help adolescents and young adults (AYAs) communicate their preferences to their caregivers and clinical team, yet little is known about willingness to hold conversations, content, and evolution of care preferences. We aimed to assess change in care preferences and reasons for such changes over time and examine the reasons for engaging or not engaging in ACP discussions and content of these discussions among AYAs and their caregivers.

METHODS

We conducted a pilot randomized controlled trial of a novel video-based ACP tool among AYA patients aged 18-39 with advanced cancer and their caregivers. Participants were asked their care preferences at baseline, after viewing the video or hearing verbal description (post questionnaire), and again 3 months later. Three-month phone calls also queried if any ACP conversations occurred since the initial study visit. Study team notes from these phone calls were evaluated using content analysis.

RESULTS

Forty-five AYAs and 40 caregivers completed the 3-month follow-up. Nearly half of AYAs and caregivers changed their care preference from post questionnaire to 3-month follow-up. Increased reflection and learning on the topic (n = 45) prompted preference change, with participants often noting the nuanced and context-specific nature of these decisions (n = 20). Most AYAs (60%) and caregivers (65%) engaged in ACP conversation(s), often with a family member. Disease-related factors (n = 8), study participation (n = 8), and a desire for shared understanding (n = 6) were common reasons for initiating discussions. Barriers included disease status (n = 14) and timing (n = 12). ACP discussions focused on both specific wishes for treatment (n = 26) and general conversations about goals and values (n = 18).

CONCLUSION

AYAs and caregivers acknowledged the complexity of ACP decisions, identifying obstacles and aids for these discussions. Clinicians should support a personalized approach to ACP that captures these nuances, promoting ACP as an iterative, longitudinal, and collaborative process.

TRIAL REGISTRATION

This trial was registered 10/31/2019 with ClinicalTrials.gov (Identifier: NCT0414907).

Adaptive Care Planning: A paradigm shift

A key challenge of implementing advance care planning lies in the fact that decisions made in advance require patients and their family members to imagine what their clinical picture will look like rather than knowing or experiencing the clinical circumstances as they unfold. Even more important is the acknowledgment of the unpredictability of a given clinical course. This type of situation requires adaptiveness and flexibility in decision-making that frequently occurs in the moment(s) triggered by changes in health state(s). We describe an alternative frameshifting approach called "Adaptive Care Planning (AdaptCP)," which features an evolving communication between physicians and patients/families with ongoing incorporation of the patient's/family's perspective. This process continues iteratively until each decision can be reached in a way that is both harmonious with the patient's/family's perspective and is consistent with medical treatment options that are actionable for the healthcare team. We include a table of tools drawn from the literature that can help clinicians when implementing AdaptCP.

Patient preferences in geriatric wards, a survey of health care professionals' practice, experience and attitudes

PURPOSE

We aimed to identify whether health care professionals (HCP) examine their patient and next-of-kin preferences, and to study whether medical decisions follow these preferences.

METHOD

A cross-sectional web-based survey was conducted with multidisciplinary HCP from 12 geriatric wards in the South-Eastern Norway Regional Health Authority.

RESULTS

Of the 289 HCPs responding (response rate 61%), mean age 37.8 years (SD 11.3), 235 (81.3%) women, 12.4 (SD 9.6) years of experience and 67 (23.2%) medical doctors, only half report clarifying patients' preferences. The majority reported that they did not inform, involve and treat in line with such preferences. However, 53% believe that HCP, patients and next-of-kin should make clinical decisions together.

DISCUSSION

Our findings indicate a lack of engagement in conversation and inclusion of patient preferences when providing health interventions in geriatric wards. Measures for change of culture are needed.

Impact of Advance Care Planning Support on Patients Treated in the Intensive Care Unit After High-Risk Surgery

INTRODUCTION

Efforts to enhance support for advance care planning (ACP) in patients requiring emergency and intensive care are currently being explored. In addition, few studies have reported the effects and impact of support for these patients and their families. The researcher developed a patient decision aid to initiate support for ACP for patients who plan to enter the intensive care unit after surgery and their families. This study aimed to provide ACP support to patients before high-risk surgery and to determine its impact.

METHODS

The study design was qualitative. The participants included 10 patients who were scheduled to be admitted to the intensive care unit after high-risk surgery at an acute-care hospital in Japan, and the patients' families. The researcher used decision aids to implement ACP support before the patients were admitted. Participants were interviewed in a semi-structured manner regarding their experiences and the impact of receiving ACP support after discharge. Interviews were recorded using an integrated circuit recorder, followed by verbatim transcripts. The analysis was performed in a qualitative descriptive manner.

RESULTS

ACP support prior to treatment initiation led patients to think about life-sustaining treatments and consider ideal living. By understanding the risks of treatment, patients can calmly assume complications and discuss their mortality and life after surgery. Patients perceived receiving ACP support as a valuable benefit prior to undergoing treatment in the intensive care unit. After discharge, they wanted to promote shared decision-making among their physicians. On the other hand, family members were more anxious about ACP topics than patients. In addition, the patients and their families felt that it was difficult to discuss their thoughts and wishes regarding ACP before surgery.

CONCLUSION

It is suggested that pretreatment ACP support could serve as an introductory phase for patients anticipating the need for intensive care, allowing them to contemplate their preferences regarding life-sustaining treatment. However, it is difficult for patients and their family members to openly discuss their thoughts on life-sustaining treatment, even if they are aware of the risk of a sudden crisis. Therefore, when patients and their families discuss ACP, the inclusion of healthcare coaching and counseling may be more effective. These measures of ACP support could add to increased family discussions, concordance, and shared decision-making with physicians.

Perspectives of Patients With Relapsed and Refractory Acute Myeloid Leukemia and High-Risk Myelodysplastic Syndrome on Patient-Clinician Communication About Prognosis and the Future

Background

Patients with acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS) experience unpredictable disease trajectories and high prognostic uncertainty, which serve as barriers to patient-clinician communication about prognosis and their values and preferences for the future in the event of worsening health. Little is known about patients' day-to-day lived experiences and how this shapes their willingness to engage in such conversations.

Objectives

To explore participant perspectives on living with their illness and patient-clinician communication about prognosis and the future.

Design

This is a qualitative study using semi-structured interviews.

Setting/Subjects

Patients with relapsed and refractory (R/R) AML and high-risk MDS from a northeastern U.S. cancer center.

Data Collection

Interviews were transcribed verbatim and thematic analysis was used to generate findings.

Results

Of the 14 participants, the mean age was 66 years, 79% were men, 93% were White, married, and had AML. The overarching theme that describes the experience was "Taking One Day at a Time" in a Fog of Uncertainty. Uncertainty was a universal perception related to the challenges for clinicians to predict prognosis. To cope with uncertainty, most participants tried to focus on the present and maintain normality in everyday life. Participants valued encouragement and positivity in patient-clinician communication, however, the majority were not ready to discuss prognosis and the future in the event of worsening health. Of note, 7 of 14 participants died within three months after the interview.

Conclusions

These data describe a unique perspective of patients with R/R AML and high-risk MDS that clinicians could use to enhance communication strategies.

Factors Associated with Antimicrobial Use at the End-Of-Life Among Hospitalized Cancer Patients

Background: Antimicrobials are frequently administered at end-of-life (EOL) and their non-beneficial use may subject patients to unnecessary harms. Studies analyzing factors for antimicrobial prescribing in solid tumor cancer patients at the EOL are lacking. Thus, we aimed to identify factors and patterns associated with antimicrobial use in hospitalized adults with cancer at EOL. Methods: We used a retrospective cohort design to review electronic medical records of terminal hospitalized patients ≥18 years with solid tumors admitted to non-intensive care units in a metropolitan comprehensive cancer center during 2019 and assessed antimicrobial use in the last 7 days of life. Results: Among 633 cancer patients, 59% (n = 376) received antimicrobials (AM+) within the last 7 days of life. AM + patients were older (P = .012), mostly of male gender (55%), and non-Hispanic ethnicity (87%). AM + patients were significantly more likely to have a foreign device, suspected signs of infection, neutropenia, positive blood culture result, documented advance directive; receive laboratory or radiologic testing, and a palliative care or infectious disease consultation (all P < .05). No statistically significant differences were observed in the presence of documented goals of care discussions, or EOL discussions/EOL care orders. Conclusion: Antimicrobial use at the EOL is common in solid tumor cancer patients at the EOL and is associated with increased utilization of invasive interventions. There is an opportunity for infectious disease specialists to build primary palliative care skills and partner with antimicrobial stewardship programs to better advise patients, decision makers, and primary teams on the use of antimicrobials at the EOL.

Perspectives on advance care planning needs of persons with advanced dementia from their surrogates and clinicians

Objectives

This study was designed to understand the experience and needs surrounding advance care planning (ACP) discussions for surrogate decision-makers of persons with advanced dementia (PWAD).

Methods

Semi-structured qualitative interviews based on end-of-life communication models with a convenience sample of 17 clinicians, and 15 surrogates of PWAD. We used a hybrid approach of deductive and inductive thematic analysis.

Results

Two main themes emerged. 1)Deficits in communication: Often surrogates did not fully comprehend the disease trajectory or medical treatments, like the likelihood of pneumonia and use of mechanical ventilation, nor concepts related to ACP, particularly legal documents and orders such as Do Not Hospitalize, which made decision-making challenging as perceived by clinicians. 2)Decision-making conflicts: Clinicians perceived a disconnect between surrogates' understanding of their loved one's preferences and knowing how or when to operationalize them.

Conclusions

Significant gaps in knowledge surrounding disease trajectory and complications, such as pneumonia, and aspects of ACP, exist. These gaps create decision-making challenges for surrogates and clinicians alike.

Innovation

This study assessed both clinicians and surrogate decision-makers' perspectives on communication and decision-making concerning care preferences, goals, and ACP. The study findings from a national cohort can inform decision-support interventions for clinicians and surrogate decision-makers of PWAD.

Patient and Clinician Stakeholder Perspectives on a Patient Portal Questionnaire Eliciting Illness and Treatment Understanding and Core Health-Related Values

Introduction

Person-centered communication is foundational to cancer care. In pilot research, a questionnaire eliciting patients' illness and treatment understanding (ITU) and core health-related values (HRV) through the electronic patient portal demonstrated feasibility, acceptability, and efficacy. The aim of this study was to elicit stakeholder feedback to refine the design of the portal-based intervention, remain end-user centered, and optimize future system-wide integration.

Methods

Between April and June 2023, we purposively sampled patients and clinicians from a previous pilot study to participate in a 20-30-minute semistructured interview about their opinions of and experiences with the portal questionnaire on ITU and HRV. An interdisciplinary coding team used a two-phase rapid analysis to identify themes, subthemes, and illustrative participant quotations.

Results

Fourteen patients (mean age = 68 years) and 12 clinicians participated (total n = 26). Colorectal cancer was the commonest malignancy (64%) among patients. Clinicians were mostly physicians (50%), nurse practitioners (33%), and registered nurses (17%), with two-thirds having >15 years of experience in their specialty. Analysis generated four themes: (1) clinical utility of questionnaire, (2) barriers to questionnaire implementation, (3) considerations and strategies for modifying the questionnaire, and (4) considerations and strategies for questionnaire implementation. Themes captured key information about incorporating this questionnaire into clinical practice.

Conclusion

Patients with cancer and their clinicians found a portal-based ITU and HRV questionnaire clinically useful to improve multiple aspects of person-centered communication. Participant recommendations about questionnaire timing and sharing of questionnaire responses with the clinical team will inform future questionnaire implementation and scaling in clinical settings.

Evaluating the pragmatic characteristics of advance care planning outcome measures in dementia clinical trials: A scoping review

BACKGROUND

Advance care planning (ACP) is a process that involves discussing a person's goals, values, and preferences; it is particularly important for persons living with dementia (PLWD) given that dementia is incurable and progressive. To ensure results that will impact real-world practices, ACP outcome measures must be psychometrically strong, meaningful to key partners, and pragmatic to collect. Therefore, we conducted a scoping review of outcome measures utilized in ACP randomized controlled clinical trials (RCTs) enrolling PLWD or their care partners and evaluated their pragmatic characteristics.

METHODS

We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for peer-reviewed ACP RCTs enrolling PLWD or their care partners from 2011 to 2021. We abstracted characteristics of primary and secondary outcome measures, including pragmatic characteristics using an adapted Psychometric and Pragmatic Evidence Rating Scale and ACP outcome domains using the standardized ACP Outcome Framework (i.e., process, action, healthcare, or quality of care).

RESULTS

We included 21 ACP RCTs. Trials included 103 outcome measures (39 primary and 64 secondary), of which 11% measured process, 14% measured action, 49% measured healthcare, and 26% measured quality of care. Twenty-four (23%) outcome measures were highly pragmatic, the majority of which (67%) reflected healthcare outcome measures. Sixty-one (59%) outcomes were assessed as highly relevant to PLWD or their care partners. Only 20% (n = 21) of outcome measures were embedded into clinical practice. Most (62%) RCTs were conducted in nursing homes, and 33% were focused PLWD with advanced stage disease.

CONCLUSIONS

In RCTs testing ACP interventions to support PLWD, only 23% of outcome measures were highly pragmatic, and most of these measured healthcare utilizations. Outcome assessments were rarely integrated into the EHR during routine clinical care. New outcome measures that address the lived experience of PLWD and their care partners plus have high pragmatic characteristics are needed for embedded pragmatic clinical trials.

Quality and Satisfaction With Advance Care Planning Conversations Among English- and Spanish-Speaking Older Adults

Background: Little is known about the patient-reported quality of and satisfaction with advance care planning (ACP) conversations with surrogates and clinicians among English- and Spanish-speaking older adults, or the potential disparities associated with ACP communication satisfaction. Objectives: To determine patients' perceived quality of and satisfaction with ACP surrogate/clinician conversations and associated patient characteristics. Design: Cross-sectional baseline data were used from two ACP trials, 2013-2017. Outcomes included self-reported ACP conversation quality ("general" vs. "detailed") and communication satisfaction (5-point Likert scale). Associations were determined by chi-squared and t-tests. Setting/Subjects: Subjects were primary care patients ≥55 years with chronic/serious illness in the United States. Results: Of 1398 patients, mean age was 65.6 years (±7.7), 46% women, 32% Spanish speaking, 34% had limited health literacy, and 589 (42%) reported conversations with surrogates and 216 (15%) with clinicians. Of these, less than half rated the conversations as detailed high quality (clinician: 43%; surrogate: 37%). Five-point communication satisfaction scores were higher with detailed versus general conversations (e.g., surrogates: 4.4 vs. 4.1, p = 0.001; clinicians: 4.4 vs. 4.2, p = 0.18) and more often reported by men versus women [(4.4 (0.8) vs. 4.0 (1.0), p = 0.003]; those with adequate versus limited health literacy [4.4 (0.8) vs. 4.0 (0.9), p = 0.002]; and English versus Spanish speakers [4.5 (0.7) vs. 3.5 (0.9), p < 0.001]. Conclusions: Among English- and Spanish-speaking older adults, ACP conversations were infrequent and most were general in quality. Higher quality detailed conversations resulted in greater communication satisfaction. Interventions are needed to improve conversation quality, particularly for Spanish-speaking patients and those with limited health literacy. Trial Registrations: ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941.

Factors and Barriers to Goals-of-Care Conversations for Patients With Cancer and Inpatient Mortality

PURPOSE

Conversations about personal values and goals of care (GOC) at the end of life are essential in caring for patients with advanced cancer. However, GOC conversations may be influenced by patient and oncologist factors during transitions of care.

METHODS

We electronically administered surveys to medical oncologists of inpatients who died from May 1, 2020, to May 31, 2021. Primary outcomes included oncologists' knowledge of inpatient death, anticipation of patient death, and recollection of GOC discussions. Secondary outcomes, including GOC documentation and advance directives (ADs), were collected retrospectively from electronic health records. Outcomes were analyzed for association with patient, oncologist, and patient-oncologist relationship factors.

RESULTS

For 75 patients who died, 104/158 (66%) surveys were completed by 40 inpatient and 64 outpatient oncologists. Eighty-one oncologists (77.9%) were aware of patients' deaths, 68 (65.4%) anticipated patients' deaths within 6 months, and 67 (64.4%) recalled having GOC discussions before or during the terminal hospitalization. Outpatient oncologists were more likely to report knowledge of patient death (P < .001), as were those with longer therapeutic relationships (P < .001). Inpatient oncologists were more likely to correctly anticipate patient death (P = .014). Secondary outcomes revealed 21.3% of patients had documented GOC discussions before admission and 33.3% had ADs; patients with a longer duration of cancer diagnosis were more likely to have ADs (P = .003). Oncologist-reported barriers to GOC included unrealistic expectations from patients or family (25%) and decreased patient participation because of clinical conditions (15%).

CONCLUSION

Most oncologists recalled having GOC discussions for patients with inpatient mortality, yet documentation of serious illness conversations remained suboptimal. Further studies are needed to examine barriers to GOC conversations and documentation during transitions of care and across health care settings.

Development and Evaluation of Serious Illness Conversation Training for Interprofessional Primary Care Teams

Background: Early advance care planning (ACP) conversations are essential to deliver patient-centered care. While primary care is an ideal setting to initiate ACP, such as Serious Illness Conversations (SICs), many barriers exist to implement such conversations in routine practice. An interprofessional team approach holds promises to address barriers. Objective: To develop and evaluate SIC training for interprofessional primary care teams (IP-SIC). Design: An existing SIC training was adapted for IP-SIC and then implemented and evaluated for acceptability and effectiveness. Setting/Context: Interprofessional teams in 15 primary care clinics in five US states. Measures: Acceptability of the IP-SIC training and participants' self-reported likelihood to engage in ACP after the training. Results: The 156 participants were a mix of physicians and advanced practice providers (APPs) (44%), nurses and social workers (31%), and others (25%). More than 90% of all participants rated the IP-SIC training positively. While nurse/social worker and other groups were less likely than physician and APP group to engage in ACP before training (4.4, 3.7, and 6.4 on a 1-10 scale, respectively), all groups showed significant increase in likelihood to engage in ACP after the IP-SIC training (8.5, 7.7, and 9.2, respectively). Both physician/APP and nurse/social worker groups showed significant increase in likelihood to use the SIC Guide after the IP-SIC training, whereas an increase in likelihood to use SIC Guide among other groups was not statistically significant. Conclusion: The new IP-SIC training was well accepted by interprofessional team members and effective to improve their likelihood to engage in ACP. Further research exploring how to facilitate collaboration among interprofessional team members to maximize opportunities for more and better ACP is warranted. ClinicalTrials.gov ID: NCT03577002.

Interventions to Promote End-of-Life Conversations: A Systematic Review and Meta-Analysis

CONTEXT

Although several interventions aimed to promote end-of-life conversations are available, it is unclear whether and how these affect delivery of end-of-life conversations. Measuring the processes associated with high-quality end-of-life care may trigger improvement.

OBJECTIVES

To estimate the effect of interventions aimed to promote end-of-life conversations in clinical encounters with patients with advanced chronic or terminal illness or their family, on process indicators of end-of-life conversations.

METHODS

Systematic review with meta-analysis (PROSPERO no. CRD42021289471). Four databases (PubMed, CINAHL, PsycINFO, and Scopus) were searched up to September 30, 2021. The primary outcomes were any process indicators of end-of-life conversations. Results of pairwise meta-analyses were presented as Risk Ratio (RR) for occurrence, standardized mean difference (SMD) for quality and ratio of means (ROM) for duration. Meta-analysis was not performed when fewer than four studies were available.

RESULTS

A total of 4,663 articles were scanned. Eighteen studies were included in the systematic review and 16 entered at least one meta-analysis: documented occurrence (n = 8), patient-reported occurrence (n = 4), patient-reported-quality (n = 4), duration (n = 4). There was significant variability in settings, patients' clinical conditions, and professionals. No significant effect of interventions on documented occurrence (RR 1.54, 95% CI 0.84-2.84; I2 91%), patient-reported occurrence (RR 1.52, 95% CI 0.80-2.91; I2 95%), patient-reported quality (SMD 0.83, 95% CI -1.06 to 2.71; I2 99%), or duration (ROM 1.20, 95% CI 0.95-1.51; I2 65%) of end-of-life conversations was found. Data on frequency were conflicting. Interventions targeting multiple stakeholders promoted earlier and more comprehensive conversations.

CONCLUSION

Heterogeneity was considerable, but findings suggest no significant effect of interventions on occurrence, patient-reported quality and duration of end-of-life conversations. Nevertheless, we found indications for interventions targeting multiple stakeholders to promote earlier and more comprehensive conversations.