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Lange AV, Mehta AB, Bekelman DB. How Important is Spirometry for Identifying Patients with COPD Appropriate for Palliative Care? J Pain Symptom Manage 2023; 65:e181-e187. [PMID: 36423798 PMCID: PMC10998735 DOI: 10.1016/j.jpainsymman.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Providing palliative care to patients with chronic obstructive pulmonary disease (COPD) is a priority. Spirometry demonstrating airflow limitation is a diagnostic test for COPD and a common inclusion criterion for palliative care research. However, requiring spirometry with airflow limitation may exclude appropriate patients unable to complete spirometry, or patients with preserved-ratio impaired spirometry and symptoms or imaging consistent with COPD. MEASURES To determine differences in quality of life (QOL) and symptoms between patients with COPD identified based on International Classification of Diseases (ICD) codes and spirometry with airflow limitation compared to ICD codes only. INTERVENTION Patients with COPD enrolled in a palliative care trial were included. Patients were at high risk of hospitalization and death and reported poor QOL. Baseline measures of QOL (Functional Assessment of Cancer Therapy-General (FACT-G), the Clinical COPD Questionnaire, and Quality of Life at the End of Life), and symptoms (Patient Health Questionnaire-8, Generalized Anxiety Disorder-7, fatigue, Insomnia Severity Index) were compared. OUTCOMES Two hundred eight patients with COPD were predominantly male, White, and average age was 68.4. Between patients with ICD codes and spirometry with airflow limitation compared to patients with ICD codes only, there were no significant differences in FACT-G (59.0 vs. 55.0, P = 0.33), other measures of QOL, or symptoms between groups. CONCLUSION These results imply that spirometry may not need to be a requirement for inclusion into palliative care research or clinical care for patients with poor quality of life and at high risk for adverse outcomes.
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Affiliation(s)
- Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine (A.L., A.M.); University of Colorado Anschutz Medical Campus; Aurora, Colorado.
| | - Anuj B Mehta
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine (A.L., A.M.); University of Colorado Anschutz Medical Campus; Aurora, Colorado; Division of Pulmonary and Critical Care Medicine, Department of Medicine (A.M.), Denver Health and Hospital Authority; Denver, Colorado
| | - David B Bekelman
- Medical Service (D.B.), Rocky Mountain Regional Veterans Affairs Medical Center; Aurora, Colorado; Denver-Seattle Center of Innovation (D.B.); Rocky Mountain Regional Veterans Affairs Medical Center; Aurora, Colorado; Division of General Internal Medicine, Department of Medicine (D.B.); University of Colorado Anschutz Medical Campus; Aurora, Colorado
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2
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Barradell AC, Singh SJ, Houchen-Wolloff L, Robertson N, Bekker HL. A pulmonary rehabilitation shared decision-making intervention for patients living with COPD: PReSent: protocol for a feasibility study. ERJ Open Res 2022; 8:00645-2021. [PMID: 35677396 PMCID: PMC9168082 DOI: 10.1183/23120541.00645-2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/25/2022] [Indexed: 11/05/2022] Open
Abstract
Background Despite the variety of pulmonary rehabilitation programmes for patients living with COPD, uptake remains low. To improve this, it is recommended that health professionals engage patients in informed decisions about pulmonary rehabilitation. Shared decision-making (SDM) facilitates informed and value-based decision-making between patients and health professionals. This protocol describes the development and evaluation of a complex SDM intervention for patients living with COPD, who are referred for pulmonary rehabilitation, and their pulmonary rehabilitation health professional. Methods and analysis We are developing a complex SDM intervention involving a patient decision aid (PtDA) and a decision coaching workshop. Prior to patient recruitment, pulmonary rehabilitation health professionals will attend the workshop. Upon referral to pulmonary rehabilitation, patients will receive the PtDA to support their decision-making prior to and during their pulmonary rehabilitation assessment with a health professional. The intervention will be evaluated in a one-arm exploratory study to investigate its feasibility and acceptability for patients and health professionals, with an integrated fidelity assessment. The primary outcome is recruitment feasibility, data collection feasibility and intervention fidelity. Secondary outcomes include routine pulmonary rehabilitation data, decisional conflict, patient activation, intervention attendance/attrition and patient and pulmonary rehabilitation health professional experience of the intervention. Quantitative outcomes will be evaluated using the most appropriate statistical test, dependent on the sample distribution. Qualitative outcomes will be evaluated using reflexive thematic analysis. Fidelity will be assessed using the Observer OPTION 5 scale. Conclusion This intervention will provide structure for an informed and values-based decision-making consultation between a patient with COPD and a pulmonary rehabilitation health professional with the potential for optimising pulmonary rehabilitation decision-making.
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Affiliation(s)
- Amy C. Barradell
- Dept of Respiratory Sciences, University of Leicester, Leicester, UK
- Centre for Exercise and Rehabilitation Science, Leicester Biomedical Research Centre-Respiratory, Glenfield Hospital, Leicester, UK
- National Institute for Health Research Applied Research Collaboration (East Midlands), College of Medicine, Biological Sciences and Psychology, Leicester General Hospital, Leicester, UK
| | - Sally J. Singh
- Dept of Respiratory Sciences, University of Leicester, Leicester, UK
- Centre for Exercise and Rehabilitation Science, Leicester Biomedical Research Centre-Respiratory, Glenfield Hospital, Leicester, UK
| | - Linzy Houchen-Wolloff
- Dept of Respiratory Sciences, University of Leicester, Leicester, UK
- Centre for Exercise and Rehabilitation Science, Leicester Biomedical Research Centre-Respiratory, Glenfield Hospital, Leicester, UK
| | - Noelle Robertson
- Dept of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
| | - Hilary L. Bekker
- Leeds Unit of Complex Intervention Development, School of Medicine, University of Leeds, Leeds, UK
- Research Centre for Patient Involvement, Central Denmark Region and Aarhus University, Aarhus, Denmark
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3
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Brown L, Gardner G, Bonner A. A randomized controlled trial testing a decision support intervention for older patients with advanced kidney disease. J Adv Nurs 2019; 75:3032-3044. [DOI: 10.1111/jan.14112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/03/2019] [Accepted: 04/17/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Leanne Brown
- School of Nursing and Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane Qld Australia
| | - Glenn Gardner
- School of Nursing and Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane Qld Australia
| | - Ann Bonner
- School of Nursing and Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane Qld Australia
- Chronic Kidney Disease Centre for Research Excellence University of Queensland Brisbane Qld Australia
- Visiting Research Fellow, Kidney Health Service Metro North Hospital and Health Service Brisbane Qld Australia
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Zhang Y, Morgan RL, Alonso-Coello P, Wiercioch W, Bała MM, Jaeschke RR, Styczeń K, Pardo-Hernandez H, Selva A, Ara Begum H, Morgano GP, Waligóra M, Agarwal A, Ventresca M, Strzebońska K, Wasylewski MT, Blanco-Silvente L, Kerth JL, Wang M, Zhang Y, Narsingam S, Fei Y, Guyatt G, Schünemann HJ. A systematic review of how patients value COPD outcomes. Eur Respir J 2018; 52:13993003.00222-2018. [PMID: 30002103 DOI: 10.1183/13993003.00222-2018] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 05/21/2018] [Indexed: 01/06/2023]
Abstract
Our objective was to summarise systematically all research evidence related to how patients value outcomes in chronic obstructive pulmonary disease (COPD).We conducted a systematic review (systematic review registration number CRD42015015206) by searching PubMed, Embase, PsycInfo and CINAHL, and included reports that assessed the relative importance of outcomes from COPD patients' perspective. Two authors independently determined the eligibility of studies, abstracted the eligible studies and assessed risk of bias. We narratively summarised eligible studies, meta-analysed utilities for individual outcomes and assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach.We included 217 quantitative studies. Investigators most commonly used utility measurements of outcomes (n=136), discrete choice exercises (n=13), probability trade-off (n=4) and forced choice techniques (n=46). Patients rated adverse events as important but on average, less so than symptom relief. Exacerbation and hospitalisation due to exacerbation are the outcomes that COPD patients rate as most important. This systematic review provides a comprehensive registry of related studies.
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Affiliation(s)
- Yuan Zhang
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Rebecca L Morgan
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Pablo Alonso-Coello
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Iberoamerican Cochrane Centre, CIBERESP-IIB Sant Pau, Barcelona, Spain
| | - Wojtek Wiercioch
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Małgorzata M Bała
- Dept of Hygiene and Dietetics, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Rafał R Jaeschke
- Section of Affective Disorders, Dept of Psychiatry, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Styczeń
- Section of Affective Disorders, Dept of Psychiatry, Jagiellonian University Medical College, Krakow, Poland
| | | | - Anna Selva
- Clinical Epidemiology and Cancer Screening, Corporació Sanitària Parc Taulí, Sabadell, Spain.,Research Network on Health Services in Chronic Diseases (REDISSEC), Spain
| | - Housne Ara Begum
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gian Paolo Morgano
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Marcin Waligóra
- REMEDY, Research Ethics in Medicine Study Group, Dept of Philosophy and Bioethics, Jagiellonian University Medical College, Krakow, Poland
| | - Arnav Agarwal
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,School of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew Ventresca
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Karolina Strzebońska
- REMEDY, Research Ethics in Medicine Study Group, Dept of Philosophy and Bioethics, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz T Wasylewski
- REMEDY, Research Ethics in Medicine Study Group, Dept of Philosophy and Bioethics, Jagiellonian University Medical College, Krakow, Poland
| | - Lídia Blanco-Silvente
- TransLab Research Group, Dept of Medical Sciences, University of Girona, Girona, Spain
| | - Janna-Lina Kerth
- Dept for Medical Didactics and Curricular Development, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Mengxiao Wang
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Saiprasad Narsingam
- Dept of Medicine, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Yutong Fei
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Gordon Guyatt
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Dept of Medicine, McMaster University, Hamilton, ON, Canada
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5
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Yoo SH, Yun YH, Kim KN, Lee JL, Park J, Choi YS, Lim YK, Kim S, Jeong HS, Kang JH, Oh HS, Park JC, Kim SY, Song HS, Lee KS, Heo DS, Hong YS. The impact of caregiver’s role preference on decisional conflicts and psychiatric distresses in decision making to help caregiver’s disclosure of terminal disease status. Qual Life Res 2018; 27:1571-1581. [DOI: 10.1007/s11136-018-1814-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 11/28/2022]
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Oczkowski SJ, Chung HO, Hanvey L, Mbuagbaw L, You JJ. Communication Tools for End-of-Life Decision-Making in Ambulatory Care Settings: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0150671. [PMID: 27119571 PMCID: PMC4847908 DOI: 10.1371/journal.pone.0150671] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 02/16/2016] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patients with serious illness, and their families, state that better communication and decision-making with healthcare providers is a high priority to improve the quality of end-of-life care. Numerous communication tools to assist patients, family members, and clinicians in end-of-life decision-making have been published, but their effectiveness remains unclear. OBJECTIVES To determine, amongst adults in ambulatory care settings, the effect of structured communication tools for end-of-life decision-making on completion of advance care planning. METHODS We searched for relevant randomized controlled trials (RCTs) or non-randomized intervention studies in MEDLINE, EMBASE, CINAHL, ERIC, and the Cochrane Database of Randomized Controlled Trials from database inception until July 2014. Two reviewers independently screened articles for eligibility, extracted data, and assessed risk of bias. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the quality of evidence for each of the primary and secondary outcomes. RESULTS Sixty-seven studies, including 46 RCTs, were found. The majority evaluated communication tools in older patients (age >50) with no specific medical condition, but many specifically evaluated populations with cancer, lung, heart, neurologic, or renal disease. Most studies compared the use of communication tools against usual care, but several compared the tools to less-intensive advance care planning tools. The use of structured communication tools increased: the frequency of advance care planning discussions/discussions about advance directives (RR 2.31, 95% CI 1.25-4.26, p = 0.007, low quality evidence) and the completion of advance directives (ADs) (RR 1.92, 95% CI 1.43-2.59, p<0.001, low quality evidence); concordance between AD preferences and subsequent medical orders for use or non-use of life supporting treatment (RR 1.19, 95% CI 1.01-1.39, p = 0.028, very low quality evidence, 1 observational study); and concordance between the care desired and care received by patients (RR 1.17, 95% CI 1.05-1.30, p = 0.004, low quality evidence, 2 RCTs). CONCLUSIONS The use of structured communication tools may increase the frequency of discussions about and completion of advance directives, and concordance between the care desired and the care received by patients. The use of structured communication tools rather than an ad-hoc approach to end-of-life decision-making should be considered, and the selection and implementation of such tools should be tailored to address local needs and context. REGISTRATION PROSPERO CRD42014012913.
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Affiliation(s)
- Simon J. Oczkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| | - Han-Oh Chung
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Louise Hanvey
- Canadian Hospice Palliative Care Association, Ottawa, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - John J. You
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
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7
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Aslakson RA, Schuster ALR, Reardon J, Lynch T, Suarez-Cuervo C, Miller JA, Moldovan R, Johnston F, Anton B, Weiss M, Bridges JFP. Promoting perioperative advance care planning: a systematic review of advance care planning decision aids. J Comp Eff Res 2015; 4:615-50. [PMID: 26346494 DOI: 10.2217/cer.15.43] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This systematic review identifies possible decision aids that promote perioperative advance care planning (ACP) and synthesizes the available evidence regarding their use. Using PubMed, EMBASE, Cochrane, SCOPUS, Web of Science, CINAHL, PsycINFO and Sociological Abstracts, researchers identified and screened articles for eligibility. Data were abstracted and risk of bias assessed for included articles. Thirty-nine of 5327 articles satisfied the eligibility criteria. Primarily completed in outpatient ambulatory populations, studies evaluated a variety of ACP decision aids. None were evaluated in a perioperative population. Fifty unique outcomes were reported with no head-to-head comparisons conducted. Findings are likely generalizable to a perioperative population and can inform development of a perioperative ACP decision aid. Future studies should compare the effectiveness of ACP decision aids.
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Affiliation(s)
- Rebecca A Aslakson
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Anne L R Schuster
- Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 22105, USA
| | - Jessica Reardon
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Thomas Lynch
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Catalina Suarez-Cuervo
- The Johns Hopkins Evidence-based Practice Center, Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Judith A Miller
- Patient/Family Member Co-investigator, Architecture by Design, Ellicott City, MD 21042, USA
| | - Rita Moldovan
- Department of Medicine Nursing, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Fabian Johnston
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Blair Anton
- William H. Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Matthew Weiss
- Department of Surgery, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - John F P Bridges
- Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 22105, USA
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8
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Chiarchiaro J, Ernecoff NC, Buddadhumaruk P, Rak KJ, Arnold RM, White DB. Key stakeholders' perspectives on a Web-based advance care planning tool for advanced lung disease. J Crit Care 2015; 30:1418.e7-1418.e12. [PMID: 26404957 DOI: 10.1016/j.jcrc.2015.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/10/2015] [Accepted: 09/01/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE There is a paucity of scalable advance care planning strategies that achieve the diverse goals of patients, families, and clinicians. We convened key stakeholders to gain their perspectives on developing a Web-based advance care planning tool for lung disease. MATERIALS AND METHODS We conducted semistructured interviews with 50 stakeholders: 21 patients with lung disease, 18 surrogates, and 11 clinicians. Interviews explored stakeholders' desired content and design features of a Web-based advance care planning tool. Participants also rated the tool's acceptability and potential usefulness. We analyzed the interviews with modified grounded theory and validated themes through member checking. RESULTS Stakeholders highly rated the acceptability (median, 5; interquartile range, 5-5) and potential usefulness (median, 5; interquartile range, 4-5) of a Web-based tool. Interviewees offered several suggestions: (1) use videos of medical scenarios and patient narratives rather than text, (2) include interactive content, and (3) allow the user control over how much they complete in 1 sitting. Participants identified challenges and potential solutions, such as how to manage the emotional difficulty of thinking about death and accommodate low computer literacy users. CONCLUSIONS There is strong stakeholder support for the development of a Web-based advance care planning tool for lung disease.
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Affiliation(s)
- Jared Chiarchiaro
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh PA; Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA.
| | - Natalie C Ernecoff
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA
| | - Praewpannarai Buddadhumaruk
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA
| | - Kimberly J Rak
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh PA
| | - Douglas B White
- Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh PA; Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA; Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Austin CA, Mohottige D, Sudore RL, Smith AK, Hanson LC. Tools to Promote Shared Decision Making in Serious Illness: A Systematic Review. JAMA Intern Med 2015; 175:1213-21. [PMID: 25985438 PMCID: PMC4794743 DOI: 10.1001/jamainternmed.2015.1679] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Serious illness impairs function and threatens survival. Patients facing serious illness value shared decision making, yet few decision aids address the needs of this population. OBJECTIVE To perform a systematic review of evidence about decision aids and other exportable tools that promote shared decision making in serious illness, thereby (1) identifying tools relevant to the treatment decisions of seriously ill patients and their caregivers, (2) evaluating the quality of evidence for these tools, and (3) summarizing their effect on outcomes and accessibility for clinicians. EVIDENCE REVIEW We searched PubMed, CINAHL, and PsychInfo from January 1, 1995, through October 31, 2014, and identified additional studies from reference lists and other systematic reviews. Clinical trials with random or nonrandom controls were included if they tested print, video, or web-based tools for advance care planning (ACP) or decision aids for serious illness. We extracted data on the study population, design, results, and risk for bias using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Each tool was evaluated for its effect on patient outcomes and accessibility. FINDINGS Seventeen randomized clinical trials tested decision tools in serious illness. Nearly all the trials were of moderate or high quality and showed that decision tools improve patient knowledge and awareness of treatment choices. The available tools address ACP, palliative care and goals of care communication, feeding options in dementia, lung transplant in cystic fibrosis, and truth telling in terminal cancer. Five randomized clinical trials provided further evidence that decision tools improve ACP documentation, clinical decisions, and treatment received. CONCLUSIONS AND RELEVANCE Clinicians can access and use evidence-based tools to engage seriously ill patients in shared decision making. This field of research is in an early stage; future research is needed to develop novel decision aids for other serious diagnoses and key decisions. Health care delivery organizations should prioritize the use of currently available tools that are evidence based and effective.
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Affiliation(s)
- C Adrian Austin
- Center for Aging and Health, Division of Geriatrics, University of North Carolina, Chapel Hill
| | | | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco4San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco4San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Laura C Hanson
- Center for Aging and Health, Division of Geriatrics, University of North Carolina, Chapel Hill5Palliative Care Program, University of North Carolina, Chapel Hill
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10
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Bereza BG, Troelsgaard Nielsen A, Valgardsson S, Hemels MEH, Einarson TR. Patient preferences in severe COPD and asthma: a comprehensive literature review. Int J Chron Obstruct Pulmon Dis 2015; 10:739-44. [PMID: 25914530 PMCID: PMC4399696 DOI: 10.2147/copd.s82179] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background Management of chronic incurable diseases such as chronic obstructive pulmonary disease (COPD) and asthma is difficult. Incorporation of patient preferences is widely encouraged. Purpose To summarize original research articles determining patient preference in moderate-to-severe disease. Methods Acceptable articles consisted of original research determining preferences for any aspect of care in patients with COPD/asthma. The target population included those with severe disease; however, articles were accepted if they separated outcomes by severity or if the majority had at least moderate-to-severe disease. We also accepted simulation research based on scenarios describing situations involving moderate-to-severe disease that elicited preferences. Two reviewers searched Medline and Embase for articles published from the date of inception of the databases until the end of November 2014, with differences resolved through consensus discussion. Data were tabulated and analyzed descriptively. Results About 478 articles identified, 448 were rejected and 30 analyzed. There were 25 on COPD and five on asthma. Themes identified as most important in COPD were symptom relief (dyspnea/breathlessness), a positive patient–physician relationship, quality-of-life impairments, and information availability. Patients strongly preferred sponsors’ inhalers. At end-of-life, 69% preferred receiving CPR, 70% wanted noninvasive, and 58% invasive mechanical intervention. While patients with asthma preferred treatments that increased symptom-free days, they were willing to trade days without symptoms for a reduction in adverse events and greater convenience. Asthma patients were willing to pay for waking up once and not needing their inhaler over waking up once overnight and needing their inhaler. Conclusion Few studies have examined patient preference in these diseases. More research is needed to fill in knowledge gaps.
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Affiliation(s)
- Basil G Bereza
- Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
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11
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Uhler LM, Pérez Figueroa RE, Dickson M, McCullagh L, Kushniruk A, Monkman H, Witteman HO, Hajizadeh N. InformedTogether: Usability Evaluation of a Web-Based Decision Aid to Facilitate Shared Advance Care Planning for Severe Chronic Obstructive Pulmonary Disease. JMIR Hum Factors 2015; 2:e2. [PMID: 27025896 PMCID: PMC4797670 DOI: 10.2196/humanfactors.3842] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 01/21/2015] [Accepted: 01/21/2015] [Indexed: 11/20/2022] Open
Abstract
Background Advance care planning may help patients receive treatments that better align with their goals for care. We developed a Web-based decision aid called InformedTogether to facilitate shared advance care planning between chronic obstructive pulmonary disease (COPD) patients and their doctors. Objective Our objective was to assess the usability of the InformedTogether decision aid, including whether users could interact with the decision aid to engage in tasks required for shared decision making, whether users found the decision aid acceptable, and implications for redesign. Methods We conducted an observational study with 15 patients and 8 doctors at two ethnically and socioeconomically diverse outpatient clinics. Data included quantitative and qualitative observations of patients and doctors using the decision aid on tablet or laptop computers and data from semistructured interviews. Patients were shown the decision aid by a researcher acting as the doctor. Pulmonary doctors were observed using the decision aid independently and asked to think aloud (ie, verbalize their thoughts). A thematic analysis was implemented to explore key issues related to decision aid usability. Results Although patients and doctors found InformedTogether acceptable and would recommend that doctors use the decision aid with COPD patients, many patients had difficulty understanding the icon arrays that were used to communicate estimated prognoses and could not articulate the definitions of the two treatment choices—Full Code and Do Not Resuscitate (DNR). Minor usability problems regarding content, links, layout, and consistency were also identified and corresponding recommendations were outlined. In particular, participants suggested including more information about potential changes in quality of life resulting from the alternative advance directives. Some doctor participants thought the decision aid was too long and some thought it may cause nervousness among patients due to the topic area. Conclusions A decision aid for shared advance care planning for severe COPD was found acceptable to most COPD patients and their doctors. However, many patient participants did not demonstrate understanding of the treatment options or prognostic estimates. Many participants endorsed the use of the decision aid between doctors and their patients with COPD, although they desired more information about quality of life. The design must optimize comprehensibility, including revising the presentation of statistical information in the icon array, and feasibility of integration into clinical workflow, including shortening the decision aid.
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Affiliation(s)
- Lauren M Uhler
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, North Shore LIJ Health System, Manhasset, NY, United States
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Cox CE, White DB, Abernethy AP. A universal decision support system. Addressing the decision-making needs of patients, families, and clinicians in the setting of critical illness. Am J Respir Crit Care Med 2014; 190:366-73. [PMID: 25019639 DOI: 10.1164/rccm.201404-0728cp] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the setting of a complex critical illness, preference-sensitive decision making-choosing between two or more reasonable treatment options-can be difficult for patients, families, and clinicians alike. A common challenge to making high-quality decisions in this setting is a lack of critical information access and sharing among participants. Decision aids-brochures, web applications, and videos-are a major focus of current research because mounting evidence suggests they can improve decision-making quality and enhance collaborative shared decision making. However, many decision aids have important limitations, including a relatively narrow capacity for personalization, an inability to gather and generate clinical data, a focus on only a single disease or treatment, and high developmental costs. To address these issues and to help guide future research, we propose a model of "universal" electronic decision support that can be easily adapted by clinicians and patients/families for whatever decision is at hand. In this scalable web-based platform, a general shared decision-making core structure would accommodate simple, interchangeable disease and treatment information modules. The format and content of the system could be adapted to decisional participants' unique characteristics, abilities, and needs. Universal decision support can better standardize a decisional approach and also allow a unique degree of personalization within a framework of shared decision making. We also discuss potential criticisms of this approach as well as strategies that can overcome them in a critical illness setting.
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Affiliation(s)
- Christopher E Cox
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine
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Nguyen M, Chamber-Evans J, Joubert A, Drouin I, Ouellet I. Exploring the advance care planning needs of moderately to severely ill people with COPD. Int J Palliat Nurs 2013; 19:389-95. [DOI: 10.12968/ijpn.2013.19.8.389] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marilyse Nguyen
- Médecins Sans Frontières, 1470 Peel, Suite 220, Montréal, Québec, H3A 1T1, Canada
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14
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QUANTITATIVE PATIENT PREFERENCE EVIDENCE FOR HEALTH TECHNOLOGY ASSESSMENT: A CASE STUDY. Int J Technol Assess Health Care 2013; 29:290-300. [DOI: 10.1017/s0266462313000329] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objectives: We conducted a systematic review of quantitative research regarding patients’ preferences, perspectives and values for ventilation among chronic obstructive pulmonary disease (COPD) patients. Our objective was to explore the feasibility and desirability of incorporating patient preferences within the health technology assessment (HTA) process by working through a case study.Methods: Medical and economic databases were searched for studies published in English from 1990 through March 4, 2011. Studies were selected based on title and abstract. Due to the heterogeneity of the studies, data were analyzed using a narrative synthesis approach.Results: Among 1833 identified citations, twelve studies met our inclusion criteria. Ten of these studies pertained to COPD patient preferences for ventilation. Results indicate that a significant proportion of COPD patients are willing to forgo ventilation, particularly when it is expressed as “indefinite life support” (60–78 percent) rather than as temporary modality. Results indicate that patient preferences for mechanical or noninvasive ventilation cannot be predicted by covariates (e.g., age, quality of life) or by others who are frequently called upon to make decisions are their behalf.Conclusions: We found that it is indeed feasible to conduct a systematic review of quantitative preference-related evidence for an HTA topic. However, the process of conducting this preference-related case study also revealed several challenges because there is a high degree of variation in taxonomy, instrumentation, and study design. Therefore, we do not recommend it as a routine part of the HTA process, but we suggest that it is a promising area to pursue for preference-sensitive technological decisions.
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Horton R, Rocker G, Dale A, Young J, Hernandez P, Sinuff T. Implementing a palliative care trial in advanced COPD: a feasibility assessment (the COPD IMPACT study). J Palliat Med 2013; 16:67-73. [PMID: 23317322 DOI: 10.1089/jpm.2012.0285] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Patients and caregivers living with advanced chronic obstructive pulmonary disease (COPD) have complex care needs and may benefit from palliative care intervention. Little is known about how best to implement and evaluate such initiatives. OBJECTIVES To determine the feasibility of: 1) implementing a customized home-based palliative care service for patients and caregivers living with advanced COPD and 2) measuring outcomes of providing such services. DESIGN Single-centre cohort longitudinal observational study. SETTING/SUBJECTS Patients with advanced COPD and their caregivers were followed in their homes for 6 months. MEASUREMENTS Health-related quality of life (HRQoL), caregiver burden, symptom severity, patient/caregiver satisfaction, utilization of acute care services, end-of-life (EOL) outcomes. RESULTS 30 patients and 18 caregivers were enrolled over 33 months. 25 patients (83%) and 14 caregivers (77%) reached our study endpoint. 13 patients (52%) and 5 caregivers (36%) completed outcome measurements at baseline and endpoint. HRQoL, caregiver burden and symptom severity did not change. Palliative care services were welcomed and valued, yet, despite a stated preference to die at home, 16 patients who died within 18 months of study enrollment died in hospital. CONCLUSIONS Providing home-based palliative care services for patients with advanced COPD is feasible but completing repeated questionnaires is impractical. Despite significant palliative supports, managing terminal symptoms exceeded caregivers' capacity to cope and forced hospital admission. Insights into systemic barriers and limitations of current palliative care service models can provide opportunities for local program innovation aimed at improving care for advanced COPD.
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Affiliation(s)
- Robert Horton
- Division of Palliative Medicine, QEII Health Science Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
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Desroches S, Lapointe A, Ratté S, Gravel K, Légaré F, Turcotte S. Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults. Cochrane Database Syst Rev 2013:CD008722. [PMID: 23450587 PMCID: PMC4900876 DOI: 10.1002/14651858.cd008722.pub2] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND It has been recognized that poor adherence can be a serious risk to the health and wellbeing of patients, and greater adherence to dietary advice is a critical component in preventing and managing chronic diseases. OBJECTIVES To assess the effects of interventions for enhancing adherence to dietary advice for preventing and managing chronic diseases in adults. SEARCH METHODS We searched the following electronic databases up to 29 September 2010: The Cochrane Library (issue 9 2010), PubMed, EMBASE (Embase.com), CINAHL (Ebsco) and PsycINFO (PsycNET) with no language restrictions. We also reviewed: a) recent years of relevant conferences, symposium and colloquium proceedings and abstracts; b) web-based registries of clinical trials; and c) the bibliographies of included studies. SELECTION CRITERIA We included randomized controlled trials that evaluated interventions enhancing adherence to dietary advice for preventing and managing chronic diseases in adults. Studies were eligible if the primary outcome was the client's adherence to dietary advice. We defined 'client' as an adult participating in a chronic disease prevention or chronic disease management study involving dietary advice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of the studies. They also assessed the risk of bias and extracted data using a modified version of the Cochrane Consumers and Communication Review Group data extraction template. Any discrepancies in judgement were resolved by discussion and consensus, or with a third review author. Because the studies differed widely with respect to interventions, measures of diet adherence, dietary advice, nature of the chronic diseases and duration of interventions and follow-up, we conducted a qualitative analysis. We classified included studies according to the function of the intervention and present results in a narrative table using vote counting for each category of intervention. MAIN RESULTS We included 38 studies involving 9445 participants. Among studies that measured diet adherence outcomes between an intervention group and a control/usual care group, 32 out of 123 diet adherence outcomes favoured the intervention group, 4 favoured the control group whereas 62 had no significant difference between groups (assessment was impossible for 25 diet adherence outcomes since data and/or statistical analyses needed for comparison between groups were not provided). Interventions shown to improve at least one diet adherence outcome are: telephone follow-up, video, contract, feedback, nutritional tools and more complex interventions including multiple interventions. However, these interventions also shown no difference in some diet adherence outcomes compared to a control/usual care group making inconclusive results about the most effective intervention to enhance dietary advice. The majority of studies reporting a diet adherence outcome favouring the intervention group compared to the control/usual care group in the short-term also reported no significant effect at later time points. Studies investigating interventions such as a group session, individual session, reminders, restriction and behaviour change techniques reported no diet adherence outcome showing a statistically significant difference favouring the intervention group. Finally, studies were generally of short duration and low quality, and adherence measures varied widely. AUTHORS' CONCLUSIONS There is a need for further, long-term, good-quality studies using more standardized and validated measures of adherence to identify the interventions that should be used in practice to enhance adherence to dietary advice in the context of a variety of chronic diseases.
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Affiliation(s)
- Sophie Desroches
- Centre de recherche du Centre hospitalier universitaire de Québec (CHUQ), St-François d’Assise Hôpital, Québec, Canada.
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Matlock DD, Keech TAE, McKenzie MB, Bronsert MR, Nowels CT, Kutner JS. Feasibility and acceptability of a decision aid designed for people facing advanced or terminal illness: a pilot randomized trial. Health Expect 2011; 17:49-59. [PMID: 22032553 DOI: 10.1111/j.1369-7625.2011.00732.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients nearing the end of their lives face an array of difficult decisions. OBJECTIVE This study was designed to assess the feasibility and acceptability of a decision aid (DA) designed for patients facing advanced or terminal illness. DESIGN We conducted a pilot randomized clinical trial of Health Dialog's Looking Ahead: choices for medical care when you're seriously ill DA (booklet and DVD) applied to patients on a hospital-based palliative care (PC) service. SETTING University of Colorado Hospital - December 2009 and May 2010. PARTICIPANTS All adult, English-speaking patients or their decision makers were potentially eligible. Patients were not approached if they were in isolation, did not speak English or if any provider felt that they were not appropriate because of issues such as family conflict or actively dying. INTERVENTION All participants received a standard PC consultation. Participants in the intervention arm also received a copy of the DA. Measurements Primary outcomes included decision conflict and knowledge. Participants in the intervention arm also completed an acceptability questionnaire and qualitative exit interviews. RESULTS Of the 239 patients or decision makers, 51(21%) enrolled in the trial. The DA had no significant effect on decision conflict or knowledge. Exit interviews indicated it was acceptable and empowering, although they wished they had access to the DA earlier. CONCLUSIONS While the DA was acceptable, feasibility was limited by late-life illness challenges. Future trials of this DA should be performed on patients earlier in their illness trajectory and should include additional outcome measures such as self-efficacy and confidence.
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Affiliation(s)
- Dan D Matlock
- Department of Medicine, University of Colorado School of MedicineColorado Health Outcomes Program, University of Colorado School of Medicine, Aurora CO, USA
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Kryworuchko J, Stacey D, Peterson WE, Heyland DK, Graham ID. A qualitative study of family involvement in decisions about life support in the intensive care unit. Am J Hosp Palliat Care 2011; 29:36-46. [PMID: 21737407 DOI: 10.1177/1049909111414176] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We explored family involvement in decisions about life support interventions in the intensive care unit study using a critical incident technique to focus on specific case exemplars contributed by participants. A total of 6 family members and 9 health care professionals were interviewed. Participants described 2 options (life support or comfort care) and values associated with options: maintaining quality of life, surviving critical illness, minimizing pain and suffering, not being attached to machines, needing adjustment time, and judicious health care resource use. Barriers to involvement included not being offered alternative options; no specific trigger to initiate decision making; dominant influence of professionals' values; and families lacking understandable information. Family members are unlikely to engage in decision making unless professionals identify the decision and address other barriers to family involvement.
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Insights into chronic obstructive pulmonary disease patient attitudes on ventilatory support. Curr Opin Pulm Med 2011; 17:98-102. [DOI: 10.1097/mcp.0b013e32834318d3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Reinke LF, Griffith RG, Wolpin S, Donesky-Cuenco D, Carrieri-Kohlman V, Nguyen HQ. Feasibility of a webinar for coaching patients with chronic obstructive pulmonary disease on end-of-life communication. Am J Hosp Palliat Care 2010; 28:147-52. [PMID: 20834035 DOI: 10.1177/1049909110376807] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
RATIONALE Previous research has shown that patients with chronic obstructive pulmonary disease (COPD) desire conversations about end-of-life wishes. However, most clinicians do not initiate these discussions. We explored whether educating patients via Web conferencing (webinar) would equip them with knowledge and skills to engage in conversations about end-of-life care. RESULTS Prewebinar, 6 of the 7 patients had completed advanced care planning forms but only half had shared these with their clinicians. Most patients felt confident about discussing end-of-life preferences. At 3 months, all participants had taken further action on end-of-life planning. Five felt the webinar was an acceptable option if unable to participate in person. All patients voiced that adding a video stream would have promoted interaction in the context of these sensitive conversations. CONCLUSIONS This pilot project demonstrated that a webinar to educate patients on end-of-life communication was acceptable for the majority of patients. Improvements in audio and video bandwidth may facilitate more interaction among virtual participants. This may be particularly useful for patient education on sensitive topics.
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Affiliation(s)
- Lynn F Reinke
- Department of Veterans Affairs, VA Puget Sound Health Care System, Health Services Research & Development, University of Washington, Seattle, WA 98101, USA.
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Vandemheen KL, Aaron SD, Poirier C, Tullis E, O'Connor A. Development of a decision aid for adult cystic fibrosis patients considering referral for lung transplantation. Prog Transplant 2010. [PMID: 20397351 DOI: 10.7182/prtr.20.1.fh22gmm184867021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Most adults with cystic fibrosis are eventually required to make a decision about referral for lung transplantation. OBJECTIVE To identify the decisional needs of these patients and to develop a decision aid to address these needs. METHODS A comprehensive review of the literature, a review of Canadian transplant statistics from 2002 to 2006, and a self-assessment survey of patients who had already made a decision about referral were performed to identify the decisional needs of patients. A decision aid was then developed and evaluated by an expert panel of health care professionals and patients. RESULTS Transplant referral patterns vary widely among Canadian cystic fibrosis clinics. Canadian patients with cystic fibrosis who were not residing in transplant centers between 2002 and 2006 were significantly less likely to undergo lung transplants (P < .001). Decisional needs identified by patients included wanting more information on (1) relocation to the transplant center, (2) the benefits and risks of surgery, and (3) how to cope with anxiety and depression when making the decision. In response to these identified needs, a decision aid for lung transplantation was developed. A panel of health care professionals and patients reviewed the decision aid and agreed that the content was appropriate, easy to understand, and unbiased. CONCLUSION The decisional needs of patients with cystic fibrosis who are considering lung transplantation are not being addressed in Canadian cystic fibrosis clinics, especially in clinics outside of transplant centers. An evidence-based decision aid could serve as a useful tool to help address these needs.
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Vandemheen KL, Aaron SD, Poirier C, Tullis E, O'Connor A. Development of a Decision Aid for Adult Cystic Fibrosis Patients considering Referral for Lung Transplantation. Prog Transplant 2010; 20:81-7. [DOI: 10.1177/152692481002000113] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Context Most adults with cystic fibrosis are eventually required to make a decision about referral for lung transplantation. Objective To identify the decisional needs of these patients and to develop a decision aid to address these needs. Methods A comprehensive review of the literature, a review of Canadian transplant statistics from 2002 to 2006, and a self-assessment survey of patients who had already made a decision about referral were performed to identify the decisional needs of patients. A decision aid was then developed and evaluated by an expert panel of health care professionals and patients. Results Transplant referral patterns vary widely among Canadian cystic fibrosis clinics. Canadian patients with cystic fibrosis who were not residing in transplant centers between 2002 and 2006 were significantly less likely to undergo lung transplants ( P < .001). Decisional needs identified by patients included wanting more information on (1) relocation to the transplant center, (2) the benefits and risks of surgery, and (3) how to cope with anxiety and depression when making the decision. In response to these identified needs, a decision aid for lung transplantation was developed. A panel of health care professionals and patients reviewed the decision aid and agreed that the content was appropriate, easy to understand, and unbiased. Conclusion The decisional needs of patients with cystic fibrosis who are considering lung transplantation are not being addressed in Canadian cystic fibrosis clinics, especially in clinics outside of transplant centers. An evidence-based decision aid could serve as a useful tool to help address these needs.
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Affiliation(s)
- Katherine L. Vandemheen
- The Ottawa Health Research Institute, University of Ottawa, Ontario (KLV, SDA, AO), Centre Hospitalier de l'Universite de Montreal, Quebec (CP), St Michael's Hospital, Toronto, Ontario (ET)
| | - Shawn D. Aaron
- The Ottawa Health Research Institute, University of Ottawa, Ontario (KLV, SDA, AO), Centre Hospitalier de l'Universite de Montreal, Quebec (CP), St Michael's Hospital, Toronto, Ontario (ET)
| | - Charles Poirier
- The Ottawa Health Research Institute, University of Ottawa, Ontario (KLV, SDA, AO), Centre Hospitalier de l'Universite de Montreal, Quebec (CP), St Michael's Hospital, Toronto, Ontario (ET)
| | - Elizabeth Tullis
- The Ottawa Health Research Institute, University of Ottawa, Ontario (KLV, SDA, AO), Centre Hospitalier de l'Universite de Montreal, Quebec (CP), St Michael's Hospital, Toronto, Ontario (ET)
| | - Annette O'Connor
- The Ottawa Health Research Institute, University of Ottawa, Ontario (KLV, SDA, AO), Centre Hospitalier de l'Universite de Montreal, Quebec (CP), St Michael's Hospital, Toronto, Ontario (ET)
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Allen RS, Allen JY, Hilgeman MM, DeCoster J. End-of-life decision-making, decisional conflict, and enhanced information: race effects. J Am Geriatr Soc 2008; 56:1904-9. [PMID: 18775035 DOI: 10.1111/j.1532-5415.2008.01929.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine the effect of enhanced information regarding the risks, benefits, and life-sustaining treatment alternatives on hypothetical medical decisions and decisional conflict in older, community-dwelling Caucasian and African-American adults. DESIGN Two-group (enhanced information; no information) between-subjects design. SETTING Community-based dwellings, two assisted living facilities, and one senior citizen center. PARTICIPANTS Seventy-eight adults (aged 74.5+/-7.18) with a mean Telephone Interview for Cognitive Status--Modified (TICS-m) score of 31.5+/-4.7 were recruited through personal contacts and informational talks held at the recruitment sites. MEASUREMENTS Measures included the Life Support Preferences/Predictions Questionnaire--modified (LSPQ-m); the Decisional Conflict Scale; and enhanced information, including detailed descriptions of life-sustaining treatment options for each LSPQ-m illness scenario, risks of the treatment, benefits of the treatment, and alternatives for each treatment (called medical information stimuli). RESULTS Enhanced information (e.g., medical information stimuli) reduced decisional conflict (P=.049, d=0.47) for hypothetical life-sustaining treatment decisions. A mixed analysis of variance with group and race as between-subjects variables and illness and treatment as within-subjects variables revealed significant main effects of race, illness, and treatment, as well as a significant race-by-illness-by-group interaction (Wilk's lambda=0.923, F(2, 73)=3.05, P=.05, partial eta(2)=0.08). Enhanced information produced different patterns of desire for life-sustaining treatments in African Americans and Caucasians. CONCLUSION Physicians and other healthcare professionals can reduce decisional conflict in patients by providing enhanced information regarding treatment risks, benefits, and alternatives. Such decision aids may provide new information or knowledge and thus reduce desire for treatment in African Americans.
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Affiliation(s)
- Rebecca S Allen
- Department of Psychology, University of Alabama, Tuscaloosa, Alabama 35487-0348, USA
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Nelson WL, Han PKJ, Fagerlin A, Stefanek M, Ubel PA. Rethinking the objectives of decision aids: a call for conceptual clarity. Med Decis Making 2007; 27:609-18. [PMID: 17873251 DOI: 10.1177/0272989x07306780] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Health decision aids are a potentially valuable adjunct to patient-physician communication and decision making. Although the overarching goal of decision aids--to help patients make informed, preference-sensitive choices--is widely accepted, experts do not agree on the means to achieve this end. In this article, the authors critically examine the theoretical basis and appropriateness of 2 widely accepted criteria used to evaluate decision aids: values clarification and reduction of decisional conflict. First, they argue that although clarifying values is central to decision making under uncertainty, it is not clear that decision aids--as they have been conceived and operationalized so far--can and should be used to achieve this goal. The pursuit of clarifying values, particularly values clarification exercises, raises a number of ethical, methodological, and conceptual issues, and the authors suggest research questions that should be addressed before values clarification is routinely endorsed. Second, the authors argue that the goal of reducing decisional conflict is conceptually untenable and propose that it be eliminated as an objective of decision aids.
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Affiliation(s)
- Wendy L Nelson
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA.
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25
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Rocker GM, Sinuff T, Horton R, Hernandez P. Advanced chronic obstructive pulmonary disease: innovative approaches to palliation. J Palliat Med 2007; 10:783-97. [PMID: 17592991 DOI: 10.1089/jpm.2007.9951] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
By the year 2020, chronic obstructive pulmonary disease (COPD) will be the third leading cause of death globally. While there have been consistent calls for increased palliative care involvement in the care of patients with advanced COPD, these calls should be based on empirical evidence that such an approach improves the symptom burden and poor quality of life associated with advanced COPD. Rather than reviewing the traditional treatments of airflow obstruction and palliative measures familiar to the palliative care community, we will focus on some novel approaches to the management of patients with advanced COPD from the perspective of clinicians involved in end of life care provision and research. By combining the clinical and research skills of pulmonologists and palliative medicine specialists we can advance the care of patients with this progressive and incurable disease.
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Affiliation(s)
- Graeme M Rocker
- Division of Respirology, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
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Graham ID, Logan J, Bennett CL, Presseau J, O'Connor AM, Mitchell SL, Tetroe JM, Cranney A, Hebert P, Aaron SD. Physicians' intentions and use of three patient decision aids. BMC Med Inform Decis Mak 2007; 7:20. [PMID: 17617908 PMCID: PMC1931587 DOI: 10.1186/1472-6947-7-20] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Accepted: 07/06/2007] [Indexed: 11/23/2022] Open
Abstract
Background Decision aids are evidence based tools that assist patients in making informed values-based choices and supplement the patient-clinician interaction. While there is evidence to show that decision aids improve key indicators of patients' decision quality, relatively little is known about physicians' acceptance of decision aids or factors that influence their decision to use them. The purpose of this study was to describe physicians' perceptions of three decision aids, their expressed intent to use them, and their subsequent use of them. Methods We conducted a cross-sectional survey of random samples of Canadian respirologists, family physicians, and geriatricians. Three decision aids representing a range of health decisions were evaluated. The survey elicited physicians' opinions on the characteristics of the decision aid and their willingness to use it. Physicians who indicated a strong likelihood of using the decision aid were contacted three months later regarding their actual use of the decision aid. Results Of the 580 eligible physicians, 47% (n = 270) returned completed questionnaires. More than 85% of the respondents felt the decision aid was well developed and that it presented the essential information for decision making in an understandable, balanced, and unbiased manner. A majority of respondents (>80%) also felt that the decision aid would guide patients in a logical way, preparing them to participate in decision making and to reach a decision. Fewer physicians (<60%) felt the decision aid would improve the quality of patient visits or be easily implemented into practice and very few (27%) felt that the decision aid would save time. Physicians' intentions to use the decision aid were related to their comfort with offering it to patients, the decision aid topic, and the perceived ease of implementing it into practice. While 54% of the surveyed physicians indicated they would use the decision aid, less than a third followed through with this intention. Conclusion Despite strong support for the format, content, and quality of patient decision aids, and physicians' stated intentions to adopt them into clinical practice, most did not use them within three months of completing the survey. There is a wide gap between intention and behaviour. Further research is required to study the determinants of this intention-behaviour gap and to develop interventions aimed at barriers to physicians' use of decision aids.
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Affiliation(s)
- Ian D Graham
- Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
- University of Ottawa, Faculty of Health Sciences, Ottawa, ON, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, ON, Canada
| | - Jo Logan
- University of Ottawa, Faculty of Health Sciences, Ottawa, ON, Canada
| | - Carol L Bennett
- Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
| | - Justin Presseau
- Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
| | - Annette M O'Connor
- Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
- University of Ottawa, Faculty of Health Sciences, Ottawa, ON, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, ON, Canada
| | - Susan L Mitchell
- Hebrew Senior Life Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jacqueline M Tetroe
- Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
| | - Ann Cranney
- Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, ON, Canada
- Division of Rheumatology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Paul Hebert
- Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, ON, Canada
| | - Shawn D Aaron
- Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, ON, Canada
- Division of Respiratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada
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Akl EA, Grant BJB, Guyatt GH, Montori VM, Schünemann HJ. A decision aid for COPD patients considering inhaled steroid therapy: development and before and after pilot testing. BMC Med Inform Decis Mak 2007; 7:12. [PMID: 17504536 PMCID: PMC1877801 DOI: 10.1186/1472-6947-7-12] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Accepted: 05/15/2007] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Decision aids (DA) are tools designed to help patients make specific and deliberative choices among disease management options. DAs can improve the quality of decision-making and reduce decisional conflict. An area not covered by a DA is the decision of a patient with chronic obstructive pulmonary disease (COPD) to use inhaled steroids which requires balancing the benefits and downsides of therapy. METHODS We developed a DA for COPD patients considering inhaled steroid therapy using the Ottawa Decision Support Framework, the best available evidence for using inhaled steroid in COPD and the expected utility model. The development process involved patients, pulmonologists, DA developers and decision making experts. We pilot tested the DA with 8 COPD patients who completed an evaluation questionnaire, a knowledge scale, and a validated decisional conflict scale. RESULTS The DA is a computer-based interactive tool incorporating four different decision making models. In the first part, the DA provides information about COPD as a disease, the different treatment options, and the benefits and downsides of using inhaled steroids. In the second part, it coaches the patient in the decision making process through clarifying values and preferences. Patients evaluated 10 out of 13 items of the DA positively and showed significant improvement on both the knowledge scale (p = 0.008) and the decisional conflict scale (p = 0.008). CONCLUSION We have developed a computer-based interactive DA for COPD patients considering inhaled steroids serving as a model for other DAs in COPD, in particular related to inhaled therapies. Future research should assess the DA effectiveness.
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Affiliation(s)
- Elie A Akl
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
- Department of Social & Preventive Medicine, University at Buffalo, Buffalo, NY, USA
| | - Brydon JB Grant
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
- Department of Social & Preventive Medicine, University at Buffalo, Buffalo, NY, USA
- Department of Medicine, VAMC, Buffalo, NY, USA
- Department of Biostatistics, University at Buffalo, Buffalo, NY, USA
- Department of Physiology and Biophysics, University at Buffalo, Buffalo, NY, USA
| | - Gordon H Guyatt
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Victor M Montori
- Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Holger J Schünemann
- INFORMA, Dept. of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy
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Feldman-Stewart D, Brennenstuhl S, McIssac K, Austoker J, Charvet A, Hewitson P, Sepucha KR, Whelan T. A systematic review of information in decision aids. Health Expect 2007; 10:46-61. [PMID: 17324194 PMCID: PMC5060377 DOI: 10.1111/j.1369-7625.2006.00420.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE We completed a systematic review of information reported as included in decision aids (DAs) for adult patients, to determine if it is complete, balanced and accurate. SEARCH STRATEGY DAs were identified using the Cochrane Database of DAs and searches of four electronic databases using the terms: 'decision aid'; shared decision making' and 'patients'; 'multimedia or leaflets or pamphlets or videos and patients and decision making'. Additionally, publications reporting DA development and actual DAs that were reported as publicly available on the Internet were consulted. Publications were included up to May 2006. DATA EXTRACTION Data were extracted on the following variables: external groups consulted in development of the DA, type of study used, categories of information, inclusion of probabilities, use of citation lists and inclusion of patient experiences. MAIN RESULTS 68 treatment DAs and 30 screening DAs were identified. 17% of treatment DAs and 47% of screening DAs did not report any external consultation and, of those that did, DA producers tended to rely more heavily on medical experts than on patients' guidance. Content evaluations showed that (i) treatment DAs frequently omit describing the procedure(s) involved in treatment options and (ii) screening DAs frequently focus on false positives but not false negatives. About 1/2 treatment DAs reported probabilities with a greater emphasis on potential benefits than harms. Similarly, screening DAs were more likely to provide false-positive than false-negative rates. CONCLUSIONS The review led us to be concerned about completeness, balance and accuracy of information included in DAs.
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Affiliation(s)
- Deb Feldman-Stewart
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Canada.
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