1
|
Issa TZ, McCurdy MA, Lee Y, Lambrechts MJ, Sherman MB, Kalra A, Goodman P, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. The Impact of Socioeconomic Status on the Presence of Advance Care Planning Documents in Patients With Acute Cervical Spinal Cord Injury. J Am Acad Orthop Surg 2024; 32:354-361. [PMID: 38271675 DOI: 10.5435/jaaos-d-23-00763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/27/2023] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Patients presenting with spinal cord injury (SCI) often times have notable deficits or polytrauma and may require urgent decision making for early management. However, their presentation may affect decision-making ability. Although advance care planning (ACP) may help guide spine surgeons as to patient preferences, the rate at which they are available and disparities in ACP completion are still not understood. The objective of this study was to evaluate disparities in the completion of ACP among patients with acute SCI. METHODS All patients presenting with cervical SCI to the emergency department at an urban, tertiary level I trauma center from 2010 to 2021 were identified from a prospective database of all consults evaluated by the spine service. Each patient's medical record was reviewed to assess for the presence of ACP documents such as living will, power of attorney, or advance directive. Community-level socioeconomic status was assessed using the Distressed Communities Index. Bivariable and multivariable analyses were performed. RESULTS We identified 424 patients: 104 (24.5%) of whom had ACP. Patients with ACP were older (64.8 versus 56.5 years, P = 0.001), more likely White (78.8% versus 71.9%, P = 0.057), and present with ASIA Impairment Scale grade A SCI (21.2% versus 12.8%, P = 0.054), although the latter two did not reach statistical significance. On multivariable logistic regression, patients residing in at-risk communities were significantly less likely to have ACP documents compared with those in prosperous communities (odds ratio [OR]: 0.29, P = 0.03). Although patients living in distressed communities were less likely to complete ACP compared with those in prosperous communities (OR 0.50, P = 0.066), this did not meet statistical significance. Female patients were also less likely to have ACP (OR: 0.43, P = 0.005). CONCLUSION Female patients and those from at-risk communities are markedly less likely to complete ACP. Attention to possible disparities during admission and ACP discussions may help ensure that patients of all backgrounds have treatment goals documented.
Collapse
Affiliation(s)
- Tariq Z Issa
- From the Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA (Issa, McCurdy, Lee, Sherman, Kalra, Goodman, Canseco, Hilibrand, Vaccaro, Schroeder, and Kepler), the Feinberg School of Medicine, Northwestern University, Chicago, IL (Issa), and the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO (Lambrechts)
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Fischer SM, Min SJ, Kline DM, Lester K, Gozansky W, Schifeling C, Himberger J, Lopez J, Fink RM. Patient Navigator Intervention to Improve Palliative Care Outcomes for Hispanic Patients With Serious Noncancer Illness: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:384-393. [PMID: 38345793 PMCID: PMC10862271 DOI: 10.1001/jamainternmed.2023.8145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/08/2023] [Indexed: 02/15/2024]
Abstract
Importance Disparities persist across the trajectory of serious illness, including at the end of life. Patient navigation has been shown to reduce disparities and improve outcomes for underserved populations. Objective To determine the effectiveness of a lay patient navigator intervention, Apoyo con Cariño, in improving palliative care outcomes among Hispanic patients. Design, Setting, and Participants This was a multicenter randomized clinical trial that took place across academic, nonprofit, safety-net, and community health care systems in urban, rural, and mountain/frontier regions of Colorado from January 2017 to January 2021. Self-identifying Hispanic adults with serious noncancer medical illness and limited prognosis were recruited. Data were collected and analyzed from July 2022 to July 2023. Interventions Participants randomized to the intervention group received 5 home visits from a bilingual, bicultural lay patient navigator; participants randomized to control received care as usual. Both groups received culturally tailored educational materials. Investigators/outcome accessors remained blinded to participant assignment. Main Outcomes and Measures Change in score from baseline to 3 months on the Functional Assessment of Chronic Illness Therapy (FACIT) General quality of life (QOL) scale (primary outcome), Advance Care Planning (ACP) Engagement Survey, Brief Pain Inventory, Edmonton Symptom Assessment Scale, and FACIT Spiritual Well-Being subscale; at 6 months, advance directive (AD) documentation; and at 46 months or death, hospice utilization and length of stay, as well as aggressiveness of care at end of life. Results Of 209 patients enrolled (mean [SD] age, 63.6 [14.3] years; 108 [51.7%] male), 105 patients were randomized to control and 104 patients to the intervention. There were no statistically significant differences in the change in mean (SD) QOL score between the intervention and control groups (5.0 [16.5] vs 4.3 [15.5]; P = .75). Participants in the intervention group, compared with the control group, had statistically significant greater increases in mean (SD) ACP engagement (0.8 [1.3] vs 0.1 [1.4]; P < .001) and were more likely to have a documented AD (62 of 104 [59.6%] vs 28 of 105 [26.9%]; P < .001). There were no statistically significant differences in mean (SD) change in pain intensity score (0-10) between patients in the intervention group compared with control (-0.4 [2.6] vs -0.5 [2.8]; P = .79), nor pain interference (-0.2 [3.7] vs -0.4 [3.7]; P = .71). Patients receiving the intervention were more likely to be referred to hospice compared with patients receiving control (19 of 43 patients [44.2%] vs 7 of 33 patients [21.2%]; P = .04) and less likely to receive aggressive care at end of life (27 of 42 patients [64.3%] vs 28 of 33 patients [84.8%]; P = .046). Conclusion and Relevance In this randomized clinical trial, a culturally tailored patient navigator intervention did not improve QOL for patients. However, the intervention did increase ACP engagement, AD documentation, and hospice utilization in Hispanic persons with serious medical illness. Trial Registration ClinicalTrials.gov Identifier: NCT03181750.
Collapse
Affiliation(s)
- Stacy M. Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | | | | | | | | | | | | | - Joseph Lopez
- University of Colorado Health North, Fort Collins
| | - Regina M. Fink
- University of Colorado School of Medicine, Aurora
- University of Colorado College of Nursing, Aurora
| |
Collapse
|
3
|
McMahan RD, Hickman SE, Sudore RL. What Clinicians and Researchers Should Know About the Evolving Field of Advance Care Planning: a Narrative Review. J Gen Intern Med 2024; 39:652-660. [PMID: 38169025 PMCID: PMC10973287 DOI: 10.1007/s11606-023-08579-5] [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: 10/05/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
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.
Collapse
Affiliation(s)
- Ryan D McMahan
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Veterans Administration Medical Center, San Francisco, CA, USA.
| | - Susan E Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
- Indiana University Center for Aging Research, Regenstrief Institute Inc, Indianapolis, IN, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Veterans Administration Medical Center, San Francisco, CA, USA
| |
Collapse
|
4
|
Payne J, Sadeghi MA, Liu J, Siess S, Moyer A. The comprehensiveness and comprehensibility of publicly-available, state-approved advance directive documents. PSYCHOL HEALTH MED 2023; 28:3131-3148. [PMID: 35477323 DOI: 10.1080/13548506.2022.2067341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
The COVID-19 pandemic has increased attention to end-of-life decision-making and advance care planning. Advance directives (ADs) are documents that express an individual's wishes regarding their medical care if they are incapacitated and may appoint someone to make decisions for them. The purpose of the current study was to evaluate the comprehensiveness and comprehensibility of the widely available state-approved AD documents provided to the public online. Their content was coded using a grounded theory approach, and the reading level of the documents was assessed. Preferences related to important issues, such as pain relief, were commonly included (92.2% of forms), but other issues, such as whether someone would approve of artificial respiration (39.2%) or CPR (35.3%), were less often addressed. The average reading level of the forms (M = grade 7.64; SD = 1.28) was above the recommended 5th grade level. Overall, there was meaningful variability in the comprehensiveness and comprehensibility of AD documents, suggesting incompatibility for those recording their end-of-life preferences across states and the need for future work to increase their user-friendliness and ability to record authentic advance care wishes.
Collapse
Affiliation(s)
- Jackelyn Payne
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | | | - Jaimie Liu
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | - Samantha Siess
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | - Anne Moyer
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| |
Collapse
|
5
|
Gelfman LP, Barnes DE, Goldstein N, Volow AM, Shi Y, Li B, Sudore RL. Quality and Satisfaction With Advance Care Planning Conversations Among English- and Spanish-Speaking Older Adults. J Palliat Med 2023; 26:1380-1385. [PMID: 37335910 PMCID: PMC10551762 DOI: 10.1089/jpm.2022.0565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 06/21/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Deborah E. Barnes
- Department of Psychiatry and University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Nathan Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aiesha M. Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ying Shi
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
6
|
Sudore RL, Walling AM, Gibbs L, Rahimi M, Wenger NS. Implementation Challenges for a Multisite Advance Care Planning Pragmatic Trial: Lessons Learned. J Pain Symptom Manage 2023; 66:e265-e273. [PMID: 37098388 PMCID: PMC10358280 DOI: 10.1016/j.jpainsymman.2023.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/06/2023] [Accepted: 04/16/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND/PROBLEM Advance care planning (ACP) pragmatic trials are needed. PROPOSED SOLUTION We determined key system-level activities to implement ACP interventions for a cluster-randomized pragmatic trial. We identified patients with serious illness from 50 primary care clinics across three University of California health systems using a validated algorithm. If patients lacked documented ACP within the last 3 years, they were eligible for an intervention: (Arm 1) an advance directive (AD); (Arm 2) AD + PREPAREforYourCare.org; (Arm 3) AD + PREPARE + lay health navigator outreach. Triggered by an appointment, we mailed and sent interventions through automated electronic health record (EHR) messaging. We collaborated with patients/caregivers, clinicians, payors, and national/health system leader advisors. We are currently finalizing 24 months follow-up data. OUTCOMES/METHODS We used the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to track secular trends and implementation efforts. KEY MESSAGE/RESULTS Required multisite, system-level activities: 1) obtaining leadership, legal/privacy, and EHR approvals; 2) standardizing ACP documentation; 3) providing clinician education; 3) validating an automated serious illness identification algorithm; 4) standardizing ACP messaging with input from over 100 key advisors; 5) monitoring secular trends (e.g., COVID); and 6) standardizing ACP workflows (e.g., scanned ADs). Of 8707 patients with serious illness, 6883 were eligible for an intervention. Across all arms, 99% received the mailed intervention, 78.3% had an active patient portal (64.2% opened intervention), and 90.5% of arm three patients (n = 2243) received navigator outreach. LESSONS LEARNED Implementing a multisite health system-wide ACP program and pragmatic trial, with automated EHR-based cohort identification and intervention delivery, requires a high level of multidisciplinary key advisor engagement, standardization, and monitoring. These activities provide guidance for the implementation of other large-scale, population-based ACP efforts.
Collapse
Affiliation(s)
- Rebecca L Sudore
- Department of Medicine (R.L.S.), University of California, San Francisco, California; San Francisco VA Medical Center (R.L.S), San Francisco, California
| | - Anne M Walling
- Department of Medicine (A.M.W., N.S.W.), University of California, Los Angeles, California; VA Greater Los Angeles Health System (A.M.W.), Los Angeles, California.
| | - Lisa Gibbs
- Division of Geriatric Medicine and Gerontology (L.G.), Department of Family Medicine, University of California, Irvine, California
| | - Maryam Rahimi
- Division of General Internal Medicine and Primary Care (M.R.), Department of Medicine, University of California, Irvine, California
| | - Neil S Wenger
- Department of Medicine (A.M.W., N.S.W.), University of California, Los Angeles, California
| |
Collapse
|
7
|
Pajka SE, Kushel M, Handley MA, Olsen P, Li B, Enriquez C, Kaplan L, Sudore RL. Using behavioral theory to adapt advance care planning for homeless-experienced older adults in permanent supportive housing. J Am Geriatr Soc 2023; 71:2615-2626. [PMID: 36928791 PMCID: PMC10440262 DOI: 10.1111/jgs.18314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 01/31/2023] [Accepted: 02/18/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Older adults experiencing chronic homelessness (i.e., prolonged homelessness and a disabling condition) have low rates of advance care planning (ACP) despite high rates of morbidity and mortality. Rehousing of homeless-experienced individuals into permanent supportive housing (PSH) may present an opportunity to introduce ACP; but this is unknown. Therefore, we explored staff and resident perceptions of conducting ACP in PSH. METHODS We conducted semi-structured interviews with PSH staff (n = 13) and tenants (PSH residents) (n = 26) in San Francisco. We used the capability (C), opportunity (O), motivation (M), behavior (COM-B) framework within the Behavior Change Wheel model and the Theoretical Domains Framework (TDF) to inform interviews, categorize themes, and guide qualitative thematic analysis. RESULTS The mean age of PSH residents was 67 (SD = 6.1) years and 52% were women. Of staff, 69% were women. Important COM-B barriers included ACP complexity (C), complicated relationship dynamics (O), resource limitations (O), pessimism (M), variable staff confidence (M), and competing priorities (M). Facilitators included easy-to-use documents/videos, including the PREPARE for Your Care program (C), stability with housing (O), exposure to health crises (O), potential for strong relationships (O), and belief that ACP is impactful (M). Recommendations included adapting materials to the PSH setting, providing staff trainings/scripts, and using optional one-on-one or group sessions. CONCLUSIONS We identified behavioral determinants related to ACP for formerly chronically homeless older adults in PSH. Future interventions should include using easy-to-use ACP materials and developing resources to educate PSH residents, train staff, and model ACP in groups or one-on-one sessions.
Collapse
Affiliation(s)
- Sarah E Pajka
- Medical Student, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Margot Kushel
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, The University of California San Francisco, San Francisco, California, USA
| | - Margaret A Handley
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Pamela Olsen
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Celeste Enriquez
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Lauren Kaplan
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
8
|
Hickman SE, Lum HD, Walling AM, Savoy A, Sudore RL. The care planning umbrella: The evolution of advance care planning. J Am Geriatr Soc 2023; 71:2350-2356. [PMID: 36840690 PMCID: PMC10958534 DOI: 10.1111/jgs.18287] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Susan E. Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Hillary D. Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Center, Colorado, Aurora, USA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, School of Medicine, University of California Los Angeles, California, Los Angeles, USA
- VA Greater Los Angeles Health System, Los Angeles, California, USA
| | - April Savoy
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
9
|
Peters PN, Havrilesky LJ, Davidson BA. Guidelines for goals of care discussions in patients with gynecologic cancer. Gynecol Oncol 2023; 174:247-252. [PMID: 37243995 DOI: 10.1016/j.ygyno.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/07/2023] [Accepted: 05/15/2023] [Indexed: 05/29/2023]
Abstract
This article represents a distillation of literature to provide guidance for goals of care discussions with patients who have gynecologic malignancies. As clinicians who provide surgical care, chemotherapy, and targeted therapeutics, gynecologic oncology clinicians are uniquely positioned to form longitudinal relationships with patients that can enable patient-centered decision making. In this review, we describe optimal timing, components, and best practices for goals of care discussions in gynecologic oncology.
Collapse
Affiliation(s)
- Pamela N Peters
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University Health System, Durham, NC 27710, United States of America.
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University Health System, Durham, NC 27710, United States of America
| | - Brittany A Davidson
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University Health System, Durham, NC 27710, United States of America
| |
Collapse
|
10
|
Nayfeh A, Conn LG, Dale C, Kratina S, Hales B, Das Gupta T, Chakraborty A, Taggar R, Fowler R. The effect of end-of-life decision-making tools on patient and family-related outcomes of care among ethnocultural minorities: A systematic review. PLoS One 2022; 17:e0272436. [PMID: 35925996 PMCID: PMC9352046 DOI: 10.1371/journal.pone.0272436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 07/20/2022] [Indexed: 11/19/2022] Open
Abstract
Background End-of-life decision-making tools are used to establish a shared understanding among patients, families and healthcare providers about medical treatment and goals of care. This systematic review aimed to understand the availability and effect of end-of-life decision-making tools on: (i) goals of care and advance care planning; (ii) patient and/or family satisfaction and well-being; and (iii) healthcare utilization among racial/ethnic, cultural, and religious minorities. Methods A search was conducted in four electronic databases (inception to June 2021). Articles were screened for eligibility using pre-specified criteria. We focused on adult patients (aged ≥18 years) and included primary research articles that used quantitative, qualitative, and mixed-methods designs. Complementary quality assessment tools were used to generate quality scores for individual studies. Extracted data were synthesized by outcome measure for each type of tool, and an overall description of findings showed the range of effects. Results Among 14,316 retrieved articles, 37 articles were eligible. We found that advance care planning programs (eleven studies), healthcare provider-led interventions (four studies), and linguistically-tailored decision aids (three studies) increased the proportion of patients documenting advance care plans. Educational tools (three studies) strongly reduced patient preferences for life-prolonging care. Palliative care consultations (three studies) were strongly associated with do-not-resuscitate orders. Advance care planning programs (three studies) significantly influenced the quality of patient-clinician communication and healthcare provider-led interventions (two studies) significantly influenced perceived patient quality of life. Conclusion This review identified several end-of-life decision-making tools with impact on patient and family-related outcomes of care among ethnocultural minorities. Advance care planning programs, healthcare provider-led interventions and decision aids increased documentation of end-of-life care plans and do-not-resuscitate orders, and educational tools reduced preferences for life-prolonging care. Further research is needed to investigate the effect of tools on healthcare utilization, and with specific patient population subgroups across different illness trajectories and healthcare settings.
Collapse
Affiliation(s)
- Ayah Nayfeh
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
| | - Lesley Gotlib Conn
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Craig Dale
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Sarah Kratina
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Brigette Hales
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tracey Das Gupta
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Ru Taggar
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Robert Fowler
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- H. Barrie Fairley Professor of Critical Care at the University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
11
|
Malhotra C, Shafiq M, Batcagan-Abueg APM. What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials. BMJ Open 2022. [PMCID: PMC9301802 DOI: 10.1136/bmjopen-2021-060201] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives To conduct an up-to-date systematic review of all randomised controlled trials assessing efficacy of advance care planning (ACP) in improving patient outcomes, healthcare use/costs and documentation. Design Narrative synthesis conducted for randomised controlled trials. We searched electronic databases (MEDLINE/PubMed, Embase and Cochrane databases) for English-language randomised or cluster randomised controlled trials on 11 May 2020 and updated it on 12 May 2021 using the same search strategy. Two reviewers independently extracted data and assessed methodological quality. Disagreements were resolved by consensus or a third reviewer. Results We reviewed 132 eligible trials published between 1992 and May 2021; 64% were high-quality. We categorised study outcomes as patient (distal and proximal), healthcare use and process outcomes. There was mixed evidence that ACP interventions improved distal patient outcomes including end-of-life care consistent with preferences (25%; 3/12 with improvement), quality of life (0/14 studies), mental health (21%; 4/19) and home deaths (25%; 1/4), or that it reduced healthcare use/costs (18%; 4/22 studies). However, we found more consistent evidence that ACP interventions improve proximal patient outcomes including quality of patient–physician communication (68%; 13/19), preference for comfort care (70%; 16/23), decisional conflict (64%; 9/14) and patient-caregiver congruence in preference (82%; 18/22) and that it improved ACP documentation (a process outcome; 63%; 34/54). Conclusion This review provides the most comprehensive evidence to date regarding the efficacy of ACP on key patient outcomes and healthcare use/costs. Findings suggest a need to rethink the main purpose and outcomes of ACP. PROSPERO registration number CRD42020184080.
Collapse
Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Mahham Shafiq
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | | |
Collapse
|
12
|
Davis J, Olazo K, Sierra M, Tarver ME, Caldwell B, Saha A, Lisker S, Lyles C, Sarkar U. Do patient-reported outcome measures measure up? A qualitative study to examine perceptions and experiences with heart failure proms among diverse, low-income patients. J Patient Rep Outcomes 2022; 6:6. [PMID: 35032226 PMCID: PMC8760874 DOI: 10.1186/s41687-022-00410-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a Patient-Reported Outcome Measure (PROM) used to evaluate the health status of patients with heart failure (HF) but has predominantly been tested in settings serving predominately white, male, and economically well-resourced populations. We sought to examine the acceptability of the shorter version of the KCCQ (KCCQ-12) among racially and ethnically diverse patients receiving care in an urban, safety-net setting.
Methods We conducted cognitive interviews with a diverse population of patients with heart failure in a safety net system to assess their perceptions of the KCCQ-12. We conducted a thematic analysis of the qualitative data then mapped themes to the Capability, Opportunity, Motivation Model of Behavior framework. Results We interviewed 18 patients with heart failure and found that patients broadly endorsed the concepts of the KCCQ-12 with minor suggestions to improve the instrument’s content and appearance. Although patients accepted the KCCQ-12, we found that the instrument did not adequately measure aspects of health care and quality of life that patients identified as being important components of managing their heart failure. Patient-important factors of heart failure management coalesced into three main themes: social support, health care environment, and mental health. Conclusions Patients from this diverse, low-income, majority non-white population experience unique challenges and circumstances that impact their ability to manage disease. In this study, patients were receptive to the KCCQ-12 as a tool but perceived that it did not adequately capture key health components such as mental health and social relationships that deeply impact their ability to manage HF. Further study on the incorporation of social determinants of health into PROMs could make them more useful tools in evaluating and managing HF in diverse, underserved populations. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00410-9.
Collapse
Affiliation(s)
- Jonathan Davis
- Division of Cardiology, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, 1001 Potrero Avenue, 94110, San Francisco, CA, USA
| | - Kristan Olazo
- Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, Building 10, Ward 13, San Francisco, CA, 94110, USA.,Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco, CA, USA
| | - Maribel Sierra
- Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, Building 10, Ward 13, San Francisco, CA, 94110, USA.,Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco, CA, USA
| | - Michelle E Tarver
- Food and Drug Administration, Center for Devices and Radiological Health, Silver Spring, MD, USA
| | - Brittany Caldwell
- Food and Drug Administration, Center for Devices and Radiological Health, Silver Spring, MD, USA
| | - Anindita Saha
- Food and Drug Administration, Center for Devices and Radiological Health, Silver Spring, MD, USA
| | - Sarah Lisker
- Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, Building 10, Ward 13, San Francisco, CA, 94110, USA.,Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco, CA, USA
| | - Courtney Lyles
- Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, Building 10, Ward 13, San Francisco, CA, 94110, USA.,Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Urmimala Sarkar
- Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, Building 10, Ward 13, San Francisco, CA, 94110, USA. .,Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco, CA, USA. .,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
| |
Collapse
|
13
|
Scheerens C, Gilissen J, Volow AM, Powell JL, Ferguson CM, Farrell D, Li B, Berry C, Sudore RL. Developing eHealth tools for diverse older adults: Lessons learned from the PREPARE for Your Care Program. J Am Geriatr Soc 2021; 69:2939-2949. [PMID: 34081773 PMCID: PMC8497394 DOI: 10.1111/jgs.17284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Electronic Health (eHealth) tools offer opportunities for people to access health information online; yet, most tools are not designed to meet the unique needs of diverse older adults, leading to health disparities. Our goal was to provide guidance for the development of eHealth tools for diverse older populations for use in geriatric care models. DESIGN Guidance for eHealth tools was compiled from user design resources and eHealth design literature. Pragmatic examples were provided from an evidenced-based eHealth tool called PREPAREforYourCare.org (PREPARE). We used quantitative feasibility data from PREPARE research studies and qualitative analysis of PREPARE focus groups, cognitive interviews, and feedback from randomized trials to further inform our recommendations. RESULTS Guidance and lessons learned include: (1) define clear objectives and a conceptual framework; (2) co-create with the target population; (3) optimize the design and layout for accessibility and ease of use, such as text at the 5th grade reading level, closed captioning, etc.; (4) use simple, standardized navigation design; (5) use actionable information to enhance behavior change, such as modeling of behaviors; (6) align accompanying written materials with the eHealth tool; and (7) create tracking mechanisms for ongoing user feedback. PREPARE is used as a case example to provide pragmatic illustrations for how the guidance may be operationalized. CONCLUSION eHealth tools can be tailored to the unique characteristics, preferences, and needs of diverse older populations. Following the "lessons learned" may help decrease health disparities among diverse older adults and ensure eHealth tools are readily accessible and culturally appropriate.
Collapse
Affiliation(s)
- Charlotte Scheerens
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
- Department of Public Health and Primary Health Care, Ghent University, Ghent, Belgium
| | - Joni Gilissen
- Department of Public Health and Primary Health Care, Ghent University, Ghent, Belgium
- Atlantic Fellow for Equity in Brain Health, Global Brain Health Institute (GBHI), University of California, San Francisco, California, USA
| | - Aiesha M Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Jana L Powell
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Clarissa M Ferguson
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | | | - Brookelle Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | | | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Innovation and Implementation Center on Aging and Palliative Care, Division of Geriatrics, University of California, San Francisco, California, USA
| |
Collapse
|
14
|
Kotwal AA, Barnes DE, Volow A, Li B, Boscardin J, Sudore RL. Engaging Diverse Older Adults With Cognitive Impairment and Caregivers in Advance Care Planning: A Pilot Study of the Interactive PREPARE Website. Alzheimer Dis Assoc Disord 2021; 35:342-349. [PMID: 34310443 PMCID: PMC8604734 DOI: 10.1097/wad.0000000000000465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/05/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Engaging patients with cognitive impairment in advance care planning (ACP), including completing advance directives and naming health care proxies, before they lose decision-making capacity is important. METHODS We determined the feasibility of the PREPAREforYourCare.org ACP program among 20 diverse older adults with mild-to-moderate cognitive impairment and their caregivers in a 1-week, pre-post pilot. We examined ease-of-use, satisfaction, and feasibility using validated scales, and change in ACP Engagement scores, including knowledge, contemplation, self-efficacy, and readiness subscales (5-point scales), from baseline to 1-week. RESULTS Participants were on average 70 years old (SD=9.0), 45% Spanish-speaking, 60% had limited health literacy, and 15% felt comfortable using the internet. Patients and caregivers rated PREPARE a mean of 8.6 (SD=1.6) and 9.4 (SD=1.1) on the 10-point ease-of-use scale, 4.7 (SD=0.4) and 4.7 (SD=0.3) on the 5-point satisfaction scale, and 4.9 (SD=0.4) and 4.8 (SD=0.6) on the 5-point feasibility scale, respectively. ACP engagement scores increased for 16 of 20 (80%) patients (P=0.03) and 16 of 20 (80%) caregivers (P=0.18). Caregivers experienced increased knowledge (3.8 to 4.7, P=0.002) and self-efficacy (3.6 to 4.5, P=0.034) for ACP. DISCUSSION The PREPARE website was feasible and may facilitate ACP engagement among diverse older adults with cognitive impairment and their caregivers.
Collapse
Affiliation(s)
- Ashwin A. Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - Deborah E. Barnes
- Weill Institute for Neurosciences, Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Aiesha Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - Brookelle Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| |
Collapse
|
15
|
A review of clinical trials of advance care planning interventions adapted for limited health literacy. Palliat Support Care 2021; 20:593-599. [PMID: 34446129 DOI: 10.1017/s1478951521001152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Advance care planning is vital for ensuring individuals receive end-of-life care that is consistent with their care preferences and improves patient quality of life and satisfaction with care; however, only 11% of Americans have discussed advance care planning with a healthcare provider. Individuals with limited health literacy are even less likely to participate in advance care planning due to difficulty comprehending complex health information. The purpose of this review was to identify randomized controlled trials designed to address the effects of limited health literacy on advance care planning, evaluate the quality of these studies, and summarize evaluation data to inform future studies. METHODS This systematic review examined randomized controlled trials published from January 1997 to July 2020 using the PubMed, CINAHL, PsycINFO, and Scopus databases. Data were extracted and two reviewers independently evaluated the quality of studies using the Joanna Briggs Institute Critical Appraisal Tool. RESULTS The database search yielded 253 studies and five studies were included in the final review. Studies were conducted in mostly White patients in outpatient clinics in the United States. Researchers wrote text at lower reading levels, added images to materials, and created videos to enhance communication. Health literacy interventions increased participant knowledge, preference for comfort care, engagement, and care documentation; however, several methodological issues were identified, including baseline differences in treatment and control groups, issues with blinding, lack of valid and reliable outcome measures, and inappropriate statistical analyses. SIGNIFICANCE OF RESULTS More high-quality intervention studies that address the effects of limited health literacy on advance care planning in diverse populations and settings are needed. Future intervention studies should use reliable and valid instruments to measure advance care planning outcomes. Clinicians should use materials appropriate for their patients' health literacy levels to address their advance care planning needs.
Collapse
|
16
|
Barker PC, Holland NP, Shore O, Cook RL, Zhang Y, Warring CD, Hagen MG. The Effect of Health Literacy on a Brief Intervention to Improve Advance Directive Completion: A Randomized Controlled Study. J Prim Care Community Health 2021; 12:21501327211000221. [PMID: 33719708 PMCID: PMC7968018 DOI: 10.1177/21501327211000221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Completion of an advance directive (AD) document is one component of advanced care planning. We evaluated a brief intervention to enhance AD completion and assess whether the intervention effect varied according to health literacy. METHODS A randomized controlled study was conducted in 2 internal medicine clinics. Participants were over 50, without documented AD, no diagnosis of dementia, and spoke English. Participants were screened for health literacy utilizing REALM-SF. Participants were randomized in a 1:1 ratio to the intervention, a 15-minute scripted introduction (grade 7 reading level) to our institution's AD forms (grade 11 reading level) or to the control, in which subjects were handed blank AD forms without explanation. Both groups received reminder calls at 1, 3, and 5 months. The primary outcome was AD completion at 6 months. RESULTS Five hundred twenty-nine subjects were enrolled; half were of limited and half were of adequate health literacy. The AD completion rate was 21.7% and was similar in the intervention vs. the control group (22.4% vs 22.2%, P = .94).More participants with adequate health literacy completed an AD than those with limited health literacy (28.4% vs 16.2%, P = .0008), although the effect of the intervention was no different within adequate or limited literacy groups. CONCLUSION A brief intervention had no impact on AD completion for subjects of adequate or limited health literacy. PRACTICE IMPLICATIONS Our intervention was designed for easy implementation and to be accessible to patients of adequate or limited health literacy. This intervention was not more likely than the control (handing patients an AD form) to improve AD completion for patients of either limited or adequate health literacy. Future efforts and research to improve AD completion rates should focus on interventions that include: multiple inperson contacts with patients, contact with a trusted physician, documents at 5th grade reading level, and graphic/video decision aids. TRIAL REGISTRATION NUMBER NCT02702284, Protocol ID IRB201500776.
Collapse
Affiliation(s)
| | | | | | | | - Yang Zhang
- University of Florida, Gainesville, FL, USA
| | | | | |
Collapse
|
17
|
Feasibility of Group Visits for Advance Care Planning Among Patients with Heart Failure and Their Caregivers. J Am Board Fam Med 2021; 34:171-180. [PMID: 33452095 PMCID: PMC8607823 DOI: 10.3122/jabfm.2021.01.200184] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Group visits have the potential to help patients identify their health care values and engage in the emotionally and cognitively challenging task of advance care planning (ACP) in a resource-efficient manner by providing a forum for social learning and social support. OBJECTIVE To evaluate the feasibility and acceptability of disease-specific group visits for patients with heart failure and their caregivers. DESIGN Feasibility trial of a 90-minute group visit held for 10 separate groups and led by a trained facilitator using the video-based PREPARE for Your Care ACP tool. SETTING/SUBJECTS Older adults with recent hospitalization for heart failure (n = 36; median age, 74 years) and their caregivers (n = 21). MEASUREMENTS Pre- and post-visit surveys and a postvisit telephone interview assessing perceived value and acceptability; structured nonparticipant observations to assess process and feasibility. RESULTS Mean scores from the postgroup visit evaluation showed that participants reported that they felt comfortable discussing ACP in a group (4.59), understood the information covered (4.70), and were able to identify and clarify their health care values (4.43). Interview and observation data demonstrated that participants were able to identify and clarify their preferences by listening and learning from a diverse range of perspectives in the group and that the disease-focused nature of the group visit created a supportive space for participants to share their experiences. CONCLUSIONS Disease-focused ACP group visits were feasible to conduct and acceptable to participants, underscoring their value as an efficient intervention to engage patients and caregivers in the otherwise time- and resource-intensive task of ACP.
Collapse
|
18
|
Barwise A, Yeow ME, Partain DK. The Premise and Development of CHECK IN-Check-In for Exchange of Clinical and Key Information to Enhance Palliative Care Discussions for Patients With Limited English Proficiency. Am J Hosp Palliat Care 2020; 38:533-538. [PMID: 33295185 DOI: 10.1177/1049909120979982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Communication regarding serious illness is challenging in most circumstances. Patients with Limited English Proficiency (LEP) have unique language and cultural needs that often require collaboration with a trained medical interpreter, especially when the clinical encounter involves serious illness decision making or elucidation of patient goals, preferences, and values. Although there is mounting evidence to support interpreter/clinician huddles before a serious illness communication encounter, no current initiatives exist to operationalize this evidence. We are currently in the process of developing, evaluating, and implementing a formal interpreter/clinician huddle process to promote high quality care for patients with LEP. Our huddle guide, called the Check-In for Exchange of Clinical and Key Information (CHECK-IN), is designed to facilitate collaboration between an interpreter and clinician during a serious illness encounter by prompting exchange of relevant sociocultural and clinical information between clinicians and interpreters.
Collapse
Affiliation(s)
- Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, 4352Mayo Clinic, Rochester, MN, USA
| | - Mei-Ean Yeow
- Department of General Internal Medicine, Center for Palliative Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Daniel K Partain
- Department of General Internal Medicine, Center for Palliative Medicine, 6915Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
19
|
Dierickx S, Pardon K, Pype P, Stevens J, Vander Stichele R, Deliens L, De Vleminck A. 'Advance care planning, general practitioners and patients: a phase II cluster-randomised controlled trial in chronic life-limiting illness'. BMJ Support Palliat Care 2020; 12:bmjspcare-2020-002712. [PMID: 33268475 DOI: 10.1136/bmjspcare-2020-002712] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/18/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Although general practice is an ideal setting for ensuring timely initiation of advance care planning (ACP) in people with chronic life-limiting illness, evidence on the effectiveness of ACP in general practice and how it can be implemented is lacking. This study aims to evaluate feasibility and acceptability of study procedures and intervention components of an intervention to facilitate the initiation of ACP in general practice for people with chronic life-limiting illness. METHODS Pilot cluster-randomised controlled trial testing a complex ACP intervention in general practice versus usual care (ClinicalTrials.gov: NCT02775032). We used a mixed methods approach using detailed documentation of the recruitment process, questionnaires and semi-structured interviews. RESULTS A total of 25 general practitioners (GPs) and 38 patients were enrolled in the study. The intervention was acceptable to GPs and patients, with GPs valuing the interactive training and patients finding ACP conversations useful. However, we found a number of challenges regarding feasibility of recruitment procedures, such GP as recruitment proceeding more slowly than anticipated as well as difficulty applying the inclusion criteria for patients. Some GPs found initiating ACP conversations difficult. The content of the patient booklet was determined to potentially be too complex for patients with a lower health literacy. CONCLUSION Although the intervention was well-accepted by GPs and patients, we identified critical points for improvement with regard to the study procedures as well as potential improvements of the intervention components. When these points are addressed, the intervention can proceed to a large-scale, phase III trial to test its effectiveness.
Collapse
Affiliation(s)
- Sigrid Dierickx
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Peter Pype
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Julie Stevens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Aline De Vleminck
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| |
Collapse
|
20
|
Nouri S, Lyles CR, Rubinsky AD, Patel K, Desai R, Fields J, DeRouen MC, Volow A, Bibbins-Domingo K, Sudore RL. Evaluation of Neighborhood Socioeconomic Characteristics and Advance Care Planning Among Older Adults. JAMA Netw Open 2020; 3:e2029063. [PMID: 33301019 PMCID: PMC7729427 DOI: 10.1001/jamanetworkopen.2020.29063] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Advance care planning (ACP) is low among older adults with socioeconomic disadvantage. There is a need for tailored community-based approaches to increase ACP, but community patterns of ACP are poorly understood. OBJECTIVE To examine the association between neighborhood socioeconomic status (nSES) and ACP and to identify communities with both low nSES and low rates of ACP. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study examined University of California San Francisco electronic health record (EHR) data and place-based data from 9 San Francisco Bay Area counties. Participants were primary care patients aged 65 years or older and living in the San Francisco Bay Area in July 2017. Statistical analysis was performed from May to June 2020. EXPOSURES Patients' home addresses were geocoded and assigned to US Census tracts. The primary factor, nSES, an index combining area-level measures of income, education, poverty, employment, occupation, and housing or rent values, was divided into quintiles scaled to the distribution of all US Census tracts in the Bay Area (Q1 = lowest nSES). Covariates were from the EHR and included health care use (primary care, outpatient specialty, emergency department, and inpatient encounters in the prior year). MAIN OUTCOMES AND MEASURES ACP was defined as a scanned document (eg, advance directive), ACP Current Procedural Terminology code, or ACP note type in the EHR. RESULTS There were 13 104 patients included in the cohort-mean (SD) age was 75 (8) years, with 7622 female patients (58.2%), 897 patients (6.8%) identified as Black, 913 (7.0%) as Latinx, 3788 (28.9%) as Asian/Pacific Islander, and 748 (5.7%) as other minority race/ethnicity, and 2393 (18.3%) self-reported that they preferred to speak a non-English language. Of these, 3827 patients (29.2%) had documented ACP. The cohort was distributed across all 5 quintiles of nSES (Q1: 1426 patients [10.9%]; Q2: 1792 patients [13.7%]; Q3: 2408 patients [18.4%]; Q4: 3330 patients [25.4%]; Q5: 4148 patients [31.7%]). Compared with Q5 and after adjusting for health care use, all lower nSES quintiles showed a lower odds of ACP in a graded fashion (Q1: adjusted odds ratio [aOR] = 0.71 [95% CI, 0.61-0.84], Q2: aOR = 0.74 [95% CI, 0.64-0.86], Q3: aOR = 0.81 [95% CI, 0.71-0.93], Q4: aOR = 0.82 [95% CI, 0.72-0.93]. A bivariable map of ACP by nSES allowed identification of 5 neighborhoods with both low nSES and ACP. CONCLUSIONS AND RELEVANCE In this study, lower nSES was associated with lower ACP documentation after adjusting for health care use. Using EHR and place-based data, communities of older adults with both low nSES and low ACP were identified. This is a first step in partnering with communities to develop targeted, community-based interventions to meaningfully increase ACP.
Collapse
Affiliation(s)
- Sarah Nouri
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco
| | - Courtney R. Lyles
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Anna D. Rubinsky
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Riya Desai
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Jessica Fields
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Mindy C. DeRouen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
| | - Aiesha Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Kirsten Bibbins-Domingo
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Rebecca L. Sudore
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| |
Collapse
|
21
|
Kawakami A, Kwong EW, Lai CK, Song MS, Boo S, Yamamoto-Mitani N. Advance care planning and advance directive awareness among East Asian older adults: Japan, Hong Kong and South Korea. Geriatr Gerontol Int 2020; 21:71-76. [PMID: 33217170 DOI: 10.1111/ggi.14086] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 09/28/2020] [Accepted: 10/20/2020] [Indexed: 11/28/2022]
Abstract
AIM Population aging is a global phenomenon, and East Asian countries are no exception. However, the use of advance care planning (ACP) and advance directives (ADs) are not widespread in East Asia. This study aimed to examine the awareness of ACP/ADs and its related factors among community-dwelling older persons in Japan, Hong Kong and South Korea. METHODS This was a cross-sectional, cross-cultural questionnaire conducted among a convenience sample of community-dwelling persons. The questionnaire included information regarding awareness of ACP/ADs and personal information. Multiple logistic regression was used assess relationships between awareness of ACP/ADs and potential related factors. RESULTS The sample consisted of 404 community-dwelling older adults: 174 (43.0%) from Japan, 132 (32.7%) from Hong Kong and 98 (24.3%) from South Korea. In total, 122 participants (30.2%) had heard of ACP/ADs. Multiple logistic regression analysis revealed that an educational level >12 years was significantly associated with increased ACP/ADs awareness (adjusted odds ratio [AOR]: 2.19, 95% confidence interval (CI): 1.18-4.07, P = 0.01). The rate of those who have heard of ACP/ADs was significantly higher among Japanese than South Koreans were (AOR: 4.54, 95% CI: 1.64-12.58, P < 0.01), those from Hong Kong than South Korea (AOR: 5.15, 95% CI 1.89-14.0, P < 0.01) after some variables with significant differences among the three countries were controlled. CONCLUSIONS In particular, support tailored to the targets' educational levels will be required. It is also suggested that support is needed to enhance awareness of ACP/ADs in East Asia, although there is a difference in degree of awareness among the three countries. Geriatr Gerontol Int 2021; 21: 71-76.
Collapse
Affiliation(s)
- Aki Kawakami
- Department of Critical and Invasive-Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Enid Wy Kwong
- School of Nursing, Putian University, Putian, China.,School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Claudia Ky Lai
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong.,Division of Nursing Studies, School of Continuing Education, The Hong Kong Baptist University, Kowloon, Hong Kong
| | - Mi Sook Song
- College of Nursing Research Institute of Nursing Sciences, Ajou University, Suwon, South Korea
| | - Sunjoo Boo
- College of Nursing Research Institute of Nursing Sciences, Ajou University, Suwon, South Korea
| | - Noriko Yamamoto-Mitani
- Department of Gerontological Homecare & Long-term Care Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
22
|
Gupta A, Bahl B, Rabadi S, Mebane A, Levey R, Vasudevan V. Value of Advance Care Directives for Patients With Serious Illness in the Era of COVID Pandemic: A Review of Challenges and Solutions. Am J Hosp Palliat Care 2020; 38:191-198. [PMID: 33021094 DOI: 10.1177/1049909120963698] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Advance care directives (ACDs) are instructions regarding what types of medical treatments a patient desires and/or who they would like to designate as a healthcare surrogate to make important healthcare decisions when the patient is mentally incapacitated. At end-of-life, when faced with poor prognosis for a meaningful health-related quality of life, most patients indicate their preference to abstain from aggressive, life-sustaining treatments. Patients whose wishes are left unsaid often receive burdensome life sustain therapy by default, prolonging patient suffering. The CoVID pandemic has strained our healthcare resources and raised the need for prioritization of life-sustaining therapy. This highlights the urgency of ACDs more than ever. Despite ACDs' potential to provide patients with care that aligns with their values and preferences and reduce resource competition, there has been relatively little conversation regarding the overlap of ACDs and CoVID-19. There is low uptake among patients, lack of training for healthcare professionals, and inequitable adoption in vulnerable populations. However, solutions are forthcoming and may include electronic medical record completion, patient outreach efforts, healthcare worker programs to increase awareness of at-risk minority patients, and restructuring of incentives and reimbursement policies. This review carefully describes the above challenges and unique opportunities to address them in the CoVID-19 era. If solutions are leveraged appropriately, ACDs have the potential to address the described challenges and ethically resolve resource conflicts during the current crisis and beyond.
Collapse
Affiliation(s)
- Amol Gupta
- 24508The Brooklyn Hospital Center, NY, USA
| | | | - Saher Rabadi
- 12340University of Texas Health Sciences Center, Houston, TX, USA
| | | | | | | |
Collapse
|
23
|
McMahan RD, Tellez I, Sudore RL. Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review. J Am Geriatr Soc 2020; 69:234-244. [PMID: 32894787 DOI: 10.1111/jgs.16801] [Citation(s) in RCA: 197] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVES Advance care planning (ACP) has shown benefit in some, but not all, studies. It is important to understand the utility of ACP. We conducted a scoping review to identify promising interventions and outcomes. DESIGN Scoping review. MEASUREMENTS We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for ACP randomized controlled trials from January 1, 2010, to March 3, 2020. We used standardized Preferred Reporting Items for Systematic Review and Meta-Analyses methods to chart study characteristics, including a standardized ACP Outcome Framework: Process (e.g., readiness), Action (e.g., communication), Quality of Care (e.g., satisfaction), Health Status (e.g., anxiety), and Healthcare Utilization. Differences between arms of P < .05 were deemed positive. RESULTS Of 1,464 articles, 69 met eligibility; 94% were rated high quality. There were variable definitions, age criteria (≥18 to ≥80 years), diseases (e.g., dementia and cancer), and settings (e.g., outpatient and inpatient). Interventions included facilitated discussions (42%), video only (20%), interactive, multimedia (17%), written only (12%), and clinician training (9%). For written only, 75% of primary outcomes were positive, as were 69% for multimedia programs; 67% for facilitated discussions, 59% for video only, and 57% for clinician training. Overall, 72% of Process and 86% of Action outcomes were positive. For Quality of Care, 88% of outcomes were positive for patient-surrogate/clinician congruence, 100% for patients/surrogate/clinician satisfaction with communication, and 75% for surrogate satisfaction with patients' care, but not for goal concordance. For Health Status outcomes, 100% were positive for reducing surrogate/clinician distress, but not for patient quality of life. Healthcare Utilization data were mixed. CONCLUSION ACP is complex, and trial characteristics were heterogeneous. Outcomes for all ACP interventions were predominantly positive, as were Process and Action outcomes. Although some Quality of Care and Health Status outcomes were mixed, increased patient/surrogate satisfaction with communication and care and decreased surrogate/clinician distress were positive. Further research is needed to appropriately tailor interventions and outcomes for local contexts, set appropriate expectations of ACP outcomes, and standardize across studies.
Collapse
Affiliation(s)
- Ryan D McMahan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Ismael Tellez
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| |
Collapse
|
24
|
Nouri SS, Ritchie C, Volow A, Li B, McSpadden S, Dearman K, Kotwal A, Sudore RL. A Toolkit for Community-Based, Medicaid-Funded Case Managers to Introduce Advance Care Planning to Frail, Older Adults: A Pilot Study. J Palliat Med 2020; 24:428-432. [PMID: 32865472 DOI: 10.1089/jpm.2020.0200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Advance care planning (ACP) among frail, older adults receiving in-home care is low. Leveraging case managers to introduce ACP may increase engagement. Objective: Pilot an ACP-Toolkit for case managers and their clients. Design: Feasibility pilot of an ACP-Toolkit for case managers to introduce ACP and the PREPAREforYourCare.org website and advance directives. Setting/Subjects: Case managers from four local aging service organizations who referred English-speaking clients ≥55 years old. Measurements: Using validated surveys (five-point Likert scales), we assessed changes in case managers' attitudes, confidence, and readiness to facilitate ACP and clients' readiness to engage in ACP from baseline to follow-up (one-week) using Wilcoxon signed-rank tests. Results: We enrolled 9 case managers and 12 clients (median age 69 [standard deviation 8], 75% minority race/ethnicity). At follow-up, case managers' confidence increased (3.2 [0.7] to 4.2 [0.7]; p = 0.02), and clients' readiness increased (2.8 [1.5] to 3.4 [1.4]; p = 0.06). All case managers agreed the Toolkit was easy to use, helped start ACP conversations, and would recommend it to others. All clients found the Toolkit easy to understand and were comfortable with case managers using it. Nearly all clients (92%) would recommend it to others. Suggestions for improvement included offering the Toolkit in other languages and disseminating it in clinical and community settings. Conclusions: The ACP-Toolkit resulted in higher case manager confidence in facilitating ACP and client readiness to engage in ACP, and usability was high. A brief ACP-Toolkit may be a feasible solution to increase ACP engagement among frail, older adults receiving in-home care.
Collapse
Affiliation(s)
- Sarah S Nouri
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Aiesha Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Shireen McSpadden
- San Francisco Department of Disability and Aging Services, San Francisco, California, USA
| | - Kelly Dearman
- San Francisco In-Home Supportive Services Public Authority, San Francisco, California, USA
| | - Ashwin Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
25
|
Barwise A, Balls-Berry J, Soleimani J, Karki B, Barrett B, Castillo K, Kreps S, Kunkel H, Vega B, Erwin P, Espinoza Suarez N, Wilson ME. Interventions for End of Life Decision Making for Patients with Limited English Proficiency. J Immigr Minor Health 2020; 22:860-872. [PMID: 31749066 PMCID: PMC7706216 DOI: 10.1007/s10903-019-00947-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients with limited English proficiency (LEP) experience disparities in end-of-life decision making and advance care planning. Our objective was to conduct a systematic review to assess the literature about interventions addressing these issues. Our search strategy was built around end-of-life (EOL), LEP, ACP, and goals of care. The databases included Ovid MEDLINE(R), and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily from 1946 to November 9, 2018, Ovid EMBASE. Eight studies from the US and Australia were included (seven studies in Spanish and one study in Greek and Italian). Interventions used trained personnel, video images, web-based programs, and written materials. Interventions were associated with increased advance directive completion and decreased preferences for some life-prolonging treatments. Interventions were deemed to be feasible and acceptable. Few interventions exist to improve end-of-life care for patients with LEP. Data are limited regarding intervention effectiveness.
Collapse
Affiliation(s)
- Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Joyce Balls-Berry
- Office for Community Engagement in Research, Center for Clinical and Translational Science, Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Jalal Soleimani
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Bibek Karki
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | | | - Samantha Kreps
- Health Sciences, University of Minnesota, Rochester, MN, USA
| | - Hilary Kunkel
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Beatriz Vega
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Patricia Erwin
- Department of Education Administration, Rochester, MN, USA
| | | | - Michael E Wilson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
26
|
Rolnick JA, Oredeko F, Cooney-Zingman E, Asch DA, Halpern SD. Comparison of Web-Based and Paper Advance Directives: A Pilot Randomized Clinical Trial. Am J Hosp Palliat Care 2020; 38:230-237. [PMID: 32648476 DOI: 10.1177/1049909120940210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Digital tools to document care preferences in serious illnesses are increasingly common, but their impact is unknown. We developed a web-based advance directive (AD) featuring (1) modular content eliciting detailed care preferences, (2) the ability to electronically transmit ADs to the electronic health record (EHR), and (3) use of nudges to promote document transmission and sharing. OBJECTIVE To compare a web-based, EHR-transmissible AD to a paper AD. METHODS Patients with gastrointestinal and lung malignancies were randomized to the web or paper AD. The primary outcome was the proportion of patients with newly documented advance care plans in the EHR at 8 weeks. Secondary outcomes assessed through an e-mail survey included the change in satisfaction with end-of-life plans, AD acceptability, and self-reported sharing with a surrogate. RESULTS Ninety-one participants were enrolled: 46 randomly allocated to the web AD and 45 to paper. Thirteen patients assigned to web AD (28%) had new documentation versus 7 (16%) assigned to paper (P = .14). Adjusted for demographic factors and primary diagnosis, the odds ratio of new documentation with web AD was 3.7 (95% CI: 0.8-17.0, P = .10). Satisfaction with advance care planning and AD acceptability were high in both groups and not significantly different. Among patients completing web ADs, 79% reported sharing plans with their caregivers, compared with 65% of those completing paper ADs (P = .40). CONCLUSION Web-based ADs hold promise for promoting documentation and sharing of preferences, but larger studies are needed to quantify effects on these intermediate end points and on patient-centered outcomes.
Collapse
Affiliation(s)
- Joshua A Rolnick
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,National Clinician Scholars Program, 14640University of Pennsylvania, PA, USA
| | - Francisca Oredeko
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth Cooney-Zingman
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Center for Health Care Innovation, Penn Medicine, Philadelphia PA, USA
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
27
|
Miyashita J, Kohno A, Cheng SY, Hsu SH, Yamamoto Y, Shimizu S, Huang WS, Kashiwazaki M, Kamihiro N, Okawa K, Fujisaki M, Tsai JS, Fukuhara S. Patients' preferences and factors influencing initial advance care planning discussions' timing: A cross-cultural mixed-methods study. Palliat Med 2020; 34:906-916. [PMID: 32356489 DOI: 10.1177/0269216320914791] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although advance care planning discussions are increasingly accepted worldwide, their ideal timing is uncertain and cultural factors may pertain. AIM To evaluate timing and factors affecting initiation of advance care planning discussions for adult patients in Japan and Taiwan. DESIGN Mixed-methods questionnaire survey to quantitatively determine percentages of patients willing to initiate advance care planning discussions at four stages of illness trajectory ranging from healthy to undeniably ill, and to identify qualitative perceptions underlying preferred timing. SETTING/PARTICIPANTS Patients aged 40-75 years visiting outpatient departments at four Japanese and two Taiwanese hospitals were randomly recruited. RESULTS Overall (of 700 respondents), 72% (of 365) in Japan and 84% (of 335) in Taiwan (p < 0.001) accepted discussion before illness. In Japan, factors associated with willingness before illness were younger age and rejection of life-sustaining treatments; in Taiwan, older age, stronger social support, and rejection of life-sustaining treatments. Four main categories of attitudes were extracted: the most common welcomed discussion as a wise precaution, responses in this first category outnumbered preference for postponement of discussion until imminent end of life, acceptance of the universal inevitability of death, and preference for discussion at healthcare providers' initiative. CONCLUSION The majority of patients are willing to begin discussion before their health is severely compromised; about one out of five patients are unwilling to begin until clearly facing death. To promote advance care planning, healthcare providers must be mindful of patients' preferences and factors associated with acceptance and reluctance to initiate advance care planning.
Collapse
Affiliation(s)
- Jun Miyashita
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ayako Kohno
- Department of Health Informatics, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Su-Hsuan Hsu
- Department of Family Medicine, Taipei City Hospital, Taipei, Taiwan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sayaka Shimizu
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Wei-Sheng Huang
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | | | - Noriki Kamihiro
- The Kansai Centre for Family Medicine, Kanai Hospital, Kyoto, Japan
| | - Kaoru Okawa
- Department of Home Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Masami Fujisaki
- Department of General Medicine, Medical Center Narita Hospital, Chiba, Japan
| | - Jaw-Shiun Tsai
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Shunichi Fukuhara
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| |
Collapse
|
28
|
Freytag J, Street RL, Barnes DE, Shi Y, Volow AM, Shim JK, Alexander SC, Sudore RL. Empowering Older Adults to Discuss Advance Care Planning During Clinical Visits: The PREPARE Randomized Trial. J Am Geriatr Soc 2020; 68:1210-1217. [PMID: 32157684 DOI: 10.1111/jgs.16405] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND/OBJECTIVES A patient-directed, online program (PREPARE for Your Care [PREPARE]; prepareforyourcare.org) has been shown to increase advance care planning (ACP) documentation. However, the mechanisms underlying PREPARE are unknown. Our objectives were to compare the efficacy of PREPARE plus an easy-to-read advance directive (AD) vs an AD alone to increase active patient participation in ACP discussions during clinic visits and to examine effects of active patient participation on ACP documentation. DESIGN Audio recordings of postintervention primary care visits from two randomized trials (2013-2016). SETTING Seven primary care clinics at a veterans affair and safety-net hospital in San Francisco, CA. PARTICIPANTS English- and Spanish-speaking adults, aged 55 years and older, with two or more chronic/serious conditions. INTERVENTION PREPARE plus an easy-to-read AD or an AD alone. MEASUREMENTS The primary outcome was the number of active patient participation utterances about ACP (eg, asking questions, stating preferences) measured by the validated Active Patient Participation Coding Scheme. We examined differences in utterances by study arm using mixed effects negative binomial models and utterances as a mediator of PREPARE's effect on documentation using adjusted logistic regression. Models were adjusted for health literacy, prior care planning, and clinician. RESULTS Among 393 participants, the mean (SD) age was 66 (8.1) years, 120 (30.5%) had limited health literacy, and 99 (25.2%) were Spanish speaking. PREPARE plus the AD resulted in 41% more active patient participation in ACP discussions compared with the AD alone (mean [SD] = 10.1 [16.8] vs 6.6 [13.4] utterances; incidence rate ratio = 1.41; 95% confidence interval = 1.00-1.98). For every additional utterance, participants had 15% higher odds of ACP documentation, and active patient participation accounted for 16% of PREPARE's effect on documentation. CONCLUSIONS The PREPARE program and easy-to-read AD empowered patients to actively participate in ACP discussions during clinical visits more than the AD alone. Increased activation was associated with increased ACP documentation. Therefore, PREPARE may mitigate barriers to ACP among English- and Spanish-speaking older adults. TRIAL REGISTRATION 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. J Am Geriatr Soc 68:1210-1217, 2020.
Collapse
Affiliation(s)
- Jennifer Freytag
- Center for Innovations in Quality Effectiveness, and Safety, Houston, Texas.,Michael E. DeBakey VA Medical Center, Houston, Texas.,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Richard L Street
- Center for Innovations in Quality Effectiveness, and Safety, Houston, Texas.,Michael E. DeBakey VA Medical Center, Houston, Texas.,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas.,Texas A&M University, College Station, Texas
| | - Deborah E Barnes
- Department of Psychiatry, University of California, San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Ying Shi
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Aiesha M Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Janet K Shim
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, California
| | | | - Rebecca L Sudore
- Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California.,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
| |
Collapse
|
29
|
Zanobini P, Lorini C, Baldasseroni A, Dellisanti C, Bonaccorsi G. A Scoping Review on How to Make Hospitals health Literate Healthcare Organizations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17031036. [PMID: 32041282 PMCID: PMC7037285 DOI: 10.3390/ijerph17031036] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 01/27/2020] [Accepted: 02/04/2020] [Indexed: 12/13/2022]
Abstract
The concept of health literacy is increasingly being recognised as not just an individual trait, but also as a characteristic related to families, communities, and organisations providing health and social services. The aim of this study is to identify and describe, through a scoping review approach, the characteristics and the interventions that make a hospital a health literate health care organisation (HLHO), in order to develop an integrated conceptual model. We followed Arksey and O’Malley’s five-stage scoping review framework, refined with the Joanna Briggs Institute methodology, to identify the research questions, identify relevant studies, select studies, chart the data, and collate and summarize the data. Of the 1532 titles and abstracts screened, 106 were included. Few studies have explored the effect of environmental support on health professionals, and few outcomes related to staff satisfaction/perception of helpfulness have been reported. The most common types of interventions and outcomes were related to the patients. The logical framework developed can be an effective tool to define and understand priorities and related consequences, thereby helping researchers and policymakers to have a wider vision and a more homogeneous approach to health literacy and its use and promotion in healthcare organizations.
Collapse
Affiliation(s)
- Patrizio Zanobini
- Department of Health Sciences, University of Florence, Viale GB Morgagni 48, 50134 Florence, Italy; (C.L.); (G.B.)
- Correspondence: ; Tel.: +39-3663435179
| | - Chiara Lorini
- Department of Health Sciences, University of Florence, Viale GB Morgagni 48, 50134 Florence, Italy; (C.L.); (G.B.)
| | - Alberto Baldasseroni
- Tuscany Regional Centre for Occupational Injuries and Diseases (CeRIMP), Central Tuscany LHU, Via di San Salvi, 12, 50135 Florence, Italy;
| | - Claudia Dellisanti
- Department of Epidemiology, Regional Health Agency of Tuscany, Via Pietro Dazzi, 1, 50141 Florence, Italy;
| | - Guglielmo Bonaccorsi
- Department of Health Sciences, University of Florence, Viale GB Morgagni 48, 50134 Florence, Italy; (C.L.); (G.B.)
| |
Collapse
|
30
|
Fink RM, Kline DM, Bailey FA, Handel DL, Jordan SR, Lum HD, Fischer SM. Community-Based Conversations about Advance Care Planning for Underserved Populations Using Lay Patient Navigators. J Palliat Med 2020; 23:907-914. [PMID: 31944875 DOI: 10.1089/jpm.2019.0470] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Widespread community engagement in advance care planning (ACP) is needed to overcome barriers to ACP implementation. Objective: Develop, implement, and evaluate a model for community-based ACP in rural populations with low English language fluency and health care access using lay patient navigators. Design: A statewide initiative to improve ACP setting/subjects-trained in a group session approach, bilingual patient navigators facilitated 1-hour English and Spanish ACP sessions discussing concerns about choosing a surrogate decision maker and completing an advance directive (AD). Participants received bilingual informational materials, including Frequently Asked Questions, an AD in English or Spanish, and Goal Setting worksheet. Measurement: Participants completed a program evaluation and 4-item ACP Engagement Survey (ACP-4) postsession. Results: For 18 months, 74 ACP sessions engaged 1034 participants in urban, rural, and frontier areas of the state; 39% were ethnically diverse, 69% female. A nurse or physician co-facilitated 49% of sessions. Forty-seven percent of participants completed an ACP-4 with 29% planning to name a decision maker in the next 6 months and 21% in the next 30 days; 31% were ready to complete an AD in the next 6 months and 22% in the next 30 days. Evaluations showed 98% were satisfied with sessions. Thematic analysis of interviews with facilitators highlighted barriers to delivering an ACP community-based initiative, strategies used to build community buy-in and engagement, and ways success was measured. Conclusion: Patient navigators effectively engaged underserved and ethnically diverse rural populations in community-based settings. This model can be adapted to improve ACP in other underserved populations.
Collapse
Affiliation(s)
- Regina M Fink
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Danielle M Kline
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - F Amos Bailey
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Daniel L Handel
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sarah R Jordan
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado, USA
| | - Stacy M Fischer
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
31
|
Taylor GH, Krakauer EL, Sanders JJ. "Find Out What They Lack, Try to Provide": A Qualitative Investigation of Palliative Care Services Adapted to Local Need in a Low-Resource Setting. J Palliat Med 2020; 23:792-800. [PMID: 31910351 DOI: 10.1089/jpm.2019.0406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: People in low- and middle-income countries with serious health problems rarely have access to palliative care. Promising models of palliative care delivery have emerged in India despite widespread poverty and poor health care infrastructure. Objective: To explore structural and philosophical aspects of palliative care delivery in a low-resource setting. Design: One author spent six months as a participant observer at Pallium India (PI), a nongovernmental organization recognized for leadership in palliative care delivery in Kerala, India. We collected administrative data, conducted semistructured interviews with key stakeholders, and observed clinical encounters and other organization-led events. Results: We performed 73 interviews with patients, families, clinicians, staff, and volunteers, and observed 180 patient encounters. The majority of palliative care patients did not have cancer. Many had chronic diseases that were not immediately life threatening. Services addressed a broad range of patients' medical, psychological, social, and/or financial needs. PI's care delivery maximizes accessibility. Conclusions: PI employs an expansive definition of palliative care and adapts services to respond to patients' diverse needs. This accessible, people-centered care is necessary in low-resource settings to alleviate multifaceted suffering caused by gaps in the health care system, poor social support, and poverty.
Collapse
Affiliation(s)
- Grace H Taylor
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Eric L Krakauer
- Department of Global Health and Social Medicine, Harvard Medical School, Global Palliative Care Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Justin J Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Ariadne Labs, Boston, Massachusetts, USA
| |
Collapse
|
32
|
Fischer SM, Kline DM, Min SJ, Okuyama-Sasaki S, Fink RM. Effect of Apoyo con Cariño (Support With Caring) Trial of a Patient Navigator Intervention to Improve Palliative Care Outcomes for Latino Adults With Advanced Cancer: A Randomized Clinical Trial. JAMA Oncol 2019; 4:1736-1741. [PMID: 30326035 DOI: 10.1001/jamaoncol.2018.4014] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Strategies to increase access to palliative care, particularly for racial/ethnic minorities, must maximize primary palliative care and community-based models to meet the ever-growing need in a culturally sensitive and congruent manner. Objective To investigate if a culturally tailored patient navigator intervention can improve palliative care outcomes for Latino adults with advanced cancer. Design, Setting, and Participants The Apoyo con Cariño (Support With Caring) randomized clinical trial was conducted from July 2012 to March 2016. The setting was clinics across the state of Colorado, including an academic National Cancer Institute-designated cancer center, community cancer clinics (urban and rural), and a safety-net cancer center. Participants were adults who self-identified as Latino and were being treated for advanced cancer. Intervention Culturally tailored patient navigator intervention. Main Outcomes and Measures Primary outcome measures were advance care planning in the medical record, the Brief Pain Inventory, and hospice use. Secondary outcome measures included the McGill Quality of Life Questionnaire (MQOL), hospice length of stay, and aggressiveness of care at the end of life. This study used an intent-to-treat design. Results In total, 223 Latino adults enrolled (mean [SD] age, 58.1 [13.6] years; 55.6% female) and were randomized to control (n = 111) or intervention (n = 112) groups. Intervention group patients were more likely to have a documented advance directive compared with control group patients (73 of 112 [65.2%] vs 40 of 111 [36.0%], P < .001). Both groups reported mild pain intensity (mean pain rating of 3 on a scale of 0-10). Intervention group patients had a mean (SD) reported change from baseline in the Brief Pain Inventory pain severity subscale score (range, 0-10) of 0.1 (2.6) vs 0.2 (2.7) in control group patients (P = .88) and a mean (SD) reported change from baseline in the Brief Pain Inventory pain interference subscale score of 0.1 (3.2) vs -0.2 (3.0) in control group patients (P = .66). Hospice use was similar in both groups. Secondary outcomes of overall MQOL score and aggressiveness of care at the end of life showed no significant differences between groups. The MQOL physical subscale showed a mean (SD) significant change from baseline of 1.4 (3.1) in the intervention group vs 0.1 (3.0) in the control group (P = .004). Conclusions and Relevance The intervention had mixed results. The intervention increased advance care planning and improved physical symptoms; however, it had no effect on pain management and hospice use or overall quality of life. Further research is needed to determine the role and scope of lay navigators in palliative care. Trial Registration ClinicalTrials.gov identifier: NCT01695382.
Collapse
Affiliation(s)
- Stacy M Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | - Danielle M Kline
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | - Sung-Joon Min
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora
| | | | - Regina M Fink
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora.,CU College of Nursing, University of Colorado, Aurora
| |
Collapse
|
33
|
Feuz MA, Odierna DH, Katen M, Volow A, McMahan RD, Ritchie CS, McSpadden S, Dearman K, Sudore RL. Leveraging In-Home Supportive Services Programs to Engage People in Advance Care Planning: Input from Staff, Providers, and Client Stakeholders. J Palliat Med 2019; 22:1430-1438. [PMID: 31596644 DOI: 10.1089/jpm.2018.0429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: In-Home Supportive Services (IHSS) cares for millions of Medicaid-eligible older adults who are often homebound and socially isolated. Advance care planning (ACP) can be challenging for this population, and IHSS programs may play an important role. Objective: To explore the feasibility of an IHSS ACP program for frail older adults. Design: Semistructured focus groups. Setting/Subjects: Fifty IHSS stakeholders (20 administrators, 9 case managers, 13 in-home caregivers, and 8 clients) participated in 10 focus groups in San Francisco. Measurements: Qualitative thematic content analysis by two independent coders. Results: Four main themes emerged: (1) Unmet needs: patients' wishes unknown during a medical crisis, lack of education/training for clients and staff; (2) Barriers: conflict of interest and potential medical overreach of IHSS caregivers, lack of billing avenues, time limitations, and cultural, literacy, and language barriers; (3) Facilitators: leveraging established workflows, available technology, and training programs; and (4) Implementation: use a tailored, optional approach based on clients' readiness, focus on case managers not caregivers to prevent conflict of interest; use established intake, follow-up, and training procedures; consider cultural and literacy-appropriate messaging; and standardize easy-to-use procedures, simple scripts, and educational guides, within established workflow to support case managers. Conclusions: An IHSS ACP program is important and feasible for Medicaid-eligible, frail older adults. Implementation suggestions for success by IHSS stakeholders include focusing on case managers rather than in-home caregivers to prevent conflict of interest; tailoring programs to clients' readiness, literacy, and language; creating educational programs for IHSS staff, clients, and community; and standardizing easy-to-use guides and procedures into IHSS workflows.
Collapse
Affiliation(s)
- Mariko A Feuz
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Donna H Odierna
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California
| | - Mary Katen
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Aiesha Volow
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Ryan D McMahan
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California
| | - Christine S Ritchie
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California.,Tideswell at UCSF and the Innovation and Implementation Center on Aging and Palliative Care at the University of California, San Francisco, San Francisco, California
| | - Shireen McSpadden
- San Francisco Department of Aging and Adult Services, San Francisco, California
| | - Kelly Dearman
- San Francisco In-Home Supportive Services Public Authority, San Francisco, California
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California.,Tideswell at UCSF and the Innovation and Implementation Center on Aging and Palliative Care at the University of California, San Francisco, San Francisco, California
| |
Collapse
|
34
|
Risk J, Mohammadi L, Rhee J, Walters L, Ward PR. Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis. BMJ Open 2019; 9:e030275. [PMID: 31537570 PMCID: PMC6756326 DOI: 10.1136/bmjopen-2019-030275] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice? DESIGN A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting. SETTING Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews. RESULTS The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging. CONCLUSION Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice. PROSPERO REGISTRATION NUMBER CRD42018088838.
Collapse
Affiliation(s)
- Jo Risk
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Leila Mohammadi
- Library, Flinders University, Adelaide, South Australia, Australia
| | - Joel Rhee
- General Practice Academic Unit, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Lucie Walters
- Rural Health, Flinders University, Adelaide, South Australia, Australia
| | - Paul R Ward
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| |
Collapse
|
35
|
Baddour NA, Siew ED, Robinson-Cohen C, Salat H, Mason OJ, Stewart TG, Karlekar M, El-Sourady MH, Lipworth L, Abdel-Kader K. Serious Illness Treatment Preferences for Older Adults with Advanced CKD. J Am Soc Nephrol 2019; 30:2252-2261. [PMID: 31511360 DOI: 10.1681/asn.2019040385] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/19/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Patient-centered care for older adults with CKD requires communication about patient's values, goals of care, and treatment preferences. Eliciting this information requires tools that patients understand and that enable effective communication about their care preferences. METHODS Nephrology clinic patients age ≥60 years with stage 4 or 5 nondialysis-dependent CKD selected one of four responses to the question, "If you had a serious illness, what would be important to you?" Condensed versions of the options were, "Live as long as possible;" "Try treatments, but do not suffer;" "Focus on comfort;" or "Unsure." Patients also completed a validated health outcome prioritization tool and an instrument determining the acceptability of end-of-life scenarios. Patient responses to the three tools were compared. RESULTS Of the 382 participants, 35% (n=134) selected "Try treatments, but do not suffer;" 33% (n=126) chose "Focus on comfort;" 20% (n=75) opted for "Live as long as possible;" and 12% (n=47) selected "Unsure." Answers were associated with patients' first health outcome priority and acceptability of end-of-life scenarios. One third of patients with a preference to "Focus on comfort" reported that a life on dialysis would not be worth living compared with 5% of those who chose "Live as long as possible" (P<0.001). About 90% of patients agreed to share their preferences with their providers. CONCLUSIONS Older adults with advanced CKD have diverse treatment preferences and want to share them. A single treatment preference question correlated well with longer, validated health preference tools and may provide a point of entry for discussions about patient's treatment goals.
Collapse
Affiliation(s)
| | - Edward D Siew
- Division of Nephrology and Hypertension, Department of Medicine.,Vanderbilt Center for Kidney Disease
| | - Cassianne Robinson-Cohen
- Division of Nephrology and Hypertension, Department of Medicine.,Vanderbilt Center for Kidney Disease
| | - Huzaifah Salat
- Department of Medicine, St. Barnabas Hospital Health System, Bronx, New York
| | | | | | - Mohana Karlekar
- Division of General Internal Medicine, Public Health, and Palliative Medicine, and
| | - Maie H El-Sourady
- Division of General Internal Medicine, Public Health, and Palliative Medicine, and
| | - Loren Lipworth
- Vanderbilt Center for Kidney Disease.,Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Department of Medicine, .,Vanderbilt Center for Kidney Disease
| |
Collapse
|
36
|
Walling AM, Sudore RL, Bell D, Tseng CH, Ritchie C, Hays RD, Gibbs L, Rahimi M, Sanz J, Wenger NS. Population-Based Pragmatic Trial of Advance Care Planning in Primary Care in the University of California Health System. J Palliat Med 2019; 22:72-81. [PMID: 31486723 PMCID: PMC6916115 DOI: 10.1089/jpm.2019.0142] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction: Varying intensity of advance care planning (ACP) interventions at the population level has not been compared among seriously ill patients in primary care. This project will implement, test, and disseminate real-world scalable ACP interventions among primary care clinics across three University of California Health systems. The three ACP interventions are (1) distribution of an advance directive (AD) with targeted ACP messaging, (2) the AD, messaging, plus prompting patients to engage with the Prepare For Your Care website (PREPARE), and (3) the AD, messaging, PREPARE, plus Care Coordinator engagement with patients and clinicians. Methods: We will identify a population cohort of seriously ill primary care patients and implement the ACP interventions using electronic health record (EHR) patient portals and postal mailings. Forty-five clinics across the three health systems will be cluster randomized to one of the three ACP interventions. The primary outcome for the population cohort is AD or Physician Orders for Life-Sustaining Treatment documentation in the EHR. A subset of the population cohort will be surveyed to assess patient-centered outcomes, including care consistent with goals at baseline, 12 months, and 24 months. Caregivers will be interviewed if patients are unable to be surveyed or die. ACP documentation, goal concordant care, and among decedents, health care utilization will be compared among intervention arms. Study Implementation: Challenges and Contributions: The project is guided by a Study Advisory Group and Community Advisory Groups at each site to ensure rigorous patient-centered methods and consistency of implementation. Intervention fidelity will be evaluated using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. Challenges to implementation of this three-site health system trial and to intervention fidelity stem from site/clinic/system cultures, increasing attention to end-of-life care from payers and regulators, and growing pressures by health systems to implement ACP interventions. Stakeholder engagement is required to ensure consistent interventions across sites.
Collapse
Affiliation(s)
- Anne M. Walling
- Department of Medicine, University of California, Los Angeles, California
- VA Greater Los Angeles Health System, Los Angeles, California
| | - Rebecca L. Sudore
- Department of Medicine, University of California, San Francisco, California
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Doug Bell
- Department of Medicine, University of California, Los Angeles, California
| | - Chi-Hong Tseng
- Department of Medicine, University of California, Los Angeles, California
| | - Christine Ritchie
- Department of Medicine, University of California, San Francisco, California
| | - Ron D. Hays
- Department of Medicine, University of California, Los Angeles, California
| | - Lisa Gibbs
- Departments of Medicine and Family Medicine, University of California, Irvine, California
| | - Maryam Rahimi
- Departments of Medicine and Family Medicine, University of California, Irvine, California
| | - Javier Sanz
- Department of Medicine, University of California, Los Angeles, California
| | - Neil S. Wenger
- Department of Medicine, University of California, Los Angeles, California
| |
Collapse
|
37
|
Dalal RS, Osterman MT, Buchner AM, Praestgaard A, Lewis JD, Lichtenstein GR. A User-Friendly Prediction Tool to Identify Colectomy Risk in Patients With Ulcerative Colitis. Inflamm Bowel Dis 2019; 25:1550-1558. [PMID: 30753443 DOI: 10.1093/ibd/izz014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/04/2019] [Accepted: 01/18/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Many patients with ulcerative colitis (UC) fear the potential side effects of immunosuppressive therapies. However, those with medically refractory disease often require total proctocolectomy (TPC) with a permanent ostomy or pouch, which may reduce quality of life. Prior studies have identified TPC predictors; however, no clinically useful prognostic tools exist to guide shared therapeutic decision-making. We therefore sought to develop a prediction tool of future TPC risk in UC patients. METHODS In this retrospective study, clinic charts of UC patients were reviewed from January 1, 2017, to December 31, 2017. Cases had TPC performed for refractory UC after January 1, 2008. Controls had no prior UC surgery. Clinical data were assessed 1-12 months preceding TPC or clinic visit for cases and controls, respectively. We randomly selected two-thirds of patients to develop a TPC prediction model using multivariable logistic regression. One-third was reserved for model validation. RESULTS We identified 115 cases and 325 controls. TPC predictors included albumin, 9-point Mayo score >5, Mayo endoscopic subscore >1, and corticosteroid use within 6 months. The areas under the receiver operating characteristic curve for the multivariable model were 0.94 (95% confidence interval [CI], 0.92-0.95) and 0.92 (95% CI, 0.89-0.95) for the test and validation cohorts, respectively. The validation cohort demonstrated a significant difference in calculated probability distributions between patients who did and did not have TPC (P < 0.01). We incorporated our model into a web-based application to allow convenient calculation of a patient's TPC risk. CONCLUSIONS We created a user-friendly tool to assess TPC risk in UC. Prospective assessment will determine its utility for shared therapeutic decision-making.
Collapse
Affiliation(s)
- Rahul S Dalal
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark T Osterman
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anna M Buchner
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Praestgaard
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary R Lichtenstein
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
38
|
Nouri SS, Barnes DE, Volow AM, McMahan RD, Kushel M, Jin C, Boscardin J, Sudore RL. Health Literacy Matters More Than Experience for Advance Care Planning Knowledge Among Older Adults. J Am Geriatr Soc 2019; 67:2151-2156. [PMID: 31424575 DOI: 10.1111/jgs.16129] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/02/2019] [Accepted: 07/13/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Advance care planning (ACP) engagement is low among vulnerable populations, including those with limited health literacy (LHL). Limited knowledge about ACP may be a modifiable mediator of the relationship between LHL and ACP. Our goal was to determine whether health literacy is associated with ACP knowledge. DESIGN Cross-sectional design. SETTING A public health delivery system and Veterans Affairs Medical Center in San Francisco, CA. PARTICIPANTS English- and Spanish-speaking patients (N = 1400). MEASUREMENTS ACP knowledge was assessed with seven validated multiple-choice questions. Health literacy was measured using a validated scale. Sociodemographic measures included age, sex, language, education, race, health status, and social support. Prior ACP experience was defined as having documented legal forms and/or goals-of-care discussions in the medical record. We used Kruskal-Wallis tests and linear regression to examine associations of ACP knowledge with LHL, prior ACP experience, and sociodemographic factors. RESULTS Mean age of participants was 65 (±10) years, 48% were women, 34% had LHL, 32% were Spanish speaking, 47% had high school education or less, and 70% were nonwhite. Mean 7-point knowledge scores were lower for those with limited vs adequate health literacy (3.8 [SD = 1.9 vs 5.5 (SD = 1.7); P < .001). In multivariable analysis, ACP knowledge scores were 1.0 point lower among those with LHL; 0.6 points lower among Spanish speakers and those with high school education or less; and 0.5 points lower among individuals of nonwhite race (P < .001 for all). Knowledge scores were 0.02 points lower per year of older age (P = .007) and 0.01 points higher per point of greater social support (P = .005). Prior ACP experience was not associated with knowledge after adjustment (P = .7). CONCLUSIONS Health literacy and sociodemographics are stronger predictors than prior ACP experience of ACP knowledge. This study suggests that providing easy-to-understand ACP materials is paramount and should be offered even if patients have previous experience with the ACP process. J Am Geriatr Soc 67:2151-2156, 2019.
Collapse
Affiliation(s)
- Sarah S Nouri
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Deborah E Barnes
- Department of Psychiatry, University of California, San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Division of Geriatrics, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Innovation and Implementation Center in Aging and Palliative Care Research), University of California, San Francisco, San Francisco, California
| | - Aiesha M Volow
- Division of Geriatrics, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Innovation and Implementation Center in Aging and Palliative Care Research), University of California, San Francisco, San Francisco, California.,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Ryan D McMahan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Margot Kushel
- Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| | - Chengshi Jin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Innovation and Implementation Center in Aging and Palliative Care Research), University of California, San Francisco, San Francisco, California
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Innovation and Implementation Center in Aging and Palliative Care Research), University of California, San Francisco, San Francisco, California.,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| |
Collapse
|
39
|
|
40
|
Maldonado LY, Goodson RB, Mulroy MC, Johnson EM, Reilly JM, Homeier DC. Wellness in Sickness and Health (The W.I.S.H. Project): Advance Care Planning Preferences and Experiences Among Elderly Latino Patients. Clin Gerontol 2019; 42:259-266. [PMID: 29206578 DOI: 10.1080/07317115.2017.1389793] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess advance care planning (ACP) preferences, experiences, and comfort in discussing end-of-life (EOL) care among elderly Latinos. METHODS Patients aged 60 and older from the Los Angeles County and University of Southern California (LAC+USC) Medical Center Geriatrics Clinic (n = 41) participated in this intervention. Trained staff conducted ACP counseling with participants in their preferred language, which included: (a) pre-counseling survey about demographics and EOL care attitudes, (b) discussion of ACP and optional completion of an advance directive (AD), and (c) post-session survey. RESULTS Patients were primarily Spanish speaking with an average of 2.7 chronic medical conditions. Most had not previously documented (95%) or discussed (76%) EOL wishes. Most were unaware they had control over their EOL treatment (61%), but valued learning about EOL options (83%). Post-counseling, 85% reported comfort discussing EOL goals compared to 66% pre-session, and 88% elected to complete an AD. Nearly half of patients reported a desire to discuss EOL wishes sooner. CONCLUSIONS Elderly Latino patients are interested in ACP, given individualized, culturally competent counseling in their preferred language. CLINICAL IMPLICATIONS Patients should be offered the opportunity to discuss and document EOL wishes at all primary care appointments, regardless of health status. Counseling should be completed in the patient's preferred language, using culturally competent materials, and with family members present if this is the patient's preference. Cultural-competency training for providers could enhance the impact of EOL discussions and improve ACP completion rates for Latino patients.
Collapse
Affiliation(s)
- Lauren Y Maldonado
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA
| | - Ruth B Goodson
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA
| | - Matthew C Mulroy
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA
| | - Emily M Johnson
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA.,b Department of Family Medicine, LAC+USC Medical Center , Los Angeles , California , USA
| | - Jo M Reilly
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA.,b Department of Family Medicine, LAC+USC Medical Center , Los Angeles , California , USA
| | - Diana C Homeier
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA.,c Department of Family Medicine and Geriatrics Clinic, LAC+USC Medical Center , Los Angeles , California , USA
| |
Collapse
|
41
|
Eneanya ND, Olaniran K, Xu D, Waite K, Crittenden S, Hazar DB, Volandes AE, Temel JS, Thadhani R, Paasche-Orlow MK. Health Literacy Mediates Racial Disparities in Cardiopulmonary Resuscitation Knowledge among Chronic Kidney Disease Patients. J Health Care Poor Underserved 2019; 29:1069-1082. [PMID: 30122684 DOI: 10.1353/hpu.2018.0080] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Black patients with chronic kidney disease (CKD) receive more cardiopulmonary resuscitation (CPR) than other racial groups, and knowledge of CPR influences preferences for care. As limited health literacy disproportionately affects Blacks and contributes to disparities in end-of-life (EOL) care, we investigated whether health literacy mediates racial disparities in CPR knowledge. Black and White adult patients with advanced CKD completed CPR knowledge surveys. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine. Among 149 patients, Black patients were more likely to have limited health literacy and lower mean CPR knowledge scores than White patients. In adjusted analyses, health literacy mediated racial differences in CPR knowledge. Knowledge of CPR is lower among Black compared with White CKD patients and health literacy is a mediator of this difference. Future CPR educational interventions should target health literacy barriers to improve informed decision-making and decrease racial disparities at the end of life.
Collapse
|
42
|
de Vries K, Banister E, Dening KH, Ochieng B. Advance care planning for older people: The influence of ethnicity, religiosity, spirituality and health literacy. Nurs Ethics 2019; 26:1946-1954. [PMID: 30943848 DOI: 10.1177/0969733019833130] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In this discussion paper we consider the influence of ethnicity, religiosity, spirituality and health literacy on Advance Care Planning for older people. Older people from cultural and ethnic minorities have low access to palliative or end-of-life care and there is poor uptake of advance care planning by this group across a number of countries where advance care planning is promoted. For many, religiosity, spirituality and health literacy are significant factors that influence how they make end-of-life decisions. Health literacy issues have been identified as one of the main reasons for a communication gaps between physicians and their patients in discussing end-of-life care, where poor health literacy, particularly specific difficulty with written and oral communication often limits their understanding of clinical terms such as diagnoses and prognoses. This then contributes to health inequalities given it impacts on their ability to use their moral agency to make appropriate decisions about end-of-life care and complete their Advance Care Plans. Currently, strategies to promote advance care planning seem to overlook engagement with religious communities. Consequently, policy makers, nurses, medical professions, social workers and even educators continue to shape advance care planning programmes within the context of a medical model. The ethical principle of justice is a useful approach to responding to inequities and to promote older peoples' ability to enact moral agency in making such decisions.
Collapse
|
43
|
Culturally Acceptable Advance Care Planning and Advance Directives for Persons Experiencing Homelessness. J Hosp Palliat Nurs 2019; 21:350-357. [DOI: 10.1097/njh.0000000000000530] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
44
|
Improving the Adoption of Advance Directives in Primary Care Practices. J Am Board Fam Med 2019; 32:168-179. [PMID: 30850453 PMCID: PMC6937160 DOI: 10.3122/jabfm.2019.02.180236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/30/2018] [Accepted: 12/04/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Oklahoma's Advance Directive completion rate is less than 10%. We compared the implementation performance of 2 advance directive forms to determine which form could be more successfully disseminated. METHODS The implementation of the Oklahoma Advance Directive (OKAD) and the Five Wishes form were compared in an 8-month pair-matched cluster randomized study in 6 primary care practices. The outcomes measured during the 22-week implementation included form offering rate, acceptance/completion rate by patients, and documentation in the chart. Twenty semistructured interviews with patients and clinicians were conducted to assess intervention experience. RESULTS A total of 2748 patient encounters were evaluated. OKAD was offered in 33% of eligible patient visits (493/1494) and accepted 54% of the time (266/493). Five Wishes was offered in 36% of eligible patient visits (450/1254) and accepted 82% of the time (369/450). Unadjusted analyses found no significant difference in offering of advance directive forms between groups. However, the odds of accepting Five Wishes were 3.89 times that of OKAD (95% CI, 2.88 to 5.24; P < .0001). Logistic regression models controlling for several confounders indicated that the acceptance of Five Wishes was favored significantly over OKAD (OR = 1.52; 95% CI, 1.27 to 1.81; P < .0001). Qualitative analyses indicated a clear clinician and patient preference for Five Wishes. CONCLUSIONS Results suggest that Five Wishes was more readable, understandable, appealing, and usable. It seemed to capture patient preferences for end-of-life care more effectively and it more readily facilitated patient-clinician conversations.
Collapse
|
45
|
Sudore RL, Schillinger D, Katen MT, Shi Y, Boscardin WJ, Osua S, Barnes DE. Engaging Diverse English- and Spanish-Speaking Older Adults in Advance Care Planning: The PREPARE Randomized Clinical Trial. JAMA Intern Med 2018; 178:1616-1625. [PMID: 30383086 PMCID: PMC6342283 DOI: 10.1001/jamainternmed.2018.4657] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Advance care planning improves the receipt of medical care aligned with patients' values; however, it remains suboptimal among diverse patient populations. To mitigate literacy, cultural, and language barriers to advance care planning, easy-to-read advance directives and a patient-directed, online advance care planning program called PREPARE For Your Care (PREPARE) were created in English and Spanish. OBJECTIVE To compare the efficacy of PREPARE plus an easy-to-read advance directive with an advance directive alone to increase advance care planning documentation and patient-reported engagement. DESIGN, SETTING, AND PARTICIPANTS A comparative efficacy randomized clinical trial was conducted from February 1, 2014, to November 30, 2017, at 4 safety-net, primary-care clinics in San Francisco among 986 English-speaking or Spanish-speaking primary care patients 55 years or older with 2 or more chronic or serious illnesses. INTERVENTIONS Participants were randomized to PREPARE plus an easy-to-read advance directive (PREPARE arm) or the advance directive alone. There were no clinician-level or system-level interventions. Staff were blinded for all follow-up measurements. MAIN OUTCOMES AND MEASURES The primary outcome was documentation of new advance care planning (ie, legal forms and/or documented discussions) at 15 months. Patient-reported outcomes included advance care planning engagement at baseline, 1 week, 3 months, 6 months, and 12 months using validated surveys. Intention-to-treat analyses were performed using mixed-effects logistic and linear regression, controlling for time, health literacy, and baseline advance care planning, clustering by physician, and stratifying by language. RESULTS Among the 986 participants (603 women and 383 men), the mean (SD) age was 63.3 (6.4) years, 387 of 975 (39.7%) had limited health literacy, and 445 (45.1%) were Spanish speaking. No participant characteristic differed between the 2 groups, and retention was 85.9% (832 of 969) among survivors. Compared with the advance directive alone, PREPARE resulted in a higher rate of advance care planning documentation (unadjusted, 43.0% [207 of 481] vs 33.1% [167 of 505]; P < .001; adjusted, 43.0% vs 32.0%; P < .001) and higher self-reported increased advance care planning engagement scores (98.1% vs 89.5%; P < .001). Results remained significant among English speakers and Spanish speakers. CONCLUSIONS AND RELEVANCE The patient-facing PREPARE program and an easy-to-read advance directive, without clinician-level or system-level interventions, increased documentation of advance care planning and patient-reported engagement, with statistically higher gains for PREPARE vs advance directive alone. These tools may mitigate literacy and language barriers to advance care planning, allow patients to begin planning on their own, and could substantially improve the process for diverse English-speaking and Spanish-speaking populations. TRIAL REGISTRATION ClinicalTrials.gov identifiers: NCT01990235 and NCT02072941.
Collapse
Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco.,Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, California.,Northern California Institute for Research and Education, San Francisco.,Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California.,Department of Medicine, University of California, San Francisco
| | - Dean Schillinger
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California.,Department of Medicine, University of California, San Francisco.,Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
| | - Mary T Katen
- Division of Geriatrics, Department of Medicine, University of California, San Francisco.,Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, California.,Northern California Institute for Research and Education, San Francisco.,Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Ying Shi
- Division of Geriatrics, Department of Medicine, University of California, San Francisco.,Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco.,Department of Epidemiology & Biostatistics, University of California, San Francisco
| | - Stacy Osua
- Division of Geriatrics, Department of Medicine, University of California, San Francisco.,Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, California.,Northern California Institute for Research and Education, San Francisco.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California.,Department of Medicine, University of California, San Francisco
| | - Deborah E Barnes
- Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, California.,Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco.,Department of Epidemiology & Biostatistics, University of California, San Francisco.,Department of Psychiatry, University of California, San Francisco
| |
Collapse
|
46
|
CİNGİ CC. Patients' Degree of Health Literacy: A Cross-Sectional Survey from Eskisehir, Turkey. ENT UPDATES 2018. [DOI: 10.32448/entupdates.471921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
47
|
Kata A, Sudore R, Finlayson E, Broering JM, Ngo S, Tang VL. Increasing Advance Care Planning Using a Surgical Optimization Program for Older Adults. J Am Geriatr Soc 2018; 66:2017-2021. [PMID: 30289968 DOI: 10.1111/jgs.15554] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To describe an innovative model of care, the Surgery Wellness Program (SWP), that uses a multidisciplinary team to develop and implement preoperative care plans for older adults, and its effect on engagement in advance care planning (ACP). DESIGN Retrospective analysis of clinical demonstration project. SETTING Preoperative optimization program for older adults undergoing surgery at a 796-bed academic tertiary hospital. PARTICIPANTS Older adults (N=131) who participated in the SWP from February 2015 to August 2017. INTERVENTION All SWP participants met with a geriatrician who engaged them in a semistructured ACP discussion. Trained medical and nurse practitioner students were used as health coaches who contacted participants regularly to address and document ACP. MEASUREMENTS Self-report of ACP engagement before and after participation in the SWP was determined using SWP geriatrician and health coach progress notes. Medical records were examined for scanned documentation. Feasibility data on number of health coach calls were collected. RESULTS After completion of the program, the proportion of participants with a designated surrogate increased from 67% to 78% (p<.001), completed advance directive (AD) from 51% to 72% (p<.001), and an AD scanned into the medical record from 14% to 60% (p<.001). Participants who underwent surgery received a median of 4 health coaching calls over a median of 27 days between their clinic visit and surgery. Case examples are presented to highlight how the SWP attends to the many components of the ACP process. CONCLUSION Preoperative optimization programs provide a unique opportunity to engage older adults in ACP.
Collapse
Affiliation(s)
- Anna Kata
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
| | - Emily Finlayson
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Department of Surgery, University of California, San Francisco, California
| | | | - Sarah Ngo
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
| | - Victoria L Tang
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Division of Hospital Medicine, Department of Medicine, Veterans Affairs Medical Center, San Francisco, California
| |
Collapse
|
48
|
Lum HD, Barnes DE, Katen MT, Shi Y, Boscardin J, Sudore RL. Improving a Full Range of Advance Care Planning Behavior Change and Action Domains: The PREPARE Randomized Trial. J Pain Symptom Manage 2018; 56:575-581.e7. [PMID: 29940209 PMCID: PMC6138565 DOI: 10.1016/j.jpainsymman.2018.06.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 12/15/2022]
Abstract
CONTEXT Advance care planning (ACP) engagement includes a wide range of behaviors and actions related to discussions and documentation, yet few ACP intervention studies measure the full process. OBJECTIVES The objective of the study was to compare the effects of an easy-to-read advance directive (AD) versus an ACP web site plus the AD (PREPARE + AD) on Behavior Change Processes and Actions, including discussions and documentation. METHODS Secondary data were from a completed ACP trial. Participants were primary care patients, ≥60 years old, with two comorbidities. We used the validated ACP Engagement Survey to examine six-month change in subscales measuring Behavior Change Processes (knowledge, contemplation, self-efficacy, readiness) and Actions (decision makers, quality of life, flexibility for decision makers, asking clinicians questions), specifically related to discussions and documentation. We used adjusted mixed-effects linear models to compare mean change and engagement over time. RESULTS Compared to the AD-only, PREPARE + AD resulted in greater increases in all Behavior Change Processes subscales and Actions related to decision makers, quality of life, and flexibility (all P-values ≤0.005). Both interventions significantly increased the proportion of participants who engaged in ACP discussions (PREPARE + AD, 99.5%; AD-only, 93.3%) and documentation (PREPARE + AD, 99.5%; AD-only, 90.4%), with greater increases for PREPARE + AD (all P-values <0.001). CONCLUSION Both PREPARE plus an easy-to-read AD and an AD-only markedly increased ACP engagement in a full range of ACP behaviors, including discussions and documentation, and engagement was nearly 100% with PREPARE + AD. Future ACP studies should examine a full range of ACP behaviors beyond ADs and the impact of PREPARE and easy-to-read AD implementation on health care systems.
Collapse
Affiliation(s)
- Hillary D Lum
- Eastern Colorado VA Geriatric Research Education and Clinical Center, Denver, Colorado, USA; Division of Geriatric Medicine, Department of Medicine, University of Colorado, Aurora, Colorado, USA.
| | - Deborah E Barnes
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA; Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Mary T Katen
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Ying Shi
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| |
Collapse
|
49
|
Sudore RL, Cuervo IA, Tieu L, Guzman D, Kaplan LM, Kushel M. Advance Care Planning for Older Homeless-Experienced Adults: Results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age Study. J Am Geriatr Soc 2018; 66:1068-1074. [PMID: 29741765 DOI: 10.1111/jgs.15417] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety-net healthcare settings.
Collapse
Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | - Lina Tieu
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.,Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - David Guzman
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.,Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - Lauren M Kaplan
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.,Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - Margot Kushel
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.,Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| |
Collapse
|
50
|
Strategies used to facilitate the discussion of advance care planning with older adults in primary care settings: A literature review. J Am Assoc Nurse Pract 2018; 30:270-279. [DOI: 10.1097/jxx.0000000000000025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|