The care planning umbrella: The evolution of advance care planning

Expanded care planning paradigm for older adults with type 2 diabetes: Rationale, design, and protocol of the PREPARE for Your Diabetes Care randomized trial

BACKGROUND

As adults with type 2 diabetes (T2D) age, they are increasingly vulnerable to treatment-related hypoglycemia and subsequent complications including falls and hospitalizations. Care planning helps patients communicate what is most important for their medical care with their family, friends, and clinicians and could help reduce treatment-related complications of T2D in older adults.

METHODS

We applied an expanded care planning paradigm to the specific clinical problem of type 2 diabetes management in older patients. Applying user-centered design methods, we developed an educational, web-based program called "PREPARE for Your Diabetes Care," incorporating input and feedback from patient and provider key informants. A randomized controlled trial (RCT) of this program vs. usual care is being conducted among Kaiser Permanente Northern California members ≥75 years of age, prescribed insulin or sulfonylureas, and at high risk for hypoglycemia. The primary outcome of the RCT is clinically significant hypoglycemia episodes (self-reported 3+ symptomatic episodes of hypoglycemia, self-reported severe hypoglycemia, and/or ED or hospitalization for hypoglycemia). Secondary outcomes will include medication de-intensification, 5-item RAND Patient Satisfaction, and 5-item Perceived Efficacy in Patient - Physician Interactions.

RESULTS

This study has completed enrollment and randomized 673 participants; trial completion is expected in late 2025.

CONCLUSIONS

This research will evaluate an expanded care planning intervention to reduce treatment-related hypoglycemia in older adults with T2D. If successful, this web-based expanded care planning strategy could be applied to a wide variety of geriatric conditions requiring individualization of treatment based on patients' preferences.

TRIAL REGISTRATION NUMBERS

NCT05263310; Pre-results.

Could life story work support relational autonomy in advance care planning? Stories from the EARLI project

OBJECTIVES

Advance care planning has evolved from a narrow focus on advance directives completion towards a greater emphasis on ongoing conversations and value clarification. This evolution aligns with a relational perspective on autonomy in a social context. However, limited research explores how relational autonomy might be operationalised in practice. Life story work is a novel approach that may serve to operationalise relational autonomy in advance care planning.

METHODS

This paper presents three vignettes from the Enhanced Advance Care Planning and Life Review Longitudinal Intervention (EARLI) project, an arts-based intervention that uses life story work to support advance care planning among older adults living in the community.

RESULTS

The vignettes illustrated how life story work facilitated discussions about values and preferences, enhanced relational autonomy and influenced participants' engagement with advance care planning across different stages.

CONCLUSIONS

Integrating life story work into advance care planning provides a practical approach to fostering relational autonomy. This method offers insight into the ways personal narratives can shape decision-making and communication within the advance care planning process.

'They Were Talking to Each Other but Not to Me': Examining the Drivers of Patients' Poor Experiences During the Transition From the Hospital to Skilled Nursing Facility

INTRODUCTION

Hospital-to-skilled nursing facility (SNF) transitions have been characterised as fragmented and having poor quality. The drivers, or the factors and actions, that directly lead to these poor experiences are not well described. It is essential to understand the drivers of these experiences so that specific improvement targets can be identified. This study aimed to generate a theory of contributing factors that determine patient and caregiver experiences during the transition from the hospital to SNF.

METHODS

We conducted a grounded theory study on the Medicine Service at an academic medical centre (AMC) and a short-term rehabilitation SNF. We conducted individual in-depth interviews with patients, caregivers and clinicians, as well as ethnographic observations of hospital and SNF care activities. We analysed data using dimensional analysis to create an explanatory matrix that identified prominent dimensions and considered the context, conditions and processes that result in patient and caregiver consequences and experiences.

RESULTS

We completed 41 interviews (15 patients, 5 caregivers and 15 AMC and 6 SNF clinicians) and 40 h of ethnographic observations. 'They were talking to each other, but not to me' was the dimension with the greatest explanatory power regarding patient and caregiver experience. Patients and caregivers consistently felt disconnected from their care teams and lacked sufficient information leading to uncertainty about their SNF admission and plans for recovery. Key conditions driving these outcomes were patient and care team processes, including interdisciplinary team-based care, clinical training and practice norms, pressure to maintain hospital throughput, patient behaviours, the availability and provision of information, and patient's physical and emotional vulnerability. The relationships between conditions and processes were complex, dynamic and, at times, interrelated.

CONCLUSION

This study has conceptualised the root causes of poor-quality experiences within the hospital-to-SNF care transition. Our theory generation identifies targets for clinical practice improvement, tailored intervention development and medical education innovations.

PATIENT OR PUBLIC CONTRIBUTION

We partnered with the Hospital Medicine Reengineering Network (HOMERuN) Patient and Family Advisory Council during all stages of this study.

Planning Ahead: protocol for a randomised trial of advance care planning for community dwelling older adults at increased mortality risk

INTRODUCTION

An important goal of advance care planning (ACP) is ensuring that patients receive care concordant with their preferences. High-quality evidence is needed about the effect of ACP on this and other outcomes.

METHODS AND ANALYSIS

Planning Ahead is a randomised controlled trial to test the effectiveness of facilitated ACP in community-dwelling older adults including those with normal cognition and those with Alzheimer's Disease and Related Dementias (ADRD) who are at high risk of death. The primary aim is to determine the effect of the intervention on discordance between preferences for medical treatments and the treatments received in the year after the intervention. Secondary outcomes include decision-making quality, care at the end of life and cost. Eligible patients have a primary care provider at one of two Midwest health systems, have an approximate 33% mortality risk and do not have a POLST form at baseline. Patients with capacity can invite the person they would choose to be their healthcare decision maker to participate as a study partner. A surrogate decision maker enrols and receives the intervention for patients who lack capacity due to ADRD. The intervention uses the Respecting Choices Advanced Steps (RCAS) model of ACP delivered by a registered nurse and includes identification of the patient's values and goals, education about ACP and the POLST form and the opportunity to complete a POLST form.

ETHICS AND DISSEMINATION

The study is approved by the Indiana University Institutional Review Board. Primary and secondary analyses will be published in peer-reviewed journals. We also plan dissemination through the media. We will construct a deidentified data set that could be available to other researchers. Survey data will be preserved and shared via the NIH-supported National Archive of Computerised Data on Ageing's (NACDA) Open Ageing Repository (OAR).

TRIAL REGISTRATION NUMBER

NCT04070183.

"You like to be in control of your own destiny to a degree, don't you?": conscientious autonomy and planning for future care with dementia

BACKGROUND

We explored people with dementia and their family carers' experiences of future care planning, guided by Kukla's model of conscientious autonomy. This relational autonomy concept focuses on the alignment of self-managed health-care practices with people's authentic goals and values. It involves people adopting recommended practices for their own authentic reasons, questioning them where necessary, and being supported by the health and care system to understand their rationale and implement them effectively.

METHODS

In-depth interviews were conducted with 16 people recently diagnosed with dementia and 31 family carers, purposively and selectively sampled from a large research cohort on the basis of their 'conscientiousness,' using the indicator of already having had informal family conversations about future care. Data were analysed thematically using NVivo software and methods informed by interpretive grounded theory.

FINDINGS

Participants sought to feel secure by following recommended practices, manage uncertainty, avoid crises, share burdens within families, and avoid poor end-of-life experiences. However, support was often lacking. Many were unable to speak with specialists and described limited conversations with GPs, leaving them with unaddressed questions. Some described feelings of abandonment. Disease progression was commonly poorly explained, with some participants later encountering information they found confronting. Carers who continued researching the condition felt responsible but under-resourced for discussing disease progression with their relative and believed this should be undertaken by a professional. Formal processes-e.g. Lasting Power of Attorney (LPAs), advance care planning, Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) could prompt informal discussions but gaining an overview was difficult, with confusion about how they would be utilised, what information to include and apparent overlap between processes. Misunderstandings about medical and end-of-life decision-making were commonplace.

CONCLUSION

If even those who are most conscientious about planning for future care struggle to access adequate support, others likely face greater challenges. Clearer communication, at an individual and public level, about disease progression, the practical challenges of medical and end-of-life decision-making, and palliative care options is urgently needed. Early group education sessions and communication strategies that engage with existing lay concepts and public discourse are likely to be helpful. Formal care planning processes should be clearer, more streamlined, and better aligned with the practical goals of people with dementia and their family carers.

Influence of pediatric advance care planning on the secondary outcomes of the BOOST pACP trial: determinants of communication between parents and adolescents with cancer

This study explores the impact of a pediatric advance care planning program (BOOST pACP) on adolescents with cancer and their parents, focusing on behavioral determinants such as attitudes, self-efficacy, intention, and behavior regarding the discussion of ACP topics. A multi-center, parallel-group superiority trial was conducted with adolescent-parent dyads recruited from four pediatric oncology wards in Belgium. The intervention group received four structured ACP sessions facilitated by an external professional, while the control group received care as usual. The acquired insights were shared with their oncologist. The behavioral determinants were measured through self-developed questionnaires based on the Theory of Planned Behavior (TPB) at baseline (T0), 3 months (T1), and 7 months (T2). This secondary data analysis used exploratory factor analysis and linear mixed models to assess the impact of the intervention. Forty-nine families were enrolled and randomized to the BOOST pACP group (n=24) or care-as-usual (n=25). At T1, fathers in the intervention group had significantly lower negative attitudes towards discussing ACP topics than their counterparts in the control group; mothers in the intervention group had increased intentions to discuss end-of-life care topics; and adolescents had reduced intentions to discuss ACP topics with their oncologist. No significant differences between intervention and control were observed in self-efficacy and mothers' attitudes.

CONCLUSION

Our RCT suggests a limited effectiveness of a pediatric ACP intervention in changing behavioral determinants associated with ACP communication. As the study was eventually underpowered, these findings underscore the need for a better understanding of the mechanisms driving or hindering outcomes and impact of pediatric ACP and highlight the complexity of influencing ACP behaviors within the pediatric oncology setting.

TRIAL REGISTRATION

ISRCTN, number 33228289 10.1186/ISRCTN33228289. Registration date: 22/01/2021.

WHAT IS KNOWN

• Pediatric advance care planning (pACP) helps families and healthcare professionals discuss future care but is challenging due to evolving decision-making capacity, family dynamics, and parental distress. • Healthcare professionals also report barriers to engage in pACP.

WHAT IS NEW

• This study evaluated the impact of a structured pACP intervention (BOOST pACP) on behavioral determinants of ACP communication from the perspective of the adolescents, mothers, and fathers separately. • Findings highlight the complexity of influencing ACP behaviors and contributes to the important discussion on what ACP for this target group should look like.

An Intervention to Increase Advance Care Planning Among Older Adults With Advanced Cancer: A Randomized Clinical Trial

Importance

Many older adults with advanced cancer never communicate goals of care or treatment preferences to their clinicians, raising the risk that care received will not match their values. Scalable models of care may help surmount this barrier.

Objective

To test whether a combined patient and clinician intervention increased the rate of advance care planning (ACP) documentation in large health care systems.

Design, Setting, and Participants

This stepped-wedge cluster randomized clinical trial using an open cohort design included patients aged 65 years or older with advanced cancer seen at oncology clinics in 3 health care systems located in the US South, Midwest, and Mid-Atlantic regions from April 1, 2020, to November 30, 2022. Data collection ended in 2024.

Intervention

The intervention involved delivering brief evidence-based patient-facing video decision aids available in 25 languages as well as goals-of-care communication training to oncology clinicians. Patients in the control period received usual care.

Main Outcomes and Measures

The primary outcome was ACP documentation, which included any electronic health record documentation of a goals-of-care conversation, palliative care, hospice, or limitation of life-sustaining treatments, identified via a validated natural language processing program. Analysis was performed on an intention-to-treat basis.

Results

Twenty-nine practices, comprising 13 800 unique eligible patients with a total of 29 357 repeated measurements, were included (mean [SD] age, 74.5 [6.6] years; 52.3% men [15 344 of 29 357 measurements]). The proportion of patients with ACP documentation was greater in the intervention phase compared with the usual care phase (adjusted rate difference, 6.8% [95% CI, 2.8%-10.8%]; P < .001). ACP documentation in the intervention phase occurred among 3980 of 15 754 patients (25.3%) (goals-of-care conversation, 21.4% [3377 of 15 754]; palliative care, 9.6% [1517 of 15 754]; hospice, 5.4% [847 of 15 754]; and limitation of life-sustaining treatments, 7.2% [1128 of 15 754]). In comparison, ACP documentation in the usual care phase occurred among 2834 of 13 603 patients (20.8%) (goals-of-care conversation, 16.8% [2281 of 13 603]; palliative care, 9.5% [1287 of 13 603]; hospice, 5.3% [724 of 13 603]; and limitation of life-sustaining treatments, 8.4% [1149 of 13 603]).

Conclusions and Relevance

In this stepped-wedge cluster randomized clinical trial for older adults with advanced cancer, a bundled evidence-based decision aid and communication training intervention increased the proportion of older patients with ACP documentation. This approach offers an innovative paradigm with a clinically meaningful increase in ACP documentation, a widely used quality metric that reflects high-quality patient-centered care delivery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03609177.

Trust in Physicians and End-of-Life Discussions and Preferences for Place of Care Among US Chinese Older Adults

BACKGROUND

Patient trust in physicians is essential for effective end-of-life discussions. Little is known about how Chinese older adults' trust in physicians relates to their end-of-life care discussions and care setting preferences.

OBJECTIVE

To examine the association between medical trust among Chinese older adults and their views on end-of-life discussions and care setting preferences.

DESIGN

Secondary analysis of longitudinal cohort data from the Population Study of Chinese Elderly (PINE) using linear mixed-effects logistic and multinomial logistic regressions, adjusting for covariates. Predicted probabilities of outcome measures were reported.

PARTICIPANTS

A total of 2192 Chinese older adult immigrants in greater Chicago participated in the PINE study from 2017 to 2020.

MAIN MEASURES

Outcome variables encompass four dimensions of end-of-life care planning: (1) beliefs about the importance of discussions with family; (2) discussions of end-of-life options with family; (3) preference for counseling with a healthcare provider as a resource; and (4) preferred place of care. The main independent variable was trust in physicians. Covariates included age, sex, education, income, years in the United States, living children, self-rated health, and medical conditions.

KEY RESULTS

Respondents with strong trust were less likely to consider end-of-life discussions with family important (AOR = 0.70, 95% CI: 0.55-0.88). Those with strong trust were more likely than those with weak trust to value counseling with a healthcare provider for end-of-life discussions with family (AOR = 5.86, 95% CI: 4.65-7.38). Moderate trust was associated with a preference for end-of-life care in a hospital (AOR = 1.63, 95% CI: 1.30-2.05) over home care, relative to weak trust.

CONCLUSIONS

Older Chinese immigrants with strong trust tended to place less emphasis on end-of-life discussions with family and favored one-on-one counseling with a healthcare provider for end-of-life discussion. Patient education and family engagement in end-of-life discussions led by trusted healthcare providers may be promising approaches to ensure goal-concordant care for this population.

External validation of a proprietary risk model for 1-year mortality in community-dwelling adults aged 65 years or older

OBJECTIVE

To examine the discrimination, calibration, and algorithmic fairness of the Epic End of Life Care Index (EOL-CI).

MATERIALS AND METHODS

We assessed the EOL-CI's performance by estimating area under the receiver operating characteristic curve (AUC), sensitivity, and positive and negative predictive values in community-dwelling adults ≥65 years of age in a single health system in the Southeastern United States. Algorithmic fairness was examined by comparing the model's performance across sex, race, and ethnicity subgroups. Using a machine learning approach, we also explored local re-calibration of the EOL-CI considering additional information on past hospitalizations and frailty.

RESULTS

Among 215 731 patients (median age = 74 years, 57% female, 12% of Black race), 10% were classified as medium risk (15-44) and 3% as high risk (≥45) by the EOL-CI. The observed 1-year mortality rate was 3%. The EOL-CI had an AUC 0.82 for 1-year mortality, with a positive predictive value of 22%. Predictive performance was generally similar across sex and race subgroups, though the EOL-CI displayed better performance with increasing age and in older adults with 2 or more outpatient encounters in the past 24 months. Local re-calibration of the EOL-CI was required to provide absolute estimates of mortality risk, and calibration was further improved when the EOL-CI was augmented with data on inpatient hospitalizations and frailty.

DISCUSSION

The EOL-CI demonstrates reasonable discrimination, albeit with better performance in older adults and in those with greater health system contact.

CONCLUSION

Local refinement and calibration of the EOL-CI score is required to provide direct estimates of prognosis, with the goal of making the EOL-CI a more a valuable tool at the point of care for identifying patients who would benefit from targeted palliative care interventions and proactive care planning.

Evaluating a Clinical Chaplain Pilot Intervention to Facilitate Advance Care Planning in a Primary Care Clinic

BACKGROUND

While advance care planning (ACP) conversations align an individual's healthcare options to their goals, primary care physicians (PCPs) often have limited time and training to conduct ACP in clinic. A clinical chaplain's unique expertise may provide targeted support to help overcome these barriers by assessing the complex dynamics around ACP for patients and providers alike.

OBJECTIVES

Assess the feasibility and impact of a chaplain pilot intervention to facilitate ACP between PCPs and patients.

DESIGN

This pilot quality improvement study was conducted at an urban academic primary care clinic in the Southeastern United States.

PARTICIPANTS

Two hundred and six patients at high risk of hospitalization, determined by an institutional algorithm, were assigned to either intervention or control groups.

INTERVENTION

For each intervention patient, the chaplain reviewed their chart through a pastoral "empathetic, holistic, and relational framework" to (1) determine patient-specific ACP needs and barriers, and (2) complete targeted next steps to facilitate ACP with the PCP.

MAIN MEASURES

Feasibility outcomes were measured using the RE-AIM framework. ACP documentation metrics were compared between study arms before and 6 months after intervention.

KEY RESULTS

The chaplain determined that 75 out of 92 (82%) intervention patients needed additional ACP conversations. Average chart review time was 10 min (range 5-25). The chaplain contacted 62 PCPs and 11 patients, requested 26 appointments, and coordinated 19 interdisciplinary consultations. Compared to controls, intervention patients had a significant increase in ACP notes (35 vs. 2, p =  < 0.001), healthcare power of attorney forms (9 vs. 2, p = 0.02), and advance directive forms (6 vs. 0, p = 0.01) after the intervention.

CONCLUSIONS

A clinical chaplain's unique training and experience may provide feasible and worthwhile support to help identify patient-specific needs and barriers and facilitate ACP conversations between PCPs and high-risk patients.

Caregivers' Perspectives on Discussions of Medical Treatment Preferences for People Living With Dementia Are Associated With Their Dementia Health Literacy and the Caregiving Relationship

BACKGROUND AND OBJECTIVES

People living with dementia experience progressive functional decline and increased dependence on caregivers. This study examined the influence of caregivers' dementia health literacy on perceptions of medical care preferences and advance care planning (ACP) in people living with dementia.

RESEARCH DESIGN AND METHODS

This analysis used data from a cross-sectional survey, "Care Planning for Individuals with Dementia," administered nationwide by Alzheimer's Disease Centers. We conducted binary, ordinal, and multinomial logistic regression.

RESULTS

On average, surveyed caregivers (n = 431) were 78.3 years, had 16 years of education, and were mainly White (88.5%). Most lived with (76.8%) and were the designated healthcare proxy (95.1%), with high dementia knowledge scores (mean = 8.4/10). As caregivers' dementia knowledge scores increased, they were 1.27 times more likely (p = .02) to endorse comfort care. Caregivers with greater knowledge about severe dementia were less likely to need further treatment preference-related discussions (knowing a lot: odds ratio [OR] = 0.17, p < .001; knowing some things: OR = 0.37, p = .006). Caregivers live apart from patients were 2.71 times more likely to know about such discussions (p < .001). Caregivers of people in earlier stages endorsed greater needs for further conversations with clinicians (no impairment and mild cognitive impairment [MCI]: OR = 7.38, p = .002; mild impairment: OR = 5.32, p = .005) and their care recipients (no impairment and MCI: OR = 5.24, p = .02).

DISCUSSION AND IMPLICATIONS

These findings highlight the role of dementia-specific education in ACP discussions among people living with dementia, caregivers, and healthcare clinicians. These findings are important because evidence suggests that ACP may promote quality of life, reduce iatrogenic harm, minimize healthcare overutilization, and alleviate care-related burdens.

Medical complications and advance medical decision-making in the minimally conscious state

OBJECTIVES

Medical complications occur frequently in MCS and influence advance medical decision-making. This study aimed to report on medical complications and advance medical decision-making in a nationwide group of MCS patients.

METHODS

In this descriptive cross-sectional study, clinical and advance medical decision-making characteristics were collected in a survey, completed by the treating physician.

RESULTS

The MCS population consisted of 32 patients: 65.6% traumatic etiology, 68.8% male. Patients had a median of five complications: hypertonia/spasticity (81.3%) and pneumonia (50.0%) occurred most frequently. Most patients had curative goals: three patients had a fully curative treatment scenarios, 29 a curative scenario with ≥ 1 treatment restrictions, two a palliative and two a symptomatic scenario. Conversations about advance medical decision-making were complicated by disputes with next of kin, inability to evaluate medical treatment because of medical instability, next of kin not being ready to discuss medical treatment, or a treatment scenario explicitly based on requests of next of kin.

CONCLUSION

Medical complications are common in MCS patients and advance medical decision making was complicated. This legitimates realization of specialized care across acute, post-acute and long-term care. Further longitudinal research into advance medical decision-making is recommended.

Advance Care Planning in the Inpatient Setting: The Role of the Hospitalist

Advance care planning (ACP) is critical to patient-centered health care, particularly in hospital settings where acute and end-of-life decisions often occur. As frontline providers, hospitalists are uniquely positioned to initiate and guide ACP discussions. This article explores the role of hospitalists in ACP, identifies barriers to its implementation, and highlights strategies to overcome these challenges. Key barriers include time constraints, lack of formal training, and uncertainty regarding the appropriate timing of discussions. To address these issues, hospitalists can benefit from structured communication training, integration of ACP prompts into electronic health records, and collaboration with multidisciplinary teams. While ACP has demonstrated benefits, including the alignment of care with patient preferences, reduced unnecessary interventions, and improved satisfaction for patients and families, challenges remain in ensuring consistent and culturally sensitive implementation. This article also examines the ongoing debate regarding the advantages of ACP, balancing its potential to enhance care with concerns about emotional discomfort and operational barriers. Ultimately, ACP represents a pivotal opportunity to advance patient autonomy and deliver compassionate care. By addressing barriers and leveraging institutional and policy-level support, hospitalists can lead the charge in making ACP a standard and meaningful aspect of health care delivery.

Navigating the Life-Limiting Illness Journey: A Mixed-Method Systematic Review of Advance Care Planning Experiences Among Healthcare Providers, Patients and Family

BACKGROUND

Advance care planning (ACP) enables individuals with life-limiting illnesses to make decisions regarding future healthcare. It involves patients, families and healthcare providers in discussions on treatment preferences and end-of-life care. Understanding their experiences is key to improving ACP practice.

AIMS

To systematically review and analyse the experiences of patients, families and healthcare providers with ACP for life-limiting illnesses.

DESIGN

This study employed a mixed-methods systematic review (MMSR) with a convergent integrated approach.

METHODS

Literature searches were conducted using CINAHL, Cochrane Library, ERIC, MEDLINE, Scopus and Web of Science, as well as hand searches and reference list checking, for articles published between 2010 and August 2024. Two independent reviewers extracted and analysed the data using the JBI guidelines for MMSR.

RESULTS

Of the 1405 citations, 26 studies involving 1599 participants (1076 patients, 398 healthcare providers and 125 family members) were included. The main findings highlight the importance of patient empowerment, family involvement and the integration of ACP into routine care. Eliminating barriers, such as lack of training, resource limitations and challenges with timing discussions, are essential for effective ACP implementation.

CONCLUSION

The MMSR emphasises the need for patient-centred ACP that actively involves families and addresses systemic barriers. Early initiation, tailored emotional support and equitable care across conditions are crucial for an effective ACP.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The MMSR highlights the importance of family involvement and enhanced training for healthcare providers in ACP, emphasising the need for emotional support and systemic changes to improve patient care. These improvements should include better educational programs and policies to ensure early, effective and equitable ACP discussions among various patient groups.

IMPACT

The MMSR underscores the need for structured ACP practices that are currently limited by insufficient training and vague guidelines. Early initiation of ACP discussions and inclusion of patient and family preferences are essential for improving care for individuals with life-limiting conditions. These findings are vital for healthcare providers, policymakers and educators to implement more effective patient-centred ACP approaches. Family involvement remains a key aspect, with the review advocating for a support system that empowers families to play an active role in ACP.

REPORTING METHODS

Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA).

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Advance care planning readiness, barriers, and facilitators among seriously ill Black older adults and their surrogates: A mixed methods study

OBJECTIVES

Advance care planning (ACP) supports communication and medical decision-making and is best conceptualized as part of the care planning continuum. Black older adults have lower ACP engagement and poorer quality of care in serious illness. Surrogates are essential to effective ACP but are rarely integrated in care planning. Our objective was to describe readiness, barriers, and facilitators of ACP among seriously ill Black older adults and their surrogates.

METHODS

We used an explanatory sequential mixed methods study design. The setting was 2 ambulatory specialty clinics of an academic medical center and 1 community church in Northern California, USA. Participants included older adults and surrogates. Older adults were aged 60+, self-identified as Black, and had received care at 1 of the 2 clinics or were a member of the church congregation. Surrogates were aged 18+ and could potentially make medical decisions for the older adult. The validated ACP engagement survey was used to assess confidence and readiness for ACP. What "matters most" and barriers and facilitators to ACP employed questions from established ACP materials and trials. Semi-structured interviews were conducted after surveys to further explain survey results.

RESULTS

Older adults (N = 30) and surrogates (N = 12) were confident that they could engage in ACP (4.1 and 4.7 out of 5), but many were not ready for these conversations (3.1 and 3.9 out of 5). A framework with 4 themes - illness experience, social connections, interaction with health providers, burden - supports identification of barriers and facilitators to ACP engagement.

SIGNIFICANCE OF RESULTS

We identified barriers and facilitators and present a framework to support ACP engagement. Future research can assess the impact of this framework on communication and decision-making.

Essential Advance Care Planning Intervention Features in Low-Income Communities: A Qualitative Study

CONTEXT

Older adults with low socioeconomic status (SES) participate in advance care planning (ACP) at lower rates than those with higher SES. Community feedback is an essential component of intervention design for communities with fewer social and health resources to ensure that the intervention is relevant and meaningful.

OBJECTIVES

To understand the perspectives for potential interventions, we aimed to qualitatively explore participant priorities for ACP intervention development.

METHODS

Using a qualitative descriptive design, we recruited and conducted individual and one-time, semi-structured interviews with older adults (aged 50+) with low income (< $20,000/year) (n = 20), Recruitment methods included flyers and in-person recruitment and purposive and snowball sampling methods. Following a thematic analysis plan, themes emerged from recursive transcript review by two independent coders and inductive categorization of the most robust codes.

RESULTS

Two themes captured participants' perspectives regarding ACP intervention development: 1) specialist advocacy and reliability and 2) person-centered communication. Older adults with low SES prioritize ACP communication that is driven by their goals and that is led by trustworthy specialists that advocate for their needs.

CONCLUSION

Our work highlights that intervention preferences were informed by the prior strain and struggle of waiting on other kinds of health and social services. We propose an adapted model for community research collaboration to promote equity in addition to practice and policy recommendations.

Advance care planning in adults ages 80 years and older with impaired cognition: Using actual conversations to examine best practices

INTRODUCTION

Recommendations for advance care planning (ACP) in persons with cognitive impairment are based on expert input without insight from actual ACP conversations.

METHODS

We used thematic analysis to analyze transcripts of ACP conversations for 88 older adults with normal cognition (n = 15), mild cognitive impairment (n = 13), and scores consistent with dementia (n = 60).

RESULTS

Patients with dementia were least verbally active; however, some shared values and identified surrogates. We identified three themes: (1) cognitive impairment inhibits participation in ACP, but individuals with dementia are able to contribute; (2) care partners have a key role in supporting ACP across the spectrum of cognitive impairment; and (3) structured questions about values and tailored communication strategies can facilitate engagement of older adults with dementia.

DISCUSSION

Our findings reinforce best practice recommendations for early ACP and identify strategies to increase patient engagement among older adults with cognitive impairment with support of care partners.

HIGHLIGHTS

Data from actual ACP conversations involving older adults with a range of cognitive function and their care partners reinforce best practice recommendations and suggest practical implications for education and training. Family involvement in ACP was valued by older adults and improved engagement. ACP initiatives should prioritize eliciting values of older adults with dementia and improving skills for communication to increase engagement.

Psychometric evaluation and translation of the Persian version of the Organizational Silence Behavior Scale (OSBS-P) for clinical nurses

BACKGROUND

Healthcare professionals have a crucial responsibility to provide optimal patient care. However, maintaining silence within an organization can often lead to ethical dilemmas and negatively impact the quality of care. Healthcare professionals must speak up and ensure their concerns are heard and addressed to promote a safe and ethical healthcare environment. This study aimed to translate and assess the psychometric properties of the Persian version of the Organizational Silence Behavior Scale (OSBS-P) for clinical nurses.

METHODS

A methodological study was conducted on 338 clinical nurses to evaluate the psychometric properties of the Persian version of the 32-item OSBS-P. A multilevel approach was used: forward-backward translation, face and content validity, construct validity (confirmatory factor analysis), and reliability (internal consistency and stability) of the Persian version of the OSBS-P were analyzed, respectively.

RESULTS

The psychometric evaluation demonstrated that the Persian version of OSBS-P is not only understandable but also retains the conceptual integrity of the original English version. Confirmatory factor analysis validated its alignment with the proposed four-factor model, indicating robust construct validity. The OSBS-P's reliability was excellent, with a Cronbach's alpha coefficient of α = 0.969, and stability was confirmed with an intraclass correlation coefficient (ICC) of 0.951 (95% CI, 0.919-0.945).

CONCLUSION

The OSBS-P is a valid tool for evaluating the organizational silence behavior of clinical nurses.

Action plans increase advance care planning documentation and engagement among English and Spanish-speaking older adults

BACKGROUND

Advance care planning (ACP) has been reconceptualized as a health behavior. Action plans (APs), or patient-directed mini contracts, improve behavior change. However, no prior studies have assessed whether APs can increase ACP documentation and engagement.

METHODS

We included English and Spanish-speaking primary care patients from San Francisco, ≥55 years of age, with ≥2 serious or chronic illnesses. Participants were in the intervention arm of the PREPAREforYOURcare.org trial and asked at baseline to choose 1 of 5 actions (e.g., choose a surrogate). At 6 months, we assessed whether participants completed their AP and if completion was associated with demographics, electronic health record (EHR) ACP documentation, and five-point ACP Engagement Survey scores. We used t-tests, chi-squared, multivariate analysis adjusted for baseline ACP and clustering by physician, and qualitative thematic analysis to explore reasons for non-completion.

RESULTS

The mean age of 586 participants was 65 ± 10 years; 44.0% women, 45.9% Spanish-speaking, 31.4% had limited health literacy, and 43% completed an AP at 6 months; surrogate-related (47.4%), tell others about medical wishes (33.7%), ask clinicians questions (13.7%), and decide what matters most in life (5.2%). Participants with limited versus adequate health literacy were less likely to complete an AP (25.4% vs 35.9%, p = 0.01). Completing an AP was associated with greater ACP EMR documentation 49.8% vs 35.6%, p < 0.001 (adjusted odds ratio: 2.06; 95% CI [1.43-2.97]) and engagement (adjusted five-point scores [3.69; 95% CI 3.57-3.81 vs 3.10; 95% CI: 2.98-3.21], p < 0.001). Themes for non-completion included not being ready and logistical issues (e.g., surrogate deceased).

CONCLUSIONS

Among English and Spanish-speaking older adults, creating an ACP AP resulted in greater documentation and engagement. APs may help facilitate ACP behavior change as part of effective ACP interventions. Additional support may be needed for patients with limited health literacy and those facing logistical barriers.

Facilitated Advance Care Planning Interventions: A Narrative Review

Introduction: Multiple interventions have been designed to employ facilitators to address gaps in Advance Care Planning (ACP). Objective: To collect and review available evidence related to facilitated ACP interventions. Methods/Design: Narrative review using a previously described framework for scoping reviews. We searched PubMed using structured criteria and report synthesized themes detailing the design, target populations, methods, and outcome measurements for interventions in which a facilitator-who may or may not be clinical staff-engaged a patient and/or a patient's caregiver in some part of the ACP process. Results: Of 1492 articles discovered on our search, 28 met the inclusion criteria. Twelve (42.9%) studies utilized a nurse facilitator, two (7.1%) utilized trained social workers, and one (3.6%) embedded multiple facilitators. The remaining 13 (46.4%) utilized facilitators from other various professional and community backgrounds, such as lay navigators, care coordinators, and peer mentors. Twenty-five (89.2%) studies included patients with serious or chronic illness, at the end-of-life, or having a high risk of need for medical care. Four (14.3%) articles focused on marginalized populations. Intervention settings varied notably across studies. Eighteen (64.3%) integrated interventions into existing clinical workflows. Primary outcomes were measured in one of three ways: documentation in the Electronic Health Record (EHR) (25.0%); questionnaires, scales, patient reports, or non-EHR documentation (64.3%); or multiple measures (10.7%). Twenty-three (82.1%) of the studies were determined a success by study authors. Conclusion: We identified a variety of key characteristics that can be modified to target facilitated ACP interventions towards gaps in current applications of ACP.

Perspectives of Nursing Home Staff in Advance Care Planning Conversations: Experiences from the APPROACHES Project

OBJECTIVES

Advance care planning (ACP) is considered a best practice in the nursing home setting; however, there is a lack of consistency in the training of nursing home staff and implementation of structured ACP programs. A qualitative study interviewing ACP specialists in nursing homes was conducted to understand the experience of staff engaged in Aligning Patient Preferences - a Role offering Alzheimer's patients, Caregivers, and Healthcare providers Education and Support (APPROACHES), an embedded pragmatic clinical trial to improve ACP.

DESIGN

Qualitative interviews regarding ACP specialists' experiences and perceived intervention impact.

SETTING AND PARTICIPANTS

Staff of intervention-assigned nursing home facilities who completed a minimum of 10 ACP conversations with residents during APPROACHES program implementation.

METHODS

Fourteen staff were interviewed. Interviews were transcribed and coded by the research team.

RESULTS

There were 21 codes identified that were then distilled into the following 5 themes: (1) experiences with the ACP specialist program, (2) engaging in ACP conversations, (3) considerations related to dementia, (4) benefits and challenges of ACP, and (5) involvement of multiple people in the ACP process. Participant responses suggested variability in experiences with the ACP specialist program and highlighted many aspects relevant to engaging in conversations with families and residents, particularly those living with dementia. Benefits of ACP, including relationship building and increased preparedness for changes in health status, were balanced with challenges related to sensitive conversation topics and logistical difficulties in scheduling ACP discussions. ACP specialists discussed the multiple roles that others played in the ACP process.

CONCLUSIONS AND IMPLICATIONS

Findings from this analysis provide insights into tailoring APPROACHES and other ACP programs for full-scale implementation in the nursing home setting. Nursing home staff experiences tailoring the program to fit their environments were reflective of the pragmatic nature of the ACP specialist program.

Racial, Ethnic, and Socioeconomic Differences in Critical Care Near the End of Life: A Narrative Review

Patients from groups that are racially/ethnically minoritized or of low socioeconomic status receive more intensive care near the end of life, endorse preferences for more life-sustaining treatments, experience lower quality communication from clinicians, and report worse quality of dying than other patients. There are many contributory factors, including system (eg, lack of intensive outpatient symptom management resources), clinician (eg, low-quality serious illness communication), and patient (eg, cultural norms) factors. System and clinician factors contribute to disparities and ought to be remedied, while patient factors simply reflect differences in care and may not be appropriate targets for intervention.

Feasibility and Effectiveness of Virtual Group Advance Care Planning Visits During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic necessitated the transition from in person to virtual advance care planning (ACP) engagement efforts. This pilot initiative evaluated virtual group visits (GVs) and in-person GVs for ACP to determine their feasibility and effectiveness.

METHODS

Participants included patients in a Geriatric Medicine clinic who were referred by their primary care physician to an ACP GVs intervention. The ACP GVs had 2 sessions, led by clinicians with ACP expertise who facilitated a discussion on patients' values, goals, and preferences. Participants were provided with technical assistance to support use of the virtual platform. Evaluation included an ACP readiness survey, post-session feedback, GV observations, and electronic health record review at baseline and a 6 month follow-up for goals of care documentation and advance directives.

RESULTS

Seventy patients attended 46 ACP GVs from August 2019 to February 2022, including 16 in-person GVs and 54 virtual GVs. At a 6 month follow-up, for virtual GVs participants (n = 54), goals of care documentation increased from 31% to 93%, and advance directives increased from 22% to 30%. For in-person GVs participants (n = 16), goals of care documentation increased from 25% to 100%, and advance directives increased from 69% to 75%. All surveyed patients in both formats would recommend ACP GVs.

CONCLUSION

ACP GVs are feasible and effective for supporting ACP, demonstrating an increase in both goals of care conversations and advance directives completion.

Advance care planning in patients with respiratory failure

Advance care planning (ACP) is a complex and iterative communication process between patients, surrogates and clinicians that defines goals of care that may include, but is not limited to, documentation of advance directives. The aim of ACP is to promote patient-centred care tailored to the patient's clinical situation through informed preparation for the future and improved communication between patient, clinicians and surrogates, if the latter need to make decisions on patient's behalf.The aim of this article is to review research related to ACP in acute and chronic respiratory failure, regarding the process, communication, shared decision-making, implementation and outcomes.Research has produced controversial results on ACP interventions due to the heterogeneity of measures and outcomes, but positive outcomes have been described regarding the quality of patient-physician communication, preference for comfort care, decisional conflict and patient-caregiver congruence of preferences and improved documentation of ACP or advance directives.The main barriers to ACP in chronic respiratory failure are the uncertainty of prognosis (particularly in the organ failure trajectory), the choice of the best timing for initiation and the lack of training of healthcare workers. In acute respiratory failure, the ACP process can be very short, should include the patient whenever possible, and is based on a discussion of treatments appropriate to the patient's functional status prior to the event (e.g. assessment of frailty) and clear communication of the likely consequences of possible options.All healthcare worker dealing with patients with serious illnesses should have training in communication skills to promote engagement in ACP discussions.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

Communication processes in an advance care planning initiative: A socio-ecological perspective for service evaluation

BACKGROUND

Advance care planning initiatives are becoming more widespread, increasing expectations for providers to engage in goals of care conversations. However, less is known about how providers communicate advance care planning within and throughout a health care system.

AIM

To explore perspectives of communication processes in the rollout of an advance care planning initiative.

DESIGN

Theoretically informed secondary analysis of 31 semi-structured interviews.

SETTING/PARTICIPANTS

Key partners in a Veterans Health Administration goals of care initiative.

RESULTS

Using the constant comparative approach followed by qualitative mapping of themes to the layers of the Socio-Ecological Model, four themes and corresponding Socio-Ecological layers were identified: Goals of Care Communication Training (Policy, Community, and Institutional) requires more resources across sites and better messaging to reduce provider misconceptions and promote an institutional culture invested in advance care planning; Interprofessional Communication (Interpersonal) suggests care team coordination is needed to facilitate continuity in goals of care messaging; Communication in Documentation (Institutional, Interpersonal, and Intrapersonal) highlights the need for capturing the context for goals of care preferences; and Patient/Family Communication (Interpersonal and Intrapersonal) encourages offering materials and informational resources early to facilitate rapport building and readiness to determine goals of care.

CONCLUSIONS

Findings support the need for initiatives to incorporate an evaluation of how goals of care are discussed beyond the interpersonal exchange between patient and provider and signal opportunities for applying the Socio-Ecological Model to better understand goals of care communication processes, including opportunities to improve initiation and documentation of goals of care.

Advanced Care Planning in Chronic Kidney Disease: Qualitative Impact of the MY WAY Intervention

CONTEXT

Despite recommendations for shared decision-making and advanced care planning (ACP) for people with chronic kidney disease (CKD), such conversations are infrequent. The MY WAY educational and patient coaching intervention aimed to promote high-quality ACP.

OBJECTIVES

This qualitative substudy sought to gain participant feedback on the MY WAY ACP coaching intervention, and how it impacted their wishes, perceptions of kidney care, and factors that helped them reflect on ACP.

METHODS

We conducted semi-structured interviews with participants from the intervention arm of the MY WAY study about their prior experience with ACPs in the context of CKD, impressions of the MY WAY intervention, and outcomes of the MY WAY intervention. We conducted a qualitative thematic analysis of transcribed interviews.

RESULTS

Among 15 intervention participants, the following major themes emerged: 1) Patients with CKD approach ACP with varied experiences; 2) Patients felt the MY WAY coaching intervention supported ACP by reinforcing values; and 3) Patients found the coaching intervention focused on end of life, but not necessarily on decision making regarding CKD.

CONCLUSION

Participants perceived the coaching intervention to have high utility in facilitating ACP, but had a limited impact on CKD-specific decision-making. These findings suggest that the coach plays a crucial role in comfort with ACP conversations and that ACP readiness and engagement may not correlate with treatment preferences or understanding of CKD treatment decisions.

Making advance care planning easier for adults with kidney disease and their clinicians

Advance care planning (ACP) has evolved from a narrow focus on end-of-life preference, such as resuscitation, to a continuum of care planning across the life course. Older adults with kidney disease have high morbidity and mortality, and easy-to-use tools can make ACP easier for patients and clinicians.

Perioperative Care of the Patient with Directives Limiting Life-Sustaining Treatments

Like most complex aspects of procedural care, sound perioperative management of limits to life-sustaining medical therapy requires a multidisciplinary team-based approach bolstered by appropriate care management strategies. This article discusses the implications of care for the patient for whom limitations of life-sustaining care are in place and the roles and responsibilities of each provider in supporting quality procedural care compatible with patients' right to self-determination. The authors focus on the roles of the surgeon, preoperative clinic provider, anesthesiologist, and postoperative care consultants and discuss how the health care system and care pathways can support and improve adherence to best practices.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

SETTING/SUBJECTS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04857060.

Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy

BACKGROUND

Documenting goals of care in the electronic health record is meant to relay patient preferences to other clinicians. Evaluating the content and documentation of nurse and social worker led goals of care conversations can inform future goals of care initiative efforts.

METHODS

As part of the ADvancing symptom Alleviation with Palliative Treatment trial, this study analyzed goals of care conversations led by nurses and social workers and documented in the electronic health record. Informed by a goals of care communication guide, we identified five goals of care components: illness understanding, goals and values, end of life planning, surrogate, and advance directives. Forty conversation transcripts underwent content analysis. Through an iterative team process, we defined documentation accuracy as four categories: (1) Complete-comprehensive accurate documentation of the conversation, (2) Incomplete-partial documentation of the conversation, (3) Missing-discussed and not documented, and (4) Incorrect-misrepresented in documentation. We also defined-Not Discussed-for communication guide questions that were not discussed nor documented. A constant comparative approach was used to determine the presence or absence of conversation content in the documentation.

RESULTS

All five goals of care components were discussed in 67% (27/40) of conversation transcripts. Compared to the transcripts, surrogate (37/40, 93%) and advance directives (36/40, 90%) were often documented completely. Almost 40% of goals and values (15/40, 38%) and half of end of life planning (19/40, 48%) were incomplete. Illness understanding was missing (13/40, 33%), not discussed (13/40, 33%), or incorrect (2/40, 5%).

CONCLUSION

Nurse and social worker led goals of care conversations discussed and documented most components of the goals of care communication guide. Further research may guide how best to determine the relative importance of accuracy, especially in the broad setting of incomplete, missing, and incorrect EHR documentation.

'It's not making a decision, it's prompting the discussions': a qualitative study exploring stakeholders' views on the acceptability and feasibility of advance research planning (CONSULT-ADVANCE)

BACKGROUND

Health and care research involving people who lack capacity to consent requires an alternative decision maker to decide whether they participate or not based on their 'presumed will'. However, this is often unknown. Advance research planning (ARP) is a process for people who anticipate periods of impaired capacity to prospectively express their preferences about research participation and identify who they wish to be involved in future decisions. This may help to extend individuals' autonomy by ensuring that proxy decisions are based on their actual wishes. This qualitative study aimed to explore stakeholders' views about the acceptability and feasibility of ARP and identify barriers and facilitators to its implementation in the UK.

METHODS

We conducted semi-structured interviews with 27 researchers, practitioners, and members of the public who had participated in a preceding survey. Interviews were conducted remotely between April and November 2023. Data were analysed thematically.

RESULTS

Participants were supportive of the concept of ARP, with differing amounts of support for the range of possible ARP activities depending on the context. Six main themes were identified: (1) Planting a seed - creating opportunities to initiate/engage with ARP; (2) A missing part of the puzzle - how preferences expressed through ARP could help inform decisions; (3) Finding the sweet spot - optimising the timing of ARP; (4) More than a piece of paper - finding the best mode for recording preferences; (5) Keeping the door open to future opportunities - minimising the risk of unintended consequences; and (6) Navigating with a compass - principles underpinning ARP to ensure safeguarding and help address inequalities. Participants also identified a number of implementation challenges, and proposed facilitative strategies that might overcome them which included embedding advance research planning in existing future planning processes and research-focused activities.

CONCLUSIONS

This study provides a routemap to implementing ARP in the UK to enable people anticipating impaired capacity to express their preferences about research, thus ensuring greater opportunities for inclusion of this under-served group, and addressing the decisional burden experienced by some family members acting as proxies. Development of interventions and guidance to support ARP is needed, with a focus on ensuring accessibility.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

ISRCTN12995230; prospectively registered on 19/06/2020.

Impact of the COVID-19 Pandemic on Cancer Death Locations in Japan: An Analysis of Excess Mortality Through February 2023

BACKGROUND

The novel coronavirus disease 2019 (COVID-19) pandemic has significantly impacted end-of-life decisions for cancer patients in Japan, with disparities existing between preferred and actual care settings. Our study investigates the potential shifts in cancer death locations during the pandemic and if there were excess cancer deaths.

METHODS

Utilizing national mortality data from the Ministry of Health, Labour and Welfare from January 2012 to February 2023, we identified cancer deaths using International Classification of Disease, 10th revision codes. We assessed death locations, including medical institutions, nursing facilities, and homes. The Farrington algorithm was employed to estimate expected death counts, and the differences between observed and expected counts were denoted as excess deaths.

RESULTS

From January 2018 to February 2023, there was consistently increase in the weekly observed cancer deaths. The presence of a definitive excess during the pandemic period remains uncertain. The percentage of deaths in medical institutions declined from 83.3% to 70.1%, while home deaths increased from 12.1% to 22.9%. Between April 2020 and February 2023, deaths in medical institutions frequently fell below the 95% prediction lower limit. Home deaths consistently exceeded the 95% prediction upper limit, with significant excess deaths reported annually.

CONCLUSION

Our study found a shift in cancer death locations from medical institutions to homes in Japan during the COVID-19 pandemic. Our study did not confirm an overall increase in cancer deaths during this period. As with global trends, the profound shift from hospitals to homes in Japan calls for a comprehensive exploration to grasp the pandemic's multifaceted impact on end-of-life cancer care decisions.

Cardiopulmonary Resuscitation Outcomes and Trainee Perception of Code Status Discussions in Patients with Cirrhosis

BACKGROUND

Cardiopulmonary resuscitation (CPR) outcomes among patients with cirrhosis are poor, but factors associated with outcomes and provider awareness remain under-evaluated.

AIMS

We retrospectively investigated in-hospital CPR mortality among patients with cirrhosis, and, using these results, undertook an educational study among providers to improve knowledge of CPR outcomes and code status in patients with cirrhosis.

METHODS

We identified patients with cirrhosis admitted from 2012 to 2022 who underwent CPR at our center; the primary outcome was survival-to-discharge. A brief video based on these results was presented online to Internal Medicine residents, along with paired pre/post-surveys assessing attitudes toward holding code status conversations and knowledge of CPR outcomes in patients with cirrhosis.

RESULTS

97 cases of CPR were identified. 27 patients (28%) survived to discharge post-CPR. A history of liver decompensation was significantly associated with lower survival (OR 0.21, p < 0.05). 22 residents participated in the educational intervention; afterward, their estimation of survival after CPR for patients with cirrhosis significantly improved (p < 0.05). Mean confidence in answering patient questions about prognosis, measured from 1 to 5, also significantly improved (2.4-"a little confident" vs. 3.8-"confident", p < 0.05). 59% of surveyed residents identified impact on liver transplant candidacy as at least a "somewhat significant" barrier to code status conversations.

CONCLUSIONS

We identified significant trainee uncertainty about outcomes in patients with cirrhosis. These deficits improved after an educational intervention and gave providers more confidence in holding informed code status conversations with patients with cirrhosis, a population that faces barriers to adequate code discussions.

Treatment strategy for older patients with pneumonia independent of the risk of drug resistance in the world's top country for longevity

The number of older people with impaired swallowing function increases with aging population. Aspiration pneumonia is one of the most cases of pneumonia developing among older people. As aspiration pneumonia may develop as a result of age-related deterioration, it is crucial to consider it as an unavoidable event with aging. While pneumonia is diagnosed based on respiratory symptoms and radiological features, the lung involvement of aspiration pneumonia may be undetectable via a frontal chest radiograph in some cases. Bacterial profiles show the predominance of drug-resistant bacteria, such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA), but isolated bacteria from respiratory samples do not necessarily indicate causative pathogens. Furthermore, there is no evidence regarding treatment superiority using broad-spectrum antibiotics compared with narrow-spectrum antibiotics. Even if isolated pathogens are a causative factor for pneumonia among older patients, the use of broad-spectrum antibiotics covering the bacteria may not improve their outcomes. Therefore, we propose a treatment strategy independent of the risk of drug resistance focusing on the discrimination of patients who are unlikely to respond to broad-spectrum antibiotics. An aspiration risk is associated with increased in-hospital mortality in patients with pneumonia, which could also lead to a greater risk of poor long-term outcomes with increased 1-year mortality. Advance care planning is now recognized as a process for communication and medical decision-making across the life course. This approach would be widely recommended for older people with aspiration risk.

Clinicians' experiences implementing an advance care planning pathway in two Canadian provinces: a qualitative study

BACKGROUND

Advance care planning (ACP) is a process which enables patients to communicate wishes, values, fears, and preferences for future medical care. Despite patient interest in ACP, the frequency of discussions remains low. Barriers to ACP may be mitigated by involving non-physician clinic staff, preparing patients ahead of visits, and using tools to structure visits. An ACP care pathway incorporating these principles was implemented in longitudinal generalist outpatient care, including primary care/family medicine and general internal medicine, in two Canadian provinces. This study aims to understand clinician experiences implementing the pathway.

METHODS

The pathway was implemented in one family practice in Alberta, two family practices in British Columbia (BC), and one BC internal medicine outpatient clinic. Physicians and allied health professionals delivered structured pathway visits based on the Serious Illness Conversation Guide. Twelve physicians and one social worker participated in interviews or focus groups at the end of the study period. Qualitative data were coded inductively using an iterative approach, with regular meetings between coders.

RESULTS

Clinicians described experiences with the ACP care pathway, impact at the clinician level, and impact at the patient level. Within each domain, clinicians described barriers and facilitators experienced during implementation. Clinicians also reflected candidly about potential for future implementation and the sustainability of the pathway.

CONCLUSIONS

While the pathway was implemented slightly differently between provinces, core experiences were that implementation of the pathway, and integration with current practice, were feasible. Across settings, similar themes recurred regarding usefulness of the pathway structure and its tools, impact on clinician confidence and interactions with patients, teamwork and task delegation, compatibility with existing workflow, and patient preparation and readiness. Clinicians were supportive of ACP and of the pathway.

TRIAL REGISTRATION

The study was prospectively registered with clinicaltrials.gov (NCT03508557). Registered April 25, 2018. https://classic.

CLINICALTRIALS

gov/ct2/show/NCT03508557 .

Improving Dementia Caregiver Activation With a Brief Communication Module

Objective: Palliative care often plays a pivotal role in supporting informal caregivers of persons living with dementia who experience a lack of continuity in care. Dementia caregiver activation, the caregiver's willingness and ability to navigate care needs, requires communication skills for developing relationships with healthcare providers. Communication activation is important because caregivers facilitate physician and patient information exchange. This study aimed to explore changes in communication outcomes (attitude, knowledge, and skills) and impact on caregiver communication activation (confidence, self-report) following completion of a brief communication module. Methods: A 15-minute asynchronous online module was developed to provide caregivers with communication skills for working with doctors and nurses. Caregivers completed pre/post module measures of communication outcomes, a vignette for applying communication strategies and were interviewed within a week of module completion to assess self-reported communication activation. Module acceptability was also evaluated. Results: Communication knowledge (P < .01) significantly increased and nearly all participants (99%) demonstrated use of module-specific communication skills after completing the module. While not statistically significant, caregiver attitudes were in the expected direction. Caregiver self-reported communication confidence (P < .001) significantly increased and 84% of caregivers described communication activation at post-module. Caregivers (83%) were likely to recommend the module. Conclusions: The brief communication module for dementia caregivers in this project offers an online resource with low time-burden that results in caregiver communication activation. Future testing in the clinical setting will increase understanding of its efficacy and integration and could be a viable resource for palliative care providers.

A Personalized and Interactive Web-Based Advance Care Planning Intervention for Older Adults (Koda Health): Pilot Feasibility Study

Background

Advance care planning (ACP) is a process that involves patients expressing their personal goals, values, and future medical care preferences. Digital applications may help facilitate this process, though their use in older adults has not been adequately studied.

Objective

This pilot study aimed to evaluate the reach, adoption, and usability of Koda Health, a web-based patient-facing ACP platform, among older adults.

Methods

Older adults (aged 50 years and older) who had an active Epic MyChart account at an academic health care system in North Carolina were recruited to participate. A total of 2850 electronic invitations were sent through MyChart accounts with an embedded hyperlink to the Koda platform. Participants who agreed to participate were asked to complete pre- and posttest surveys before and after navigating through the Koda Health platform. Primary outcomes were reach, adoption, and System Usability Scale (SUS) scores. Exploratory outcomes included ACP knowledge and readiness.

Results

A total of 161 participants enrolled in the study and created an account on the platform (age: mean 63, SD 9.3 years), with 80% (129/161) of these participants going on to complete all steps of the intervention, thereby generating an advance directive. Participants reported minimal difficulty in using the Koda platform, with an overall SUS score of 76.2. Additionally, knowledge of ACP (eg, mean increase from 3.2 to 4.2 on 5-point scale; P<.001) and readiness (eg, mean increase from 2.6 to 3.2 on readiness to discuss ACP with health care provider; P<.001) significantly increased from before to after the intervention.

Conclusions

This study demonstrated that the Koda Health platform is feasible, had above-average usability, and improved ACP documentation of preferences in older adults. Our findings indicate that web-based health tools like Koda may help older individuals learn about and feel more comfortable with ACP while potentially facilitating greater engagement in care planning.

Measures of Patient and Surrogate Preparedness for End-of-Life Decision-Making

CONTEXT

Reliable and valid measures are critical in accurately assessing outcomes of advance care planning interventions (ACP) for end-of-life (EOL) decision-making.

OBJECTIVES

To develop measures of preparedness for EOL decision-making for patients with end-stage renal disease and their surrogates (an exemplar population).

METHODS

In this 3-phase study, Phases 1 and 2 included a cross-discipline concept analysis of the preparedness construct, item generation for patient and surrogate scales (82 items), evaluation of content validity and readability, cognitive interviewing, and item reduction. In phase 3, the retained 26 patient and 25 surrogate items were administered to 426 patients and 426 surrogates during a multisite trial of an ACP intervention versus care-as-usual and evaluated internal consistency, 2-week test-retest reliability, and construct validity.

RESULTS

Scales were reduced to 20 patient and 19 surrogate items during phase 3. Cronbach's alphas were 0.86 (patient) and 0.90 (surrogate). There was a strong correlation between preparedness at baseline and two weeks for both scales (r = 0.66-0.69, P < 0.001). Confirmatory factor analysis and item-response analyses suggested unidimensionality. A significant correlation was shown between patient preparedness and patient decisional conflict (r = -0.53, P < 0.001), and surrogate preparedness and surrogate decision-making confidence (r = 0.44, P < 0.001). Among those who received the ACP intervention, the effect size of change was medium: Cohen's d = 0.54, P < 0.001 for patients and d = 0.57, P < 0.001 for surrogates.

CONCLUSIONS

The preparedness scales demonstrated strong psychometric properties. Future studies should examine scale performance in other populations.

"It Gives Me Peace of Mind So I Can Focus on Healing": Views on Advance Care Planning for Older Surgical Patients

Introduction: The period of time before an elective operation may be an opportune time to engage older adults in advance care planning (ACP). Past interventions have not been readily incorporated into surgical workflows leaving a need for ACP tools that are generalizable, easy to implement, and effective. Design: This is a qualitative study. Setting and Subjects: Older adults with a history of cancer and a recent major operation were recruited through their surgical oncologist at a tertiary medical center in the United States. Interviews were conducted to determine how to adapt the validated PrepareForYourCare.org ACP program with electronic health record prompts for the perioperative setting and openness to introducing ACP during a presurgical visit. We used qualitative content analysis to determine themes. Results: Eight themes were identified: (1) ACP as static and private, (2) people expected a prompt, (3) family trusted to do the "right" thing, (4) lack of relationship or comfort with providers, (5) a team-based approach can be helpful, (6) surgeon's expertise (e.g., prognosis and surgical risk), (7) ACP belongs on the surgical checklist, and (8) patients would welcome a conversation starter. Discussion: Older surgical patients are interested in engaging with ACP, particularly if prompted, and believe it has a place on the preoperative "checklist." Conclusions: To effectively engage patients with ACP, a combination of routine prompts by the health care team and patient-centered follow-up may be required.

Future policy and research for advance care planning in dementia: consensus recommendations from an international Delphi panel of the European Association for Palliative Care

Advance care planning (ACP) is increasingly recognised in the global agenda for dementia care. The European Association for Palliative Care (EAPC) Taskforce on ACP in Dementia aimed to provide recommendations for policy initiatives and future research. We conducted a four-round Delphi study with a 33-country panel of 107 experts between September, 2021, and June, 2022, that was approved by the EAPC Board. Consensus was achieved on 11 recommendations concerning the regulation of advance directives, equity of access, and dementia-inclusive approaches and conversations to express patients' values. Identified research gaps included the need for an evidence-based dementia-specific practice model that optimises engagement and communication with people with fluctuating and impaired capacity and their families to support decision making, while also empowering people to adjust their decisions if their goals or preferences change over time. Policy gaps included insufficient health services frameworks for dementia-inclusive practice. The results highlight the need for more evidence and policy development that support inclusive ACP practice models.

Serious Illness Communication in Cirrhosis Care: Tools to Improve Illness Understanding, Prognostic Understanding, and Care Planning

Patients with cirrhosis frequently experience an unpredictable illness trajectory, with frequent hospitalizations and complications. Along with the uncertain nature of the disease, the possibility of a lifesaving and curative transplant often makes prognostic discussions and future care decisions challenging. Serious illness communication (SIC) refers to supportive communication whereby clinicians assess patients' illness understanding, share prognostic information according to patients' preferences, explore patients' goals, and make recommendations for care that align with these goals. SIC includes 3 key components: (1) illness understanding; (2) prognostic understanding; and (3) care planning. In this piece, we explore current barriers to early implementation of SIC in cirrhosis care and share possible solutions, including adopting a multidisciplinary approach, delivering culturally competent care, and training clinicians in SIC core skills. By use of a case example, we aim to demonstrate SIC in action and to provide clinicians with tools and skills that can be used in practice.

An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go?

OBJECTIVES

POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research.

DESIGN

Integrative review.

SETTING AND PARTICIPANTS

Not applicable.

METHODS

We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization.

RESULTS

Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified.

CONCLUSIONS AND IMPLICATIONS

Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.

Bolstering Advance Care Planning Measurement Using Natural Language Processing

Despite its growth as a clinical activity and research topic, the complex dynamic nature of advance care planning (ACP) has posed serious challenges for researchers hoping to quantitatively measure it. Methods for measurement have traditionally depended on lengthy manual chart abstractions or static documents (e.g., advance directive forms) even though completion of such documents is only one aspect of ACP. Natural language processing (NLP), in the form of an assisted electronic health record (EHR) review, is a technological advancement that may help researchers better measure ACP activity. In this article, we aim to show how NLP-assisted EHR review supports more accurate and robust measurement of ACP. We do so by presenting three example applications that illustrate how using NLP for this purpose supports (1) measurement in research, (2) detailed insights into ACP in quality improvement, and (3) identification of current limitations of ACP in clinical settings.

User appraisal of a booklet for advance care planning in multiple sclerosis: a multicenter, qualitative Italian study

OBJECTIVES

Implementation of advance care planning (ACP) in people with progressive multiple sclerosis (PwPMS) is limited. We aimed to involve users (PwPMS, significant others, and healthcare professionals involved in PwPMS care) in the evaluation and refinement of a booklet to be used during the ACP conversations.

METHODS

This qualitative study consisted of cognitive interviews with PwPMS and significant others and a focus group with healthcare professionals from three Italian centers. We analyzed the interviews using the framework method and the focus group using thematic analysis.

RESULTS

We interviewed 10 PwPMS (3 women; median age 54 years; median Expanded Disability Status Scale score 6.0) and three significant others (2 women; 2 spouses and one daughter). The analysis yielded three themes: booklet comprehensibility and clarity, content acceptability and emotional impact, and suggestions for improvement. Twelve healthcare professionals (7 neurologists, 3 psychologists, one nurse, and one physiotherapist) participated in the focus group, whose analysis identified two themes: booklet's content importance and clarity and challenges to ACP implementation. Based on analysis results, we revised the booklet (text, layout, and pictures) and held a second-round interviews with two PwPMS and one significant other. The interviewees agreed on the revisions but reaffirmed their difficulty in dealing with the topic and the need for a physician when using the booklet.

CONCLUSIONS

Appraisal of the booklet was instrumental in improving its acceptability and understandability before using it in the ConCure-SM feasibility trial. Furthermore, our data reveal a lack of familiarity with ACP practice in the Italian context.

A Mixed-Methods Comparison of Interventions to Increase Advance Care Planning

PURPOSE

Although interventions can increase advance care planning (ACP) engagement, it remains unclear which interventions to choose in primary care settings. This study compares a passive intervention (mailed materials) to an interactive intervention (group visits) on participant ACP engagement and experiences.

METHODS

We used mixed methods to examine ACP engagement at baseline and six months following two ACP interventions. Eligible patients were randomized to receive mailed materials or participate in two ACP group visits. We administered the 4-item ACP Engagement survey (n = 110) and conducted interviews (n = 23). We compared mean scores and percent change in ACP engagement, analyzed interviews with directed content analysis to understand participants' ACP experiences, and integrated the findings based on mailed materials or group visits intervention.

RESULTS

All participants demonstrated increased ACP engagement scores. At six months, group visit participants reported higher percent change in mean overall score compared with mailed materials participants (+8% vs +3%, P < .0001). Group visits participants reported that being prompted to think about end-of-life preferences, gaining knowledge about ACP, and understanding the value of completing ACP documentation influenced their ACP readiness. While both interventions encouraged patients to start considering and refining their end-of-life preferences, group visits made patients feel more knowledgeable about ACP, highlighted the importance of completing ACP documentation early, and sparked further ACP discussions with others.

CONCLUSIONS

While primary care patients may benefit from mailed ACP materials, patients reported increased readiness after ACP group visits. Group visits emphasized the value of upstream preparation, ongoing conversations, and increased knowledge about ACP.

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

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