Feasibility and acceptability of introducing advance care planning on a thoracic medicine inpatient ward: an exploratory mixed method study

Cancer patients have a reduced likelihood of dying in hospital with advance care planning in primary health care and a summarizing palliative plan: a prospective controlled non-randomized intervention trial

BACKGROUND

Advance care planning (ACP) allows patients to define their goals and preferences. Spending more time at home and less time in the hospital, along with avoiding death in the hospital, are often considered desirable outcomes of palliative care (PC). In 2015, 36% of cancer patients died in the hospital and 13% died at home in Norway.

METHOD

From 2015 to 2022, this prospective controlled non-randomized intervention trial observed 144 cancer patients with or without an organized ACP conversation in primary health care and a summarizing palliative plan (ClinicalTrials.gov Identifier: NCT02170168, 23 June 2014). The patients were identified through contact with the local cancer outpatient clinic or hospital-based PC team.

RESULTS

A total of 128 patients died during the observation period. Of these, 67 patients had an organized ACP conversation and summarizing palliative plan (intervention (I) group) and 61 had not (control (C) group). Dying in the hospital was significantly less common for patients in the I group compared to the C group (17.9% vs. 34.4%; X2 (1, n = 128) = 4.55, p = 0.033). There were no differences between the groups in terms of where they spent their time in the last 90 days of life (home, nursing home, or hospital). Most patients (62%) preferred to die at home. The observed differences between the groups regarding preferred and actual places of death did not reach statistical significance.

CONCLUSION

With organized ACP conversations in primary health care and a summarizing palliative plan, cancer patients died less often in the hospital in our observational study. A structured ACP approach integrating palliative care for cancer patients into primary health care can support patients´ preferences at the end of life.

[Advance care planning in the acute hospital: A qualitative analysis of terms and conditions]

Advance care planning in the acute hospital: A qualitative analysis of terms and conditions Abstract: Background: Advance Care Planning (ACP) is an internationally established concept aimed to facilitate anticipatory care planning in the event of future inability to consent. In Germany, ACP is currently not regularly offered to patients in acute care hospitals. Aim: We aimed to identify preconditions for implementation of ACP in acute care hospitals in Germany through review of the international literature and expert interviews. Methods: A systematic literature search was carried out in the databases MEDLINE and CINAHL for internationally used strategies for implementing ACP in acute care hospitals. Consecutively, a guide for interviews with experts to evaluate the strategies was developed. Interviews were analyzed by qualitative content analysis according to Mayring. Results: Out of 13 included publications, 17 preconditions were identified and assigned to 16 categories after evaluation by experts. In international ACP programs, it was described how to proceed and organize the ACP conversation. German experts emphasized that appropriate preconditions, such as sufficient time resources and training, must be granted, whereas the literature search revealed the conversation process and organization as important determinants. Conclusions: The implementation of ACP programs is conceivable, but requires specific conditions as legal regulation and defining and structuring of the processes.

"The challenge is the complexity" - A qualitative study about decision-making in advanced lung cancer treatment

INTRODUCTION

The value of shared decision-making and decision aids (DA) has been well documented yet remain difficult to integrate into clinical practice. We wanted to investigate needs and challenges regarding decision-making about advanced lung cancer treatment after first-line therapy, focusing on DA applicability.

METHODS

Qualitative data from separate, semi-structured focus groups with patients/relatives and healthcare professionals were analysed using systematic text condensation. 12 patients with incurable lung cancer, seven relatives, 12 nurses and 18 doctors were recruited from four different hospitals in Norway.

RESULTS

The participants described the following needs and challenges affecting treatment decisions: 1) Continuity of clinician-patient-relationships as a basic framework for decision-making; 2) barriers to information exchange; 3) negotiation of autonomy; and 4) assessment of uncertainty and how to deal with it. Some clinicians feared DA would steal valuable time and disrupt consultations, arguing that such tools could not incorporate the complexity and uncertainty of decision-making. Patients and relatives reported a need for more information and the possibility both to decline or continue burdensome therapy. Participants welcomed interventions supporting information exchange, like communicative techniques and organizational changes ensuring continuity and more time for dialogue. Doctors called for tools decreasing uncertainty about treatment tolerance and futile therapy.

CONCLUSION

Our study suggests it is difficult to develop an applicable DA for advanced lung cancer after first-line therapy that meets the composite requirements of stakeholders. Comprehensive decision support interventions are needed to address organizational structures, communication training including scientific and existential uncertainty, and assessment of frailty and treatment toxicity.

European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease

There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available.

Implementation of Advance Care Planning in Norway

Advance Care Planning has a relatively short history in the Norwegian health care services. This article gives an overview of advance care planning research and its implementation in the health care services in Norway. Advance care planning has received increased attention from policymakers and the health care services. Research projects have been performed, and several are on-going. Implementation has largely treated advance care planning as a complex intervention, with a whole-system approach that puts emphasis on the conversation and patient activation. Advance directives have a peripheral role in this context.

The Effectiveness of Video Decision Aid on Advance Care Planning With Adult Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The purpose of this review was to examine the effect of video decision aids on adult patients' advance care planning-related outcomes. Seven English electronic databases (PubMed, Cochrane, MEDLINE, EMBASE, PsycINFO, CINAHL, OpenGray) and 3 Chinese databases (CNKI, WanFang, and VIP) were searched to identify relevant studies. Fourteen randomized controlled trials were included. The results of the meta-analysis showed that video decision aids reduced patients' preferences for life-prolonging care (risk ratio [RR], 0.43; 95% confidence interval [CI], 0.31-0.61; P < .01), cardiopulmonary resuscitation (RR, 0.54; 95% CI, 0.46-0.64; P < .01), and intubation tube placement (RR, 1.65; 95% CI, 1.09-2.48; P = .02) and increased patients' willingness to have a goals-of-care conversation (RR, 1.87; 95% CI, 1.32-2.65; P = .0004) and knowledge of advance care planning (RR, 0.80; 95% CI, 0.50-1.09; P < .01). However, because of the variability among the studies, the results have limitations. Future research needs to increase the sample size and improve the experimental design to confirm the impact of video decision aids on advance care planning.

Effect of Nursing Model Based on Rosenthal Effect on Self-Efficacy and Cognition of Life Meaning in Patients with Non-Small-Cell Lung Cancer

Objective

To study the influence of nursing model based on Rosenthal effect on self-efficacy and cognition of life meaning in patients with non-small-cell lung cancer (NSCLC).

Methods

120 patients with NSCLC treated in the hospital were selected from November 2020 to November 2021 and were randomly divided into the nursing group and the Rosenthal group, with 60 cases in each group. The nursing group received routine nursing intervention, while the Rosenthal group was intervened by nursing model based on the Rosenthal effect, and both groups were intervened for 1 month. The self-efficacy (General Self-Efficacy Scale (GSES)), negative emotions (Hospital Anxiety and Depression Scale (HADS)), self-burden (Self-Perceived Burden Scale for Cancer Patients (SPBS-CP)), meaning of life (Meaning of Life Scale for Advanced Cancer Patients (MiLS)), and quality of life (Functional Assessment of Cancer Therapy-Lung (FACT-L)) were compared between the two groups before and after intervention.

Results

After 1 month of intervention, the scores of GSES and MiLS of patients in the two groups were significantly higher than those before intervention, and the scores in the Rosenthal group were significantly higher than those in the nursing group (P < 0.05). The scores of HADS, SPBS-CP, and FACT-L in the two groups were significantly lower than those before intervention, and the scores were significantly lower in the Rosenthal group than those in the nursing group (P < 0.05).

Conclusion

Nursing model intervention based on Rosenthal effect enhances the self-efficacy and meaning of life and reduces the negative emotions and self-burden in patients with NSCLC.

Cancer patients spend more time at home and more often die at home with advance care planning conversations in primary health care: a retrospective observational cohort study

Background

Spending time at home and dying at home is advocated to be a desirable outcome in palliative care (PC). In Norway, home deaths among cancer patients are rare compared to other European countries. Advance care planning (ACP) conversations enable patients to define goals and preferences, reflecting a person’s wishes and current medical condition.

Method

The study included 250 cancer patients in the Romsdal region with or without an ACP conversation in primary health care who died between September 2018 and August 2020. The patients were identified through their contact with the local hospital, cancer outpatient clinic or hospital-based PC team.

Results

During the last 90 days of life, patients who had an ACP conversation in primary health care (N=125) were mean 9.8 more days at home, 4.5 less days in nursing home and 5.3 less days in hospital. Having an ACP conversation in primary health care, being male or having a lower age significantly predicted more days at home at the end of life (p< .001). Patients with an ACP conversation in primary health care where significantly more likely to die at home (p< .001) with a four times higher probability (RR=4.5). Contact with the hospital-based PC team was not associated with more days at home or death at home. Patients with contact with the hospital-based PC team were more likely to have an ACP conversation in primary health care.

Conclusion

Palliative cancer patients with an ACP conversation in primary health care spent more days at home and more frequently died at home. Data suggest it is important that ACP conversations are conducted in primary health care setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00952-1.

Which factors influence the quality of end-of-life care in interstitial lung disease? A systematic review with narrative synthesis

BACKGROUND

People dying from interstitial lung disease experience considerable symptoms and commonly die in an acute healthcare environment. However, there is limited understanding about the quality of their end-of-life care.

AIM

To synthesise evidence about end-of-life care in interstitial lung disease and identify factors that influence quality of care.

DESIGN

Systematic literature review and narrative synthesis. The review protocol was prospectively registered with PROSPERO (CRD42020203197).

DATA SOURCES

Five electronic healthcare databases were searched (Medline, Embase, PubMed, Scopus and Web of Science) from January 1996 to February 2021. Studies were included if they focussed on the end-of-life care or death of patients with interstitial lung disease. Quality was assessed using the Critical Appraisal Skills Programme checklist for the relevant study design.

RESULTS

A total of 4088 articles were identified by initial searches. Twenty-four met the inclusion criteria, providing evidence from 300,736 individuals across eight countries. Most patients with interstitial lung disease died in hospital, with some subjected to a high burden of investigations or life-prolonging treatments. Low levels of involvement with palliative care services and advance care planning contributed to the trend of patients dying in acute environments. This review identified a paucity of research that addressed symptom management in the last few days or weeks of life.

CONCLUSIONS

There is inadequate knowledge regarding the most appropriate location for end-of-life care for people with interstitial lung disease. Early palliative care involvement can improve accordance with end-of-life care wishes. Future research should consider symptom management at the end-of-life and association with location of death.

Benefits, for patients with late stage chronic obstructive pulmonary disease, of being cared for in specialized palliative care compared to hospital. A nationwide register study

BACKGROUND

In early stage chronic obstructive pulmonary disease (COPD), dyspnea has been reported as the main symptom; but at the end of life, patients dying from COPD have a heavy symptom burden. Still, specialist palliative care is seldom offered to patients with COPD; they more often receive end of life care in hospitals. Furthermore, symptoms, symptom relief and care activities in the last week of life for COPD patients are rarely studied. The aim of this study was to compare patient and care characteristics in late stage COPD patients treated in specialized palliative care (SPC) versus hospital.

METHODS

Two nationwide registers were merged, the Swedish National Airway Register (SNAR) and the Swedish Register of Palliative Care (SRPC). Patients with COPD and < 50% of predicted forced expiratory volume in 1 s (FEV1), who had died in inpatient or outpatient SPC (n = 159) or in hospital (n = 439), were identified. Clinical COPD characteristics were extracted from the SNAR, and end of life (EOL) care characteristics from the SRPC. Descriptive statistics were used to describe the sample and the registered care and treatments. Independent samples t-test, Mantel-Haenszel chi-square test and Fisher's exact test was used to compare variables. To examine predictors of place of death, bivariate and multivariate logistic regression analyses were performed with a dependent variable with demographic and clinical variables used as independent variables.

RESULTS

The patients in hospitals were older and more likely to have heart failure or hypertension. Pain was more frequently reported and relieved in SPC than in hospitals (p = 0.001). Rattle, anxiety, delirium and nausea were reported at similar frequencies between the settings; but rattle, anxiety, delirium, and dyspnea were more frequently relieved in SPC (all p < 0.001). Compared to hospital, SPC was more often the preferred place of care (p < 0.001). In SPC, EOL discussions with patients and families were more frequently held than in hospital (p < 0.001). Heart failure increased the probability of dying in hospital while lung cancer increased the probability of dying in SPC.

CONCLUSION

This study provides evidence for referring more COPD patients to SPC, which is more focused on symptom management and psychosocial and existential support.

Psychological resilience among palliative patients with advanced cancer: A systematic review of definitions and associated factors

OBJECTIVE

The palliative journey can be emotionally stressful for both patients with advanced cancer and their families. Psychological resilience is crucial in aiding with patients' adaptation and post-traumatic growth. The aim of this systematic review was to critically examine the definitions of psychological resilience and its associated factors in palliative patients with advanced cancer.

METHODS

Four databases were systematically searched from inception to August 2020. Both qualitative and quantitative studies that examined factors associated with psychological resilience in a sample of patients with advanced cancer undergoing palliative care were included.

RESULTS

A total of 15 studies met the criteria, of which 10 were qualitative and five were quantitative. Nine studies included a definition of psychological resilience, from which five common themes of buffering, adaptation, resources, recovery, and growth were derived. The quantitative studies found association between resilience and hope, independence, social support, fatigue, emotional distress, and coping strategies. The qualitative studies reported additional sources of resilience such as spirituality, social support, prior experience dealing with illness and life adversity, meaning-making, reconciling with life's finiteness, acceptance of illness, control, determination, positive attitude, dignity, engagement with palliative care and quality of life being supported by palliative care.

CONCLUSIONS

More research is needed for developing an overarching definition of psychological resilience in palliative advanced cancer patients that acknowledges and appreciates the contextual sensitivity of this concept among different cultural groups. Further studies are also needed to examine a holistic range of bio-psycho-socio-spiritual factors associated with psychological resilience among these patients and their families.

How Do Patients with Life-Limiting Illness and Caregivers Want End-Of-Life Prognostic Information Delivered? A Pilot Study

We aimed to identify the level of prognostic disclosure, type of prognostic information and delivery format of prognostic communication that older adults diagnosed with a life-limiting illness or caregivers prefer to receive. We developed and pilot tested an open-ended survey to 15 older patients and caregivers who had experience in health services for life-limiting illness either for a relative, friend or themselves. Five hypothetical clinical scenarios of prognostic options were presented to ascertain preferences. The preferred format to receive prognostic information was verbal delivery by the clinician with a written summary. Photos and videos were less favoured, and a table with numbers/percentages was least preferred. Distress levels to the prognostic scenarios were low, with the exception of a photo. We conclude that older patients/caregivers want end-of-life prognostic information delivered the traditional way, verbally by clinicians. Options to deliver prognostic information may vary across patient groups but empower clinicians in introducing end-of-life discussions with patients/caregivers. Our study illustrates the feasibility of involving terminal patients and caregivers in research that contributes to eliciting prognostic preferences. Further research is needed to understand whether the prognostic preferences of hospitalized patients with life-limiting illness differ.