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Bigger SE, Hemphill JC, Njoroge T, Doyon K, Glenn L. Black Americans, hospitalization, and advance care planning: Structural vulnerability in Home Health Value-Based Purchasing. Am J Hosp Palliat Care 2024; 41:140-149. [PMID: 37192103 DOI: 10.1177/10499091231176281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
Skilled home health (HH) is the largest long-term care setting and the fastest-growing site of healthcare in the United States (U.S.). Home Health Value-Based Purchasing (HHVBP) is a structure of Medicare that penalizes U.S. HH agencies for high hospitalization rates. Prior studies have shown inconsistent evidence about associations of race with hospitalization rates in HH. Evidence supports that Black or African Americans are less likely to participate in advance care planning (ACP), or to complete written advance directives, which could affect their potential for hospitalization when nearing end of life. In this quasi-experimental study, we used Medicare administrative datasets, the Weighted Acute Care Services Use Rates (WACSUR) score, and the Advance Care Planning Protocol (ACPP) score to determine whether the proportion of Black HH patients in the U.S. was correlated with acute care use rates and the robustness of agency protocols on ACP. We used primary and secondary data from the U.S. from 2016-2020. We included Medicare-certified HH agencies. Spearman's correlation coefficient was used. We found a statistical trend showing that the greater proportion of Black patients enrolled in a HH agency, the greater tendency to have a high hospitalization rate. Our findings suggest that HHVBP may encourage patient selection and exacerbate health disparities. Our findings support recommendations for alternative measures of quality in HH to include measures of goal-concordant care coordination when patients are denied admission to HH.
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Mechanisms and contextual influences on the implementation of advance care planning for older people in long-term care facilities: A realist review. Int J Nurs Stud 2022; 133:104277. [PMID: 35717924 DOI: 10.1016/j.ijnurstu.2022.104277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 01/10/2023]
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Bigger SE, Glenn L. Emergency Department Use and Advance Care Planning in Home Health Value-Based Purchasing. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2022. [DOI: 10.1177/10848223221082660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Advance care planning (ACP) is a conversation about values, future treatment choices, and designation of a surrogate decision-maker, held in advance of a health crisis. ACP protocols are established by home health agencies (HHAs) to support the staff in talking about patients’ future treatment choices, which can include opting against acute care use. In 2016, Medicare implemented an experimental incentive program called Home Health Value-Based Purchasing (HHVBP) in 9 regionally representative states. These agencies were required to compete on value, where reimbursement rates were tied to outcomes in a Total Performance Score (TPS). With home health’s aim of avoiding unplanned acute care use, in-patient hospitalization was weighted the heaviest as a poor outcome, followed by emergency department (ED) use. The purpose of this quasi-interventional study was to determine the relationship between advance care planning protocols and ED use among HHAs in the U. S. by the status of participation HHVBP intervention group. The Advance Care Planning Protocol (ACPP) score was measured by scoring survey questions. Our findings show (1) ACPP score intensity was higher in states that participated in the HHVBP program; (2) high measurement reliability for the ACPP scores; (3) no significant relationship between ACPP and ED use overall; but (4) the relationship between ACPP intensity and ED use was equal-and-opposite for the HHVBP and non-HHVBP groups. These findings suggest that the HHVBP intervention altered the influence of ACPP intensity on ED use. Recommendations are made for the HHVBP program regarding ACP’s role in goal-concordant care.
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Affiliation(s)
| | - Lee Glenn
- East Tennessee State University, Johnson City, TN, USA
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Bigger SE, Haddad L, Glenn L. Cardiac and Pulmonary Diagnoses and Advance Care Planning in Home Health. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2022. [DOI: 10.1177/10848223211073711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic cardiovascular and pulmonary diseases are prevalent in the US home health population. Heart failure and chronic obstructive pulmonary disease are both chronic and terminal, but they are not always perceived as serious illnesses with imminent death. Therefore, they provide a context for advance care planning that is distinct from the diagnostic contexts of cancer, end-stage renal disease, or dementia. Advance care planning is defined as a process that supports adults at any age or stage of health in understanding and sharing their goals, values, and preferences about future medical care, including the designation of a surrogate decision-maker. This study tests the hypothesis that US home health agencies with higher percentages of patients with chronic cardiovascular and pulmonary conditions have less robust advance care planning protocols. The Spearman correlation coefficient was r = 0.22 ( S = 74684, P = .025, 1-tailed), which was statistically significant and an unexpected finding. The greater percentage of patients with chronic cardiac and pulmonary diagnoses in an agency, the more robust the advance care planning protocol was. This supports our previous findings and existing literature indicating that agencies may be using exacerbation events marked by acute care use as opportunities to initiate or repeat advance care planning.
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Affiliation(s)
| | - Lisa Haddad
- East Tennessee State University, Johnson City, TN, USA
| | - Lee Glenn
- East Tennessee State University, Johnson City, TN, USA
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Sellars M, White B, Yates P, Willmott L. Knowledge of end-of-life law: A cross-sectional survey of general practitioners working in aged care. Australas J Ageing 2021; 41:265-273. [PMID: 34787355 DOI: 10.1111/ajag.13018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/25/2021] [Accepted: 10/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the knowledge of end-of-life law and experiences in practice at the end of life amongst Australian general practitioners (GPs). METHODS A cross-sectional online survey of GPs practising in aged care settings in Queensland (QLD), New South Wales (NSW) and Victoria (VIC). RESULTS From 521 potential GPs, 160 (response rate 30.7%) were included in the final sample. Most participants (62%) reported experience with six key end-of-life areas at least 'a few times', including 74% administering medication for pain and symptom relief, and 67% facilitating advance care planning 'several' or 'many times' and perceiving they had 'some' knowledge of end-of-life law (53%, n = 84). However, low-to-moderate actual levels of end-of-life legal knowledge were identified (mean correct response of 5.24 out of 9). CONCLUSION Australian GPs working in aged care may have low-to-moderate knowledge about end-of-life law despite frequently making end-of-life decisions in clinical practice.
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Affiliation(s)
- Marcus Sellars
- Department of Health Services Research & Policy, Research School of Population Health, College of Health & Medicine, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Ben White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia.,Centre for Palliative Care Research and Education, Queensland Health, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
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Gloeckler S, Krones T, Biller-Andorno N. Advance care planning evaluation: a scoping review of best research practice. BMJ Support Palliat Care 2021:bmjspcare-2021-003193. [PMID: 34667065 DOI: 10.1136/bmjspcare-2021-003193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Abstract
Various indicators have been used to evaluate advance care planning, including completion rates, type of care received, and satisfaction. Recent consensus suggests, though, that receiving care consistent with one's goals is the primary outcome of advance care planning and assessment should capture this metric. Goal concordant care is challenging to measure, and there is little clarity about how best to do so. The aim of this scoping review is to explore what methods have been used to measure goal concordant care in the evaluation of advance care planning. PubMed, Embase, PsycINFO, CINAHL and Cochrane were searched in September 2020 to identify studies that aimed to track whether advance care planning affected the likelihood of patients receiving care that matched their preferred care. 135 original studies were included for review. Studies used retrospective chart review (36%, n=49), questionnaire (36%, n=48) and interview (31%, n=42), focusing on both patients and proxies. Studies considered both actual care received (55%, n=74) and hypothetical scenarios anticipating possible future care (49%, n=66); some studies did both. While the reviewed studies demonstrate the possibility of working towards a solid methodology, there were significant weaknesses. Notably, studies often lacked enough reporting clarity to be reproducible and, relatedly, key concepts, such as end-of-life or preferred care, were left undefined. The recommendations that follow from these findings inform future research approaches, supporting the development of a strong evidence base to guide advance care planning implementation in practice.
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Affiliation(s)
- Sophie Gloeckler
- Institute for Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
- School of Nursing, Columbia University, New York, New York, USA
| | - Tanja Krones
- Institute for Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
- Clinical Ethics, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Nikola Biller-Andorno
- Institute for Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
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Crawford GB, Hodgetts K, Burgess T, Eliott J. Documenting plans for care: advance care directives and the 7-step pathway in the acute care context. BMC Palliat Care 2021; 20:138. [PMID: 34503479 PMCID: PMC8431875 DOI: 10.1186/s12904-021-00838-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Advance care planning involves the discussion and documentation of an individual’s values and preferences to guide their future healthcare should they lose capacity to make or communicate treatment decisions. Advance care planning can involve the individual’s completion of an Advance Care Directive (ACD), a legislated and common-law instrument which may include appointment of a substitute decision-maker and binding refusals of treatment. In South Australia, ACDs intersect in the acute-care context with the Resuscitation Plan 7-Step Pathway (7-SP), an integrated care plan written for and by clinicians, designed to organise and improve patients’ end-of-life care through the use of structured documentation. Here, we examine the perspectives of healthcare professionals (HCPs) within a hospital setting on the practical integration of ACDs and the 7-SP, exploring the perceived role, function, and value of each as they intersect to guide end-of-life care in an Australian hospital setting. Methods Qualitative data were collected via eight focus groups with a total of 74 HCPs (acute care, and oncology specialists; medical intern; general and emergency nurses; social workers) across two hospitals. Audio recordings were transcribed and thematically analysed. Results HCPs viewed ACDs as a potentially valuable means of promoting patient autonomy, but as rarely completed and poorly integrated into hospital systems. Conversely, the process and documentation of the 7-SP was perceived as providing clarity about clinicians’ responsibilities, and as a well-understood, integrated resource. Participants sometimes exhibited uncertainty around which document takes precedence if both were present. Sometimes, the routinisation of the 7-SP meant it was understood as the ‘only way’ to determine patient wishes and provide optimal end-of-life care. When this occurs, the perceived authority of ACDs, or of patients’ choice not to participate in end-of-life discussions, may be undermined. Conclusions The intersection of ACDs and the 7-SP appears problematic within acute care. Clinicians’ uncertainty as to whether an ACD or 7-SP takes precedence, and when it should do so, suggests a need for further clarity and training on the roles of these documents in guiding clinical practice, the legislative context within which specific documentation is embedded, and the dynamics associated with collaborative decision-making in end-of-life care.
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Affiliation(s)
- Gregory Brian Crawford
- Northern Adelaide Local Health Network, C/- Modbury Hospital, Smart Road, Modbury, 5092, Australia. .,Discipline of Medicine, University of Adelaide, Adelaide, 5005, Australia.
| | - Katherine Hodgetts
- School of Public Health, University of Adelaide, Adelaide, 5005, Australia
| | - Teresa Burgess
- School of Public Health, University of Adelaide, Adelaide, 5005, Australia
| | - Jaklin Eliott
- School of Public Health, University of Adelaide, Adelaide, 5005, Australia
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Bigger SE, Haddad L, Ahluwalia SC, Glenn L. Advance Care Planning Protocols and Hospitalization Rates in Home Health Value-Based Purchasing. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2021. [DOI: 10.1177/10848223211021393] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.
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Affiliation(s)
| | - Lisa Haddad
- East Tennessee State University, Johnson City, TN, USA
| | | | - Lee Glenn
- East Tennessee State University, Johnson City, TN, USA
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Goodwin J, Shand B, Wiseman R, Brough N, McGeoch G, Hamilton G, Grundy K. Achievements and challenges during the development of an advance care planning program. Australas J Ageing 2021; 40:301-308. [PMID: 33847458 DOI: 10.1111/ajag.12945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 11/26/2022]
Abstract
A nationwide program to promote preparation of advance care plans (AC Plans) was introduced in Canterbury, New Zealand, in 2013. The program was developed by local facilitators who provided support and organised education seminars and an accredited training program for health-care professionals. Information and templates for an AC Plan were available to these professionals and the community on local health-care websites and secure online systems designed to allow plans to be viewed across all health-care sectors. The number of AC Plans prepared has increased steadily, although people in minority ethnic populations or in the most deprived socioeconomic quintile are less likely to have a plan. While nurses have become the predominant group guiding people through the process of preparing an AC Plan, the involvement of staff in residential care homes has remained low. Local audit showed that 82% of people with an AC Plan died in a community setting, frequently their preferred place of death.
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Affiliation(s)
- Jane Goodwin
- The Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Brett Shand
- The Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Rachel Wiseman
- Respiratory Medicine, Canterbury District Health Board, Christchurch, New Zealand
| | - Natalie Brough
- The Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Graham McGeoch
- The Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Greg Hamilton
- Planning and Funding and Decision Support, Canterbury District Health Board, Christchurch, New Zealand
| | - Kate Grundy
- Oncology Services, Canterbury District Health Board, Christchurch, New Zealand
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Role of a Clinical Ethics Committee in Residential Aged Long-Term Care Settings: A Systematic Review. J Am Med Dir Assoc 2020; 21:1852-1861.e8. [DOI: 10.1016/j.jamda.2020.05.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 01/19/2023]
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11
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Chua TH, Foong JRJ, Tan RR, Rukasha PN, Hullick C. Assessment of advance care planning documentation for residents of residential aged care facilities presenting to the emergency department. AUST HEALTH REV 2020; 44:847-852. [PMID: 33213690 DOI: 10.1071/ah19238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/12/2020] [Indexed: 11/23/2022]
Abstract
Objective This study assessed the availability and quality of advance care planning (ACP) documentation among older residential aged care facility (RACF) residents who presented to the emergency department (ED). Methods A prospective review of the medical records of RACF residents aged ≥75 years who presented to the ED from May to June 2018 was conducted. Availability of ACP was determined based on the presence of an ACP document inclusive of an advance care directive (ACD) in the medical record. The quality of ACP documentation was determined based on the presence of nine key components. Results In all, 48.8% of patients presented to the ED with either ACP or an ACD. However, only a mean total of 3.8 (out of 9) ACP components were documented in these documents. Conclusions Just under half (48.8%) of RACF residents presented to the ED with ACP documentation. There was limited coverage of core ACP components needed to guide clinical decision making. What is known about the topic? RACF residents are in the last years of their life and commonly lack capacity to make decisions regarding health care. Residents are at high risk of dying when acutely unwell in hospital. ACP documentation, when readily available, helps provide appropriate end-of-life care and improves both patient and family satisfaction. What does this paper add? Less than half the residents reporting to the ED from an RACF had ACP documentation available for clinicians. For those who presented to the ED with ACP documentation, most lacked sufficient information needed to provide care in full accordance with the patient's preferences. What are the implications for practitioners? There is a need to encourage, initiate, actively engage and develop systems for ACP conversations, documentation and availability when acutely unwell for people living in RACFs to provide sufficient information to guide clinical decision making. Without quality ACP, the provision of patient-centred health care may be compromised.
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Affiliation(s)
- Tzy Harn Chua
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia. ; ; ;
| | - Jessica Ru-Jia Foong
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia. ; ; ;
| | - Ryan Renxin Tan
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia. ; ; ;
| | - Princess Natsai Rukasha
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia. ; ; ;
| | - Carolyn Hullick
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia. ; ; ; ; and Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia; and Belmont Hospital, Croudace Bay Road, Belmont, NSW 2280, Australia; and Corresponding author.
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Rodi H, Detering K, Sellars M, Macleod A, Todd J, Fullerton S, Waller A, Nolte L. Exploring advance care planning awareness, experiences, and preferences of people with cancer and support people: an Australian online cross-sectional study. Support Care Cancer 2020; 29:3677-3688. [DOI: 10.1007/s00520-020-05878-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/05/2020] [Indexed: 01/05/2023]
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Werner P, Schiffman IK. Nursing home staff members' attitudes regarding advance care planning: relationships with different types of knowledge. Aging Clin Exp Res 2020; 32:2091-2098. [PMID: 31686389 DOI: 10.1007/s40520-019-01398-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/22/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Advanced care planning (ACP) is an essential component of quality palliative care in nursing homes. Despite the benefits associated with ACP in nursing homes, completion rates are low. Staff members' knowledge and attitudes toward ACP were found to be main determinants of ACP completion. AIMS To assess nursing home staff members' attitudes towards ACP and their association to different types of knowledge. METHODS A convenience sample of 138 nursing home staff members (69% female, 53% non-Jewish, 46% nurses) who reported having heard the terms advanced directives and durable power of attorney completed a structured questionnaire assessing attitudes toward ACP, subjective knowledge, and three types of objective knowledge (declarative, legal and procedural) regarding ACP, as well as socio-demographic and professional factors. RESULTS Participants expressed positive attitudes toward formal and informal aspect of ACP, although their subjective and objective knowledge in the topic was moderate. Hierarchical regression analyses revealed that the three dimensions of objective knowledge improved significantly the participants' attitude scores. DISCUSSION There is a need to integrate different types of knowledge in educational programs provided to nursing home staff members to improve their involvement in ACP initiatives with residents and family members.
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Affiliation(s)
- Perla Werner
- Department of Community Mental Health, University of Haifa, Mt. Carmel, Haifa, Israel.
| | - Ile Kermel Schiffman
- Department of Community Mental Health, University of Haifa, Mt. Carmel, Haifa, Israel
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Abstract
AbstractFor many years, dementia care has been dominated by the standard medical approach, in which dementia is treated mainly with drugs, such as anti-anxiety, antidepressant and anti-psychotic medications. With the aim of seeking effective treatments for patients with dementia, over the last years, several contributions have criticised the pervasive use of drugs for the management of behavioural and physiological symptoms related to dementia, proposing personalised interventions aimed at supporting patients and their relatives from diagnosis until death. With particular reference to long-term settings, in this work, we aim at understanding the organisational implications of three types of interventions (labelled supportive care interventions – SCIs) that have characterised this shift in dementia care: person-centred, palliative and multi-disciplinary care. Conducted by following the integrative review method, our review underlines how SCIs have controversial consequences on the quality of care, the care-givers’ quality of life and cultural backgrounds. After an in-depth analysis of selected papers, we offer some considerations about the implications of SCIs for long-term care organisations and future research directions.
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Craswell A, Wallis M, Coates K, Marsden E, Taylor A, Broadbent M, Nguyen KH, Johnston-Devin C, Glenwright A, Crilly J. Enhanced primary care provided by a nurse practitioner candidate to aged care facility residents: A mixed methods study. Collegian 2020. [DOI: 10.1016/j.colegn.2019.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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16
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Blackman I, Henderson J, Weger K, Willis E. Causal links associated with missed residential aged care. J Nurs Manag 2019; 28:1909-1917. [DOI: 10.1111/jonm.12889] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/03/2019] [Accepted: 10/21/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Ian Blackman
- College of Nursing & Health Sciences Flinders University Adelaide South Australia Australia
| | - Julie Henderson
- College of Nursing & Health Sciences Flinders University Adelaide South Australia Australia
| | - Kate Weger
- Southern Cross Care (SA & NT) Glenside South Australia Australia
| | - Eileen Willis
- College of Nursing & Health Sciences Flinders University Adelaide South Australia Australia
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Frey R, Balmer D, Boyd M, Robinson J, Gott M. Palliative care nurse specialists' reflections on a palliative care educational intervention in long-term care: an inductive content analysis. BMC Palliat Care 2019; 18:103. [PMID: 31744507 PMCID: PMC6864945 DOI: 10.1186/s12904-019-0488-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 11/12/2019] [Indexed: 12/02/2022] Open
Abstract
Background Older people in long-term care facilities are at a greater risk of receiving care at the end of life that does not adequately meet their needs, yet staff in long-term care are often unprepared to provide palliative care. The objective of the study was to explore palliative care nurse specialists’ experiences regarding the benefits of and barriers to the implementation of a palliative care educational intervention, Supportive Hospice Aged Residential Exchange (SHARE) in 20 long-term care facilities. Methods Reflective logs (465), recorded over the course of the yearlong SHARE intervention by the three palliative care nurse specialists from two local hospices, who were the on-site mentors, were qualitatively analyzed by two researchers utilizing inductive content analysis. Results Categories emerging from the logs include the importance of relationships, knowledge exchange, communication, and the challenges of providing palliative care in a long-term care setting. Conclusion Evidence from the logs indicated that sustained relationships between the palliative care nurse specialists and staff (registered nurses, healthcare assistants) as well as reciprocal learning were key factors supporting the implementation of this palliative care educational intervention. Challenges remain however in relation to staffing levels, which further emphasizes the importance of palliative care nurse specialist presence as a point of stability.
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Affiliation(s)
- Rosemary Frey
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand.
| | - Deborah Balmer
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Michal Boyd
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Jackie Robinson
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
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18
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Friedewald MI, Cleasby PA. Advance care directive documentation: issues for clinicians in New South Wales. AUST HEALTH REV 2019; 42:89-92. [PMID: 28147212 DOI: 10.1071/ah16205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 12/09/2016] [Indexed: 11/23/2022]
Abstract
Objective The aim of the present study was to assess the characteristics of documents presented as advance care directives (ACDs) at a public health organisation in New South Wales (NSW). It was envisaged that the findings would inform the refinement of locally developed educational strategies. Methods All ACD documents provided during hospital admissions and entered into the electronic medical record system over a 12-month period were reviewed. An audit tool was developed and used to identify whether key requirements for ACDs in NSW had been addressed. Results Of the 100 ACDs that were reviewed, only 50 were assessed as being valid to inform future clinical scenarios. Multiple templates with different designs and of varying length had been used. Conclusions Documents identified as ACDs may carry doubt about their validity. Clinicians require education about differences in template formats, the application of content to clinical decisions and associated legal responsibilities. What is known about this topic? Advance Care Directives in NSW exist without a specific legislative framework or prescriptive format. Clinicians are presented with a wide variety of documents with broad variance in content. What does this paper add? This paper describes the variance found within ACDs in detail, and identifies concerns about validity that healthcare systems need to consider. What are the implications for practitioners? Clinicians need to discern the validity and utility of ACDs before the content is used in the process of clinical decision-making.
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Affiliation(s)
- Mark I Friedewald
- Clinical Governance Directorate, Central Coast Local Health District, Level 1, 67 Holden Street, Gosford, NSW 2250, Australia
| | - Peter A Cleasby
- Specialist Palliative Care Services, Central Coast Local Health District, PO Box 6088, Long Jetty, NSW 2261, Australia. Email
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Hemsley B, Meredith J, Bryant L, Wilson NJ, Higgins I, Georgiou A, Hill S, Balandin S, McCarthy S. An integrative review of stakeholder views on Advance Care Directives (ACD): Barriers and facilitators to initiation, documentation, storage, and implementation. PATIENT EDUCATION AND COUNSELING 2019; 102:1067-1079. [PMID: 30799141 DOI: 10.1016/j.pec.2019.01.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To examine the views and experiences of patients and their health care providers on developing advance care planning (ACP) and advance care directives (ACD); and determine barriers and facilitators to ACD development, storage, and use, including implications for people with communication disability. METHOD An integrative review of 93 studies, analysed according to their content themes. RESULTS Content themes encapsulated the initiation, documentation, and implementation stages of ACP/ACD. Lack of guidance for initiating and supporting ACP/ACD impedes discussions, and both patients and healthcare providers avoid discussions owing to fear of dying and reluctance to think about end-of-life. CONCLUSIONS There are several barriers and facilitators to the initiation of ACP discussions, documentation and implementation of ACD, and little research exploring the views of legal professionals on the development, storage, or use of ACP documents. Further research is needed to explore the timing and responsibility of both legal and health professionals in initiating and supporting ACP discussions. PRACTICE IMPLICATIONS It is important for healthcare providers to raise ACP discussions regularly so that patients have time to make informed advance care decisions. Storage of the document in an electronic health record might facilitate better access to and implementation of patients' end-of-life care decisions.
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Affiliation(s)
- Bronwyn Hemsley
- The University of Technology Sydney, Building 7, Faculty of Science and Graduate School of Health Building, 67 Thomas Street, Ultimo, Australia @BronwynHemsley.
| | - Jacqueline Meredith
- The University of Newcastle, University Drive, Callaghan, 2308, NSW, Australia.
| | - Lucy Bryant
- The University of Technology Sydney, Building 7, Faculty of Science and Graduate School of Health Building, 67 Thomas Street, Ultimo, Australia @BronwynHemsley.
| | - Nathan J Wilson
- Western Sydney University, Building G10/Office 10, Hawkesbury Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia.
| | - Isabel Higgins
- The University of Newcastle, University Drive, Callaghan, 2308, NSW, Australia.
| | - Andrew Georgiou
- Macquarie University, Room L6 36, Level 6, 75 Talavera Road, NSW, 2109, Australia.
| | - Sophie Hill
- La Trobe University, School of Psychology and Public Health, College of Science, Health and Engineering, VIC, 3086, Australia.
| | - Susan Balandin
- Deakin University, Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC, 3125, Australia.
| | - Shaun McCarthy
- The University of Newcastle, University Drive, Callaghan, 2308, NSW, Australia.
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Abstract
ABSTRACTThe purpose of this study was to analyse the consistency and extent of palliative content across high-level guiding documents related to the care of persons residing in Canadian long-term care homes. A systematic search was conducted examining documents at the national level and across five provinces (Alberta, Ontario, Saskatchewan, Manitoba, and Quebec). Twenty-five documents were selected based on inclusion criteria from 273 documents identified in the systematic search. The majority of these documents were created nationally (48%) or in Ontario (28%). Documents varied in palliative topics discussed, and long-term care was discussed minimally. A minimal number of palliative care guiding documents were found. Long-term care specific documents were absent, and all documents lacked consistency on palliative topics. It is imperative that palliative principles are present and consistent in high-level documents in order to improve the quality of life and care for long-term care residents across Canada.
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Udo C, Neljesjö M, Strömkvist I, Elf M. A qualitative study of assistant nurses' experiences of palliative care in residential care. Nurs Open 2018; 5:527-535. [PMID: 30338098 PMCID: PMC6177554 DOI: 10.1002/nop2.159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/16/2018] [Indexed: 01/20/2023] Open
Abstract
AIM To explore assistant nurses' experiences and perceptions of both positive and negative aspects of providing palliative care for older people in residential care facilities. DESIGN A qualitative explorative study. METHODS Critical incidents were collected through semi-structured face-to-face interviews and analysed by performing a qualitative content analysis. RESULTS A total of 40 critical incidents from daily work was described by assistant nurses. The results showed that close cooperation between unlicensed and licensed professionals was crucial to provide good care but was sometimes negatively affected by the organizational structure. The availability of professionals was identified as a critical factor in providing good care at the end of life in a consultative organization. The most prominent findings were those that indicated that, especially in a consultative organization, there seems to be a need for clear roles, comprehensive and clear care plans and a solid support structure to ensure continuity of care.
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Affiliation(s)
- Camilla Udo
- School of Education, Health and Social StudiesDalarna UniversityFalunSweden
- Center for Clinical Research DalarnaFalunSweden
| | - Maria Neljesjö
- School of Education, Health and Social StudiesDalarna UniversityFalunSweden
| | | | - Marie Elf
- School of Education, Health and Social StudiesDalarna UniversityFalunSweden
- Karolinska InstitutetDepartment of Neurobiology, Care Sciences and SocietyStockholmSweden
- Chalmers University of TechnologySchool of ArchitectureGothenburgSweden
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22
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Piers R, Albers G, Gilissen J, De Lepeleire J, Steyaert J, Van Mechelen W, Steeman E, Dillen L, Vanden Berghe P, Van den Block L. Advance care planning in dementia: recommendations for healthcare professionals. BMC Palliat Care 2018; 17:88. [PMID: 29933758 PMCID: PMC6014017 DOI: 10.1186/s12904-018-0332-2] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/10/2018] [Indexed: 01/08/2023] Open
Abstract
Background Advance care planning (ACP) is a continuous, dynamic process of reflection and dialogue between an individual, those close to them and their healthcare professionals, concerning the individual’s preferences and values concerning future treatment and care, including end-of-life care. Despite universal recognition of the importance of ACP for people with dementia, who gradually lose their ability to make informed decisions themselves, ACP still only happens infrequently, and evidence-based recommendations on when and how to perform this complex process are lacking. We aimed to develop evidence-based clinical recommendations to guide professionals across settings in the practical application of ACP in dementia care. Methods Following the Belgian Centre for Evidence-Based Medicine’s procedures, we 1) performed an extensive literature search to identify international guidelines, articles reporting heterogeneous study designs and grey literature, 2) developed recommendations based on the available evidence and expert opinion of the author group, and 3) performed a validation process using written feedback from experts, a survey for end users (healthcare professionals across settings), and two peer-review groups (with geriatricians and general practitioners). Results Based on 67 publications and validation from ten experts, 51 end users and two peer-review groups (24 participants) we developed 32 recommendations covering eight domains: initiation of ACP, evaluation of mental capacity, holding ACP conversations, the role and importance of those close to the person with dementia, ACP with people who find it difficult or impossible to communicate verbally, documentation of wishes and preferences, including information transfer, end-of-life decision-making, and preconditions for optimal implementation of ACP. Almost all recommendations received a grading representing low to very low-quality evidence. Conclusion No high-quality guidelines are available for ACP in dementia care. By combining evidence with expert and user opinions, we have defined a unique set of recommendations for ACP in people living with dementia. These recommendations form a valuable tool for educating healthcare professionals on how to perform ACP across settings.
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Affiliation(s)
- Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium.,End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Gwenda Albers
- Flanders Federation for Palliative Care, Vilvoorde, Belgium
| | - Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, ACHG, KU Leuven, Leuven, Belgium
| | - Jan Steyaert
- Department of Sociology, University of Antwerp, Antwerp, Belgium.,Flemish Expertise Centre on Dementia Care, Antwerp, Belgium
| | - Wouter Van Mechelen
- Department of Public Health and Primary Care, ACHG, KU Leuven, Leuven, Belgium
| | - Els Steeman
- Academic Centre for Nursing and Midwifery, KULeuven, Leuven, Belgium
| | - Let Dillen
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Brussels, Belgium.
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Detering KM, Carter RZ, Sellars MW, Lewis V, Sutton EA. Prospective comparative effectiveness cohort study comparing two models of advance care planning provision for Australian community aged care clients. BMJ Support Palliat Care 2017; 7:486-494. [PMID: 28918387 DOI: 10.1136/bmjspcare-2017-001372] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/20/2017] [Accepted: 08/30/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Conduct a prospective comparative effectiveness cohort study comparing two models of advance care planning (ACP) provision in community aged care: ACP conducted by the client's case manager (CM) ('Facilitator') and ACP conducted by an external ACP service ('Referral') over a 6-month period. METHODS This Australian study involved CMs and their clients. Eligible CM were English speaking, ≥18 years, had expected availability for the trial and worked ≥3 days per week. CMs were recruited via their organisations, sequentially allocated to a group and received education based on the group allocation. They were expected to initiate ACP with all clients and to facilitate ACP or refer for ACP. Outcomes were quantity of new ACP conversations and quantity and quality of new advance care directives (ACDs). RESULTS 30 CMs (16 Facilitator, 14 Referral) completed the study; all 784 client's files (427 Facilitator, 357 Referral) were audited. ACP was initiated with 508 (65%) clients (293 Facilitator, 215 Referral; p<0.05); 89 (18%) of these (53 Facilitator, 36 Referral) and 41 (46%) (13 Facilitator, 28 Referral; p<0.005) completed ACDs. Most ACDs (71%) were of poor quality/not valid. A further 167 clients (facilitator 124; referral 43; p<0.005) reported ACP was in progress at study completion. CONCLUSIONS While there were some differences, overall, models achieved similar outcomes. ACP was initiated with 65% of clients. However, fewer clients completed ACP, there was low numbers of ACDs and document quality was generally poor. The findings raise questions for future implementation and research into community ACP provision.
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Affiliation(s)
- Karen Margaret Detering
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, Melbourne University, Melbourne, Victoria, Australia
| | - Rachel Zoe Carter
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
| | - Marcus William Sellars
- Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia.,Kolling Institute, Northern Clinical School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Virginia Lewis
- Australian Institute for Primary Care and Ageing, La Trobe University, Melbourne, Victoria, Australia
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McGlade C, Daly E, McCarthy J, Cornally N, Weathers E, O'Caoimh R, Molloy DW. Challenges in implementing an advance care planning programme in long-term care. Nurs Ethics 2016; 24:87-99. [PMID: 27637549 DOI: 10.1177/0969733016664969] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A high prevalence of cognitive impairment and frailty complicates the feasibility of advance care planning in the long-term-care population. Research aim: To identify challenges in implementing the 'Let Me Decide' advance care planning programme in long-term-care. RESEARCH DESIGN This feasibility study had two phases: (1) staff education on advance care planning and (2) structured advance care planning by staff with residents and families. Participants and research context: long-term-care residents in two nursing homes and one community hospital. Ethical considerations: The local research ethics committee granted ethical approval. FINDINGS Following implementation, over 50% of all residents had completed some form of end-of-life care plan. Of the 70 residents who died in the post-implementation period, 14% had no care plan, 10% (with capacity) completed an advance care directive and lacking such capacity, 76% had an end-of-life care plan completed for them by the medical team, following discussions with the resident (if able) and family. The considerable logistical challenge of releasing staff for training triggered development of an e-learning programme to facilitate training. DISCUSSION The challenges encountered were largely concerned with preserving resident's autonomy, avoiding harm and suboptimal or crisis decision-making, and ensuring residents were treated fairly through optimisation of finite resources. CONCLUSIONS Although it may be too late for many long-term-care residents to complete their own advance care directive, the ' Let Me Decide' programme includes a feasible and acceptable option for structured end-of-life care planning for residents with variable capacity to complete an advance care directive, involving discussion with the resident (to the extent they were able) and their family. While end-of-life care planning was time-consuming to deliver, nursing staff were willing to overcome this and take ownership of the programme, once the benefits in improved communication and enhanced peace of mind among all parties involved became apparent in practice.
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25
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Frey R, Boyd M, Foster S, Robinson J, Gott M. Necessary but not yet sufficient: a survey of aged residential care staff perceptions of palliative care communication, education and delivery. BMJ Support Palliat Care 2016; 6:465-473. [PMID: 27288399 DOI: 10.1136/bmjspcare-2015-000943] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 03/18/2016] [Accepted: 05/21/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Previous research has indicated that staff in aged residential care (ARC) may be unprepared for their role in palliative care provision. The need for palliative care knowledge among ARC staff has been characterised as 'pervasive'. Determining the palliative care education, communication and support needs of ARC clinical care staff is, therefore, of critical importance to the delivery of quality healthcare in this setting. METHODS A survey of clinical staff (n=431) in 52 ARC facilities in 1 urban district health board was conducted, using a paper-based questionnaire. Instruments included the 3-item Experiences with End of Life scale, developed measures of communication and support (13 items), support accessibility (12 items), and palliative care education (19 items). RESULTS Only 199 (46.2%) of staff participants reported undertaking palliative care education. Nurses were more likely to have engaged in palliative care education in comparison with healthcare assistants (HCAs) (χ2(1, N=387)=18.10, p=0.00). Participants (n=347) who wanted further education preferred an interactive, hands-on applied education (13.9%) in comparison to short topic-specific sessions/seminars (6.5%) or lecture-based courses (7.7%). CONCLUSIONS The study reveals an ongoing need for staff palliative care education. Results suggest the development of an integrated model of care which draws on both hospice and ARC staff expertise.
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Affiliation(s)
- Rosemary Frey
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Michal Boyd
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Waitemata District Health Board, Auckland, New Zealand
| | - Sue Foster
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Jackie Robinson
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Auckland District Health Board, Auckland, New Zealand
| | - Merryn Gott
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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26
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Bollig G, Gjengedal E, Rosland JH. They know!-Do they? A qualitative study of residents and relatives views on advance care planning, end-of-life care, and decision-making in nursing homes. Palliat Med 2016; 30:456-70. [PMID: 26396227 PMCID: PMC4838176 DOI: 10.1177/0269216315605753] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Residents living in long-term care facilities are a vulnerable population. For many residents, a nursing home is their place of death. Palliative care and end-of-life decisions are important components of their care provision. AIM To study the views of cognitively able residents and relatives on advance care planning, end-of-life care, and decision-making in nursing homes. DESIGN A qualitative study with in-depth interviews with nursing home residents and focus group interviews with relatives of nursing home residents. Analysis is based on interpretive description. SETTING/PARTICIPANTS In total, 43 informants from nine nursing homes participated in the study (25 nursing home residents and 18 relatives). All included residents had capacity to provide informed consent and lived in long-term care. RESULTS The main findings of this study were the differing views about decision-making and advance care planning of residents and relatives. Residents do trust relatives and staff to make important decisions for them. The relatives are in contrast insecure about the residents' wishes and experience decision-making as a burden. The majority of the residents had not participated in advance care planning. None of the residents stated challenges connected to end-of-life care or mentioned the wish for euthanasia. CONCLUSION Although most residents seem to be satisfied with decision-making and end-of life care, there is a need for systematic advance care planning. Advance care planning could help to explore future wishes for care and ease decision-making for the relatives, physicians, and staff and should be offered to all cognitively able nursing homes residents.
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Affiliation(s)
- Georg Bollig
- Department of Clinical Medicine, University of Bergen, Bergen, Norway Sunniva Centre for Palliative Care, Department of Internal Medicine, Haraldsplass Deaconess Hospital Bergen, Bergen, Norway Department of Anesthesiology, Intensive Care, Palliative Medicine and Pain Therapy, HELIOS Klinikum Schleswig, Schleswig, Germany
| | - Eva Gjengedal
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway Molde University College, Molde, Norway
| | - Jan Henrik Rosland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway Sunniva Centre for Palliative Care, Department of Internal Medicine, Haraldsplass Deaconess Hospital Bergen, Bergen, Norway
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27
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Schröder L, Hommel G, Sahm S. Intricate decision making: ambivalences and barriers when fulfilling an advance directive. Patient Prefer Adherence 2016; 10:1583-9. [PMID: 27574407 PMCID: PMC4993391 DOI: 10.2147/ppa.s109040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite a recent statutory ruling stating the binding nature of advance directives (ADs), only a minority of the population has signed one. Yet, a majority deem it of utmost importance to ensure their wishes are followed through in case they are no longer able to decide. The reasons for this discrepancy have not yet been investigated sufficiently. PATIENTS AND METHODS This article is based on a survey of patients using a well-established structured questionnaire. First, patients were asked about their attitudes with respect to six therapeutic options at the end of life: intravenous fluids, artificial feeding, antibiotics, analgesia, chemotherapy/dialysis, and artificial ventilation; and second, they were asked about the negative effects related to the idea of ADs surveying their apprehensions: coercion to fulfill an AD, dictatorial reading of what had been laid down, and abuse of ADs. RESULTS A total of 1,260 interviewees completed the questionnaires. A significant percentage of interviewees were indecisive with respect to therapeutic options, ranging from 25% (analgesia) to 45% (artificial feeding). There was no connection to health status. Apprehensions about unwanted effects of ADs were widespread, at 51%, 35%, and 43% for coercion, dictatorial reading, and abuse, respectively. CONCLUSION A significant percentage of interviewees were unable to anticipate decisions about treatment options at the end of life. Apprehensions about negative adverse effects of ADs are widespread.
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Affiliation(s)
- Lars Schröder
- Department of Gynecology and Obstetrics, Center of Integrated Oncology, University Hospital Bonn, Bonn
- Correspondence: Lars Schröder, Department of Gynecology and Obstetrics, Center of Integrated Oncology, University Hospital Bonn, Sigmund-Freud Street 25, 53127 Bonn, Germany, Tel +49 151 1968 9224, Email
| | - Gerhard Hommel
- Institute of Medical Biometry, Epidemiology and Informatics, Johannes Gutenberg University, Mainz
| | - Stephan Sahm
- Department of Gastroenterology and Oncology, Ketteler Hospital, Offenbach
- Institute for Ethics and History of Medicine, Johann Wolfgang Goethe University, Frankfurt, Germany
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28
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Sellars M, Silvester W, Masso M, Johnson CE. Advance care planning in palliative care: a national survey of health professionals and service managers. AUST HEALTH REV 2015; 39:146-153. [PMID: 25607322 DOI: 10.1071/ah14118] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/27/2014] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To identify the attitudes, knowledge and practices regarding advance care planning (ACP) in palliative care. METHODS A nationwide online survey was distributed to Australian palliative care services associated with the Palliative Care Outcomes Collaboration (n=105). Seventy-three health professionals (HPs) and 59 service managers completed the survey. RESULTS Regarding ACP, 51% of service managers reported relevant policies and procedures were in place in their service and 44% included ACP in job descriptions. Most HPs were confident in undertaking ACP, including initiating discussions with patients and complying with documents; however, only 44% reported receiving ACP specific training. Although 58% of HPs reported having conversations about ACP with more than 11 patients in the past 6 months, only 44% of managers report that it is offered to most patients. Thirty per cent of HPs were aware of others not adhering to patient wishes in the past 6 months and only 43% of HPs (and 37% of managers) believed ACP is done well within their service. CONCLUSIONS This first national survey examining ACP in palliative care services demonstrates there is a need to improve systems to support ACP and to understand circumstances in which ACP wishes are not followed.
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Affiliation(s)
- Marcus Sellars
- Respecting Patient Choices Program, Austin Hospital, PO Box 5555, Heidelberg, Vic. 3084, Australia. Email
| | - William Silvester
- Respecting Patient Choices Program, Austin Hospital, PO Box 5555, Heidelberg, Vic. 3084, Australia. Email
| | - Malcolm Masso
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, iC Enterprise 1, Innovation Campus, University of Wollongong, Wollongong, NSW 2522, Australia. Email
| | - Claire E Johnson
- Cancer and Palliative Care Research and Evaluation Unit, School of Surgery, The University of Western Australia, M507, 35 Stirling Hwy, Crawley, WA 6009, Australia. Email
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29
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Sellars M, Detering KM, Silvester W. Current advance care planning practice in the Australian community: an online survey of home care package case managers and service managers. BMC Palliat Care 2015; 14:15. [PMID: 25903912 PMCID: PMC4416336 DOI: 10.1186/s12904-015-0018-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 04/15/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is the process of planning for future healthcare that is facilitated by a trained healthcare professional, whereby a person's values, beliefs and treatment preferences are made known to guide clinical decision-making at a future time when they cannot communicate their decisions. Despite the potential benefits of ACP for community aged care clients the availability of ACP is unknown, but likely to be low. In Australia many of these clients receive services through Home Care Package (HCP) programs. This study aimed to explore current attitudes, knowledge and practice of advance care planning among HCP service managers and case managers. METHODS An invitation to take part in a cross-sectional online survey was distributed by email to all HCP services across Australia in November 2012. Descriptive analyses were used to examine overall patterns of responses to each survey item in the full sample. RESULTS 120 (response rate 25%) service managers and 178 (response rate 18%) case managers completed the survey. Only 34% of services had written ACP policies and procedures in place and 48% of case managers had previously completed any ACP training. In addition, although most case managers (70%) had initiated an ACP discussion in the past 12 months and viewed ACP as part of their role, the majority of the conversations (80%) did not result in documentation of the client's wishes and most (85%) of the case managers who responded did not believe ACP was done well within their service. CONCLUSIONS This survey shows low organisational ACP systems and support for case managers and a lack of a normative approach to ACP across Australian HCP services. As HCPs become more prevalent it is essential that a model of ACP is developed and evaluated in this setting, so that clients have the opportunity to discuss and document their future healthcare wishes if they choose to.
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Affiliation(s)
- Marcus Sellars
- Respecting Patient Choices, Austin Health, Melbourne, Australia. .,Respecting Patient Choices Program, Austin Hospital, PO Box 5555, Heidelberg, Melbourne, VIC, 3084, Australia.
| | - Karen M Detering
- Respecting Patient Choices, Austin Health, Melbourne, Australia.
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30
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Laging B, Ford R, Bauer M, Nay R. A meta-synthesis of factors influencing nursing home staff decisions to transfer residents to hospital. J Adv Nurs 2015; 71:2224-36. [DOI: 10.1111/jan.12652] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Bridget Laging
- School of Nursing, Midwifery and Paramedicine; Australian Catholic University; Melbourne Victoria Australia
- Australian Centre for Evidence Based Aged Care (ACEBAC); La Trobe University; Melbourne Victoria Australia
| | - Rosemary Ford
- School of Nursing, Midwifery and Paramedicine; Australian Catholic University; Melbourne Victoria Australia
| | - Michael Bauer
- Australian Centre for Evidence Based Aged Care (ACEBAC); La Trobe University; Melbourne Victoria Australia
| | - Rhonda Nay
- La Trobe University; Melbourne Victoria Australia
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31
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White B, Tilse C, Wilson J, Rosenman L, Strub T, Feeney R, Silvester W. Prevalence and predictors of advance directives in Australia. Intern Med J 2014; 44:975-80. [DOI: 10.1111/imj.12549] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 08/05/2014] [Indexed: 11/28/2022]
Affiliation(s)
- B. White
- Australian Centre for Health Law Research, Faculty of Law; Queensland University of Technology; Brisbane Queensland Australia
| | - C. Tilse
- School of Social Work and Human Services; The University of Queensland; Brisbane Queensland Australia
| | - J. Wilson
- School of Social Work and Human Services; The University of Queensland; Brisbane Queensland Australia
| | - L. Rosenman
- Collaborative Research Networks Program Leader; Charles Darwin University; Darwin Northern Territory Australia
| | - T. Strub
- Criminal Justice Research; Department of the Premier and Cabinet; Queensland Government; Brisbane Queensland Australia
| | - R. Feeney
- School of Social Work and Human Services; The University of Queensland; Brisbane Queensland Australia
| | - W. Silvester
- Respecting Patient Choices Program; Austin Health; Melbourne Victoria Australia
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32
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Lovell A, Yates P. Advance Care Planning in palliative care: a systematic literature review of the contextual factors influencing its uptake 2008-2012. Palliat Med 2014; 28:1026-35. [PMID: 24821708 DOI: 10.1177/0269216314531313] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advance Care Planning is an iterative process of discussion, decision-making and documentation about end-of-life care. Advance Care Planning is highly relevant in palliative care due to intersecting clinical needs. To enhance the implementation of Advance Care Planning, the contextual factors influencing its uptake need to be better understood. AIM To identify the contextual factors influencing the uptake of Advance Care Planning in palliative care as published between January 2008 and December 2012. METHODS Databases were systematically searched for studies about Advance Care Planning in palliative care published between January 2008 and December 2012. This yielded 27 eligible studies, which were appraised using National Institute of Health and Care Excellence Quality Appraisal Checklists. Iterative thematic synthesis was used to group results. RESULTS Factors associated with greater uptake included older age, a college degree, a diagnosis of cancer, greater functional impairment, being white, greater understanding of poor prognosis and receiving or working in specialist palliative care. Barriers included having non-malignant diagnoses, having dependent children, being African American, and uncertainty about Advance Care Planning and its legal status. Individuals' previous illness experiences, preferences and attitudes also influenced their participation. CONCLUSION Factors influencing the uptake of Advance Care Planning in palliative care are complex and multifaceted reflecting the diverse and often competing needs of patients, health professionals, legislature and health systems. Large population-based studies of palliative care patients are required to develop the sound theoretical and empirical foundation needed to improve uptake of Advance Care Planning in this setting.
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Affiliation(s)
- Allison Lovell
- Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia Specialist Palliative Care Service, Division of Internal Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Patsy Yates
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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Duke GJ, Barker A, Knott CI, Santamaria JD. Outcomes of older people receiving intensive care in Victoria. Med J Aust 2014; 200:323-6. [PMID: 24702089 DOI: 10.5694/mja13.10132] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 10/25/2013] [Indexed: 11/17/2022]
Abstract
UNLABELLED OBJECTIVE To assess trends in service use and outcome of critically ill older people (aged ≥ 65 years) admitted to an intensive care unit (ICU). DESIGN, PATIENTS AND SETTING Retrospective cohort analysis of administrative data on older patients discharged from ICUs at all 23 adult public hospitals with onsite ICUs in Victoria between 1 July 1999 and 30 June 2011. Subgroups examined included those aged ≥ 80 years, major diagnosis categories, and those receiving mechanical ventilation. MAIN OUTCOME MEASURES Resource use and hospital survival; also length of stay (LOS) and discharge destination trends. RESULTS Over 12 years, 108,171 people aged ≥ 65 years were admitted to ICUs; of these, 49,912 (46.1%) received mechanical ventilation and 17,772 (16.4%) died. Despite an increase in the older age population (2.5% per annum) and acute care admissions (7.3% per annum) over the period studied, there was a net reversal in prevalence trends for ICU admissions (- 1.7% per annum; P = 0.04) and admissions of patients requiring mechanical ventilation (- 1.6% per annum) in the 8 years since 2004. Annual risk-adjusted mortality fell (odds ratio, 0.97 per year; 95% CI, 0.96-0.97 per year; P < 0.001) without prolongation of hospital or ICU LOS (P = 0.49) or discharge to residential aged care (RAC). Similar trends were noted in all a priori subgroups. CONCLUSIONS Improved hospital survival without an increase in demand for ICU admission or RAC or an increase in LOS suggests there has been improvement in the care of the older age population.
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Affiliation(s)
| | - Anna Barker
- Centre of Research Execllence in Patient Safety, Monash University, Melbourne, VIC, Australia
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McVey P, McKenzie H, White K. A community-of-care: the integration of a palliative approach within residential aged care facilities in Australia. HEALTH & SOCIAL CARE IN THE COMMUNITY 2014; 22:197-209. [PMID: 24200015 DOI: 10.1111/hsc.12077] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/23/2013] [Indexed: 06/02/2023]
Abstract
In developed countries, residential aged care facilities (RACFs) are increasingly becoming the place of care and site of death for older people with complex chronic illnesses. Consequently, it is becoming ever more relevant for these facilities to provide appropriate complex, as well as end-of-life care for this growing group of people. Evidence-based guidelines for providing a 'palliative approach' were developed and introduced in Australia in 2004, with the emphasis on improving symptom control earlier in the disease trajectory. The aim of the study reported here was to explore the extent to which a palliative approach was being used in the organisation and provision of care for older people with complex needs living in mixed-level (a combination of low- and high-level care) RACFs. This paper primarily reports on the qualitative findings. Two residential aged care organisations, one in rural New South Wales and the other in Sydney, Australia, participated. Data were collected over a 9-month period from May until December 2008. Residents, family members and aged care staff were interviewed. Thematic analysis of participant interviews shows that while the various elements of a palliative approach are incorporated into the care of high-level care residents, the discourse itself is not used. In this paper, we argue for a new conceptualisation of care for people in mixed-level care facilities: a community-of-care, in which a palliative approach is one of several components of the care provided. The findings illuminate aged care staff experiences of providing care to high-level care residents. They also provide valuable insights into high-level care residents' perceptions of their health, care provided and the way in which they foresee their care being provided in future. These findings will be important for informing clinical practice, research and policy in these settings.
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Affiliation(s)
- Peta McVey
- Clinical Training Centre, Greenwich Hospital, HammondCare Health & Hospitals, Greenwich, New South Wales, Australia; Sydney Nursing School, The University of Sydney, Sydney, New South Wales, Australia
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Silvester W, Parslow RA, Lewis VJ, Fullam RS, Sjanta R, Jackson L, White V, Hudson R. Development and evaluation of an aged care specific Advance Care Plan. BMJ Support Palliat Care 2013; 3:188-95. [PMID: 23626906 PMCID: PMC3632978 DOI: 10.1136/bmjspcare-2012-000392] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objectives To report on the quality of advance care planning (ACP) documents in use in residential aged care facilities (RACF) in areas of Victoria Australia prior to a systematic intervention; to report on the development and performance of an aged care specific Advance Care Plan template used during the intervention. Design An audit of the quality of pre-existing documentation used to record resident treatment preferences and end-of-life wishes at participating RACFs; development and pilot of an aged care specific Advance Care Plan template; an audit of the completeness and quality of Advance Care Plans completed on the new template during a systematic ACP intervention. Participants and setting 19 selected RACFs (managed by 12 aged care organisations) in metropolitan and regional areas of Victoria. Results Documentation in use at facilities prior to the ACP intervention most commonly recorded preferences regarding hospital transfer, life prolonging treatment and personal/cultural/religious wishes. However, 7 of 12 document sets failed to adequately and clearly specify the resident's preferences as regards life prolonging medical treatment. The newly developed aged care specific Advance Care Plan template was met with approval by participating RACFs. Of 203 Advance Care Plans completed on the template throughout the project period, 49% included the appointment of a Medical Enduring Power of Attorney. Requests concerning medical treatment were specified in almost all completed documents (97%), with 73% nominating the option of refusal of life-prolonging treatment. Over 90% of plans included information concerning residents’ values and beliefs, and future health situations that the resident would find to be unacceptable were specified in 78% of completed plans. Conclusions Standardised procedures and documentation are needed to improve the quality of processes, documents and outcomes of ACP in the residential aged care sector.
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Affiliation(s)
- William Silvester
- Respecting Patient Choices, Austin Health, Heidelberg, Victoria, Australia
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