Barriers to advance care planning in chronic obstructive pulmonary disease

Revolutionizing Chronic Obstructive Pulmonary Disease Care with the Open AI Application: ChatGPT

Chronic Obstructive Pulmonary Disease (COPD) is one of the major and leading threats to human being. To cope with this health challenge, several studies have been undertaken in the literature. However, COPD is not paid close attention to eliminate it entirely. The current study aims to examine the role of ChatGPT application to bring improvement in controlling and managing COPD in patients. ChatGPT is used to give prompt answers of text-based questions in a variety of fields. It has potential role in knowing the symptoms of COPD, and letting individuals to modify their life styles. ChatGPT suggests medications for COPD individuals based on the established medical guidelines. Compared to the literature, ChatGPT provides a comprehensive list of COPD test and evaluation methods. ChatGPT has the potential to help physicians to take decisions in diagnosing, treating, and managing COPD among individuals in its upcoming versions. More researches can be conducted to identify the limits of ChatGPT application in future works.

Advance care planning for patients with chronic obstructive pulmonary disease on home non-invasive ventilation: A qualitative study exploring barriers, facilitators and patients' and healthcare professionals' recommendations

BACKGROUND

Although home non-invasive ventilation for patients with chronic obstructive pulmonary disease and persisting hypercapnia prolongs time to hospital readmission and prognosis, they retain a poor long-term prognosis. Requiring non-invasive ventilation in this population should trigger advance care planning, yet only 50% of patients are engaged in such discussions.

AIM

This study aimed to explore the barriers and facilitators to advance care planning for patients with chronic obstructive pulmonary disease on home non-invasive ventilation and generate recommendations for improving practice.

STUDY DESIGN

A cross-sectional interview study took place with 10 patients with chronic obstructive pulmonary disease on home non-invasive ventilation and 12 North East Assisted Ventilation Service healthcare professionals from the North East of England.

RESULTS

Three themes ('overlooked', 'disjointed care' and 'awareness and expertise') were identified. Patients with chronic obstructive pulmonary disease are a 'forgotten about' population, exacerbated by prejudice and unpredictable disease trajectories. Recognition as a distinct and underserved population may improve care and advance care planning. All participants recognised a lack of care continuity, including limited collaboration and communication between services, as a significant barrier to advanced care planning. Additionally, lacking understanding of the rationale and positive impacts of advance care planning, exacerbated by a lack of expertise in difficult conversations, was a barrier to advance care planning.

CONCLUSIONS

Patients and healthcare professionals highlighted the need for individualised and ongoing advance care planning, particularly around prognosis and care preferences. Discussions should be initiated by familiar clinicians. Effective communication between services, clear agreements and protocols and upskilling healthcare professionals may ensure continuity of care.

Patient-Centered Discussions About Disease Progression, Symptom, and Treatment Burden in Chronic Obstructive Pulmonary Disease Could Facilitate the Integration of End-of-Life Discussions in the Disease Trajectory: Patient, Clinician, and Literature Perspectives: A Multimethod Approach

Background: Patients with chronic obstructive pulmonary disease (COPD) seldom discuss preferences for future care/treatments with clinicians. The lack of discussions prevents the delivery of care grounded on patient preferences. Instead, treatments become increasingly burdensome as disease progresses and patients approach the end of life. Objective: Identify current and best practice in initiating and conducting conversations about future and palliative care, by integrating data from multiple sources. Design: Multiphasic study where the findings of a systematic literature review and qualitative interviews were combined and synthesized using a triangulation protocol. Setting/Participants: Thirty-three patients with COPD and 14 clinicians from multiple backgrounds were recruited in the United Kingdom. Results: Clinicians' and patients' poor understanding about palliative care and COPD, difficulties in timing and initiating discussions, and service rationing were the main factors for late discussions. Divergent perspectives between patients and clinicians about palliative care discussions often prevented their start. Instead, early and gradual patient-centered discussions on treatment choices, symptom, and treatment burden were recommended by patients, clinicians, and the literature. Earlier patient-centered discussions may reduce their emotional impact and enable patients to participate fully, while enabling clinicians to provide timely and accurate information on illness progression and appropriate self-management techniques. Conclusion: Current approaches toward palliative care discussions in COPD do not guarantee that patients' preferences are met. Early and gradual patient-centered discussions may enable patients to fully express their care preferences as they evolve over time, while minimizing the impact of symptom and treatment burden.

Culturally Adapted Consensus Definition and Action Guideline: Japan's Advance Care Planning

CONTEXT

A conceptual framework for advance care planning is lacking in societies like Japan's valuing family-centered decision-making.

OBJECTIVES

A consensus definition of advance care planning with action guideline adapted to Japanese society.

METHODS

We conducted a multidisciplinary modified Delphi study 2020-2022. Thirty physicians, 10 healthcare and bioethics researchers, six nurses, three patient care managers, three medical social workers, three law experts, and a chaplain evaluated, in 7 rounds (including two web-based surveys where the consensus level was defined as ratings by ≥70% of panelists of 7-9 on a nine-point Likert scale), brief sentences delineating the definition, scope, subjects, and action guideline for advance care planning in Japan.

RESULTS

The resulting 29-item set attained the target consensus level, with 72%-96% of item ratings 7-9. Advance care planning was defined as "an individual's thinking about and discussing with their family and other people close to them, with the support as necessary of healthcare providers who have established a trusting relationship with them, preparations for the future, including the way of life and medical treatment and care that they wish to have in the future." This definition/action guideline specifically included support for individuals hesitant to express opinions to develop and express preparations for the future.

CONCLUSION

Adaptation of advance care planning to Japanese culture by consciously enhancing and supporting individuals' autonomous decision-making may facilitate its spread and establishment in Japan and other societies with family-centered decision-making cultures.

Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.

Discussing prognosis and the end of life with patients with advanced cancer or COPD: A qualitative study

Objectives

To explore patients’ experiences and recommendations for discussions about their prognosis and end of life with their physicians.

Methods

Patients with advanced cancer or advanced chronic obstructive pulmonary disease (COPD) were enrolled in qualitative interviews, which were analyzed with a phenomenological and thematic approach.

Results

During interviews with fourteen patients (median age 64 years), we identified the following themes for discussion about prognosis and the end of life: topics discussed, the timing, the setting, physician–patient relationship, responsibilities for clinicians, and recommendations. Patients preferred the physician to initiate such discussion, but wanted to decide about its continuation and content. The discussions were facilitated by an established physician–patient relationship or attendance of relatives. Patients with cancer had had discussions about prognosis at rather clear-cut moments of deterioration than patients with COPD. Patients with COPD did not consider end-of-life discussions a responsibility of the pulmonologist. Patients recommended an understandable message, involvement of relatives or other clinicians, sufficient time, and sensitive non-verbal communication.

Conclusions

Patients appreciated open, sensitive, and negotiable discussions about prognosis and the end of life.

Practice implications

Patients’ recommendations could be used for communication training. Possible differences in the need for such discussions between patients with cancer or COPD warrant further research.

Interventions for interpersonal communication about end of life care between health practitioners and affected people

BACKGROUND

Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes.

OBJECTIVES

To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing.

SELECTION CRITERIA

This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life,  we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes.

DATA COLLECTION AND ANALYSIS

Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies.

MAIN RESULTS

Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials.  Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication.  Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations.  Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions  (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life.  Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear.

AUTHORS' CONCLUSIONS

Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.

Chronic obstructive pulmonary disease and advance care planning: A synthesis of qualitative literature on patients' experiences

OBJECTIVE

Advance Care Planning supports patients to share their personal values, goals, and preferences for future medical care with their family members and healthcare professionals. The aim of this review was to uncover what is known about patients with Chronic Obstructive Pulmonary Disease and their experiences with Advance Care Planning.

METHODS

A systematic review and thematic synthesis of qualitative studies was undertaken. Five databases were searched for qualitative articles published between 2009-2019. The review was guided by the PRISMA framework and seven studies met the eligibility criteria. Thematic synthesis of descriptive themes in each article was undertaken to develop overarching analytical themes, related to the experience of patients with Chronic Obstructive Pulmonary Disease and Advance Care Planning.

RESULTS

Four analytical themes emerged from the review of the articles that met the inclusion criteria: patient readiness and willingness for Advance Care Planning discussions; considering the future; trusted relationships with healthcare professionals; and shared decision making.

DISCUSSION

Patients with Chronic Obstructive Pulmonary Disease are generally open to Advance Care Planning discussions with healthcare professionals who are well-informed, and trusted by the patient. Models of care that integrate Advance Care Planning are beneficial in other non-malignant settings, and may be a way forward to support Advance Care Planning as part of routine care for patients with Chronic Obstructive Pulmonary Disease.

Clinician Perspectives on How to Hold Earlier Discussions About Palliative and End-of-Life Care With Chronic Obstructive Pulmonary Disease Patients: A Qualitative Study

Chronic obstructive pulmonary disease is associated with progressive symptoms and increased treatment burden, especially at the end of life. However, most patients do not receive palliative care until late in their lives or discuss their end-of-life preferences with clinicians. This study explored clinicians' perspectives on the timing and nature of palliative care discussions. Qualitative interviews were conducted with 7 physicians and 7 nurses working in primary and secondary care settings. Data were analyzed using a thematic analysis. Participants advocated for early, gradual, and informed palliative and future care discussions, because these discussions were thought to be less traumatic and better accepted by patients. Despite this, patient- and clinician-related barriers severely affected clinicians' ability to start discussions at earlier stages. Participants felt many patients were not ready for these discussions and feared damaging hope if the subject was broached. Therefore, clinicians delayed discussions until patients approached the end of life. Stand-alone conversations about and near the end of life were described as current practice; however, clinicians believed these discussions reduced patients' hope and were potentially upsetting. Instead, individualized early, regular, and gradual discussions about immediate and long-term care plans were thought to be less negative and be better accepted.

Efficacy of models of palliative care delivered beyond the traditional physician-led, subspecialty consultation service model: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to determine the effectiveness of non-physician provider-led palliative care (PC) interventions in the management of adults with advanced illnesses on patient-reported outcomes and advance care planning (ACP).

METHODS

We included randomised trials and cluster trials published in MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Register of Controlled Trials and ClinicalTrials.gov searched until July 2021 that examined individuals ≥18 years with a diagnosis of advanced, life-limiting illness and received a PC intervention led by a non-physician (nurse, advance practitioner or social worker). Our primary outcome was quality of life (QOL), which was extracted as unadjusted or adjusted estimates and measures of variability. Secondary outcomes included anxiety, depression and ACP.

RESULTS

Among the 21 studies (2370 subjects), 13 included patients with cancer, 3 with heart failure, 4 with chronic respiratory disease and 1 with chronic kidney disease. The interventions were diverse and varied with respect to team composition and services offered. For QOL, the standardised mean differences suggested null effects of PC interventions compared with usual care at 1-2 months (0.04; 95% CI=-0.14 to 0.23, n=10 randomised controlled trials (RCTs)) and 6-7 months (0.10; 95% CI=-0.15 to 0.34, n=6 RCTs). The results for anxiety and depression were not significant also. For the ACP, there was a strong benefit for the PC intervention (absolute increase of 0.32% (95% CI=0.06 to 0.57).

CONCLUSIONS

In this meta-analysis, PC interventions delivered by non-physician were not associated with improvement in QOL, anxiety or depression but demonstrated an impact on the ACP discussion and documentation.

Advance care planning in primary care: a retrospective medical record study among patients with different illness trajectories

Background

Advance Care Planning (ACP) enables physicians to align healthcare with patients’ wishes, reduces burdensome life-prolonging medical interventions, and potentially improves the quality of life of patients in the last phase of life. However, little objective information is available about the extent to which structured ACP conversations are held in general practice.

Our aim was to examine the documentation of ACP for patients with cancer, organ failure and multimorbidity in medical records (as a proxy for ACP application) in Dutch general practice.

Methods

We chose a retrospective medical record study design in seven primary care facilities. Medical records of 119 patients who died non-suddenly (55 cancer, 28 organ failure and 36 multimorbidity) were analysed. Other variables were: general characteristics, data on ACP documentation, correspondence between medical specialist and general practitioner (GP), and healthcare utilization in the last 2 years of life.

Results

In 65% of the records, one or more ACP items were registered by the GP. Most often documented were aspects regarding euthanasia (35%), the preferred place of care and death (29%) and concerns and hopes towards the future (29%). Median timing of the first ACP conversation was 126 days before death (inter-quartile range (IQR) 30–316). ACP was more often documented in patients with cancer (84%) than in those with organ failure (57%) or multimorbidity (42%) (p = 0.000). Patients with cancer had the most frequent (median 3 times, IQR 2–5) and extensive (median 5 items, IQR 2–7) ACP consultations.

Conclusion

Documentation of ACP items in medical records by GPs is present, however limited, especially in patients with multimorbidity or organ failure. We recommend more attention for – and documentation of – ACP in daily practice, in order to start anticipatory conversations in time and address the needs of all people living with advanced conditions in primary care.

Development and validation of a prediction index for recent mortality in advanced COPD patients

The primary barrier to initiating palliative care for advanced COPD patients is the unpredictable course of the disease. We enroll 752 COPD patients into the study and validate the prediction tools for 1-year mortality using the current guidelines for palliative care. We also develop a composite prediction index for 1-year mortality and validate it in another cohort of 342 patients. Using the current prognostic models for recent mortality in palliative care, the best area under the curve (AUC) for predicting mortality is 0.68. Using the Modified Medical Research Council dyspnea score and oxygen saturation to define the combined dyspnea and oxygenation (DO) index, we find that the AUC of the DO index is 0.84 for predicting mortality in the validated cohort. Predictions of 1-year mortality based on the current palliative care guideline for COPD patients are poor. The DO index exhibits better predictive ability than other models in the study.

'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication?

Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'

Palliative Care For Patients with Advanced COPD in Primary Care

Patients with advanced COPD have a high symptom burden that is often multidimensional. Identification of patients who might benefit from palliative care through validated identification tools, multidimensional symptom management, and timely discussion of advance planning are elements of a palliative care approach for these patients and their families. Coordination among stakeholders providing care and support to these patients is central to ensuring high-quality care and meeting all of their needs.

Healthcare Providers' Perceptions on the Timing of Initial Advance Care Planning Discussions in Japan: a Mixed-Methods Study

BACKGROUND

Most adult patients are willing to discuss advance care planning before the onset of any illness. There might be differences in preferences for timing when it comes to initiating advance care planning discussions by healthcare providers with patients.

OBJECTIVE

To identify healthcare providers' willingness to initiate advance care planning discussions in Japan.

DESIGN

A mixed-methods questionnaire comprising three case scenarios based on three different illness trajectories.

PARTICIPANTS

The study participants were physicians and nurses employed in four community hospitals in Japan.

MAIN MEASURES

Percentages of physicians' and nurses' willingness to initiate advance care planning discussions at four stages of patients' illness trajectory were quantitatively determined, and perceptions on preferred timing were qualitatively identified.

KEY RESULTS

From 108 physician and 123 nurse respondents (response rate: 99%), 291 physician and 362 nurse responses about three case scenarios were obtained. Overall, 51.2% of physicians and 65.5% of nurses (p < 0.001) accepted discussion before illness. Less than one-third of physicians considered advance care planning a "wise precaution," while about two-thirds of nurses did. Additionally, more than half of both physicians and nurses preferred to postpone advance care planning until the patient's imminent death.

CONCLUSIONS

Physicians are less willing than nurses to begin advance care planning discussions before patients' health has deteriorated though most prefer to wait until the patients are close to death. Healthcare providers' attitudes toward advance care planning will need to be addressed to improve rates of completion in Japan.

A multi-site study on the impact of an advance care planning workshop on attitudes, beliefs and behavioural intentions over a 6-month period

BACKGROUND

This study evaluated the impact of the adapted version of the Respecting Choices® The Living Matters Advance Care Planning (ACP) facilitator training programme on trainees' attitudes on facilitation 6 months post-training.

SETTING AND PARTICIPANTS

Two hundred and twenty-one healthcare professionals consisting of doctors, nurses, medical social workers from different training venues in Singapore participated in the first phase of the study (pre- and post) of which 107 participated in the second phase 6 months later (follow-up).

METHODS

Participants self-rated their attitudes, beliefs and behavioural intentions through surveys at three time points in an evaluation design that utilised repeated measures one-way ANOVA (pre-, post-, follow-up). Between-group differences were also examined using independent t-test.

RESULTS

At follow-up, mean scores increased significantly in understanding, confidence, and competence. Changes in effect sizes were large. Although trainees continued to think that ACP is emotionally draining for facilitators, more than before, facilitation experience was considered pleasant for themselves with the positive change significant and moderate in effect size. Those who had experience completing/initiating ACP significantly held more positive views than those who did not.

CONCLUSIONS

The ACP facilitator training programme had lasting effects on enhancing the understanding, competence, and confidence of trainees. Importantly, findings showed that experience in actual facilitation within 6 months after training was important and giving trainees opportunities to facilitate is recommended.

Emergency Healthcare Providers' Knowledge about and Attitudes toward Advance Directives: A Cross-Sectional Study between Nurses and Emergency Medical Technicians at an Emergency Department

This study aimed to explore and compare knowledge levels about advance directives (ADs) and life-sustaining treatment (LST) plans in end-of-life patients between emergency nurses and emergency medical technicians (EMTs). Using a cross-sectional study design and convenience sampling, 96 nurses and 68 EMTs were recruited from 12 emergency medical centers. A survey on knowledge about and attitudes toward ADs was performed using both online and offline methods between November and December 2019. Emergency healthcare providers were conceptually knowledgeable regarding ADs and LST, although approximately half or fewer had knowledge about ADs (such as the legal process for preparation, family or healthcare providers’ role, and the healthcare proxy). The knowledge levels of nurses and EMTs were moderate. Nurses had significantly greater knowledge relative to EMTs about ADs and LST. Positive attitudes of emergency healthcare providers were also moderately low, with nurses having less positive views than EMTs. Significant differences regarding ADs were found, with younger emergency healthcare providers having fewer career years, no personal end-of-life experiences, and less need for ADs having less knowledge. Emergency healthcare providers’ knowledge about and attitudes toward ADs were moderately low, with EMTs demonstrating a greater knowledge deficit and nurses exhibiting lower positive attitudes. Younger and novice providers had lower knowledge, but younger providers had more positive attitudes, implying that professional education and training should begin early in their careers to enhance their confidence for emergency delivery of advanced care planning.

Palliative Care Needs and Integration of Palliative Care Support in COPD: A Qualitative Study

BACKGROUND

The provision of palliative care for severe COPD remains low, resulting in unmet needs in patients and carers.

RESEARCH QUESTIONS

What are the palliative care needs of patients living with severe COPD and their caregivers? What views of accessing and providing palliative care and factors influence these experiences. To what extent have palliative care and COPD services been integrated?

STUDY DESIGN AND METHODS

A multicentre qualitative study was undertaken in COPD services and specialist palliative care in the United Kingdom involving patients with severe COPD, their carers, and health professionals. Data were collected using semistructured interviews and were analyzed using framework analysis. Themes were integrated using the constant comparison process, enabling systematic data synthesis.

RESULTS

Four themes were generated from interviews with 20 patients, six carers, and 25 health professionals: management of exacerbations, palliative care needs, access to palliative care and pathways, and integration of palliative care support. Uncertainty and fear were common in patients and carers, with identified needs for reassurance, rapid medical access, home care, and finance advice. Timely palliative care was perceived as important by health professionals. Palliative care was integrated into COPD services, although models of working varied across regions. Reliable screening tools and needs assessment, embedded psychological care, and enhanced training in palliative care and communication skills were perceived to be important by health professionals for timely palliative care referrals and optimized management.

INTERPRETATION

Palliative care increasingly is being implemented for nonmalignant diseases including COPD throughout the United Kingdom, although models of working vary. A theoretical model was developed to illustrate the concept and pathway of the integration of palliative care support. A standardized screening and needs assessment tool is required to improve timely palliative care and to address the significant needs of this population.

General practitioners' considerations when deciding whether to initiate end-of-life conversations: a qualitative study

BACKGROUND

End-of-life discussions often are not initiated until close to death, even in the presence of life-limiting illness or frailty. Previous research shows that doctors may not explicitly verbalize approaching end-of-life in the foreseeable future, despite shifting their focus to comfort care. This may limit patients' opportunity to receive information and plan for the future. General Practitioners (GPs) have a key role in caring for increasing numbers of patients approaching end-of-life.

OBJECTIVE

To explore GPs' thought processes when deciding whether to initiate end-of-life discussions.

METHODS

A qualitative approach was used. We purposively recruited 15 GPs or GP trainees from South-East Queensland, Australia, and each participated in a semi-structured interview. Transcripts were analyzed using inductive thematic analysis.

RESULTS

Australian GPs believe they have a responsibility to initiate end-of-life conversations, and identify several triggers to do so. Some also describe caution in raising this sensitive topic, related to patient, family, cultural and personal factors.

CONCLUSIONS

These findings enable the development of approaches to support GPs to initiate end-of-life discussions that are cognizant both of GPs' sense of responsibility for these discussions, and factors that may contribute to caution initiating them, such as anticipated patient response, cultural considerations, societal taboos, family dynamics and personal challenges to doctors.

Palliative and End-of-Life Care Conversations with Older People with Chronic Obstructive Pulmonary Disease in Croatia-A Pilot Study

Despite the progressive nature of chronic obstructive pulmonary disease (COPD), its association of high morbidity and mortality with severe COPD, and the view that discussions between patients and clinicians about palliative care plans should be grounded in patients’ preferences, many older patients do not receive timely end-of-life care (EOLC) discussions with healthcare professionals (HPs), potentially risking inadequate care at the advanced stages of the disease. The aim of this pilot study was to evaluate EOLC discussions and resuscitation issues as a representative and illustrative part within EOLC in older patients with COPD in the University Hospital Center Osijek, Slavonia (Eastern Region), Croatia, as such data have not yet been explored. The study was designed as cross-sectional research. Two groups of participants, namely, patients at least 65 years old with COPD and healthcare professionals, were interviewed anonymously. In total, 83 participants (22 HPs and 61 patients with COPD) were included in the study. According to the results, 77% of patients reported that they had not had EOLC discussions with HPs, 64% expressed the opinion that they would like such conversations, and the best timing for such discussion would be during frequent hospital admissions. Furthermore, 77% of HPs thought that EOLC communication is important, but only 14% actually discussed such issues with their patients because most of them felt uncomfortable starting such a topic. The majority of older patients with COPD did not discuss advanced care planning with their HPs, even though the majority of them would like to have such a discussion. EOLC between HPs and older patients with COPD should be encouraged in line with patients’ wishes, with the aim to improve their quality of care by anticipating patients’ likely future needs in a timely manner and thereby providing proactive support in accordance with patients’ preferences.

Patients' preferences and factors influencing initial advance care planning discussions' timing: A cross-cultural mixed-methods study

BACKGROUND

Although advance care planning discussions are increasingly accepted worldwide, their ideal timing is uncertain and cultural factors may pertain.

AIM

To evaluate timing and factors affecting initiation of advance care planning discussions for adult patients in Japan and Taiwan.

DESIGN

Mixed-methods questionnaire survey to quantitatively determine percentages of patients willing to initiate advance care planning discussions at four stages of illness trajectory ranging from healthy to undeniably ill, and to identify qualitative perceptions underlying preferred timing.

SETTING/PARTICIPANTS

Patients aged 40-75 years visiting outpatient departments at four Japanese and two Taiwanese hospitals were randomly recruited.

RESULTS

Overall (of 700 respondents), 72% (of 365) in Japan and 84% (of 335) in Taiwan (p < 0.001) accepted discussion before illness. In Japan, factors associated with willingness before illness were younger age and rejection of life-sustaining treatments; in Taiwan, older age, stronger social support, and rejection of life-sustaining treatments. Four main categories of attitudes were extracted: the most common welcomed discussion as a wise precaution, responses in this first category outnumbered preference for postponement of discussion until imminent end of life, acceptance of the universal inevitability of death, and preference for discussion at healthcare providers' initiative.

CONCLUSION

The majority of patients are willing to begin discussion before their health is severely compromised; about one out of five patients are unwilling to begin until clearly facing death. To promote advance care planning, healthcare providers must be mindful of patients' preferences and factors associated with acceptance and reluctance to initiate advance care planning.

Advance Care Planning for Individuals With Chronic Obstructive Pulmonary Disease: A Scoping Review of the Literature

CONTEXT

Individuals with chronic obstructive pulmonary disease (COPD) typically experience a gradual worsening of the illness in the years before death. Owing to difficulties in predicting the disease trajectory or the timing of acute exacerbations, advance care planning (ACP) may be of particular importance for individuals with COPD.

OBJECTIVES

The objective of this study was to review and summarize the available literature on current practices around ACP in COPD.

METHODS

A scoping review of the literature was conducted following the Arksey and O'Malley framework. Original research studies of any design were included.

RESULTS

Twenty-eight studies were included. Across studies, there was agreement that ACP should be incorporated into routine COPD management. There was evidence that this does not occur in everyday practice, with conversations tending to focus on day-to-day symptom management. Barriers included prognosis uncertainty, insufficient time and training, and a lack of protocols for who is responsible for initiating ACP. Facilitators included the use of transition points for identifying the appropriate time to initiate ACP, and an increased focus on ACP in professional education. The occurrence of repeated episodes of acute care was identified as a key transition point for identifying the palliative stage of COPD and an appropriate time to initiate ACP.

CONCLUSION

The findings of this review confirm agreement among health care professionals and patients with COPD and their carers that ACP should be incorporated into routine COPD management. The use of transition points may help health care professionals overcome the barrier of prognosis uncertainty and identify patients who might benefit from ACP.

Advance Care Planning Education Sessions During Pulmonary Rehabilitation in Ireland

PURPOSE

This study aimed to investigate the practice of advance care planning (ACP) education within pulmonary rehabilitation programs (PRPs) in Ireland.

METHODS

All 27 PRPs in the Republic of Ireland were surveyed between May and September 2015, eliciting detailed quantitative and qualitative information about ACP education delivery. Data were analyzed using SPSS statistical software and content analysis.

RESULTS

Twenty-two PRPs (82%) took part in the survey, with 86% (n = 19) of these being delivered in a hospital setting. Forty-five percent (n = 10) included ACP education of at least 20-min duration (n = 5) or as part of another session (n = 5). ACP topics discussed differed significantly across PRP sites. Sessions were delivered by respiratory nurses, physiotherapists, physicians, or palliative care physicians. Of the 12 sites currently not providing ACP education, almost half (n = 5) indicated a willingness to include this in the near future. Respondents identified enablers and barriers to ACP education, as well as staff education and service delivery gaps.

CONCLUSIONS

Results demonstrate an overwhelmingly positive attitude toward ACP education. There is a need for ACP-specific education for all staff members involved in PRPs. Practical guidance on how to deliver this patient education component needs to be developed.

Trained facilitators' experiences with structured advance care planning conversations in oncology: an international focus group study within the ACTION trial

BACKGROUND

In oncology, Health Care Professionals often experience conducting Advance Care Planning (ACP) conversations as difficult and are hesitant to start them. A structured approach could help to overcome this. In the ACTION trial, a Phase III multi-center cluster-randomized clinical trial in six European countries (Belgium, Denmark, Italy, the Netherlands, Slovenia, United Kingdom), patients with advanced lung or colorectal cancer are invited to have one or two structured ACP conversations with a trained facilitator. It is unclear how trained facilitators experience conducting structured ACP conversations. This study aims to understand how facilitators experience delivering the ACTION Respecting Choices (RC) ACP conversation.

METHODS

A qualitative study involving focus groups with RC facilitators. Focus group interviews were recorded, transcribed, anonymized, translated into English, and thematically analysed, supported by NVivo 11. The international research team was involved in data analysis from initial coding and discussion towards final themes.

RESULTS

Seven focus groups were conducted, involving 28 of in total 39 trained facilitators, with different professional backgrounds from all participating countries. Alongside some cultural differences, six themes were identified. These reflect that most facilitators welcomed the opportunity to participate in the ACTION trial, seeing it as a means of learning new skills in an important area. The RC script was seen as supportive to ask questions, including those perceived as difficult to ask, but was also experienced as a barrier to a spontaneous conversation. Facilitators noticed that most patients were positive about their ACTION RC ACP conversation, which had prompted them to become aware of their wishes and to share these with others. The facilitators observed that it took patients substantial effort to have these conversations. In response, facilitators took responsibility for enabling patients to experience a conversation from which they could benefit. Facilitators emphasized the need for training, support and advanced communication skills to be able to work with the script.

CONCLUSIONS

Facilitators experienced benefits and challenges in conducting scripted ACP conversations. They mentioned the importance of being skilled and experienced in carrying out ACP conversations in order to be able to explore the patients' preferences while staying attuned to patients' needs.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number registry 63110516 ( ISRCTN63110516 ) per 10/3/2014.

Using Implementation Science to Further the Adoption and Implementation of Advance Care Planning in Rural Primary Care

PURPOSE

To analyze the literature on advance care planning (ACP) in primary care through the lens of implementation science, with a focus on implications for rural settings.

DESIGN

Scoping review of the literature.

METHODS

The Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PsycINFO, and the Psychology and Behavioral Sciences Collection databases were searched for studies related to ACP adoption and implementation in primary care. The Theoretical Domains Framework was used to map the literature to 14 determinants that serve as barriers or facilitators to ACP. The Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors was used to analyze the stage of implementation for each of the included studies.

FINDINGS

Four steps to ACP were specified: identification, conversation, documentation, and follow-up. Determinants were identified for each step, but studies largely focused on the conversation step. Professional role and identity, environmental context and resources, and emotion were the most frequently cited determinants in initiating conversations. The identification step was largely determined by behavioral regulation. For documenting ACP, environmental context and resource determinants were most prevalent. In the few studies that addressed follow-up, providers expressed a desire for electronic reminders as a behavioral regulator to follow-up.

CONCLUSIONS

While ACP has been shown to have patient, family, and societal benefits, its uptake in primary care has been minimal. Because ACP is a complex process that is highly context dependent, implementation science is critical to inform its successful adoption and implementation. Smaller healthcare networks, adaptable professional roles, trusted relationships, and tight-knit community might be important facilitators of ACP in rural primary care.

CLINICAL RELEVANCE

Findings from this study can be used to accelerate ACP implementation in rural primary care.

Helping hospital professionals to implement Advance Care Planning in daily practice: a European Delphi study from field experts

BACKGROUND

Advance Care Planning (ACP) communication is difficult to implement in hospital. Possibly this has to do with the fact that the concept is not well tuned to the needs of hospital professionals or that they experience implementation barriers in practice.

AIMS

The aim of this study was to investigate what is valued in having ACP conversations by hospital professionals (physicians, nurses, psychologists and social workers) and what they experience as barriers and facilitating factors for having ACP conversations with patients.

METHODS

A Delphi study consisting of two rounds with respectively 21 and 19 multidisciplinary experts from seven European countries was organised. Data were analysed using content analysis and descriptive statistics.

RESULTS

Participants agreed that ACP is valued mostly because it is seen to improve transmural continuation of care, emotional processing of the loss of a patient, and serenity at the end of life. Reported barriers are patient characteristics blocking patient-centred communication and a lack of knowledge to have these conversations. An important facilitator is multidisciplinary cooperation.

CONCLUSIONS

There is consensus by experts from different settings and countries suggesting that these results can theoretically be applied to hospital settings in Europe. This study reveals that hospital professionals value ACP in hospital practice, but that they encounter several barriers to its implementation.

A sense of belonging: A meta-ethnography of the experience of patients with chronic obstructive pulmonary disease receiving care through telemedicine

AIM

To synthesize the qualitative research in the literature addressing how patients with chronic obstructive pulmonary disease experience care received by telemedicine.

DESIGN

Meta-ethnography.

DATA SOURCES

Twelve studies, published from 2013 - 2018, were identified by a search of relevant systematic databases in June 2017, including updated searches performed in June 2018.

REVIEW METHODS

The studies were reviewed and critically appraised independently by three researchers. The review followed the seven steps of meta-ethnography developed by Noblit and Hare, including a line-of-argument synthesis.

RESULTS

The synthesis revealed three second-order constructs: presence, transparency, and ambivalence. Using a line-of-argument synthesis, a model was developed that showed patients' experience of a sense of belonging when receiving care by telemedicine.

CONCLUSION

This meta-ethnography contributes to the existing and contradictory evidence base of telemedicine to chronic obstructive pulmonary disease patients. It addresses and adds renewed understanding of who would benefit from telemedicine and why, by illustrating the interrelationship between the conditions of telemedicine care, the severity of COPD, and the need for connectedness and emphasizes that the need to belong in telemedicine care increases with the progression of illness burden and severity.

IMPACT

The present study endorses the view that the patients with a severe illness burden are likely to benefit the most when receiving care by telemedicine. However, the benefits rely on the fact that the telemedicine interventions involve emotional, social, and clinical support, including regular contact with healthcare professionals, to meet the requirements to belong.

Palliative care for people with non-malignant respiratory disease and their carers: a review of the current evidence

Background

Internationally, non-malignant respiratory disease is on the increase. However, although palliative care is recommended as an appropriate healthcare option for this client group, evidence suggests that these patients and their carers do not receive the same standards of palliative care as patients with a malignant lung condition.

Aim

The aim of this review was to provide a critical overview of the current evidence base in relation to the palliative service provision for people with non-malignant respiratory disease and their carers.

Methods

A review of the literature was conducted in July 2015 and updated in October 2017 and focused on the palliative care service provision for patients with interstitial lung disease, chronic obstructive pulmonary disease and bronchiectasis.

Results

In total, 71 empirical studies were included in the review and grouped into two main themes: patient and carer's bio-psychosocial symptom needs and management, and palliative care service provision for patients with non-malignant respiratory disease and their carers.

Conclusion

The majority of palliative research focuses on patients with a diagnosis of chronic obstructive pulmonary disease. A deeper insight is required into the palliative service provision experienced by those with other forms of non-malignant respiratory disease such as bronchiectasis and interstitial lung disease.

Non-invasive positive pressure ventilation in the home setting

Noninvasive ventilation is becoming a more commonly used long-term treatment for various conditions in which the patient experiences chronic hypercapnic respiratory failure (type 2 respiratory failure). This article aims to discuss why patients require long-term noninvasive positive pressure ventilation (NPPV), and to describe some of the care considerations required for this patient group, in addition to challenges that nurses in the home care environment face when supporting these patients at home. The article provides a brief pathophysiological overview, while also discussing the use of NPPV as symptom support for patients with severe disease in the later stages of their lives. The term 'noninvasive positive pressure ventilation' is used to cover a number of different noninvasive systems, although the study primarily focuses on bi-level ventilation systems.

Perspectives on End-of-Life Treatment among Patients with COPD: A Multicenter, Cross-sectional Study in Japan

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality. Since patients with severe COPD may experience exacerbations and eventually face mortality, advanced care planning (ACP) has been increasingly emphasized in the recent COPD guidelines. We conducted a multicenter, cross-sectional study to survey the current perspectives of Japanese COPD patients toward ACP. "High-risk" COPD patients and their attending physicians were consecutively recruited. The patients' family configurations, understanding of COPD pathophysiology, current end-of-life care communication with physicians and family members, and preferences for invasive life-sustaining treatments including mechanical ventilation (MV) and cardiopulmonary resuscitation (CPR) were evaluated using a custom-made, structured, self-administered questionnaire. Attending physicians were also interviewed, and we evaluated the patient-physician agreement. Among the 224 eligible "high-risk" patients, 162 participated. Half of the physicians (54.4%) thought they had communicated detailed information; however, only 19.4% of the COPD patients thought the physicians did so (κ score = 0.16). Less than 10% of patients wanted to receive invasive treatment (MV, 6.3% and CPR, 9.4%); interestingly, more than half marked their decision as "refer to the physician" (MV 42.5% and CPR 44.4%) or "refer to family" (MV, 13.8% and CPR, 14.4%). Patients with less knowledge of COPD were less likely to indicate that they had already made a decision. Although ACP is necessary to cope with severe COPD, Japanese "high-risk" COPD patients were unable to make a decision on their preferences for invasive treatments. Lack of disease knowledge and communication gaps between patients and physicians should be addressed as part of these patients' care.

Advance care planning for the severely ill in the hospital: a randomized trial

OBJECTIVES

To investigate the impact of advance care planning (ACP) including decision aids for severely ill medical inpatients.

METHODS

Single-centre randomised controlled trial at a Swiss university hospital. Patients were randomly assigned (1:1) to receive an extra consultation with the hospital social service or a consultation with in-house facilitators trained according to an internationally established ACP programme. Trial participants with the exception of the observers were fully blinded. 115 competent severely ill adults, their surrogates and their attending physicians were enrolled and followed for 6 months after discharge or 3 months after death. The patient's wishes regarding resuscitation (primary outcome), last place of care and other end-of-life wishes were recorded. Knowledge and respect of the patient's wishes by the surrogates and attending physician were monitored.

RESULTS

Compared with controls, 6 months after the intervention, fewer patients wished to be resuscitated or were undecided (p=0.01), resuscitation wishes were documented more frequently (89% vs 64%, p=0.02) and surrogates and/or attending physicians had greater knowledge of the patient's wishes (62% vs 30%, p=0.01). Groups were not different with regard to wishes being fulfilled, with the exception of last place of care being achieved more frequently in the intervention group (29% vs 11 %, p=0.05).

CONCLUSION

ACP including decision aids offered to severely ill medical inpatients leads to greater knowledge, documentation and respect of treatment and end-of-life wishes. Introducing ACP to these patients however may be too late for many patients. Early integration of ACP during the illness trajectory and a broader regional approach may be more appropriate.

COPD patients in need of palliative care: Identification after hospitalization through the surprise question

Currently, few patients suffering from chronic obstructive pulmonary disease (COPD) who might benefit from a palliative care approach are referred to a palliative care team. Tools to identify patients eligible for a palliative care approach have been found to be difficult to apply in daily practice. Therefore, there is need for a simple and easily applicable tool to identify those patients who would benefit from referral to a palliative care team. The aim of this study was to determine if the surprise question (SQ) "Would I be surprised if this patient dies within 12 months?" in a subset of recently hospitalized COPD patients identifies those subjects. Recently hospitalized COPD patients were included, and the answer to the SQ was provided by the treating pulmonologist. The gold standards framework (GSF) prognostic indicator guidance was regarded as the gold standard test and was assessed for each patient. Sensitivity, specificity, and negative and positive predictive values were calculated to determine the accuracy of the SQ plus recent hospitalization compared to the variables of the GSF. A total of 93 patients were analyzed. In 35 patients (38%), the answer to the SQ was "not surprised"; 78 patients (84%) met ≥1 criteria of the GSF (15 (16%) did not meet any criteria). Specificity and positive predictive value for the SQ were both 100% ((78.2-100) and (87.7-100), respectively). Sensitivity was 44.9% (33.7-56.5) and negative predictive value was 25.9% (22.2-29.9). The "not surprised" group fulfilled significantly more GSF criteria. The SQ after recent hospitalization for COPD has a very high specificity compared to a standardized tool and is therefore a useful tool for the quick identification of patients who are most likely to benefit from palliative care. However, this method doesn't identify all patients who are eligible for referral to palliative care.

The advance care planning nurse facilitator: describing the role and identifying factors associated with successful implementation

Advance care planning (ACP) has been shown to improve end-of-life care, yet uptake remains limited. Interventions aimed at increasing ACP uptake have often used a ‘specialist ACP facilitator’ model. The present qualitative study appraised the components of an ACP facilitator intervention comprising nurse-led patient screening and ACP discussions, as well as factors associated with the successful implementation of this model in primary care and acute hospital settings across rural and metropolitan Western Australia. Semistructured interviews were undertaken with 17 health professionals who were directly or indirectly involved in the facilitator ACP intervention among patients with severe respiratory disease. Additional process data (nurse facilitator role description, agreements with participating sites) were used to describe the nurse facilitator role. The interview data identified factors associated with successful implementation, including patient factors, health professional factors, ACP facilitator characteristics and the optimal settings for the intervention. The primary care setting was seen as most appropriate, and time limitations were a key consideration. Factors associated with successful implementation included trusting relationships between the nurse facilitator and referring doctor, as well as opportunities for meaningful encounters with patients. This study suggests a model of ACP nurse facilitation based in primary care may be an acceptable and effective method of increasing ACP uptake.

Exploring the extent of Communication Surrounding Transitions to Palliative Care in Heart Failure: The perspectives of Health Care Professionals

Introduction: The aim of this study was to explore the perspectives of health care professionals (HCPs) on the transition of heart failure (HF) patients to a palliative care approach. Method: Qualitative data were generated from 24 HCPs specializing in cardiology, care for the elderly, and palliative care. Data were analyzed using the principles of thematic analysis. Results: Emergent themes related to the unpredictable trajectory of HF, causing prognostic ambiguity; the use of structured pathways in end-of-life decision making; and comparison of HF and cancer patients in terms of their requirements and access to high-quality palliative care. Conclusion: There is a need for both established prognostic guidelines and further education to develop the communication skills to facilitate end-of-life discussions with HF patients.

Prevalence and predictors of Transition to A Palliative Care Approach among Hospital Inpatients in England

Aim: The aim of this research was to quantify the extent of palliative care transitions among patients in two acute hospitals and to identify factors predicting the initiation of a transition to palliative care. Methods: We conducted a prospective survey of hospital inpatients in two hospitals in the United Kingdom in which we examined hospital case notes for evidence of palliative care need. Further data were collected from medical staff, nursing staff, patients, and proxy consultees. Results: Of 514 participating patients, 183 (36.2 percent) fulfilled criteria for palliative care need. In 61 cases (33 percent), there was evidence of transition to a palliative care approach. There was an increased likelihood of palliative care transition among patients with cancer, dementia, or stroke. Conclusions: There is a need for discussion of the meaning, and operational-ization, of palliative care transitions if UK policy to increase the extent of transitions is to be enacted. This study has implications internationally, given the increased global focus on the role of the acute hospital in palliative care.

First year experiences with a palliative out-patients structure for patients with COPD: a qualitative study of health professionals' expectations and experiences

Background

To improve the care of patients with advanced COPD and be able to address their palliative needs a new outpatient organization (CAPTAIN) was developed and implemented. CAPTAIN was inspired by best practice and existing guidelines and changed the traditional organization of an outpatient structure including the roles of nurses and doctors. Only sparse knowledge exists of the health professionals’ expectations and experiences to organizational changes in an outpatient setting. This insight is necessary as health professionals are key stakeholders in implementing new structures and successfully transforming knowledge into practice. The aim of this study was to explore the health professionals’ expectations and experiences of a new palliative out-patients structure for patients with advanced COPD.

Methods

The design was interpretive description as described by Thorne. Focus groups and individual interviews were conducted with pulmonary nurses, pulmonary doctors and municipality nurses from 2014 to 2016.

Results

The overall theme was dualism. Both nurses and doctors were pending between aspiration and concern in their expectations to the new structure, meanwhile their actual experiences were pending between perceived gain and improvements versus consequences with the new structure. Nurses’ and doctors’ existing practice was altered and the new structure required new ways for them to cooperate and ways in which skills from each profession were most efficiently utilized.

Conclusion

Nurses and doctors considered the new structure as a quality boost and it fulfilled their hope of improving the quality of care offered to patients with advanced COPD, however with increased work-related stress as a derived consequence.

Couples affected by dementia and their experiences of advance care planning: a grounded theory study

Global policy places emphasis on the implementation and usage of advance care planning (ACP) to inform decision making at the end of life. For people with dementia, where its use is encouraged at the point of diagnosis, utilisation of ACP is relatively poor, particularly in parts of Europe. Using a constructivist grounded theory methodology, this study explores the ways in which co-residing couples considered ACP. Specifically, it seeks to understand the ways in which people with dementia and their long-term co-residing partners consider and plan, or do not plan, for future medical and social care. Sixteen participants were interviewed. They identified the importance of relationships in the process of planning alongside an absence of formal service support and as a result few engaged in ACP. The study recognises the fundamental challenges for couples in being obliged to consider end-of-life issues whilst making efforts to ‘live well’. Importantly, the paper identifies features of the ACP experience of a relational and biographical nature. The paper challenges the relevance of current global policy and practice, concluding that what is evident is a process of ‘emergent planning’ through which couples build upon their knowledge of dementia, their networks and relationships, and a number of ‘tipping points’ leading them to ACP. The relational and collective nature of future planning is also emphasised.

Are older long term care residents accurately prognosticated and consequently informed about their prognosis? Results from SHELTER study data in 5 European countries

BACKGROUND

Informing residents in long term care facilities (LTCFs) about their prognosis can help them prepare for the end of life. This study aimed to examine which proportion of European LTCF residents, close to death, are accurately prognosticated and consequently informed about their prognosis; and to examine factors related to accurate prognostication and discussion of prognosis.

METHODS

A subsample of SHELTER study data was used, consisting of: 500 residents from 5 European countries, who died within 6 months after their last assessment, and had a valid answer on the item 'End stage disease, 6 or fewer months to live'. This item was used to indicate whether an accurate prognosis was established and discussed with residents. Generalized estimating equations were used to examine factors related to establishment and discussion of accurate prognosis.

RESULTS

86.4% of residents close to death did not receive an accurate prognosis. Residents with cancer; fatigue; dehydration; and normal mode of nutritional intake were more likely to have an accurate prognosis established and discussed. Accurate prognostication and prognosis discussion was less likely for residents who: had a diagnosis under 'other'; initiated interactions; and residents from Germany, Italy and the Netherlands.

CONCLUSIONS

The great majority of residents close to death did not receive an accurate prognosis. Prognostication tools might help clinicians to increase their prognostic accuracy and communication training might help to discuss prognosis with residents.

Whose job? The staffing of advance care planning support in twelve international healthcare organizations: a qualitative interview study

Background

ACP involving a facilitated conversation with a health or care professional is more effective than document completion alone. In policy, there is an expectation that health and care professionals will provide ACP support, commonly within their existing roles. However, the potential contributions of different professionals are outlined only broadly in policy and guidance. Research on opportunities and barriers for involving different professionals in providing ACP support, and feasible models for doing so, is currently lacking.

Methods

We identified twelve healthcare organizations aiming to offer system-wide ACP support in the United States, Canada, Australia and New Zealand. In each, we conducted an average 13 in-depth interviews with senior managers, ACP leads, dedicated ACP facilitators, physicians, nurses, social workers and other clinical and non-clinical staff. Interviews were analyzed thematically using NVivo software.

Results

Organizations emphasized leadership for ACP support, including strategic support from senior managers and intensive day-to-day support from ACP leads, to support staff to deliver ACP support within their existing roles. Over-reliance on dedicated facilitators was not considered sustainable or scalable. We found many professionals, from all backgrounds, providing ACP support. However, there remained barriers, particularly for facilitating ACP conversations. A significant barrier for all professionals was lack of time. Physicians sometimes had poor communication skills, misunderstood medico-legal aspects and tended to have conversations of limited scope late in the disease trajectory. However, they could also have concerns about the appropriateness of ACP conversations conducted by others. Social workers had good facilitation skills and understood legal aspects but needed more clinical support than nurses. While ACP support provided alongside and as part of other care was common, ACP conversations in this context could easily get squeezed out or become fragmented. Referrals to other professionals could be insecure. Team-based models involving a physician and a nurse or social worker were considered cost-effective and supportive of good quality care but could require some additional resource.

Conclusions

Effective staffing of ACP support is likely to require intensive local leadership, attention to physician concerns while avoiding an entirely physician-led approach, some additional resource and team-based frameworks, including in evolving models of care for chronic illness and end of life.

Living with breathlessness: a systematic literature review and qualitative synthesis

What is the experience of people living with breathlessness due to medical conditions, those caring for them and those treating them, with regard to quality of life and the nature of clinical interactions?Electronic databases (Ovid MEDLINE, Embase, CINAHL Plus and PsycINFO) were searched (January 1987 to October 2017; English language), for qualitative studies exploring the experience of chronic breathlessness (patients, carers and clinicians). Two independent reviewers screened titles, abstracts and papers retrieved against inclusion criteria. Disagreements were resolved with a third reviewer. Primary qualitative data were extracted and synthesised using thematic synthesis.Inclusion and synthesis of 101 out of 2303 international papers produced four descriptive themes: 1) widespread effects of breathlessness; 2) coping; 3) help-seeking behaviour; and 4) clinicians' responsiveness to the symptom of breathlessness. The themes were combined to form the concept of "breathing space", to show how engaged coping and appropriate help-seeking (patient) and attention to symptom (clinician) helps maximise the patient's quality of living with breathlessness.Breathlessness has widespread impact on both patient and carer and affects breathing space. The degree of breathing space is influenced by interaction between the patient's coping style, their help-seeking behaviour and their clinician's responsiveness to breathlessness itself, in addition to managing the underlying disease.

Barriers to palliative care in people with chronic obstructive pulmonary disease in home care: A qualitative study of the perspective of professional caregivers

AIMS AND OBJECTIVES

To examine the experiences with palliative care in people with chronic obstructive pulmonary disease among professional caregivers in a Danish home care setting.

BACKGROUND

Many patients with advanced chronic obstructive pulmonary disease depend on professional caregivers in the primary sector to provide assistance and care. However, chronic obstructive pulmonary disease patients receive no or only very little palliative care compared to patients with cancer although they may have many burdensome symptoms.

DESIGN

Qualitative explorative study.

METHODS

In 2013-2014, ten professional caregivers from three districts in a Danish municipality were followed during home visits to patients with chronic obstructive pulmonary disease and individual interviews about palliative care were subsequently conducted. In 2014, 66 professional caregivers, representing eleven home care districts, participated in ten group discussions about palliative care needs in this group of patients. Data were analysed using qualitative descriptive analysis.

RESULTS

The study revealed a nonawareness of palliative care for patients with chronic obstructive pulmonary disease among the professional caregivers who expressed vague understanding of palliative care and lack of knowledge about the disease. Organisational barriers, such as lack of time and continuity in patient care, lack of opportunity to discuss palliative care and lack of peer learning were experienced as challenging in the provision of palliative care. Nonawareness and organisational barriers led to difficulties in identifying palliative care needs and reluctance to initiate conversations about palliative care.

CONCLUSION

The findings indicate a need for education, training and reflection among professional caregivers in home care. Also, organisational changes may be needed to reduce the barriers to palliative care.

RELEVANCE TO CLINICAL PRACTICE

The findings uncovered barriers to palliative care that must be addressed. Targeted educational programmes and organisational changes may increase the ability to identify palliative care needs and initiate and evaluate palliative interventions.

Exploring Opportunities for Primary Outpatient Palliative Care for Adults with Cystic Fibrosis: A Mixed-Methods Study of Patients' Needs

BACKGROUND

Persons with cystic fibrosis (CF) experience high morbidity and mortality, yet little is known about their palliative care needs and how clinicians may address these needs.

OBJECTIVES

(1) To identify palliative care and advance care planning needs of patients with CF and their families; and (2) to identify clinicians' potential roles in meeting these needs.

METHODS

A mixed-methods study of adult patients (age ≥18 years) with moderate-to-severe CF [forced expiratory volume in the first second (FEV₁) <65% predicted] were recruited from a CF Center. Semi-structured interviews (30-60 minutes) and questionnaires were administered in person or by phone. Grounded theory was used to analyze the interviews. Questionnaires were analyzed descriptively.

RESULTS

Forty-nine patients (FEV₁ % range = 19%-63%) participated; the participation rate was 80% for eligible patients. Three main domains of palliative care needs were identified: (1) to be listened to, feel heard, and be "seen"; (2) understanding the context around CF and its trajectory, with the goal of preparing for the future; and (3) information about, and potential solutions to, practical and current circumstances that cause stress. In questionnaires, few patients (4.3%) reported talking with their clinician about their wishes for care if they were to become sicker, but mixed-methods data demonstrated that more than half of participants were willing to receive palliative care services provided those services were adapted to CF.

CONCLUSION

Patients expressed a need for and openness to palliative care services, as well as some reluctance. They appreciated clinician communication that was open, forthcoming, and attuned to individualized concerns.