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Ouchi K, Prachanukool T, Aaronson EL, Lakin JR, Higuchi M, Liu SW, Kennedy M, Revette AC, Chary AN, Kaithamattam J, Lee B, Neville TH, Hasdianda MA, Sudore R, Schonberg MA, Tulsky JA, Block SD. The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study. Acad Emerg Med 2024; 31:18-27. [PMID: 37814372 PMCID: PMC10794002 DOI: 10.1111/acem.14818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. METHODS We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews. RESULTS Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. CONCLUSIONS Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Thidathit Prachanukool
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Emily L. Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R. Lakin
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Masaya Higuchi
- Division of Palliative Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shan W. Liu
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anita N. Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jenson Kaithamattam
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Brandon Lee
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Thanh H. Neville
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Mohammad A. Hasdianda
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Susan D. Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Fischer C, Bednarz D, Simon J. Methodological challenges and potential solutions for economic evaluations of palliative and end-of-life care: A systematic review. Palliat Med 2024; 38:85-99. [PMID: 38142280 PMCID: PMC10798028 DOI: 10.1177/02692163231214124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
BACKGROUND Given the increasing demand for palliative and end-of-life care, along with the introduction of costly new treatments, there is a pressing need for robust evidence on value. However, comprehensive guidance is missing on methods for conducting economic evaluations in this field. AIM To identify and summarise existing information on methodological challenges and potential solutions/recommendations for economic evaluations of palliative and end-of-life care. DESIGN We conducted a systematic review of publications on methodological considerations for economic evaluations of adult palliative and end-of-life care as per our PROSPERO protocol CRD42020148160. Following initial searches, we conducted a two-stage screening process and quality appraisal. Information was thematically synthesised, coded, categorised into common themes and aligned with the items specified in the Consolidated Health Economic Evaluation Reporting Standards statement. DATA SOURCES The databases Medline, Embase, HTADatabase, NHSEED and grey literature were searched between 1 January 1999 and 5 June 2023. RESULTS Out of the initial 6502 studies, 81 were deemed eligible. Identified challenges could be grouped into nine themes: ambiguous and inaccurate patient identification, restricted generalisability due to poor geographic transferability of evidence, narrow costing perspective applied, difficulties defining comparators, consequences of applied time horizon, ambiguity in the selection of outcomes, challenged outcome measurement, non-standardised measurement and valuation of costs as well as challenges regarding a reliable preference-based outcome valuation. CONCLUSION Our review offers a comprehensive context-specific overview of methodological considerations for economic evaluations of palliative and end-of-life care. It also identifies the main knowledge gaps to help prioritise future methodological research specifically for this field.
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Affiliation(s)
- Claudia Fischer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Damian Bednarz
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Judit Simon
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute Applied Diagnostics, Vienna, Austria
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Zhou Y, Bai Z, Cheng L, Zheng Q, Li L. Reliability and Validity of the Chinese Version of Advance Care Planning Self-efficacy Scale for Physicians. J Palliat Care 2024; 39:36-46. [PMID: 37415494 DOI: 10.1177/08258597231185679] [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: 07/08/2023]
Abstract
Background: Chinese patients prefer physicians to initiate advance care planning (ACP) conversations, but there is no appropriate tool to evaluate physicians' ACP self-efficacy level in mainland China. This study aimed to translate the ACP self-efficacy scale into Chinese (ACP-SEc) and measure its psychometric properties among clinical physicians. Method: The original scale was translated by literal translation, synthesis, and reverse translation, according to Brislin's translation model. Seven experts were invited to further revise the scale and evaluate the content validity. 348 physicians were conveniently sampled to evaluate the reliability and validity of the scale from May to June 2021 in 7 tertiary hospitals. Results: The ACP-SEc contained 17 items, 1 dimension, with a total score of 17 to 85 points. In this study, the critical ratios of the items ranged from 12.533 to 23.306, the item-total correlation coefficients ranged from 0.619 to 0.839. The item-content validity index ranged from 0.86 to 1.00, and the average scale-level content validity index was 0.98. In total, 75.507% of the total variance was explained by 1 common factor. The results of confirmatory factor analysis showed that the fitting indices of the modified model were desirable. The ACP-SEc was moderately correlated with General Self-Efficacy Scale (r = 0.675, P < .001), and it differentiated between physician groups based on the knowledge level of ACP, palliative care or ACP-related training experience, attitude toward ACP, willingness to initiate ACP discussions with patients, and experience of discussing ACP with family and friends, willingness to initiate ACP discussions with family and friends (P <.05). The total Cronbach's α and test-retest reliability of the scale were .960 and .976, respectively. Conclusion: The ACP-SEc shows good reliability and validity, and it can be used to assess the ACP self-efficacy level of physicians.
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Affiliation(s)
- Yanan Zhou
- Department of Nursing, The Third Affiliated Hospital of the Naval Military Medical University, Shanghai, China
| | - Zhiling Bai
- Department of Pharmacy, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Lin Cheng
- Military patient management section, The 926th Hospital of the joint logistics support force of the Chinese people's Liberation Army, Kaiyuan, China
| | - Qin Zheng
- Department of Nursing, The Third Affiliated Hospital of the Naval Military Medical University, Shanghai, China
| | - Li Li
- Department of Nursing, The Third Affiliated Hospital of the Naval Military Medical University, Shanghai, China
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Wang J, Shand J, Gomes M. End-of-life care costs and place of death across health and social care sectors. BMJ Support Palliat Care 2023:spcare-2023-004356. [PMID: 37673471 DOI: 10.1136/spcare-2023-004356] [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: 04/27/2023] [Accepted: 08/21/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVES This study explores the relationship between end-of-life care costs and place of death across different health and social care sectors. METHODS We used a linked local government and health data of East London residents (n=4661) aged 50 or over, deceased between 2016 and 2020. Individuals who died in hospital were matched to those who died elsewhere according to a wide range of demographic, socioeconomic and health factors. We reported mean healthcare costs and 95% CIs by care sectors over the 12-month period before death. Subgroup analyses were conducted to investigate if the role of place of death differs according to long-term conditions and age. RESULTS We found that mean difference in total cost between hospital and non-hospital decedents was £4565 (95% CI £3132 to £6046). Hospital decedents were associated with higher hospital cost (£5196, £4499 to £5905), higher mental healthcare cost (£283, £78 to £892) and lower social care cost (-£838, -£1,209 to -£472), compared with individuals who died elsewhere. Subgroup analysis shows that the association between place of death and healthcare costs differs by age and long-term conditions, including cancer, mental health and cardiovascular diseases. CONCLUSION This study suggests that trajectories of end-of-life healthcare costs vary by place of death in a differential way across health and social care sectors. High hospital burden for cancer patients may be alleviated by strengthening healthcare provision in less cost-intensive settings, such as community and social care.
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Affiliation(s)
- Jiunn Wang
- Department of Applied Health Research, University College London, London, UK
| | - Jenny Shand
- UCLPartners, London, UK
- Department of Clinical, Education and Health Psychology, University College London, London, UK
| | - Manuel Gomes
- Department of Applied Health Research, University College London, London, UK
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Ben-Moshe S, Curseen KA. Advance Care Planning in the Geriatrics Clinic. Clin Geriatr Med 2023; 39:407-416. [PMID: 37385692 DOI: 10.1016/j.cger.2023.05.003] [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: 07/01/2023]
Abstract
Advance care planning (ACP) is a process that allows individuals to express their health-care preferences and make decisions about their future medical care. Clinicians practicing in a Geriatrics clinic or with many patients who are aged 65 years or older have a unique opportunity to discuss patients' goals of care. ACP is particularly important for older adults, who may be facing serious health issues and/or end-of-life decisions. This review article will provide an overview of the importance of ACP in the geriatrics clinic, discuss the barriers to implementation, and explore strategies for successful integration..
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Affiliation(s)
- Sivan Ben-Moshe
- Department of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine, Geriatrics Clinic, Emory Healthcare, 1525 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Kimberly A Curseen
- Division of Palliative Medicine, Emory Palliative Care Center, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30322, USA.
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Bryant J, Mansfield E, Cameron E, Sanson-Fisher R. Experiences and preferences for advance care planning following a diagnosis of dementia: Findings from a cross-sectional survey of carers. PLoS One 2023; 18:e0286261. [PMID: 37307258 DOI: 10.1371/journal.pone.0286261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/12/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Future medical and financial planning is important for persons with dementia given the impact of the disease on capacity for decision making. AIMS To explore from the perspective of carers of persons with dementia: (1) Participation in future medical and financial planning by the person they care for, including when planning was undertaken and the characteristics associated with having an advance care directive completed; (2) The type of healthcare providers who discussed advance care planning following diagnosis; and (3) Preferences for timing of discussions about advance care planning following diagnosis. METHODS Recruitment and data collection took place between July 2018 and June 2020. Carers of persons with dementia aged 18 years and older were mailed a survey. Participants completed questions regarding completion of various future planning documents by the person they support, including time of completion and who discussed advance care planning following diagnosis. Participants were presented with information about the benefits and consequences of early and late discussions of advance care planning and asked when discussions about advance care planning were best initiated. RESULTS 198 carers participated. Most participants were female (74%) and had been a carer for more than 2 years (82%). Most participants reported that the person with dementia they support had made a Will (97%) and appointed an Enduring Guardian (93%) and Enduring Power of Attorney (89%). Only 47% had completed an advance care directive. No significant associations were found between characteristics of persons with dementia and completion of an advance care directive. Geriatricians (53%) and GPs (51%) most often discussed advance care planning following diagnosis. Most carers thought that discussions about advance care planning should occur in the first few weeks or months following diagnosis (32%), at the healthcare provider's discretion (31%), or at the time of diagnosis (25%). CONCLUSIONS More than half of persons with dementia do not have an advance care directive. There is variability in preferences for timing of discussions following dementia diagnosis.
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Affiliation(s)
- Jamie Bryant
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Elise Mansfield
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Emilie Cameron
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Rob Sanson-Fisher
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
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Ouchi K, Lee RS, Block SD, Aaronson EL, Hasdianda MA, Wang W, Rossmassler S, Lopez RP, Berry D, Sudore R, Schonberg MA, Tulsky JA. An emergency department nurse led intervention to facilitate serious illness conversations among seriously ill older adults: A feasibility study. Palliat Med 2023; 37:730-739. [PMID: 36380515 PMCID: PMC10183478 DOI: 10.1177/02692163221136641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Serious illness conversations may lead to care consistent with patients' goals near the end of life. The emergency department could serve as an important time and location for these conversations. AIM To determine the feasibility of an emergency department-based, brief motivational interview to stimulate serious illness conversations among seriously ill older adults by trained nurses. DESIGN A pre-/post-intervention study. SETTINGS/PARTICIPANTS In an urban, tertiary care, academic medical center and a community hospital from January 2021 to January 2022, we prospectively enrolled adults ⩾50 years of age with serious illness and an expected prognosis <1 year. We measured feasibility outcomes using the standardized framework for feasibility studies. In addition, we also collected the validated 4-item Advance Care Planning Engagement Survey (a 5-point Likert scale) at baseline and 4-week follow-up and reviewing the electronic medical record for documentation related to newly completed serious illness conversations. RESULTS Among 116 eligible patients who were willing and able to participate, 76 enrolled (65% recruitment rate), and 68 completed the follow-up (91% retention rate). Mean patient age was 64.4 years (SD 8.4), 49% were female, and 58% had metastatic cancer. In all, 16 nurses conducted the intervention, and all participants completed the intervention with a median duration of 27 min. Self-reported Advance Care Planning Engagement increased from 2.78 pre to 3.31 post intervention (readiness to "talk to doctors about end-of-life wishes," p < 0.008). Documentation of health care proxy forms increased (62-70%) as did Medical Order for Life Sustaining Treatment (1-11%) during the 6 months after the emergency department visit. CONCLUSION A novel, emergency department-based, nurse-led brief motivational interview to stimulate serious illness conversations is feasible and may improve advance care planning engagement and documentation in seriously ill older adults.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Serious Illness Care Program, Ariadne Labs, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rachel S. Lee
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Susan D. Block
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Emily L. Aaronson
- Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mohammad A. Hasdianda
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Wei Wang
- Harvard Medical School, Boston, MA, USA
- Division of Circadian and Sleep Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Sarah Rossmassler
- Department of Nursing, MGH Institute on Health Professions, Boston, MA, USA
- Division of Geriatrics and Palliative Care, Baystate Medical Center, Springfield, MA, USA
| | - Ruth Palan Lopez
- Department of Nursing, MGH Institute on Health Professions, Boston, MA, USA
| | - Donna Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Rebecca Sudore
- Division of Geriatrics Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mara A. Schonberg
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James A. Tulsky
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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Hong N, Root A, Handel B. The Role of Information and Nudges on Advance Directives and End-of-Life Planning: Evidence From a Randomized Trial. Med Care Res Rev 2023; 80:283-292. [PMID: 36935565 DOI: 10.1177/10775587231157800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Despite the substantial personal and economic implications of end-of-life decisions, many individuals fail to document their wishes, which often leads to patient dissatisfaction and unnecessary medical spending. We conducted a randomized trial of 1,200 patients aged 55 years and older to facilitate advance directive (AD) completion and better understand why patients fail to engage in high-value planning. We found that including a physical AD form with paper letters as a nudge to decrease hassle costs increased AD completion by 9.0 percentage points (95% confidence interval [CI] = [4.2, 13.9] percentage points). The intervention was especially effective for individuals aged 70 years and older, as AD completion increased by 17.5 percentage points (95% CI = [5.7, 9.4] percentage points). When compared with the impact of costless electronic reminders, each additional AD completion from the letter interventions costs as little as US$37. Our findings suggest that simple, inexpensive interventions with paper communication as behavioral nudges can be effective, especially in older populations.
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Affiliation(s)
- Nianyi Hong
- Congressional Budget Office, Washington, DC, USA
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Nwankwo H, Coast J, Hewison A, Kinghorn P, Madathil S, Bailey C. A think-aloud study of the feasibility of patients with end-stage organ failure completing the ICECAP-SCM. Palliat Med 2022; 36:1559-1569. [PMID: 36114631 PMCID: PMC9749016 DOI: 10.1177/02692163221122979] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ICECAP-Supportive Care Measure (SCM) is a self-complete measure developed to inform economic decision making at the end-of-life. Previous research has demonstrated its feasibility in hospice and nursing home settings. This is the first study of its use with patients on the organ failure trajectory. AIM To determine the feasibility of using the ICECAP-SCM with patients experiencing end-stage organ failure in a hospital setting. DESIGN Participants were asked to 'think aloud' when completing the ICECAP-SCM, ICECAP-A and EQ-5D-5L measures. The interviews were transcribed verbatim and examined for errors in comprehension, retrieval, judgement, and response by five raters. Qualitative data were collected to explore reasons for errors in completing the measures and participants' views about the measures. SETTING/PARTICIPANTS Sixty patients (with end-stage renal failure n = 18; end-stage heart failure n = 21; end-stage chronic obstructive pulmonary disease n = 21) participated. Senior clinicians applied prognostic criteria to determine eligibility. RESULTS Participants reported that the measures were acceptable, clear, and easy to complete. Error rates in completing the measures were low (ICECAP-A = 3%,and ICECAP-SCM = 5.7% and EQ-5D-5L = 6.3%). There was some variation in responses between patients with different end-stage conditions, particularly those with symptom fluctuation. Some patients had not considered their end-of-life (i.e. advance care planning) and reported finding questions about this difficult to answer. CONCLUSION It is feasible to use the ICECAP-SCM with patients with end-stage organ failure receiving care in hospital settings. This study provides evidence for researchers and policy makers involved in measuring end-of-life care globally. The ICECAP-SCM can be recommended for research with patients in end-stage organ failure to appropriately capture the broader benefits of end-of-life care.
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Affiliation(s)
- Henry Nwankwo
- Centre for Health Economics at Warwick, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Joanna Coast
- Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alistair Hewison
- School of Nursing, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Philip Kinghorn
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Shyam Madathil
- Respiratory Medicine Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Cara Bailey
- School of Nursing, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
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Prachanukool T, Block SD, Berry D, Lee RS, Rossmassler S, Hasdianda MA, Wang W, Sudore R, Schonberg MA, Tulsky JA, Ouchi K. Emergency department-based, nurse-initiated, serious illness conversation intervention for older adults: a protocol for a randomized controlled trial. Trials 2022; 23:866. [PMID: 36210436 PMCID: PMC9549655 DOI: 10.1186/s13063-022-06797-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/27/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Visits to the emergency department (ED) are inflection points in patients' illness trajectories and are an underutilized setting to engage seriously ill patients in conversations about their goals of care. We developed an intervention (ED GOAL) that primes seriously ill patients to discuss their goals of care with their outpatient clinicians after leaving the ED. The aims of this study are (i) to test the impact of ED GOAL administered by trained nurses on self-reported, advance care planning (ACP) engagement after leaving the ED and (ii) to evaluate whether ED GOAL increases self-reported completion of serious illness conversation and other patient-centered outcomes. METHODS This is a two-armed, parallel-design, single-blinded, randomized controlled trial of 120 seriously ill older adults in two academic and one community EDs in Boston, MA. Participants are English-speaking adults 50 years and older with a serious life-limiting illness with a recent ED visit. Patients with a valid MOLST (medical order for life-sustaining treatment) form or other documented goals of care within the last 3 months are excluded. We enroll the caregivers of patients with cognitive impairment. Patients are assigned to the intervention or control group using block randomization. A blinded research team member will perform outcome assessments. We will assess (i) changes in ACP engagement within 6 months and (ii) qualitative assessments of the effect of ED GOAL. DISCUSSION In seriously ill older adults arriving in the ED, this randomized controlled trial will test the effects of ED GOAL on patients' self-reported ACP engagement, EMR documentation of new serious illness conversations, and improving patient-centered outcomes. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT05209880.
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Affiliation(s)
- Thidathit Prachanukool
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Susan D Block
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Donna Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Rachel S Lee
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sarah Rossmassler
- Department of Nursing, MGH Institute on Health Professions, Boston, MA, USA
- Division of Geriatrics and Palliative Care, Baystate Medical Center, Springfield, MA, USA
| | - Mohammad A Hasdianda
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Wei Wang
- Division of Circadian and Sleep Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mara A Schonberg
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - James A Tulsky
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
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11
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Kaminski A. Let's Talk About Dying: An Educational Pilot Program to Improve Providers' Competency in End-Of-Life Discussions. Am J Hosp Palliat Care 2022:10499091221127994. [PMID: 36154272 DOI: 10.1177/10499091221127994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Advance care planning (ACP) conversations occur infrequently due to lack of provider confidence-level, education, and workplace support for gaining skills in initiating goals of care and end-of-life discussions. METHODS A 3-month quality improvement project was carried out between October 2021 to January 2022 using a short, accessible virtual presentation on provider initiation of goals of care conversations. A pre-test/post-test design was implemented using the End-of-Life Professional Caregiver Survey and frequency of ACP documentation of surgical intensive care unit providers. RESULTS Over the study period, 17 providers reviewed the virtual presentation. The End-of-Life Professional Caregiver Survey sum score increased significantly from pre-to post-test (P < .001) reflecting increased provider confidence in initiating goals of care conversations. There was also significant increase in ACP documentation from pre-intervention to the third and final monthly cycle. DISCUSSION Structured education increased ICU providers confidence in having goals of care conversations and improved the frequency of ACP documentation.
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Affiliation(s)
- Ashley Kaminski
- School of Nursing, 7712University of Connecticut, Storrs, CT, USA
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12
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Zhuang Q, Chong PH, Ong WS, Yeo ZZ, Foo CQZ, Yap SY, Lee G, Yang GM, Yoon S. Longitudinal patterns and predictors of healthcare utilization among cancer patients on home-based palliative care in Singapore: a group-based multi-trajectory analysis. BMC Med 2022; 20:313. [PMID: 36131339 PMCID: PMC9494890 DOI: 10.1186/s12916-022-02513-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/03/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Home-based palliative care (HPC) is considered to moderate the problem of rising healthcare utilization of cancer patients at end-of-life. Reports however suggest a proportion of HPC patients continue to experience high care intensity. Little is known about differential trajectories of healthcare utilization in patients on HPC. Thus, we aimed to uncover the heterogeneity of healthcare utilization trajectories in HPC patients and identify predictors of each utilization pattern. METHODS This is a cohort study of adult cancer patients referred by Singapore Health Services to HCA Hospice Service who died between 1st January 2018 and 31st March 2020. We used patient-level data to capture predisposing, enabling, and need factors for healthcare utilization. Group-based multi-trajectory modelling was applied to identify trajectories for healthcare utilization based on the composite outcome of emergency department (ED) visits, hospitalization, and outpatient visits. RESULTS A total of 1572 cancer patients received HPC (median age, 71 years; interquartile range, 62-80 years; 51.1% female). We found three distinct trajectory groups: group 1 (31.9% of cohort) with persistently low frequencies of healthcare utilization, group 2 (44.1%) with persistently high frequencies, and group 3 (24.0%) that begin with moderate frequencies, which dropped over the next 9 months before increasing in the last 3 months. Predisposing (age, advance care plan completion, and care preferences), enabling (no medical subsidy, primary decision maker), and need factors (cancer type, comorbidity burden and performance status) were significantly associated with group membership. High symptom needs increased ED visits and hospitalizations in all three groups (ED visits, group 1-3: incidence rate ratio [IRR] 1.74-6.85; hospitalizations, group 1-3: IRR 1.69-6.60). High home visit intensity reduced outpatient visits in all three groups (group 1-3 IRR 0.54-0.84), while it contributed to reduction of ED visits (IRR 0.40; 95% CI 0.25-0.62) and hospitalizations (IRR 0.37; 95% CI 0.24-0.58) in group 2. CONCLUSIONS This study on HPC patients highlights three healthcare utilization trajectories with implications for targeted interventions. Future efforts could include improving advance care plan completion, supporting care preferences in the community, proactive interventions among symptomatic high-risk patients, and stratification of home visit intensity.
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Affiliation(s)
- Qingyuan Zhuang
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, 169610, Singapore.
| | | | - Whee Sze Ong
- Division of Clinical Trials and Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | | | - Cherylyn Qun Zhen Foo
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, 169610, Singapore
| | - Su Yan Yap
- Palliative Care Services, Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Guozhang Lee
- Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Grace Meijuan Yang
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, 169610, Singapore.,Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Sungwon Yoon
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Centre for Population Health Research and Implementation, Singapore Regional Health System, Singapore, Singapore
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13
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Views of advance care planning in older hospitalized patients following an emergency admission: A qualitative study. PLoS One 2022; 17:e0273894. [PMID: 36048853 PMCID: PMC9436063 DOI: 10.1371/journal.pone.0273894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 08/17/2022] [Indexed: 11/19/2022] Open
Abstract
Background There is increasing evidence of the need to consider advance care planning (ACP) for older adults who have been recently admitted to hospital as an emergency. However, there is a gap in knowledge regarding how to facilitate ACP following acute illness in later life. Aim/Objectives To explore the perceived impact of ACP on the lives of older persons aged 70+ who have been acutely admitted to hospital. Method Semi-structured qualitative interviews were conducted with older adults aged 70+ who were admitted to hospital as an emergency. Thematic analysis was enhanced by dual coding and exploration of divergent views within an interdisciplinary team. Results Twenty participants were interviewed. Thematic analysis generated the following themes: (1) Bespoke planning to holistically support a sense of self, (2) ACP as a socio-cultural phenomenon advocating for older persons rights, (3) The role of personal relationships, (4) Navigating unfamiliar territory and (5) Harnessing resources. Conclusion These findings indicate that maintaining a sense of personal identity and protecting individuals’ wishes and rights during ACP is important to older adults who have been acutely unwell. Following emergency hospitalization, older persons believe that ACP must be supported by a network of relationships and resources, improving the likelihood of adequate preparation to navigate the uncertainties of future care in later life. Therefore, emergency hospitalization in later life, and the uncertainty that may follow, may provide a catalyst for patients, carers and healthcare professionals to leverage existing or create new relationships and target resources to enable ACP, in order to uphold older persons’ identity, rights and wishes following acute illness.
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14
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Wong SPY, Foglia MB, Cohen J, Oestreich T, O'Hare AM. The VA Life-Sustaining Treatment Decisions Initiative: A qualitative analysis of veterans with advanced kidney disease. J Am Geriatr Soc 2022; 70:2517-2529. [PMID: 35435246 PMCID: PMC9790645 DOI: 10.1111/jgs.17807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Documentation of patients' goals of care is integral to promoting goal-concordant care. In 2017, the Department of Veterans Affairs (VA) launched a system-wide initiative to standardize documentation of patients' preferences for life-sustaining treatments (LST) and related goals-of-care conversations (GoCC) that included using a note template in its national electronic medical record system. We describe implementation of the LST note based on documentation in the medical records of patients with advanced kidney disease, a group that has traditionally experienced highly intensive patterns of care. METHODS We performed a qualitative analysis of documentation in the VA electronic medical record for a national random sample of 500 adults with advanced kidney disease for whom at least one LST note was completed between July 2018 and March 2019 to identify prominent themes pertaining to the content and context of LST notes. RESULTS During the observation period, a total of 723 (mean 1.5, range 1-6) LST notes were completed for this cohort. Two themes emerged from the analysis: (1) Reactive approach: LST notes were largely completed in response to medical crises, in which they focused on short-term goals and preferences rather than patients' broader health and goals, or certain clinical encounters designated by the initiative as "triggering events" for LST note completion; (2) Practitioner-driven: Documentation suggested that practitioners would attempt to engage patients/surrogates in GoCC to lay out treatment options in order to move care forward, but patients/surrogates sometimes appeared reluctant to engage in GoCC and had difficulty communicating in ways that practitioners could understand. CONCLUSIONS Standardized documentation of patients' treatment preferences and related GoCC was used to inform in-the-moment decision-making during acute illness and certain junctures in care. There is opportunity to expand standardized documentation practices and related GoCC to address patients'/surrogates' broader health concerns and goals and to enhance their engagement in these processes.
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Affiliation(s)
- Susan P. Y. Wong
- Division of NephrologyVA Puget Sound Health Care SystemSeattleWashingtonUSA
| | - Mary Beth Foglia
- VA National Center for Ethics in Health CareSeattleWashingtonUSA
| | - Jennifer Cohen
- VA National Center for Ethics in Health CareSeattleWashingtonUSA
| | - Taryn Oestreich
- Division of NephrologyVA Puget Sound Health Care SystemSeattleWashingtonUSA
| | - Ann M. O'Hare
- Division of NephrologyVA Puget Sound Health Care SystemSeattleWashingtonUSA
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15
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Bryant J, Waller A, Bowman A, Pickles R, Hullick C, Price E, White B, Willmott L, Knight A, Ryall MA, Sanson-Fisher R. Junior Medical Officers' knowledge of advance care directives and substitute decision making for people without decision making capacity: a cross sectional survey. BMC Med Ethics 2022; 23:74. [PMID: 35850728 PMCID: PMC9295359 DOI: 10.1186/s12910-022-00813-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/13/2022] [Indexed: 11/15/2022] Open
Abstract
Background For the benefits of advance care planning to be realised during a hospital admission, the treating team must have accurate knowledge of the law pertaining to implementation of advance care directives (ACDs) and substitute decision making. Aims To determine in a sample of Junior Medical Officers (JMOs): (1) knowledge of the correct order to approach people as substitute decision makers if a patient does not have capacity to consent to treatment; (2) knowledge of the legal validity of ACDs when making healthcare decisions for persons without capacity to consent to treatment, including the characteristics associated with higher knowledge; and (3) barriers to enacting ACDs.
Methods A cross-sectional survey was conducted at five public hospitals in New South Wales, Australia. Interns, residents, registrars, and trainees on clinical rotation during the recruitment period were eligible to participate. Consenting participants completed an anonymous pen-and-paper survey. Results A total of 118 JMOs completed a survey (36% return rate). Fifty-five percent of participants were female and 56.8% were aged 20–29 years. Seventy-five percent of JMOs correctly identified a Guardian as the first person to approach if a patient did not have decision-making capacity, and 74% correctly identified a person’s spouse or partner as the next person to approach. Only 16.5% identified all four persons in the correct order, and 13.5% did not identify any in the correct order. The mean number of correct responses to the questions assessing knowledge of the legal validity of ACDs was 2.6 (SD = 1.1) out of a possible score of 6. Only 28 participants (23.7%) correctly answered four or more knowledge statements correctly. None of the explored variables were significantly associated with higher knowledge of the legal validity of ACDs. Uncertainty about the currency of ACDs and uncertainty about the legal implications of relying on an ACD when a patient’s family or substitute decision maker disagree with it were the main barriers to enacting ACDs. Conclusion JMOs knowledge of the legal validity of ACDs for persons without decision making capacity and the substitute decision making hierarchy is limited. There is a clear need for targeted education and training to improve knowledge in this area for this cohort.
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Affiliation(s)
- Jamie Bryant
- Health Behaviour Research Collaborative, University of Newcastle, Callaghan, Australia. .,School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia. .,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia. .,Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
| | - Amy Waller
- Health Behaviour Research Collaborative, University of Newcastle, Callaghan, Australia.,School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Alison Bowman
- Health Behaviour Research Collaborative, University of Newcastle, Callaghan, Australia.,School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
| | - Robert Pickles
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,John Hunter Hospital, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Carolyn Hullick
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Belmont Hospital, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Emma Price
- John Hunter Hospital, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Ben White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD, Australia
| | - Anne Knight
- Manning Education Centre, University of Newcastle Department of Rural Health, 69a High St, Taree, NSW, Australia
| | - Mary-Ann Ryall
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Wyong Hospital, Central Coast Local Health District, Gosford, NSW, Australia
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, University of Newcastle, Callaghan, Australia.,School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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16
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Sun F, Lipinsky DeGette R, Cummings EC, Deng LX, Hauser KA, Kopp Z, Penner JC, Scott BS, Raffel KE, Kantor MA. Capturing what matters: A retrospective observational study of advance care planning documentation at an academic medical center during the COVID-19 pandemic. Palliat Med 2022; 36:342-347. [PMID: 34920691 DOI: 10.1177/02692163211065928] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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 allows patients to share their preferences for medical care with the aim of ensuring goal-concordant care in times of serious illness. The morbidity and mortality of the COVID-19 pandemic has increased the importance and public visibility of advance care planning. However, little is known about the frequency and quality of advance care planning documentation during the pandemic. AIM This study examined the frequency, quality, and predictors of advance care planning documentation among hospitalized medical patients with and without COVID-19. DESIGN This retrospective cohort analysis used multivariate logistic regression to identify factors associated with advance care planning documentation. SETTING/PARTICIPANTS This study included all adult patients tested for COVID-19 and admitted to a tertiary medical center in San Francisco, CA during March 2020. RESULTS Among 262 patients, 31 (11.8%) tested positive and 231 (88.2%) tested negative for SARS-CoV-2. The rate of advance care planning documentation was 38.7% in patients with COVID-19 and 46.8% in patients without COVID-19 (p = 0.45). Documentation consistently addressed code status (100% and 94.4% for COVID-positive and COVID-negative, respectively), but less often named a surrogate decision maker, discussed prognosis, or elaborated on other wishes for care. Palliative care consultation was associated with increased advance care planning documentation (OR: 6.93, p = 0.004). CONCLUSION This study found low rates of advance care planning documentation for patients both with and without COVID-19 during an evolving global pandemic. Advance care planning documentation was associated with palliative care consultation, highlighting the importance of such consultation to ensure timely, patient-centered advance care planning.
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Affiliation(s)
- Fangdi Sun
- Department of Medicine, University of California, San Francisco, CA, USA
| | | | | | - Lisa X Deng
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Karen A Hauser
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Zoë Kopp
- Department of Medicine, University of California, San Francisco, CA, USA
| | - John C Penner
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Brandon S Scott
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Katie E Raffel
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Molly A Kantor
- Department of Medicine, University of California, San Francisco, CA, USA
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17
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Kaur P, Wu HY, Hum A, Heng BH, Tan WS. Medical cost of advanced illnesses in the last-year of life-retrospective database study. Age Ageing 2022; 51:6406695. [PMID: 34673931 DOI: 10.1093/ageing/afab212] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE This study aims to quantify medical care utilisation, and to describe the cost trajectories of individuals with advanced illnesses in the last-year of life, differentiated by advanced cancer, end-stage organ failure and progressive neurological disorders. METHODS This retrospective database study included decedents who had previous inpatient or outpatient encounters at a public hospital in Singapore. Patients with advanced diseases were identified based on diagnostic codes and clinical criteria. Using a look-back approach, the amount of healthcare services utilised and the corresponding mean monthly and annual costs to the healthcare system in the last 12-months of life were quantified. RESULTS The last 12-months of life among 6,598 decedents was associated with £20,524 (95% confidence interval: £20,013-£21,036) in medical costs, of which 80% was accounted for by inpatient admissions. Costs increased sharply in the last 2-months of life, with a large proportion of monthly costs accounted for by inpatient admissions which rose rapidly from 61% at 12-months prior to death to 94% in the last-month of life. Compared to patients with cancer, individuals diagnosed with non-cancer advanced illnesses accumulated 1.6 times more healthcare costs in the last-year of life with significant differences across patients with end-stage organ failure and progressive neurological disorders. CONCLUSION Healthcare costs varied across disease conditions at the end-of-life. With advance care planning and close collaboration between the inpatient clinical team and the community providers, it may be possible to re-direct some of the hospitalisation costs to community-based palliative care services.
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Affiliation(s)
- Palvinder Kaur
- Health Services and Outcomes Research Department, National Healthcare Group, Singapore 138543
| | - Huei Yaw Wu
- Department of Palliative Medicine, Tan Tock Seng Hospital Singapore, Singapore 308433
- Palliative Care Centre for Excellence in Research and Education, Singapore 308436
| | - Allyn Hum
- Department of Palliative Medicine, Tan Tock Seng Hospital Singapore, Singapore 308433
- Palliative Care Centre for Excellence in Research and Education, Singapore 308436
| | - Bee Hoon Heng
- Health Services and Outcomes Research Department, National Healthcare Group, Singapore 138543
| | - Woan Shin Tan
- Health Services and Outcomes Research Department, National Healthcare Group, Singapore 138543
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18
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Martínez Ques ÁA, Braña Marcos B, Martín Arribas C, Vázquez Campo M, Rumbo Prieto JM, López Castro J, Herrero Olivera L, Gómez Salgado J. [Design and validation of an instrument about quality of the advance care planning for professionals]. GACETA SANITARIA 2022; 36:401-408. [PMID: 34991901 DOI: 10.1016/j.gaceta.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/10/2021] [Accepted: 11/10/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop a questionnaire aimed to measure the quality of the advance care planning process in healthcare professionals and to assess its psychometric quality. METHOD Instrumental questionnaire validation study. SCOPE primary care centers and outpatients clinics from general hospitals in Ferrol, Ourense, Monforte-Lugo and Health Area V of the Health Service of Asturias. PARTICIPANTS physicians and nurses. Phases: (1) design of the first version of the questionnaire using the Delphi technique; (2) construction of the second version of 21 items, after judges' agreement and Kendall's W test; (3) pilot study: internal consistency using Cronbach's alpha and omega coefficient, retest-test by Pearson's correlation coefficient; (4) validation: Barlett's spherity test and Kaiser-Meyer-Olkin measurement, exploratory factor analysis with varimax rotation and study of the dimensions of the questionnaire (number, CCI and correlation), internal consistency using Cronbach's alpha. RESULTS Pilot study with 28 professionals. Reliability ɷ=0.917, α=0.841, and test-retest correlation coefficient of 0.785 (95% confidence interval: 0.587-0.894; p<0.001). Validation of the questionnaire (21 items) in 204 professionals. Ítem analysis and exploratory factor analysis (Barlett's test [χ2=1298,789] and KMO=0.808; p<0.001) yielded a five-factor model explaining 64.377% of the total variance, with 18 items grouped into 5 dimensions (information, preferences, behavioral intention, training and communication). Cronbach's alpha of the global questionnaire was 0.841. CONCLUSIONS The ProPAD-pro questionnaire has showed to be a valid and reliable instrument to assess the quality of the advance care planning process.
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Affiliation(s)
- Ángel Alfredo Martínez Ques
- Área Sanitaria de Orense, Verín y Barco de Valdeorras, Servicio Gallego de Salud (Sergas), Orense, España; Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), Vigo, España
| | - Beatriz Braña Marcos
- Área Sanitaria V, Servicio de Salud del Principado de Asturias (SESPA), Gijón, España; Dirección General de Cuidados, Humanización y Atención Sociosanitaria, Consejería de Salud del Principado de Asturias, Oviedo, España; Grupo de Determinantes de la Salud y Profesión Enfermera, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, España.
| | | | - Miriam Vázquez Campo
- Área Sanitaria de Ourense, Verín y Barco de Valdeorras, Servicio Gallego de Salud (Sergas), Orense, España
| | - José María Rumbo Prieto
- Unidad de Docencia e Investigación, Área Sanitaria de Ferrol, Servicio Gallego de Salud (Sergas), Ferrol, España
| | - José López Castro
- Servicio de Medicina Interna, Área Sanitaria de Lugo, Cervo y Monforte de Lemos (Sergas), Lugo, España
| | - Laura Herrero Olivera
- Facultad de Filosofía, Universidad Nacional de Educación a Distancia, Madrid, España
| | - Juan Gómez Salgado
- Área de Medicina Preventiva y Salud Pública, Departamento de Sociología, Trabajo Social y Salud Pública. Facultad de Ciencias del Trabajo. Universidad de Huelva, Huelva, España; Programa de Posgrado de Seguridad y Salud, Universidad Espíritu Santo, Guayaquil, Ecuador
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19
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Diegelmann S, Bidmon S, Terlutter R. Promoting advance care planning via mediated health resources: A systematic mixed studies review. PATIENT EDUCATION AND COUNSELING 2022; 105:15-29. [PMID: 34144856 DOI: 10.1016/j.pec.2021.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 05/05/2021] [Accepted: 06/07/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This systematic review aims (a) to analyze the message design of mediated advance care planning (ACP) interventions targeted at adults from a social marketing and health communication perspective, (b) to identify associations between message design and ACP outcomes, and (c) to illuminate gaps in the literature and highlight needs for future research. METHODS A systematic mixed studies review was conducted. Empirical articles on mediated ACP interventions were systematically searched by using nine scientific databases with keywords related to ACP and mediated health communication. Data were synthesized using a sequential explanatory approach. RESULTS A total of 11,824 titles were identified, of which 36 studies were included. Interventions disseminated ACP messages via video (36%), digital channels (22%), print (19%), a combination of channels (19%), and mass media (3%). The interventions used generic (42%), targeted (33%), and tailored (25%) communication. Overall, the evidence suggests that mediated ACP resources positively impact ACP Process and Action outcomes. CONCLUSION This study has shown that mediated ACP interventions use various contents, formats, and structures to influence patient-centered ACP outcomes. Most message design techniques were associated with positive ACP outcomes. PRACTICE IMPLICATIONS Mediated ACP resources are a promising approach to encourage ACP among adults.
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Affiliation(s)
- Svenja Diegelmann
- Alpen-Adria-Universität Klagenfurt, Department of Marketing and International Management, Universitätsstrasse 65-67, 9020 Klagenfurt, Austria.
| | - Sonja Bidmon
- Alpen-Adria-Universität Klagenfurt, Department of Marketing and International Management, Universitätsstrasse 65-67, 9020 Klagenfurt, Austria
| | - Ralf Terlutter
- Alpen-Adria-Universität Klagenfurt, Department of Marketing and International Management, Universitätsstrasse 65-67, 9020 Klagenfurt, Austria
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20
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Forschner A, Loquai C, Meiss F, Huening S, Pawlowski J, Bradfisch F, Lehr S, Nashan D. Gibt es eine Überbehandlung von Melanompatienten am Ende ihres Lebens? Ergebnisse einer multizentrischen Studie an 193 Melanompatienten. J Dtsch Dermatol Ges 2021; 19:1297-1306. [PMID: 34541790 DOI: 10.1111/ddg.14501_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 02/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Frank Meiss
- Abteilung für Dermatologie und Venerologie, Medizinisches Zentrum - Universität Freiburg, Medizinische Fakultät, Universität Freiburg
| | | | - Johannes Pawlowski
- Abteilung für Dermatologie, Universitätsklinikum Tübingen.,Klinik für Dermatologie, Universitätsklinikum Mainz
| | | | - Saskia Lehr
- Abteilung für Dermatologie und Venerologie, Medizinisches Zentrum - Universität Freiburg, Medizinische Fakultät, Universität Freiburg
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21
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Koeberlein-Neu J, Hoffmann F, Schweda M. 'Value' of advance care plans: health economics revisited. BMJ Support Palliat Care 2021; 12:bmjspcare-2021-003192. [PMID: 34470771 DOI: 10.1136/bmjspcare-2021-003192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/17/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Juliane Koeberlein-Neu
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
| | - Falk Hoffmann
- Department of Health Services Research, University of Oldenburg School of Medicine and Health Sciences, Oldenburg, Niedersachsen, Germany
| | - Mark Schweda
- Department of Health Services Research, University of Oldenburg School of Medicine and Health Sciences, Oldenburg, Niedersachsen, Germany
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22
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Forschner A, Loquai C, Meiss F, Huening S, Pawlowski J, Bradfisch F, Lehr S, Nashan D. Is there an overtreatment of melanoma patients at the end of their life? Results of a multicenter study on 193 melanoma patients. J Dtsch Dermatol Ges 2021; 19:1297-1305. [PMID: 34357677 DOI: 10.1111/ddg.14501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 02/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES There is a lack of data regarding the situation of melanoma patients receiving systemic therapies in their last months of life. PATIENTS AND METHODS All melanoma patients who died in 2016 or 2017 and who had been treated by systemic therapies within the last three months of life were retrospectively analyzed. The study was conducted within the Committee "supportive therapy" of the Work Group Dermatological Oncology (ADO). RESULTS 193 patients from four dermato-oncological centers were included. More than 60 % of the patients had ECOG ≥ 2 and most of them received immune checkpoint inhibitors (ICI) or targeted therapies (TT). 41 patients benefited from the last therapy in terms of radiological and laboratory findings or state of health. Although ECOG was worse in the TT cohort compared to the ICI group, the proportion of patients benefiting from the last therapy with TT was significantly higher and TT therapy could be carried out more often on an outpatient basis. CONCLUSIONS This study indicates that there is a tendency towards an overtreatment at the end of life. Nevertheless, TT might be a reasonable therapeutic option for advanced BRAF mutant melanoma, even in highly palliative situations.
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Affiliation(s)
- Andrea Forschner
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Carmen Loquai
- Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | - Frank Meiss
- Department of Dermatology and Venereology, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Svea Huening
- Department of Dermatology, Hospital Dortmund, Dortmund, Germany
| | - Johannes Pawlowski
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany.,Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | | | - Saskia Lehr
- Department of Dermatology and Venereology, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Dorotheé Nashan
- Department of Dermatology, Hospital Dortmund, Dortmund, Germany
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Jeong S, Ohr SO, Cleasby P, Barrett T, Davey R, Deeming S. A cost-consequence analysis of normalised advance care planning practices among people with chronic diseases in hospital and community settings. BMC Health Serv Res 2021; 21:729. [PMID: 34301254 PMCID: PMC8305493 DOI: 10.1186/s12913-021-06749-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A growing body of international literature concurs that comprehensive and complex Advance Care Planning (ACP) programs involving specially qualified or trained healthcare professionals are effective in increasing documentation of Advance Care Directives (ACDs), improving compliance with patients' wishes and satisfaction with care, and quality of care for patients and their families. Economic analyses of ACDs and ACP have been more sporadic and inconclusive. This study aimed to contribute to the evidence on resource use associated with implementation of ACP and to inform key decision-makers of the resource implications through the conduct of a cost-consequence analysis of the Normalised Advance Care Planning (NACP) trial. METHODS The outcomes for the economic evaluation included the number of completed "legally binding" ACDs and the number of completed Conversation Cards (CC). The cost analysis assessed the incremental difference in resource utilisation between Usual Practice and the Intervention. Costs have been categorised into: 1) Contract staff costs; 2) Costs associated with the development of the intervention; 3) Implementation costs; 4) Intervention (delivery) costs; and 5) Research costs. RESULTS The cost incurred for each completed ACD was A$13,980 in the hospital setting and A$1248 in the community setting. The cost incurred for each completed Conversation Card was A$7528 in the hospital setting and A$910 in the community setting. CONCLUSIONS The cost-consequence analysis does not support generalisation of the specified intervention within the hospital setting. The trial realised an estimated incremental cost per completed ACD of $1248, within the community setting. This estimate provides an additional benchmark against which decision-makers can assess the value of either 1) this approach towards the realisation of additional completed ACDs; and/or 2) the value of ACP and ACDs more broadly, when this estimate is positioned within the potential health outcomes and downstream health service implications that may arise for people with or without a completed ACD. TRIAL REGISTRATION The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record.
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Affiliation(s)
- Sarah Jeong
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW 2258 Australia
| | - Se Ok Ohr
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW 2258 Australia
- Hunter New England Nursing and Midwifery Research Centre, Hunter New England Local Health District, James Fletcher Campus, Gate Cottage, 72 Watt St, Newcastle, NSW 2300 Australia
| | - Peter Cleasby
- Division of Aged, Subacute and Complex Care, PO Box 6088 Long Jetty, Central Coast Local Health District, NSW 2261 Gosford, Australia
| | - Tomiko Barrett
- Department of Aged Care Services, Wyong Hospital, PO Box 4200, Lakehaven, Central Coast Local Health District, Wyong, NSW 2263 Australia
| | - Ryan Davey
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW 2258 Australia
| | - Simon Deeming
- Hunter Medical Research Institute, Lot 1, Kookaburra Circuit, New Lambton Heights, Newcastle, NSW 2305 Australia
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Park EJ, Jo M, Park M, Kang SJ. Advance care planning for older adults in community-based settings: An umbrella review. Int J Older People Nurs 2021; 16:e12397. [PMID: 34216191 DOI: 10.1111/opn.12397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 05/05/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Advance care planning (ACP) is critical to ensure better quality end of life care, and older adults are often a target of ACP. However, ACP interventions and their outcomes are neither standardised nor conclusive. OBJECTIVES To synthesise existing ACP systematic reviews and identify the types and outcomes of ACP interventions for older adults in community-based settings. METHODS An umbrella review of systematic reviews. The Joanna Briggs Institute Reviewer's Manual was followed. Relevant systematic reviews were searched by utilising bibliographic databases, grey literature sources, and manual searches between April and July, 2019. Nine systematic reviews met the inclusion criteria. Critical appraisal on the selected reviews was conducted. Data were independently extracted using a data extraction tool by two researchers and synthesised based on consensus. RESULTS The systematic reviews suggest the critical features of ACP interventions for older adults in community-based settings including clinicians' face-to-face communication with patients and their family members, comprehensive and individualized decisional aids, a proper intensity of ACP interventions, and professional training. When categorising ACP outcomes according to Sudore et al.'s (Journal of Pain and Symptom Management, 55, 2018, 245) framework, action outcomes (e.g., documentation, discussion) were frequently measured with positive outcomes. Quality of care outcomes such as congruence with care preference and healthcare outcomes such as health status were not reported sufficiently. CONCLUSIONS The reviews suggested essential features of ACP interventions, which were often omitted in ACP interventions for older adults. Although the outcomes were generally positive, it is inconclusive as to whether ACP interventions eventually improved quality of end of life care or health status of older adults in community-based settings. IMPLICATIONS FOR PRACTICE For ACP interventions to be effective and comparable in their outcomes, we recommend adopting the key intervention components identified in this study. As the effects of ACP interventions are inconclusive, further investigations are warranted.
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Affiliation(s)
- Eun-Jun Park
- Department of Nursing, Konkuk University, Chungju-si, South Korea
| | - Minjeong Jo
- College of Nursing, The Catholic University of Korea, Seoul, South Korea
| | - Mihyun Park
- College of Nursing, The Catholic University of Korea, Seoul, South Korea
| | - Seok-Jung Kang
- Department of Nursing, Semyung University, Jecheon-si, South Korea
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Comparison of Two Methods for Implementing Comfort Care Order Sets in the Inpatient Setting: a Cluster Randomized Trial. J Gen Intern Med 2021; 36:1928-1936. [PMID: 33547573 PMCID: PMC8298677 DOI: 10.1007/s11606-020-06482-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND There is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings. OBJECTIVE To compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs). DESIGN Cluster randomized implementation trial conducted March 2015-April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites. PARTICIPANTS One hundred thirty-two providers from PCCTs at 47 VAMCs. INTERVENTIONS Both training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers. MAIN MEASUREMENTS Several processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates. KEY RESULTS Eighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement. CONCLUSION Findings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02383173.
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Bauer A, Dixon J, Knapp M, Wittenberg R. Exploring the cost-effectiveness of advance care planning (by taking a family carer perspective): Findings of an economic modelling study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:967-981. [PMID: 32783319 DOI: 10.1111/hsc.13131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/15/2020] [Accepted: 07/21/2020] [Indexed: 06/11/2023]
Abstract
Advance care planning is considered an important part of high-quality end-of-life care. Its cost-effectiveness is currently unknown. In this study, we explore the cost-effectiveness of a strategy, in which advance care planning is offered systematically to older people at the end-of-life compared with standard care. We conducted decision-analytic modelling. The perspective was health and social care and the time horizon was 1 year. Outcomes included were quality-adjusted life years as they referred to the surviving carers. Data sources included published studies, national statistics and expert views. Average total cost in the advance care planning versus standard care group was £3,739 versus £3,069. The quality-adjusted life year gain to carers was 0.03 for the intervention in comparison with the standard care group. Based on carer's health-related quality-of-life, the average cost per quality-adjusted life year was £18,965. The probability that the intervention was cost-effective was 55% (70%) at a cost per quality-adjusted life year threshold of £20,000 (£30,000). Conducting cost-effectiveness analysis for advance care planning is challenging due to uncertainties in practice and research, such as a lack of agreement on how advance care planning should be provided and by whom (which influences its costs), and about relevant beneficiary groups (which influences its outcomes). However, even when assuming relatively high costs for the delivery of advance care planning and only one beneficiary group, namely, family carers, our analysis showed that advance care planning was probably cost-effective.
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Affiliation(s)
- Annette Bauer
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
| | - Josie Dixon
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
| | - Raphael Wittenberg
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
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Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews. BMC Palliat Care 2021; 20:89. [PMID: 34162377 PMCID: PMC8223342 DOI: 10.1186/s12904-021-00782-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND As the demand for palliative care increases, more information is needed on how efficient different types of palliative care models are for providing care to dying patients and their caregivers. Evidence on the economic value of treatments and interventions is key to informing resource allocation and ultimately improving the quality and efficiency of healthcare delivery. We assessed the available evidence on the economic value of palliative and end-of-life care interventions across various settings. METHODS Reviews published between 2000 and 2019 were included. We included reviews that focused on cost-effectiveness, intervention costs and/or healthcare resource use. Two reviewers extracted data independently and in duplicate from the included studies. Data on the key characteristics of the studies were extracted, including the aim of the study, design, population, type of intervention and comparator, (cost-) effectiveness resource use, main findings and conclusions. RESULTS A total of 43 reviews were included in the analysis. Overall, most evidence on cost-effectiveness relates to home-based interventions and suggests that they offer substantial savings to the health system, including a decrease in total healthcare costs, resource use and improvement in patient and caregivers' outcomes. The evidence of interventions delivered across other settings was generally inconsistent. CONCLUSIONS Some palliative care models may contribute to dual improvement in quality of care via lower rates of aggressive medicalization in the last phase of life accompanied by a reduction in costs. Hospital-based palliative care interventions may improve patient outcomes, healthcare utilization and costs. There is a need for greater consistency in reporting outcome measures, the informal costs of caring, and costs associated with hospice.
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Tang MY, Li XL, Shi ZY, Fu WJ. Knowledge of and willingness to promote advanced care planning among oncology nurses in southwest China. Int J Palliat Nurs 2021; 26:175-182. [PMID: 32378488 DOI: 10.12968/ijpn.2020.26.4.175] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Nurses feature prominently in promoting advance care planning (ACP), but only a limited amount of relevant research has been conducted from the nurses' viewpoint, and little is known about the nurses' knowledge of and their willingness to promote ACP in China. AIMS The aims of this study were to investigate oncology nurses' knowledge of and their willingness to promote ACP, and to explore associated factors. METHODS A multi-centre study was conducted to investigate 350 nurses in the oncology departments of four university hospitals in southwestern China. Cluster sampling was used in data collection, which involved three categories of questionnaires concerning demographic characteristics, knowledge about ACP and willingness to promote ACP. Chi-squared tests and multiple linear regression were employed in data analysis. RESULTS Some 293 valid questionnaires were collected, among which, 60.1% of respondents never received palliative care education, 89.1% never received training about ACP and 72.7% had not even heard of ACP. Nurses with higher position titles (χ2=18.41, p<0.001) and longer working experience (χ2=12.25, p=0.001) were more likely to have received palliative care education; nurses with higher educational background levels (χ2=12.91, p<0.001), higher position titles (χ2=9.77, p=0.003) and longer working experience (χ2=7.92, p=0.006) were more likely to have learned about ACP; nurses with higher position titles had more access to relevant training (χ2=5.10, p=0.03). Furthermore, whether the nurse had 'heard about ACP' (B=3.113, p=0.018) and 'received training about ACP' (B=3.894, p=0.04) were both associated with their willingness to promote ACP. CONCLUSIONS The findings of this study indicated that oncology nurses were highly inclined to promote ACP, but limited by their lack of knowledge and understanding of it. Therefore, a systematic and adequate training programme about ACP for nurses is an urgent requirement to effectively enhance the implementation of ACP in China.
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Affiliation(s)
- Meng-Yan Tang
- Master's Student, School of Nursing, Sichuan University, China
| | - Xiao-Ling Li
- Professor, School of Nursing, Sichuan University; Department of Nursing, West China Hospital of Sichuan University, China
| | - Zheng-Yan Shi
- Master's Student, School of Nursing, Sichuan University, China
| | - Wen-Jing Fu
- Master's Student, School of Nursing, Sichuan University, China
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Abstract
Advance care planning (ACP) is promoted as beneficial practice internationally. This article critically examines different ways of understanding and measuring success in ACP. It has been 50 years since Luis Kutner first published his original idea of the Living Will, which was thought to be a contract between health carers and patients to provide for instructions about treatment choices in cases of mental incapacity. Its purpose was to extend a patient's right to autonomy and protect health carers from charges of wrong-doing. Yet, it can be doubtful whether different types of ACP achieve these goals rather than aiming at secondary gains. My discussion suggests that the current promotion of ACP is not always engaging critically with the original ACP intentions and may even pursue notions of success that may run contrary to respecting autonomy. The risk of this may especially be the case when high participation rates are taken as indicators of success for institutional ACP programs. I further suggest that Kutner's two original aims of protecting patient autonomy and preventing charges of wrong-doing are near impossible to achieve in conjunction, because their simultaneous pursuit fails to acknowledge that patients and carers have opposing needs for reassurance about possible judgment errors. I conclude that the most realistic idea of success of modern ACP is an acknowledgement of the importance of ongoing dialogue about what constitutes appropriate care and a diversity of aims rather than any kind of advance, contractual insurance in the face of controversy.
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Howard M, Robinson CA, McKenzie M, Fyles G, Hanvey L, Barwich D, Bernard C, Elston D, Tan A, Yeung L, Heyland DK. Effect of "Speak Up" educational tools to engage patients in advance care planning in outpatient healthcare settings: A prospective before-after study. PATIENT EDUCATION AND COUNSELING 2021; 104:709-714. [PMID: 33308881 DOI: 10.1016/j.pec.2020.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/13/2020] [Accepted: 11/23/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Tools for advance care planning (ACP) are advocated to help ensure patient values guide healthcare decisions. Evaluation of the effect of tools introduced to patients in clinical settings is needed. OBJECTIVE To evaluate the effect of the Canadian Speak Up Campaign tools on engagement in advance care planning (ACP), with patients attending outpatient clinics. Patient involvement: Patients were not involved in the problem definition or solution selection in this study but members of the public were involved in development of tools. The measurement of impacts involved patients. METHODS This was a prospective pre-post study in 15 primary care and two outpatient cancer clinics. The outcome was scores on an Advance Care Planning Engagement Survey measuring Behavior Change Process on 5-point scales and Actions (0-21-point scale) administered before and six weeks after using a tool, with reminders at two or four weeks. RESULTS 177 of 220 patients (81%) completed the study (mean 68 years of age, 16% had cancer). Mean Behavior Change Process scores were 2.9 at baseline and 3.5 at follow-up (mean change 0.6, 95% confidence interval 0.5 to 0.7; large effect size of 0.8). Mean Action Measure score was 3.7 at baseline and 4.8 at follow-up (mean change 1.1, 95% confidence interval 0.6-1.5; small effect size of 0.2). PRACTICAL VALUE Publicly available ACP tools may have utility in clinical settings to initiate ACP among patients. More time and motivation may be required to stimulate changes in patient behaviors related to ACP.
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Affiliation(s)
- Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Carole A Robinson
- School of Nursing, Thompson Rivers University, Kamloops, British Columbia, Canada.
| | - Michael McKenzie
- British Columbia Cancer Agency, Vancouver Cancer Centre, Vancouver, British Columbia, Canada.
| | - Gillian Fyles
- Division of Palliative Care, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; B.C. Centre for Palliative Care, New Westminster, British Columbia, Canada.
| | - Louise Hanvey
- Canadian Hospice Palliative Care Association, Ottawa, Ontario, Canada.
| | - Doris Barwich
- Division of Palliative Care, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; B.C. Centre for Palliative Care, New Westminster, British Columbia, Canada.
| | - Carrie Bernard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Dawn Elston
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Amy Tan
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Lorenz Yeung
- British Columbia Cancer Agency, Vancouver Cancer Centre, Vancouver, British Columbia, Canada.
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
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Dalmau-Bueno A, Saura-Lazaro A, Busquets JM, Bullich-Marín I, García-Altés A. Advance directives and real-world end-of-life clinical practice: a case-control study. BMJ Support Palliat Care 2021; 12:bmjspcare-2020-002851. [PMID: 33753359 PMCID: PMC9380474 DOI: 10.1136/bmjspcare-2020-002851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Advance directives (ADs) have been legally regulated to promote autonomy over health decisions among patients who later lose decision-making capacity. AIMS AND OBJECTIVES To analyse the differences in clinical practice at end of life among people who had completed an AD versus those who had not. METHODS Retrospective case-control study (1:2), matched by age, sex, year, cause of death and region of residence. The data sources used were the ADs registry, central registry of insured persons, hospital discharge, pharmacy and billing databases, and the mortality registry. Conditional logistic regression models (crude and adjusted by socioeconomic level) were performed. The outcome variable was the frequency of medical procedures performed during the last year of life. RESULTS 1723 people with ADs who died in Catalonia during 2014-2015 were matched with 3446 dead controls (without ADs). Thoracentesis was the procedure with the greatest reduction among women with an AD (adjusted OR (ORadj) 0.54, 95% CI: 0.32 to 0.89) in conjunction with artificial nutrition (ORadj 0.54, 95% CI: 0.31 to 0.95). Intubation was the procedure with the greatest reduction (ORadj 0.56, 95% CI: 0.33 to 0.94) among men. Slight differences could be seen in the case of cancer deaths. There were no relevant differences when adjusting by socioeconomic level. CONCLUSIONS ADs are an effective tool to adjust the realisation of some procedures at end of life. These results can help better plan for the treatment of patients with ADs, as well as increase the awareness among clinical personnel, families and the general population.
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Affiliation(s)
- Albert Dalmau-Bueno
- Catalan Health System Observatory, Agency for Health Quality and Assessment (AQuAS), Barcelona, Spain
| | | | - Josep Ma Busquets
- Ministry of Health, Government of Catalonia, Barcelona, Catalonia, Spain
| | | | - Anna García-Altés
- Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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Hasdianda MA, Gray TF, Bello JL, Ballaron B, Egorova NA, Berry DL, Ouchi K. Nurses' Perceptions of Facilitating Advance Care Planning Conversations in the Emergency Department. Palliat Med Rep 2021; 2:65-70. [PMID: 34223506 PMCID: PMC8241390 DOI: 10.1089/pmr.2020.0116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Nurses are well positioned to initiate advance care planning (ACP) conversations because of their unique strength in communication and central patient-facing role in the interdisciplinary team. Nurse-led ACP conversations have demonstrated promising results in settings outside of the emergency department (ED). Understanding ED nurses' perspectives regarding ACP conversations is needed before implementing similar practices in the ED. Objective: To explore ED nurses' perception of facilitating ACP conversations. Design: We conducted a cross-sectional survey to assess ED nurses' perceptions of facilitating ACP conversations in the ED. Setting: ED nurses at one academic hospital and one community hospital located within the northeastern region of the United States. Results: Seventy-seven (53.1%) out of 145 eligible ED nurses completed the survey. All participants perceived ACP conversations in the ED as at least somewhat important. Forty (51.9%) felt somewhat comfortable in facilitating these conversations. The majority of participants (77.9%) agreed that a specially trained nurse consultation model might be helpful in the ED. We found a correlation between total clinical experience and interest in facilitating ACP conversations in the ED (p = 0.045). Conclusion: ED nurses are well positioned to help patients clarify their goals-of-care and end-of-life care preferences. They perceived ACP conversations to be important and felt comfortable to facilitate them in the ED. Additional studies are needed to empirically test its implementation.
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Affiliation(s)
- Mohammad Adrian Hasdianda
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Josephine Lo Bello
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Brittany Ballaron
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Natasha A Egorova
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Donna L Berry
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
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Yen CC, Lin CP, Su YT, Tsu CH, Chang LM, Sun ZJ, Lin BS, Wu JS. The Characteristics and Motivations of Taiwanese People toward Advance Care Planning in Outpatient Clinics at a Community Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18062821. [PMID: 33802074 PMCID: PMC7999986 DOI: 10.3390/ijerph18062821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022]
Abstract
Advance care planning (ACP) provides access to complete advance decisions (ADs). Despite the legalization of ACP in Taiwan, it is underutilized in community settings. The objective of this study is to describe the service at a community hospital in Southern Taiwan. We retrospectively analyzed participants who were engaged in ACP consultations from January 2019 to January 2020. The characteristics, motivations, content, and satisfaction of participants are reported. Factors associated with refusing life-sustaining treatments (LST) or artificial nutrition/hydration (ANH) were analyzed using multivariate logistic regression. Of the 178 participants, 123 completed the ACP. The majority were female (64.2%), aged 61 on average and more than 80% had never signed a do-not-resuscitate order. In the ADs, most participants declined LST (97.2%) and ANH (96.6%). Family-related issues (48.9%) were the most prevalent motivations. Rural residence (OR 8.6, p = 0.005), increased age (OR 7.2, p = 0.025), and reluctance to consent to organ donation (OR 5.2, p = 0.042) correlated with refusing LST or ANH. Participants provided a positive feedback regarding overall satisfaction (good, 83%) compared to service charge (fair/poor, 53%). The study demonstrated high AD completion when refusing LST or ANH. These findings may facilitate the development of ACP as a community-based service.
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Affiliation(s)
- Chih-Chieh Yen
- Division of Hematology/Oncology, Department of Internal Medicine, Douliou Branch, National Cheng Kung University Hospital, Yunlin 640, Taiwan;
- Institute of Clinical Medicine, School of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Cheng-Pei Lin
- Institute of Community Health Care, School of Nursing, National Yang Ming Chiao Tung University, Taipei 112, Taiwan;
| | - Yu-Ting Su
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
| | - Chiu-Hua Tsu
- Department of Social Work, Douliou Branch, National Cheng Kung University Hospital, Yunlin 640, Taiwan;
| | - Li-Mei Chang
- Department of Nursing, Douliou Branch, National Cheng Kung University Hospital, Yunlin 640, Taiwan;
| | - Zih-Jie Sun
- Division of Family Medicine, Department of Internal Medicine, Douliou Branch, National Cheng Kung University Hospital, Yunlin 640, Taiwan; (Z.-J.S.); (B.-S.L.)
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Bing-Sheng Lin
- Division of Family Medicine, Department of Internal Medicine, Douliou Branch, National Cheng Kung University Hospital, Yunlin 640, Taiwan; (Z.-J.S.); (B.-S.L.)
| | - Jin-Shang Wu
- Division of Family Medicine, Department of Internal Medicine, Douliou Branch, National Cheng Kung University Hospital, Yunlin 640, Taiwan; (Z.-J.S.); (B.-S.L.)
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Correspondence:
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Advance Care Planning in Asia: A Systematic Narrative Review of Healthcare Professionals’ Knowledge, Attitude, and Experience. J Am Med Dir Assoc 2021; 22:349.e1-349.e28. [DOI: 10.1016/j.jamda.2020.12.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/09/2020] [Accepted: 12/09/2020] [Indexed: 11/18/2022]
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Bouttell J, Gonzalez N, Geue C, Lightbody CJ, Taylor DR. Cost impact of introducing a treatment escalation/limitation plan during patients' last hospital admission before death. Int J Qual Health Care 2020; 32:694-700. [PMID: 33210722 DOI: 10.1093/intqhc/mzaa132] [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: 05/26/2020] [Revised: 08/31/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE A recent study found that the use of a treatment escalation/limitation plan (TELP) was associated with a significant reduction in non-beneficial interventions (NBIs) and harms in patients admitted acutely who subsequently died. We quantify the economic benefit of the use of a TELP. DESIGN NBIs were micro-costed. Mean costs for patients with a TELP were compared to patients without a TELP using generalized linear model regression, and results were extrapolated to the Scottish population. SETTING Medical, surgical and intensive care units of district general hospital in Scotland, UK. PARTICIPANTS Two hundred and eighty-seven consecutive patients who died over 3 months in 2017. Of these, death was 'expected' in 245 (85.4%) using Gold Standards Framework criteria. INTERVENTION Treatment escalation/limitation plan. MAIN OUTCOME MEASURE Between-group difference in estimated mean cost of NBIs. RESULTS The group with a TELP (n = 152) had a mean reduction in hospital costs due to NBIs of GB £220.29 (US $;281.97) compared to those without a TELP (n = 132) (95% confidence intervals GB £323.31 (US $413.84) to GB £117.27 (US $150.11), P = <0.001). Assuming that a TELP could be put in place for all expected deaths in Scottish hospitals, the potential annual saving would be GB £2.4 million (US $3.1 million) from having a TELP in place for all 'expected' deaths in hospital. CONCLUSIONS The use of a TELP in an acute hospital setting may result in a reduction in costs attributable to NBIs.
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Affiliation(s)
- Janet Bouttell
- University of Glasgow, Institute of Health and Wellbeing, Health Economics and Health Technology Assessment, Glasgow, Scotland, UK
| | - Nelson Gonzalez
- Western University Canada and London Health Sciences Center London, Ontario, Canada UK
| | - Claudia Geue
- University of Glasgow, Institute of Health and Wellbeing, Health Economics and Health Technology Assessment, Glasgow, Scotland, UK
| | - Calvin J Lightbody
- University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, Scotland, UK
| | - Douglas Robin Taylor
- University Hospital Wishaw, NHS Lanarkshire, Wishaw, Scotland, UK.,Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, UK
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Callahan K, Kitko L, Van Scoy LJ, Hollenbeak CS. Do-not-resuscitate orders and readmission among elderly patients with heart failure in Pennsylvania: An observational study, 2011 - 2014. Heart Lung 2020; 49:812-816. [PMID: 33010520 DOI: 10.1016/j.hrtlng.2020.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 09/03/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Readmissions for patients with heart failure (HF) continues to be a target of value-based purchasing initiatives. Do-not-resuscitate (DNR) orders-one part of advance care planning (ACP)-have been shown to be related to other patient outcomes but has not been explored as a risk factor for HF readmission. OBJECTIVES Examine the association between DNR and 30-day readmissions among elderly patients with HF admitted to hospitals in Pennsylvania. METHODS Data included hospital discharges from 2011 to 2014 of patients 65+ years with a primary diagnosis of HF. Logistic regression was used to model the relationship between DNR and 30-day readmission. RESULTS Among 107,806 patients, 20.9% were readmitted within 30 days. After controlling for covariates, patients with HF who had a DNR were less likely to be readmitted to the hospital (OR=0.85, 95% CI: 0.80-0.91, p<0.001). CONCLUSIONS Documentation of a DNR may inform efforts to reduce readmissions among elderly patients with HF.
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Affiliation(s)
- Katherine Callahan
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, 604E Donald H. Ford Building, University Park, PA 16802 United States.
| | - Lisa Kitko
- School of Nursing, The Pennsylvania State University, University Park, PA, United States
| | - Lauren J Van Scoy
- Department of Pulmonary Medicine, College of Medicine, The Pennsylvania State University, Hershey, PA, United States
| | - Christopher S Hollenbeak
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, 604E Donald H. Ford Building, University Park, PA 16802 United States
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McMahan RD, Tellez I, Sudore RL. Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review. J Am Geriatr Soc 2020; 69:234-244. [PMID: 32894787 DOI: 10.1111/jgs.16801] [Citation(s) in RCA: 207] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVES Advance care planning (ACP) has shown benefit in some, but not all, studies. It is important to understand the utility of ACP. We conducted a scoping review to identify promising interventions and outcomes. DESIGN Scoping review. MEASUREMENTS We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for ACP randomized controlled trials from January 1, 2010, to March 3, 2020. We used standardized Preferred Reporting Items for Systematic Review and Meta-Analyses methods to chart study characteristics, including a standardized ACP Outcome Framework: Process (e.g., readiness), Action (e.g., communication), Quality of Care (e.g., satisfaction), Health Status (e.g., anxiety), and Healthcare Utilization. Differences between arms of P < .05 were deemed positive. RESULTS Of 1,464 articles, 69 met eligibility; 94% were rated high quality. There were variable definitions, age criteria (≥18 to ≥80 years), diseases (e.g., dementia and cancer), and settings (e.g., outpatient and inpatient). Interventions included facilitated discussions (42%), video only (20%), interactive, multimedia (17%), written only (12%), and clinician training (9%). For written only, 75% of primary outcomes were positive, as were 69% for multimedia programs; 67% for facilitated discussions, 59% for video only, and 57% for clinician training. Overall, 72% of Process and 86% of Action outcomes were positive. For Quality of Care, 88% of outcomes were positive for patient-surrogate/clinician congruence, 100% for patients/surrogate/clinician satisfaction with communication, and 75% for surrogate satisfaction with patients' care, but not for goal concordance. For Health Status outcomes, 100% were positive for reducing surrogate/clinician distress, but not for patient quality of life. Healthcare Utilization data were mixed. CONCLUSION ACP is complex, and trial characteristics were heterogeneous. Outcomes for all ACP interventions were predominantly positive, as were Process and Action outcomes. Although some Quality of Care and Health Status outcomes were mixed, increased patient/surrogate satisfaction with communication and care and decreased surrogate/clinician distress were positive. Further research is needed to appropriately tailor interventions and outcomes for local contexts, set appropriate expectations of ACP outcomes, and standardize across studies.
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Affiliation(s)
- Ryan D McMahan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Ismael Tellez
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
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Electronic medical orders for life-sustaining treatment in New York State: Length of stay, direct costs in an ICU setting. Palliat Support Care 2020; 17:584-589. [PMID: 30636653 DOI: 10.1017/s1478951518000822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In the United States, approximately 20% patients die annually during a hospitalization with an intensive care unit (ICU) stay. Each year, critical care costs exceed $82 billion, accounting for 13% of all inpatient hospital costs. Treatment of sepsis is listed as the most expensive condition in US hospitals, costing more than $20 billion annually. Electronic Medical Orders for Life-Sustaining Treatment (eMOLST) is a standardized documentation process used in New York State to convey patients' wishes regarding cardiopulmonary resuscitation and other life-sustaining treatments. No study to date has looked at the effect of eMOLST as an advance care planning tool on ICU and hospital costs using estimates of direct costs. The objective of our study was to investigate whether signing of eMOLST results in any reduction in length of stay and direct costs for a community-based hospital in New York State. METHOD A retrospective chart review was conducted between July 2016 and July 2017. Primary outcome measures included length of hospital stay, ICU length of stay, total direct costs, and ICU costs. Inclusion criteria were patients ≥65 years of age and admitted into the ICU with a diagnosis of sepsis. An independent samples t test was used to test for significant differences between those who had or had not completed the eMOLST form. RESULT There were no statistical differences for patients who completed or did not complete the eMOLST form on hospital's total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU. SIGNIFICANCE OF RESULTS Completing an eMOLST form did not have any effect on reducing total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU.
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Deng R, Zhang J, Chen L, Miao J, Duan J, Qiu Y, Leung D, Chan H, Lee DT. The effectiveness of a modified advance care planning programme. Nurs Ethics 2020; 27:1569-1586. [PMID: 32588743 DOI: 10.1177/0969733020922893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Frailty is a natural consequence of the aging process. With the increasing aging population in Mainland China, the quality of life and end-of-life care for frail older people need to be taken into consideration. Advance Care Planning has also been used worldwide in long-term facilities, hospitals and communities to improve the quality of end-of-life care, increase patient and family satisfaction, and reduce healthcare costs and hospital admissions in Western countries. However, it has not been practiced in China. RESEARCH OBJECTIVE This study aimed to evaluate the effectiveness of a modified Advance Care Planning intervention in certainty of end-of-life care, preferences for end-of-life care, quality of life concerns, and healthcare utilization among frail older people. RESEARCH DESIGN This study used a quasi-experimental design, with a single-blind, control group, pretest and repeated posttest approach. PARTICIPANTS AND RESEARCH CONTEXT A convenience sample of 74 participates met the eligibility criteria in each nursing home. A total of 148 frail older people were recruited in two nursing homes in Zhejiang Province, China. ETHICAL CONSIDERATIONS The study received ethical approval from the Clinical Research Ethics Committee, the Faculty of Medicine, and The Chinese University of Hong Kong, CREC Ref. No: 2016.059. FINDINGS The results indicated the Advance Care Planning programme was effective at increasing autonomy in decision making on end-of-life care issues, decreasing decision-making conflicts over end-of-life care issues, and increasing their expression about end-of-life care. DISCUSSION This study promoted the participants' autonomy and broke through the inherent custom of avoiding talking about death in China. CONCLUSION The modified Advance Care Planning intervention is effective and recommended to support the frail older people in their end-of-life care decision in Chinese society.
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Affiliation(s)
- Renli Deng
- 26451The Chinese University of Hong Kong, China
| | | | - Liuliu Chen
- 485858The Fifth Affiliated (Zhuhai) Hospital of Zunyi Medical University, China.,26451The Chinese University of Hong Kong, China
| | - Jiarui Miao
- 398625Zunyi Medical University, China.,26451The Chinese University of Hong Kong, China
| | | | - Yeyin Qiu
- 485858The Fifth Affiliated (Zhuhai) Hospital of Zunyi Medical University, China.,26451The Chinese University of Hong Kong, China
| | - Doris Leung
- 26451The Chinese University of Hong Kong, China
| | - Helen Chan
- 26451The Chinese University of Hong Kong, China
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Lakin JR, Neal BJ, Maloney FL, Paladino J, Vogeli C, Tumblin J, Vienneau M, Fromme E, Cunningham R, Block SD, Bernacki RE. A systematic intervention to improve serious illness communication in primary care: Effect on expenses at the end of life. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100431. [PMID: 32553522 DOI: 10.1016/j.hjdsi.2020.100431] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/26/2020] [Accepted: 04/29/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND At a population level, conversations between clinicians and seriously ill patients exploring patients' goals and values can drive high-value healthcare, improving patient outcomes and reducing spending. METHODS We examined the impact of a quality improvement intervention to drive better communication on total medical expenses in a high-risk care management program. We present our analysis of secondary expense outcomes from a prospective implementation trial of the Serious Illness Care Program, which includes clinician training, coaching, tools, and system interventions. We included patients who died between January 2014 and September 2016 who were selected for serious illness conversations, using the "Surprise Question," as part of implementation of the program in fourteen primary care clinics. RESULTS We evaluated 124 patients and observed no differences in total medical expenses between intervention and comparison clinic patients. When comparing patients in intervention clinics who did and did not have conversations, we observed lower average monthly expenses over the last 6 ($6297 vs. $8,876, p = 0.0363) and 3 months ($7263 vs. $11,406, p = 0.0237) of life for patients who had conversations. CONCLUSIONS Possible savings observed in this study are similar in magnitude to previous studies in advance care planning and specialty palliative care but occur earlier in the disease course and in the context of documented conversations and a comprehensive, interprofessional case management program. IMPLICATIONS Programs designed to drive more, earlier, and better serious illness communication hold the potential to reduce costs. LEVEL OF EVIDENCE Prospectively designed trial, non-randomized sample, analysis of secondary outcomes.
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Affiliation(s)
- Joshua R Lakin
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA.
| | - Brandon J Neal
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Francine L Maloney
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Christine Vogeli
- Harvard Medical School, Boston, MA, USA; Partners Healthcare, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Erik Fromme
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rebecca Cunningham
- Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachelle E Bernacki
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
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Schnakenberg R, Silies K, Berg A, Kirchner Ä, Langner H, Chuvayaran Y, Köberlein-Neu J, Haastert B, Wiese B, Meyer G, Köpke S, Hoffmann F. Study on advance care planning in care dependent community-dwelling older persons in Germany (STADPLAN): protocol of a cluster-randomised controlled trial. BMC Geriatr 2020; 20:142. [PMID: 32303198 PMCID: PMC7164271 DOI: 10.1186/s12877-020-01537-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/25/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In Germany, advance care planning (ACP) was first introduced by law in 2015. However, ACP is still uncommon in Germany and only few people have advance directive forms. This study aims to evaluate an ACP program in care dependent community-dwelling persons, compared to optimised usual care. METHODS A cluster-randomised controlled trial of 12 months duration will be conducted in 3 German study sites comparing the pretested ACP-counselling offered by trained nurses with a control group receiving optimised usual care. Using external concealed randomisation, 16 home care services each will be included in the intervention and the control group (30 participants per cluster; n = 960). Eligibility criteria for patients are: ≥60 years, somehow care dependent, adequate German language skills, assumed life-expectancy of ≥4 weeks, and cognitive ability for participation. ACP will be delivered by trained nurse facilitators of the respective home care services and communication will include proxy decision-makers. The primary endpoint will be patient activation, assessed by the Patient Activation Measure (PAM-13). Secondary endpoints include ACP-engagement, proportion of prepared advance directives, number and duration of hospitalisations, quality of life as well as depression and anxiety. Further, comprehensive economic and process evaluations will be conducted. DISCUSSION STADPLAN is the first study in Germany that assesses an adapted ACP intervention with trained nurses in home care services and the first international study focusing on cost effectiveness of ACP in community-dwelling older persons. The results will help to improve the understanding and communicating of patients' preferences regarding medical treatment and care and thereby contribute to patients' autonomy. TRIAL REGISTRATION German Clinical Trials Register: DRKS00016886 (Date of registration: 04.06.2019).
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Affiliation(s)
- Rieke Schnakenberg
- Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Katharina Silies
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Lübeck, Germany
| | - Almuth Berg
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Änne Kirchner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Henriette Langner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Yuliya Chuvayaran
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | | | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Gabriele Meyer
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Sascha Köpke
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Lübeck, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Sinclair C, Auret KA, Evans SF, Jane F, Dormer S, Wilkinson A, Greeve K, Koay MA, Brims F. Impact of a Nurse-Led Advance Care Planning Intervention on Satisfaction, Health-Related Quality of Life, and Health Care Utilization Among Patients With Severe Respiratory Disease: A Randomized Patient-Preference Trial. J Pain Symptom Manage 2020; 59:848-855. [PMID: 31790750 DOI: 10.1016/j.jpainsymman.2019.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 11/24/2022]
Abstract
CONTEXT Previous work has found that facilitated advance care planning (ACP) interventions are effective in increasing ACP uptake among patients with severe respiratory disease. OBJECTIVES The objective of this study was to investigate whether a nurse-led, facilitated ACP intervention among participants with severe respiratory disease impacts self-reported or clinical outcomes. METHODS A multicenter, open-label, patient-preference, randomized controlled trial of a nurse-led facilitated ACP intervention was performed. Outcome measures included self-report scales (health care satisfaction and EQ-5D-5L health-related quality of life at three- and six-month follow-up), 12-month mortality, and health care utilization during the final 90 days of life. RESULTS One hundred forty-nine participants were recruited across two study settings (metropolitan tertiary hospital respiratory department and rural sites) and 106 were allocated to receive the ACP intervention. There was no effect of the intervention on satisfaction with health care, health-related quality of life, or 12-month mortality rates. Among those participants who died during the follow-up period (N = 54), those allocated to the ACP intervention had significantly fewer outpatient consultations (7.51 vs. 13.6, P < 0.001). There were no changes in emergency department attendances, total hospital admissions or length of stay, or home nursing visits. Among those allocated to the ACP intervention, there was a reduced length of stay in acute hospital settings (7.76 vs. 11.5 nights, P < 0.001) and increased length of stay in palliative hospital settings (5.54 vs. 2.08, P < 0.001) during the final 90 days of life. CONCLUSION A facilitated ACP intervention among patients with severe respiratory disease did not have an impact on satisfaction, health-related quality of life, or 12-month mortality rate. Facilitated ACP may be associated with a different type of health care utilization during the end-of-life period.
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Affiliation(s)
| | | | | | - Fiona Jane
- University of Western Australia, Perth, WA, Australia
| | | | | | - Kim Greeve
- Department of Health Western Australia, Perth, WA, Australia
| | - M Audrey Koay
- Department of Health Western Australia, Perth, WA, Australia
| | - Fraser Brims
- Sir Charles Gairdner Hospital, Perth, WA, Australia
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Yun YH, Kang E, Park S, Koh SJ, Oh HS, Keam B, Do YR, Chang WJ, Jeong HS, Nam EM, Jung KH, Kim HR, Choo J, Lee J, Sim JA. Efficacy of a Decision Aid Consisting of a Video and Booklet on Advance Care Planning for Advanced Cancer Patients: Randomized Controlled Trial. J Pain Symptom Manage 2019; 58:940-948.e2. [PMID: 31442484 DOI: 10.1016/j.jpainsymman.2019.07.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 11/15/2022]
Abstract
CONTEXT Few randomized controlled trials of advance care planning (ACP) with a decision aid (DA) show an effect on patient preferences for end-of-life (EOL) care over time, especially in racial/ethnic settings outside the U.S. OBJECTIVES The objective of this study was to examine the effect of a decision aid consisting of a video and an ACP booklet for EOL care preferences among patients with advanced cancer. METHODS Using a computer-generated sequence, we randomly assigned (1:1) patients with advanced cancer to a group that received a video and workbook that both discussed either ACP (intervention group) or cancer pain control (control group). At baseline, immediately after intervention, and at 7 weeks, we evaluated the subjects' preferences. The primary outcome was preference for EOL care (active treatment, life-prolonging treatment, or hospice care) on the assumption of a fatal disease diagnosis and the expectation of death 1) within 1 year, 2) within several months, and 3) within a few weeks. We used Bonferroni correction methods for multiple comparisons with an adjusted P level of 0.005. RESULTS From August 2017 to February 2018, we screened 287 eligible patients, of whom 204 were enrolled to the intervention (104 patients) or the control (100 patients). At postintervention, the intervention group showed a significant increase in preference for active treatment, life-prolonging treatment, and hospice care on the assumption of a fatal disease diagnosis and the expectation of death within 1 year (P < 0.005). Assuming a life expectancy of several months, the change in preferences was significant for active treatment and hospice care (P < 0.005) but not for life-prolonging treatment. The intervention group showed a significant increase in preference for active treatment, life-prolonging treatment, and hospice care on the assumption of a fatal disease diagnosis and the expectation of death within a few weeks (P < 0.005). From baseline to 7 weeks, the decrease in preference in the intervention group was not significant for active treatment, life-prolonging treatment, and hospice care in the intervention group in the subset expecting to die within 1 year, compared with the control group. Assuming a life expectancy of several months and a few weeks, the change in preferences was not significant for active treatment and for life-prolonging treatment but was significantly greater for hospice care in the intervention group (P < 0.005). CONCLUSION ACP interventions that included a video and an accompanying book improved preferences for EOL care.
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Affiliation(s)
- Young Ho Yun
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, South Korea; Department of Family Medicine, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea.
| | - EunKyo Kang
- Department of Family Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Sohee Park
- Department of Biostatics, Graduate School of Public Health, Yonsei University, Seoul, South Korea
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, South Korea
| | - Ho-Suk Oh
- Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Young Rok Do
- Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea
| | - Won Jin Chang
- Division of Hemato-Oncology, Department of Internal medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hyun Sik Jeong
- Department of Internal Medicine, G Sam Hospital, Gunpo, South Korea
| | - Eun Mi Nam
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hak Ro Kim
- Department of Hematology and Oncology, Pohang Semyeng Christianity Hospital, Pohang, Kyeongbuk, South Korea
| | - Jiyeon Choo
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, South Korea
| | - Jihye Lee
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin-Ah Sim
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
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Douglas SL, Daly BJ, Meropol NJ, Lipson AR. Patient-physician discordance in goals of care for patients with advanced cancer. ACTA ACUST UNITED AC 2019; 26:370-379. [PMID: 31896935 DOI: 10.3747/co.26.5431] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background Shared decision-making at end of life (eol) requires discussions about goals of care and prioritization of length of life compared with quality of life. The purpose of the present study was to describe patient and oncologist discordance with respect to goals of care and to explore possible predictors of discordance. Methods Patients with metastatic cancer and their oncologists completed an interview at study enrolment and every 3 months thereafter until the death of the patient or the end of the study period (15 months). All interviewees used a 100-point visual analog scale to represent their current goals of care, with quality of life (scored as 0) and survival (scored as 100) serving as anchors. Discordance was defined as an absolute difference between patient and oncologist goals of care of 40 points or more. Results The study enrolled 378 patients and 11 oncologists. At baseline, 24% discordance was observed, and for patients who survived, discordance was 24% at their last interview. For patients who died, discordance was 28% at the last interview before death, with discordance having been 70% at enrolment. Dissatisfaction with eol care was reported by 23% of the caregivers for patients with discordance at baseline and by 8% of the caregivers for patients who had no discordance (p = 0.049; ϕ = 0.20). Conclusions The data indicate the presence of significant ongoing oncologist-patient discordance with respect to goals of care. Early use of a simple visual analog scale to assess goals of care can inform the oncologist about the patient's goals and lead to delivery of care that is aligned with patient goals.
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Affiliation(s)
- S L Douglas
- Case Comprehensive Cancer Center, Cleveland, OH.,Case Western Reserve University, Cleveland, OH
| | - B J Daly
- Flatiron Health, an independent subsidiary of the Roche Group, New York, NY, U.S.A.,Case Comprehensive Cancer Center, Cleveland, OH.,Case Western Reserve University, Cleveland, OH
| | - N J Meropol
- Case Comprehensive Cancer Center, Cleveland, OH.,Case Western Reserve University, Cleveland, OH.,University Hospitals Cleveland Medical Center, Cleveland, OH.,Flatiron Health, an independent subsidiary of the Roche Group, New York, NY, U.S.A
| | - A R Lipson
- Case Comprehensive Cancer Center, Cleveland, OH
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Jayatunga W, Lewer D, Shand J, Sheringham J, Morris S, George J. Health and social care costs at the end of life: a matched analysis of linked patient records in East London. Age Ageing 2019; 49:82-87. [PMID: 31732735 DOI: 10.1093/ageing/afz137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/16/2019] [Accepted: 10/02/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND care in the final year of life accounts for 10% of inpatient hospital costs in UK. However, there has been little analysis of costs in other care settings. We investigated the publicly funded costs associated with the end of life across different health and social care settings. METHOD we performed cross-sectional analysis of linked electronic health records of residents aged over 50 in a locality in East London, UK, between 2011 and 2017. Those who died during the study period were matched to survivors on age group, sex, deprivation, number of long-term conditions and time period. Mean costs were calculated by care setting, age and months to death. RESULTS across 8,720 matched patients, the final year of life was associated with £7,450 (95% confidence interval £7,086-£7,842, P < 0.001) of additional health and care costs, 57% of which related to unplanned hospital care. Whilst costs increased sharply over the final few months of life in emergency and inpatient hospital care, in non-acute settings costs were less concentrated in this period. Patients who died at older ages had higher social care costs and lower healthcare costs than younger patients in their final year of life. CONCLUSIONS the large proportion of costs relating to unplanned hospital care suggests that end-of-life planning could direct care towards more appropriate settings and lead to system efficiencies. Death at older ages results in an increasing proportion of care costs relating to social care than to healthcare, which has implications for an ageing society.
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Affiliation(s)
- Wikum Jayatunga
- Institute of Health Informatics, University College London, London NW1 2DA, UK
| | - Dan Lewer
- Institute of Epidemiology and Health Care, University College London, London WC1E 7HB, UK
| | - Jenny Shand
- Institute of Epidemiology and Health Care, University College London, London WC1E 7HB, UK
| | - Jessica Sheringham
- Institute of Epidemiology and Health Care, University College London, London WC1E 7HB, UK
| | - Stephen Morris
- Institute of Epidemiology and Health Care, University College London, London WC1E 7HB, UK
| | - Julie George
- Institute of Health Informatics, University College London, London NW1 2DA, UK
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Lennard C. Best interest versus advance decisions to refuse treatment in advance care planning for neurodegenerative illness. ACTA ACUST UNITED AC 2019; 27:1261-1267. [PMID: 30457382 DOI: 10.12968/bjon.2018.27.21.1261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article describes the role of nurses assisting people with degenerative illness in advance care planning (ACP) for a time when they may lose decision-making capacity. It looks at the concept of advance decisions to refuse treatment (ADRT), as defined in the Mental Capacity Act 2005 , exploring the legal, ethical and philosophical ramifications of carrying out, or overriding, formerly expressed wishes of someone who has subsequently lost decision-making capacity. It uses an illustrative composite case study of an individual with Huntington's disease whose prognosis includes future deterioration in swallowing, together with consideration of whether to have or refuse a percutaneous endoscopic gastrostomy. The author, who as part of his role cares for people with neurodegenerative conditions, including Huntington's disease, discusses the difficulties and dilemmas that nurses experience with ADRTs, drawing on personal experience. He suggests that, rather than focusing on ADRTs, ACP may be most effective in preparing people and their surrogates to make real-time decisions, based on a shared understanding of the individual's values.
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Affiliation(s)
- Chris Lennard
- Registered mental health nurse, Pirton Grange Specialist Care Centre, Pirton, Worcestershire
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Ouchi K, Strout T, Haydar S, Baker O, Wang W, Bernacki R, Sudore R, Schuur JD, Schonberg MA, Block SD, Tulsky JA. Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital. JAMA Netw Open 2019; 2:e1911139. [PMID: 31517962 PMCID: PMC6745053 DOI: 10.1001/jamanetworkopen.2019.11139] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making. OBJECTIVE To determine the association of the question, "Would you be surprised if your patient died in the next one month?" (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019. EXPOSURES Treating emergency clinicians were required to answer the surprise question, "Would you be surprised if your patient died in the next one month?" in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital. MAIN OUTCOMES AND MEASURES The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality. RESULTS The full cohort included 10 737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10 157 [94.6%] white) in 16 223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P < .001). However, the diagnostic test characteristics of the surprise question were poor (sensitivity, 20%; specificity, 93%; positive predictive value, 43%; negative predictive value, 82%; accuracy, 78%; area under the receiver operating curve of the multivariable model, 0.73 [95% CI, 0.72-0.74; P < .001]). CONCLUSIONS AND RELEVANCE This study found that asking the surprise question of emergency clinicians may be a valuable tool to identify older patients in the ED with a high risk of 1-month mortality. The effect of implementing the surprise question to improve population-level health care for older adults in the ED who are seriously ill remains to be seen.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
| | - Tania Strout
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine
| | - Samir Haydar
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine
| | - Olesya Baker
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Wei Wang
- Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rachelle Bernacki
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rebecca Sudore
- Department of Medicine, University of California, San Francisco
| | - Jeremiah D. Schuur
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Susan D. Block
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Hall A, Rowland C, Grande G. How Should End-of-Life Advance Care Planning Discussions Be Implemented According to Patients and Informal Carers? A Qualitative Review of Reviews. J Pain Symptom Manage 2019; 58:311-335. [PMID: 31004772 DOI: 10.1016/j.jpainsymman.2019.04.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 11/16/2022]
Abstract
CONTEXT The goal of advance care planning (ACP) is to help ensure that the care people receive during periods of serious illness is consistent with their preferences and values. There is a lack of clear understanding about how patients and their informal carers feel ACP discussions should be implemented. OBJECTIVES The objective of this study was to synthesize literature reviews pertaining to patients' and informal carers' perspectives on ACP discussions. METHODS This is a systematic review of reviews. RESULTS We identified 55 literature reviews published between 2007 and 2018. ACP discussions were facilitated by a diverse range of formats and tools, all of which were acceptable to patients and carers. Patients and carers preferred health professionals to initiate discussions, with the relationships they had with the professionals being particularly important. There were mixed feelings about the best timing, with many people preferring to defer discussions until they perceived them to be clinically relevant. ACP was felt to bring benefits including a greater sense of peace and less worry, but it could also be disruptive and distressing. Patients and carers perceived many benefits from ACP discussions, but these may differ from the dominant narratives about ACP in health policy and may move away from the narratives of RCTs and standardization in research and practice. CONCLUSION Researchers and clinicians may need to adjust their approaches as current practices are not aligned enough with patients' and carers' preferences. Future research may need to test implementation strategies of ACP interventions to elucidate how benefits from standardization and flexibility might both be realized.
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Affiliation(s)
- Alex Hall
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC), Greater Manchester, UK.
| | - Christine Rowland
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC), Greater Manchester, UK
| | - Gunn Grande
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC), Greater Manchester, UK
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Radhakrishnan K, Van Scoy LJ, Jillapalli R, Saxena S, Kim MT. Community-based game intervention to improve South Asian Indian Americans' engagement with advanced care planning. ETHNICITY & HEALTH 2019; 24:705-723. [PMID: 28748743 DOI: 10.1080/13557858.2017.1357068] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/14/2017] [Indexed: 06/07/2023]
Abstract
Objective: Advance care planning (ACP) allows individuals to express their preferences for medical treatment in the event that they become incapable of making their own decisions. This study assessed the efficacy of a conversation game intervention for increasing South Asian Indian Americans' (SAIAs') engagement in ACP behaviors as well as the game's acceptability and cultural appropriateness among SAIAs. Design: Eligible community-dwelling SAIAs were recruited at SAIA cultural events held in central Texas during the summer of 2016. Pregame questionnaires included demographics and the 55-item ACP Engagement Survey. Played in groups of 3-5, the game consists of 17 open-ended questions that prompt discussions of end-of-life issues. After each game session, focus groups and questionnaires were used to examine the game's cultural appropriateness and self-rated conversation quality. Postintervention responses on the ACP Engagement Survey and rates of participation in ACP behaviors were collected after 3 months through phone interviews or online surveys. Data were analyzed using descriptive statistics, frequencies, and paired t-tests comparing pre/post averages at a .05 significance level. Results: Of the 47 participants, 64% were female, 62% had graduate degrees, 92% had lived in the U.S. for >10 years, 87% were first-generation immigrants, and 74% had no advance directive prior to the game. At the 3-month follow-up, 58% of participants had completed at least one ACP behavior, 42% had discussed end-of-life issues with loved ones, 15% did so with their healthcare providers, and 18% had created an advanced directive. ACP Engagement Survey scores increased significantly on all four of the process subscales by 3 months postgame. Conclusion: SAIA individuals who played a conversation game had a relatively high rate of performing ACP behaviors 3 months after the intervention. These findings suggest that conversation games may be useful tools for motivating people from minority communities to engage in ACP behaviors.
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Affiliation(s)
| | - Lauren Jodi Van Scoy
- b Medicine and Humanities , The Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Regina Jillapalli
- a School of Nursing , University of Texas - Austin , Austin , TX , USA
| | - Shubhada Saxena
- c South Asian Indian Volunteer Association (SAIVA) , Austin , TX , USA
| | - Miyong T Kim
- a School of Nursing , University of Texas - Austin , Austin , TX , USA
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Sellars M, Simpson J, Kelly H, Chung O, Nolte L, Tran J, Detering K. Volunteer Involvement in Advance Care Planning: A Scoping Review. J Pain Symptom Manage 2019; 57:1166-1175.e1. [PMID: 30853554 DOI: 10.1016/j.jpainsymman.2019.02.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 11/20/2022]
Abstract
CONTEXT Volunteer involvement may support organizations to initiate and operationalize complex interventions such as advance care planning (ACP). OBJECTIVES A scoping review was conducted to map existing research on volunteer involvement in ACP and to identify gaps in current knowledge base. METHODS We followed the PRISMA extension for Scoping Reviews (PRISMA-ScR) guidelines. The review included studies of any design reporting original research. ACP was defined as any intervention aimed at supporting people to consider and communicate their current and future health treatment goals in the context of their own preferences and values. Studies were included if they reported data relating to volunteers at any stage in the delivery of ACP. RESULTS Of 11 studies identified, nine different ACP models (initiatives to improve uptake of ACP) were described. Most of the models involved volunteers facilitating ACP conversations or advance care directive completion (n = 6); and three focused on ACP education, training, and support. However, a framework for volunteer involvement in ACP was not described; the studies often provided limited detail of the scope of volunteers' roles in ACP, and in three of the models, volunteers delivered ACP initiatives in addition to undertaking other tasks, in their primary role as a volunteer navigator. Increased frequency of ACP conversation or documentation was most commonly used to evaluate the effectiveness of the studies, with most showing a trend toward improvement. CONCLUSIONS Current literature on volunteer involvement in ACP is lacking a systematic approach to implementation. We suggest future research should focus on person-centered outcomes related to ACP to evaluate the effectiveness of volunteer involvement.
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Affiliation(s)
- Marcus Sellars
- Advance Care Planning Australia, Austin Health, Melbourne, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia.
| | - Jamie Simpson
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Helana Kelly
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Olivia Chung
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Julien Tran
- Advance Care Planning Australia, Austin Health, Melbourne, Australia
| | - Karen Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, Melbourne University, Parkville, Victoria, Australia
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