Reliability and Validity of the Traditional Chinese Version of the Advance Care Planning Engagement Survey: A Pilot Evaluation in Taiwanese Outpatients

Use of multimedia shared decision-making aids (EATING program) for improving advance care planning engagement among community-dwelling older adults with chronic diseases: A cluster randomized controlled trial

BACKGROUND

Discussing advance care planning (ACP) preferences for nasogastric tube (NG) insertion remains challenging among older adults. Multimedia decision-making aids have demonstrated potential to enhance understanding and support informed decision-making.

AIM

To evaluate the effectiveness of the EATING program (multimedia decision-making aids + traditional educational module) compared to usual care (traditional educational module alone) in improving ACP readiness on NG insertion for community older adults with chronic illness.

METHODS

A single blind, two-arm parallel cluster randomized controlled trial was conducted across four community villages in Northern Taiwan. Participants from two villages received the EATING program, while the other two villages received the usual care. Eligible criteria included community older adults aged ≥65 with at least one chronic disease who were able to provide informed consent. Exclusion criteria included hearing or visual impairments or a history of mental illness. Pre- and post-intervention outcomes, along with one-month follow-up data, were analyzed using descriptive statistics and generalized estimating equations.

RESULTS

Both groups showed significant immediate improvements in knowledge (p < 0.001), belief/behavior (p < 0.001), decision confidence (p < 0.001), and readiness for ACP (p < 0.001). The experimental group showed greater improvement, particularly in emotional response and preferences (Z = -5.51, p < 0.001), observed only in this group. Sustained effect on knowledge (B = 35.029, p < 0.001), emotional response and preferences (B = 9.342, p < 0.001), refusal NG tube insertion (Z = -2.770, p = 0.006), and likelihood of signing official documents (p = 0.035) were observed after one month.

CONCLUSION

The study highlights the potential of multimedia program to enhance NG insertion discussions among community older adults. Further qualitative investigations and cultural adaptation are recommended.

The influence of an interactive educational approach on advance care planning counseling in individuals with psychiatric disorders

BACKGROUND

In Taiwan, psychiatric patients often face premature judgments regarding cognitive impairment, emotional instability, communication barriers, or issues related to guardianship rights due to their psychiatric diagnosis. This leads to a reduction in their autonomy in healthcare decision-making. Advocacy for and experiential understanding of Advance Care Planning (ACP) among individuals with psychiatric disorders are significantly lacking. This research explores the influence of an interactive educational approach on the ACP process for psychiatric patients and whether this approach can enhance their comprehension, attitudes, and intentions regarding Advance Decisions (AD).

METHODS

To accommodate potential variances and ensure robustness in our findings, we ultimately elected to recruit 90 participants. Using a computer-generated random number generator, we conducted a randomized trial, assigning 45 individuals to the control group and an equal number to the intervention group. The control group continued with the routine self-care educational curriculum, while the intervention group, in addition to the standard curriculum, participated in bi-weekly intervention sessions for three months. This resulted in six group health education sessions, each lasting one hour. To evaluate participants' knowledge, attitudes, and intent to sign regarding ACP, the effects of group, time, and their interactions were assessed using Generalized Estimating Equations.

RESULTS

Both groups were homogeneous at baseline. Post-intervention, Knowledge improved by 3.31 points (p < 0.001) and Attitude by 4.91 points (p < 0.001). However, the increase in Intent to Sign (0.73 points, p = 0.222) was not statistically significant. The overarching findings indicate that the application of an interactive educational model significantly enhances psychiatric patients' knowledge and attitudes toward ACP, although it does not substantially impact their intention to sign.

CONCLUSIONS

Interactive education effectively enhances psychiatric patients' knowledge and attitudes toward ACP but does not significantly influence their intent to sign AD. We advocate for their empowerment in ACP discussions. This study highlights the feasibility of integrating ACP promotion into routine psychiatric care.

Measurement properties of patient-reported outcome measures for advance care planning in older people: A COSMIN systematic review

OBJECTIVES

This review provides an overview of patient-reported outcome measure (PROMs) utilized to assess the impact of advance care planning (ACP) among older adults and evaluates their psychometric properties.

METHODS

The inclusion criteria were as follows: (1) studies that targeted older adults; (2) studies using of any type of measurement tools that measure patient-reported ACP program outcomes; and (3) studies published in English or Korean. Following PRISMA guidelines, a systematic review was conducted, encompassing electronic searches across 5 databases including PubMed, EMBASE, Cochrane Library, CINHAL, and PsycINFO and manual searches of umbrella reviews on ACP interventions. General characteristics of the selected measures were extracted, and their methodological quality was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

RESULTS

Out of 19,503 studies initially identified, 74 met the inclusion criteria, reporting on a total of 202 measures. These measures were categorized into 4 domains reflecting the targets of ACP interventions: process (n = 56), action (n = 18), process and action (n = 16), quality of care (n = 63), and health status (n = 49). Despite the breadth of measures identified, none fully met all recommended psychometric properties outlined in the checklist.

SIGNIFICANCE OF RESULTS

While this review aids in the selection of measures for both practical and research purposes, it underscores the necessity for further validation of PROMs in assessing ACP outcomes in older adults, advocating for rigorous psychometric evaluations and adherence to standards like the COSMIN checklist to ensure reliable and valid data. It suggests the need for shortened versions and researcher assistance to address the challenges older adults face with self-reported PROMs and improve participation rates.

Cross-sectional survey on public attitudes and factors related to physician-assisted dying in Taiwan

OBJECTIVE

To examine the public's stance on physician-assisted dying (PAD) in Taiwan across different PAD scenarios and identify demographic and psychosocial factors associated with the levels of support.

DESIGN

Cross-sectional survey design. Independent variables included individual sociodemographic characteristics, healthcare professionals, perceived quality of life, formal caregiver experience, Patient Right to Autonomy Act (PRAA) awareness and advance care planning (ACP) preparedness.

SETTING

An online survey of the general population in Taiwan was conducted in 2022.

PARTICIPANTS

A total of 3922 Taiwanese adults who completed all survey questions.

OUTCOME MEASURES

Agreement levels with PAD in three scenarios: terminal illnesses, unbearable non-terminal pain and severe cognitive impairments. Multivariate logistic regression was used to examine agreement with each PAD scenario as separate dependent variables in the first three models and overall agreement across all scenarios as the dependent variable in the fourth model.

RESULTS

High levels of public support for PAD were observed, with 86.2% supporting PAD for terminal illnesses, 79.2% for unbearable non-terminal pain and 72.6% for severe cognitive impairments. Support for PAD was associated with factors including younger age, male gender, lack of religious affiliation, a non-healthcare professional background, employment as a formal caregiver, lack of awareness of PRAA and higher preparedness in ACP.

CONCLUSIONS

The results indicate a potential cultural shift in Taiwan towards greater emphasis on individual autonomy in end-of-life decisions. There appears to be significant public support for developing legal frameworks in favour of PAD, carefully considering the psychosocial factors that highlight the importance of individual rights in end-of-life care.

Validation of the advance care planning engagement survey in Singapore

BACKGROUND

Singapore has an ageing population. End-of-life care and advance care planning are becoming increasingly important. To assess advance care planning engagement, valid tools are required. The primary objective of the study is to validate the 15-, 9- and 4-item versions of the ACP Engagement Survey in Singapore.

METHODS

10 inpatients in a Singapore community hospital were purposively sampled for a cognitive debriefing interview on the ACP Engagement Survey. We recruited patients 21 years and older, who were able to understand and speak English, without a diagnosis of dementia, and who were not admitted under the palliative care service. Next, 150 inpatients and caregivers were recruited using convenience sampling across 2 Singapore community hospitals to complete the 15-item ACP Engagement Survey. We assessed content validity, internal consistency with Cronbach's alpha, construct validity with hypotheses testing and test-retest reliability using intraclass correlation coefficients.

RESULTS

The ACPES scores were significantly higher for those who reported yes for pre-planning activities such as making a will, making a lasting power of attorney, telling one's doctor about end-of-life care preferences, and telling family or loved ones about end-of-life care preferences. Cronbach's alpha was 0.945 for the 15-item version, 0.915 for the 9-item version, and 0.912 for the 4-item version. Intraclass correlation coefficient was 0.933 for the 15-item version, 0.938 for the 9-item version and 0.865 for the 4-item version.

CONCLUSIONS

This study provided good psychometric support for the validity of the 15-item, 9-item and 4-item versions of the ACP Engagement Survey in Singapore.

TRIAL REGISTRATION

SingHealth Centralised Institutional Review Board (CIRB) approved this study (reference 2022/2025).

Association Between Current Medical Decision-Making Participation Self-Efficacy and Advance Care Planning Engagement Among Older Adults: Baseline Findings from a Nationwide Longitudinal Cohort Study

Background and Objectives: Misconceptions of and cultural differences in aging influence older adults' medical decision-making self-efficacy and engagement in advance care planning (ACP). This study aims to investigate the association between current medical decision-making participation self-efficacy and ACP engagement among older individuals receiving home-based medical care (HBMC) in Taiwan. Design: Baseline data analysis of a nationwide cohort study. Setting and Participants: Patients aged ≥50 years who had been consistently receiving HBMC for > two months between November 2019 and December 2022 were recruited. Study recruitment took place at six hospitals and 12 community home care institutions. Measurement and Analysis: A structured questionnaire was used to collect data on sociodemographic characteristics, decision-making participation self-efficacy, and ACP engagement. Descriptive, stratified, and multivariate logistic regression analyses were performed. Results: In total, 408 HBMC recipients were enrolled (average age: 80.4 years; 55% women). The respondents reported moderate decision-making participation self-efficacy but low ACP engagement. In light of the transtheoretical model of behavior change, participants with moderate or high self-efficacy had a significantly higher chance of reaching the "contemplation stage" for ACP decisions (odds ratio or OR 4.06-27.13). Participants were more likely to reach the "preparation and action stages" for ACP decisions only when they had high self-efficacy (OR 2.76-14.73). Conclusions: Although participants with better current medical decision-making self-efficacy were more likely to contemplate ACP, many did not take action beyond appointing a medical surrogate(s). Strategies to enhance decisional self-efficacy, thereby increasing timely ACP discussions among older adults in home settings in Chinese culture, are warranted. Trial registration number: ClinicalTrials.gov Identifier is NCT04250103 which has been registered on 31st January 2020.

Psychometric Properties of the Advance Care Planning Engagement Survey-9 in Cardiovascular and Metabolic Diseases

The purpose of this study was to test the reliability and validity of the Advance Care Planning Engagement Survey-9 Korean version in patients with cardiovascular diseases or metabolic syndrome. In this cross-sectional study, data on advance care planning engagement, registration of advance directives and the intention, and sociodemographic characteristics were collected from 105 patients (mean age, 66.3 years) at 4 medical institutions. Cronbach α was used to test the reliability. Confirmatory factor analysis and independent t tests were used to test the validity. Cronbach α s for the total scale and the self-efficacy and readiness dimensions were .93, .82, and .97, respectively. In confirmatory factor analysis with 2 factors, all indices of model fit were acceptable: comparative fit index, 0.995; Tucker-Lewis index, 0.989; standardized root-mean-square residual, 0.024; root-mean-square error of approximation, 0.059; and factor loadings > 0.65. Patients who registered advance directives ( P < .001) or had the intention ( P < .001) had higher scores of the Advance Care Planning Engagement Survey-9 Korean version than their counterparts. The findings demonstrate that the Advance Care Planning Engagement Survey-9 Korean version was a reliable and valid instrument. Health care providers, including nurses, can use this instrument to assess and manage advance care planning engagement in Korean patients with cardiovascular diseases or metabolic syndrome.

Verification of the Mandarin Chinese version of Advance Care Planning Engagement Survey Scale in community-dwelling older people

BACKGROUND

Advance care planning (ACP) has become increasingly critical for older people. The Advance Care Planning Engagement Survey (ACPES) develops targeted interventions for older people by measuring ACP-related behaviours, while previous studies focus only on advance directives. Moreover, while ACPES has English and Dutch versions, it does not yet have a Mandarin Chinese version (ACPES-MC) that can be used for Chinese populations.

OBJECTIVES

To translate the ACPES into Mandarin Chinese and test its reliability and validity in community-dwelling older people with chronic diseases.

METHODS

The English version of the ACPES was translated into Mandarin Chinese using Functional Assessment of Chronic Illness Therapy. Four communities were recruited in central China (N = 450) by convenience sampling. Internal consistency and construct validity were used to evaluate the reliability and validity of the ACPES-MC.

RESULTS

The ACPES-MC consists of 34 items across five domains, with good internal consistency (0.817), with each dimension ranging from 0.606 to 0.881; exploratory factor analysis was distributed to four different factors and the total variance explained was 63.537%; and confirmatory factor analysis results showed that χ²  = 3791.131 (p < .001), χ² /df = 1.106, CFI = 0.980, IFI = 0.980, NFI = 0.827 and RMR = 0.027, indicating a good model fit to previous factor structures.

CONCLUSIONS

The ACPES-MC is an effective and reliable tool that can measure the ACP-related behaviour stage of community-dwelling older people and evaluate the effect of ACP intervention.

IMPLICATIONS FOR PRACTICE

The ACPES-MC can be used in healthcare to identify potential ACP-related behaviours in community-dwelling older people with chronic diseases, including native and ethnic Chinese, evaluate their behaviour change stages and promote the application of ACP.