Caregivers' End-of-Life Care Goals for Persons with Severe Dementia Change Over Time

Awareness of Disease Incurability Moderates the Association between Patients' Health Status and Their Treatment Preferences

BACKGROUND

With advancing illness, some patients with heart failure (HF) opt to receive life-extending treatments despite their high costs, while others choose to forgo these treatments, emphasizing cost containment. We examined the association between patients' health status and their preferences for treatment cost containment versus life extension and whether their patients' awareness of disease incurability moderated this association.

METHODS

In a prospective cohort of patients (N = 231) with advanced HF in Singapore, we assessed patients' awareness of disease incurability, health status, and treatment preferences every 4 mo for up to 4 y (up to 13 surveys). Using random effects multinomial logistic regression models, we assessed whether patients' awareness of disease incurability moderated the association between their health status and treatment preferences.

RESULTS

About half of the patients in our study lacked awareness of HF's incurability. Results from regression analyses showed that patients with better health status, as indicated by lower distress scores (odds ratio [OR] [95% confidence interval {CI}]: 0.862 [0.754, 0.985]) and greater physical well-being (1.12 [1.03, 1.21]); and who lacked awareness of their disease's incurability were more likely to prefer higher cost containment/minimal life extension treatments compared with lower cost containment/maximal life extension.

CONCLUSIONS

This study underscores the significance of patients' awareness in disease incurability in shaping the relationship between their health status and treatment preferences. Our findings emphasize the need to incorporate illness education during goals-of-care conversations with patients and the importance of revisiting these conversations frequently to accommodate changing treatment preferences.

HIGHLIGHTS

The health status of patients with advanced heart failure was associated with their treatment preferences.Patients whose health status improved and who lacked awareness of their disease's incurability were more likely to prefer higher cost containment/minimal life extension treatments.

Development and Usability of an Advance Care Planning Website (My Voice) to Empower Patients With Heart Failure and Their Caregivers: Mixed Methods Study

Background

Web-based advance care planning (ACP) interventions offer a promising solution to improve ACP engagement, but none are specifically designed to meet the needs of patients with heart failure and their caregivers.

Objective

We aimed to develop and assess the usability and acceptability of a web-based ACP decision aid called "My Voice," which is tailored for patients with heart failure and their caregivers.

Methods

This study's team and advisory board codeveloped the content for both patient and caregiver modules in "My Voice." Using a mixed methods approach, we iteratively tested usability and acceptability, incorporating feedback from patients, caregivers, and health care professionals (HCPs).

Results

We interviewed 30 participants (11 patients, 9 caregivers, and 10 HCPs). Participants found the website easy to navigate, with simple and clear content facilitating communication of patients' values and goals. They also appreciated that it allowed them to revisit their care goals periodically. The average System Usability Scale score was 74 (SD 14.8; range: 42.5-95), indicating good usability. Over 80% (8/11) of patients and 87% (7/8) of caregivers rated the website's acceptability as good or excellent. Additionally, 70% (7/10) of HCPs strongly agreed or agreed with 11 of the 15 items testing the website's acceptability.

Conclusions

"My Voice" shows promise as a tool for patients with heart failure to initiate and revisit ACP conversations with HCPs and caregivers. We will evaluate its efficacy in improving patient and caregiver outcomes in a randomized controlled trial.

Reimagining and rebranding advance care planning

Advance care planning (ACP) has traditionally aimed at ensuring that patients' end-of-life (EOL) wishes are understood and respected. However, recent literature raises concerns about its effectiveness, with many trials indicating that ACP does not significantly improve goal-concordant care, enhance quality of life or reduce healthcare costs. This is because patients' future decisions are influenced by their transient preferences due to projection bias. To remain relevant, ACP requires a radical shift in perspective, implementation and branding. First, ACP's mission must be redefined with a focus on: Educate, Share and Prepare. This perspective emphasises ongoing conversations about patient health and illness, sharing of patients' current values and goals of care and preparation for the future, rather than making definitive future decisions. Second, ACP should be integrated into routine care, normalising these discussions. Simplifying ACP processes and shifting incentives to support shared responsibility among stakeholders can enhance integration. Last, rebranding ACP as 'Advance Care Preparation' can clarify its purpose, distinguishing it from EOL planning and increasing its uptake. This rebranding ensures that ACP meets the evolving needs of patients and their families, ultimately enhancing the quality of care and patient satisfaction. These changes in perspective, implementation and branding can transform ACP into a valuable tool for delivering compassionate, patient-centred healthcare, making it relevant to all individuals.

Prognostic understanding among advanced heart failure patients and their caregivers: A longitudinal dyadic study

OBJECTIVES

To examine heart failure patients' and caregivers' prognostic understanding (PU) over time, and patient and caregiver factors associated with their own and each other's PU.

METHODS

We used longitudinal dyadic data from Singapore, involving surveys with 95 heart failure patient-caregiver dyads every 4 months for up to 4 years. We assessed the association of PU with patient health status, caregiver psychological distress and caregiving hours using random effects multinomial logistic models, controlling for patient and caregiver characteristics.

RESULTS

At baseline, half of patients and caregivers reported correct PU. Patient and caregiver variables were associated with their own and each other's PU. Patients with poorer functional well-being were less likely to report correct PU [Average Marginal Effects (95 % CI) 0.008 (0.002, 0.015)] versus incorrect PU. Greater caregiver psychological distress was associated with a lower likelihood of caregivers reporting a correct PU [- 0.008 (-0.014, -0.002)]. Higher caregiving hours reduced the likelihood of patients reporting correct [- 0.002 (-0.003, -0.001)] and increased the likelihood of patients reporting uncertain [0.001 (0, 0.002)] PU.

CONCLUSIONS

We found PU among patients and caregivers was influenced by their own and each other's experience. Our findings highlight the importance of ongoing communication to enhance PU of patients and caregivers.

Caregivers' Burden and Anticipatory Grief Increases Acute Health Care Use in Older Adults with Severe Dementia

OBJECTIVES

To assess the bidirectional association of caregivers' burden and anticipatory grief with acute health care use (inpatient or emergency admission) among older adults with severe dementia.

DESIGN

Prospective cohort.

SETTING AND PARTICIPANTS

A total of 215 family caregivers of older adults with severe dementia in Singapore were surveyed every 4 months for 3 years (up to 10 surveys). We measured caregiver burden using the Caregiver Reaction Assessment scale and anticipatory grief using the Marwit Meuser Caregiver Grief Inventory-Short Form.

METHODS

Using separate multivariable mixed-effects logistic regressions, controlling for relevant confounders, we assessed the association of caregiver burden and anticipatory grief (independent variables measured at time t) with older adults' acute health care use in the next 4 months (outcome measured at time t + 1). We also performed separate multivariable mixed-effects linear regressions to assess the association of older adults' acute health care use in the past 4 months (independent variable measured at time t) with caregiver burden and anticipatory grief (outcomes measured at time t).

RESULTS

At baseline, 33% of the older adults had an inpatient or emergency admission in the past 4 months. Regression results showed that higher caregiver burden [odds ratio (OR), 1.58; 95% CI, 1.15-2.16] and anticipatory grief (OR, 1.02; 95% CI, 1.00-1.04) significantly increased the likelihood of older adults experiencing acute health care use in the next 4 months. However, older adults' acute health care use in the past 4 months did not significantly change their caregivers' burden or anticipatory grief.

CONCLUSIONS AND IMPLICATIONS

Higher caregiver burden and anticipatory grief increase the likelihood of older adults having acute health care use. Addressing caregivers' well-being has implications for reducing acute health care use in older adults and the economic burden of severe dementia.