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Abstract
Background: Despite documented benefits of Advance Care Planning (ACP), it is still under-utilized in the U.S. Our study aimed to examine whether experiencing a loved one's death is associated with one's own ACP behavior among adults in the U.S. and the potential moderating effect of age. Method: Using a nationwide cross-sectional survey design with probability sampling weights, our study included 1006 adults in the U.S. who participated in and completed the Survey on Aging and End-of-Life Medical Care. Three binary logistic regression models were established to investigate the relationship between death exposure and different aspects of ACP (i.e., informal conversations with family members and doctors and formal advance directives completion). The moderation analysis was subsequently conducted to examine moderating effects of age. Results: The exposure to a loved one's death was significantly associated with higher odds of having conversations with family about end-of-life medical care preferences among the 3 indicators of ACP (OR = 2.03, P < .001). Age significantly moderated the association between death exposure and ACP conversations with doctors (OR = .98, P = .017). The facilitation effect of death exposure on informal ACP engagement in discussing end-of-life medical wishes with doctors is stronger among younger adults than older adults. Conclusions: Exploring an individual's previous experience with a loved one's death might be an effective way to broach the concept of ACP among adults of all ages. This strategy may be particularly useful in facilitating discussions of end-of-life medical wishes with doctors among younger adults than older adults.
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Affiliation(s)
- Peiyuan Zhang
- University of Maryland School of Social Work, Baltimore, MD, USA
| | - Sarah Clem
- University of Maryland School of Social Work, Baltimore, MD, USA
| | - Roderick Rose
- University of Maryland School of Social Work, Baltimore, MD, USA
| | - John G Cagle
- University of Maryland School of Social Work, Baltimore, MD, USA
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2
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Hasegawa T, Okuyama T, Akechi T. The trajectory of prognostic cognition in patients with advanced cancer: is the traditional advance care planning approach desirable for patients? Jpn J Clin Oncol 2024; 54:507-515. [PMID: 38336476 DOI: 10.1093/jjco/hyae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/15/2024] [Indexed: 02/12/2024] Open
Abstract
Most patients with advanced cancer initially express a desire to be informed of their prognosis, and prognostic discussions between patients and their oncologists can trigger the subsequent trajectory of prognostic cognitions. On the continuum of prognostic cognition, including inaccurate/accurate prognostic awareness (awareness of incurability of cancer, terminal nature of illness or life expectancy) and prognostic acceptance (accepting one's prognosis), patients' perceptions of being informed of their prognosis by oncologists and patients' coping strategy for serious medical conditions regulate prognostic cognitions. However, nearly half of the patients with advanced cancer have poor prognostic awareness, and few patients achieve prognostic acceptance. These phenomena partly act as barriers to participation in advance care planning. When oncologists engage in advance care planning conversations, they must assess the patient's prognostic cognition and readiness for advance care planning. Considering the inaccurate prognostic awareness in a non-negligible proportion of patients and that astatic patients' preferences for future treatment and care are influenced by prognostic cognition, more research on decision-making support processes for high-quality and goal-concordant end-of-life care is needed along with research of advance care planning. In addition to making decisions regarding future medical treatment and care, oncologists must engage in continuous and dynamic goal-of-care conversations with empathic communication skills and compassion from diagnosis to end-of-life care.
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Affiliation(s)
- Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Toru Okuyama
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Department of Psychiatry/Palliative Care Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Tatsuo Akechi
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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3
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Song MK, Higgins MK, Ward SE, Lee H, Noorani N, Happ MB. Measures of Patient and Surrogate Preparedness for End-of-Life Decision-Making. J Pain Symptom Manage 2024; 67:429-440.e2. [PMID: 38355069 PMCID: PMC11032227 DOI: 10.1016/j.jpainsymman.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/16/2024]
Abstract
CONTEXT Reliable and valid measures are critical in accurately assessing outcomes of advance care planning interventions (ACP) for end-of-life (EOL) decision-making. OBJECTIVES To develop measures of preparedness for EOL decision-making for patients with end-stage renal disease and their surrogates (an exemplar population). METHODS In this 3-phase study, Phases 1 and 2 included a cross-discipline concept analysis of the preparedness construct, item generation for patient and surrogate scales (82 items), evaluation of content validity and readability, cognitive interviewing, and item reduction. In phase 3, the retained 26 patient and 25 surrogate items were administered to 426 patients and 426 surrogates during a multisite trial of an ACP intervention versus care-as-usual and evaluated internal consistency, 2-week test-retest reliability, and construct validity. RESULTS Scales were reduced to 20 patient and 19 surrogate items during phase 3. Cronbach's alphas were 0.86 (patient) and 0.90 (surrogate). There was a strong correlation between preparedness at baseline and two weeks for both scales (r = 0.66-0.69, P < 0.001). Confirmatory factor analysis and item-response analyses suggested unidimensionality. A significant correlation was shown between patient preparedness and patient decisional conflict (r = -0.53, P < 0.001), and surrogate preparedness and surrogate decision-making confidence (r = 0.44, P < 0.001). Among those who received the ACP intervention, the effect size of change was medium: Cohen's d = 0.54, P < 0.001 for patients and d = 0.57, P < 0.001 for surrogates. CONCLUSIONS The preparedness scales demonstrated strong psychometric properties. Future studies should examine scale performance in other populations.
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Affiliation(s)
- Mi-Kyung Song
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA.
| | - Melinda K Higgins
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA
| | - Sandra E Ward
- School of Nursing (S.E.W.), University of Wisconsin-Madison, Signe Skott Cooper Hall, 701 Highland Avenue, Madison, WI 53705, USA
| | - Haerim Lee
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA
| | - Naziya Noorani
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA
| | - Mary Beth Happ
- College of Nursing (M.B.H.), The Ohio State University, 1577 Neil Ave, Columbus, OH 43210, USA
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Swiderski D, Taniguchi RN, Chuang E. Are Safety-Net Primary Care Physicians Prepared to Engage in Serious Illness Conversations? Am J Hosp Palliat Care 2024; 41:486-491. [PMID: 37533362 DOI: 10.1177/10499091231190354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Advance Care Planning (ACP) has not reliably improved care for patients at end-of-life. Serious Illness Conversations when patients are in the late stages of chronic illness might be more effective to address patients' goals. The Serious Illness Conversation (SIC) Guide has been helpful but was not developed for use in safety-net settings serving racial and ethnic minority populations. METHODS Physicians were recruited to complete a needs assessment survey prior to training in the use of the SIC Guide. RESULTS Of the 44 physician participants, most were female (82%) and white, non-Hispanic (62%). Less than half of respondents rated themselves as skilled or very skilled in basic serious illness communication related tasks such as setting up goals of care discussions (44%), assessing informational preferences (42%), sharing prognosis (38%), exploring goals for future care (49%) and managing family dynamics (44%). Respondents reported lower skill levels in conducting goals of care conversations via telehealth and establishing trust in racially discordant provider/patient pairs. CONCLUSIONS Most participants expressed the need for further training in critical end-of-life communications skills, including help with encounters with racial and/or language discordance. This may help to explain the failure of ACP discussions to reliably result in appropriate end-of-life care.
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Affiliation(s)
| | | | - Elizabeth Chuang
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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Wood GJ, Clepp RK, Lee J, Twaddle ML, Ogunseitan A, Neagle J, Szmuilowicz E. Outcomes of a Multi-Site Mentored Implementation Approach to Promoting Goals of Care Conversations. J Pain Symptom Manage 2024:S0885-3924(24)00744-9. [PMID: 38697406 DOI: 10.1016/j.jpainsymman.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/20/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
CONTEXT The Preference-Aligned Communication and Treatment (PACT) Project is a multi-site quality improvement effort that has been shown to increase the frequency of goals of care (GOC) conversations in hospitalized patients with serious illness. OBJECTIVES To evaluate the effect of PACT on goal-discordant care and resource utilization. METHODS Hospitals enrolled in a multi-year mentored implementation quality improvement initiative to facilitate GOC conversations for seriously ill hospitalized patients. The primary outcome was the percentage of patients with care discordant with stated preferences, assessed by comparing documented wishes to Medicare claims data for patients who were admitted to intervention units and died over the study period. Secondary outcomes evaluated end-of-life resource utilization by comparing Medicare claims data for intervention patients with propensity score-matched controls. RESULTS In the 9 hospitals included in the study, 1347 intervention group patients were compared to 4019 in the control group. Rates of discordance between wishes and care were generally low in the intervention group. Compared to the control group, patients in the intervention group had lower costs (-976.05 dollars, p=0.010), were less likely to be admitted to the ICU (OR 0.9, p=0.005), less likely to be on a ventilator or undergo CPR or cardioversion, more likely to enroll in hospice (OR 1.81, p<0.001) and had a longer hospice stay (3.35 more days, p=0.041). CONCLUSION A multi-site mentored implementation quality improvement intervention for seriously ill hospitalized patients resulted in care aligned with goals and decreased resource utilization at the end of life.
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Affiliation(s)
- Gordon J Wood
- Division of Hospital Medicine, Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Rebecca K Clepp
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Martha L Twaddle
- Northwestern Lake Forest Hospital, Palliative Medicine and Supportive Care, Lake Forest, IL, USA
| | - Adeboye Ogunseitan
- Division of Hospital Medicine, Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jayson Neagle
- Division of Hospital Medicine, Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Eytan Szmuilowicz
- Division of Hospital Medicine, Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Pollack LR, Nomitch JT, Downey L, Paul SR, Reed MJ, Uyeda AM, Kiker WA, Dotolo DG, Dzeng E, Lee RY, Engelberg RA, Kross EK. Mechanical ventilation in older adults with dementia: opportunities to promote goal-concordant care. J Pain Symptom Manage 2024:S0885-3924(24)00741-3. [PMID: 38685288 DOI: 10.1016/j.jpainsymman.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 02/07/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
CONTEXT Recent studies show increasing use of mechanical ventilation among people living with dementia. There are concerns that this trend may not be driven by patient preferences. OBJECTIVES To better understand decision-making regarding mechanical ventilation in people living with dementia. METHODS This was an electronic health record-based retrospective cohort study of older adults with dementia (n=295) hospitalized at one of two teaching hospitals between 2015 and 2019 who were supported with mechanical ventilation (n=191) or died without mechanical ventilation (n=104). Multivariable logistic regression was used to examine associations between patient characteristics and mechanical ventilation use. RESULTS The median age was 78 years (IQR 71-86), 41% were female, 28% resided in a nursing home, and 58% had clinical markers of advanced dementia (dehydration, weight loss, mobility limitations, or pressure ulcers). Among patients supported with mechanical ventilation, 70% were intubated within 24 hours of presentation, including 31% intubated before hospital arrival. Younger age, higher illness acuity, and absence of a treatment-limiting Physician Orders for Life-Sustaining Treatment document were associated with mechanical ventilation use; nursing home residence and clinical markers of advanced dementia were not. Most patients (89%) had a documented goals of care discussion (GOCD) during hospitalization. CONCLUSION Future efforts to promote goal-concordant care surrounding mechanical ventilation use for people living with dementia should involve identifying barriers to goal-concordant care in pre-hospital settings, assessing the timeliness of in-hospital GOCD, and developing strategies for in-the-moment crisis communication across settings.
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Affiliation(s)
- Lauren R Pollack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.
| | - Jamie T Nomitch
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | | | - May J Reed
- Division of Geriatric Medicine, University of Washington, Seattle, WA
| | - Alison M Uyeda
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Whitney A Kiker
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Danae G Dotolo
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Elizabeth Dzeng
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Robert Y Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
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Glover AC, Jia Z, Waybill K, Vesel T. "Life-Sustaining Treatment and Advance Care Documentation among Chinese American ICU Decedents". J Pain Symptom Manage 2024:S0885-3924(24)00700-0. [PMID: 38574875 DOI: 10.1016/j.jpainsymman.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
CONTEXT Despite being one of the fastest growing ethnic groups in the U.S., there exists a gap in how treatment preferences among Chinese Americans are expressed and enacted upon in inpatient settings. OBJECTIVES To compare the rates of advance care documentation and life-sustaining treatment between Chinese American and White American ICU decedents. METHODS In this matched retrospective decedent cohort study, we included four ICUs within a tertiary medical center located in a Chinatown neighborhood. The Chinese American cohort included adult patients during the terminal admission in the ICU with primary language identified as Chinese (Mandarin, Cantonese, Taishanese). The White American cohort was matched according to age, sex, year of death, and admitting diagnosis. RESULTS We identified 154 decedents in each cohort. Despite similar odds on admission, Chinese American decedents had higher odds of DNR completion (OR 1.82; 95%CI 0.99-3.40) and DNI completion (OR 1.81; 95%CI, 1.07-1.57) during the terminal ICU admission. Although Chinese American decedents had similar odds of intubation (aOR 0.90; 95%CI, 0.55-1.48), a higher proportion signed a DNI after intubation (41% vs 25%). Chinese American decedents also had higher odds of CPR (aOR 2.03; 95%CI, 1.03-41.6) with three Chinese American decedents receiving CPR despite a signed DNR order (12% vs 0%). CONCLUSIONS During terminal ICU admissions, Chinese American decedents were more likely to complete advance care documentation and to receive CPR than White American decedents. Changes in code status were more common for Chinese Americans after intubation. Further research is needed to understand these differences and identify opportunities for goal-concordant care.
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Affiliation(s)
- Avery Caz Glover
- Tufts University School of Medicine (A.C.G.), Boston, MA; Brandeis University (A.C.G.), Heller School for Social Policy and Management, Waltham, MA
| | - Zhimeng Jia
- Temmy Latner Centre for Palliative Care (Z.J.), Toronto, Ontario, Canada; Department of Family and Community Medicine (Z.J.), University of Toronto, Ontario, Canada; Program in Global Palliative Care (Z.J.), Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | - Kathleen Waybill
- Tufts Medical Center (K.W.), Division of Pulmonary and Critical Care, Boston, MA
| | - Tamara Vesel
- Chief, Division of Palliative Care (T.V.), Tufts Medical Center, Associate Professor, Medicine and Pediatrics, Tufts University School of Medicine, Boston, MA.
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Singh S, Jones L, Grant M, Freeland D. Federal Advance Care Planning Policy Primer - Key Aspects, Barriers, and Opportunities. Am J Hosp Palliat Care 2024; 41:348-354. [PMID: 37207663 DOI: 10.1177/10499091231175641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
Advance care planning (ACP) is a nuanced process where patients identify their goals and consider their preferences for medical care over time. Recent systematic reviews have shown mixed findings about the association of ACP with the provision of goal-concordant care, completion of advance directives, and health care utilization. Despite a lack of consistent benefit, patients and clinicians value ACP and policy makers at the state and federal level have been moving ACP policies forward. All fifty states have policies regarding advance directives, and federal policy has had important implications on promoting awareness of ACP and its corresponding legal documents such as advance directives. However, challenges to effectively incentivize and facilitate the delivery of high-quality ACP exist. This paper provides an overview of key federal policy aspects and barriers that affect ACP use including: limitations of Medicare ACP billing codes, disparities in telemedicine access, difficulties with interoperability of advance directives, and underutilization of ACP as a mandatory measure in federal programs. This paper highlights key opportunities to improve federal ACP policy. Because ACP is an essential part of high-quality care and is deeply embedded in state and federal policies, it is imperative that clinicians are knowledgeable about these issues so they may more effectively engage in ACP policy.
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Affiliation(s)
- Sarguni Singh
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - LaCinda Jones
- Senior Social Worker, Department of Veterans Affairs, Seattle, WA, USA
| | - Marian Grant
- Senior Regulatory Advisor, Coalition to Transform Advanced Care, Washington, DC, USA
| | - Deborah Freeland
- Division of Geriatric Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA
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Fischer SM, Min SJ, Kline DM, Lester K, Gozansky W, Schifeling C, Himberger J, Lopez J, Fink RM. Patient Navigator Intervention to Improve Palliative Care Outcomes for Hispanic Patients With Serious Noncancer Illness: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:384-393. [PMID: 38345793 PMCID: PMC10862271 DOI: 10.1001/jamainternmed.2023.8145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/08/2023] [Indexed: 02/15/2024]
Abstract
Importance Disparities persist across the trajectory of serious illness, including at the end of life. Patient navigation has been shown to reduce disparities and improve outcomes for underserved populations. Objective To determine the effectiveness of a lay patient navigator intervention, Apoyo con Cariño, in improving palliative care outcomes among Hispanic patients. Design, Setting, and Participants This was a multicenter randomized clinical trial that took place across academic, nonprofit, safety-net, and community health care systems in urban, rural, and mountain/frontier regions of Colorado from January 2017 to January 2021. Self-identifying Hispanic adults with serious noncancer medical illness and limited prognosis were recruited. Data were collected and analyzed from July 2022 to July 2023. Interventions Participants randomized to the intervention group received 5 home visits from a bilingual, bicultural lay patient navigator; participants randomized to control received care as usual. Both groups received culturally tailored educational materials. Investigators/outcome accessors remained blinded to participant assignment. Main Outcomes and Measures Change in score from baseline to 3 months on the Functional Assessment of Chronic Illness Therapy (FACIT) General quality of life (QOL) scale (primary outcome), Advance Care Planning (ACP) Engagement Survey, Brief Pain Inventory, Edmonton Symptom Assessment Scale, and FACIT Spiritual Well-Being subscale; at 6 months, advance directive (AD) documentation; and at 46 months or death, hospice utilization and length of stay, as well as aggressiveness of care at end of life. Results Of 209 patients enrolled (mean [SD] age, 63.6 [14.3] years; 108 [51.7%] male), 105 patients were randomized to control and 104 patients to the intervention. There were no statistically significant differences in the change in mean (SD) QOL score between the intervention and control groups (5.0 [16.5] vs 4.3 [15.5]; P = .75). Participants in the intervention group, compared with the control group, had statistically significant greater increases in mean (SD) ACP engagement (0.8 [1.3] vs 0.1 [1.4]; P < .001) and were more likely to have a documented AD (62 of 104 [59.6%] vs 28 of 105 [26.9%]; P < .001). There were no statistically significant differences in mean (SD) change in pain intensity score (0-10) between patients in the intervention group compared with control (-0.4 [2.6] vs -0.5 [2.8]; P = .79), nor pain interference (-0.2 [3.7] vs -0.4 [3.7]; P = .71). Patients receiving the intervention were more likely to be referred to hospice compared with patients receiving control (19 of 43 patients [44.2%] vs 7 of 33 patients [21.2%]; P = .04) and less likely to receive aggressive care at end of life (27 of 42 patients [64.3%] vs 28 of 33 patients [84.8%]; P = .046). Conclusion and Relevance In this randomized clinical trial, a culturally tailored patient navigator intervention did not improve QOL for patients. However, the intervention did increase ACP engagement, AD documentation, and hospice utilization in Hispanic persons with serious medical illness. Trial Registration ClinicalTrials.gov Identifier: NCT03181750.
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Affiliation(s)
- Stacy M. Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | | | | | | | | | | | | | - Joseph Lopez
- University of Colorado Health North, Fort Collins
| | - Regina M. Fink
- University of Colorado School of Medicine, Aurora
- University of Colorado College of Nursing, Aurora
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Marshall KH, Riddiford-Harland DL, Meller AE, Caplan GA, Naganathan V, Cullen J, Gonski P, Zwar NA, O’Keeffe JA, Krysinska K, Rhee JJ. Feasibility and Acceptability of Facilitated Advance Care Planning in Outpatient Clinics: A Qualitative Study of Patient and Caregivers Experiences. J Appl Gerontol 2024; 43:339-348. [PMID: 37949095 PMCID: PMC10875901 DOI: 10.1177/07334648231206742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023] Open
Abstract
Guidelines recommend advance care planning (ACP) for people with advanced illness; however, evidence supporting ACP as a component of outpatient care is lacking. We sought to establish the feasibility and acceptability of a facilitated ACP intervention for people attending tertiary outpatient clinics. Data from 20 semi-structured interviews with patient (M = 79.3 ± 7.7, 60% male) and caregiver (M = 68.1 ± 11.0, 60% female) participants recruited as part of a pragmatic, randomized controlled trial (RCT) were analyzed using qualitative descriptive methodology. Patients were randomized to intervention (e.g., facilitated support) or control (e.g., standard care). Intervention patients expressed high satisfaction, reporting the facilitated ACP session was clear, straightforward, and suited to their needs. Intervention caregivers did not report any significant concerns with the facilitated ACP process. Control participants reported greater difficulty completing ACP compared to intervention participants. Embedding facilitated ACP into tertiary outpatient care appears feasible and acceptable for people with advanced illnesses.
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Affiliation(s)
- Kate H. Marshall
- UNSW Academic General Practice Network, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Anne E. Meller
- Advance Care Planning Services, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Gideon A. Caplan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - John Cullen
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Peter Gonski
- Southcare Aged and Extended Community Care, Sutherland Hospital, Sydney, NSW, Australia
| | - Nicholas A. Zwar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Julie-Ann O’Keeffe
- Aged, Chronic Care and Rehabilitation, Sydney Local Health District, Sydney, NSW, Australia
| | - Karolina Krysinska
- Centre for Primary Health Care and Equity, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Joel J. Rhee
- UNSW Academic General Practice Network, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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11
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Wilkin K, Fang ML, Sixsmith J. Implementing advance care planning in palliative and end of life care: a scoping review of community nursing perspectives. BMC Geriatr 2024; 24:294. [PMID: 38549045 PMCID: PMC10976700 DOI: 10.1186/s12877-024-04888-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 03/13/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Advance care planninganning (ACP) is a priority within palliative care service provision. Nurses working in the community occupy an opportune role to engage with families and patients in ACP. Carers and family members of palliative patients often find ACP discussions difficult to initiate. However, community nurses caring for palliative patients can encourage these discussions, utilising the rapport and relationships they have already built with patients and families. Despite this potential, implementation barriers and facilitators continue to exist. To date, no research synthesis has captured the challenges community nurses face when implementing ACP, nor the facilitators of community nurse-led ACP. Considering this, the review question of: 'What factors contribute to or hinder ACP discussion for nurses when providing care to palliative patients?' was explored. METHOD To capture challenges and facilitators, a global qualitative scoping review was undertaken in June 2023. The Arksey and O'Malley framework for scoping reviews guided the review methodology. Six databases were searched identifying 333 records: CINAHL (16), MEDLINE (45), PUBMED (195), EMBASE (30), BJOCN (15), IJOPN (32). After de-duplication and title and abstract screening, 108 records remained. These were downloaded, hand searched (adding 5 articles) and subject to a full read. 98 were rejected, leaving a selected dataset of 15 articles. Data extracted into a data extraction chart were thematically analysed. RESULTS Three key themes were generated: 'Barriers to ACP', 'Facilitators of ACP' and 'Understanding of professional role and duty'. Key barriers were - lack of confidence, competence, role ambiguity and prognostic uncertainty. Key facilitators concerned the pertinence of the patient-practitioner relationship enabling ACP amongst nurses who had both competence and experience in ACP and/or palliative care (e.g., palliative care training). Lastly, nurses understood ACP to be part of their role, however, met challenges understanding the law surrounding this and its application processes. CONCLUSIONS This review suggests that community nurses' experience and competence are associated with the effective implementation of ACP with palliative patients. Future research is needed to develop interventions to promote ACP uptake in community settings, enable confidence building for community nurses and support higher standards of palliative care via the implementation of ACP.
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Affiliation(s)
| | - Mei Lan Fang
- School of Health Sciences, University of Dundee, Dundee, Scotland
- Urban Studies and Department of Gerontology, Simon Fraser University, Vancouver, Canada
| | - Judith Sixsmith
- School of Health Sciences, University of Dundee, Dundee, Scotland.
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12
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Rao A, Pottash M. Ethical and Moral Complexities of Left Ventricular Assist Device Deactivation: Embracing the Uncertainty. JACC Heart Fail 2024; 12:599. [PMID: 38448154 DOI: 10.1016/j.jchf.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 12/06/2023] [Indexed: 03/08/2024]
Affiliation(s)
- Anirudh Rao
- Georgetown University School of Medicine, Washington, DC, USA; MedStar Washington Hospital Center, Washington, DC, USA.
| | - Michael Pottash
- Georgetown University School of Medicine, Washington, DC, USA; MedStar Washington Hospital Center, Washington, DC, USA
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13
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Goyal P, Didomenico RJ, Pressler SJ, Ibeh C, White-Williams C, Allen LA, Gorodeski EZ. Cognitive Impairment in Heart Failure: A Heart Failure Society of America Scientific Statement. J Card Fail 2024; 30:488-504. [PMID: 38485295 DOI: 10.1016/j.cardfail.2024.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 03/19/2024]
Abstract
Cognitive impairment is common among adults with heart failure (HF), as both diseases are strongly related to advancing age and multimorbidity (including both cardiovascular and noncardiovascular conditions). Moreover, HF itself can contribute to alterations in the brain. Cognition is critical for a myriad of self-care activities that are necessary to manage HF, and it also has a major impact on prognosis; consequently, cognitive impairment has important implications for self-care, medication management, function and independence, and life expectancy. Attuned clinicians caring for patients with HF can identify clinical clues present at medical encounters that suggest cognitive impairment. When present, screening tests such as the Mini-Cog, and consideration of referral for comprehensive neurocognitive testing may be indicated. Management of cognitive impairment should focus on treatment of underlying causes of and contributors to cognitive impairment, medication management/optimization, and accommodation of deficiencies in self-care. Given its implications on care, it is important to integrate cognitive impairment into clinical decision making. Although gaps in knowledge and challenges to implementation exist, this scientific statement is intended to guide clinicians in caring for and meeting the needs of an increasingly complex and growing subpopulation of patients with HF.
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Affiliation(s)
- Parag Goyal
- Program for the Care and Study of the Aging Heart, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Robert J Didomenico
- University of Illinois Chicago College of Pharmacy, Department of Pharmacy Practice, Chicago, IL
| | | | - Chinwe Ibeh
- Columbia University Irving Medical Center, New York, NY
| | | | - Larry A Allen
- University of Colorado School of Medicine, Aurora, CO
| | - Eiran Z Gorodeski
- University Hospitals, Harrington Heart & Vascular Institute, and Case Western Reserve University School of Medicine, Cleveland, OH.
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14
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McMahan RD, Hickman SE, Sudore RL. What Clinicians and Researchers Should Know About the Evolving Field of Advance Care Planning: a Narrative Review. J Gen Intern Med 2024; 39:652-660. [PMID: 38169025 PMCID: PMC10973287 DOI: 10.1007/s11606-023-08579-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
Advance care planning (ACP) has been recognized as crucial by patients, families, and clinicians; however, different definitions and measurements have led to inconsistencies in practice and mixed evidence in the literature. This narrative review explores ACP's evolution, innovations, and outcomes using thematic analysis to synthesize data from randomized controlled trials, reviews, and editorials. Key findings include (1) ACP has evolved over the past several decades from a sole focus on code status and advance directive (AD) forms to a continuum of care planning over the life course focused on tailored preparation for patients and surrogate decision-makers and (2) ACP measurement has evolved from traditional outcome metrics, such as AD completion, to a comprehensive outcomes framework that includes behavior change theory, systems, implementation science, and a focus on surrogate outcomes. Since the recent development of an ACP consensus definition and outcomes framework, high-quality trials have reported mainly positive outcomes for interventions, especially for surrogates, which aligns with the patient desire to relieve decision-making burden for loved ones. Additionally, measurement of "clinically meaningful" ACP information, including documented goals of care discussions, is increasingly being integrated into electronic health records (EHR), and emerging, real-time assessments and natural language processing are enhancing ACP evaluation. To make things easier for patients, families, and care teams, clinicians and researchers can use and disseminate these evolved definitions; provide patients validated, easy-to-use tools that prime patients for conversations and decrease health disparities; use easy-to-access clinician training and simple scripts for interdisciplinary team members; and document patients' values and preferences in the medical record to capture clinically meaningful ACP so this information is available at the point of care. Future efforts should focus on efficient implementation, expanded reimbursement options, and seamless integration of EHR documentation to ensure ACP's continued evolution to better serve patients and their care partners.
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Affiliation(s)
- Ryan D McMahan
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Veterans Administration Medical Center, San Francisco, CA, USA.
| | - Susan E Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
- Indiana University Center for Aging Research, Regenstrief Institute Inc, Indianapolis, IN, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Veterans Administration Medical Center, San Francisco, CA, USA
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15
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Zhang P, Cagle JG. Previous Experience in Medical Decision Making and Advance Care Planning Conversations: Findings From a Nationwide Cross-Sectional Survey. Am J Hosp Palliat Care 2024; 41:281-287. [PMID: 37167438 DOI: 10.1177/10499091231174621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
Background: Despite the extensive literature on facilitating advance care planning (ACP) with patients with serious illnesses, opportunities to include surrogates or family caregivers are overlooked. The research objective was to examine whether previous medical decision-making involvement for a loved one is associated with one's own ACP conversations with family and the potential mediating effect of knowledge of a loved one's end-of-life treatment preferences. Methods: This study employed a cross-sectional design using data from the 2016 Kaiser Family Foundation/The Economist Four-Country Survey on Aging and End-of-Life Medical Care. The sample included 627 US adults who completed the survey and were involved in making medical decisions for a loved one in the past. Multiple binary logistic regression and linear regression models were established for mediation analyses. Results: Participants in our nationally derived sample were largely confident in their knowledge of a deceased loved one's end-of-life treatment preferences. 66.8% of the sample had ACP conversations with family. The involvement in a loved one's medical decision making was significantly associated with higher odds of having ACP conversations with family (OR = 1.93, P = .01), but this relationship was significantly mediated by knowledge of one's end-of-life treatment preferences (b = .31, Boot CI = .12-.49). Conclusions: Previous experience in making medical decisions for a loved one may facilitate one's own ACP behavior through knowing a loved one's end-of-life treatment preferences. Clinicians in end-of-life settings are uniquely positioned to engage family members who were involved in medical decision-making for others before in ACP.
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Affiliation(s)
- Peiyuan Zhang
- School of Social Work, University of Maryland School of Social Work, Baltimore, MD, USA
| | - John G Cagle
- School of Social Work, University of Maryland School of Social Work, Baltimore, MD, USA
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16
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Pinto Taylor E, Halpin SN, Marconi VC, Justice AC, Johnson TM, McInnes DK, Perkins MM. "Call 911 - That's my [Advance Care] Plan": Factors that Inform Advance Care Planning Conversation Readiness Among Aging Persons Living With HIV. J Appl Gerontol 2024:7334648241233377. [PMID: 38375619 DOI: 10.1177/07334648241233377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
Antiretroviral therapy has dramatically increased the lifespan of people living with HIV (PLWH), but advance care planning (ACP) and hospice services are underutilized in this population. The purpose of this study was to understand barriers and facilitators to ACP among this group. PLWH (n = 25) were recruited from an HIV Clinic at a Veterans Affairs (VA) Medical Center in Atlanta, GA to represent a range of sociodemographic characteristics and experiences. Semi-structured interviews were analyzed using thematic analysis. More than half of participants (64%) indicated not engaging in ACP. We identified four key barriers to ACP: (1) a self-image among PLWH as "survivors" (and a reluctance to think about ACP); (2) a history of mistrust and mistreatment; (3) weak social ties and a desire to avoid disclosure of HIV status; and (4) a value for self-reliance. Findings have important implications for interventions to overcome these barriers.
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Affiliation(s)
- Emily Pinto Taylor
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sean N Halpin
- RTI International, Research Triangle Park, Raleigh, NC, USA
| | - Vincent C Marconi
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Atlanta Veterans Affairs Health System, Decatur, GA, USA
| | - Amy C Justice
- Yale University School of Medicine, New Haven, CT, USA
- Veterans Affairs Medical Center, West Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Theodore M Johnson
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Birmingham-Atlanta Geriatric Research Education and Clinical Center (GRECC), Atlanta Veterans Affairs Health System, Decatur, GA, USA
| | - D Keith McInnes
- Boston University School of Public Health, Boston, MA, USA
- Veterans Affairs Medical Center, Bedford, MA, USA
| | - Molly M Perkins
- Birmingham-Atlanta Geriatric Research Education and Clinical Center (GRECC), Atlanta Veterans Affairs Health System, Decatur, GA, USA
- Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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17
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Kimpel CC, Lauderdale J, Schlundt DG, Dietrich MS, Ratcliff AC, Maxwell CA. Life-Stage and Contextual Factors of Advance Care Planning Among Older Adults With Limited Income. J Appl Gerontol 2024:7334648241230024. [PMID: 38350612 DOI: 10.1177/07334648241230024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Patient perspectives are essential to understand healthcare disparities such as low rates of advance care planning (ACP) among adults with limited income. We completed twenty semi-structured interviews using purposive and snowball sampling. Initial and final themes emerged from inductive inclusion of recurring codes and deductive application of the cumulative disadvantage theory. Four themes emerged: (1) structural, (2) life-stage, (3) social stressors and resources, and (4) individual stress responses and ACP readiness. ACP resources among participants included positive structural and social support and previous familial death experiences that were mitigated by stress avoidance and competing priorities. Structural resources and healthcare stressors should be addressed with policy and research to improve continuous healthcare participation and support early, comprehensive ACP.
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Affiliation(s)
| | | | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Mary S Dietrich
- Department of Biostatistics, Vanderbilt University Schools of Medicine and Nursing, Nashville, TN, USA
| | - Amy C Ratcliff
- Department of Infectious Diseases, Tennessee Valley Healthcare System VA, Nashville, TN, USA
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18
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Ekaireb RI, Kopecky KE. Are we measuring what matters most? ACP completion among patients undergoing gastrostomy tube placement. Am J Surg 2024:S0002-9610(24)00064-3. [PMID: 38365556 DOI: 10.1016/j.amjsurg.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/18/2024]
Affiliation(s)
- R I Ekaireb
- Department of Surgery, University of California Davis, USA
| | - K E Kopecky
- Department of Surgery, Division of Surgical Oncology, University of Alabama at Birmingham, USA.
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19
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Hasegawa T, Okuyama T, Uemura T, Matsuda Y, Otani H, Shimizu J, Horio Y, Watanabe N, Yamaguchi T, Fukuda S, Oguri T, Maeno K, Taniguchi Y, Nosaki K, Fukumitsu K, Akechi T. Elements of End-of-Life Discussions Associated With Patients' Reported Outcomes and Actual End-of-Life Care in Patients With Pretreated Lung Cancer. Oncologist 2024; 29:e282-e289. [PMID: 37669003 PMCID: PMC10836313 DOI: 10.1093/oncolo/oyad245] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/03/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND End-of-life discussions for patients with advanced cancer are internationally recommended to ensure consistency of end-of-life care with patients' values. This study examined the elements of end-of-life discussions associated with end-of-life care. MATERIALS AND METHODS We performed a prospective observational study among consecutive patients with pretreated non-small cell lung cancer after the failure of first-line chemotherapy. We asked oncologists whether they had ever discussed "prognosis," "do not attempt resuscitation," "hospice," and "preferred place of death" with a patient at baseline. The quality of life (QOL) and depressive symptoms of patients were assessed using validated questionnaires at baseline and 3 months later. The end-of-life care that patients received was investigated using medical records. Oncologists' compassion and caregivers' preferences for hospice care were also assessed using questionnaires. Multiple regression analyses were conducted to examine the association between elements of end-of-life discussions and patient-reported outcomes as well as actual end-of-life care. RESULTS We obtained 200 valid responses at baseline, 147 valid responses 3 months later, and 145 data points for medical care at the end-of-life stage. No element of the end-of-life discussion between the patient and their oncologist was significantly associated with patients' reported outcomes or actual end-of-life care. In addition, oncologists' compassion was significantly associated with improvement in both comprehensive QOL and depressive symptoms, and caregivers' preferences for hospice care and high educational level were significantly associated with hospice death. CONCLUSION Oncologist-patient alliances and caregivers' involvement in end-of-life discussions may be influential in achieving optimal end-of-life care.
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Affiliation(s)
- Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Aichi, Japan
| | - Toru Okuyama
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Aichi, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
- Department of Psychiatry/Palliative Care Center, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
| | - Takehiro Uemura
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
- Department of Thoracic Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization, Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Hiroyuki Otani
- Department of Palliative Care Team, Palliative and Supportive Care, National Hospital Organization Kyushu Cancer Center, Fukuoka, Fukuoka, Japan
- Department of Palliative Care Team, Palliative and Supportive Care, St. Mary’s Hospital, Kurume, Fukuoka, Japan
| | - Junichi Shimizu
- Department of Thoracic Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Yoshitsugu Horio
- Department of Thoracic Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Naohiro Watanabe
- Department of Thoracic Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Teppei Yamaguchi
- Department of Thoracic Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Satoshi Fukuda
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Tetsuya Oguri
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
- Department of Education and Research Center for Community Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Ken Maeno
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Yoshihiko Taniguchi
- Department of Internal Medicine, National Hospital Organization, Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Kaname Nosaki
- Department of Thoracic Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Fukuoka, Japan
- Department of Thoracic Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Kensuke Fukumitsu
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Tatsuo Akechi
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Aichi, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
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20
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Fang L, Hsiao LP, Fang SH. Intention to sign an advance directive among nephrology medical staff and its related factors. Int J Palliat Nurs 2024; 30:57-65. [PMID: 38407155 DOI: 10.12968/ijpn.2024.30.2.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND Advance care planning enables people to record their future health and care wishes and appoint someone as an advocate. An advance directive can be made in the event that a person is incapacitated, so that their wishes are still upheld. The beliefs of the nephrology team might affect patients' choices and willingness to sign an advance directive. To increase the number of dialysis patients who have signed an advance directive, it is necessary to educate the nephrology medical staff. AIM To explore the intention to sign an advance directive and its related factors among nephrology medical staff. METHODS A cross-sectional and correlational design was used. This study recruited 160 nephrology medical staff. Data were analysed by using the Statistical Package for Social Science 21.0 for Windows. FINDINGS The results found that the longer someone has worked as part of the nephology medical staff, the more knowledgeable they were about an advance directive. This led to them being more likely to want to sign an advance directive for themselves. CONCLUSION In order to improve the knowledge and awareness of advance directives among nephrology medical staff, hospital managers should provide continuing education on this topic.
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Affiliation(s)
- Li Fang
- Associate Professor, Fooyin University, Taiwan
| | - Li-Ping Hsiao
- Supervisor, Department of Nursing, Pingtung Christian Hospital, Taiwan
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21
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Moody SY, Bell CL, Lindenberger EC, Reid MC. Adaptive Care Planning: A paradigm shift. J Am Geriatr Soc 2024; 72:337-345. [PMID: 38193787 DOI: 10.1111/jgs.18731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/06/2023] [Accepted: 11/19/2023] [Indexed: 01/10/2024]
Abstract
A key challenge of implementing advance care planning lies in the fact that decisions made in advance require patients and their family members to imagine what their clinical picture will look like rather than knowing or experiencing the clinical circumstances as they unfold. Even more important is the acknowledgment of the unpredictability of a given clinical course. This type of situation requires adaptiveness and flexibility in decision-making that frequently occurs in the moment(s) triggered by changes in health state(s). We describe an alternative frameshifting approach called "Adaptive Care Planning (AdaptCP)," which features an evolving communication between physicians and patients/families with ongoing incorporation of the patient's/family's perspective. This process continues iteratively until each decision can be reached in a way that is both harmonious with the patient's/family's perspective and is consistent with medical treatment options that are actionable for the healthcare team. We include a table of tools drawn from the literature that can help clinicians when implementing AdaptCP.
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Affiliation(s)
- Sandra Y Moody
- Department of Medicine/Divisions of Hospital & Geriatrics Medicine, University of California, San Francisco, California, USA
| | - Christina L Bell
- Hawaii Permanente Medical Group, Department of Geriatric Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, USA
| | - Elizabeth C Lindenberger
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Carrington Reid
- Department of Medicine/Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York, USA
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22
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Hirayama T, Ishiki H, Yanai Y, Horiguchi S, Sugisawa A, Sato J, Kojima R, Sato K, Mizuta T, Kojima R, Udagawa R, Kojima Y, Satomi E. Feasibility of an Electronic Patient-Reported Outcome Tool for Screening Distress and Supportive Care Needs of Adolescents and Young Adults with Cancer. J Adolesc Young Adult Oncol 2024; 13:138-146. [PMID: 37252764 PMCID: PMC10890963 DOI: 10.1089/jayao.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Purpose: Although adolescent and young adult (AYA) cancer patients are digital natives and have high digital communication needs, previous studies of screening tools for AYAs have primarily used paper when measuring patient-reported outcomes (PROs). There are no reports on using an electronic PRO (ePRO) screening tool with AYAs. This study evaluated the feasibility of such a tool in clinical settings, and assessed the prevalence of AYAs' distress and supportive care needs. Methods: An ePRO tool based on the Distress Thermometer and Problem List (DTPL)-Japanese (DTPL-J) version for AYAs was implemented in a clinical setting for 3 months. To determine the prevalence of distress and need for supportive care, descriptive statistics were calculated for participant characteristics, selected items, and Distress Thermometer (DT) scores. Response rates, referral rates to an attending physician and other experts, and time required to complete PRO tools were assessed to evaluate feasibility. Results: From February to April 2022, 244 (93.8%) of 260 AYAs completed the ePRO tool based on the DTPL-J for AYAs. Based on a DT cutoff of ≥5, 65 of 244 patients (26.6%) had high distress. Worry (n = 81, 33.2%) was the most frequently selected item. Primary nurses referred 85 (32.7%) patients to an attending physician or other experts. The referral rate resulting from ePRO screening was significantly higher than that after PRO screening (χ2(1) = 17.99, p < 0.001). The average response time did not differ significantly between ePRO and PRO screening (p = 0.252). Conclusion: This study suggests the feasibility of an ePRO tool based on the DTPL-J for AYAs.
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Affiliation(s)
- Takatoshi Hirayama
- Department of Psycho-Oncology and National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Yuko Yanai
- Department of Psycho-Oncology and National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Saki Horiguchi
- Department of Nursing, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Akiko Sugisawa
- Department of Nursing, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Jun Sato
- Department of Nursing, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Ryugo Kojima
- Department of Nursing, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Kaori Sato
- Department of Nursing, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Tomoko Mizuta
- Department of Psycho-Oncology and National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Rebekah Kojima
- Department of Palliative Medicine, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Ryoko Udagawa
- Department of Pharmacy, and National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Yuki Kojima
- Department of Medical Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Eriko Satomi
- Department of Palliative Medicine, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
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23
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Barnett MD, Bennett-Leleux LJ, Guillory LA. End-of-life treatment preferences and advanced care planning among older adults. Death Stud 2024; 48:95-102. [PMID: 36931063 DOI: 10.1080/07481187.2023.2189326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
End-of-life treatment preferences (EOLTPs) refer to the amount of medical intervention an individual would wish to receive in a life-threatening scenario. This study aimed to investigate relationships between older adults' EOLTPs and advance care planning (ACP). Using archival data from two interview surveys of community-dwelling older adults (study 1 n = 331, study 2 n = 338; age 60-102), results found that a desire for less end-of-life medical intervention was associated with greater EOL discussion with physicians. This relationship was explained by greater death preparation and younger age. Older adults may use ACP to limit unwanted medical interventions.
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Affiliation(s)
- Michael D Barnett
- Department of Psychology and Counseling, The University of Texas at Tyler, Tyler, Texas, USA
| | - Lauren J Bennett-Leleux
- Deparment of Behavioral and Brain Sciences, The University of Texas at Dallas, Dallas, Texas, USA
| | - Logan A Guillory
- Department of Psychology and Counseling, The University of Texas at Tyler, Tyler, Texas, USA
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Liu X, Ho MH, Wang T, Cheung DST, Lin CC. Effectiveness of Dyadic Advance Care Planning: A Systematic Review and Meta-Analysis. J Pain Symptom Manage 2024:S0885-3924(24)00047-2. [PMID: 38272378 DOI: 10.1016/j.jpainsymman.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/04/2024] [Accepted: 01/06/2024] [Indexed: 01/27/2024]
Abstract
CONTEXT Making decisions regarding end-of-life care is particularly challenging for patients and their family caregivers. Studies have advocated that family involvement in advance care planning is important to provide goal-concordant care and to increase family caregivers' preparation for surrogate decision-making. However, there is a lack of evidence to examine the effectiveness of advance care planning using the patient-caregiver dyadic approach. OBJECTIVES To evaluate the effectiveness of dyadic advance care planning. METHODS A literature search was systematically carried out in 7 databases from inception to March 2023. All randomized controlled trials with advance care planning interventions for mentally competent adults and their family caregivers were included. Meta-analysis was conducted for available quantitative data related to end-of-life care; Otherwise, narrative syntheses were performed. RESULTS In total, 14 randomized controlled trials were included. The main contents of all interventions were summarized into five categories, namely sharing illness experience and perception, introducing knowledge about advance care planning and end-of-life care, discussing individual's/dyads' values, goals, and care preferences, addressing dyads' discordance, and providing supports to complete advance care planning behaviors. The meta-analysis showed that dyadic advance care planning had significant effects on advance directive documentation (OR = 7.58, 95% CI [1.41, 40.63], P = 0.02) and proactive communication with doctors (OR = 2.42, 95% CI [1.42, 4.12], P = 0.001). In addition, interventions may improve dyad's congruence on end-of-life care, family caregivers' confidence in surrogate decision-making, and quality of end-of-life communication. CONCLUSIONS This review supports that dyadic advance care planning is a promising approach to preparing patients and their family caregivers for end-of-life communication and decision-making. Given that this multifaceted process is influenced by multiple factors within the socio-cultural context, future studies are warranted to identify the barriers and facilitators to implement dyadic advance care planning in real-world settings.
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Affiliation(s)
- Xiaohang Liu
- School of Nursing (X.L., M.H.H., T.W., D.S.T.C., C.C.L.), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Mu-Hsing Ho
- School of Nursing (X.L., M.H.H., T.W., D.S.T.C., C.C.L.), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Tongyao Wang
- School of Nursing (X.L., M.H.H., T.W., D.S.T.C., C.C.L.), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Denise Shuk Ting Cheung
- School of Nursing (X.L., M.H.H., T.W., D.S.T.C., C.C.L.), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Chia-Chin Lin
- School of Nursing (X.L., M.H.H., T.W., D.S.T.C., C.C.L.), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong.
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Osman AD, Howell J, Yates P, Jones D, Braitberg G. Examining emergency departments practices on advance care directives and medical treatment decision making using the victorian emergency minimum dataset. Australas Emerg Care 2024:S2588-994X(24)00001-0. [PMID: 38262819 DOI: 10.1016/j.auec.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/04/2023] [Accepted: 01/06/2024] [Indexed: 01/25/2024]
Abstract
INTRODUCTION Existence of Advance Care Planning (ACP) documents including contact details of Medical Treatment Decision Makers (MTDM), are essential patient care records that support Emergency Department (ED) clinicians in implementing treatment concordant with patients' expressed wishes. Based upon previous findings, we conducted a statewide study to evaluate the performance of Victorian public hospital emergency departments on reporting of availability of records for ACP. METHOD The study is a quantitative retrospective observational comparative design based upon ED tier levels as defined by the Australasian College for Emergency Medicine (ACEM) for the calendar year 2021. RESULTS Of 1.8 million total Victorian ED attendances, 15,222 patients had an ACP alert status recorded. Of these, 7296 were aged ≥ 65 years (study group). Of the thirty-one public EDs that submitted data, 65 % were accredited and assigned a level of service tier. The presence of ACP alerts positively correlated to location, tier level, age and gender (MANOVA wilk's; p < 0.001, value=.981, F = (12, 15,300), partial ƞ2 = .006, observed power = 1.0 = 95.919). CONCLUSION The identified rate of ACP reporting is low. Strategies to improve the result include synchronising ACP (generated at different points) electronically, staff education, training and further validation of the data at the sending and receiving agencies.
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Affiliation(s)
- Abdi D Osman
- Austin Health, Emergency Department, Heidelberg, Melbourne, Australia; Victoria University, St Albans, Melbourne, Australia; University of Melbourne, Department of Critical Care, Australia.
| | - Jocelyn Howell
- Austin Health, Emergency Department, Heidelberg, Melbourne, Australia
| | - Paul Yates
- Austin Health, Emergency Department, Heidelberg, Melbourne, Australia
| | - Daryl Jones
- Austin Health, Emergency Department, Heidelberg, Melbourne, Australia
| | - George Braitberg
- Austin Health, Emergency Department, Heidelberg, Melbourne, Australia; University of Melbourne, Department of Critical Care, Australia
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Angelos P, Taylor LJ, Roggin K, Schwarze ML, Vaughan LM, Wightman SC, Sade RM. Decision-Making in Surgery. Ann Thorac Surg 2024:S0003-4975(24)00010-9. [PMID: 38242340 DOI: 10.1016/j.athoracsur.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/03/2024] [Indexed: 01/21/2024]
Abstract
Surgeons face unique challenges in perioperative decision-making and communication with patients and families. In cardiothoracic surgery, the stakes are high, life and death decisions must be made quickly, and surgeons often lack a longstanding relationship with patients and families prior to intervention. This review considers specific challenges in the preoperative period followed by those faced postoperatively. While preoperative deliberation and informed consent focus on reaching a decision between 2 or more alternative approaches, the most vexing postoperative decisions often involve the patient's discontent with the best-case outcome or how to ensure goal-concordant care when complications arise. This review explores the preoperative ethical and legal requirement for informed consent by describing the contemporary preferred method, shared decision-making. We also present a framework to optimize surgeon communication and promote patient and family engagement in the setting of high-risk surgery for older patients with serious illness. In the postoperative period the family is often tasked with deciding what to do about major complications when the patient has lost decision-making capacity. We discuss several examples and offer strategies for surgeons to navigate these challenging situations. We also explore the concepts of clinical heroism and futility in relation to communicating with patients and families about the outcomes of surgery. Persistent ethical challenges in decision-making suggest that surgeons should improve their skills in communicating with patients to better engage with them, both before and after surgery.
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Affiliation(s)
- Peter Angelos
- Department of Surgery, The University of Chicago, Chicago, Illinois; MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois
| | - Lauren J Taylor
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia; Department of Surgery, Central Virginia VA Healthcare System, Richmond, Virginia
| | - Kevin Roggin
- Division of Surgical Oncology, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Margaret L Schwarze
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Leigh M Vaughan
- Division of General Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Sean C Wightman
- Division of Thoracic Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Robert M Sade
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Tolchin DW, Rushin C, Tolchin B, Slocum C, Meyerson JL, Havercamp SM, Keeney T, Schwartz AW, Schaefer K, Ross M, Stein MA, Jones CA, Rosa WE, Brooks FA. Top Ten Tips Palliative Care Clinicians Should Know About Providing Care for People With Disabilities. J Palliat Med 2024. [PMID: 38232708 DOI: 10.1089/jpm.2023.0662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Palliative care (PC) clinicians are well poised to help people with disabilities (PWD) live well in the context of serious illness. PC prioritizes person-centered care with a focus on function, autonomy, and quality of life. This approach aligns with principles of high-quality care for PWD. An understanding of the unique experiences and needs of PWD can advance the delivery of comprehensive, equitable PC for this population. In this article, we provide 10 tips to help PC clinicians develop an informed disability lens in their approach to care.
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Affiliation(s)
- Dorothy W Tolchin
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital/MassGeneral Brigham/Harvard Medical School, Boston, Massachusetts, USA
| | | | - Ben Tolchin
- Center for Clinical Ethics, Yale New Haven Health, New Haven, Connecticut, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Chloe Slocum
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital/MassGeneral Brigham/Harvard Medical School, Boston, Massachusetts, USA
| | - Jordana L Meyerson
- Harvard Medical School, Boston, Massachusetts, USA
- Section of Geriatrics and Palliative Care, Department of Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | | | - Tamra Keeney
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrea W Schwartz
- Harvard Medical School, Boston, Massachusetts, USA
- New England Geriatric Research Education and Clinical Center, Boston Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kristen Schaefer
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Care Dimensions Hospice, Danvers, Massachusetts, USA
| | - Melissa Ross
- Ross Psychotherapy, Arlington, Massachusetts, USA
| | - Michael A Stein
- Harvard Law School, Cambridge, Massachusetts, USA
- Harvard Law School Project on Disability, Cambridge, Massachusetts, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Forrest A Brooks
- Department of Medicine, Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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Malhotra C, Huynh VA, Shafiq M, Batcagan-Abueg APM. Advance care planning and caregiver outcomes: intervention efficacy - systematic review. BMJ Support Palliat Care 2024; 13:e537-e546. [PMID: 35788465 DOI: 10.1136/spcare-2021-003488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 06/13/2022] [Indexed: 11/04/2022]
Abstract
CONTEXT Caregivers make difficult end-of-life (EOL) decisions for patients, often adversely affecting their own psychological health. Understanding whether advance care planning (ACP) interventions benefit caregivers can enable healthcare systems to use these approaches to better support them. OBJECTIVE We conducted a systematic review and meta-analysis to identify and quantify the impacts of ACP interventions on caregiver outcomes. METHODS We searched MEDLINE, Embase and Cochrane databases for English-language randomised or cluster randomised controlled trials (RCTs) published until May 2021. Two reviewers independently assessed methodological quality using the Physiotherapy Evidence-Based Database Scale. We conducted a narrative synthesis for each outcome. Difference between arms with a p value of <0.05 was considered statistically significant. RESULTS Of the 3487 titles reviewed, 35 RCTs met eligibility; 68.6% were rated high quality. Included RCTs were heterogeneous in intervention characteristics, setting and disease. Meta-analysis of 17 RCTs showed that ACP had large and significant improvement in congruence in EOL care preferences between caregivers and patients (standardised mean difference 0.73, 95% CI 0.42 to 1.05). The effect of ACP on this outcome, however, declined over time. We also found some evidence that ACP improved bereavement outcomes (three of four RCTs), satisfaction with care quality/communication (four of the six RCTs), reduced decisional conflict (two of the two RCTs) and burden (one RCT). No study showed that mental health of caregivers were adversely affected. CONCLUSION The review provides most comprehensive evidence about the efficacy of ACP on caregiver outcomes. Findings suggest some evidence of benefit of ACP on caregiver outcomes.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Vinh Anh Huynh
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Mahham Shafiq
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
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Jackson VA, Emanuel L. Navigating and Communicating about Serious Illness and End of Life. N Engl J Med 2024; 390:63-69. [PMID: 38118003 DOI: 10.1056/nejmcp2304436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Affiliation(s)
- Vicki A Jackson
- From the Department of Medicine, Division of Palliative Care and Geriatric Medicine (V.A.J.), and the Center for Aging and Serious Illness Research (V.A.J., L.E.) and Cancer Outcomes Research and Education Program (V.A.J.), the Mongan Institute, Massachusetts General Hospital, and the Harvard Medical School Center for Palliative Care (V.A.J.) - both in Boston; and the Department of Supportive Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Medical Group, Feinberg School of Medicine, Chicago (L.E.)
| | - Linda Emanuel
- From the Department of Medicine, Division of Palliative Care and Geriatric Medicine (V.A.J.), and the Center for Aging and Serious Illness Research (V.A.J., L.E.) and Cancer Outcomes Research and Education Program (V.A.J.), the Mongan Institute, Massachusetts General Hospital, and the Harvard Medical School Center for Palliative Care (V.A.J.) - both in Boston; and the Department of Supportive Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Medical Group, Feinberg School of Medicine, Chicago (L.E.)
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MacMartin M, Zhang J, Barnato A. The role of specialty palliative care interdisciplinary team members in acute care decision support: a qualitative study protocol. BMC Palliat Care 2024; 23:5. [PMID: 38166884 PMCID: PMC10763013 DOI: 10.1186/s12904-023-01328-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Specialty palliative care interdisciplinary teams (IDT) can play an important role in supporting patients and family members during acute care decision-making. Despite guidelines and evidence emphasizing decision-making support as a key domain of specialty palliative care, little is known about how decision-making support is actually implemented by specialty palliative care IDTs. This study aims to (1) describe the structure and processes of inpatient decision-making support delivered by specialty palliative care IDT, and (2) examine the perspectives of IDT members on their role in this decision-support. METHODS A team of clinician and non-clinician researchers will conduct non-participant observation ethnography at a single medical center in northern New England. The ethnography will focus on the work of IDT members in supporting decision making, particularly elements of specialty palliative care that have limited descriptions in the literature (e.g. systems and processes of care). Observations of formal and informal interactions between IDT members and clinical encounters will be conducted at one site over four months. Participants include patients, care partners, non-specialty palliative care providers, and specialty palliative care IDT members. Additionally, we will conduct semi-structured interviews with IDT members across three geographically diverse specialty palliative care teams across the United States to explore providers' first-person perspective on their roles and function in decision-making support for hospitalized patients. Field notes and transcripts from observation and interviews will be uploaded to Dedoose software for management and thematic analysis following an inductive approach. DISCUSSION To our knowledge, this will be the first observational study of the roles of interdisciplinary specialty palliative care teams. Results from this research will support further investigation into implementation of decision-making support across different types of medical teams.
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Affiliation(s)
- Meredith MacMartin
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
- Section of Palliative Care, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
| | - Jingyi Zhang
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Amber Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Section of Palliative Care, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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Song MK, Manatunga A, Plantinga L, Metzger M, Kshirsagar AV, Lea J, Abdel-Rahman EM, Jhamb M, Wu E, Englert J, Ward SE. Effectiveness of an Advance Care Planning Intervention in Adults Receiving Dialysis and Their Families: A Cluster Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2351511. [PMID: 38289604 PMCID: PMC10828909 DOI: 10.1001/jamanetworkopen.2023.51511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/26/2023] [Indexed: 02/01/2024] Open
Abstract
Importance Evidence of effectiveness of advance care planning (ACP) strategies for patients receiving dialysis and their families is needed. Objectives To test the effectiveness of an ACP intervention to prepare patients and their surrogates for end-of-life (EOL) decision-making and to improve surrogate bereavement outcomes. Design, Setting, and Participants This cluster randomized clinical trial, An Effectiveness-Implementation Trial of SPIRIT (Sharing Patients' Illness Representations to Increase Trust) in ESRD, was conducted from December 2017 to March 2023 and included 42 dialysis clinics in 5 US states (Georgia, New Mexico, North Carolina, Pennsylvania, and Virginia) randomized to provide intervention or usual care. Recruitment was from February 15, 2018, to January 31, 2022, and patient-surrogate dyads were followed up for 21 months (until January 17, 2023) or until patient death. Intervention Each clinic selected 1 or 2 health care workers (eg, nurse practitioner, registered nurse, or social worker) to conduct 45- to 60-minute ACP discussions with dyads in the clinic or remotely. After March 13, 2020 (commencement of the COVID-19 emergency declaration), all discussions were conducted remotely. An ACP summary was placed in patients' medical records. Main Outcomes and Measures The primary, 2-week preparedness outcomes were dyad congruence on EOL goals of care, patient decisional conflict, surrogate decision-making confidence, and a composite of dyad congruence and surrogate decision-making confidence. Secondary bereavement outcomes were anxiety, depression, and posttraumatic distress 3 months after patient death. To adjust for COVID-19 pandemic effects on bereavement outcomes, a variable to indicate the timing of baseline and 3-month assessment relative to the COVID-19 emergency declaration was created. Results Of the 426 dyads enrolled, 231 were in the intervention clinics, and 195 were in the control clinics. Among all dyads, the mean (SD) patient age was 61.9 (12.7) years, and the mean (SD) surrogate age was 53.7 (15.4) years. At 2 weeks, after adjusting for baseline values, dyad congruence (odds ratio [OR], 1.61; 95% CI, 1.12-2.31; P = .001), decisional conflict scores (β, -0.10; 95% CI, -0.13 to -0.07; P < .001), and the composite (OR, 1.57; 95% CI, 1.06-2.34; P = .03) were higher in the intervention group than in the control group. Surrogate decision-making confidence was similar between groups (β, 0.06; 95% CI, -0.01 to 0.13; P = .12). Among 77 bereaved surrogates, after adjusting for baseline values and assessment timing, intervention group anxiety was lower than control group anxiety (β, -1.55; 95% CI, -3.08 to -0.01; P = .05); however, depression (β, -0.18; 95% CI, -2.09 to 1.73; P = .84) and posttraumatic distress (β, -0.96; 95% CI, -7.39 to 5.46; P = .75) were similar. Conclusions and Relevance In this randomized clinical trial, the ACP intervention implemented by health care workers at dialysis centers improved preparation for EOL decision-making but showed mixed effectiveness on bereavement outcomes. The ACP intervention implemented in dialysis centers may be an effective strategy to the dyad preparation for end-of-life care as opposed to the current focus on advance directives. Trial Registration ClinicalTrials.gov Identifier: NCT03138564.
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Affiliation(s)
- Mi-Kyung Song
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Amita Manatunga
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura Plantinga
- Division of Rheumatology, Department of Medicine, University of California, San Francisco
- Division of Nephrology, Department of Medicine, University of California, San Francisco
| | | | - Abhijit V. Kshirsagar
- UNC Kidney Center, University of North Carolina at Chapel Hill School of Medicine
- Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine
| | - Janice Lea
- Division of Renal Medicine, Emory University School of Medicine, Emory University, Atlanta, Georgia
| | - Emaad M. Abdel-Rahman
- Division of Nephrology, University of Virginia School of Medicine, University of Virginia, Charlottesville
| | - Manisha Jhamb
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Emily Wu
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jacob Englert
- Rollins School of Public Health, Emory University, Atlanta, Georgia
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Dietrich CG, Schoppmeyer K. [Opportunities and risks of advance directives : An appraisal of the practice in Germany after legal regulation in 2009]. Schmerz 2024:10.1007/s00482-023-00771-0. [PMID: 38165491 DOI: 10.1007/s00482-023-00771-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Living wills/advance directives (AD) are an important tool for specifying patient wishes regarding medical care in the case of future inability to consent. Since 2009, German legislation defines framework conditions for the creation and validity of such directives in § 1901a BGB. METHODS An extensive literature search in an international and a German-language database was conducted to identify, analyze, and evaluate scientific articles on opportunities, risks, and problems in the creation and implementation of living wills. RESULTS Between 10 and 40% of patients have an AD. Among the stipulations in the AD, the demand for sufficient pain therapy is very important. However, numerous problems in the preparation and implementation of ADs reduce their value in everyday clinical practice. In particular, unclear conditions of validity, unspecific instructions for action, and lack of availability of the directives prevent practitioners from determining the patient's will. Other fundamental problems include frequent patient ambivalence and clinical ethical dissent. In addition, the framework condition of unlimited coverage set by the law carries the risk that changes of opinion in the course of life or disease are not taken into account. CONCLUSION Preparing an AD requires a high level of information, consultation, and time, as well as regular review or adjustment of its content. These factors are often not considered, thus complicating implementation and reducing the value of living wills. Possible solutions to these problems or alternative concepts for different patient settings are discussed in this review.
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Affiliation(s)
- Christoph G Dietrich
- Gastro-Praxis Wiesbaden im Medicum, Langenbeckplatz 2, 65189, Wiesbaden, Deutschland.
| | - Konrad Schoppmeyer
- Klinik für Innere Medizin II, Euregio-Klinik GmbH, Nordhorn, Deutschland, Albert-Schweitzer-Str. 10, 48527
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Kita K, Kuroda K, Saito M, Kuroda M, Ogawa D, Kuroiwa M. Family Physicians' Perspectives and Practices on Advance Care Planning in Regional Cities in Japan and the United States: A Convergent Parallel Mixed-Methods Study. Cureus 2024; 16:e53260. [PMID: 38435895 PMCID: PMC10905047 DOI: 10.7759/cureus.53260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Advance care planning (ACP) has been widely recognized and practiced worldwide since the 1990s. However, only a few studies have compared clinicians' international perceptions of and experiences with ACP. Therefore, this study explored the perceptions and practices of family physicians (FPs) regarding ACP in Japan and the United States. METHODS We conducted a convergent parallel mixed-methods study using a cross-sectional web-based anonymous questionnaire survey to examine how the perceptions and practices of ACP differ between Japanese and American FPs working in regional cities. RESULTS Responses from 20 and 19 FPs in Japan and the United States were obtained, respectively. Both FP groups received ACP training during their residency and practiced ACP with the highest regard for the patient's wishes and values. Quantitative analysis revealed that American FPs placed more emphasis on documentation and patient language skills. Qualitative analysis revealed that Japanese FPs equally emphasized communication with patients' families and with patients. We merged the results of both analyses and hypothesized that the variations in the FPs' approaches to ACP might reflect variations in their backgrounds, such as health insurance systems, cultures, and values in the two countries, rather than differences between individual physicians. CONCLUSION Our study showed that both Japanese and American FPs respect patients' wishes in ACP, with some differences in their perceptions and practices. Therefore, FPs should understand and be flexible with their patients' values and cultural backgrounds as intercultural translators while following appropriate management procedures for successful ACP.
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Affiliation(s)
- Keiichiro Kita
- General Internal Medicine, Toyama University Hospital, Toyama, JPN
| | - Kaku Kuroda
- Family Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Mayuko Saito
- General Internal Medicine, Toyama University Hospital, Toyama, JPN
| | - Moe Kuroda
- Public Health, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Daishi Ogawa
- Internal Medicine, Nanto Municipal Hospital, Nanto, JPN
| | - Maiko Kuroiwa
- General Internal Medicine, Toyama University Hospital, Toyama, JPN
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Aller A, Shirazi A, Pedell L, Altschuler A, Hauser K, Cheslock M, Wei J, Duffens A, Whitehead H, Lim P, Katzel J, Martinez F, Lin A, Aller S, Aller C, Jones T, Yen SM, Liu R. What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients. Am J Hosp Palliat Care 2023:10499091231223144. [PMID: 38112439 DOI: 10.1177/10499091231223144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care. METHODS At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified. RESULTS A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only." CONCLUSIONS Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.
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Affiliation(s)
- Ashley Aller
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Aida Shirazi
- Department of Graduate Medical Education, Kaiser Permanente Northern California, San Francisco, CA, USA
| | | | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Karen Hauser
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Megan Cheslock
- Department of Geriatrics Medicine, Edith Nourse Rogers Memorial Veterans' Hospital, Bedford, MA, USA
| | - Jenny Wei
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Ali Duffens
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Hannah Whitehead
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Peggy Lim
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Jed Katzel
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Francisco Martinez
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Amy Lin
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Steve Aller
- Department of Hematology-Oncology, Seattle Children's Hospital, Seattle, WA, USA
| | - Cynthia Aller
- Department of Hematology, Providence Regional Cancer System Lacey Cancer Clinic, Lacey, WA, USA
| | - Tyler Jones
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Sue May Yen
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Raymond Liu
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Rahemi Z, Malatyali A, Bacsu JDR, Sefcik JS, Petrovsky DV, Baker ZG, Ma KPK, Smith ML, Adams SA. Healthcare Utilization and Advance Care Planning among Older Adults Across Cognitive Levels. J Appl Gerontol 2023; 42:2294-2303. [PMID: 37525608 PMCID: PMC10828104 DOI: 10.1177/07334648231191667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
This study examined the impact of advance care planning (ACP) on healthcare utilization among older adults with normal cognition and impaired cognition/dementia. Using datasets from the Health and Retirement Study, we conducted a cross-sectional study on 17,698 participants aged 51 years and older. Our analyses included survey descriptive and logistic regression procedures. ACP measures included a living will and durable power of attorney for healthcare. Healthcare utilization was measured using the days spent in hospitals, hospice care, nursing homes, and home care. Of the participants, 77.8% had normal cognition, and 22% had impaired cognition/dementia. The proportion of impaired cognition/dementia was higher among racially minoritized participants, single/widowed participants, and those who lived alone and were less educated. The results showed that having an ACP was associated with longer stays in hospitals, nursing homes, and home healthcare in all participants.
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Affiliation(s)
- Zahra Rahemi
- School of Nursing, Clemson University, Greenville, SC, USA
| | - Ayse Malatyali
- Nursing Systems Department, College of Nursing, University of Central Florida, Orlando, FL, USA
| | | | - Justine S Sefcik
- College of Nursing and Health Professions, Drexel University College of Nursing and Health Professions, Philadelphia, PA, USA
| | - Darina V Petrovsky
- School of Nursing, Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Zachary G Baker
- Edson College of Nursing and Health Innovation, Arizona State University, Tempe, AZ, USA
| | - Kris Pui Kwan Ma
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Matthew L Smith
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Swann A Adams
- Department of Biobehavioral and Nursing Science, College of Nursing, University of South Carolina, Columbia, SC, USA
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Lim MK, Wong PS, Othman S, Mohd Mydin FH, Lim PS, Lai PSM. A Systematic Review of Non-Seriously Ill Community-Dwelling Asians' Views on Advance Care Planning. J Am Med Dir Assoc 2023; 24:1831-1842. [PMID: 37844872 DOI: 10.1016/j.jamda.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVES To systematically synthesize the views of community-dwelling Asians on Advance care planning and to summarize the factors and reasons affecting their uptake of ACP. DESIGN Mixed-methods systematic review (PROSPERO: CRD42018091033). SETTING AND PARTICIPANTS Asian adults (≥18 years old) living in the community globally. METHODS Medline (Ovid), Web of Science, CINAHL (EBSCO), Open Grey, and Google Scholar were searched from inception to June 30, 2022. Qualitative, quantitative, or mixed-methods studies reporting on the views of non-seriously ill community-dwelling Asian adults on ACP or the factors influencing their ACP uptake were included. Secondary research, studies not published in English, or studies not available as full text were excluded. Two independent teams of researchers extracted data, assessed methodologic quality, and performed the data analysis. Data analysis was conducted using the multistep convergent integrated approach based on Joanna Briggs Institute methodology for mixed-methods systematic review. RESULTS Fifty-eight studies were included. Non-seriously ill community-dwelling Asians were willing to engage in ACP (46.5%-84.4%) although their awareness (3.1%-42.9%) and uptake of ACP remained low (14.0%-53.4%). Background factors (sociodemographic factors, and health status, as well as experience and exposure to information) and underlying beliefs (attitude toward ACP, subjective norm, and perceived behavioral control) were found to affect their uptake of ACP. A conceptual framework was developed to facilitate a proper approach to ACP for this population. CONCLUSIONS AND IMPLICATIONS A flexible approach toward ACP is needed for non-seriously ill community-dwelling Asians. There is also a need to raise end-of-life and ACP literacy, and to explore ways to narrow the gap in the expectations and implementation of ACP so that trust in its effective execution can be built.
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Affiliation(s)
- Mun Kit Lim
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia; School of Pharmacy, Monash University, Selangor, Malaysia
| | - Pei Se Wong
- International Medical University, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Sajaratulnisah Othman
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Fadzilah Hanum Mohd Mydin
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Pei Shan Lim
- Anaesthetic Department, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia.
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Sharma A. Palliative Care and Care Partner Support in Neuro-oncology. Continuum (Minneap Minn) 2023; 29:1872-1895. [PMID: 38085902 DOI: 10.1212/con.0000000000001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
ABSTRACT The journey for a patient with a brain tumor and their loved ones can be extremely challenging due to the high burden of physical symptoms and the emotional distress caused by the diagnosis. Optimizing quality of life by addressing symptoms and reducing this emotional distress can improve treatment tolerance and outcomes and alleviate care partner distress and burden. Symptoms in patients with central nervous system (CNS) tumors can vary in onset and intensity, ranging from headaches, seizures, and focal weakness to emotional distress and cognitive dysfunction. Additionally, care partners may demonstrate distress due to the high burden of care and need appropriate support structures and access to resources to alleviate this stress. Evidence-based recommendations are unfortunately limited given the lack of high-quality research in this area, but patients living with CNS tumors and their loved ones can benefit from early and routine symptom identification and management, compassionate and transparent communication, and practical guidance for the future. These principles are part of palliative care, a field of medicine focused on alleviating suffering in patients with serious, chronic illness. Clinicians involved in the care of patients with CNS tumors must be educated in these important primary palliative care principles. This article focuses on key symptom management, strategies for high-quality communication, a discussion of advance care planning, and an overview of end-of-life care.
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Malhotra C. Advance care planning: It is time to rethink our goals. J Am Geriatr Soc 2023; 71:3963-3966. [PMID: 37522615 DOI: 10.1111/jgs.18511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/29/2023] [Indexed: 08/01/2023]
Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
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Arch JJ, Bright EE, Finkelstein LB, Fink RM, Mitchell JL, Andorsky DJ, Kutner JS. Anxiety and Depression in Metastatic Cancer: A Critical Review of Negative Impacts on Advance Care Planning and End-of-Life Decision Making With Practical Recommendations. JCO Oncol Pract 2023; 19:1097-1108. [PMID: 37831973 PMCID: PMC10732500 DOI: 10.1200/op.23.00287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 10/15/2023] Open
Abstract
PURPOSE Providers treating adults with advanced cancer increasingly seek to engage patients and surrogates in advance care planning (ACP) and end-of-life (EOL) decision making; however, anxiety and depression may interfere with engagement. The intersection of these two key phenomena is examined among patients with metastatic cancer and their surrogates: the need to prepare for and engage in ACP and EOL decision making and the high prevalence of anxiety and depression. METHODS Using a critical review framework, we examine the specific ways that anxiety and depression are likely to affect both ACP and EOL decision making. RESULTS The review indicates that depression is associated with reduced compliance with treatment recommendations, and high anxiety may result in avoidance of difficult discussions involved in ACP and EOL decision making. Depression and anxiety are associated with increased decisional regret in the context of cancer treatment decision making, as well as a preference for passive (not active) decision making in an intensive care unit setting. Anxiety about death in patients with advanced cancer is associated with lower rates of completion of an advance directive or discussion of EOL wishes with the oncologist. Patients with advanced cancer and elevated anxiety report higher discordance between wanted versus received life-sustaining treatments, less trust in their physicians, and less comprehension of the information communicated by their physicians. CONCLUSION Anxiety and depression are commonly elevated among adults with advanced cancer and health care surrogates, and can result in less engagement and satisfaction with ACP, cancer treatment, and EOL decisions. We offer practical strategies and sample scripts for oncology care providers to use to reduce the effects of anxiety and depression in these contexts.
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Affiliation(s)
- Joanna J. Arch
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
- Division of Cancer Prevention and Control, University of Colorado Cancer Center, Aurora, CO
| | - Emma E. Bright
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
| | - Lauren B. Finkelstein
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
| | - Regina M. Fink
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
- University of Colorado College of Nursing, Anschutz Medical Campus, Aurora, CO
| | | | | | - Jean S. Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
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Demirkapu H, Van den Block L, De Maesschalck S, De Vleminck A, Colak FZ, Devroey D. Advance care planning among older adults in Belgium with Turkish backgrounds and palliative care needs: A qualitative interview study. Eur J Gen Pract 2023; 29:2271661. [PMID: 37870049 PMCID: PMC10990253 DOI: 10.1080/13814788.2023.2271661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Data on advance care planning (ACP) among migrants in Europe is lacking. Research has shown that few older migrants in the United States perform ACP due to healthcare system distrust, collectivistic values and spirituality/religion. OBJECTIVES To explore the ACP knowledge and perspectives of older Turkish-origin adults in Belgium requiring palliative care. METHOD General practitioners (GPs) in Brussels and Antwerp recruited Turkish-origin participants aged ≥ 65 years with palliative care eligibility for this qualitative study. A GP conducted semi-structured interviews in Turkish in respondents' homes between May 2019 and February 2022 using a topic guide. Two researchers performed combined inductive/deductive thematic data analysis. RESULTS All 15 interviewees (average age, 79 years) lacked ACP awareness and information. Some had discussed specific end-of-life preferences (e.g. care location, burial place) with family. Still, many did not feel the need to discuss future healthcare preferences, due mainly to trust in God and family for caretaking and decision-making. Some respondents viewed ACP discussions as applicable, relieving the burden on family and enabling proactive addressing of 'what if' questions. Self-identified ACP barriers were fear of making wrong decisions, 'living in the moment' and difficulty discussing death. Facilitators were obtaining sufficient ACP information and recent family illness or death. CONCLUSION Our sample of Turkish-origin older adults in Belgium requiring palliative care lacked ACP knowledge. Our findings suggest that their lack of engagement in discussing end-of-life medical care planning was linked to their family dynamics and religion. The findings have implications for healthcare providers to ethnic-minority groups.
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Affiliation(s)
- Hakki Demirkapu
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels and Ghent, Belgium
| | | | - Aline De Vleminck
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels and Ghent, Belgium
| | - F. Zehra Colak
- Department of Education, University of Utrecht, Utrecht, The Netherlands
| | - Dirk Devroey
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel [VUB], Brussels, Belgium
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Chen Z, Liang N, Zhang H, Li H, Yang Y, Zong X, Chen Y, Wang Y, Shi N. Harnessing the power of clinical decision support systems: challenges and opportunities. Open Heart 2023; 10:e002432. [PMID: 38016787 PMCID: PMC10685930 DOI: 10.1136/openhrt-2023-002432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/31/2023] [Indexed: 11/30/2023] Open
Abstract
Clinical decision support systems (CDSSs) are increasingly integrated into healthcare settings to improve patient outcomes, reduce medical errors and enhance clinical efficiency by providing clinicians with evidence-based recommendations at the point of care. However, the adoption and optimisation of these systems remain a challenge. This review aims to provide an overview of the current state of CDSS, discussing their development, implementation, benefits, limitations and future directions. We also explore the potential for enhancing their effectiveness and provide an outlook for future developments in this field. There are several challenges in CDSS implementation, including data privacy concerns, system integration and clinician acceptance. While CDSS have demonstrated significant potential, their adoption and optimisation remain a challenge.
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Affiliation(s)
- Zhao Chen
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ning Liang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Haili Zhang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Huizhen Li
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yijiu Yang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xingyu Zong
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yaxin Chen
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanping Wang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Nannan Shi
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
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Rahemi Z, Malatyali A, Adams SA, Jarrín OF, Demiris G, Parker V, Anaraky RG, Dye CJ. Advance Care Planning Among Older Adults with Cognitive Impairment. Am J Hosp Palliat Care 2023; 40:1182-1189. [PMID: 36541134 PMCID: PMC10282104 DOI: 10.1177/10499091221146255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
In this study, we used data from the Health and Retirement Study (HRS) to investigate factors associated with older adults' engagement with advance care planning (ACP) across varying levels of cognitive functioning status. Our analysis used a sample of 17,698 participants in the HRS 2014 survey. Survey descriptive procedures (Proc SurveyMeans, Proc SurveyFreq) and logistic regression procedures (Proc SurveyLogistic) were used. Race, ethnicity, level of cognition, education, age, and number of chronic diseases consistently predicted ACP. Participants with lower levels of cognition were less likely to have a living will and durable power of attorney for healthcare (DPOAH). African American and Hispanic participants, younger participants, and those with lower cognition and education levels were less likely to engage in ACP. Marital status and loneliness predicted ACP engagement. Some results varied across the cognition cohorts. Our results indicated that sociodemographic status, together with health and cognitive status, has a significant role in predicting ACP. The results can provide valuable insights on ACP for older adults with or at risk of Alzheimer's disease and related dementia and other cognitive impairments, caregivers, families, and healthcare providers.
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Affiliation(s)
- Zahra Rahemi
- School of Nursing, Clemson University, Clemson, SC, USA
| | - Ayse Malatyali
- Nursing Systems Department, College of Nursing, University of Central Florida, Orlando, FL, USA
| | - Swann A. Adams
- Department of Epidemiology & Biostatistics, College of Nursing, University of South Carolina, Columbia, SC, USA
| | - Olga F. Jarrín
- School of Nursing, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - George Demiris
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Cheryl J. Dye
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
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Lee K, Kummerfeld E, Robinson E, Anderson L, Rantz M. Data-Driven Analytics to Discover APRN's Impact on Nursing Home Hospitalization: Causal Discovery Analysis. J Am Med Dir Assoc 2023; 24:1746-1754. [PMID: 37302798 DOI: 10.1016/j.jamda.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Research shows advanced practice registered nurses (APRNs) embedded in nursing homes (NHs) reduce resident hospitalizations. However, the specific APRN activities that reduce hospitalizations have not been adequately investigated. This study aims to identify the causal links between APRN activities and NHs resident hospitalization. The study also examined relationships among other variables, including advanced directives, clinical diagnosis, and length of hospitalization. DESIGN Secondary data analysis. SETTING AND PARTICIPANTS Residents of NHs participating in the Missouri Quality Initiative for Nursing Homes, 2016-2019. METHODS We performed a secondary analysis of data from the Missouri Quality Initiative for Nursing Homes Intervention using causal discovery analysis, a machine learning, data-driven technique to determine causal relationships across data. The resident roster and INTERACT resident hospitalization datasets were combined to create the final dataset. Variables in the analysis model were divided into before and after hospitalization. Expert consensus was used to validate and interpret the outcomes. RESULTS The research team analyzed 1161 hospitalization events and their associated NH activities. APRNs evaluated NH residents before a transfer, expedited follow-up nursing assessments, and authorized hospitalization when necessary. No significant causal relationships were found between APRN activities and the clinical diagnosis of a resident. The analysis also showed multifaceted relationships related to having advanced directives and duration of hospitalization. CONCLUSIONS AND IMPLICATIONS This study demonstrated the importance of APRNs embedded in NHs to improve resident outcomes. APRNs in NHs can facilitate communication and collaboration among the nursing team, leading to early identification and treatment for resident status changes. APRNs can also initiate more timely transfers by reducing the need for physician authorization. These findings emphasize the crucial role of APRNs in NHs and suggest that budgeting for APRN services may be an effective strategy to reduce hospitalizations. Additional findings regarding advance directives are discussed.
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Affiliation(s)
- Knoo Lee
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.
| | - Erich Kummerfeld
- Institute of Health Informatics, University of Minnesota, Minneapolis, MN, USA
| | - Erin Robinson
- School of Health Professions, University of Missouri, Columbia, MO, USA
| | - Linda Anderson
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Marilyn Rantz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
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Mohan D, O'Malley AJ, Chelen J, MacMartin M, Murphy M, Rudolph M, Engel JA, Barnato AE. Using a Video Game Intervention to Increase Hospitalists' Advance Care Planning Conversations with Older Adults: a Stepped Wedge Randomized Clinical Trial. J Gen Intern Med 2023; 38:3224-3234. [PMID: 37429972 PMCID: PMC10651818 DOI: 10.1007/s11606-023-08297-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 06/16/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Guidelines recommend Advance Care Planning (ACP) for seriously ill older adults to increase the patient-centeredness of end-of-life care. Few interventions target the inpatient setting. OBJECTIVE To test the effect of a novel physician-directed intervention on ACP conversations in the inpatient setting. DESIGN Stepped wedge cluster-randomized design with five 1-month steps (October 2020-February 2021), and 3-month extensions at each end. SETTING A total of 35/125 hospitals staffed by a nationwide physician practice with an existing quality improvement initiative to increase ACP (enhanced usual care). PARTICIPANTS Physicians employed for ≥ 6 months at these hospitals; patients aged ≥ 65 years they treated between July 2020-May 2021. INTERVENTION Greater than or equal to 2 h of exposure to a theory-based video game designed to increase autonomous motivation for ACP; enhanced usual care. MAIN MEASURE ACP billing (data abstractors blinded to intervention status). RESULTS A total of 163/319 (52%) invited, eligible hospitalists consented to participate, 161 (98%) responded, and 132 (81%) completed all tasks. Physicians' mean age was 40 (SD 7); most were male (76%), Asian (52%), and reported playing the game for ≥ 2 h (81%). These physicians treated 44,235 eligible patients over the entire study period. Most patients (57%) were ≥ 75; 15% had COVID. ACP billing decreased between the pre- and post-intervention periods (26% v. 21%). After adjustment, the homogeneous effect of the game on ACP billing was non-significant (OR 0.96; 95% CI 0.88-1.06; p = 0.42). There was effect modification by step (p < 0.001), with the game associated with increased billing in steps 1-3 (OR 1.03 [step 1]; OR 1.15 [step 2]; OR 1.13 [step 3]) and decreased billing in steps 4-5 (OR 0.66 [step 4]; OR 0.95 [step 5]). CONCLUSIONS When added to enhanced usual care, a novel video game intervention had no clear effect on ACP billing, but variation across steps of the trial raised concerns about confounding from secular trends (i.e., COVID). TRIAL REGISTRATION Clinicaltrials.gov; NCT04557930, 9/21/2020.
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Affiliation(s)
- Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Room 638 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - A James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice and Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Julia Chelen
- Advanced Communications Research Group, National Institute of Standards and Technology, U.S. Department of Commerce, Boulder, CO, USA
| | - Meredith MacMartin
- Department of Medicine and The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Megan Murphy
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - Jaclyn A Engel
- Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice and Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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Quail P, Keller H, Vucea V, Heckman G, Sasan M, Boscart V, Ramsey C, Garland A. A Qualitative Study of Nursing Home Staff Lived Experience With Advance Care Planning. J Am Med Dir Assoc 2023; 24:1761-1766. [PMID: 37536660 DOI: 10.1016/j.jamda.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE Advance care planning (ACP) within nursing homes (NHs) is an integral component of resident-centered care yet remains an ongoing area for improvement. This study explored health care providers' experiences when facilitating ACP discussions with residents and their families. DESIGN Interpretive description was used to explore meanings and generate knowledge that is applicable for clinical contexts. SETTING AND PARTICIPANTS A purposive sample of 27 staff members (2 directors of care, 3 assistant directors of care, 1 nurse practitioner, 11 registered nurses, 3 registered practical nurses, and 7 social workers) from 29 NHs located across 3 Canadian provinces that participated in cluster-randomized intervention study to improve ACP. METHODS Semistructured interviews were conducted between January and July 2020. Interpretive description methods were used for analysis. RESULTS Three themes were identified. "Navigating Relational Tensions During ACP with Families" captures the relational tensions that participants experienced while navigating ACP processes with residents and their families. The second theme, "Where's the Doctor?" highlights the general lack of physician involvement in ACP discussions and the subsequent pressures faced by participants when supporting residents and families. The last theme, "Crises Change the Best Laid Plans," illustrates the challenges participants face when trying to adhere to existing care plans during residents' medical crises. CONCLUSION AND IMPLICATIONS Participants' experiences indicate that current ACP processes in NHs do not meet the needs of residents, families, or care teams. Additional support from physicians and changes to structural processes are needed to support resident-centered end-of-life planning within this care context.
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Affiliation(s)
- Patrick Quail
- Department of Family Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada.
| | - Heather Keller
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Vanessa Vucea
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - George Heckman
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Mehar Sasan
- McMaster University, Hamilton, Ontario, Canada
| | - Veronique Boscart
- Conestoga College, Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Clare Ramsey
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allan Garland
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Redelmeier DA, Namakian S. The Planning Fallacy in Patients With Chronic Lung Disease. JAMA Netw Open 2023; 6:e2343988. [PMID: 37988081 DOI: 10.1001/jamanetworkopen.2023.43988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Affiliation(s)
- Donald A Redelmeier
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences in Ontario
- Centre for Quality Improvement & Patient Safety, Sunnybrook, Toronto, Ontario, Canada
| | - Shina Namakian
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Carter C, Mohammed S, Upshur R, Kontos P. "I don't see the whole picture of their health": a critical ethnography of constraints to interprofessional collaboration in end-of-life conversations in primary care. BMC Prim Care 2023; 24:225. [PMID: 37898764 PMCID: PMC10612350 DOI: 10.1186/s12875-023-02171-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/04/2023] [Indexed: 10/30/2023]
Abstract
CONTEXT Interprofessional collaboration is recommended in caring for frail older adults in primary care, yet little is known about how interprofessional teams approach end-of-life (EOL) conversations with these patients. OBJECTIVE To understand the factors shaping nurses' and allied health clinicians' involvement, or lack of involvement in EOL conversations in the primary care of frail older adults. METHODS/SETTING A critical ethnography of a large interprofessional urban Family Health Team in Ontario, Canada. Data production included observations of clinicians in their day-to-day activities excluding direct patient care; one-to-one semi-structured interviews with clinicians; and document review. Analysis involved coding data using an interprofessional collaboration framework as well as an analysis of the normative logics influencing practice. PARTICIPANTS Interprofessional clinicians (n = 20) who cared for mildly to severely frail patients (Clinical Frailty Scale) at the Family Health Team. RESULTS Findings suggest primary care nurses and allied health clinicians have the knowledge, skills, and inclination to engage frail older adults in EOL conversations. However, the culture of the clinic prioritizes biomedical care, and normalizes nurses and allied health clinicians providing episodic task-based care, which limits the possibility for these clinicians' engagement in EOL conversations. The barriers to nurses' and allied health clinicians' involvement in EOL conversations are rooted in neoliberal-biomedical ideologies that shapes the way primary care is governed and practiced. CONCLUSIONS Our findings help to explain why taking an individual-level approach to addressing the challenge of delayed or avoided EOL conversations, is unlikely to result in practice change. Instead, primary care teams can work to critique and redevelop quality indicators and funding models in ways that promote meaningful interprofessional practice that recognize the expertise of nursing and allied health clinicians in providing high quality primary care to frail older patients, including EOL conversations.
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Affiliation(s)
- Celina Carter
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Ross Upshur
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Pia Kontos
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
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Lin CP, Chiang CH, Sheu SJ. Using the Kipling method to explore the contextual factors of decision-making during advance care planning for older cancer patients, their family, and health-care professionals: A qualitative secondary analysis. Palliat Support Care 2023:1-7. [PMID: 37859416 DOI: 10.1017/s1478951523001256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
OBJECTIVES Advance care planning (ACP) interventions are supposed to affect patients' autonomy and family health-care outcomes positively. However, the clinical benefits of ACP actualization and associated contextual factors merit questioning. Therefore, this study explores the critical contextual and procedural factors related to ACP decision-making based on the actual situation of older patients with cancer encountering end-of-life care in Taiwan. METHODS This retrospective qualitative secondary analysis used the Kipling method (5W1H) to explore further the critical contextual and procedural factors related to ACP decision-making processes. We applied thematic analysis and dual coding for 35 narratives, including 10 patients with cancer, 10 family caregivers, and 15 health-care staff, derived from a preliminary qualitative study regarding palliative care decision-making among patients with advanced cancer, their families, and health-care staff. RESULTS We identified 6 domains detailing the contextual factors for ACP decision-making: (1) WHO (decision makers); (2) WHAT (discussion content); (3) WHEN (care plan for which disease stage); (4) WHERE (patient's situational location); (5) WHY (reasons underpinning the decisions); and (6) HOW (the way to form the decisions). SIGNIFICANCE OF RESULTS Using the Kipling method to elaborate the contextual factors for ACP decision-making among older patients with cancer strengthens the understanding of complicated end-of-life care decision-making procedure. This study also demonstrates the dynamic and cultural complexity and the various factors considered during end-of-life care and future ACP discussion.
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Affiliation(s)
- Cheng-Pei Lin
- Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London, London, UK
| | - Chia-Hsuan Chiang
- Department of Nursing, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shuh-Jen Sheu
- Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
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50
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Liu X, Wang T, Cheung DST, Chau PH, Ho MH, Han Y, Lin CC. Dyadic advance care planning: systematic review of patient-caregiver interventions and effects. BMJ Support Palliat Care 2023:spcare-2023-004430. [PMID: 37857471 DOI: 10.1136/spcare-2023-004430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/29/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Family caregiver's involvement in advance care planning (ACP) is essential to provide high-quality end-of-life (EOL) care and to ease the surrogate decision-making burden. However, no systematic review has focused on existing ACP interventions involving patients and their families. AIM To systematically summarise current ACP interventions involving patients and their families. METHODS Five English and two Chinese databases were searched from inception to September 2022. The eligible studies were experimental studies describing original data. The Joanna Briggs Institute critical appraisal tools assessed the methodological quality. Narrative synthesis was conducted for data analysis. RESULTS In total, twenty-eight articles were included. Fifteen studies were randomised controlled trials, and the rest 13 studies were quasi-experimental studies. The data synthesis identified: (1) Key intervention components: strategies to promote ACP, ACP discussion and follow-up, as well as the role of family caregivers; (2) Effects on intended outcomes: interventions have shown benefit on completion of ACP actions, while inconsistent findings were found on the process outcomes and quality of EOL care. In addition, a logic model for patient-caregiver dyadic ACP was created, and the underlying mechanisms of action included well-preparation, open discussion and adequate support for plan/action. CONCLUSIONS This review provides comprehensive evidence about patient-caregiver dyadic ACP, a promising intervention to better prepare for EOL communication and decision-making. A logic model has been mapped to give a preliminary indication for future implementation. More empirical studies are needed to improve this model and culturally adapt it in a real-world setting.
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Affiliation(s)
- Xiaohang Liu
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Tongyao Wang
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Denise Shuk Ting Cheung
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Pui Hing Chau
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Mu-Hsing Ho
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Yuanxia Han
- Department of Pancreatic Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chia-Chin Lin
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
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