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Alam A, Barton C, Prathivadi P, Mazza D. Advance care planning in dementia: a qualitative study of Australian general practitioners. Aust J Prim Health 2021; 28:69-75. [PMID: 34844662 DOI: 10.1071/py20307] [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] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022]
Abstract
As the population ages, so does the prevalence of dementia, a condition in which timely advance care planning (ACP) is recommended. This study explored the barriers and enablers of ACP for Australian GPs caring for people with dementia. Semi-structured qualitative telephone interviews informed by the theoretical domains framework (TDF) were conducted with 16 GPs from the south-east region of metropolitan Melbourne. The most prevalent domains of the TDF were: (1) environmental context and resources; (2) beliefs about consequences; and (3) social/professional role and identity. Further thematic analysis found that: (1) ACP was felt to be within the scope of general practice, but more so before the onset of dementia because lack of confidence in capacity assessment acted as a barrier once a diagnosis was made; (2) beliefs about the perceived benefits of ACP motivated GPs to engage patients in ACP; and (3) doctors felt that patients were often reluctant to discuss ACP, especially in the time-pressured context of the standard consultation. This study's use of the TDF provides direction for potential interventions to alleviate challenges faced by Australian GPs with ACP in dementia. Improving ACP in general practice may require a focus on public health campaigns to educate patients about the benefits of ACP before the onset of dementia. GPs' difficulty assessing a patient's decisional capacity may be addressed through skills development workshops.
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Affiliation(s)
- Adnan Alam
- Hobart Place General Practice, Level 2 & 3, 28 University Avenue, Canberra, ACT 2601, Australia; and Corresponding author
| | - Christopher Barton
- Department of General Practice, Monash University, Level 1, Building 1, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia
| | - Pallavi Prathivadi
- Department of General Practice, Monash University, Level 1, Building 1, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Level 1, Building 1, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia
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Lewis ET, Mahimbo A, Linhart C, Williamson M, Morgan M, Hammill K, Hall J, Cardona M. General practitioners' perceptions on the feasibility and acceptability of implementing a risk prediction checklist to support their end-of-life discussions in routine care: a qualitative study. Fam Pract 2020; 37:703-710. [PMID: 32297645 DOI: 10.1093/fampra/cmaa036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND General practitioners' (GPs) play a central role in facilitating end-of-life discussions with older patients nearing the end-of-life. However, prognostic uncertainty of time to death is one important barrier to initiation of these discussions. OBJECTIVE To explore GPs' perceptions of the feasibility and acceptability of a risk prediction checklist to identify older patients in their last 12 months of life and describe perceived barriers and facilitators for implementing end-of-life planning. METHODS Qualitative, semi-structured interviews were conducted with 15 GPs practising in metropolitan locations in New South Wales and Queensland between May and June 2019. Data were analysed thematically. RESULTS Eight themes emerged: accessibility and implementation of the checklist, uncertainty around checklist's accuracy and usefulness, time of the checklist, checklist as a potential prompt for end-of-life conversations, end-of-life conversations not an easy topic, end-of-life conversation requires time and effort, uncertainty in identifying end-of-life patients and limited community literacy on end-of-life. Most participants welcomed a risk prediction checklist in routine practice if assured of its accuracy in identifying which patients were nearing end-of-life. CONCLUSIONS Most participating GPs saw the value in risk assessment and end-of-life planning. Many emphasized the need for appropriate support, tools and funding for prognostic screening and end-of-life planning for this to become routine in general practice. Well validated risk prediction tools are needed to increase clinician confidence in identifying risk of death to support end-of-life care planning.
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Affiliation(s)
- Ebony T Lewis
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,School of Psychology, University of New South Wales, Sydney, Australia
| | - Abela Mahimbo
- Centre for Primary Health Care & Equity, University of New South Wales, Sydney, Australia
| | - Christine Linhart
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Margaret Williamson
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,Centre for Primary Health Care & Equity, University of New South Wales, Sydney, Australia
| | - Mark Morgan
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Kathrine Hammill
- School of Science & Health, Western Sydney University, Sydney, Australia
| | - John Hall
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Magnolia Cardona
- Gold Coast University Hospital, Gold Coast, Australia.,Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
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Quadri SZ, Huynh T, Cappelen-Smith C, Wijesuriya N, Mamun A, Beran RG, McDougall AJ, Cordato D. Reflection on stroke deaths and end-of-life stroke care. Intern Med J 2018; 48:330-334. [PMID: 28892278 DOI: 10.1111/imj.13619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 07/16/2017] [Revised: 09/03/2017] [Accepted: 09/05/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The benefit of palliative care referral for severe stroke patients on end-of-life care pathway (EOLCP) is increasingly recognised. Palliative care provides assistance with symptom management and transition to end-of-life care. Advance care planning (ACP) may help accommodate patient/family expectations and guide management. METHODS This is a retrospective study of all stroke deaths (2014-2015) at Liverpool Hospital, Sydney, Australia. Data examined included age, comorbidities, living arrangements, pre-existing ACP, palliative care referral rates and 'survival time'. RESULTS In total, 123 patient (mean age ± SD = 76 ± 13 years) deaths were identified from 1067 stroke admissions (11.5% mortality); 64 (52%) patients had ischaemic stroke and 59 (48%) intracerebral haemorrhage (ICH), and 40% suffered a prior stroke, and 43% required a carer at home or were in an aged care facility. Survival time from admission was significantly longer in patients with ischaemic stroke compared to intracerebral haemorrhage (median, interquartile range [IQR]: 9.5 [18] vs 2 [4] days, P < 0.001). Only two patients had pre-existing ACP; 44% of patients were referred to palliative care and 41% were commenced on dedicated EOLCP. Palliative care referral was less likely in patients who died under neurosurgery. EOLCP were significantly less likely to be commenced in patients who underwent acute intervention or were not referred to palliative care. CONCLUSION In this cohort, palliative care referral and EOLCP were commenced in less than 50% of patients, highlighting significant variations in clinical care. These data support the need to promote awareness of ACP, particularly in patients with prior stroke or significant comorbidities. This may help reduce potentially futile invasive investigations and treatment.
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Affiliation(s)
- Syed Z Quadri
- Department of Palliative Medicine, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Thang Huynh
- Department of Palliative Medicine, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
| | - Nirupama Wijesuriya
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
| | - Abul Mamun
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
| | - Roy G Beran
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
- School of Medicine, Griffith University, Queensland, Australia
| | - Alan J McDougall
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
| | - Dennis Cordato
- Sydney South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurophysiology, Liverpool Hospital, Sydney, Liverpool, New South Wales, Australia
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