Normalising advance care planning in a general medicine service of a tertiary hospital: an exploratory study

2016 ◽  
Vol 40 (4) ◽  
pp. 391 ◽  
Author(s):  
Ian A. Scott ◽  
Nalaka Rajakaruna ◽  
Darshan Shah ◽  
Leyton Miller ◽  
Elizabeth Reymond ◽  
...  
Keyword(s):  
Advance Care Planning ◽  
General Medicine ◽  
Tertiary Hospital ◽  
Care Plan ◽  
Care Planning ◽  
Care Plans ◽  
Medicine Service ◽  
Advance Care Plan ◽  
Advance Care ◽  
Program Components

Objective The aim of the present study was to develop, implement and explore the effects of a program in advance care planning (ACP) within a tertiary hospital general medicine service. Methods Before–after exploratory mixed-methods analysis was conducted of an ACP program comprising seven components designed to overcome well-documented barriers to ACP in clinical practice. The results of pre-ACP program audits performed in June 2014 were compared with those of post-ACP audits performed over 5 months from July to November 2014. The main outcome measure was the number of advance care plans completed in patients considered eligible for ACP based on a life expectancy of 12 months or less as assessed by two prognostication instruments. Questionnaire surveys ascertained staff perceptions of ACP and the usefulness of training and resources in ACP. Results Pre-ACP program analysis of 166 consecutive patients deemed eligible for ACP revealed that only 1% had a documented advance care plan. Following ACP implementation, 115 of 215 (53%) potentially eligible patients were considered able to participate in ACP discussions and were approached to do so before discharge, of whom 89 (77.4%) completed an advance care plan, whereas 26 (23.6%) declined. This equated to an overall completion rate for all potentially eligible patients of 41% compared to 1% pre-ACP (P < 0.001). Major barriers to ACP perceived by at least 30% of questionnaire respondents included the reluctance of patients and family to discuss ACP, insufficient time to initiate or complete ACP, patient and/or family factors that rendered ACP impractical, inadequate communication skills around end-of-life issues, confusion about who was primarily responsible for conducting ACP and difficulty using ACP documentation forms. Enabling factors included dedicated ACP workshops, facilitator and resource packages for staff, and ACP brochures for patients and family. Conclusion A multifaceted ACP program in a general medicine service led to completion of an advance care plan in more than three of four patients considered eligible for, and who participated in, ACP. However, although program components were tailored to overcome known barriers to ACP, staff indicated ongoing difficulties, with less than half of ACP-eligible patients completing advance care plans. What is known about this topic? Advance care planning is increasingly recognised as an important part of hospital care for older patients with advanced chronic disease. However, research indicates that ACP discussions are rare in hospital settings because of various barriers that are not adequately addressed in the design of ACP programs. What does this paper add? The present exploratory study of the development, implementation and evaluation of an ACP program in a tertiary hospital general medicine service shows that program components designed to overcome specific barriers to ACP discussions was associated with a >75% completion rate of advance care plans among ACP-eligible patients who participated in ACP discussions. Dedicated staff training and resources in ACP, employment of an ACP facilitator and ready access to ACP documentation forms were important enabling strategies. What are the implications for practitioners? Hospital units caring for significant numbers of older patients with limited life expectancy can implement ACP programs that help normalise ACP discussions within routine clinical care.

Utilizing the Electronic Health Record to Improve Advance Care Planning: A Systematic Review

2017 ◽  
Vol 35 (3) ◽  
pp. 532-541 ◽  
Author(s):  
Michael Todd Huber ◽  
Janelle Deneen Highland ◽  
Venkatesan Ram Krishnamoorthi ◽  
Joyce Wing-Yi Tang
Keyword(s):  
Electronic Health Record ◽  
Advance Care Planning ◽  
Point Of Care ◽  
Care Plan ◽  
Health Record ◽  
Care Planning ◽  
Care Plans ◽  
Advance Care Plan ◽  
Advance Care ◽  
Electronic Health

Purpose: Advance care planning may ensure care that is concordant with patient wishes. However, advance care plans are frequently absent when needed due to failure to engage patients in planning, inability to access prior documentation, or poor documentation quality. Interventions utilizing tools within the electronic health record (EHR) may address these barriers at the point of care. We aimed to identify EHR interventions previously utilized to improve advance care plans. Methods: We systematically searched 7 databases for observational and experimental studies of EHR interventions associated with advance care plans. We abstracted information on the study populations, EHR and non-EHR components of the interventions, and the efficacy for advance care plan–related outcomes. Results: We identified 16 articles that contained an EHR intervention to improve advance care plans. Study populations, study designs, and EHR components of the interventions were heterogeneous. Documentation templates were the most common EHR tool reported (n = 8), followed by automated prompts (n = 7) and electronic order sets (n = 5). The most common reported outcomes were documentation of an advance care planning conversation in the EHR (n = 7) and the placement of code status orders (n = 7). All studies reporting efficacy (n = 9) demonstrated an improvement in 1 or more advance care planning outcomes. Conclusions: The use of EHR interventions may improve advance care plan completion and availability at the point of care. Further work should seek to develop and evaluate standardized EHR tools for advance care planning.

scholarly journals How do Lawyers Assist Their Clients With Advance Care Planning? Findings From a Cross-Sectional Survey of Lawyers in Alberta

2018 ◽  
Author(s):  
Nola M. Ries ◽  
Maureen Douglas ◽  
Jessica Simon ◽  
Konrad Fassbender
Keyword(s):  
Advance Care Planning ◽  
Care Plan ◽  
Care Planning ◽  
Cross Sectional Survey ◽  
Future Health ◽  
Cross Sectional ◽  
Legal Professionals ◽  
Advance Care Plan ◽  
Future Health Care ◽  
Advance Care

Advance care planning (ACP) is the process of thinking about, discussing and documenting one’s preferences for future health care. ACP has important benefits: people who have a written directive are more likely to receive care that accords with their preferences, have fewer hospitalizations, and die in their preferred location. This article focuses on the important role that legal professionals have in advising and assisting clients with ACP. Studies report that people who have a written advance care plan are more likely to have received assistance in preparing the document from a lawyer than from a doctor. Yet virtually no research engages with the legal profession to understand lawyers’ attitudes, beliefs, and practices in this important area. This article starts to fill this gap by reporting the findings of a survey of lawyers in the province of Alberta. The results reveal lawyers’ practices in relation to ACP, their perceptions of their professional role and factors that support or hinder lawyers in working with clients on ACP, and their preferences for resources to assist them in helping their clients. To the authors’ knowledge, this is the first survey of lawyers on their practices in relation to ACP.

scholarly journals Advance care planning and syringe drivers in palliative and end-of-life care

2020 ◽  
Vol 29 (17) ◽  
pp. 1010-1015
Author(s):  
Aby Mitchell ◽  
Scott Elbourne
Keyword(s):  
End Of Life ◽  
Advance Care Planning ◽  
End Of Life Care ◽  
Symptom Control ◽  
Care Plan ◽  
Care Planning ◽  
Life Care ◽  
Advance Care Plan ◽  
Syringe Driver ◽  
Advance Care

This article discusses the practicalities of syringe drivers (subcutaneous continuous infusion pumps) for symptom control in patients requiring palliative or end-of-life care, which may form part of an advance care plan. It includes a discussion of palliative and end-of-life care, advance care planning, and when a syringe driver might be beneficial for the patient. It also provides step-by-step clinical guidance on setting up a syringe driver.

scholarly journals 52 A Community Cure for Frequent Reattenders: Developing An Interface Geriatrics Service

2020 ◽  
Vol 49 (Supplement_1) ◽  
pp. i14-i17
Author(s):  
O Davies ◽  
S James
Keyword(s):  
Social Services ◽  
Advance Care Planning ◽  
Care Plan ◽  
Care Planning ◽  
Care Plans ◽  
Frequent Attenders ◽  
Frequent Attender ◽  
Frail Patients ◽  
Complex Patients ◽  
Advance Care

Abstract Topic Setting up an interface geriatrics service in a seaside area with a large elderly population. Many elderly patients are readmitted due to the challenge of managing their chronic health conditions in the community. These patients are frail, with frequently exacerbated chronic conditions causing regular readmissions. We noted that treatment was rarely changed during these admissions and patients were not uniformly managed. Aims Aims for this project were to improve care for older people, reduce readmissions and produce clear patient care plans. Interventions Our first PDSA cycle involved implementing geriatrician presence at community MDTs (involving social services, GPs, intermediate care teams, and various others). This generated home visits to several patients, with a mix of acute and chronic issues. We offered Advance Care planning where appropriate to these patients. We noted several patients were repeatedly discussed at MDT. This brought into focus frequent attenders who were usually well-known to the community. In the next cycle we introduced ‘frequent attender’ plans for these patients, ensuring a unified approach to their management. Subsequent cycles involved geriatrician presence at the ‘frequent attenders’ steering group, and further links with community teams. Our primary intervention has been Advance care & frequent attender plans offering tailored management for complex patients. These are completed by a geriatrician discussing patients wishes for treatment and future care. Improvements Readmission rates show up to 90% reduction in admissions/ED attendances for patients following care plan implementation. Feedback from families and patients is positive – the service is ‘pragmatic and supportive’, delivering ‘empathetic care’. Discussion Implementing an interface geriatrics service highlights the importance of caring for frail patients in their preferred place of care, reducing unnecessary/inappropriate hospitalisations. Geriatrician presence at community MDTs has improved care by offering prompt access to medical advice and review of complex patients. It highlights patients presenting frequently to services, allowing us to work with patients and families to improve management. A frequent attender list generated by the hospital helps target patients for whom intervention will give significant benefit. We plan to extend this further by working with nursing homes that have high conveyancing rates. The service is being extended to more areas within our region, and we are working with GPs and care homes to further offer advance care planning to vulnerable and frail patients.

scholarly journals Planning for Serious Illness amongst Community-Dwelling Older Adults

2013 ◽  
Vol 2013 ◽  
pp. 1-7
Author(s):  
Donna Goodridge
Keyword(s):  
Older Adults ◽  
Advance Care Planning ◽  
Community Dwelling ◽  
Care Plan ◽  
Predictor Variables ◽  
Care Planning ◽  
Serious Illness ◽  
Substitute Decision Maker ◽  
Advance Care Plan ◽  
Advance Care

Older adults have long been encouraged to maintain their autonomy by expressing their wishes for health care before they become too ill to meaningfully participate in decision making. This study explored the manner in which community-dwelling adults aged 55 and older plan for serious illness. An online survey was conducted within the province of Saskatchewan, Canada, with 283 adults ranging in age from 55 to 88 years. Planning for future medical care was important for the majority (78.4%) of respondents, although only 25.4% possessed a written advance care plan and 41.5% had designated a substitute decision maker. Sixty percent of respondents reported conversations about their treatment wishes; nearly half had discussed unacceptable states of health. Associations between key predictor variables and planning behaviors (discussions about treatment wishes or unacceptable states of health; designation of a substitute decision maker; preparation of a written advance care plan) were assessed using binary logistic regression. After controlling for all predictor variables, self-reported knowledge about advance care planning was the key variable significantly associated with all four planning behaviors. The efforts of nurses to educate older adults regarding the process of advance care planning can play an important role in enhancing autonomy.

Advance decisions in dementia: when the past conflicts with the present

2018 ◽  
Vol 45 (3) ◽  
pp. 204-208
Author(s):  
George Gillett
Keyword(s):  
Advance Care Planning ◽  
Care Plan ◽  
Western World ◽  
Care Planning ◽  
Ronald Dworkin ◽  
The Past ◽  
Advance Care Plan ◽  
Future Selves ◽  
Advance Care ◽  
Advance Decisions

As the prevalence of dementia increases across the Western world, there is a growing interest in advance care planning, by which patients may make decisions on behalf of their future selves. Under which ethical principles is this practice justified? I assess the justification for advance care planning put forward by the philosopher Ronald Dworkin, which he rationalises through an integrity-based conception of autonomy. I suggest his judgement is misguided by arguing in favour of two claims. First, that patients with dementia qualify for some right to contemporary autonomy conceptualised under the ‘sense of liberty’ it provides. Second, that respecting precedent autonomy, such as an advance care plan, is not essential to Dworkin’s integrity-based account of autonomy. Together, my claims problematise the practice of using advance decisions in the context of dementia.

scholarly journals Nurse-led advance care planning with older people who have end-stage kidney disease: feasibility of a deferred entry randomised controlled trial incorporating an economic evaluation and mixed methods process evaluation (ACReDiT)

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Peter O’Halloran ◽  
Helen Noble ◽  
Kelly Norwood ◽  
Peter Maxwell ◽  
Fliss Murtagh ◽  
...  
Keyword(s):  
Kidney Disease ◽  
Data Collection ◽  
Advance Care Planning ◽  
Care Plan ◽  
Care Planning ◽  
End Stage Kidney Disease ◽  
Advance Care Plan ◽  
Advance Care ◽  
Randomised Controlled ◽  
End Stage

Abstract Background Advance Care Planning is recommended for people with end-stage kidney disease but evidence is limited. Robust clinical trials are needed to investigate the impact of advance care planning in this population. There is little available data on cost-effectiveness to guide decision makers in allocating resources for advance care planning. Therefore we sought to determine the feasibility of a randomised controlled trial and to test methods for assessing cost-effectiveness. Methods A deferred entry, randomised controlled feasibility trial, incorporating economic and process evaluations, with people with end-stage kidney disease, aged 65 years or older, receiving haemodialysis, in two renal haemodialysis units in Northern Ireland, UK. A nurse facilitator helped the patient make an advance care plan identifying: a surrogate decision-maker; what the participant would like to happen in the future; any advance decision to refuse treatment; preferred place of care at end-of-life. Results Recruitment lasted 189 days; intervention and data collection 443 days. Of the 67 patients invited to participate 30 (45%) declined and 36 were randomised to immediate or deferred advance care plan groups. Twenty-two (61%) made an advance care plan and completed data collection at 12 weeks; 17 (47.2%) were able to identify a surrogate willing to be named in the advance care plan document. The intervention was well-received and encouraged end-of-life conversations, but did not succeed in helping patients to fully clarify their values or consider specific treatment choices. There was no significant difference in health system costs between the immediate and deferred groups. Conclusions A trial of advance care planning with participants receiving haemodialysis is feasible and acceptable to patients, but challenging. A full trial would require a pool of potential participants five times larger than the number required to complete data collection at 3 months. Widening eligibility criteria to include younger (under 65 years of age) and less frail patients, together with special efforts to engage and retain surrogates may improve recruitment and retention. Traditional advance care planning outcomes may need to be supplemented with those that are defined by patients, helping them to participate with clinicians in making medical decisions. Trial registration Registered December 16, 2015. ClinicalTrials.gov Identifier: NCT02631200.

Advance Care Planning—A Primer

2014 ◽  
Vol 5 (1) ◽  
Author(s):  
Karishma Taneja ◽  
Puneet Sayal
Keyword(s):  
Advance Care Planning ◽  
Healthcare Professionals ◽  
Healthcare Providers ◽  
Decision Makers ◽  
Care Plan ◽  
Care Planning ◽  
Advance Care Plan ◽  
Advance Care ◽  
Substitute Decision Makers ◽  
Eol Care

Advance Care Planning (ACP) is the process by which individuals make decisions that can guide their future healthcare if they become incompetent. Creation of an Advance Care Plan should involve discussions with healthcare providers and substitute decision makers (SDM). ACP can assist individuals, their families, and healthcare professionals in planning for future and end-of-life (EOL) care. Recent research suggests that ACP can increase discussions about EOL preferences and improve the concordance between patient preferences and their EOL care. More than 50% of Canadians have not completed an Advanced Care Plan. This may be due to a variety of reasons, however it is possible that the community does not have enough knowledge about healthcare options that can be provided in the hospitals. Current research is focused on identifying barriers and facilitators to ACP, as well as implementing methods for incorporating it during standard medical care. Various stakeholders have identified ACP as a priority, and in order to raise awareness, April 16th has been designated as National Advance Care Planning Day in Canada

Advance care planning for people with dementia: a review

2011 ◽  
Vol 23 (10) ◽  
pp. 1535-1551 ◽  
Author(s):  
Karen Harrison Dening ◽  
Louise Jones ◽  
Elizabeth L. Sampson
Keyword(s):  
Advance Care Planning ◽  
Quantitative Methods ◽  
Care Plan ◽  
Current Evidence ◽  
Care Planning ◽  
Care Providers ◽  
Care Plans ◽  
People With Dementia ◽  
Current Evidence Base ◽  
Advance Care

ABSTRACTBackground: Few people with dementia have made advance plans for their health care. Advance care planning (ACP) is a process of discussion between an individual and their care providers that takes account of wishes and preferences for future care. We aimed to examine the facilitators and inhibitors to ACP in people with dementia. We also aimed to identify key themes in the literature and critically review the methodologies used.Methods: We systematically searched the English language literature including PubMed, CINAHL, AMED, PsychINFO, EMBASE and BNI. We included empirical studies which reported the characteristics of the patient population, the type of advance care planning used and the study setting, and which involved people with dementia, family members or professional carers.Results: We identified 17 studies (11 quantitative methods, one qualitative and five mixed methods). We found one ACP intervention which changed outcomes for people with dementia. Key themes were identified: there is a point at which cognition decreases critically so that an advanced care plan can no longer be made; factors present in family carers and professionals can influence decision-making and the ACP process; ACPs are affected by preferences for life sustaining treatments; ACP in dementia may differ from other illness groups; and there is a need for education relating to ACP.Conclusion: The current evidence base for ACP in dementia is limited. Since UK government policy recommends that all people should engage in ACP, more evidence is needed to understand the feasibility and acceptability of advanced care plans for people with dementia.

scholarly journals Assisted Living Administrators’ Approaches to Advance Care Planning

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 66-66
Author(s):  
Elise Abken ◽  
Alexis Bender ◽  
Ann Vandenberg ◽  
Candace Kemp ◽  
Molly Perkins
Keyword(s):  
Advance Care Planning ◽  
Assisted Living ◽  
Staff Training ◽  
Chronically Ill ◽  
External Support ◽  
Care Plan ◽  
Care Planning ◽  
Term Care ◽  
Advance Care ◽  
Eol Care

Abstract Assisted living (AL) communities are increasingly home to frail, chronically ill older adults who remain until death. State laws mandate that AL facilities request copies of any advance care planning documents residents have and make forms available upon request. Using secondary data from a larger study funded by the National Institute on Aging (R01AG047408) that focuses on end-of-life (EOL) care in AL, this project investigated barriers and facilitators to conducting advance care planning in AL. Data included in-depth interviews (of 86 minute average length) with 20 administrators from 7 facilities around the Atlanta metropolitan area and aggregate data collected from each facility regarding facility, staff, and resident characteristics. Findings from thematic analysis of qualitative data showed that key barriers to planning in AL included lack of staff training and reluctance among administrators and families to discuss advance care planning and EOL care. Important facilitators included periodic follow-up discussions of residents’ wishes, often during care plan meetings, educating families about the importance of planning, and external support for staff training and family education from agencies such as hospice and home health. Three study facilities exceeded state requirements to request and store documents by systematically encouraging residents to complete documentation. These facilities, whose administrators discuss advance care planning and residents’ EOL wishes with residents and families during regular care plan meetings, were more likely to have planning documents on file, demonstrating the potential of long-term care communities, such as AL, to successfully promote advance care planning among residents and their family members.

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