Improving advance care planning in high‐risk hospitalised patients: a knowledge translation pilot study

2021 ◽  
Vol 51 (4) ◽  
pp. 623-624
Author(s):  
Arvind Rajamani ◽  
Karen Fernandez ◽  
Hailey Carpen ◽  
Upul Liyanage ◽  
Jeffery Zijian Wang ◽  
...  
Keyword(s):  
Pilot Study ◽  
High Risk ◽  
Knowledge Translation ◽  
Advance Care Planning ◽  
Care Planning ◽  
Hospitalised Patients ◽  
Advance Care

Lessons Learned From a Pilot Project on Telemedicine Advance Care Planning in an Urban Geriatric Primary Care Office

2021 ◽  
pp. 104990912110369
Author(s):  
Olivia M. Seecof ◽  
Molly Allanoff ◽  
John Liantonio ◽  
Susan Parks
Keyword(s):  
Primary Care ◽  
Pilot Study ◽  
Medical Record ◽  
Advance Care Planning ◽  
Pilot Project ◽  
Lessons Learned ◽  
Care Planning ◽  
Geriatric Population ◽  
Advance Care ◽  
Primary Care Office

Purpose: There is a dearth of literature regarding the documentation of advance care planning (ACP) in the geriatric population, despite the controversial, yet well-studied need for ACP. The purpose of this pilot study was to provide an update to a prior study from our institution that outlined the need for increased documentation of advance care planning (ACP) in an urban geriatric population. Methods: Our study involved using telemedicine to conduct dedicated ACP visits and an electronic medical record (EMR) note-template specifically designed for these visits in an attempt to increase the amount of documented ACP in the EMR in this population. Results: The study did not yield significant results due to the inability to schedule enough patients for these dedicated visits. Discussion: While our study was ultimately unsuccessful, 3 crucial lessons were identified that will inform and fuel future interventions by the authors to further the study of documentation of ACP.

scholarly journals ‘We need a physician who is a human being too’: exploration of barriers and facilitators for hospitalised palliative patients and their families to discuss advance care planning

2019 ◽  
Vol 25 (12) ◽  
pp. 603-609
Author(s):  
Birgit Vanderhaeghen ◽  
Inge Bossuyt ◽  
Katelijne De Nys ◽  
Johan Menten ◽  
Peter Rober
Keyword(s):  
Content Analysis ◽  
Grounded Theory ◽  
Advance Care Planning ◽  
Disease Process ◽  
Care Planning ◽  
Human Being ◽  
Hospitalised Patients ◽  
Recall Procedure ◽  
Advance Care ◽  
Palliative Patients

Background: Advance care planning (ACP) is not well implemented in hospital. Implementation theory stresses the importance of knowing what hospitalised palliative patients and their families experience as barriers or as facilitators in the uptake of ACP with their treating physician. Aims: This study aimed to gain an in-depth understanding of what hospitalised palliative patients and their families experienced as barriers or facilitators for having ACP conversations. Methods: We used a tape-assisted recall procedure to conduct 29 videotaped interviews with hospitalised patients and their families. We used content analysis based on grounded theory principles. Results: Four major fields of tension were discovered: not knowing what to expect from the treating physician; not being sure the treating physician can be a trusted partner; daring to speak about ACP; and staying loyal to one's own wishes. Conclusions: Patients and families need physicians who are accessible and can be trusted ACP partners throughout the disease process.

95 Goals-Of-Care and Advance Care Planning Discussions with Hospitalised Frail Older People: What is the Evidence?

2020 ◽  
Vol 49 (Supplement_1) ◽  
pp. i30-i32
Author(s):  
S A Hopkins ◽  
A Bentley ◽  
V Phillips ◽  
S Barclay
Keyword(s):  
Literature Review ◽  
Older People ◽  
Advance Care Planning ◽  
Controlled Trial ◽  
Care Planning ◽  
Frail Older People ◽  
National Guidelines ◽  
Goals Of Care ◽  
Hospitalised Patients ◽  
Advance Care

Abstract Introduction National guidelines suggest that patients in the last year of life should be identified, their prognosis and future care options discussed, with advance care planning (ACP) recorded. Goals-of-care should be discussed with hospitalised patients at risk of deteriorating or with life-limiting conditions. The stated purpose of ACP and goals-of-care discussions is to increase goal-concordant care (i.e. patients receiving treatments they would wish to receive, and not receiving those they would not want). This literature review investigates the evidence-base for these policies and outcomes. Review question What is the evidence for goals-of-care and ACP discussions with hospitalised frail older people? Methods Systematic literature review and narrative synthesis. Electronic search of MEDLINE, CINAHL, ASSIA, PsycINFO, and Embase databases from January 1990 to September 2017. An updated search until May 2019 is currently underway. Results Of 8077 unique articles identified, 17 met inclusion criteria. There is no evidence that goals-of-care discussions lead to increased goal-concordant care; there is observational evidence that they increase the accuracy of documented preferences. Currently, rates of goals-of-care discussions are variable (38-72%), and there is poor concordance between patients’ actual and documented preferences, with agreement in only 31-33% of cases. Present rates of ACP are very low (0-3%), with mixed evidence for benefits of ACP. One single-centre randomised controlled trial suggests ACP improves outcomes for patients who die within 6 months of discharge, including increased goal-concordant care and reduced family distress. There is very limited evidence concerning patients’ and family members’ experiences of these discussions, their reasons for wishing (or not) to participate in discussions, or their perceptions of the important outcomes. Most (80%) patients would like to be involved in decisions about their care; 48% consider these conversations very important. The views and experiences of healthcare professionals have been little studied. Conclusions The asserted aim of goals-of-care and ACP discussions is to increase goal-concordant care; the extent to which this reflects patients’ priorities is unknown. In younger patient populations, while 40% of patients consider goal-concordant care the most important outcome, one third of patients consider family-related outcomes to be more important. Further research is needed to understand the perspectives of frail older patients, their families and clinicians, in order to make these discussions and subsequent care truly patient-centred.

scholarly journals Advance care planning in older hospitalised patients following an emergency admission: A mixed methods study

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0247874
Author(s):  
Anna-Maria Bielinska ◽  
Stephanie Archer ◽  
Adetokunbo Obanobi ◽  
Gehan Soosipillai ◽  
Lord Ara Darzi ◽  
...  
Keyword(s):  
Advance Care Planning ◽  
Healthcare Professionals ◽  
Mixed Methods Study ◽  
Care Planning ◽  
Emergency Admissions ◽  
Acute Hospitalisation ◽  
Hospitalised Patients ◽  
Advance Care ◽  
One Year ◽  
The One

Introduction Although advance care planning may be beneficial for older adults in the last year of life, its relevance following an emergency hospitalisation requires further investigation. This study quantifies the one-year mortality outcomes of all emergency admissions for patients aged 70+ years and explores patient views on the value of advance care planning following acute hospitalisation. Method This mixed methods study used a two-stage approach: firstly, a quantitative longitudinal cohort study exploring the one-year mortality of patients aged 70+ admitted as an emergency to a large multi-centre hospital cohort; secondly, a qualitative semi-structured interview study gathering information on patient views of advance care planning. Results There were 14,260 emergency admissions for 70+-year olds over a 12-month period. One-year mortality for admissions across all conditions was 22.6%. The majority of these deaths (59.3%) were within 3 months of admission. Binary logistic regression analysis indicated higher one-year mortality with increasing age and male sex. Interviews with 20 patients resulted in one superordinate theme, “Planning for health and wellbeing in the spectrum of illness”. Sub-themes entitled (1) Advance care planning benefitting healthcare for physical and psycho-social health, (2) Contemplation of physical deterioration death and dying and 3) Collaborating with healthcare professionals to undertake advance care planning, suggest that views of advance care planning are shaped by experiences of acute hospitalisation. Conclusion Since approximately 1 in 5 patients aged 70+ admitted to hospital as an emergency are in the last year of life, acute hospitalisation can act as a trigger for tailored ACP. Older hospitalised patients believe that advance care planning can benefit physical and psychosocial health and that discussions should consider a spectrum of possibilities, from future health to the potential of chronic illness, disability and death. In this context, patients may look for expertise from healthcare professionals for planning their future care.

scholarly journals Can a patient-directed video improve inpatient advance care planning? A prospective pre-post cohort study

2019 ◽  
Vol 28 (11) ◽  
pp. 887-893 ◽  
Author(s):  
Rajesh Nair ◽  
Samuel Abuaf Kohen
Keyword(s):  
Decision Making ◽  
Patient Satisfaction ◽  
Hospital Admission ◽  
Advance Care Planning ◽  
Therapeutic Interventions ◽  
Care Planning ◽  
Post Intervention ◽  
Patient Understanding ◽  
Hospitalised Patients ◽  
Advance Care

BackgroundPatients and their families often have an inadequate understanding of the risks and benefits of their advance care planning (ACP) options. Improving patients’ knowledge of therapeutic interventions allows them to better select treatments they believe are most appropriate for their condition.ObjectivesTo determine if a video aimed at educating and engaging hospitalised patients on a standardised ACP order set can improve (1) inpatient understanding of key ACP concepts, (2) ACP documentation within 48 hours of hospital admission, (3) concordance between a patient’s expressed and chart-documented care preferences, (4) patient satisfaction with decision-making, and (5) patient’s decisional confidence.MethodsA prospective, non-randomised, pre-post intervention study of 252 inpatients in a 215-bed community-based hospital in Comox, British Columbia, Canada.ResultsOur video decision support tool was associated with significant improvements in (1) patient understanding of key ACP concepts (70%–100%; p<0.0001), (2) ACP documentation within 48 hours of hospital admission (81%–92%; p=0.01), (3) concordance between patients’ expressed wishes and chart documentation (69%–89%; p<0.0001), (4) patient satisfaction with decision-making (Canadian Health Care Evaluation Project Lite score: 4.3–4.5, p=0.001), and (5) patient’s decisional confidence (patients with no decisional conflict, increased from 72% to 93%; p<0.0001).ConclusionA 13 min video aimed at educating and engaging inpatients on ACP concepts improved patient understanding of key ACP concepts, rates of ACP documentation and patient satisfaction with decision-making.

Advance care planning and terminal intensive care unit admissions for cancer patients: We can do better.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e23000-e23000
Author(s):  
Joseph Heng ◽  
Ramy Sedhom ◽  
Thomas J. Smith
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
High Risk ◽  
Advance Care Planning ◽  
Hematologic Malignancies ◽  
Cancer Center ◽  
Care Planning ◽  
Code Status ◽  
Risk Of Death ◽  
Advance Care

e23000 Background: Terminal oncology intensive care unit (ICU) admissions are associated with high healthcare costs and decreased quality of life. Chemotherapy can be given in non-curative settings to optimize symptom control, but use of it at the end of life does not improve longevity. In addition, goals of care are too often not addressed for patients at high risk of death. Methods: We carried out a retrospective review identifying patients of a large academic cancer center who were admitted to and expired in an ICU between January 1, 2017 to December 31, 2018. Results: 120 patients met inclusion criteria. Median age was 58 years. Only 15.0% (n = 18) of all patients had advance directives. The majority of patients (94.1%, n = 113) were FULL CODE on admission. Median duration of admission was 10 days. Median time to death from ICU admission was 7.5 days. 65.0% (n = 78) of all patients were intubated, while 15.0% (n = 15) received CPR. 58.3% (n = 70) of the study population had solid malignancies; of note, 97.1% (n = 68) of these patients were metastatic at presentation and had a median ECOG performance status of 2. Patients with metastatic solid tumors typically have a more indolent course of progression compared to patients with hematologic malignancies. However, only 23.5% (n = 16) had discussed goals of care or code status with their outpatient oncologists, despite many seeing them within the last month prior to admission (83.8%, n = 57). Similarly, only 4.0% (n = 2) of patients with hematologic malignancies had advance care planning discussions with their oncologists prior to their terminal ICU admission. 27.5% (n = 33) of all patients had an inpatient palliative care consult. The inpatient pulmonary/critical care team had a high rate of inpatient code status transitions, with 85.6% (n = 97) of FULL CODE admissions transitioning to DNR/DNI. Conclusions: These findings reflect contemporary practice at a major academic cancer center. Despite most patients having regular contact with their outpatient oncologists, the intensity of health care utilization noted highlights a need to optimize recognition of patients at high risk of death and to engage patients in advance care planning discussions to avoid terminal ICU admissions.

Serious Illness Conversations in advanced kidney disease: a mixed-methods implementation study

2021 ◽  
pp. bmjspcare-2020-002830
Author(s):  
Natanong Thamcharoen ◽  
Pitchaphon Nissaisorakarn ◽  
Robert A Cohen ◽  
Mara A Schonberg
Keyword(s):  
Mixed Methods ◽  
Pilot Study ◽  
Kidney Disease ◽  
Advance Care Planning ◽  
Disease Stage ◽  
Treatment Preferences ◽  
Care Planning ◽  
Goals Of Care ◽  
Serious Illness ◽  
Advance Care

ObjectiveAdvanced kidney disease is associated with a high risk of morbidity and mortality. Consequently, invasive treatments such as dialysis may not yield survival benefits. Advance care planning has been encouraged. However, whether such discussions are acceptable when done earlier, before end-stage kidney treatment decision-making occurs, is unclear. This pilot study aimed to explore whether use of the Serious Illness Conversation Guide to aid early advance care planning is acceptable, and to evaluate the information gained from these conversations.MethodsPatients with advanced kidney disease (stage 3B and above) and high mortality risk at 2 years were enrolled in this mixed-methods study from an academic nephrology clinic. Semi-structured interviews were conducted using the adapted Serious Illness Conversation Guide. Thematic analysis was used to assess patients’ perceptions of the conversation. Participants completed a questionnaire assessing conversation acceptability.ResultsTwenty-six patients participated, 50% were female. Participants felt that the conversation guide helped them reflect on their prognosis, goals of care and treatment preferences. Most did not feel that the conversation provoked anxiety (23/26, 88%) nor that it decreased hopefulness (24/26, 92%). Some challenges were elicited; patients expressed cognitive dissonance with the kidney disease severity due to lack of symptoms; had difficulty conceptualising their goals of care; and vocalised fear of personal failure without attempting dialysis.ConclusionsPatients in this pilot study found the adapted Serious Illness Conversation Guide acceptable. This guide may be used with patients early in the course of advanced kidney disease to gather information for future advanced care planning.

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