Innovative pilot to reimburse nurse and social work-led advance care planning.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 3-3
Author(s):  
Angela Kalisiak ◽  
Lisa Kathryn Hansen ◽  
Jamie Newell ◽  
Lydia Mills
Keyword(s):  
Advance Care Planning ◽  
Metastatic Cancer ◽  
Quality Care ◽  
Care Planning ◽  
Comfort Care ◽  
Health Leadership ◽  
Community Oncology ◽  
Advance Care ◽  
Patient Values ◽  
Eol Care

3 Background: Research has shown that advance care planning (ACP) leads to better patient care and outcomes. The Oregon Health Leadership Council (OHLC) identified ACP as an opportunity to improve care and offset costs. In 2014, the OHLC commissioned a workgroup to pilot a payment model to promote broader adoption of ACP. A community oncology provider and 4 health plans implemented the pilot for nurses (RNs) and licensed clinical social workers (LCSWs) to conduct ACP in an effort to elicit and honor patient preferences at end of life (EOL). Methods: Five RNs and 2 LCSWs underwent specific ACP training (by academic EOL educator or VitalTalk). They conducted one or more substantive ACP conversations (minimum 20 minutes) with 149 patients (89 female, 60 male; median age 64; range 24-92) between 12/5/14 and 5/9/16. Most patients had recurrent and/or metastatic cancer. Charts were reviewed in April 2017 for goals of care (GOC) discussion, ACP documents, preferences for EOL care, hospice enrollment, date of death, and death location. Results: Among all 149 patients, GOC discussion was documented for 126 (85%). Advance directives were in the chart for 34 (23%) and POLST for 53 (36%) patients. Among the 69 patients who died, 80% were on hospice (median days = 14; 15% on hospice < 3 days); 87% preferred comfort care at time of death. Three patients (4%) requested life-prolonging treatment until death. Conclusions: This pilot demonstrated that RNs and LCSWs can provide substantive ACP within robust team-based care. Hospice enrollment, POLST completion, and EOL care consistent with preferences were high. Cost data was inadequate to draw conclusions. While physician management, patient values, disease and treatment factors may also impact EOL choices, pilot data indicates that expanding ACP through trained RNs and LCSWs serves to normalize ACP as an integral component of quality care and promote outcomes congruent with GOC. [Table: see text]

Integrating POLST into Palliative Care Guidelines: A Paradigm Shift in Advance Care Planning in Oncology

2006 ◽  
Vol 4 (8) ◽  
pp. 819-829 ◽  
Author(s):  
Patricia A. Bomba ◽  
Daniel Vermilyea
Keyword(s):  
Advance Directives ◽  
Advance Care Planning ◽  
Patient Preferences ◽  
Metastatic Cancer ◽  
Health Care Team ◽  
Care Planning ◽  
Patient Centered ◽  
Code Status ◽  
Advance Care ◽  
Patient Values

Because predicting and outlining guidance for all possible scenarios is difficult, advance directives are rarely sufficiently precise to dictate patient preferences in specific situations as a disease progresses. Nonetheless, advance care planning is an essential process that should begin at the time of diagnosis, if not already initiated, to ensure that all patient and family rights are preserved. Communicating effectively with the patient and family and having the patient designate a surrogate decision-maker are critical. Attention must be paid to resolving conflicts among patient values and preferences and those of family and the health care team. Patient-centered goals for care and expectations should be elicited at first assessment and reassessed frequently as conditions change. As a disease progresses, advance directives are rarely precise enough to predict all possible scenarios and outline guidance for care. Therefore, for patients with advanced metastatic cancer and a potential life expectancy of less than 1 year, converting patient-centered treatment goals into actionable medical orders while the patient maintains capacity is a more effective way to ensure that patient preferences are honored. Physician Orders for Life-Sustaining Treatment (POLST) and similar medical order forms provide explicit direction about resuscitation status (“code status”) if the patient is pulseless and apneic. POLST also includes directions about additional interventions the patient may or may not want. A decade of research in Oregon has proved that the POLST Paradigm Program more accurately conveys end-of-life preferences that are more likely to be followed by medical professionals than traditional advance directives alone.

scholarly journals Engagement in Advance Care Planning: The Association With Cognitive Impairment and Care Preferences

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 417-418
Author(s):  
Hyo Jung Lee ◽  
Giyeon Kim
Keyword(s):  
Older Adults ◽  
Cognitive Impairment ◽  
Relative Risk ◽  
End Of Life ◽  
Advance Care Planning ◽  
Multinomial Logistic Regression ◽  
Quality Care ◽  
Care Planning ◽  
Advance Care ◽  
Four Levels

Abstract Although there has been growing evidence that Advance care planning (ACP) benefits people with cognitive impairment nearing death, our understanding about this issue is still limited. This study examines whether cognitive impairment is associated with ACP engagement and end-of-life care preferences among older adults in the U.S. Using data from the 2012 National Health and Trends Study (n=1798, aged 65 to 101), we identified four levels of ACP engagement: None (28%), Informal ACP conversation only (12%), Formal ACP only (14%), and Both informal and formal ACP (46%). Older adults with None showed the highest prevalence of having cognitive impairment (17%), followed by those with Formal ACP only (15%) and the other two (6%, 6%). The results of Multinomial Logistic Regression showed that, compared to those without, respondents with cognitive impairment had 143% increased relative risk of having None (RR = 2.43, CI: 1.58-3.73) and 81% increased relative risk of completing Formal ACP only (RR = 1.81, CI: 1.11-2.95) relative to completing Both informal and formal ACP. In addition, respondents with None were more likely to prefer to receive all treatments available nearing death than those with any ACP engagement. Achieving high quality care at the end of life can be more challenging for older adults with cognitive impairment and their family caregivers due to the limited capacity. Although encouraged, informal ACP conversation with loved ones does not necessarily occur before the formal ACP, especially, for those with cognitive impairment. Therefore, they may merit more attention such as early ACP engagement.

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.

Association of advance care planning with place of death and utilisation of life-sustaining treatments in deceased patients at Taipei City Hospital in Taiwan

2020 ◽  
pp. bmjspcare-2020-002520
Author(s):  
Yung-Feng Yen ◽  
Ya-Ling Lee ◽  
Hsiao-Yun Hu ◽  
Wen-Jung Sun ◽  
Ming-Chung Ko ◽  
...  
Keyword(s):  
Cohort Study ◽  
Advance Care Planning ◽  
Place Of Death ◽  
Care Planning ◽  
City Hospital ◽  
Taipei City ◽  
Advance Care ◽  
Eol Care ◽  
To Receive ◽  
At Home

ObjectiveEvidence is mixed regarding the impact of advance care planning (ACP) on place of death. This cohort study investigated the effect of ACP programmes on place of death and utilisation of life-sustaining treatments for patients during end-of-life (EOL) care.MethodsThis prospective cohort study identified deceased patients between 2015 and 2016 at Taipei City Hospital. ACP was determined by patients’ medical records and defined as a process to discuss patients’ preferences with respect to EOL treatments and place of death. Place of death included hospital or home death. Stepwise logistic regression determined the association of ACP with place of death and utilisation of life-sustaining treatments during EOL care.ResultsOf the 3196 deceased patients, the overall mean age was 78.6 years, and 46.5% of the subjects had an ACP communication with healthcare providers before death. During the study follow-up period, 166 individuals died at home, including 98 (6.59%) patients with ACP and 68 (3.98%) patients without ACP. After adjusting for sociodemographic factors and comorbidities, patients with ACP were more likely to die at home during EOL care (adjusted OR (AOR)=1.71, 95% CI 1.24 to 2.35). Moreover, patients with ACP were less likely to receive cardiopulmonary resuscitation (AOR 0.36, 95% CI 0.25 to 0.51) as well as intubation and mechanical ventilation support (AOR 0.54, 95% CI 0.44 to 0.67) during the last 3 months of life.ConclusionPatients with ACP were more likely to die at home and less likely to receive life-sustaining treatments during EOL care.

Use of a computer model and care coaches to increase advance care planning conversations for patients with metastatic cancer.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 8-8
Author(s):  
Divya Gupta ◽  
Touran Fardeen ◽  
Winifred Teuteberg ◽  
Briththa Seevaratnam ◽  
Mary Khay Asuncion ◽  
...  
Keyword(s):  
End Of Life ◽  
Cancer Patients ◽  
Advance Care Planning ◽  
Computer Model ◽  
Metastatic Cancer ◽  
Life Quality ◽  
Care Planning ◽  
Survival Prognosis ◽  
Advance Care ◽  
Lay Care

8 Background: Patients with metastatic cancer benefit from advance care planning (ACP) conversations. Despite initiatives which train providers to have ACP conversations using the serious illness care program (SICP) conversation guide, few patients have a documented prognosis discussion due to busy clinic schedules and difficulty in deciding the right times to have such conversations. We designed an intervention to improve ACP by incorporating a validated computer model to identify patients at high risk for mortality in combination with lay care coaches. We investigated whether this would improve end of life quality measures. Methods: Four Stanford clinics were included in this pilot; all received SICP training. Two clinics (thoracic and genitourinary) underwent the intervention (computer model + care coach), and two clinics (sarcoma and cutaneous) served as the control. For providers in the intervention, an email was sent every Sunday listing the metastatic cancer patients who would be seen in clinic the following week and a predicted prognosis generated by the model. A lay care coach contacted patients with a predicted survival ≤2 years to have an ACP conversation with them. After, the care coach notified the provider to suggest discussion regarding prognosis with the patient. Criteria for a patient visit to be included in the analysis were: age ≥18, established patient, has sufficient EMR data for computer model, and no prior prognosis documentation. The primary outcome was documentation of prognosis in the ACP form by the end of the week following the clinic visit. Results: 5330 visits in 1298 unique patients met the inclusion criteria. Median age was 67 (range 19-97); 790 male, 508 female. 1970 visits were with patients with ≤2 year predicted survival. Prognosis discussion was documented by providers in the ACP form for 8.1% of intervention visits compared to 0.07% of control visits (p=0.001 in mixed effects model). Of the 1298 unique patients, 84 were deceased by December 2020. 41.7% died in the hospital. 59.5% were enrolled in hospice prior to death, and 19.0% were hospitalized in the ICU ≤14 days prior to death. Of deceased patients with ACP form prognosis documentation, 5.0% had ≥2 hospitalizations in the 30 days before death compared to 23.4% of deceased patients with no prognosis documented (p=0.10). For ≥ 2 ER visits in the 30 days before death, the proportions were 5.0% and 20.3% (p=0.17). Conclusions: This pilot study supports that our intervention is associated with higher rates of prognosis discussions and documentation. There was a trend towards better quality of end of life care as noted by higher rates of hospice enrollment and less intensive care at end of life. These results merit further investigation as a means to improve goal-concordant care and ensure appropriate care for cancer patients at the end of life.

Limited engagement in, yet clear preferences for advance care planning in young-onset dementia: An exploratory interview-study with family caregivers

2019 ◽  
Vol 33 (9) ◽  
pp. 1166-1175 ◽  
Author(s):  
Romy Van Rickstal ◽  
Aline De Vleminck ◽  
Melissa D Aldridge ◽  
Sean R Morrison ◽  
Raymond T Koopmans ◽  
...  
Keyword(s):  
Family Caregivers ◽  
Advance Care Planning ◽  
Quality Care ◽  
Third Party ◽  
Care Planning ◽  
Structured Interviews ◽  
Young Onset ◽  
People With Dementia ◽  
Advance Care ◽  
Young Onset Dementia

Background: The significance of advance care planning in dementia is widely acknowledged. Despite the suggestion that younger people with dementia and their family might have distinct needs and preferences in this area, studies on advance care planning in young-onset dementia are absent. Aim: We aim to explore (1) whether family caregivers had already engaged in advance care planning with patients and/ or professionals and the accompanying reasons and (2) family caregivers’ preferences for how to ideally engage in the process with patients, family and professionals. Design: A qualitative study was conducted: we analysed semi-structured interviews ( n = 15) through the method of constant comparative analysis. Setting/participants: We included Flemish family caregivers of persons with young-onset dementia. Results: Plans for the future typically concerned non-medical affairs. Participants’ limited engagement in advance care planning was clarified through several reasons: not considering it useful, hindering patient behaviour, adopting a day-to-day attitude, caregivers emotionally protecting themselves and uncertainty about patients’ cognitive competence. However, endorsement for advance care planning showed from respondents’ preferences that it should be initiated timely, by a third party, and emphasize patients’ remaining capacities. Finally, the need for information and high-quality care emerged. Conclusion: A gap of knowledge, of information and in care intertwiningly hinder advance care planning. In young-onset dementia, engaging in advance care planning is not an option equally accessible as not doing so. Policy makers, institutions and professionals could reflect on their responsibility in providing these patients and caregivers an actual choice to engage in advance care planning or not.

scholarly journals Feasibility and acceptability of introducing advance care planning on a thoracic medicine inpatient ward: an exploratory mixed method study

2020 ◽  
Vol 7 (1) ◽  
pp. e000485
Author(s):  
Nina Elisabeth Hjorth ◽  
Margrethe Aase Schaufel ◽  
Katrin Ruth Sigurdardottir ◽  
Dagny R Faksvåg Haugen
Keyword(s):  
Focus Group ◽  
Advance Care Planning ◽  
Symptom Control ◽  
Care Planning ◽  
Management Support ◽  
Focus Group Interviews ◽  
Inpatient Ward ◽  
Advance Care ◽  
Patient Values ◽  
Group Interviews

Background and aimsAdvance care planning (ACP) is communication about wishes and preferences for end-of-life care. ACP is not routinely used in any Norwegian hospitals. We performed a pilot study (2014–2017) introducing ACP on a thoracic medicine ward in Norway. The aims of this study were to explore which topics patients discussed during ACP conversations and to assess how patients, relatives and clinicians experienced the acceptability and feasibility of performing ACP.MethodsConversations were led by a study nurse or physician using a semistructured guide, encouraging patients to talk freely. Each conversation was summarised in a report in the patient’s medical record. At the end of the pilot period, clinicians discussed their experiences in focus group interviews. Reports and transcribed interviews were analysed using systematic text condensation.ResultsFifty-one patients participated in ACP conversations (41–86 years; 9 COPD, 41 lung cancer, 1 lung fibrosis; 11 women); 18 were accompanied by a relative. Four themes emerged: (1) disturbing symptoms, (2) existential topics, (3) care planning and (4) important relationships. All participants appreciated the conversations. Clinicians (1 physician and 7 nurses) participated in two focus group interviews. Reports from ACP conversations revealed patient values previously unknown to clinicians; important information was passed on to primary care. Fearing they would deprive patients of hope, clinicians acted as gatekeepers for recruitment. Although they reported barriers during recruitment, many clinicians saw ACP as pertinent and called for time and skills to integrate it into their daily clinical practice.ConclusionsPatients, relatives and clinicians showed a positive attitude towards ACP. Focusing on present and future symptom control may be an acceptable way to introduce ACP. Important aspects for implementing ACP in this patient group are management support, education, training, feasible routines and allocated time to perform the conversations.

scholarly journals Does the Experience of Caring for a Severely Disabled Relative Impact Advance Care Planning? A Qualitative Study of Caregivers of Disabled Patients

2020 ◽  
Vol 17 (5) ◽  
pp. 1594
Author(s):  
Fu-Ming Chiang ◽  
Jyh-Gang Hsieh ◽  
Sheng-Yu Fan ◽  
Ying-Wei Wang ◽  
Shu-Chen Wang
Keyword(s):  
Decision Making ◽  
Medical Care ◽  
Advance Care Planning ◽  
Qualitative Content Analysis ◽  
Care Planning ◽  
Medical Decisions ◽  
Self Blame ◽  
Advance Care ◽  
Past Experiences ◽  
Eol Care

The aging of the Taiwanese population has become a major issue. Previous research has focused on the burden and stress faced by caregivers, but has not explored how the experience of these caregivers influences decisions of advance care planning (ACP). Semi-structured and in-depth interviews were conducted. Qualitative content analysis was used to identify important themes. Five themes and fourteen sub-themes were identified: (1) Past experiences: patient wishes, professional recommendations, and expectation about disease progress; (2) Impact of care on family members: positive affirmation, open-minded life, social isolation and health effects, and financial and life planning effects; (3) Attitude toward life: not forcing to stay, and not becoming a burden, (4) Expected proxy dilemmas: torment between doing or not, seeing the extension of suffering and toil, and remorse and self-blame; (5) Expectation of end of life (EOL) care: caregiver’s experience and EOL care decisions, and practicality of EOL decision making. After making multiple medical decisions for their disabled relatives, caregivers are able to calmly face their own medical decisions, and “not becoming a burden” is their primary consideration. It’s suggested that implementation of shared decision-making on medical care for patients with chronic disability will not only improve the quality of their medical care but also reduce the development of remorse and guilty feelings of caregivers after making medical decisions.

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