Characteristics of Advance Care Planning in Patients With Cancer Referred to Palliative Care

2021 ◽  
Vol 17 (2) ◽  
pp. e94-e100
Author(s):  
Callie M. Berkowitz ◽  
Steven P. Wolf ◽  
Jesse Troy ◽  
Arif H. Kamal
Keyword(s):  
Palliative Care ◽  
Data Collection ◽  
Advance Care Planning ◽  
Care Quality ◽  
Quality Data ◽  
Care Planning ◽  
Data Collection Tool ◽  
Serious Illness ◽  
Patients With Cancer ◽  
Advance Care

PURPOSE: Advance care planning (ACP) is a process in which patients share their values, goals, and preferences regarding future medical care. ACP can improve care quality, yet may be challenging to address for patients with cancer. We sought to characterize key components of ACP in patients with cancer as compared with patients with noncancer serious illness referred to palliative care (PC). METHODS: We performed a retrospective cross-sectional analysis of initial outpatient PC visits from the Quality Data Collection Tool for PC database from 2015 to 2019. Quality Data Collection Tool is a web-based point-of-care specialty PC registry to track quality metrics. RESULTS: We analyzed 1,604 patients with cancer and 1,094 patients without cancer: 44% of patients were female, 87% were White, and 98% were non-Hispanic. The average age was 72.2 years (standard deviation [SD] 15.4). Patients with cancer were on average younger than patients without cancer (66.5 [SD: 13.9] v 80.5 [SD: 13.8]) and had a higher Palliative Performance Scale (PPS) (59.5 [SD: 22.4] v 33.4 [SD: 25.1]). In our unadjusted comparison, patients with cancer were less likely to be DNR/DNI (37% v 53%; P < .0001) and less likely to have an advance directive (53% v 73%; < .0001); rates of healthcare proxy identification were similar (92.8% v 94.5%; P = .10). These differences did not persist when we accounted for age, race, sex, and PPS, with age being the primary explanatory factor. CONCLUSION: Despite having serious illness meriting PC referral, many patients with cancer in our study lacked advance directives. This highlights both the important role of oncologists in facilitating ACP and the utility of PC playing a complementary role.

Quality Improvement Initiatives to Reduce Mortality: An Opportunity to Engage Palliative Care and Improve Advance Care Planning

2018 ◽  
Vol 36 (2) ◽  
pp. 97-104 ◽  
Author(s):  
Signe Peterson Flieger ◽  
Erica Spatz ◽  
Emily J. Cherlin ◽  
Leslie A. Curry
Keyword(s):  
Palliative Care ◽  
Quality Improvement ◽  
End Of Life ◽  
Advance Care Planning ◽  
Secondary Analysis ◽  
Care Quality ◽  
Care Planning ◽  
Goals Of Care ◽  
Patient Goals ◽  
Advance Care

Background: Despite substantial efforts to integrate palliative care and improve advance care planning, both are underutilized. Quality improvement initiatives focused on reducing mortality may offer an opportunity for facilitating engagement with palliative care and advance care planning. Objective: In the context of an initiative to reduce acute myocardial infarction (AMI) mortality, we examined challenges and opportunities for engaging palliative care and improving advance care planning. Methods: We performed a secondary analysis of qualitative data collected through the Leadership Saves Lives initiative between 2014 and 2016. Data included in-depth interviews with hospital executives, clinicians, administrators, and quality improvement staff (n = 28) from 5 hospitals participating in the Mayo Clinic Care Network. Focused analysis examined emergent themes related to end-of-life experiences, including palliative care and advance care planning. Results: Participants described challenges related to palliative care and advance care planning in the AMI context, including intervention decisions during an acute event, delivering care aligned with patient and family preferences, and the culture around palliative care and hospice. Participants proposed strategies for addressing such challenges in the context of improving AMI quality outcomes. Conclusions: Clinicians who participated in an initiative to reduce AMI mortality highlighted the challenges associated with decision-making regarding interventions, systems for documenting patient goals of care, and broader engagement with palliative care. Quality improvement initiatives focused on mortality may offer a meaningful and feasible opportunity for engaging palliative care. Primary palliative care training is needed to improve discussions about patient and family goals of care near the end of life.

Advance care planning for patients with cancer in palliative care: A scoping review from a professional perspective

2020 ◽  
Vol 29 (13-14) ◽  
pp. 2069-2082
Author(s):  
Anne Kuusisto ◽  
Jenni Santavirta ◽  
Kaija Saranto ◽  
Päivi Korhonen ◽  
Elina Haavisto
Keyword(s):  
Palliative Care ◽  
Advance Care Planning ◽  
Scoping Review ◽  
Care Planning ◽  
Patients With Cancer ◽  
Professional Perspective ◽  
Advance Care

“There were more decisions and more options than just yes or no”: Evaluating a decision aid for advanced cancer patients and their family caregivers

2016 ◽  
Vol 15 (1) ◽  
pp. 44-56 ◽  
Author(s):  
Marie Bakitas ◽  
J. Nicholas Dionne-Odom ◽  
Lisa Jackson ◽  
Jennifer Frost ◽  
Margaret F. Bishop ◽  
...  
Keyword(s):  
Decision Making ◽  
Palliative Care ◽  
Advance Care Planning ◽  
Decision Aid ◽  
Care Planning ◽  
Serious Illness ◽  
Early Palliative Care ◽  
Advance Care ◽  
Seriously Ill Patients ◽  
Seriously Ill

AbstractObjective:Few decision aids are available for patients with a serious illness who face many treatment and end-of-life decisions. We evaluated the Looking Ahead: Choices for Medical Care When You're Seriously Ill® patient decision aid (PtDA), one component of an early palliative care clinical trial.Method:Our participants included individuals with advanced cancer and their caregivers who had participated in the ENABLE (Educate, Nurture, Advise, Before Life Ends) early palliative care telehealth randomized controlled trial (RCT) conducted in a National Cancer Institute-designated cancer center, a U.S. Department of Veterans Affairs medical center, and affiliated outreach clinics in rural New England. ENABLE included six weekly patient and three weekly family caregiver structured sessions. Participants watched the Looking Ahead PtDA prior to session 3, which covered content on decision making and advance care planning. Nurse coaches employed semistructured interviews to obtain feedback from consecutive patient and caregiver participants approximately one week after viewing the Looking Ahead PtDA program (booklet and DVD).Results:Between April 1, 2011, and October 31, 2012, 57 patients (mean age = 64), 42% of whom had lung and 23% gastrointestinal cancer, and 20 caregivers (mean age = 59), 80% of whom were spouses, completed the PtDA evaluation. Participants reported a high degree of satisfaction with the PtDA format, as well as with its length and clarity. They found the format of using patient interviews “validating.” The key themes were: (1) “the earlier the better” to view the PtDA; (2) feeling empowered, aware of different options, and an urgency to participate in advance care planning.Significance of results:The Looking Ahead PtDA was well received and helped patients with a serious illness realize the importance of prospective decision making in guiding their treatment pathways. We found that this PtDA can help seriously ill patients prior to the end of life to understand and discuss future healthcare decision making. However, systems to routinely provide PtDAs to seriously ill patients are yet not well developed.

Different Associations Between Inpatient or Outpatient Palliative Care and End-of-Life Outcomes for Hospitalized Patients With Cancer

2021 ◽  
Author(s):  
Jonathan C. Yeh ◽  
Arielle R. Urman ◽  
Robert J. Besaw ◽  
Laura E. Dodge ◽  
Kathleen A. Lee ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Advance Care Planning ◽  
Hospital Length ◽  
Hospitalized Patients ◽  
Hospital Length Of Stay ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Patients With Cancer ◽  
Advance Care

PURPOSE Palliative care (PC) improves outcomes in advanced cancer, and guidelines recommend early outpatient referral. However, many PC teams see more inpatient than outpatient consults. We conducted a retrospective study of hospitalized patients with cancer to quantify exposure to inpatient and outpatient PC and describe associations between PC and end-of-life (EOL) quality measures. METHODS We identified all decedents admitted to an inpatient oncology unit in 1 year (October 1, 2017-September 30, 2018) and abstracted hospitalization statistics, inpatient and outpatient PC visits, and EOL outcomes. Descriptive statistics, univariate tests, and multivariate analysis evaluated associations between PC and patient outcomes. RESULTS In total, 522 decedents were identified. 50% saw PC; only 21% had an outpatient PC visit. Decedents seen by PC were more likely to enroll in hospice (78% v 44%; P < .001), have do-not-resuscitate status (87% v 55%; P < .001), have advance care planning documents (53% v 31%; P < .001), and die at home or inpatient hospice instead of in hospital (67% v 40%; P < .01). Decedents seen by PC had longer hospital length-of-stay (LOS; 8.4 v 7.0 days; P = .03), but this association reversed for decedents seen by outpatient PC (6.3 v 8.3 days; P < .001), who also had longer hospice LOS (46.5 v 27.1 days; P < .01) and less EOL intensive care (6% v 15%; P < .05). CONCLUSION PC was associated with significantly more hospice utilization and advance care planning. Patients seen specifically by outpatient PC had shorter hospital LOS and longer hospice LOS. These findings suggest different effects of inpatient and outpatient PC, underscoring the importance of robust outpatient PC.

Unmet Needs of African Americans and Whites at the Time of Palliative Care Consultation

2016 ◽  
Vol 34 (5) ◽  
pp. 461-465 ◽  
Author(s):  
Arif H. Kamal ◽  
Janet Bull ◽  
Steven P. Wolf ◽  
Diane Portman ◽  
Jacob Strand ◽  
...  
Keyword(s):  
Palliative Care ◽  
African Americans ◽  
Advance Care Planning ◽  
Care Quality ◽  
Care Planning ◽  
Racial Groups ◽  
Palliative Care Consultation ◽  
Patient Reported ◽  
Advance Care ◽  
Care Consultation

Context: Differences among patient populations that present to consultative palliative care are not known. Such an appreciation would inform health-care delivery tailored to unique populations. Objectives: We aimed to compare characteristics and palliative care needs of African Americans (AAs) and whites during initial palliative care consultation. Methods: We analyzed patient-reported, clinician-entered clinical encounter data from a large, multisite community-based, nonhospice palliative care collaborative. We included first specialty palliative care consultations from January 1, 2014, to July 2, 2015, across 15 sites within the Global Palliative Care Quality Alliance registry. Demographics, disease, performance status, advance care planning, and symptom prevalence/severity were compared. Results: Of 775 patients, 12.9% (N = 100) were AA. African Americans were younger (63 vs 75.4 years, P < .0001). A larger proportion of AAs had a diagnosis of cancer (45.0% vs 36.3%, P = .09) and in the hospital (71% vs 61.8%, P = .07). African Americans were more likely to have a Palliative Performance Score of 0 to 30 (35.6% vs 23.7%, P = .049). Around 50% in both racial groups were full code; slightly more than 40% had an advance directive. Nearly two-thirds in both racial groups reported 3 or more symptoms of any severity; one-third reported 3 or more moderate or severe symptoms. A larger proportion of Africans than whites reported pain of any severity (66.0% vs 56.1%, P = .06). Conclusion: All patients present to palliative care consultations with significant symptom and advance care planning needs. Further research is needed to identify how to deliver palliative care: earlier, in noncancer conditions, and improve pain management in AA populations.

Developing a new model of care for patients with cancer who present to the emergency department: The Mayo Clinic experience.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 61-61
Author(s):  
Debra A. Wong ◽  
Tom R. Fitch ◽  
Eric Prommer ◽  
Yu-Hui Chang ◽  
Christopher A. Lipinski
Keyword(s):  
Emergency Department ◽  
Palliative Care ◽  
Supportive Care ◽  
Cancer Patients ◽  
Advance Care Planning ◽  
Emergency Department Visits ◽  
Cancer Type ◽  
Care Planning ◽  
Patients With Cancer ◽  
Advance Care

61 Background: Patients with cancer often have complex symptoms and morbidity that prompt frequent Emergency Department visits. The length of stay in the ED for cancer patients exceeds that of patients without cancer. Patients with cancer are also more likely to be admitted, but are often discharged within 72h. Protracted ED visits, extensive investigations, and the burdens of even a short admission may be distressing and may not be aligned with patients’ care goals and preferences. Furthermore, the healthcare resources dedicated to these patients is considerable and has economic implications. We recently established a Supportive Care Infusion Center (SCIC), an on-campus outpatient unit where patients can receive treatments for symptom relief and comfort; they are assured integrated palliative care with routine oncologic care. We believe there is a subset of cancer patients who can be safely transferred from the ED to the SCIC for appropriate care. Methods: We are retrospectively evaluating cancer patients admitted through the ED to validate clinical parameters likely to lead to admission, and also identify any differences between patients admitted for <72h vs >72h. Patients are analyzed based on symptoms, cancer type, prior cancer therapies, performance status, comorbidities, and presence/absence of advance care planning as well as previous contact with Palliative Care. Data are also being gathered on patient outcomes, including mortality within 60d of admission. Results: Previously established indicators predictive of admission included shortness of breath and SIRS criteria, which our current review validates. We also observe that patients admitted for >72h have greater symptom burden and comorbidities and have received multiple lines of therapy. They also less frequently have advance care planning in place. Data analysis is ongoing. Conclusions: There exists a difference between cancer patients admitted >72h and those discharged within 72h. Awareness of these characteristics may lead to improved workflow in the ED. Identifying patients who may be suitable for transfer to an outpatient supportive care unit rather than short-term admission will also facilitate cost-effectiveness. Future direction includes evaluation of outcomes such as mortality, quality of life, and patient-caregiver satisfaction.

Advance Care Planning Shared Decision-Making Tools for Non-Cancer Chronic Serious Illness: A Mixed Method Systematic Review

2021 ◽  
pp. 104990912199541
Author(s):  
Danetta H. Sloan ◽  
Susan M. Hannum ◽  
Lyndsay DeGroot ◽  
Sydney M. Dy ◽  
Julie Waldfogel ◽  
...  
Keyword(s):  
Decision Making ◽  
Palliative Care ◽  
Ambulatory Care ◽  
Shared Decision Making ◽  
Advance Care Planning ◽  
Advance Directive ◽  
Care Planning ◽  
Shared Decision ◽  
Serious Illness ◽  
Advance Care

Context: Shared decision-making tools can facilitate advance care planning and goals of care conversations in non-cancer serious illness. More information on integrating these tools in ambulatory care could better support clinicians and patients/caregivers in these conversations. Objectives: We evaluated effectiveness and implementation of integrating palliative care shared decision-making tools into ambulatory care for U.S. adults with serious, life-threatening illness and their caregivers. Data sources: We searched PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials (2000 - May 2020) for quantitative controlled, qualitative, and mixed-methods studies. Review methods: Two reviewers screened articles, abstracted data, and independently assessed risk of bias or study quality. For quantitative trials, we graded strength of evidence for key outcomes: patient/caregiver satisfaction, depression or anxiety, concordance between patient preferences for care and care received, and healthcare utilization, including advance directive documentation. Results: We included 6 quantitative effectiveness randomized, controlled trials and 5 qualitative implementation studies across primary care and specialty populations. Shared decision-making tools all addressed goals-of-care communication or advance care planning. Palliative care shared decision-making tools may be effective for improving patient satisfaction with communication and advance directive documentation. We were unable to draw conclusions about concordance between preferences and care received. Patients and caregivers preferred advance care planning discussions grounded in patient and caregiver experiences with individualized timing. Conclusions: For non-cancer serious illness, advance care planning shared decision-making tools may improve several outcomes. Future trials should evaluate concordance with care received and other health care utilization. Key Message: This mixed-methods review concludes that when integrating palliative care into ambulatory care for serious illness and conditions other than cancer, advance care planning shared decision-making tools may improve patient satisfaction and advance directive documentation.

Demenz aus palliativmedizinischer Perspektive: warum ein krankheitsspezifisches Advance Care Planning wichtig ist

2018 ◽  
Vol 75 (2) ◽  
pp. 105-111 ◽  
Author(s):  
Ralf J. Jox ◽  
Francesca Bosisio ◽  
Eve Rubli Truchard
Keyword(s):  
Palliative Care ◽  
Advance Care Planning ◽  
Care Planning ◽  
Advance Care ◽  
Menschen Mit Demenz

Zusammenfassung. Die Palliative Care muss sich im Zuge des demographischen Wandels vieler Gesellschaften rund um den Globus tiefgreifend wandeln. Sie muss mehr und mehr mit der Geriatrie zusammenarbeiten und geriatrische Expertise integrieren. Eine der zentralen Herausforderungen Geriatrischer Palliative Care ist die ethisch angemessene Therapieentscheidung für Menschen, die nicht mehr urteilsfähig sind. Nachdem der bisherige Ansatz herkömmlicher Patientenverfügungen erwiesenermassen enttäuscht hat, wird aktuell, gerade auch in deutschsprachigen Ländern, das systemische Konzept des Advance Care Planning (ACP) verfolgt. In diesem Artikel wird zunächst ACP mit seinen Zielen, Elementen und Effekten vorgestellt. Sodann wird gezeigt, weshalb es für Menschen mit Demenz eines adaptierten ACP-Programms bedarf und was ein solches demenzspezifisches ACP beinhalten muss.

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