scholarly journals The Characteristics and Motivations of Taiwanese People toward Advance Care Planning in Outpatient Clinics at a Community Hospital

2021 ◽  
Vol 18 (6) ◽  
pp. 2821
Author(s):  
Chih-Chieh Yen ◽  
Cheng-Pei Lin ◽  
Yu-Ting Su ◽  
Chiu-Hua Tsu ◽  
Li-Mei Chang ◽  
...  
Keyword(s):  
Advance Care Planning ◽  
Community Hospital ◽  
Artificial Nutrition ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Taiwanese People ◽  
Advance Care ◽  
Southern Taiwan ◽  
Advance Decisions ◽  
Fair Poor

Advance care planning (ACP) provides access to complete advance decisions (ADs). Despite the legalization of ACP in Taiwan, it is underutilized in community settings. The objective of this study is to describe the service at a community hospital in Southern Taiwan. We retrospectively analyzed participants who were engaged in ACP consultations from January 2019 to January 2020. The characteristics, motivations, content, and satisfaction of participants are reported. Factors associated with refusing life-sustaining treatments (LST) or artificial nutrition/hydration (ANH) were analyzed using multivariate logistic regression. Of the 178 participants, 123 completed the ACP. The majority were female (64.2%), aged 61 on average and more than 80% had never signed a do-not-resuscitate order. In the ADs, most participants declined LST (97.2%) and ANH (96.6%). Family-related issues (48.9%) were the most prevalent motivations. Rural residence (OR 8.6, p = 0.005), increased age (OR 7.2, p = 0.025), and reluctance to consent to organ donation (OR 5.2, p = 0.042) correlated with refusing LST or ANH. Participants provided a positive feedback regarding overall satisfaction (good, 83%) compared to service charge (fair/poor, 53%). The study demonstrated high AD completion when refusing LST or ANH. These findings may facilitate the development of ACP as a community-based service.

scholarly journals The Role of Advance Care Planning in Cancer Patient and Caregiver Grief Resolution: Helpful or Harmful?

Cancers ◽  
2021 ◽  
Vol 13 (8) ◽  
pp. 1977
Author(s):  
Francesca Falzarano ◽  
Holly G. Prigerson ◽  
Paul K. Maciejewski
Keyword(s):  
Cancer Patients ◽  
Family Caregivers ◽  
Advance Care Planning ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Prospective Longitudinal Study ◽  
Advance Care ◽  
Grief Resolution ◽  
Caregiver Grief ◽  
Prospective Longitudinal

Cancer patients and their family caregivers experience various losses when patients become terminally ill, yet little is known about the grief experienced by patients and caregivers and factors that influence grief as patients approach death. Additionally, few, if any, studies have explored associations between advance care planning (ACP) and grief resolution among cancer patients and caregivers. To fill this knowledge gap, the current study examined changes in grief over time in patients and their family caregivers and whether changes in patient grief are associated with changes in caregiver grief. We also sought to determine how grief changed following the completion of advance directives. The sample included advanced cancer patients and caregivers (n = 98 dyads) from Coping with Cancer III, a federally funded, multi-site prospective longitudinal study of end-stage cancer care. Participants were interviewed at baseline and at follow-up roughly 2 months later. Results suggest synchrony, whereby changes in patient grief were associated with changes in caregiver grief. We also found that patients who completed a living will (LW) experienced increases in grief, while caregivers of patients who completed a do-not-resuscitate (DNR) order experienced reductions in grief, suggesting that ACP may prompt “grief work” in patients while promoting grief resolution in caregivers.

scholarly journals Late decisions about treatment limitation in patients with cancer: empirical analysis of end-of-life practices in a haematology and oncology unit at a German university hospital

ESMO Open ◽  
2020 ◽  
Vol 5 (5) ◽  
pp. e000950
Author(s):  
Katja Mehlis ◽  
Elena Bierwirth ◽  
Katsiaryna Laryionava ◽  
Friederike Mumm ◽  
Pia Heussner ◽  
...  
Keyword(s):  
Palliative Care ◽  
Advance Care Planning ◽  
Solid Tumours ◽  
University Hospital ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Treatment Limitation ◽  
Ethics Policy ◽  
Advance Care

BackgroundDecisions to limit treatment (DLTs) are important to protect patients from overtreatment but constitute one of the most ethically challenging situations in oncology practice. In the Ethics Policy for Advance Care Planning and Limiting Treatment study (EPAL), we examined how often DLT preceded a patient’s death and how early they were determined before (T1) and after (T2) the implementation of an intrainstitutional ethics policy on DLT.MethodsThis prospective quantitative study recruited 1.134 patients with haematological/oncological neoplasia in a period of 2×6 months at the University Hospital of Munich, Germany. Information on admissions, discharges, diagnosis, age, DLT, date and place of death, and time span between the initial determination of a DLT and the death of a patient was recorded using a standardised form.ResultsOverall, for 21% (n=236) of the 1.134 patients, a DLT was made. After implementation of the policy, the proportion decreased (26% T1/16% T2). However, the decisions were more comprehensive, including more often the combination of ‘Do not resuscitate’ and ‘no intense care unit’ (44% T1/64% T2). The median time between the determination of a DLT and the patient’s death was similarly short with 6 days at a regular ward (each T1/T2) and 10.5/9 (T1/T2) days at a palliative care unit. For patients with solid tumours, the DLTs were made earlier at both regular and palliative care units than for the deceased with haematological neoplasia.ConclusionOur results show that an ethics policy on DLT could sensitise for treatment limitations in terms of frequency and extension but had no significant impact on timing of DLT. Since patients with haematological malignancies tend to undergo intensive therapy more often during their last days than patients with solid tumours, special attention needs to be paid to this group. To support timely discussions, we recommend the concept of advance care planning.

scholarly journals “My Family Wants Something Different”: Discordance in Perceived Personal and Family Treatment Preference and Its Association With Do-Not-Resuscitate Order Placement

2019 ◽  
Vol 15 (11) ◽  
pp. e942-e947
Author(s):  
Login S. George ◽  
William Breitbart ◽  
Holly G. Prigerson
Keyword(s):  
Advance Care Planning ◽  
Life Extension ◽  
Treatment Preference ◽  
Family Treatment ◽  
Treatment Preferences ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Structured Interviews ◽  
Comfort Care ◽  
Advance Care

PURPOSE: Patients make treatment decisions based not only on what they want, but what they think their families want. Discordance in such perceived preferences may therefore pose challenges for advance care planning. This study examines discordance in preference for life-extending care versus comfort-focused care and its association with do-not-resuscitate (DNR) order placement. METHODS: One hundred eighty-nine patients with advanced cancers refractory to at least one chemotherapy regimen were enrolled in a multisite observational study. In structured interviews, patients reported their preference for treatment maximizing either life extension or comfort; patients also indicated their perception of their families’ preference. DNR placement was reported by patients and verified using medical records. RESULTS: Approximately 23% of patients (n = 43) perceived discordance between their preference and their families’ preference. Patients who perceived discordance were less likely to have completed a DNR compared with those who perceived concordance, even after controlling for relevant confounds (odds ratio = .35; P = .02). Subgroups of discordance and concordance showed varying DNR placement rates (χ2, 19.95; P < .001). DNR placement rate was lowest among discordant subgroups, where there was either a personal (26.7%; four of 15) or family preference for comfort care (28.6%; eight of 28), followed by patients who perceived concordance for wanting life-extending care (34.5%; 29 of 84) and by patients who perceived concordance in wanting comfort-focused care (66.1%; 41 of 62). CONCLUSION: Many patients may perceive discordance between personal and family treatment preferences, posing impediments to advance care planning. Such patients may benefit from additional decision support.

scholarly journals Do-not-resuscitate orders as part of advance care planning in patients with COPD

2018 ◽  
Vol 4 (1) ◽  
pp. 00116-2017 ◽  
Author(s):  
Jo Raskin ◽  
Kristina Vermeersch ◽  
Stephanie Everaerts ◽  
Pascal Van Bleyenbergh ◽  
Wim Janssens
Keyword(s):  
Advance Care Planning ◽  
Prognostic Significance ◽  
Forced Expiratory Volume ◽  
Chronic Obstructive ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Obstructive Pulmonary Disease ◽  
Advance Care ◽  
Dnr Orders

There is growing awareness of the need for advance care planning in patients with chronic obstructive pulmonary disease (COPD). However, do-not-resuscitate (DNR) order implementation remains a challenge in clinical practice.We retrospectively analysed an observational cohort of 569 COPD patients with 2.5–8 years of follow-up in secondary care, to evaluate potential determinants and the prognostic significance of DNR order implementation and specification.345 patients (61%) had no DNR order, of whom 27% died during a median (interquartile range (IQR)) follow-up of 1935 (1290–2448) days. 194 (39%) patients had a DNR order, of whom 17 had the order at baseline and 82% died (median (IQR) follow-up 528 (137–901) days), while 177 received an order during follow-up and 76% died (median (IQR) follow-up 1322 (721–2018) days). 88% of DNR orders were implemented during hospitalisation. 58% of the patients with a DNR order died within the first year after admission; of them, 66% died in the hospital. Age, forced expiratory volume in 1 s, chronic oxygen dependency and previous mechanical ventilation were significantly and independently associated with DNR order implementation. DNR order specification was significantly associated with increased mortality, even after adjustment for age and disease severity.These findings identify DNR orders as independent determinants of mortality, mainly implemented just before death.

Advance care planning and treatment escalation plans

2020 ◽  
Vol 13 (2) ◽  
pp. 109-116 ◽  
Author(s):  
Ellie Courtney
Keyword(s):  
Advance Care Planning ◽  
Legal Framework ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Advance Care ◽  
The Uk ◽  
Treatment Escalation ◽  
Multiple Chronic Diseases ◽  
Huge Challenge

Medicine has advanced rapidly over the past 100 years. People are living longer, sometimes with multiple chronic diseases. When they develop life-limiting conditions, some already old and frail, achieving balance between intervening too much and too little can be a huge challenge. In many areas of the UK treatment escalation plans (TEPs) are replacing do not resuscitate orders. The aims of this article are to explore the use of TEPs and the role of advance care planning, covering the legal framework and providing some practical guidance about how to approach this important conversation.

Frailty Recognition by Clinicians and its Impact on Advance Care Planning

2021 ◽  
Vol 38 (4) ◽  
pp. 371-375
Author(s):  
Munther M. Queisi ◽  
Suheil Albert Atallah-Yunes ◽  
Farah Adamali ◽  
Nageshwar Jonnalagadda ◽  
Vida Rastegar ◽  
...  
Keyword(s):  
Advance Care Planning ◽  
The Elderly ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Patient Centered ◽  
Code Status ◽  
Centered Care ◽  
Advance Care ◽  
One Year ◽  
The Impact

Background: Frailty has important implications for the care of the elderly and how their needs are met. Objective: To assess clinicians’ acknowledgement of frailty in the electronic medical records (EMR) and the impact of frailty recognition on advance care planning (ACP). Methods: We performed a retrospective study on 119 patients 65 years or older with moderate or severe frailty assessed using a validated frailty scale. We reviewed notes to determine if primary team identified frailty and obtained data regarding ACP planning. We present the characteristics and outcomes of patients who were identified as frail and compared them with patients whose frailty was unrecognized in EMR. Results: Among the 119 frail patients, one third were ≥85 years and one-year mortality was 25.4%. Most patients were taking ≥5 medications and only 14.3% rated their health as excellent or good prior to hospitalization. Only 15 patients (12.6%) were identified as frail in the EMR. The only significant differences between those recognized versus unrecognized frail were body mass index (23.4 vs 28.6, p = 0.02) and reported weight loss in the 3 months prior to admission (93.3% vs 59.6%, p = 0.009). Geriatric or palliative care consults, and changes in code status to do-not resuscitate were more frequent among those recognized vs not. (33.3% vs 11.5%; 13.3% vs 1.9% respectively). Conclusion: Documentation of frailty in the EMR was rare and it was associated with a lower likelihood of providing advance care planning. These findings suggest a need for consistent frailty assessment, which might promote patient-centered care.

scholarly journals 46 Promoting Advance Care Planning of Patients with Parkinsonism in the Community

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i12-i42
Author(s):  
C Khuang Lim ◽  
C Miller ◽  
T Jones
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
End Of Life ◽  
Advance Care Planning ◽  
Care Planning ◽  
Advanced Care Planning ◽  
Do Not Resuscitate ◽  
Community Based ◽  
Care Plans ◽  
Advance Care

Abstract Introduction NICE guideline recommends that all patients with Parkinson’s disease should be reviewed every 6–12 months and offered opportunities to discuss Advanced Care Planning (ACP) (1, 2). There is evidence demonstrating that Advanced Care Plans results in shorter length of stay in the last year of life and lower hospital costs (2, 3). A local baseline audit showed that Advanced Care Planning was not performed adequately. Methods A local baseline audit on community care home patients with Parkinsonism was completed in February 2018. A community-based Parkinson’s clinic was commenced in June 2018. Patients with parkinsonism who were unable to attend hospital clinics due to underlying frailty, neuropsychiatry and physical issues, were reviewed. At each visit, advice was provided on medicines management and there were discussions around Advance Care Planning. A re-audit was completed in August 2019. Patient’s Electronic Patient Records were scrutinised to evaluate progress and identify those who had died. Data was analysed using Microsoft Excel. Results The initiative contributed directly to end of life care in 7/17 patients. Parkinson’s disease medications were rationalised in 11/17 (64.70%). 14/17 (82.35%) had a community-based Do Not Resuscitate order completed. Conclusions The community Parkinson’s clinic service promoted Advance Care Planning in patients with Parkinsonism. This service provides specialist input in frail older people with Parkinsonism who were unable to attend hospital clinic, promoting end of life choices around where they wished to die and avoiding unnecessary hospitalisation in the final stages of their life.

scholarly journals The Role of Advance Care Planning in Cancer Patient and Caregiver Grief Resolution: Helpful or Harmful?

2021 ◽  
Author(s):  
Francesca B Falzarano ◽  
Holly Gwen Prigerson ◽  
Paul Kevin Maciejewski
Keyword(s):  
Cancer Patients ◽  
Family Caregivers ◽  
Advance Care Planning ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Prospective Longitudinal Study ◽  
Advance Care ◽  
Grief Resolution ◽  
Caregiver Grief ◽  
Prospective Longitudinal

Cancer patients and their family caregivers experience various losses when patients become terminally ill, yet little is known about the grief experienced by patients and caregivers and factors that influence grief as patients approach death. Additionally, few, if any, studies have explored associations between advance care planning (ACP) and grief resolution among cancer patients and caregivers. To fill this knowledge gap, the current study examined changes in grief over time in patients and their family caregivers and whether changes in patient grief are associated with changes in caregiver grief. We also sought to determine how grief changed following completion of advance directives. The sample included advanced cancer patients and caregivers (n=98 dyads) from Coping with Cancer III, a federally funded, multi-site prospective longitudinal study of end-stage cancer care. Participants were interviewed at baseline and at follow-up roughly 2 months later. Results suggest synchrony, whereby changes in patient grief were associated with changes in caregiver grief. We also found that patients who completed a living will (LW) experienced increases in grief, while caregivers of patients who completed a do-not-resuscitate (DNR) order experienced reductions in grief, suggesting that ACP may prompt “grief work” in patients while promoting grief resolution in caregivers.

scholarly journals Virtual Reality Video Promotes Effectiveness in Advance Care Planning

2020 ◽  
Author(s):  
Wan-Ting Hsieh
Keyword(s):  
Virtual Reality ◽  
Blood Transfusion ◽  
End Of Life ◽  
Advance Care Planning ◽  
Decision Aid ◽  
Artificial Nutrition ◽  
Care Planning ◽  
Artificial Nutrition And Hydration ◽  
Nutrition And Hydration ◽  
Advance Care

Abstract Background: In 2019, the Patient Autonomy Act went into effect, allowing Taiwanese citizens to establish legal advance decisions. In an effort to secure a more realistic and accurate perception of situations, a virtual reality video was developed by the palliative care team of Chi-Mei hospital in southern Taiwan for citizens to use before advance care planning. This study explores the change in participants’ preference and certainty regarding end-of-life decisions after using this tool. Methods: Participants were at least 20 years old and capable of reading and understanding the information provided in the written handout with information about the legal process of making an advance decision. They completed pre-test questionnaires, viewed a six-minute 360-degree virtual reality video on a portable headset and then completed a post-test questionnaire about their preference on the 5 medical options including CPR, life-sustaining treatments, antibiotics, blood transfusion, and artificial nutrition and hydration, followed by feedback on the helpfulness of the virtual reality. The control group included 40 participants who only read the handout and they also completed pre-test and post-test questionnaires. Results: After viewing the virtual reality video, preference for refusing CPR, life-sustaining treatment, antibiotics, blood transfusion, and artificial nutrition and hydration increased significantly in the virtual reality intervention group. Uncertainty regarding the 5 medical options mentioned above are significantly decreasing. The intervention was generally recognized by participants for its help of making decision. Discussion: The decrease in the number of participants who could not make decisions indicate that the virtual reality video may be helpful for users in making end-of-life decision. According to feedback, the virtual reality video helped equip users with better understanding of medical scenarios, and it is a good decision aid for advance care planning. Conclusion: This is the first study since the Patient Autonomy Act has been passed that explores the effectiveness of using a virtual reality video as a decision aid in advance care planning and reveals decreased preference of CPR, life sustaining treatment, antibiotics, blood transfusion and artificial nutrition and hydration after intervention. This decision aid proved to be an effective tool for clarifying their end-of-life care preferences.

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