scholarly journals Evaluating if an Advance Care Planning Intervention Promotes Do-Not-Resuscitate Orders by Facilitating Accurate Prognostic Awareness

2020 ◽  
Vol 18 (12) ◽  
pp. 1658-1666
Author(s):  
Fur-Hsing Wen ◽  
Chen Hsiu Chen ◽  
Wen-Chi Chou ◽  
Jen-Shi Chen ◽  
Wen-Cheng Chang ◽  
...  
Keyword(s):  
Advance Care Planning ◽  
Hierarchical Linear Modeling ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Link Type ◽  
Advance Care ◽  
And Control ◽  
Dnr Orders

Background: Issuing do-not-resuscitate (DNR) orders has seldom been an outcome in randomized clinical trials of advance care planning (ACP) interventions. The aim of this study was to examine whether an ACP intervention facilitating accurate prognostic awareness (PA) for patients with advanced cancer was associated with earlier use of DNR orders. Patients and Methods: Participants (n=460) were randomly assigned 1:1 to the experimental and control arms, with 392 deceased participants constituting the final sample of this secondary analysis study. Participants in the intervention and control arms had each received an intervention tailored to their readiness for ACP/prognostic information and symptom-management education, respectively. Effectiveness in promoting a DNR order by facilitating accurate PA was determined by intention-to-treat analysis using multivariate logistic regression with hierarchical linear modeling. Results: At enrollment in the ACP intervention and before death, 9 (4.6%) and 8 (4.1%) participants and 168 (85.7%) and 164 (83.7%) participants in the experimental and control arms, respectively, had issued a DNR order, without significant between-arm differences. However, participants in the experimental arm with accurate PA were significantly more likely than participants in the control arm without accurate PA to have issued a DNR order before death (adjusted odds ratio, 2.264; 95% CI, 1.036–4.951; P=.041). Specifically, participants in the experimental arm who first reported accurate PA 31 to 90 days before death were significantly more likely than their counterparts in the control arm who reported accurate PA to have issued a DNR order in the next wave of assessment (adjusted odds ratio, 13.365; 95% CI, 1.989–89.786; P=.008). Both arms issued DNR orders close to death (median, 5–6 days before death). Conclusions: Our ACP intervention did not promote the overall presence of a DNR order. However, our intervention facilitated the issuance of NDR orders before death among patients with accurate PA, especially those who reported accurate PA 31 to 90 days before death, but it did not facilitate the issuance of DNR orders earlier than their counterparts in the control arm.ClinicalTrial.gov Identification: NCT01912846

scholarly journals Efficacy of Normalisation of Advance Care Planning (NACP) for people with chronic diseases in hospital and community settings: a quasi-experimental study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Sarah Jeong ◽  
Peter Cleasby ◽  
Se Ok Ohr ◽  
Tomiko Barrett ◽  
Ryan Davey ◽  
...  
Keyword(s):  
Experimental Study ◽  
Chronic Diseases ◽  
Advance Care Planning ◽  
Fixed Effects ◽  
Care Planning ◽  
Community Settings ◽  
Link Type ◽  
Quasi Experimental ◽  
Advance Care ◽  
And Control

Abstract Background Advance Care Planning (ACP) has emerged to improve end-of-life processes and experiences. However, the available evidence presents the gloomy picture of increasing number of older people living with chronic diseases and the mismatch between their preferences for and the actual place of death. The study aimed to investigate the efficacy of normalisation of an Advance Care Planning (NACP) service delivered by specially trained Registered Nurses (RNs) in hospital and community settings. Methods A quasi-experimental study was conducted involving 16 sites (eight hospital and eight community sites) in Australia. Patients who were aged ≥18 years, who had at least one of nine chronic conditions, and who did not have an Advance Care Directive (ACD) were offered the NACP service. ACP was normalised as part of routine service on admission. The intervention, NACP, was a series of facilitated conversations about the components of ACP. The primary outcomes which included the completion of ACDs, and/or appointment of an Enduring Guardian (EG), were assessed in both intervention and control sites at pre and post intervention stages. Numbers of patients who completed an ACD or appointed an EG were described by count (percentage). ACD completion was compared between intervention and control sites using a logistic mixed effects regression model. The model includes fixed effects for treatment group, period, and their interaction, as well as random site level intercepts. Secondary model included potentially confounding variables as covariates, including age, sex and chronic diseases. Results The prevalence of legally binding ACDs in intervention sites has increased from five to 85 (from 0.85% in pre to 17.6% in post), whereas it has slightly decreased from five to 2 (from 1.2% in pre and to 0.49% in post) in control sites (the difference in these changes being statistically significant p < 0.001). ACD completion rate was 3.6% (n = 4) in LHD1 and 1.2% (n = 3) in LHD2 in hospital whereas it was 53% (n = 26) in LHD1 and 80% (n = 52) in LHD2 in community. Conclusions The study demonstrated that NACP service delivered by ACP RNs was effective in increasing completion of ACDs (interaction odds ratio = 50) and was more effective in community than hospital settings. Involvement of various healthcare professionals are warranted to ensure concordance of care. Trial registration The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246) on 03/10/2018. The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx

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.

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 Differences in advance care planning among nursing home care staff

2021 ◽  
pp. 096973302199418
Author(s):  
Gilissen Joni ◽  
Wendrich-van Dael Annelien ◽  
Gastmans Chris ◽  
Vander Stichele Robert ◽  
Deliens Luc ◽  
...  
Keyword(s):  
Nursing Home ◽  
Nursing Homes ◽  
Confidence Interval ◽  
Advance Care Planning ◽  
Self Efficacy ◽  
Odds Ratio ◽  
Mean Difference ◽  
Care Staff ◽  
Care Planning ◽  
Advance Care

Background A team-based approach has been advocated for advance care planning in nursing homes. While nurses are often put forward to take the lead, it is not clear to what extent other professions could be involved as well. Objectives To examine to what extent engagement in advance care planning practices (e.g. conversations, advance directives), knowledge and self-efficacy differ between nurses, care assistants and allied care staff in nursing homes. Design Survey study. Participants/setting The study involved a purposive sample of 14 nursing homes in Flanders, Belgium. Nurses, care assistants and allied care staff (e.g. social workers, physical therapists) completed a survey. Ethical considerations The study was approved by the University Hospital of Brussels (B.U.N. 143201834759), as part of a cluster randomized controlled trial (clinicaltrials.gov NCT03521206). Results One hundred ninety-six nurses, 319 care assistants and 169 allied staff participated (67% response rate). After adjusting for confounders, nurses were significantly more likely than care assistants to have carried out advance care planning conversations (odds ratio 4; 95% confidence interval 1.73–9.82; p < 0.001) and documented advance care planning (odds ratio 2.67; 95% confidence interval 1.29–5.56; p < 0.001); differences not found between allied staff and care assistants. Advance care planning knowledge total scores differed significantly, with nurses (estimated mean difference 0.13 (score range 0–1); 95% confidence interval 0.08–0.17; p < 0.001) and allied staff (estimated mean difference 0.07; 95% confidence interval 0.03–0.12; p < 0.001) scoring higher than care assistants. We found no significant differences regarding self-efficacy. Discussion While nursing home nurses conducted more advance care planning conversations and documentation than allied care staff and care assistants, these two professional groups may be a valuable support to nurses in conducting advance care planning, if provided with additional training. Conclusions Allied care staff and care assistants, if trained appropriately, can be involved more strongly in advance care planning to enhance relational and individual autonomy of nursing home residents, alongside nurses. Future research to improve and implement advance care planning should consider this finding at the intervention development stage.

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.

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.

scholarly journals Increasing engagement in advance care planning using a behaviour change model: study protocol for the STAMP randomised controlled trials

BMJ Open ◽  
2018 ◽  
Vol 8 (8) ◽  
pp. e025340 ◽  
Author(s):  
Terri R Fried ◽  
Colleen A Redding ◽  
Steven Martino ◽  
Andrea Paiva ◽  
Lynne Iannone ◽  
...  
Keyword(s):  
Usual Care ◽  
Behaviour Change ◽  
Advance Care Planning ◽  
Randomised Controlled Trials ◽  
Institutional Review Boards ◽  
Controlled Trials ◽  
Care Planning ◽  
Link Type ◽  
Advance Care ◽  
Randomised Controlled

IntroductionAdvance care planning (ACP) is a key component of high-quality end-of-life care but is underused. Interventions based on models of behaviour change may fill an important gap in available programmes to increase ACP engagement. Such interventions are designed for broad outreach and flexibility in delivery. The purpose of the Sharing and Talking about My Preferences study is to examine the efficacy of three behaviour change approaches to increasing ACP engagement through two related randomised controlled trials being conducted in different settings (Veterans Affairs (VA) medical centre and community).Methods and analysisEligible participants are 55 years or older. Participants in the community are being recruited in person in primary care and specialty outpatient practices and senior living sites, and participants in the VA are recruited by telephone. In the community, randomisation is at the level of the practice or site, with all persons at a given practice/site receiving either computer-tailored feedback with a behaviour stage-matched brochure (computer-tailored intervention (CTI)) or usual care. At the VA, randomisation is at the level of the participant and is stratified by the number of ACP behaviours completed at baseline. Participants are randomised to one of four groups: CTI, motivational interviewing, motivational enhancement therapy or usual care. The primary outcome is completion of four key ACP behaviours: identification of a surrogate decision maker, communication about goals, completing advance directives and ensuring documents are in the medical record. Analysis will be conducted using mixed effects models, taking into account the clustered randomisation for the community study.Ethics and randomisationThe studies have been approved by the appropriate Institutional Review Boards and are being overseen by a Safety Monitoring Committee. The results of these studies will be disseminated to academic audiences and leadership in in the community and VA sites.Trial registration numbersNCT03137459andNCT03103828.

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.

Sign in / Sign up

Export Citation Format

Share Document