Making the Informal Formal: Discussing and Completing Advance Care Plans in Care Dyads with Cognitive Impairment

Background Discussing advance care planning (ACP) with care partners may be a steppingstone to the completion of advance directives (ADs) for persons with cognitive impairment (PwCIs). Objectives To examine whether PwCI-reported occurrence of and PwCI-care partner agreement about ACP discussions are associated with completion of ADs. Design and Subjects We conducted a secondary, cross-sectional analysis of data from 1672 PwCI-care partner dyads in the BLINDED study. PwCIs were Medicare beneficiaries in the US, aged >65 years, and diagnosed with mild cognitive impairment or dementia. Care partners were identified by PwCIs as being most involved in their health care. Measurements PwCIs’ completion of ADs was determined by 1 or more affirmative responses to dichotomous indicators for formalizing a living will, medical directive, or durable power of attorney for health care. Discussion occurrence was based on PwCI reports and agreement between PwCI and care partner reports of prior conversations about PwCIs’ ACP preferences between PwCIs and care partners. Results In logistic regression models adjusted for PwCI and care partner characteristics, PwCIs who had (vs. had not) discussed ACP were 10% more likely to complete ADs. PwCIs from dyads agreeing (vs. disagreeing) a discussion occurred were 7% more likely to complete ADs. PwCIs from care dyads in agreement (vs. disagreement) about non-discussion were 11% less likely to formalize ADs. Conclusions Discussing ACP with care partners plays a direct, positive role in completing ADs among PwCIs. Health care providers who approach ACP as a dyadic, communicative decision-making process from the outset may facilitate PwCIs’ uptake of ADs.

„PACIJENTOVO PISMO“ KAO PRAVNI OSNOV ZA PRIMENU PASIVNE EUTANAZIJE

The subject of the paper is the relationship between the duties of physicians and other medical professionals towards the dying patient (as a provider of medical services) and the patient's right to personal choice and preservation of his own right to self-determination in relation to body and life, which is a special subjective civil right. The author discusses the legal-medical (but also ethical) issue of the patient's ability to freely decide not to agree to a medical measure of artificial prolongation of life or suspension of already started measures. The issue is examining the limits of the so-called permissibility of “passive euthanasia”, which is indirectly recognized in domestic law by the Law on Patients' Rights and the legal basis for its application in one particular modality, the so-called "Patient letter" (living will) which is an established legal instrument in some foreign legislation and practice. Analyzing the experience of some foreign countries, the author supports the introduction of such an institute - as a kind of anticipated directives in domestic law, referring to the patient's constitutional right to self-determination, which embodies the supreme good, even more valuable than (unwanted) life. Such a solution is in line with the principle of human will autonomy, freedom to dispose of life as a personal good, and potentially a reflection of the so-called "the right to die", which is the reverse of the right to life

Change of Health and Change of Preferences on Life-Sustaining Treatment: Evidence From a Longitudinal Study

Background Decision-making for end-of-life (EoL) care is not a one-off choice. Older adults may change their preferences for life-sustaining treatments along their health continuum. Guided by prospect theory, we hypothesize that perceived change in health status is a driver behind preference changes. Method: Health and Retirement Study Wave 2012 to 2018 data. Sample is limited to 5,646 older adults who reported whether they requested to limit treatment in living will during two waves of data. Two possible preference changes were tested: from limited to default care and from default to limited care. Change in health status was indicated by changes (1=same, 2=improve, 3=decline) in physical pain, general health, activities of daily living, instrumental activities of daily living (IADL), and number of diagnoses. Multilevel logistic regression models were used to understand how change of health status was related to changes in EoL preferences. Results 700 older adults changed their preferences some time in 8 years. Those who changed their preferences are more likely to be older and not married, and to have lower socioeconomic background. Older adults who experienced deteriorated pain levels were more likely to change their preferences from default to limited care (OR=3.77, p<.05) and less likely to change from limited to default care (OR=0.63, p<.05). Change in IADL is also a significant predictor of change of preferences. Implication: The findings highlight the importance of periodic reassessment of EoL care preferences with older adults. We discuss policy and practice implications regarding health changes as underlying mechanisms of preference changes.

Implementation of 4M Age-Friendly Care in Arkansas Rural Primary Care Clinics Led to Improved Advance Care Planning

The 4Ms Age-Friendly Framework has been introduced and implemented into nearly 2,000 primary care practices across the United States by Geriatric Workforce Enhancement Program’s (GWEP) educational efforts. The AR Geriatric Education Collaborative, the GWEP in Arkansas, has provided monthly trainings to a rural federally qualified healthcare clinic system and educated clinicians about how to complete a Medicare Annual Wellness Visit (AWV) that was inclusive of an advance care plan. Specific educational training including the two main components of an ACP: living will preferences and medical power of attorney were reviewed as their role into “What Matters” was explained. Before 4Ms Age Friendly training, baseline data showed only 7% of older adults (OAs) had an established ACP in site 1 and 33% in site 2. After training, the rate of ACP rose to 47% in site 1 and 59% in site 2. During the training, not only were the two main components reviewed but case studies were provided about what questions to ask surrounding the “What Matters” question as a guide to further discuss an OAs wishes, priorities and end-of-life care. This project demonstrated that implementation of 4Ms Age-Friendly Care not only improves the completion of advance care plans but also further enhances the overall care of the older adult when “what matters” most to the older adults is known and communicated.

Stumbling and Growing: A Bibliometric Study of Academic Publications of Palliative Care in Mainland China for 2010–2020

Background: Mainland China is facing increasing demand for palliative care and has launched related policies after 2010. Research and publications are important for sustainable development of palliative care, and should be encouraged by policy. Objectives: This study aimed to describe the development of palliative care-related publications in Mainland China in various aspects. Design: We searched Web of Science, Scopus, PubMed, Cumulative Index of Nursing and Allied Health Literature, Ovid MEDLINE, and China National Knowledge Infrastructure for publications from Mainland China for 2010–2020, with the topic words “hospice,” “palliative care,” “end-of-life care,” or “terminal care.” The publishing year, region, impacts, journals, publication types, and topics were analyzed. Results: A total of 3682 publications were identified, 754 of them (20.5%) published in Chinese core journals or international journals. The annual publication number and impact factor rose rapidly after 2016 and dropped again in 2020. There is no specialized palliative care journal in Mainland China. The publication numbers differed significantly between East and Western China and were closely linked to the economy ( R2 = 0.8120, P < .0001). The megacities Beijing and Shanghai comprised 2.6% of the total population of Mainland China but produced 22.6% of the publications. Palliative care in cancer patients was the most common topic (37.7% of the publications). Practical keywords such as “pain management” and “living will” gained popularity recently. Conclusions: Palliative care-related research and publication in Mainland China are growing in recent years. However, the early stage growth is unstable, with a conspicuous regional disparity. Policies should be designed, in an equitable manner, to encourage original research and publication of palliative care.

Modeling of the Potential Effect of Revaccination against Whooping Cough in Children Aged 6–7 and 14 years within the Framework of the National of preventive vaccinations

Relevance. Currently, the national calendar of preventive vaccinations does not provide for revaccination against whooping cough in children over the age of 18 months. At the same time, the epidemiological and economic feasibility of revaccination against whooping cough in children aged 6–7 years, as well as adolescents, has been demonstrated in world practice. Aim. Based on a mathematical model, develop a forecast of pertussis morbidity dynamics and assess the potential socio-economic damage under the current and expanded vaccine prophylaxis algorithms.Methods. Mathematical modeling of the potential effect of revaccination against whooping cough in children aged 6–7 years (scenario 1) and at 6–7 years and 14 years (scenario 2) was carried out within the framework of the national calendar of preventive vaccinations. A simulation dynamic mathematical model is constructed that allows predicting the development of the epidemiological process of whooping cough on the basis of the dynamics of the main indicators of its prevalence in the population that developed in previous years. The model took into account dynamic changes in the preventive effectiveness of vaccinations and the potential level of underestimation of morbidity. The obtained arrays of indicators served as the basis for extrapolating trends in morbidity and mortality until 2034.The calculation of epidemiological benefits was carried out in the metrics of prevented loss of years of life under the two scenarios under consideration in comparison with the current vaccination algorithm. The calculation of the economic effect was carried out on the basis of the obtained indicators of epidemiological benefits in the metrics of the monetary equivalent of the average cost of a year of life, taking into account the projected inflation coefficients until 2034.Results. The projected decrease in the number of years of life lived in a state of illness, in comparison with the current situation, will total 44.5 thousand years for the period 2019–2034 under scenario 1 and 66.7 thousand years under scenario 2. The socio-economic damage from prevented cases of the disease, expressed in the monetary equivalent of the average cost of living, will decrease by 28.6% (scenario 1) or 42.0% (scenario 2).Conclusions. A comparison of the received public benefits with the costs of vaccination shows that the expansion of the NCPP with additional revaccinations against whooping cough (at 6–7 years or at 6–7 and at 14 years) is advisable both in epidemiological and economic aspects.

Activate, Inactive, Activity.

<p>Sports facilities in the Central Wellington area cater to physical activity for only a select portion of the population. Most of the time use is determined by the posts at each end of the field. Through the process of design research, I will test ways of maximizing space which is not used in thesefacilities to bring more physical and recreational options to the wider community. The theory of active living will influence the design as it has been associated with preventing diseases andimproving mental health. However, to increase physical activity in the community there needs to be new and improved devices that will encourage physical and social activity. This researchassignment will test what sports and physical activities can co-exist in the same space, maximizing the usage of land in an undulating and shrinking city. Reshaping these facilities will offer options that do not require consistent commitment and can be used whenever the user can dedicate time to recreation, shifting away from traditional sport and using other solutions to keep the community active. This I hope will stimulate and increase community mental health and reduce the risks of non-communicable diseases.</p>

Activate, Inactive, Activity.

<p>Sports facilities in the Central Wellington area cater to physical activity for only a select portion of the population. Most of the time use is determined by the posts at each end of the field. Through the process of design research, I will test ways of maximizing space which is not used in thesefacilities to bring more physical and recreational options to the wider community. The theory of active living will influence the design as it has been associated with preventing diseases andimproving mental health. However, to increase physical activity in the community there needs to be new and improved devices that will encourage physical and social activity. This researchassignment will test what sports and physical activities can co-exist in the same space, maximizing the usage of land in an undulating and shrinking city. Reshaping these facilities will offer options that do not require consistent commitment and can be used whenever the user can dedicate time to recreation, shifting away from traditional sport and using other solutions to keep the community active. This I hope will stimulate and increase community mental health and reduce the risks of non-communicable diseases.</p>

Home alone: A population neuroscience investigation of brain morphology substrates

As a social species, ready exchange with peers is a pivotal asset - our 'social capital'. Yet, single-person households have come to pervade metropolitan cities worldwide, with unknown consequences in the long run. Here, we systematically explore the morphological manifestations associated with singular living in ~40,000 UK Biobank participants. The uncovered population-level signature spotlights the highly associative default mode network, in addition to findings such as in the amygdala central, cortical and corticoamygdaloid nuclei groups, as well as the hippocampal fimbria and dentate gyrus. Sex-stratified analyses revealed male-specific neural substrates, including somatomotor, saliency and visual systems, while female-specific neural substrates centred on the dorsomedial prefrontal cortex. In line with our demographic profiling results, the discovered neural imprint of living alone is potentially linked to alcohol and tobacco consumption, anxiety, sleep quality as well as daily TV watching. The secular trend for solitary living will require new answers from public-health decision makers.