Group-based educational intervention for advance care planning in primary care: a quasi-experimental study in Japan

<p>目的：在台灣，民眾可以透過「預立醫療照護諮商」門診簽署「預立醫療決定」，然而諮商門診目前仍未被廣泛使用。本研究目的是希望了解影響民眾來本院參與預立醫療照護諮商門診和簽署完成預立醫療決定的相關因素。</p> <p>方法：我們使用回朔性病歷研究，研究對象為針對2019年1月1日到2020年2月28日來本院諮商門診的參與者。校正相關共變項後，使用羅吉斯回歸評估完成預立醫療決定的相關影響因素。</p> <p>結果：總共144位參加者被納入研究，預立醫療決定完成率為90.2%。較多的參加者為年齡較大、女性、較為健康、費用較低和之前已簽過預立安寧緩和醫療暨維生醫療抉擇意願書。校正相關共變項後，之前已簽過預立安寧緩和醫療暨維生醫療抉擇意願書的參加者有較高的機會完成預立醫療決定(aOR 14.56, 95% CI 1.62-131.23)；參加者與有社工參與的諮商團隊進行諮商有較高的機會完成預立醫療決定(aOR 5.59, 95% CI 1.05-28.87)。</p> <p>結論：諮商門診的參加者其預立醫療決定完成率高，之前已簽過預立安寧緩和醫療暨維生醫療抉擇意願書的參加者有較高機會完成預立醫療決定。諮商時，針對參加者個別情況進行討論和使用輔助資料理解諮商內容，協助完成預立醫療決定。未來能針對社區民眾衛教宣導預立醫療照護諮商門診的諮詢服務，針對從未簽過預立安寧緩和醫療暨維生醫療抉擇意願書的民眾更需進一步的推廣。</p> <p> </p><p>Purpose: Advance care planning (ACP) is the process of communicating a person’s preferences regarding future medical care. In Taiwan, people can visit an ACP outpatient clinic and complete advance directives (AD). ACP is an emerging medical service, and information about completing AD is lacking. The aim of this study was to investigate the factors affecting AD completion among ACP clinic outpatients at a regional hospital in southern Taiwan.</p> <p>Methods: This retrospective study used chart reviews to evaluate participants who attended an ACP outpatient clinic from 1 January 2019 to 28 February 2020. AD completion was analyzed using logistic regression after adjusting for covariates including previously signing do-not-resuscitate (DNR) forms.</p> <p>Results: A total of 144 participants were included, and the AD completion rate was 90.2%. Participants attending ACP sessions were more likely to be older, female, having a high school education and below, better health status, paying less for ACP sessions, and previously signing DNR forms. After adjusting for the covariates, participants who had previously signed DNR forms were more likely to complete AD (aOR 14.03, 95% CI 1.56-126.06). In addition, the presence of a social worker in the ACP team was significantly associated with higher AD completion (aOR 5.74, 95% CI 1.05-31.32).</p> <p>Conclusions: Participants previously signing DNR forms were more likely to completion AD. In addition to tailoring ACP discussions about the benefits of AD and providing supplement materials to improve AD completion, further strategies are needed to encourage the public in southern Taiwan to visit ACP outpatient clinics, especially for those who were unfamiliar with concepts such as DNR or life-sustaining treatment at the end of life.</p> <p> </p>

1 Background: Advance care planning (ACP), which includes advance directive (AD) completion, ensures that patients receive care that is consistent with their beliefs and preferences. ACP is particularly important to patients with cancer as they have high rates of hospitalization and mortality. However, AD completion rates for oncology patients have been reported to be as low as 10%. We sought to evaluate barriers and improve AD completion rates in hospitalized oncology patients in our institution. Methods: 63 patients with cancer admitted to our inpatient oncology unit were surveyed. A multi-disciplinary team, consisting of resident physicians and social workers, was constituted to educate patients and provide assistance with AD completion. Barriers to AD completion were identified and AD completion and filing rates on patients’ discharge were calculated. Results: Most patients were female (66.6%) with mean age of 63.8 years. Majority of patients had stage IV cancer (71.4%) and were receiving palliative treatment (80.9%). Only 9.5% (6/63) of the patients had completed AD on file. However, 92% of the patients had previously heard about AD. After intervention, the AD filing rate improved to 41.2% (26/63). Some of the patient-reported barriers were needing more time to discuss with family (28.5%), wanting to file in clinic (23.8%), too sick to make decision (6.3%) and did not think they needed it (4.7%). Conclusions: AD completion rate in hospitalized oncology patients in our institute was lower than anticipated. We identified the barriers and improved the AD filing rate, however there is room for further improvement. While AD discussion and filing should ideally be done in clinic, hospitalization is an opportunity that should not be missed to educate and assist completion of AD. [Table: see text]

Chinese Americans' attitudes toward advance directives: An assessment of outcomes based on a nursing-led intervention

Ethical Considerations About Clinician Reimbursement for Advance Care Planning

Advance directives (ADs) and advance care planning (ACP) aid in expressing an individual's preferences and guide future medical decision-making. Despite the potential of ADs and ACP to positively impact care, consistently low rates of ADs and ACP (5%-39%) have been documented. The purpose of this project was to increase understanding and participation in the ACP process among rural-dwelling community members. A pre-post repeated measures design with an evaluation component to measure understanding, completion, discussion, and dissemination of ADs and ACP. A sample of N = 40 were recruited to participate in a one-time nurse practitioner-led Five Wishes workshop delivered in a community setting. Postworkshop evaluations indicated an overall acceptance and understanding of ADs and ACP. Completion rates of ADs and discussion in the ACP process significantly increased at 1-month follow-up. Nurses and advanced practice nurses are well positioned to educate individuals and facilitate the ACP process. There is a need to educate individuals on importance of sharing their AD wishes with their family and primary care provider. This nurse practitioner-led workshop using the Five Wishes demonstrated the feasibility and potential effectiveness of initiating the ACP process in the community.

16 Background: Advance Care Planning (ACP) is central to patient-centered care and helps assure treatment aligns with a patient’s goals, values, and priorities. ACP is often poorly incorporated into the hematopoietic stem cell transplantation (HSCT) population, with reported advance directive (AD) rates of 23-50%. At City of Hope National Medical Center (COH), concerted efforts to improve the overall number of ADs in HSCT was undertaken and evaluated. Methods: The Department of Supportive Care Medicine at COH, in collaboration with medical faculty and administrative support, created a patient-centered ACP program. The first two years (2013/2014) broadly focused on all new COH patients. The last two years (2015/2016) included a specific focus on patients undergoing HSCT. The primary goal was a completed AD in the electronic medical record before day 0 of transplant. In addition to provider and transplant team engagement, major time points for supportive care integration to facilitate AD completion were identified including: 1) registration, 2) new patient orientation, 3) the clinical visit when transplant was decided, 4) pre-transplant education class, 5) clinical social work psychosocial assessment visit, and 6) the pre-transplant hospital days. AD completion rates were calculated with Odds Ratio and Mantel-Haenszel Chi-Square using Epi Info StatCalc. Results: Between 2012 and 2016 at COH, 1784 transplants were performed. For HSCT patients in 2012, baseline AD capture rate before day 0 of transplant was 28.6%. With the institutional AD program, the AD capture rate before day 0 of transplant was 31.6% for 2014, compared with 2012 [odds ratio, 1.17(95% CI, 0.85-1.60); p = .33]. With both institutional and hematology specific programs, AD capture rate before day 0 was 69.5% for 2016, compared to 2014[odds ratio, 4.30 (95% CI, 3.14-5.91); p < .001]. Conclusions: Compared to 2012, the institutional AD program in 2014 insignificantly impacted HSCT AD completion rates. Improving the rate of AD completion from 28.6% to 69.5% in HSCT patients required both institutional AD efforts and a targeted program. Nevertheless, more work is needed to improve AD completion rates before transplant to 100%.

"I Wish Someone had Asked Me Earlier"-Perspectives on Advance Care Planning in Surgery.

20 Background: Advance Care Planning (ACP) is a central component of patient-centered care, helping ensure patient values and preferences guide clinical decisions. Patient navigators have been utilized effectively in healthcare for numerous roles, and more recently for ACP. At City of Hope National Medical Center (COH), an ACP-focused navigator was hired to support patients, families, and staff with Advance Directive (AD) notarization and primary ACP conversations. Methods: The Department of Supportive Care Medicine at COH with significant institutional collaboration and administrative support created a patient-centered ACP program and marketing campaign, called “Plan Today for Tomorrow.” In 2016, an ACP navigator joined the team to facilitate AD completion. Referral to the ACP navigator occurred either through staff endorsement and/or the institution’s technological screening platform deployed in a majority of COH outpatient clinics. Staff referrals came from physicians, clinical social workers, nurses, or from the Sheri & Les Biller Patient and Family Resource Center. Prior to the ACP navigator, all referrals were addressed by Clinical Social Workers (CSWs). Results: In a review of 14 months of data, the ACP navigator followed up on 1,125 referrals, 574 were from staff, while 551 were from the institutional tablet-based screening platform. Follow-up on staff referrals resulted in an 86% AD completion rate. Follow-up on tablet-based screening resulted in a 23% AD completion rate. Conclusions: The presence of an available onsite ACP-focused navigator was more effective in facilitating AD completion of staff generated AD referrals as compared to AD completion of tablet-based patient screening AD referrals. The presence of the ACP navigator to facilitate AD completion decreased workload for CSWs, creating increased opportunity for CSWs to work at the top of their professional license. Further work is needed to increase the effectiveness of AD completion from tablet-based screening referrals.

Advance care planning (ACP) is becoming increasingly important in the primary care setting because of its positive impact on the end-of-life care. We aimed to investigate the relationship between patient experience of primary care and ACP. This cross-sectional study was conducted in 28 primary care clinics in Japan. We assessed patient experience of primary care using a Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided) and community orientation. The primary outcome measures were ACP discussion between patients and primary care providers and completion of advance directives (AD). We used a generalized linear mixed model to adjust clustering within clinics and individual covariates. Data were analysed for 535 primary care patients. After adjustment for patients' sociodemographic and health characteristics, the JPCAT total score was found to be significantly associated with ACP discussion [odds ratio (OR) per 1 SD increase = 4.33; 95% confidence interval (CI), 2.53-7.47] but not with completion of AD (OR per 1 SD increase = 1.42; 95% CI, 0.94-2.12). All domains of JPCAT, which represent attributes of primary care, had positive associations with ACP discussion. First contact and comprehensiveness (services provided) domain scores were significantly associated with completion of AD. We found that better patient experience of primary care was strongly associated with ACP discussion. Our findings reinforce the significance of patient experience in primary care as part of quality end-of-life care.

This study aimed to examine the effects of an advance care planning (ACP) group which was developed by social workers in Hong Kong for older adults. A quasi-experimental study was conducted. Participants were recruited from 14 residential care homes. The ACP intervention group included 59 participants for analyses, and the control group 58. Three major outcomes were measured at two time points: (a) Quality-of-life concerns, (b) End-of-life preference and (c) Advance directive (AD)-related outcomes (awareness of AD, AD completion, willingness to complete AD and communication with family members about AD). Findings indicate that the ACP group enhanced participants' awareness of AD compared with the control group. Participants were also more willing to complete AD, and more participants communicated with family members about AD after participating in the ACP group. No significant difference was found in other outcomes. This study demonstrates the efforts of social workers in promoting ACP in Hong Kong and the effectiveness of an ACP group for enhancing older adults' awareness of AD. Findings support the role of social workers in promoting ACP for deprived groups, like frail older adults. The ACP group could be considered a first step in enhancing older adults' awareness of and willingness to discuss end-of-life issues. Further follow-up is required to develop individualised ACP for older adults.

A letter to your care providers: implementation and analysis of a letter-based advance care planning initiative for gynecologic oncology patients

Purpose: Chronic Obstructive Pulmonary Disease (COPD) is one of the few causes of mortality and COPD patients are increasing especially aged 75 years and older in Japan. Advance care planning (ACP), which involves patients-provider communication about end-of-life care, is important for COPD patients to promote end-of-life discussion. This study reviewed completion rates of advance directives (AD) and related factors to ACP discussion in COPD patients. Methods: A systematic review was conducted searching of PubMed and CINAHL from 1992 to 30 June 2016. Keywords such as “Chronic Obstructive Pulmonary Disease (COPD)”, “advance care planning”, “advance directives”, “completion”, “factors”, and “predictors” were used to select the articles. Abstracts of the search results were reviewed according to inclusion criteria which described completion rates of AD and factors related to ACP process. Results: Ten articles were included for the review regarding the study purpose. Qualitative research design was used 5 studies of 10. Completion rates of AD were from 17% to 61%. A study of outpatient palliative care program for COPD reported that documented advance care plan at the initial appointment 0% changed 61% at follow-up. A multicenter, prospective, longitudinal study showed preferences regarding CPR or MV changed in 38.3% of the patients during the follow-up period, and related factors were generic health status, mobility, symptoms of anxiety and depression. Conclusion: AD Completion rates and factors related to ACP process were well-not examined in COPD. Professional support to COPD patients is important, therefore, respiratory practitioners must choose the right time to promote ACP discussion.

Achieving advance care planning in diverse, underserved populations

Improving Advance Care Planning in Outpatients With Decompensated Cirrhosis: A Pilot Study

Objectives:Published research in disparities in advance care planning, palliative, and end-of-life care is limited. However, available data points to significant barriers to palliative and end-of-life care among minority adults. The main objective of this scoping review was to summarize the current published research and literature on disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanc Blacks.Methods:The scoping review method was used because currently published research in disparities in palliative and hospice cares as well as advance care planning are limited. Nine electronic databases and websites were searched to identify English-language peer-reviewed publications published within last 20 years. A total of 147 studies that addressed palliative care, hospice care, and advance care planning and included non-Hispanic Blacks were incorporated in this study. The literature review include manuscripts that discuss the intersection of social determinants of health and end-of-life care for non-Hispanic Blacks. We examined the potential role and impact of several factors, including knowledge regarding palliative and hospice care; healthcare literacy; communication with providers and family; perceived or experienced discrimination with healthcare systems; mistrust in healthcare providers; health care coverage, religious-related activities and beliefs on palliative and hospice care utilization and completion of advance directives among non-Hispanic Blacks.Discussion:Cross-sectional and longitudinal national surveys, as well as local community- and clinic-based data, unequivocally point to major disparities in palliative and hospice care in the United States. Results suggest that national and community-based, multi-faceted, multi-disciplinary, theoretical-based, resourceful, culturally-sensitive interventions are urgently needed. A number of practical investigational interventions are offered. Additionally, we identify several research questions which need to be addressed in future research.