Care Planning Practices Research Articles

Advance Care Planning Practices For Nursing Home Residents Referred To Specialist Palliative Care In An Acute Hospital Setting

Abstract Background Advance care planning (ACP) is a structured process of discussion between patients, their loved ones and health care professionals, which aims to establish and record an individual’s goals and preferences for future medical treatment and care. It is of significant relevance to nursing home residents, a comorbid and frail population at high risk of clinical deterioration. Methods This prospective, observational study included all nursing home residents referred to an inpatient specialist palliative care (SPC) service in a model four hospital over a six-month period (November 2023 to May 2024). Basic clinical and demographic information as well as data on functional status and advance care planning was anonymised and collated using Microsoft excel. Results 36 patients (mean age 79 years) were recruited. 36% (n=13) were referred within 48 hours of admission. The average Australia-modified Karnofsky Performance Scale score was 40 on admission. 94% (n=34) had a clinical frailty score of ≥7 on admission. 72% (n=26) had an advance care plan in the nursing home. However, 22% (n=8) had not recorded their wishes pertaining to hospital readmission and 3 patients were admitted despite documenting a preference to remain in the nursing home. 53% (n=19) had not documented their preferred place for end-of-life care. 69% (n=25) died in hospital. Conclusion Most nursing home residents referred to the inpatient SPC team had severe frailty and died in hospital, reflecting the prognostic implications of severe frailty. Crucial components of the advance care plan were omitted in a significant proportion of patients, which may have influenced their referral to hospital. Provision of increased support to staff caring for older, frail adults in the residential care setting should be considered to enhance ACP.

Structure of Advance Care Planning Practice by Home Health Nurses for Multigenerational Families With Dependent Children and Terminally Ill Grandparents

The present study aimed to identify the structure of advance care planning (ACP) practices implemented by home health nurses (HHNs) for multigenerational families with dependent children and terminally ill grandparents. Interviews of 20 HHNs were conducted. The grounded theory approach was used to describe the interactions among families with dependent children, terminally ill grandparents, and HHNs. The results showed that the structure of ACP practices for multigenerational families with dependent children and terminally ill grandparents was composed of 2 levels. First, HHNs were providing the underlying foundational “Practice of supporting end-of-life care (EOL care) at home” for family members from 2 generations: sandwich generation caregivers (SGCs) and terminally ill grandparents. Second, they were providing “Practices that connect multiple generations,” “Practices that address the children,” and “Practices that involve hands-on experience and communication” for multigenerational families with dependent children and terminally ill grandparents. Practices based on providing stability among family members from 2 generations, SGCs and terminally ill grandparents, were the nursing practice structure that activated ACP for multigenerational families with dependent children and terminally ill grandparents.

Nurses' engagement in advance care planning practices: A descriptive cross-sectional study.

To describe and compare nurses' awareness of, attitudes toward, and participation in advance care planning, as well as related facilitators and challenges, in four types of healthcare settings. A cross-sectional descriptive study. Four hundred and ninety-eight registered nurses from tertiary, secondary and primary healthcare institutions, along with long-term care centres in South Korea, participated in an investigator-developed online survey. The collected data were analysed using descriptive statistics, chi-squared test, one-way ANOVA, and binary logistic regression. Participants were on average 30.6 ± 7.3 years old, mostly female (95.4%), employed as staff nurses (95.4%), held bachelor's degrees or higher (84.1%), and had worked for less than 5 years at their current institutions (69.7%). Overall, 49% of the participants were familiar with advance care planning. While most participants supported nurse involvement in advance care planning with patients and surrogates, fewer were willing to engage or recommend it. Less than half were actively engaged in advance care planning practices. A notable challenge was the lack of time due to excessive workload. Compared to those from tertiary healthcare institutions, participants from secondary and primary healthcare institutions and long-term care centres were less likely to be aware of advance care planning. Participants from secondary and primary healthcare institutions had lower odds of checking for the presence of advance directives and the physician orders for life-sustaining treatment. Nurses demonstrated low awareness and participation in advance care planning. Nurses' insufficient time and competency to conduct advance care planning in their practice should be addressed. Educational programs, initiatives (e.g. guidelines, position statements) and legal and policy-level efforts (e.g. nurse staffing, role clarification, reimbursement) are crucial to incorporate advance care planning into routine nursing practice. What problem did the study address? Nurses play an important role in advance care planning; however, limited is understood about their readiness and involvement in such practices. What were the main findings? Nurses' awareness of advance care planning practices and their participation in such practices is low across care settings. Although nurses have a positive attitude toward advance care planning, there are challenges (e.g. insufficient time to conduct advance care planning discussions and lack of relevant knowledge and skills) that impede their participation in practice. Where and on whom will the research have an impact? This study may serve as a foundation for nursing societies in countries, where advance care planning is emerging, to discuss strategies to increase nurses' competency in advance care planning and promote their participation in the practice. The STROBE checklist was followed. No patient or public contribution.

Multidisciplinary approach to advance care planning and directives in patients with end-stage renal disease: a point of view on patient-centered decision-making.

Implementing Advance Care Planning (ACP) for patients with End-Stage Kidney Disease (ESKD), particularly in the context of hemodialysis, presents significant challenges. Despite existing legal frameworks, disparities in advance care planning practices are evident across Europe. The present perspective introduces a multidisciplinary model, initiated in 2019. This model incorporates a specialized team comprising a nephrologist, a psychologist, a palliative care specialist, and an anesthesiologist/intensivist. Through this collaborative approach, we aimed to comprehensively address the intricate medical, emotional, and psychological dimensions in advance care planning. In this point of view, we discuss the strengths of our model, its potential for European Nephrology, and advocate for guidelines to enhance advance care planning implementation within the nephrology community.

Web-based questionnaire survey for exploring engagement characteristics of advance care planning in Japan: a cross-sectional study

ObjectiveDefinitive promotion of advance care planning (ACP) practices will require policy interventions tailored to the characteristics of the Japanese population and society. However, effective policies for promoting ACP are currently lacking in Japan. This study aimed to explore the characteristics of Japanese people who engaged in ACP activities through a web-based questionnaire survey, which was administered to individuals aged 25–64 years and classified into four occupational categories (non-medical/non-caregiving professionals [general population], physicians, nurses, and caregivers).ResultsThe total sample size was 1,648, with equal occupational category and age group distributions. Respondents in the general population group were less likely to discuss or document ACP than those in the other groups. Stepwise logistic regression analysis showed a significant difference in the adjusted odds ratio (aOR) of the independent variables of “attended cardiopulmonary resuscitation (CPR) training session(s)” (aOR: 1.93; 95% confidence interval [CI]: 1.18–3.15) and “having experience in performing CPR” (aOR: 2.61; 95% CI: 1.51–4.54) for respondents who discussed ACP with their families. A significant difference was observed in the aOR of the independent variable of “having experience in performing CPR” (aOR: 4.58; 95% CI: 2.30–9.13) for respondents who documented a written record of ACP.

Reliability and Validation Study of Advance Care Planning Practice Scale among Health and Social Care Professionals.

Advance care planning (ACP) is a crucial process in clinical practice, enabling individuals to articulate their care preferences and goals, with significant implications for future healthcare. However, ACP practice of health and social care professionals (HSCPs) concerning patients, or their family members are rarely explored. The objective of the study was to adapt and validate a four-item scale assessing ACP practices of HSCPs toward patients or their family members. The ACP Practice Scale was evaluated through a cross-sectional online survey administered to HSCPs in Macao, assessing its factor structure, validity, and reliability. Based on a sample of 186 valid responses, the ACP Practice Scale demonstrated satisfactory levels of validity and reliability among HSPCs in Macao. The four-item scale explained 65.87% of the variance in ACP practice and exhibited strong internal consistency, with Cronbach's alpha and McDonald's omega coefficients of 0.82. Furthermore, item factor loadings ranged from 0.71 to 0.90. The ACP Practice Scale provides reliable and valid measurements of ACP practice among HSCPs. This instrument can help to enhance our understanding of ACP practices in clinical settings and support the advancement of advance care planning.

PERSON-CENTERED CARE WHEN OLDER ADULTS WITH DEMENTIA AND THEIR FAMILY CAREGIVERS HOLD DIFFERENT CARE PRIORITIES

Abstract In person-centered care, clinicians develop care plans that incorporate “what matters most” to patients (i.e., their priorities, concerns, and preferences), a process complicated when patients’ family caregivers have their unique priorities. To investigate care planning with patients with dementia and their family caregivers, we audio-recorded, transcribed, and thematically analyzed 4 medical visits dually attended in 2022 by older patients with dementia and their spousal/adult child caregiver(s). In these visits clinicians asked both about their priorities/concerns, which mostly complemented but sometimes conflicted with each other. Older adults’ priorities related mostly to social activities and minimally to health care, emphasizing continuity. Older adults strived to resume past social activities (farmer’s market), continue enjoyable life-long activities (sports), maintain non-problematic medication regimens, and retain the same home health nurse. Caregivers’ priorities focused on emergent physical problems (patient’s worsening memory and leg pain), service access, and care coordination. When older adult and caregiver priorities did not conflict, clinicians incorporated priorities from both sources into care plans (initiated referrals for farmer’s market). When older adults and caregivers’ priorities conflicted (exercise), clinicians simultaneously acknowledged family caregiver’s concerns, expressed their (clinician) views, honored older adults’ preferences, and invited them to re-assess such preferences in future medical visits. By asking “what matters most” to both patients and their family caregivers, clinicians gain rich insights about both parties to guide care planning. Future research should examine care planning with more dementia dyads to identify care planning practices that promote both patient and caregiver outcomes and ultimately enable aging in place.

Advance Care Planning Practice Patterns Before and During a Pandemic.

Introduction: The COVID-19 pandemic resulted in introspection of the United States health care infrastructure, especially with advance care planning (ACP). Methods: This is a retrospective chart review assessing the frequency of ACP discussions and formal documents reflecting ACP wishes in an outpatient palliative medicine (PM) practice. The study site was at University Medical Center New Orleans from pre-COVID-19 surge (November 2019-February 2020) to months during and post-COVID-19 surge (March-April 2020). Results: Results showed an increase in ACP discussions during the post-COVID-19 months. Patients seen during the surge and post-COVID-19 months were more likely to discuss medical power of attorney (odds ratio [OR] = 1.78, p = 0.045) and preferred code status (OR = 2.82, p < 0.001). Conclusion: Our study showed that more ACP discussions were conducted post-COVID-19 versus pre-COVID-19. However, formal documents reflecting these wishes were lacking. These results can help guide ACP use in crisis periods and improve understanding of ACP discussions in an outpatient PM clinic.

Applying Outcomes in Community-Based Social Care Practice in England

Context: Social care outcomes (the effect of services on the quality of life of people with support needs and unpaid carers) have been proposed as a way of improving the quality and effectiveness of care. Outcomes have also been proposed as a way of reconceptualising &lsquo;needs&rsquo; that have applications in needs assessment, care planning, evaluation and care practice. Objectives: The study aimed to provide insights into social care professionals&rsquo; experiences and views on the collection and application of outcomes data in practice and what they believe are the benefits, challenges and barriers to implementation. Methods: Interviews were conducted with 25 social care professionals in England and analysed using a framework approach. Findings: Participants reported perceived benefits of using outcomes data, especially to focus effort on improving the well-being of people with support needs and carers. Perceived challenges include requirements for data collection set by funders/commissioners, the volume of data collected, difficulties in separating non-service-related influences on outcomes and the format of collection. Participants felt a more flexible approach might facilitate more meaningful conversations, rather than a &lsquo;tick-box&rsquo; exercise. Limitations: The study sample was purposive, based on established connections. It only included professionals from London and South East and Central England. Implications: Although outcomes are perceived as important in helping to improve people&rsquo;s lives, social care professionals identified a number of challenges. Further research to understand and address these challenges is needed.

End-Of-Life Care Planning and Bereavement Practices Among Adult Day Services Centers, 2018.

Introduction: This study describes the end-of-life (EOL) care planning and bereavement practices among adult day services centers (ADSC) when an ADSC participant is dying or has died. Methods: Data are from the 2018 National Study of Long-term Care Providers' biennial survey of ADSCs. Respondents were asked about the following 4 practices: 1) honoring the deceased in some public way in this center; 2) offering bereavement services to staff and participants; 3) documenting in the care plan what is important to the individual at the end of life (EOL), such as the presence of family or religious or cultural practices; and 4) discussing spiritual needs at care planning conferences. ADSC characteristics included US Census region, metropolitan statistical area status, Medicaid authorization, electronic health records (EHR) use, for-profit status, employment of aides, services provision, and model type. Results: About 50% to 30% of ADSCs offered the EOL care planning or bereavement services. Honoring the deceased was the most common practice (53%), followed by bereavement services (37%), discussing spiritual needs (29%), and documenting what is important at EOL (28%). Fewer ADSCs in the West had EOL practices relative to the other regions. The EOL planning and bereavement practices were offered more often in ADSCs that used EHRs, accepted Medicaid, employed an aide, provided nursing, hospice, and palliative care services, and were categorized as medical models, compared with ADSCs without these characteristics. Conclusion: These results highlight the importance of understanding how ADSCs provide EOL and bereavement care to participants who are near EOL.

Awareness of Disease Status Among Patients With Cancer: An Integrative Review.

As the quality of cancer care improves, oncology patients face a rapidly increasing number of treatment options. Thus, it is vital that they are full and active partners in the treatment decision-making process. Awareness of disease status has been investigated in the literature; it has been inconsistently conceptualized and operationalized. The aim of this integrative review was to develop a conceptual definition and model of the awareness of disease status among patients with cancer. Whittemore and Knafl's integrative review methodology guided this article. We obtained data through a systematic search of 8 databases. Key terms utilized were awareness, perception, truth disclosure, diagnosis, prognosis, terminal illness, status, neoplasm, and metastasis. Dates through January 2020 were searched to capture all relevant articles. Sixty-nine articles met inclusion criteria. The integrative review methodology guided the development of a conceptual definition and model. The concept of "awareness of disease status" was defined as the individual patient's understanding of being diagnosed and treated for cancer based on the multifactorial components of individual patient characteristics and contextually driven communication practices of healthcare providers. This understanding is dynamic and changes throughout the disease trajectory. These findings will inform consistency in the literature. Such consistency may improve person-centered clinical communication, care planning practices, and, ultimately, cancer-related outcomes. With a greater understanding of the complexity of patients' awareness of disease status, nurses will be able to guide their patients to make informed decisions throughout their disease trajectory.

Surgeons' perception of chance of cure predicts advance care planning practices in PDAC

Background: The optimal timing and setting for advance care planning (ACP) discussion is not well outlined for patients with high-risk malignancies, such as pancreatic ductal adenocarcinoma (PDAC), who undergo curative intent resection. Cancer patients prefer to have ACP discussions with their primary care provider given their familiarity and desire to have these discussions earlier in their disease course. The aim of this study is to evaluate surgeons’ practices regarding the timing and setting for ACP.

Nurse-Led Virtual Delivery of PIECES in Canadian Long-Term Care Homes to Support the Care of Older Adults Experiencing Behavioral Expressions During COVID-19: A Qualitative Descriptive Study.

Worldwide, the COVID-19 pandemic has resulted in profound loss of life among older adults living in long-term care (LTC) homes. As a pandemic response, LTC homes enforced infection control processes including isolating older adults in their rooms, cancelling therapeutic programs, and restricting family member visits. Social isolation negatively impacts older adults in LTC, which may result in increased rates of anxiety, depression, physical and cognitive decline, disorientation, fear, apathy, and premature death. Isolation of older adults can also cause an increase in responsive behaviours (e.g., yelling, hitting, calling out) to express frustration, fear, restricted movement and boredom. To respond to the challenges in LTC and support frontline staff, older adults and family members, a novel Registered Practical Nurse (RPN)-led delivery of the PIECESTM approach for addressing responsive behaviours among older adults with dementia using virtual training/mentoring was implemented in Canadian LTC homes. PIECESTM employs a person and family/care partner-centred, collaborative team-based approach to provide education and capacity building for nurses, engages families as active participants in care, and embeds evidence-informed practices to provide person- and family-centered care to older adults with complex needs including dementia. To describe experiences of LTC staff, family/care partners, and older adult research partners with implementing a novel RPN-led virtual adaptation of the PIECES care planning approach for responsive behaviors in two Canadian long-term care homes during the COVID-19 pandemic. Using a qualitative descriptive design, two focus groups were held with three to four staff members (e.g., RPNs, managers) per LTC home in Ontario. A third was held with three PIECES mentors. Individual semi-structured interviews were conducted with RPN champions, family/care partners, and older adult research partners. Research team meeting notes provided an additional source of data. Content analysis was conducted. A total of 22 participants took part in a focus group (n=11) or an in-depth individual interview (n=11). Participant experiences suggest that implementation of RPN-led virtual PIECES fostered individualized care, included family as partners in care, increased interdisciplinary collaboration and improved staff practices. However, virtual PIECES, as delivered, lacked opportunities for family member feedback on older adult outcomes. Implementation facilitators included the provision of mentorship and leadership at all levels of implementation, and suitable technological infrastructure. Barriers were related to availability and use of virtual communication technology (family members) and older adults became upset due to lack of comprehension during virtual care conferences. Findings give promising support to adopting virtual PIECES - a team approach to gather valuable family input and engagement to address residents' unmet needs and responsive behaviours in LTC. Future research should investigate a hybridized communication format to foster sustainable person and family-centered care planning practices to include active collaboration of families in individualized care plans. Not applicable.

What Constitutes Patient-Centered Care in Home Care? A Descriptive Study of Home Health Nurses' Attitudes, Knowledge, and Skills

In their seminal paper outlining the proposed Future of Home Care, Landers et al. (2016) stated that “patient-centered care” (PCC) is one of the “pillars” of home care. They then asked the question, what is PCC in home care and how is it measured? A qualitative descriptive study explored the answer to this question. In-depth interviews were conducted with 20 home health nurses to identify how they incorporated patient-centered and culture-sensitive care (CSC) into their assessment and care planning practices. The data were categorized into attitudes, knowledge, and skills (including relationship-building, assessment, and care planning skills) associated with patient-centered/culture-sensitive care. The home health nurses had developed multiple strategies for delivering PCC, despite a lack of education in how to provide this care. They primarily learned their techniques through their caring for patients as unique, highly valued persons and their ability to form warm caring relationships with their patients. Together they painted a portrait of the attitudes, knowledge, and skills needed for PCC and CSC. PCC and CSC are mutually reinforcing concepts essential to the high-quality, equitable care needed to mitigate healthcare disparities prevalent in home healthcare. A teaching resource for incorporating PCC/CSC into home health clinician practice was derived from the data.

Exploring the Attitudes and Needs of Advance Care Planning Practice Among the Working Generation

Exploring the Attitudes and Needs of Advance Care Planning Practice Among the Working Generation

A Survey of Clinicians Regarding Goals of Care for Patients with Severe Comorbid Illnesses Hospitalized for an Acute Deterioration.

BackgroundPatients with terminal illnesses hospitalized with acute deteriorations often suffer from unnecessary/inappropriate therapies at the end of their lives. Appropriate advance care planning (ACP) practices aligned to patients’ goals of care may mitigate this.Materials and methodsTo explore the rationale for clinical decision-making in hospitalized patients with terminal illnesses and formulate a practice pathway to streamline care. Between May and December 2018, a questionnaire survey with three case vignettes derived from intensive care unit (ICU) patients was emailed to ICU, respiratory and renal doctors, and nurses in two Sydney hospitals. Respondents chose various management options ranging from all active therapies to palliation. The primary outcome was the proportion of responses for each management option. With these and a thematic analysis of responses to identify barriers to ACP practice, a practice pathway was formulated.ResultsOf the 310 invited clinicians, 178 responded (57.4%). About 89.2% of respondents reported caring for dying patients frequently. Sixty percent saw patients suffering from prolonged therapies. Most respondents deemed patients in the case vignettes to be terminally ill, warranting ACP discussions. However, many still wanted to treat the acute deterioration with active ICU-level interventions. Most respondents reported being comfortable in having ACP discussions.ConclusionThe survey showed discordance between the stated opinions and the choice of management options for terminally ill patients with acute deteriorations; possibly due to the lack of a considered approach in choosing management options that align with medical consensus and the patient's/family's wishes, a practice pathway is suggested to improve management.How to cite this articleSarangi RK, Rajamani A, Lakshmanan R, Srinivasan S, Arvind H. A Survey of Clinicians Regarding Goals of Care for Patients with Severe Comorbid Illnesses Hospitalized for an Acute Deterioration. Indian J Crit Care Med 2022;26(4):457–463.

Barriers and facilitators to nurse-led advance care planning and palliative care practice change in primary healthcare: a qualitative study.

Primary care settings are ideal for initiating advance care planning (ACP) conversations and assessing palliative and supportive care needs. However, time constraints and a lack of confidence to sensitively and efficiently initiate such discussions are noted barriers. The Advance Project implemented a national multicomponent training package to support Australian general practice nurses (GPNs) to work with GPs to initiate ACP and palliative care conversations in their practice. This paper reports on semistructured interviews conducted with 20 GPNs to explore barriers and facilitators to implementing the Advance Project model. Participants identified a range of factors that affected implementation, including lack of time, limited support from colleagues, lack of knowledge about systems and funding processes in general practice and a need for better alignment of the Advance Project resources and practices with general practice information management platforms. Barriers related to professional roles, particularly the lack of clarity and/or limitations in the scope of practice of GPNs, highlighted the importance of defining and supporting the roles that different primary health practice staff could play to support implementation of the model. The findings underline the need for complementary training in the Advance Project model for GPs and practice managers to enable a team-based approach to implementation.

Implementation of an Advance Care Planning Inventory and Its Possible Effect on Quality of Dying: A Nationwide Cross-Sectional Study in Group Homes for Persons with Dementia in Japan.

This study aimed to develop an inventory for advance care planning implementation for persons with dementia in group homes and to examine the association between inventory implementation and residents’ quality of dying. A nationwide cross-sectional study was conducted via questionnaires mailed from 2000 group homes in Japan, selected through stratified random sampling. Participants were managers and care planners who had provided end-of-life care for recently deceased residents. The newly developed inventory was used to assess advance care planning implementation for persons with dementia, and the Quality of Dying in Long-term Care Scale was used to evaluate quality of dying. The valid response rate was 28.5% (n = 569). The factor structure of the newly developed Advance Care Planning Practice Inventory and the association between its implementation and quality of dying were verified using factor analysis and internal consistency, and logistic regression, respectively. The composite score and the factor score of the newly developed inventory were significantly associated with quality of dying (p < 0.05). The implementation of advance care planning improves the quality of dying. These findings can be used in development of educational programs, as well as research on advance care planning for care providers.

Transcultural Nurse Views on Culture-Sensitive/Patient-Centered Assessment and Care Planning: A Descriptive Study.

Culture-sensitive (CS) and patient-centered (PC) care are considered essential to achieve high-quality equitable care. The purpose of this study was to determine how expert nurses incorporate CS/PC care into their assessment and care planning practices, especially for culturally diverse and marginalized patients. Using a qualitative, descriptive design, we conducted a focus group at the October 2019 Transcultural Nursing Society Conference. Participants (n = 9) discussed how they instilled cultural sensitivity and patient-centeredness into their assessment and care planning skills. Participants revealed attitudes, knowledge, and skills associated with CS/PC assessment and care planning. They also identified specific strategies for translating CS/PC theory into assessment and care planning practices. Three principles and many pragmatic strategies for incorporating CS/PC care into daily practice emerged from the data. Nurses may find these principles and strategies helpful in integrating CS/PC care into their daily care of patients in busy clinical settings.

Knowledge, attitude and practice of advance care planning among nursing interns: A mixed-methods approach

AimTo investigate the knowledge, attitudes and practice of advance care planning and confirm their influencing factors among nursing interns in China. BackgroundDue to a lack of standardized courses on advance care planning (ACP) in China, nursing interns do not possess the knowledge of ACP and cannot apply it to clinical practice. DesignA convergent parallel mixed-methods design. Methods382 nursing interns aged > 18 years were recruited using convenience sampling. Quantitative data were collected using the General Demographic Characteristics Questionnaire and the Advance Care Planning Knowledge, Attitude and Practice Questionnaire. Thirteen nursing interns were drawn from the quantitative phase and their interviews were thematically analyzed. Results: The ACP attitudes and practice scores of nursing students were 48.85 ± 6.39 and 32.23 ± 4.58, respectively, with a high level, while their ACP knowledge score was 6.89 ± 2.70, with a medium level. The significant promotive factors included positive attitude toward death and the nursing major and experience in clinical rescues and palliative care training; The key hindrance factors included the lack of ACP education and the limitations of the working environment. ConclusionsThe study highlighted the importance of delivering systematic palliative care training and integrating the practice of ACP into routine nursing practice. Doing this can help expand advance care planning knowledge, establish positive attitudes and meet the practical needs of nursing interns for their ACP clinical practice.