Advance Care Planning Practices Research Articles

User appraisal of a booklet for advance care planning in multiple sclerosis: a multicenter, qualitative Italian study

ObjectivesImplementation of advance care planning (ACP) in people with progressive multiple sclerosis (PwPMS) is limited. We aimed to involve users (PwPMS, significant others, and healthcare professionals involved in PwPMS care) in the evaluation and refinement of a booklet to be used during the ACP conversations.MethodsThis qualitative study consisted of cognitive interviews with PwPMS and significant others and a focus group with healthcare professionals from three Italian centers. We analyzed the interviews using the framework method and the focus group using thematic analysis.ResultsWe interviewed 10 PwPMS (3 women; median age 54 years; median Expanded Disability Status Scale score 6.0) and three significant others (2 women; 2 spouses and one daughter). The analysis yielded three themes: booklet comprehensibility and clarity, content acceptability and emotional impact, and suggestions for improvement. Twelve healthcare professionals (7 neurologists, 3 psychologists, one nurse, and one physiotherapist) participated in the focus group, whose analysis identified two themes: booklet’s content importance and clarity and challenges to ACP implementation. Based on analysis results, we revised the booklet (text, layout, and pictures) and held a second-round interviews with two PwPMS and one significant other. The interviewees agreed on the revisions but reaffirmed their difficulty in dealing with the topic and the need for a physician when using the booklet.ConclusionsAppraisal of the booklet was instrumental in improving its acceptability and understandability before using it in the ConCure-SM feasibility trial. Furthermore, our data reveal a lack of familiarity with ACP practice in the Italian context.

Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned.

The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice. We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus. From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems. The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.

Advance Care Planning and palliative care for patients with advanced cancer in Uganda

The study sought to identify the extent to which Advance Care Planning (ACP) is practised by palliative care health professionals providing care to patients with advanced cancer and their families in Uganda.A mixed methods study design using qualitative and quantitative methods was used for the assessment. In-depth interviews with a group of nine highly experienced health professionals were conducted using a semi-structured interview guide. Quantitative data were retrieved and analysed from a survey administered to 124 health professionals of whom only 57 (45.9%) responded. The qualitative data were analysed using inductive thematic analysis and descriptive analysis was used for the quantitative data.Of the 57 health professionals who participated in the survey, 87% were aware of ACP and 55% reported regular practice. Fifty-five (55%) percent reported regular provision of ACP for their patients and 46% reported engaging in informal ACP practices. However, 58.5% resp. 37.5% reported that they routinely provide ACP to more than 50% resp. 75% of their patients. A group of nine highly experienced palliative care professionals had a pooled ACP prevalence of only 1.2%. There was a generally good attitude towards ACP with 98.2% acknowledging that patients should be able to determine their future care. However, 32% reported being uncomfortable withholding or withdrawing life sustaining treatment. There are a number of socio-cultural beliefs and barriers, for instance that discussing death and dying is a “taboo”, as well as witchcraft, family influence in decision-making, religious beliefs that do not agree with palliative care practices and a preference to use aggressive treatment like chemotherapy for terminally ill, etc. Institutional barriers like lack of a legal framework for ACP, limited time for health professionals to engage in ACP and other patient factors such as denial of diagnosis and collusion to withhold information from patients were reported by 78.2% resp. 84% of the respondents.Despite the good awareness and attitude to ACP, there is a range of barriers that are affecting the implementation of ACP in Uganda. There is need for development of a legal framework for ACP, more research to understand the contextual barriers and develop appropriate education and public sensitisation programs.

Advance care plans for vulnerable and disadvantaged adults: systematic review and narrative synthesis

BackgroundEvidence suggests that there is a gap in advance care planning (ACP) completion between vulnerable and disadvantaged populations compared with the general population. This review seeks to identify tools, guidelines...

Advance Care Planning in Belgium

This paper aims to 1) describe current levels of Advance Care Planning (ACP) development since 2002 in Belgium, 2) report on challenges and opportunities to inspire other countries with similar contextual characteristics and 3) support further development of ACP practice and research in Belgium. To address these aims, we consulted local researchers, 12 domain experts and (grey) literature (regulatory documents, reports, policy documents and practice guidelines) on ACP, palliative care, and related healthcare topics. Since 2002, when the Patient’s Right Law was passed in the federal Parliament, Belgium has had a specific medicolegal context for ACP. Initiatives to improve the uptake of ACP have been taken, e.g. standardised documentation, reimbursement codes for physicians provided by the government, and implementation of quality indicators in hospitals and nursing homes. Most of these initiatives are grassroots or predominantly oriented towards a single group of professions, e.g. general practitioners, disregarding the role that other professions can play. The patient groups most often targeted are those with cancer and older adults. Limited but growing attention is given to those with low health literacy or other minority groups. Main barriers to ACP in Belgium are: no unified platform to exchange outcomes of ACP discussions or advance directives between healthcare professionals and though efforts are made, ACP is still predominantly oriented towards documentation.

Timing and setting of billed advance care planning among Medicare decedents in 2017-2019.

The Centers for Medicare & Medicaid Services (CMS) began to reimburse clinicians for advance care planning (ACP) discussions, effective January 1, 2016. We sought to characterize the timing and setting of first-billed ACP discussions among Medicare decedents to inform future research on ACP billing codes. Using a random 20% sample of Medicare fee-for-service beneficiaries aged 66 years and older who died in 2017-2019, we described the timing (relative to death) and setting (inpatient, nursing home, office, or outpatient with or without Medicare Annual Wellness Visit [AWV], home or community, or elsewhere) of the first-billed ACP discussion for each beneficiary. Our study included 695,985 decedents (mean [SD] years of age, 83.2 [8.8]; 54.2% female); the proportion of decedents who had at least one billed ACP discussion increased from 9.7% in 2017 to 21.9% in 2019. We found that the proportion of first-billed ACP discussions held during the last month of life decreased from 37.0% in 2017 to 26.2% in 2019, while the proportion of first-billed ACP discussions held more than 12 months before death increased from 11.1% in 2017 to 35.2% in 2019. We also found that the proportion of first-billed ACP discussions held in the office or outpatient setting along with AWV increased over time (from 10.7% in 2017 to 14.1% in 2019), while the proportion held in the inpatient setting decreased (from 41.7% in 2017 to 38.0% in 2019). We found that with increasing exposure to the CMS policy change, uptake of the ACP billing code has increased; first-billed ACP discussions are occurring sooner before the end-of-life stage and are more likely to occur with AWV. Future studies should evaluate changes in ACP practice patterns, rather than only an increasing uptake in ACP billing codes, following the policy implementation.

Survey of Advance Care Planning Practices in Elderly COVID-19 Patients: A Multicenter Questionnaire Survey.

Objective Advance care planning (ACP) is a process in which the patient and family discuss end-of-life care in advance with healthcare providers in case decisional ability declines. Due to the rapid deterioration of symptoms and isolation for treatment, it is not easy for COVID-19 patients to discuss their end-of-life care with families and medical staff. We conducted a questionnaire survey to assess the current situation of ACP practices in hospitalized COVID-19 patients. Materials and methods Multicenter questionnaire surveys of hospitalized COVID-19 patients aged ≥60 years between January 2021 and August 2022 were conducted in two hospitals. The questionnaires assessed whether patients had discussed end-of-life medical treatment with their families and family physicians at the time of admission and their preferences for end-of-life medical treatments. Results A total of 109 patients aged 60-99 years (median 75.0 years) were enrolled. Only eight patients (7.3%) had practiced ACP at the time of admission. Age was a significant factor related to ACP practices (p=0.035). Although there was no significant difference between the ACP and non-ACP practiced groups for each end-of-life care, all eight patients in the ACP-practiced group were able to make decisions for all the end-of-life medical treatment, while 40 patients (33.0%) in the non-ACP-practiced group did not, showing a significant difference (p=0.026). Conclusion In hospitalized COVID-19 patients, the rate of ACP practice was as low as 7.3%. Awareness of ACP practice is necessary, especially for elderly patients with underlying diseases.

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.

Advance Care Planning in Serious Illness: A Narrative Review.

Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility. To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness. We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care. Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations. We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.

ADVANCE CARE PLANNING FOR SPANISH-LANGUAGE SPEAKERS: PATIENT, FAMILY, AND INTERPRETER PERSPECTIVES

Abstract Language access is a challenge to advance care planning (ACP). Spanish-language speakers are the largest non-English speaking population in the US. While ACP tools have been translated into Spanish, it is unclear how heterogeneity in country of origin may affect the generalizability of translations across diverse US Spanish-speaking populations. The study objective is to describe challenges and facilitators to ACP for diverse populations of Spanish-language speakers. We conducted 3 focus groups with a total of 29 participants from members of Spanish-language speaking communities whose countries of origin were predominantly from the Caribbean, Central, and South America. Eligibility included being 18 years or older, being a native Spanish-speaker, and having direct experience with ACP as a patient, caregiver, or medical interpreter. We conducted thematic analysis with axial coding. Themes include: 1. Linguistic Challenges with Current ACP Translations; 2. Effect of Country of Origin and Culture on ACP Understanding; 3. Impact of Local Healthcare System Cultural on ACP; and 4. Need for ACP to be Normalized into the Local Community. ACP is both a cultural practice and a clinical practice. Recommendations for improving ACP completion for non-English speakers extend far beyond translation, since simply translating ACP tools without a cultural context is neither equitable nor inclusive. A key step is normalizing ACP into the local community. Understanding the intersection of local healthcare systems of ACP practice with the patient’s and family’s cultures of origin will facilitate introducing ACP in a culturally sensitive manner.

Psychometric evaluation of the Chinese version of advance care planning self-efficacy scale among clinical nurses

BackgroundNurses are one of the most critical members of advance care planning (ACP) discussion. The evaluation of ACP self-efficacy is of great significance for developing targeted ACP interventions among clinical nurses and update their professional roles. However, there are few instruments to evaluate their ACP self-efficacy in mainland China. The purpose of this study was to translate the ACP self-efficacy scale into Chinese and evaluate its psychometric properties among clinical nurses.MethodsA methodological study of the translation and validation of the ACP self-efficacy scale was conducted from January to March 2022. It involved three phases: (1) the translation and revision of the scale; (2) the exploration and evaluation of the item (n = 436); (3) the psychometric evaluation of the scale (n = 674).ResultsAfter a rigorous translation and revision, the ACP self-efficacy scale with three dimensions and 16 items was finally formed. In this study, the critical ratios of the item ranged from 8.226 to 17.499, and the item-total correlation coefficients ranged from 0.437 to 0.732, and the factor loadings of the item ranged from 0.638 to 0.882. The content validity index of the scale was 0.946. Supported by the eigenvalues, the three-factor structure explained the cumulative 61.131% of the overall variance. As the results of confirmatory factor analysis, all the recommended fitting indexes were appropriate. The average variance extracted values ranged from 0.570 to 0.756, and the composite reliability values ranged from 0.858 to 0.925. The total Cronbach's α coefficient, split-half reliability coefficient and test–retest reliability coefficient of the scale were 0.896, 0.767 and 0.939, respectively.ConclusionThe Chinese version of ACP self-efficacy scale was successfully introduced into China, showing good psychometric properties among clinical nurses, and can effectively assess the ACP self-efficacy. Also, the scale can provide nursing educators with a significant strategy to develop ACP educational procedure and post-intervention measures for clinical nurses to improve nurse-led ACP practice.

Evaluation of an advance care planning training program for practice professionals in Japan incorporating shared decision making skills training: a prospective study of a curricular intervention

BackgroundWe developed a novel training program for health care professionals that incorporated shared decision making (SDM) skills training into an advance care planning (ACP) training course, the first in Japan. This study aimed to assess the training program’s impact on health care professionals’ knowledge, skill, attitudes, and confidence to initiate ACP.MethodsUsing the novel Japanese educational program, we evaluated the effect of 8-month programs conducted eight community training sites of professionals who can practice ACP in a local area in Aichi Prefecture (the Aichi ACP Project). SDM skills training was provided during the workshops conducted in the ACP training course, and the participants’ satisfaction and understanding of the training were assessed. After the completion of two workshops, information on SDM skill results from the training and submitted assignments were collected anonymously from the training sites.ResultA total of 404 participants completed all education programs. After the first workshop, at least 95% of trainees stated that they were satisfied with the training and that it was useful for ACP practice. The evaluation of the results between the first and second workshops indicated improvement in SDM skills on some items of the SDM measures. In the second workshop, at least 90% of participants submitted implementation reports, and after the second workshop, a survey of confidence in ACP practice was administered, with responses indicating improvement. There were high levels of interest in education related to the ACP practices of oneself and others.ConclusionsThis educational program can be an effective for developing professionals who can practice ACP with SDM skills.

Interdisciplinary staff perceptions of advance care planning in long-term care homes: a qualitative study

BackgroundResidents living in long-term care homes (LTCH) have complex care needs, multiple chronic conditions, increasing frailty and cognitive impairment. A palliative approach that incorporates advance care planning (ACP) should be integrated with chronic disease management, yet it is not a norm in most LTCHs. Despite its growing need, there remains a lack of staff engagement in the ACP process.ObjectivesThe aim of this study was to explore the perceptions and experiences of interdisciplinary staff related to the practice of ACP in LTCHs.MethodsThis study is part of a larger Canadian project, iCAN ACP, that aims to increase uptake, and access to ACP for older Canadians living with frailty. An exploratory qualitative design using an interpretive descriptive approach was employed utilizing focus groups and semi-structured interviews with staff from four LTCHs in Ontario, Canada.FindingsThere were 98 participants, including nurses (n = 36), physicians (n = 4), personal support workers (n = 34), support staff (n = 23), and a public guardian (n = 1). Three common themes and nine subthemes were derived: a) ongoing nature of ACP; b) complexities around ACP conversations; and c) aspirations for ACP becoming a standard of care in LTCHs.DiscussionThe findings of this study provide important contributions to our understanding of the complexities surrounding ACP implementation as a standard of practice in LTCHs. One of the critical findings relates to a lack of ACP conversations prior to admission in the LTCHs, by which time many residents may have already lost cognitive abilities to engage in these discussions. The hierarchical nature of LTCH staffing also serves as a barrier to the interdisciplinary collaboration required for a successful implementation of ACP initiatives. Participants within our study expressed support for ACP communication and the need for open lines of formal and informal interdisciplinary communication. There is a need for revitalizing care in LTCHs through interdisciplinary care practices, clarification of role descriptions, optimized staffing, capacity building of each category of staff and commitment from the LTCH leadership for such care.ConclusionThe findings build on a growing body of research illustrating the need to improve staff engagement in ACP communication in LTCHs.

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

Community Nurses' Perspective on Barriers to Effective Utilization of Advance Care Planning for Terminal Care of The Elderly in The Home Environment in Japan: A Systematic Review and Synthesis of Qualitative Studies

Advance care planning (ACP) allows individuals to plan the health care which dignifies their personal values at the terminal phase of their illnesses. The Japanese government previously endorsed the concept of ACP in the guideline on end-of-life care and community nurses in Japan could play an increased role to improve its utilization by patients. The current study aimed to identify challenges surrounding ACP practice in the home environment in Japan from the community nurses’ perspectives. Semi-structured interview was performed on eleven community nurses working in metropolitan areas in Japan. Qualitative data was collected and analyzed using Braun & Clarke’s six-step framework of thematic analysis (2006). Five themes were identified as barriers to effective ACP utilization: complexity surrounding family power, informed consent and discussion, cultural influence, longer life versus better life, and absence of frameworks and guidelines. The first three themes were further subdivided into subthemes: imbalance in family power and family guilt, inadequate information for decision-making and ‘no one talk about it’, and traditional ways of thinking and taboo surrounding talking about death, respectively. The identified issues surrounding the current ACP practice in Japan were interconnected and reflective of the social, cultural, legal, and ethical aspects of life and care in Japan. This study highlighted the importance of respecting patients’ preferences in care, which should be additionally protected by establishing clear policy and legal frameworks on ACP

Development of an Advance Care Planning Policy within an Evidenced-Based Evaluation Framework.

Background: As the population is aging and medical advancements enable people to live longer, advance care planning (ACP) becomes increasingly important in guiding future care decisions; however, they are often incomplete or absent from the patient chart. This study describes the development and implementation of an ACP policy in a post-acute care and long-term care setting using a systematic implementation framework. Methods: A process evaluation that parallels the Replicating Effective Programs (REP) framework was used to understand stakeholder experiences with ACP and identify gaps in practice. Physicians, multidisciplinary staff, patients, and substitute decision makers engaged in focus groups and interviews, and completed surveys. A retrospective chart review determined Plan for Life Sustaining Treatment (PLST) form completion rates. Results: Stakeholder feedback identified barriers and facilitators to ACP including a need for staff training, user-friendly resources, and standardization of ACP practice. The PLST form was developed and embedded in the electronic medical record, and had a 92% and an 87% PLST completion rate on 2 pilot units. Conclusion: The study showed the usefulness of the REP model in guiding the evaluation as an effective tool to enhance implementation practices and inform ACP policy development that can be replicated in other organizations.

Tips for Managing Ethical Challenges in Advance Care Planning: A Qualitative Analysis of Japanese Practical Textbooks for Clinicians.

(1) Background: While advance care planning (ACP) provides healthcare professionals with valuable tools to meet patients’ needs in a person-centered manner, several potential ethical challenges are inherent to the process. However, recent studies have largely focused on ACP practicalities such as implementation, execution, and completion rather than on the ethical challenges that clinicians routinely encounter in ACP practices. (2) Research question/aim/objectives: This study aimed to identify tips for clinicians managing ethical challenges in ACP practices. (3) Methods: It performed a brief search for all Japanese published books pertaining to ACP practice available as of January 2021 using the keywords “advance care planning (ACP)” and “autonomy” and analyze the content of nine practical ACP textbooks for clinicians. (4) Results: Two major themes capturing the essential recommendations for managing ethical challenges in ACP were ultimately identified, namely interprofessional ethics and informed consent. (5) Conclusion: The findings suggested tips for managing ethical challenges in ACP: refer to ethical frameworks for interprofessional collaboration and ethical decision making, assess decision-making capacity of family substitute decision makers and one’s eligibility for the role, understand the standard process of informed consent and how to handle situations when the patient are not well informed about the diagnosis and prognosis of non-cancer illness.

Effect of advance care planning video on do-not-hospitalize orders for nursing home residents with advanced illness

BackgroundThe purpose of the study is to evaluate the effect of an Advance Care Planning (ACP) Video Program on documented Do-Not-Hospitalize (DNH) orders among nursing home (NH) residents with advanced illness.MethodsSecondary analysis on a subset of NHs enrolled in a cluster-randomized controlled trial (41 NHs in treatment arm implemented the ACP Video Program: 69 NHs in control arm employed usual ACP practices). Participants included long (> 100 days) and short (≤ 100 days) stay residents with advanced illness (advanced dementia or cardiopulmonary disease (chronic obstructive pulmonary disease or congestive heart failure)) in NHs from March 1, 2016 to May 31, 2018 without a documented Do-Not-Hospitalize (DNH) order at baseline. Logistic regression with covariate adjustments was used to estimate the impact of the resident being in a treatment versus control NH on: the proportion of residents with new DNH orders during follow-up; and the proportion of residents with any hospitalization during follow-up. Clustering at the facility-level was addressed using hierarchical models.ResultsThe cohort included 6,117 residents with advanced illness (mean age (SD) = 82.8 (8.4) years, 65% female). Among long-stay residents (n = 3,902), 9.3% (SE, 2.2; 95% CI 5.0–13.6) and 4.2% (SE, 1.1; 95% CI 2.1–6.3) acquired a new DNH order in the treatment and control arms, respectively (average marginal effect, (AME) 5.0; SE, 2.4; 95% CI, 0.3–9.8). Among short-stay residents with advanced illness (n = 2,215), 8.0% (SE, 1.6; 95% CI 4.6–11.3) and 3.5% (SE 1.0; 95% CI 1.5–5.5) acquired a new DNH order in the treatment and control arms, respectively (AME 4.4; SE, 2.0; 95% CI, 0.5–8.3). Proportion of residents with any hospitalizations did not differ between arms in either cohort.ConclusionsCompared to usual care, an ACP Video Program intervention increased documented DNH orders among NH residents with advanced disease but did not significantly reduce hospitalizations.Trial registration.ClinicalTrials.gov Identifier: NCT02612688.

Effect of a Video-Assisted Advance Care Planning Intervention on End-of-Life Health Care Transitions Among Long-Stay Nursing Home Residents.

To determine the relationship between an advance care planning (ACP) video intervention, Pragmatic Trial of Video Education in Nursing Homes (PROVEN), and end-of-life health care transitions among long-stay nursing home residents with advanced illness. Pragmatic cluster randomized clinical trial. Five ACP videos were available on tablets or online at intervention facilities. PROVEN champions employed by nursing homes (usually social workers) were directed to offer residents (or their proxies) ≥1 video under certain circumstances. Control facilities employed usual ACP practices. PROVEN occurred from February 2016 to May 2019 in 360 nursing homes (119 intervention, 241 control) owned by 2 health care systems. This post hoc study of PROVEN data analyzed long-stay residents ≥65years who died during the trial who had either advanced dementia or cardiopulmonary disease (advanced illness). We required an observation time ≥90days before death. The analytic sample included 923 and 1925 advanced illness decedents in intervention and control arms; respectively. Outcomes included the proportion of residents with 1 or more hospital transfer (ie, hospitalization, emergency department use, or observation stay), multiple (≥3) hospital transfers during the last 90days of life, and late transitions (ie, hospital transfer during the last 3days or hospice admission on the last day of life). Hospital transfers in the last 90days of life among decedents with advanced illness were significantly lower in the intervention vs control arm (proportion difference=-1.7%, 95% CI -3.2%,-0.1%). The proportion of decedents with multiple hospital transfers and late transitions did not differ between the trial arms. Video-assisted ACP was modestly associated with reduced hospital transfers in the last 90days of life among nursing home residents with advanced illness. The intervention was not significantly associated with late health care transitions and multiple hospital transfers.

Effects of an Advance Care Planning Training Program for Certified Palliative Care Nurses in Japan

Education programs for certified palliative care nurses who promote advance care planning (ACP) for cancer patients are important, but not currently available in Japan. This study aimed to develop an educational program of ACP for certified palliative care nurses in Japan and evaluate its effectiveness. A program consisting of four modules was implemented for 60 certified palliative care nurses in the Kyushu, Chugoku, and Shikoku regions. Participants attended one training session, and 39 responded to a survey on changes in ACP practice and difficulties with cancer nursing 3 months after the intervention. The Wilcoxon signed-rank test was performed to compare data before and after the intervention. The results obtained showed an increase in dialogue on ACP among patients/families and healthcare professionals (mean before the intervention = 24.49, mean after the intervention = 27.59, p = 0.045), and a significant decrease in the sense of difficulty with knowledge of and skills for ACP (mean before the intervention = 4.85, mean after the intervention = 4.30, p = 0.001). More than 90% of the participants gave positive comments on the evaluation items such as understanding and satisfaction with the educational program and appropriateness of the contents. After attending the training program, participants’ sense of difficulty with their knowledge of and skills for ACP decreased, and their practice of ACP increased. This program may promote the practice of ACP for cancer patients in the future.