Preferences For Medical Care Research Articles

Assessing the Content of Goals of Care Documentation for Hospitalized Patients With Alzheimer's Disease and Related Dementias

ABSTRACTBackgroundGoals of care (GOC) conversations are an evidence‐based practice that help clarify and align patient values and preferences for medical care with treatment options. Little is known about how clinicians document the content of GOC conversations for patients with Alzheimer's disease and related dementias (AD/ADRD) in the electronic health record (EHR) and whether this may differ across hospitals. We aimed to assess the content of GOC documentation for hospitalized patients with and without AD/ADRD.MethodsWe performed a retrospective cross‐sectional study to assess documented content within a standardized GOC note written for seriously ill hospitalized adult patients admitted to 21 hospitals between 2021 and 2023. Seriously ill patients had a predicted 90‐day mortality greater than 30% as determined by an artificial intelligence mortality prediction score. Patients with AD/ADRD were identified using diagnostic codes placed by clinicians in the EHR.ResultsOur review of GOC documentation across 21 hospitals identified 5475 patients with GOC notes. The study sample had a median age of 76 years and was 52% male, 13% nonwhite, 81% with Medicare insurance, and 14% with AD/ADRD. Compared to patients without AD/ADRD, patients with AD/ADRD were more likely to have documentation of family presence at the GOC conversation (93% vs. 76%, p = < 0.001), a surrogate decision‐maker (60% vs. 54%, p = 0.003), and patient prognosis (84% vs. 78%, p = < 0.001). Patients with AD/ADRD were less likely to have documentation of patient presence at the GOC conversation (28% vs. 64%, p = < 0.001) and patient values and preferences for medical care (65% vs. 69%, p = < 0.05).ConclusionsHospitalized patients with AD/ADRD are infrequently present in GOC conversations and less likely to have their values and preferences for medical care documented within a GOC note. Further research is needed to explore the reasons for these findings.

Compensation preferences of home-based disabled beneficiaries in the long-term care insurance system in Guangzhou, China.

This study explores the preferences and willingness-to-pay of home-based disabled elderly individuals for long-term care insurance (LTCI) compensation mechanisms in Guangzhou, China, using a discrete choice experiment. The research aims to identify preferred compensation strategies, analyze heterogeneity in preferences, and provide recommendations for policy optimization. Using purposive and cluster sampling, 156 eligible participants were identified, with 96 completing the survey (response rate: 61.5.%). Disabled elderly individuals were defined based on activities of daily living assessments. A conditional Logit model was applied to analyze preferences, and subgroup analyses examined differences by education, gender, activities of daily living status, and caregiving arrangements. Key findings include preferences for medical care over life care, family caregivers over professional ones, and cash subsidies over mixed or proportional reimbursement. Respondents were willing to pay an additional $21.60 for medical care and $25.26 for cash subsidies (1 USD = 7.3 CNY). The average out-of-pocket cost for LTCI services was $27.39 per session, with a sub-average cost of $16.44 for basic care services. Subgroup analyses revealed higher-educated individuals favored medical care, while lower-educated groups prioritized affordability. Severely disabled individuals preferred professional caregivers, such as registered nurses. This study highlights the need to expand medical care services, integrate flexible compensation models, and tailor policies to demographic differences. The findings provide evidence for optimizing China's LTCI system and offer insights for aging populations in low- and middle-income countries.

Adherence to Patients' Preferences for Levels of Life-Sustaining Treatment: A 2-Year Follow-Up Study.

ObjectiveThere is increasing interest in advance care planning (ACP) and the implementation of various forms of ACP. The purpose of ACP is to define patients' goals and preferences for future medical treatment and care for patients nearing the end of life (EOL). The aim of this study was to investigate adherence to patients' preferences for levels of life-sustaining treatment in emergency situations, as documented in a Danish POLST (Physician Orders for Life-Sustaining Treatment) form.MethodsA retrospective journal review was conducted 2 years after the conversation with the patients about their wishes for treatment and care at EOL. Medical records included electronic hospital records, nursing home records, and general practice records. Patients were assessed nearing EOL and included in the study based on a negative response to the "surprise."ResultsA total of 120 patients and nursing home residents were included in the study. Overall, there were 2148 contacts with the healthcare system, of which 31 were emergency situations, where the patients were not capable of expressing their own wishes. In 4 contacts (12%), the patients (4) received treatment discordant with their wishes, as documented in the POLST form (and medical record).ConclusionsOur study shows that patients assessed nearing EOL are a patient group with many contacts with the healthcare system, and the results indicate that having had an ACP conversation and the wishes documented is useful to avoid unwanted treatment in emergency situations.

Knowledge, Awareness, and Perception of Advanced Medical Directives Among Patients and Their Relatives in the Critical Care Unit: A Pilot Study.

Advance medical directives (AMDs) are legal documents that allowindividuals to specify their medical care preferences in case they become incapacitated due to severe illness or injury. Understanding public awareness and attitudes toward AMDs is crucial for improving their implementation. A cross-sectional study was conducted in the critical care unit of a tertiary care hospital, involving 50 patients and their relatives over the age of 18 after taking informed written consent. A specially designed questionnaire was used to assess their awareness, understanding, and attitudes toward AMDs. The study revealed significant gaps in awareness and adoption of AMDs. Notably, none of the female participants had prepared theAMDs, and all individuals who had prepared one were over the age of 60. Additionally, none of the Hindu participants had AMDs, while three (8.1%) Sikh participants had prepared one. Awareness of legal formalities, such as the need for notarization or witnessing, was low. Moreover, only a minority of participants were aware that healthcare institutions could decline to comply with an AMD. While some awareness of AMDs exists, the majority of the population remains unfamiliar with their guidelines and procedures. Targeted educational initiatives are essential to bridge this knowledge gap and promote informed decision-making regarding end-of-life care.

Influencing factors and prediction algorithms to estimate public preference for painless medical procedures in China: a national cross-sectional study

ObjectivesTo improve the medical treatment process, the concept of comfortable medical care has been proposed. This concept has been fully implemented in developed countries, but there are still many restrictions...

Caregivers' Perspectives on Discussions of Medical Treatment Preferences for People Living With Dementia Are Associated With Their Dementia Health Literacy and the Caregiving Relationship.

People living with dementia experience progressive functional decline and increased dependence on caregivers. This study examined the influence of caregivers' dementia health literacy on perceptions of medical care preferences and advance care planning (ACP) in people living with dementia. This analysis used data from a cross-sectional survey, "Care Planning for Individuals with Dementia," administered nationwide by Alzheimer's Disease Centers. We conducted binary, ordinal, and multinomial logistic regression. On average, surveyed caregivers (n = 431) were 78.3 years, had 16 years of education, and were mainly White (88.5%). Most lived with (76.8%) and were the designated healthcare proxy (95.1%), with high dementia knowledge scores (mean = 8.4/10). As caregivers' dementia knowledge scores increased, they were 1.27 times more likely (p = .02) to endorse comfort care. Caregivers with greater knowledge about severe dementia were less likely to need further treatment preference-related discussions (knowing a lot: odds ratio [OR] = 0.17, p < .001; knowing some things: OR = 0.37, p = .006). Caregivers live apart from patients were 2.71 times more likely to know about such discussions (p < .001). Caregivers of people in earlier stages endorsed greater needs for further conversations with clinicians (no impairment and mild cognitive impairment [MCI]: OR = 7.38, p = .002; mild impairment: OR = 5.32, p = .005) and their care recipients (no impairment and MCI: OR = 5.24, p = .02). These findings highlight the role of dementia-specific education in ACP discussions among people living with dementia, caregivers, and healthcare clinicians. These findings are important because evidence suggests that ACP may promote quality of life, reduce iatrogenic harm, minimize healthcare overutilization, and alleviate care-related burdens.

Advance Care Planning: A Retrospective Audit in a National Referral Center for Interstitial Lung Diseases.

Idiopathic and progressive pulmonary fibrosis (IPF/PPF) of known cause are relatively rare lung diseases with a limited survival time after diagnosis. Conscious attention for palliative care is recommended. Optimal care requires collaboration to define goals and preferences for future medical treatment and care with the patient and their families, to inform (or enable) Advance Care Planning (ACP). To get insight into the frequency of key elements of ACP described after dialogues with patients with IPF/PPF. A retrospective audit included charts of patients with IPF/PPF who died between December 2017 and December 2020. A data extraction model was developed based on a guideline for patient federation and wider literature and finally consisted of fourteen key elements. Subsequently content analysis was performed. The medical charts of 60 patients showed that an element of ACP was recorded in 57(95%) of cases. No medical chart contained all fourteen key elements of ACP. Most frequently recorded ACP elements were: knowledge of illness, goals of treatment and care and fears and concerns. The lack of structural implementation of ACP in the care for patients with interstitial lung disease, results in only some elements of ACP being dialogued by health care professionals (HCP). These notes recorded are often superficial and reflect the view of the HCP. Implementation of ACP conversations and structured documentation is needed to gain better insight into the wishes and preferences of the patient.

Definition and recommendations of advance care planning: A Delphi study in five Asian sectors

Background: In Confucian-influenced Asian societies, explicit end-of-life conversations are uncommon and family involvement in decision-making is crucial, which complicates the adoption of culturally sensitive advance care planning. Aim: To develop a consensus definition of advance care planning and provide recommendations for patient-centered and family-based initiatives in Asia. Design: A five-round Delphi study was performed. The rating of a definition and 84 recommendations developed based on systematic reviews was performed by experts with clinical or research expertise using a 7-point Likert scale. A median = 1 and an inter-quartile range = 0–1 were considered very strong agreement and very strong consensus, respectively. Setting/participants: The Delphi study was carried out by multidisciplinary experts on advance care planning in five Asian sectors (Hong Kong/Japan/Korea/Singapore/Taiwan). Results: Seventy-seven of 115 (67%) experts rated the statements. Advance care planning is defined as “a process that enables individuals to identify their values, to define goals and preferences for future medical treatment and care, to discuss these values, goals, and preferences with family and/or other closely related persons, and health-care providers, and to record and review these preferences if appropriate.” Recommendations in the domains of considerations for a person-centered and family-based approach, as well as elements, roles and tasks, timing for initiative, policy and regulation, and evaluations received high levels of agreement and consensus. Conclusions: Our definition and recommendations can guide practice, education, research, and policy-making in advance care planning for Asian populations. Our findings will aid future research in crafting culturally sensitive advance care planning interventions, ensuring Asians receive value-aligned care.

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.

Nurse-Led Advance Care Planning in Adults in the U.S.- A Scoping Review.

Advance care planning involves discussing individuals' future medical treatment and care preferences. Nurses, due to their close relationships with patients and families, may be well-positioned to lead these discussions. Exploring the components and characteristics of nurse-led ACP interventions is essential for enhancing their implementation, effectiveness, and sustainability. This scoping review aimed to explore the characteristics of nurse-led ACP interventions in adult patients, identify the populations and settings where these interventions have been utilized, and the outcomes of these interventions in the U.S. A scoping review was conducted following Arksey and O'Malley's five-stage framework. Using keywords related to nurse-led ACP interventions, a comprehensive search was performed across PubMed, Web of Science, CINAHL, EMBASE, and PsycINFO databases. Twelve studies met the inclusion criteria. These studies were conducted in varied settings. Registered nurses, oncology nurse navigators, and other specialized nurses primarily delivered nurse-led ACP interventions. The interventions ranged from one to two sessions and utilized various models and resources such as the Five Wishes and Respecting Choices. Nurse-led ACP interventions have shown significant positive outcomes, including increased engagement in ACP, improved attitudes towards ADs, higher completion rates of ADs, and enhanced patient-surrogate congruence. These interventions are well-received by patients and can be implemented in diverse settings. However, a general guideline regarding nurse-led ACP interventions is needed to address the specific duration, sessions, and mode of delivery required for their optimal effectiveness.

Determining the Effects of Complex Education on Primary Care Nurse Practitioners' Self-efficacy in Advance Care Planning for Healthy Adults.

Advance care planning is a process in which capable adults communicate their preferences for medical care in case of incapacitation. Regardless of health status, most adults are interested in advance care planning conversations and prefer providers to initiate these discussions. Primary care nurse practitioners are ideally positioned to lead these conversations but lack knowledge, confidence, and communication skills to do so. This project aimed to develop, implement, and evaluate an educational program for primary care nurse practitioners regarding leading advance care planning conversations with healthy adults. This evidence-based practice project used the Advance Care Planning Self-Efficacy Scale to measure primary care nurse practitioners' self-efficacy after completing a complex educational program. The educational program was developed based on a nationally recognized program incorporating didactic, observational, and role-play learning. The findings of this project indicated that providing complex education was an effective intervention immediately and after 3 months ( P = .018 and P = .023, respectively). The results indicate that educating nurse practitioners is an effective intervention for increasing their self-efficacy in leading advance care planning conversations with healthy adults over 3 months, recommending additional intervention at least earlier than 6 months.

Experiences with a national team-based learning program for advance care planning in pediatric palliative care

BackgroundAdvance Care Planning (ACP) enables patients and relatives to define and share values, goals and preferences for future medical treatment and care. The IMplementing Pediatric Advance Care Planning Toolkit (IMPACT), developed in the Netherlands, is a method for conducting ACP in pediatric palliative care. Healthcare professionals who were trained to use IMPACT, indicated their need for ongoing support to practice ACP communication skills optimally over time. Therefore, we developed a team-based learning program aimed at teaching participants how to transfer knowledge on ACP, continue practicing ACP communication skills and reflect on ACP conversations within their own team context. The aim of this study was to evaluate the program’s transfer of knowledge as well as the professionals’ experience and team reflection on ACP.MethodsA one-day IMPACT train-the-trainer course was developed and a selection of healthcare professionals (facilitators) from pediatric palliative care teams (PPCTs) from all seven Dutch university hospitals and the specialized Center for Pediatric Oncology were invited to participate. Hereafter, facilitators were asked to transfer their course-acquired knowledge to their team members (learners) by organizing two coaching-on-the-job sessions. A mixed-methods design, combining questionnaires and field notes, was used to evaluate the level of knowledge transfer and team reflection achieved.ResultsEighteen healthcare professionals in the role of facilitator participated in the train-the-trainer course. In seven PPCTs one (n = 3) or two (n = 4) coaching-on-the-job session(s) took place, attended by 29 and 17 learners, respectively. In the questionnaires, 11 facilitators indicated that they had to some extent transferred acquired knowledge to their team members as intended. Sixteen out of 21 learners who participated in at least one coaching-on-the-job session, reported (somewhat) increased self-confidence for conducting ACP conversations. The reported main strength of the program was practicing with/learning from colleagues whereas dealing with workload and variation in existing ACP skills within PPCTs need more attention.ConclusionsThe newly developed team-based learning program resulted in intended transfer of knowledge and methodical reflection on ACP in coaching-on-the-job sessions in most participating PPCTs. Planning coaching-on-the-job sessions regarding ACP in pediatric palliative care with multiple healthcare professionals is challenging and needs more emphasis in the training.

Clinicians’ experiences implementing an advance care planning pathway in two Canadian provinces: a qualitative study

BackgroundAdvance care planning (ACP) is a process which enables patients to communicate wishes, values, fears, and preferences for future medical care. Despite patient interest in ACP, the frequency of discussions remains low. Barriers to ACP may be mitigated by involving non-physician clinic staff, preparing patients ahead of visits, and using tools to structure visits. An ACP care pathway incorporating these principles was implemented in longitudinal generalist outpatient care, including primary care/family medicine and general internal medicine, in two Canadian provinces. This study aims to understand clinician experiences implementing the pathway.MethodsThe pathway was implemented in one family practice in Alberta, two family practices in British Columbia (BC), and one BC internal medicine outpatient clinic. Physicians and allied health professionals delivered structured pathway visits based on the Serious Illness Conversation Guide. Twelve physicians and one social worker participated in interviews or focus groups at the end of the study period. Qualitative data were coded inductively using an iterative approach, with regular meetings between coders.ResultsClinicians described experiences with the ACP care pathway, impact at the clinician level, and impact at the patient level. Within each domain, clinicians described barriers and facilitators experienced during implementation. Clinicians also reflected candidly about potential for future implementation and the sustainability of the pathway.ConclusionsWhile the pathway was implemented slightly differently between provinces, core experiences were that implementation of the pathway, and integration with current practice, were feasible. Across settings, similar themes recurred regarding usefulness of the pathway structure and its tools, impact on clinician confidence and interactions with patients, teamwork and task delegation, compatibility with existing workflow, and patient preparation and readiness. Clinicians were supportive of ACP and of the pathway.Trial registrationThe study was prospectively registered with clinicaltrials.gov (NCT03508557). Registered April 25, 2018. https://classic.clinicaltrials.gov/ct2/show/NCT03508557.

A Personalized and Interactive Web-Based Advance Care Planning Intervention for Older Adults (Koda Health): Pilot Feasibility Study.

Advance care planning (ACP) is a process that involves patients expressing their personal goals, values, and future medical care preferences. Digital applications may help facilitate this process, though their use in older adults has not been adequately studied. This pilot study aimed to evaluate the reach, adoption, and usability of Koda Health, a web-based patient-facing ACP platform, among older adults. Older adults (aged 50 years and older) who had an active Epic MyChart account at an academic health care system in North Carolina were recruited to participate. A total of 2850 electronic invitations were sent through MyChart accounts with an embedded hyperlink to the Koda platform. Participants who agreed to participate were asked to complete pre- and posttest surveys before and after navigating through the Koda Health platform. Primary outcomes were reach, adoption, and System Usability Scale (SUS) scores. Exploratory outcomes included ACP knowledge and readiness. A total of 161 participants enrolled in the study and created an account on the platform (age: mean 63, SD 9.3 years), with 80% (129/161) of these participants going on to complete all steps of the intervention, thereby generating an advance directive. Participants reported minimal difficulty in using the Koda platform, with an overall SUS score of 76.2. Additionally, knowledge of ACP (eg, mean increase from 3.2 to 4.2 on 5-point scale; P<.001) and readiness (eg, mean increase from 2.6 to 3.2 on readiness to discuss ACP with health care provider; P<.001) significantly increased from before to after the intervention. This study demonstrated that the Koda Health platform is feasible, had above-average usability, and improved ACP documentation of preferences in older adults. Our findings indicate that web-based health tools like Koda may help older individuals learn about and feel more comfortable with ACP while potentially facilitating greater engagement in care planning.

Exploration of decision aids to support advance care planning: A scoping review.

Advance care planning is a process through which people communicate their goals and preferences for future medical care. Due to the complexity of the decision-making process, decision aids can assist individuals in balancing potential benefits and risks of treatment options. While decision aids have the potential to better promote advance care planning, their characteristics, content and application effectiveness are unclear and lack systematic review. Therefore, we aimed to explore these three aspects and establish a foundation for future research. Scoping review. This scoping review adheres to the framework proposed by Arksey and O'Malley and the PRISMA-ScR list. Six English-language databases were systematically searched from the time of construction until 1 December 2023. Two researchers conducted the article screening and data extraction, and the extracted data was presented in written tables and narrative summaries. Of the 1479 titles and abstracts, 20 studies fulfilled the inclusion criteria. Types of decision aids were employed, mainly websites and videos. Decision aid's primary components center around 11 areas, such as furnishing information, exploring treatment and care preferences. The main manifestations were a significant increase in knowledge and improved recognition of patients' target value preferences. Among the aids, websites and videos for advance care planning have relatively high content acceptability and decision-making process satisfaction, but their feasibility has yet to be tested. Decision aids were varied, with content focused on describing key information and exploring treatment and care preferences. Regarding application effects, the aids successfully facilitated the advance care planning process and improved the quality of participants' decisions. Overall, decision aids are efficient in improving the decision-making process for implementing advance care planning in cancer and geriatric populations. In the future, personalised decision aids should be developed based on continuous optimization of tools' quality and promoted for clinical application. The paper has adhered to the EQUATOR guidelines and referenced the PRISMAg-ScR checklist. This is a review without patient and public contribution. https://doi.org/10.17605/OSF.IO/YPHKF, Open Science DOI: 10.17605/OSF.IO/YPHKF.

Patients' and Relatives' Preferences for Outpatient and Day Care Services Within End-of-Life Care in Germany - A Discrete Choice Experiment.

In Germany, patients with incurable chronic diseases living at home increasingly have the option of using outpatient and day care hospice and specialized palliative care services. The present study examined and compared patients' and their relatives' preferences for end-of-life outpatient and day care services. The study used a questionnaire integrating a discrete choice experiment. For six scenarios, participants chose between two hypothetical end-of-life care offers, described by seven attributes. The model compared place of care, frequency and duration of care and support, specialized medical palliative care, accompanied activities, and relieving patient counselling. The model also included optional overnight care and willingness to pay. Patients and the relatives of patients suffering from incurable, chronic diseases who were not yet receiving palliative care were recruited via hospitals and self-help groups (06/2021-07/2022). The results were based on data from 436 questionnaires (patients: n=263, relatives: n=173). All attributes had a statistically significant impact on choice decisions, with place of care showing the greatest importance. All respondents highly preferred care in the patient's home over out-of-home care. Patients stressed the importance of special medical (palliative) care and valued accompanied activities, often facilitated by hospice volunteers. Relatives, but not patients, considered the frequency and duration of care highly relevant. The results suggest a higher demand for care in the patient's home than for out-of-home care. Patients' and relatives' high preference for special medical care and the relief of family caregiver burden should be considered in the design of day care services.

PRAGMATIC IMPLEMENTATION OF AN ADVANCE CARE PLANNING INTERVENTION: FINDINGS FROM SHARING CHOICES

Abstract Advance care planning (ACP) is defined as a key task in ambulatory care for patients to share values, goals, and preferences for future medical care. Ideally ACP is revisited throughout the course of serious illness and engages family in discussions with clinicians. Most interventions, however, have not targeted primary care as a setting for ACP but have instead targeted a specific illness, conversation or setting such as the inpatient hospital or nursing home. Additionally, family is often not included in ACP discussions. This symposium will discuss critical components of the SHARING Choices cluster-randomized pragmatic trial, including the setup, monitoring, and analysis of this intervention within two primary care health systems located in the Baltimore-Washington DC metropolitan corridor. Each presenter will discuss key efforts conducted during the trial that highlight challenges, lessons learned, and novel approaches of embedding an evidence-based intervention within usual care settings targeting older adults 65 years of age and older. Preliminary analyses indicate that the ACP intervention was highly effective for increasing the likelihood of having advance directives in the patients’ electronic health records within 1-year of intervention initiation (odds ratio = 2.88, p &amp;lt; 0.001). Attendees of this symposium will take away relevant insights for implementing effective ACP and communication interventions within primary care settings as well as supporting outcome data. Our discussant will provide thoughts on the implications of these results for current primary care organizations and in the field of ACP and communication for older adults including those with dementia.

Reproductive psychiatric advance directives: promoting autonomy for perinatal people with serious mental illness diagnoses.

People with serious mental illness (SMI) diagnoses who become pregnant are particularly vulnerable to symptom recurrence and resulting potential lack of decision-making capacity (Taylor et al. J Psychiatr Res 104:100-107, 2018; Bagadia et al. Int J Soc Psychiatry 66:792-798, 2020). In these situations, prenataland behavioral health providers have little legally viable guidance on what medical and/or psychiatric care the patient desires (Aneja and Arora Indian J Med Ethics V:133-139, 2020). We created a "Reproductive Psychiatric Advance Directive (PAD)," grounded in Reproductive Justice principles, that promotes patient autonomy by proactively articulating perinatal medical and psychiatric care preferences. We conducted a medical and legal literature review using two sets of terms related to (1) PADs and (2) reproductive health. We convened an expert working group of legal, medical, psychiatric, peer, and advocacy leaders and community-based organizations to develop a Reproductive PAD. Our literature review yielded no results about Reproductive PADs. We created de novo a Reproductive PAD template with sections on medical and psychiatric history, informed consent for critical medical and psychiatric care, family planning and custody preferences, and optional sections on abortion and on electroconvulsive therapy. The Reproductive PAD provides a possible legal mechanism for people of childbearing age with SMI diagnoses to articulate their medical and psychiatric care choices around reproduction and pregnancy. Future research should evaluate the Reproductive PAD as an effective tool for protecting patient autonomy during pregnancy and postpartum and guiding medical and psychiatric providers.

Exposure to a Loved One's Death and Advance Care Planning: Moderating Effects of Age.

Background: Despite documented benefits of Advance Care Planning (ACP), it is still under-utilized in the U.S. Our study aimed to examine whether experiencing a loved one's death is associated with one's own ACP behavior among adults in the U.S. and the potential moderating effect of age. Method: Using a nationwide cross-sectional survey design with probability sampling weights, our study included 1006 adults in the U.S. who participated in and completed the Survey on Aging and End-of-Life Medical Care. Three binary logistic regression models were established to investigate the relationship between death exposure and different aspects of ACP (i.e., informal conversations with family members and doctors and formal advance directives completion). The moderation analysis was subsequently conducted to examine moderating effects of age. Results: The exposure to a loved one's death was significantly associated with higher odds of having conversations with family about end-of-life medical care preferences among the 3 indicators of ACP (OR = 2.03, P < .001). Age significantly moderated the association between death exposure and ACP conversations with doctors (OR = .98, P = .017). The facilitation effect of death exposure on informal ACP engagement in discussing end-of-life medical wishes with doctors is stronger among younger adults than older adults. Conclusions: Exploring an individual's previous experience with a loved one's death might be an effective way to broach the concept of ACP among adults of all ages. This strategy may be particularly useful in facilitating discussions of end-of-life medical wishes with doctors among younger adults than older adults.

Factors Predicting Nonadherence to Treatment Recommendations for Patients With Chronic Low Back Pain in India: A Cross-Sectional Survey

Factors Predicting Nonadherence to Treatment Recommendations for Patients With Chronic Low Back Pain in India: A Cross-Sectional Survey