Patient values informing medical treatment: a pilot community and advance care planning survey

Milnes, S. et al. BMJ Supportive & Palliative Care | Published Online: 2 March 2017

Objectives: We sought to identify priorities of care for patients attending an advance care planning (ACP) clinic and among the general population, and to identify factors associated with priorities other than prolonging life.

Conclusions: ‘Living as long as possible’ was not the most important value for ACP patients, or for a younger general population. Prioritisation of other goals appeared to be independent of extreme age or illness. When end of life treatment is being discussed with patients, priorities other than merely prolonging life should be considered.

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Advance care planning uptake among patients with severe lung disease

Sinclair, C. et. al. (2017) BMJ Open. 7:e013415

Objective: Advance care planning (ACP) clarifies goals for future care if a patient becomes unable to communicate their own preferences. However, ACP uptake is low, with discussions often occurring late. This study assessed whether a systematic nurse-led ACP intervention increases ACP in patients with advanced respiratory disease.

Conclusions: Nurse-led facilitated ACP is acceptable to patients with advanced respiratory disease and effective in increasing ACP discussions and completion of formal documents. Awareness of symptom burden, readiness to engage in ACP and relevant psychosocial factors may facilitate effective tailoring of ACP interventions and achieve greater uptake.

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A qualitative study exploring use of the surprise question in the care of older people

Elliott, M. & Nicholson, C.A. (2017) BMJ Supportive & Palliative Care. 7:32-38.

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Objective: The question “Would you be surprised if this patient were to die in the next 6–12 months?” has been included in UK palliative care guidance with the aim of supporting the identification and care planning of those nearing the end of life. Little is known about how the surprise question is utilised in the care of older people within primary care. This study sought to explore the perceptions and experiences of general practitioners (GPs).

Conclusions: Greater understanding is needed as to the difficulties experienced by GPs when assessing prognosis in older people. We propose a thematic model which could support GPs by focusing assessment on the supportive and palliative care needs of older people nearing the end of life.

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Community-dwellers’ views on advance care planning in older people

Michael, N. et al. (2017) BMC Palliative. 16:2

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Background: Community-dwelling consumers of healthcare are increasing, many aging with life-limiting conditions and deteriorating cognition. However, few have had advance care planning discussions or completed documentation to ensure future care preferences are acted upon. This study examines the awareness, attitudes, and experiences of advance care planning amongst older people and unrelated offspring/caregivers of older people residing in the community.

Conclusions: Advance care planning programs traditionally assume participants are ‘planning ready’ to legally appoint a substitute decision maker (power of attorney) and record end-of-life treatment preferences in short time frames. This contrasts with how community dwelling older people and offspring/caregivers conceive future care decisions over time. Advance care planning programs need to include provision of information, which supports older people’s advance care planning understanding and management, and also supports offspring/caregivers’ development of strategies for broaching advance care planning with older people, and preparing for potential substitute decision maker roles. Development and integration of strategies to support older people’s decision-making when in the ‘grey zone’, with fluctuating cognitive capacities, needs further consideration. Findings support an advance care planning model with conversations occurring at key points across a person’s lifespan.

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A Randomized Trial of Palliative Care Discussions Linked to an Automated Early Warning System Alert.

Picker, D. et al. Critical Care Medicine. Published online: October 20 2016

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Objective: To determine whether an Early Warning System could identify patients wishing to focus on palliative care measures.

Design: Prospective, randomized, pilot study.

Setting: Barnes-Jewish Hospital, Saint Louis, MO (January 15, 2015, to December 12, 2015).

Patients: A total of 206 patients; 89 intervention (43.2%) and 117 controls (56.8%).

Interventions: Palliative care in high-risk patients targeted by an Early Warning System.

Measurements and Main Results: Advanced directive documentation was significantly greater prior to discharge in the intervention group (37.1% vs 15.4%; p < 0.001) as were first-time requests for advanced directive documentation (14.6% vs 0.0%; p < 0.001). Documentation of resuscitation status was also greater prior to discharge in the intervention group (36.0% vs 23.1%; p = 0.043). There was no difference in the number of patients requesting a change in resuscitation status between groups (11.2% vs 9.4%; p = 0.666). However, changes in resuscitation status occurred earlier and on the general medicine units for the intervention group compared to the control group. The number of patients transferred to an ICU was significantly lower for intervention patients (12.4% vs 27.4%; p = 0.009). The median (interquartile range) ICU length of stay was significantly less for the intervention group (0 [0-0] vs 0 [0-1] d; p = 0.014). Hospital mortality was similar (12.4% vs 10.3%; p = 0.635).

Conclusions: This study suggests that automated Early Warning System alerts can identify patients potentially benefitting from directed palliative care discussions and reduce the number of ICU transfers.

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Older people’s views on advance care planning

Overview:

  • A survey of people aged 65 years or older in the east midlands found that only 5% respondents said that they had been offered an opportunity to talk about advance care planning by a health or social care professional.
  • Around a third of respondents said they would be interested in attending sessions on advance care planning or discussing the topic with their GP.
  • Health and social care professionals should encourage people to make plans about their future care, even if only informally with their families.
  • Informal conversations within families need to be supported by lasting powers of attorney to give them a legal basis.

 

 

 

 

 

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Full reference: Musa, I et al. A survey of older peoples’ attitudes towards advance care planning. Age Ageing (2015) 44 (3): 371-376.

Evidence still insufficient that advance care documentation leads to engagement of healthcare professionals in end-of-life discussions: A systematic review

Lewis, E. et al. Palliative Medicine. Published online: March 7, 2016

Background: Administration of non-beneficial life-sustaining treatments in terminal elderly patients still occurs due to lack of knowledge of patient’s wishes or delayed physician–family communications on preference.

Aim: To determine whether advance care documentation encourages healthcare professional’s timely engagement in end-of-life discussions.

Design: Systematic review of the English language articles published from January 2000 to April 2015.

Data sources: EMBASE, MEDLINE, EBM REVIEWS, PsycINFO, CINAHL and Cochrane Library and manual searches of reference lists.

Results: A total of 24 eligible articles from 10 countries including 23,914 subjects met the inclusion criteria, mostly using qualitative or mixed methods, with the exception of two cohort studies. The influence of advance care documentation on initiation of end-of-life discussions was predominantly based on perceptions, attitudes, beliefs and personal experience rather than on standard replicable measures of effectiveness in triggering the discussion. While health professionals reported positive perceptions of the use of advance care documentations (18/24 studies), actual evidence of their engagement in end-of-life discussions or confidence gained from accessing previously formulated wishes in advance care documentations was not generally available.

Conclusion: Perceived effectiveness of advance care documentation in encouraging end-of-life discussions appears to be high but is mostly derived from low-level evidence studies. This may indicate a willingness and openness of patients, surrogates and staff to perceive advance directives as an instrument to improve communication, rather than actual evidence of timeliness or effectiveness from suitably designed studies. The assumption that advance care documentations will lead to higher physicians’ confidence or engagement in communicating with patients/families could not be objectively demonstrated in this review.

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