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Palliative Medicine Sep 2020Use of implantable cardioverter defibrillators is increasingly common. As patients approach the end of life, it is appropriate to deactivate the shock function. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Use of implantable cardioverter defibrillators is increasingly common. As patients approach the end of life, it is appropriate to deactivate the shock function.
AIM
To assess the prevalence of implantable cardioverter defibrillator reprogramming to deactivate the shock function at the end of life and the prevalence of advance directives among this population.
DESIGN
Following a previously established protocol available in PROSPERO, we performed a narrative synthesis of our findings and used the logit transformation method to perform our quantitative synthesis.
DATA SOURCES
We searched seven bibliographic databases (Embase, Cochrane Central register of controlled Trials, Medline-Ovid, Web-of-Science, Scopus, PsychInfo, and CINAHL) and additional sources until April 2019.
RESULTS
Of the references we identified, 14 were included. We found a pooled prevalence of implantable cardioverter defibrillator reprogramming at the end of life of 28% (95% confidence interval, 22%-36%) with higher reprogramming rates after the recommendations for managing the device at the end of life were published. Among patients with advance directives, the pooled prevalence of advance directives that explicitly mentioned the device was 1% (95% confidence interval, 1%-3%).
CONCLUSIONS
The prevalence of implantable cardioverter defibrillator reprogramming and advance directives that explicitly mentioned the device was very low. Study data suggested reprogramming decisions were made very late, after the patient experienced multiple shocks. Patient suffering could be ameliorated if physicians and other healthcare professionals adhere to clinical guidelines for the good management of the device at the end of life and include deactivating the shock function in the discussion that leads to the advance directive.
Topics: Advance Directives; Death; Defibrillators, Implantable; Humans
PubMed: 32588755
DOI: 10.1177/0269216320929548 -
Han'guk Hosup'isu Wanhwa Uiryo Hakhoe... Jun 2020The purpose of this systematic review and meta-analysis was to investigate the effects of advance care planning on end-of-life decision-making.
PURPOSE
The purpose of this systematic review and meta-analysis was to investigate the effects of advance care planning on end-of-life decision-making.
METHODS
Databases including RISS, KISS, KMbase, KoreaMed, PubMed (MEDLINE), Embase, and CINAHL were searched for studies that examined the effects of advance care planning interventions. The inclusion criteria were original studies in English or Korean; adults ≥18 years of age (population); advance care planning (intervention); completion of advance directives (AD) or advance care planning (ACP) (outcomes); and randomized or non-randomized controlled trials (RCTs and non-RCTs, respectively) (design). Study quality was measured using the checklists of the Joanna Briggs Institute. Meta-analyses were conducted with the Comprehensive Meta-Analysis program.
RESULTS
Nine RCTs and nine non-RCTs were selected for the final analysis. The effect sizes (ES) of the outcome variables in nine RCTs were meta-analyzed, and found to range from 0.142 to 0.496 for the completion of AD and ACP (ES=0.496, 95% CI: 0.157~0.836), discussion of end-of-life care (ES=0.429, 95% CI: -0.027~0.885), quality of communication (ES=0.413, 95% CI: 0.008~0.818), decisional conflict (ES=0.349, 95% CI: -0.059~0.758), and congruence between preferences for care and delivered care (ES=0.142, 95% CI: -0.267~0.552).
CONCLUSION
ACP interventions had a positive effect on the completion of AD and ACP. To apply AD or ACP in Korea, it is necessary to develop ACP interventions that reflect aspects of Korean culture.
PubMed: 37497084
DOI: 10.14475/kjhpc.2020.23.2.71 -
The Cochrane Database of Systematic... Feb 2020People with heart failure report various symptoms and show a trajectory of periodic exacerbations and recoveries, where each exacerbation event may lead to death.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
People with heart failure report various symptoms and show a trajectory of periodic exacerbations and recoveries, where each exacerbation event may lead to death. Current clinical practice guidelines indicate the importance of discussing future care strategies with people with heart failure. Advance care planning (ACP) is the process of discussing an individual's future care plan according to their values and preferences, and involves the person with heart failure, their family members or surrogate decision-makers, and healthcare providers. Although it is shown that ACP may improve discussion about end-of-life care and documentation of an individual's preferences, the effects of ACP for people with heart failure are uncertain.
OBJECTIVES
To assess the effects of advance care planning (ACP) in people with heart failure compared to usual care strategies that do not have any components promoting ACP.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, CINAHL, Social Work Abstracts, and two clinical trials registers in October 2019. We checked the reference lists of included studies. There were no restrictions on language or publication status.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) that compared ACP with usual care in people with heart failure. Trials could have parallel group, cluster-randomised, or cross-over designs. We included interventions that implemented ACP, such as discussing and considering values, wishes, life goals, and preferences for future medical care. The study participants comprised adults (18 years of age or older) with heart failure.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted outcome data from the included studies, and assessed their risk of bias. We contacted trial authors when we needed to obtain missing information.
MAIN RESULTS
We included nine RCTs (1242 participants and 426 surrogate decision-makers) in this review. The meta-analysis included seven studies (876 participants). Participants' mean ages ranged from 62 to 82 years, and 53% to 100% of the studies' participants were men. All included studies took place in the US or the UK. Only one study reported concordance between participants' preferences and end-of-life care, and it enrolled people with heart failure or renal disease. Owing to one study with small sample size, the effects of ACP on concordance between participants' preferences and end-of-life care were uncertain (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.91 to 1.55; participants = 110; studies = 1; very low-quality evidence). It corresponded to an assumed risk of 625 per 1000 participants receiving usual care and a corresponding risk of 744 per 1000 (95% CI 569 to 969) for ACP. There was no evidence of a difference in quality of life between groups (standardised mean difference (SMD) 0.06, 95% CI -0.26 to 0.38; participants = 156; studies = 3; low-quality evidence). However, one study, which was not included in the meta-analysis, showed that the quality of life score improved by 14.86 points in the ACP group compared with 11.80 points in the usual care group. Completion of documentation by medical staff regarding discussions with participants about ACP processes may have increased (RR 1.68. 95% CI 1.23 to 2.29; participants = 92; studies = 2; low-quality evidence). This corresponded to an assumed risk of 489 per 1000 participants with usual care and a corresponding risk of 822 per 1000 (95% CI 602 to 1000) for ACP. One study, which was not included in the meta-analysis, also showed that ACP helped to improve documentation of the ACP process (hazard ratio (HR) 2.87, 95% CI 1.09 to 7.59; participants = 232). Three studies reported that implementation of ACP led to an improvement of participants' depression (SMD -0.58, 95% CI -0.82 to -0.34; participants = 278; studies = 3; low-quality evidence). We were uncertain about the effects of ACP on the quality of communication when compared to the usual care group (MD -0.40, 95% CI -1.61 to 0.81; participants = 9; studies = 1; very low-quality evidence). We also noted an increase in all-cause mortality in the ACP group (RR 1.32, 95% CI 1.04 to 1.67; participants = 795; studies = 5). The studies did not report participants' satisfaction with care/treatment and caregivers' satisfaction with care/treatment.
AUTHORS' CONCLUSIONS
ACP may help to increase documentation by medical staff regarding discussions with participants about ACP processes, and may improve an individual's depression. However, the quality of the evidence about these outcomes was low. The quality of the evidence for each outcome was low to very low due to the small number of studies and participants included in this review. Additionally, the follow-up periods and types of ACP intervention were varied. Therefore, further studies are needed to explore the effects of ACP that consider these differences carefully.
Topics: Advance Care Planning; Advance Directives; Clinical Decision-Making; Disease Progression; Family; Heart Failure; Humans; Patient Participation; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 32104908
DOI: 10.1002/14651858.CD013022.pub2 -
Patient Education and Counseling Jun 2020Surrogate decision-makers play an increasingly important role in the lives of older adults who have lost their ability to make decisions. Currently, there is a lack of...
OBJECTIVE
Surrogate decision-makers play an increasingly important role in the lives of older adults who have lost their ability to make decisions. Currently, there is a lack of evidence to support family surrogates in making a variety of decisions. Additionally, a greater understanding of family caregivers' experiences and perspectives toward making surrogate decisions is needed.
METHODS
This study employed a qualitative systematic review and thematic synthesis of the research evidence using the methodologies of the Joanna Briggs Institute (2014) and Thomas and Harden (2008).
RESULTS
Decisions were classified per three main types: intensive care treatment, end-of-life treatment, and placement. Six themes were identified concerning surrogates' experiences: struggle and reluctance, seeking reassurance, communication with healthcare professionals, family support, older adults' wishes, and negative impact.
CONCLUSION
Family surrogates often lack adequate preparation and education regarding decision-making. Quality communication between surrogates and healthcare providers helps reduce the anxiety and guilt experienced when making surrogate decisions. Further research is required to elucidate these experiences with more cultural and racial nuances.
PRACTICE IMPLICATIONS
This review informs healthcare providers' awareness of the challenges faced by surrogates and fosters improved surrogate decision-making experiences.
Topics: Advance Directives; Aged; Caregivers; Communication; Decision Making; Family; Humans; Qualitative Research
PubMed: 31866198
DOI: 10.1016/j.pec.2019.12.011 -
Journal of Immigrant and Minority Health Aug 2020Patients with limited English proficiency (LEP) experience disparities in end-of-life decision making and advance care planning. Our objective was to conduct a...
Patients with limited English proficiency (LEP) experience disparities in end-of-life decision making and advance care planning. Our objective was to conduct a systematic review to assess the literature about interventions addressing these issues. Our search strategy was built around end-of-life (EOL), LEP, ACP, and goals of care. The databases included Ovid MEDLINE(R), and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily from 1946 to November 9, 2018, Ovid EMBASE. Eight studies from the US and Australia were included (seven studies in Spanish and one study in Greek and Italian). Interventions used trained personnel, video images, web-based programs, and written materials. Interventions were associated with increased advance directive completion and decreased preferences for some life-prolonging treatments. Interventions were deemed to be feasible and acceptable. Few interventions exist to improve end-of-life care for patients with LEP. Data are limited regarding intervention effectiveness.
Topics: Advance Care Planning; Advance Directives; Australia; Cultural Characteristics; Decision Making; Health Promotion; Humans; Limited English Proficiency; Terminal Care; United States
PubMed: 31749066
DOI: 10.1007/s10903-019-00947-w -
BMJ Open Sep 2019How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare...
OBJECTIVES
How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice?
DESIGN
A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting.
SETTING
Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews.
RESULTS
The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging.
CONCLUSION
Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice.
PROSPERO REGISTRATION NUMBER
CRD42018088838.
Topics: Advance Care Planning; Australia; Delivery of Health Care; General Practice; Humans; Patient Acceptance of Health Care; Primary Health Care; Qualitative Research
PubMed: 31537570
DOI: 10.1136/bmjopen-2019-030275 -
Journal of Pain and Symptom Management Dec 2019Individuals with cystic fibrosis (CF) frequently survive into adulthood, and many have multifaceted symptoms that impair quality of life.
CONTEXT
Individuals with cystic fibrosis (CF) frequently survive into adulthood, and many have multifaceted symptoms that impair quality of life.
OBJECTIVE
We conducted a systematic review to investigate opportunities to improve utilization of palliative care among adults with CF.
METHODS
We searched PubMed, Embase, Scopus, Web of Science, and CINAHL databases from inception until September 27, 2018, and reviewed references manually. Eligible articles were published in English, involved adults aged 18 years and older with CF, and contained original data regarding patient outcomes related to presence of advance care planning (ACP), symptom experience, and preferred and/or received end-of-life (EOL) care.
RESULTS
We screened 652 article abstracts and 32 full-text articles; 12 studies met inclusion criteria. All studies were published between 2000 and 2018. Pertinent findings include that although 43% to 65% of adults with CF had contemplated completing ACP, the majority only completed ACP during their terminal hospital admission. Patients also reported high prevalence of untreated symptoms, with adequate symptom control reported in 45% among those with dyspnea, 22% among those with pain, and 51% among those with anxiety and/or depression. Prevalence of in-hospital death ranged from 62% to 100%, with a third dying in the intensive care unit. The majority received antibiotics and preventative treatments during their terminal hospitalization. Finally, treatment from a palliative care specialist was associated with a higher prevalence of patient completion of advanced directives, decreased likelihood of death in intensive care unit, and decreased use of mechanical ventilation at EOL.
CONCLUSION
Adults with CF often have untreated symptoms, and many opportunities exist for palliative care specialists to improve ACP completion and quality of EOL care.
Topics: Adult; Advance Care Planning; Advance Directives; Cystic Fibrosis; Humans; Palliative Care; Terminal Care
PubMed: 31437475
DOI: 10.1016/j.jpainsymman.2019.08.017 -
Journal of Pain and Symptom Management Nov 2019Little is known about advance care planning (ACP) and palliative care needs among adults with congenital heart disease (ACHD).
CONTEXT
Little is known about advance care planning (ACP) and palliative care needs among adults with congenital heart disease (ACHD).
OBJECTIVES
The objective of this study was to identify and synthesize studies concerning palliative care among ACHD patients.
METHODS
We searched five electronic databases (PubMed, Embase, SCOPUS, Web of Science, and CINAHL) using the keywords palliative care and congenital heart disease. Inclusion criteria were adults (age > 18 years) with congenital heart disease and publications in English through March 3, 2019.
RESULTS
Our search yielded 2872 studies, and after removal of duplicates, we screened 2319 abstracts and identified seven for inclusion. Study findings were grouped into three domains: ACP, symptomatology, and end-of-life care. Among the five cross-sectional studies, only 1%-28% of ACHD patients recalled participating in ACP discussions with their doctors but 69%-78% reported a strong interest and desire to participate in ACP. In one study, 46% (n = 67) of patients had elevated anxiety symptoms (Hospital Anxiety and Depression Scale [HADS-A] ≥ 8) and 11% (n = 15) had elevated depressive symptoms (HADS-A ≥ 8). ACHD patients who had a documented goals of care conversation before cardiac decompensation had a lower incidence of resuscitation and aggressive treatments at end of life (12% [n = 3] vs. 100% [n = 12], P < 0.001).
CONCLUSION
While few ACHD patients complete advance directives, our findings support that many ACHD patients recognize the value of initiating end-of-life and goals of care conversations early on in the course of illness. Future studies investigating communication and implementation strategies of ACP as well as the symptom experience of patients with ACHD are needed.
Topics: Advance Care Planning; Advance Directives; Databases, Factual; Heart Defects, Congenital; Humans; Palliative Care; Terminal Care
PubMed: 31404639
DOI: 10.1016/j.jpainsymman.2019.07.025 -
BMC Health Services Research Jun 2019Advance care planning (ACP) is the process of ongoing communication among patients, family and health care professionals regarding what plans for future care are...
BACKGROUND
Advance care planning (ACP) is the process of ongoing communication among patients, family and health care professionals regarding what plans for future care are preferred in the event that patients become unable to make their own decisions. Clinicians play an important role in ACP as both initiators and decision coaches. However, lack of training for clinicians has frequently been reported as the reason for low involvement in ACP discussions - hence the present review evaluates the effectiveness of ACP training programs for healthcare professionals to guide the development of novel training programs for them in the future.
METHODS
A literature search for intervention studies was conducted independently by two reviewers in July 2018. Participants included all healthcare professionals working with adult patients suffering from terminal illness. The primary outcomes were the professionals' knowledge of and attitudes towards ACP, and self-perceived competence in ACP conversations. The Effective Public Health Practice Project appraisal tool was used to examine the quality of the studies included.
RESULTS
A total of 4025 articles were identified, and ten eligible articles, covering 1081 participants, were included in the review. However, there is a lack of high quality randomized controlled trials of providing ACP training for nurses working in non-palliative care hospital settings. The overall quality of the intervention studies was moderate. All the studies included used instructional sessions in their interventions, while some contained group discussion, role-play and the use of advanced technology. The training programs increased the knowledge, attitudes towards shared decision-making, perceived communication skills, confidence, comfort and experiences concerned with discussing end-of-life (EOL) issues. Patient advocacy, job satisfaction and perceived level of adequate training for EOL care were improved. The use of 'decision aids' was rated as acceptable and clinically useful.
CONCLUSIONS
Training for healthcare professionals in ACP has positive effects on their knowledge, attitude and skills. The use of decision aids and advanced technology, instructional sessions with role play, training content focused on ACP communication skills and the needs and experience of patient in the ACP process, and a values-based ACP process are all those factors that made the ACP training programs effective.
Topics: Advance Care Planning; Advance Directives; Decision Making; Evidence-Based Practice; Health Personnel; Humans; Randomized Controlled Trials as Topic
PubMed: 31174530
DOI: 10.1186/s12913-019-4192-0 -
JAMA Network Open Jun 2019Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary resuscitation (CPR) remains unclear.
OBJECTIVE
To conduct a systematic review and meta-analysis regarding the association of communication interventions with patient decisions and knowledge about CPR.
DATA SOURCES
PubMed, Embase, PsycINFO, and CINAHL were systematically searched from the inception of each database to November 19, 2018.
STUDY SELECTION
Randomized clinical trials focusing on interventions to facilitate code status discussions. Two independent reviewers performed the data extraction and assessed risk of bias using the Cochrane Risk of Bias Tool. Data were pooled using a fixed-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported.
DATA EXTRACTION AND SYNTHESIS
The study was performed according to the PRISMA guidelines.
MAIN OUTCOMES AND MEASURES
The primary outcome was patient preference for CPR, and the key secondary outcome was patient knowledge regarding life-sustaining treatment.
RESULTS
Fifteen randomized clinical trials (2405 patients) were included in the qualitative synthesis, 11 trials (1463 patients) were included for the quantitative synthesis of the primary end point, and 5 trials (652 patients) were included for the secondary end point. Communication interventions were significantly associated with a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). In a preplanned subgroup analysis, studies using resuscitation videos as decision aids compared with other interventions showed a stronger decrease in preference for life-sustaining treatment (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Also, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55; 95% CI, 0.39-0.71).
CONCLUSIONS AND RELEVANCE
Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions.
Topics: Advance Directives; Cardiopulmonary Resuscitation; Communication; Decision Making; Health Knowledge, Attitudes, Practice; Humans; Patient Preference; Resuscitation Orders
PubMed: 31173119
DOI: 10.1001/jamanetworkopen.2019.5033