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BMJ Open Mar 2019The use of advance care planning and advance decisions for psychiatric care is growing. However, there is limited guidance on clinical management when a patient presents...
BACKGROUND
The use of advance care planning and advance decisions for psychiatric care is growing. However, there is limited guidance on clinical management when a patient presents with suicidal behaviour and an advance decision and no systematic reviews of the extant literature.
OBJECTIVES
To synthesise existing literature on the management of advance decisions and suicidal behaviour.
DESIGN
A systematic search of seven bibliographic databases was conducted to identify studies relating to advance decisions and suicidal behaviour. Studies on terminal illness or end-of-life care were excluded to focus on the use of advance decisions in the context of suicidal behaviour. A textual synthesis of data was conducted, and themes were identified by using an adapted thematic framework analysis approach.
RESULTS
Overall 634 articles were identified, of which 35 were retained for full text screening. Fifteen relevant articles were identified following screening. Those articles pertained to actual clinical cases or fictional scenarios. Clinical practice and rationale for management decisions varied. Five themes were identified: (1) tension between patient autonomy and protecting a vulnerable person, (2) appropriateness of advance decisions for suicidal behaviour, (3) uncertainty about the application of legislation, (4) the length of time needed to consider all the evidence versus rapid decision-making for treatment and (5) importance of seeking support and sharing decision-making.
CONCLUSIONS
Advance decisions present particular challenges for clinicians when associated with suicidal behaviour. Recommendations for practice and supervision for clinicians may help to reduce the variation in clinical practice.
Topics: Advance Care Planning; Clinical Decision-Making; Humans; Mental Competency; Suicide, Attempted; Uncertainty
PubMed: 30872542
DOI: 10.1136/bmjopen-2018-023978 -
Palliative Care 2019A Rapid Response Team can respond to critically ill patients in hospital to prevent further deterioration and unexpected deaths. However, approximately one-third of... (Review)
Review
BACKGROUND
A Rapid Response Team can respond to critically ill patients in hospital to prevent further deterioration and unexpected deaths. However, approximately one-third of reviews involve a patient approaching the end-of-life. It is not well understood whether patients have pre-existing advance care plans at the time of significant clinical deterioration requiring Rapid Response Team review. Nor is it understood whether such critical events prompt patients, their families and treating teams to discuss advance care planning and consider referral to specialist palliative care services.
AIM AND DESIGN
This systematic review examined advance care planning with patients who experience significant clinical deterioration in hospital and require Rapid Response Team review. The prevalence of pre-existing advance directives, whether this event prompts end-of-life discussions, the provision of broader advance care planning and referral to specialist palliative care services was examined.
DATA SOURCES
Three electronic databases up to August 2017 were searched, and a manual review of article reference lists conducted. Quality of studies was appraised by the first and fourth authors.
RESULTS
Of the 324 articles identified through database searching, 31 met the inclusion criteria, generating data from 47,850 patients. There was a low prevalence of resuscitation orders and formal advance directives prior to Rapid Response Team review, with subsequent increases in resuscitation and limitations of medical treatment orders, but not advance directives. There was high short- and long-term mortality following review, and low rates of palliative care referral.
CONCLUSIONS
The failure of patients, their families and medical teams to engage in advance care planning may result in inappropriate Rapid Response Team review that is not in line with patient and family priorities and preferences. Earlier engagement in advance care planning may result in improved person-centred care and referral to specialist palliative care services for ongoing management.
PubMed: 30718959
DOI: 10.1177/1178224218823509 -
BMC Geriatrics Jan 2019Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be...
BACKGROUND
Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable.
METHODS
Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract.
RESULTS
Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital.
CONCLUSIONS
The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient's autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.
Topics: Advance Directives; Aged; Aged, 80 and over; Delivery of Health Care; Emergency Service, Hospital; Hospitalization; Humans; Nursing Homes; Nursing Staff; Patient Transfer; Qualitative Research
PubMed: 30665362
DOI: 10.1186/s12877-019-1028-z -
Journal of Pain and Symptom Management Jan 2019Despite the benefits of advance care planning (ACP), cancer patients rarely engage in ACP. ACP is a process that parallels health behavior change. This makes the...
A Systematic Review and Gap Analysis of Advance Care Planning Intervention Components and Outcomes Among Cancer Patients Using the Transtheoretical Model of Health Behavior Change.
CONTEXT
Despite the benefits of advance care planning (ACP), cancer patients rarely engage in ACP. ACP is a process that parallels health behavior change. This makes the Transtheoretical Model of Health Behavior Change (TTM) an important framework for understanding how to increase ACP among cancer patients.
OBJECTIVES
This study aimed to systematically review ACP interventions for cancer patients by 1) categorizing ACP intervention components according to the stages and processes of behavior change in the TTM, 2) conducting a gap analysis among the categorized components, and 3) identifying patterns between the categorized intervention components and the intervention outcomes.
METHODS
PubMed, CINAHL Plus, MEDLINE, Cochrane Library, and Web of Science databases were searched for articles related to ACP and cancer. ACP intervention components were abstracted, assessed for theoretical relevance, organized according to the stages and process of change in the TTM, and then synthesized.
RESULTS
The search produced 4604 articles, with 25 meeting criteria for review. Most intervention components targeted the precontemplation and contemplation stages of change, with fewer targeting preparation, action, or maintenance. Multiple processes of change were not addressed. Interventions that resulted in ACP engagement tended to take an interdisciplinary approach to implementation and consisted of multiple consultations staged over time.
CONCLUSION
ACP likely requires "high touch" interventions to induce behavior change. ACP interventions that are stage-matched, use diverse mechanisms to engage ACP (i.e., processes of change), address ACP as a process, and monitor engagement across the illness trajectory are needed for cancers patients and their caregivers.
Topics: Advance Care Planning; Health Behavior; Humans; Models, Psychological; Neoplasms
PubMed: 30595148
DOI: 10.1016/j.jpainsymman.2018.10.502 -
A systematic review of the content and delivery of education in pulmonary rehabilitation programmes.Respiratory Medicine Dec 2018Pulmonary rehabilitation (PR) is a core component of Chronic Obstructive Pulmonary Disease (COPD) management with well recognized benefits. While suggestions for...
INTRODUCTION
Pulmonary rehabilitation (PR) is a core component of Chronic Obstructive Pulmonary Disease (COPD) management with well recognized benefits. While suggestions for educational content within pulmonary rehabilitation have been detailed in clinical guidance, it is unclear what educational content is delivered as part of pulmonary rehabilitation, who delivers it, and how it is delivered.
METHODS
A systematic review was conducted to identify what educational content is delivered as part of pulmonary rehabilitation, how is this delivered and who delivers it. Databases were searched from 1981 to 2017 using multiple search terms related to "pulmonary rehabilitation" and "education".
RESULTS
Fourteen studies were identified. This included 6 survey studies, 5 quasi-experimental studies and 3 RCTs. Five key topics that were consistently included within PR programmes were identified as: 1) Anxiety/depression and stress management. 2) Early recognition of signs of infection. 3) Dyspnea and symptom management. 4) Nutrition. 5) Techniques using inhalers and nebulizers. Broader topics such as welfare/benefits, sexuality, and advance care directives did not frequently feature. Only four studies used tools to measure knowledge or learning pre and post rehabilitation in an attempt to evaluate the effectiveness of the education delivered as part of PR.
CONCLUSIONS
The delivery of education in PR programmes is variable and does not follow suggested educational topics. Education needs to take a patient centered motivational approach to ensure effective delivery. Further research into appropriate educational outcome measures are needed, in order to evaluate the changes in behaviour associated with education.
Topics: Databases, Bibliographic; Delivery of Health Care; Disease Management; Health Behavior; Health Education; Humans; Motivation; Patient-Centered Care; Pulmonary Disease, Chronic Obstructive
PubMed: 30509706
DOI: 10.1016/j.rmed.2018.11.002 -
Journal of Pain and Symptom Management Nov 2018Patients with end-stage kidney disease have a high mortality rate and disease burden. Despite this, many do not speak with health care professionals about end-of-life...
CONTEXT
Patients with end-stage kidney disease have a high mortality rate and disease burden. Despite this, many do not speak with health care professionals about end-of-life issues. Advance care planning is recommended in this context but is complex and challenging. We carried out a realist review to identify factors affecting its implementation.
OBJECTIVES
The objectives of this study are 1) to identify implementation theories; 2) to identify factors that help or hinder implementation; and 3) to develop theory on how the intervention may work.
METHODS
We carried out a systematic realist review, searching seven electronic databases: Medline, Embase, CINAHL, PsycINFO, Cochrane Library, Google Scholar, and ScienceDirect.
RESULTS
Sixty-two papers were included in the review.
CONCLUSION
We identified two intervention stages-1) training for health care professionals that addresses concerns, optimizes skills, and clarifies processes and 2) use of documentation and processes that are simple, individually tailored, culturally appropriate, and involve surrogates. These processes work as patients develop trust in professionals, participate in discussions, and clarify values and beliefs about their condition. This leads to greater congruence between patients and surrogates; increased quality of communication between patients and professionals; and increased completion of advance directives. Advance care planning is hindered by lack of training; administrative complexities; pressures of routine care; patients overestimating life expectancy; and when patients, family, and/or clinical staff are reluctant to initiate discussions. It is more likely to succeed where organizations treat it as core business; when the process is culturally appropriate and takes account of patient perceptions; and when patients are willing to consider death and dying with suitably trained staff.
Topics: Advance Care Planning; Humans; Kidney Failure, Chronic
PubMed: 30025939
DOI: 10.1016/j.jpainsymman.2018.07.008 -
The American Journal of Hospice &... Jun 2018All individuals should receive care consistent with their expressed preferences during serious and chronic illnesses. Respecting Choices (RC) is a well-known model of... (Review)
Review
All individuals should receive care consistent with their expressed preferences during serious and chronic illnesses. Respecting Choices (RC) is a well-known model of advance care planning intended to assist individuals consider, choose, and communicate these preferences to health-care providers. In this systematic review, we evaluated the published literature on the outcomes of the RC and derivative models utilizing criteria developed by the Cochrane Collaborative. Eighteen articles from 16 studies were included, of which 9 were randomized controlled trials, 6 were observational, and 1 was a pre-posttest study. Only 2 specifically included a minority population (African American). Fourteen were conducted in the United States, primarily in the Wisconsin/Minnesota region (n = 8). Seven studies examined the RC model, whereas 9 examined derivative models. There was significant heterogeneity of outcomes examined. We found that there is a low level of evidence that RC and derivative models increase the incidence and prevalence of Advance Directive and Physician Orders for Life-Sustaining Treatment completion. There is a high level of evidence that RC and derivative models increase patient-surrogate congruence in Caucasian populations. The evidence is mixed, inconclusive, and too poor in quality to determine whether RC and derivative models change the consistency of treatment with wishes and overall health-care utilization in the end of life. We urge further studies be conducted, particularly with minority populations and focused on the outcomes of preference-congruent treatment and health-care utilization.
Topics: Advance Care Planning; Black or African American; Choice Behavior; Communication; Decision Making; Humans; White People
PubMed: 29254357
DOI: 10.1177/1049909117745789 -
Journal of Pain and Symptom Management Feb 2018Research has begun to focus on whether Advance Care Planning (ACP) has the capacity to influence care, and to examine whether ACP can be effective in meeting patients'...
How Well Do Current Measures Assess the Impact of Advance Care Planning on Concordance Between Patient Preferences for End-of-Life Care and the Care Received: A Methodological Review.
BACKGROUND
Research has begun to focus on whether Advance Care Planning (ACP) has the capacity to influence care, and to examine whether ACP can be effective in meeting patients' wishes at the end of their lives. Little attention has been paid, however, to the validity and clinical relevance of existing measures.
METHODS
A search of Medline and CINHAL identified ACP studies measuring concordance between end-of-life (EoL) preferences and the care received. Databases were searched from 2000 to August 2016. We developed a checklist to evaluate the quality of included studies. Data were collected on the proportion of patients who received concordant care, extracted from manuscript tables or calculated from the text.
OUTCOMES
Of 2941 papers initially identified, nine eligible studies were included. Proportions of patients who received concordant care varied from 14% to 98%. Studies were heterogeneous and methodologically poor, with limited attention paid to bias/external validity. Studies varied with regards to design of measures, the meaning of relevant terms like "preference" "EoL care" and "concordance," and the completeness of reported data.
CONCLUSION
Methodological variations and weaknesses compromise the validity of study results, and prevent meaningful comparisons between studies or synthesis of the results. Effectively evaluating whether ACP interventions enhance a patient's capacity to receive the care they want requires harmonization of research. This demands standardization of methods across studies, validating of instruments, and consensus based on a consistent conceptual framework regarding what constitutes a meaningful outcome measure.
Topics: Advance Care Planning; Humans; Outcome Assessment, Health Care; Patient Preference; Terminal Care
PubMed: 28943359
DOI: 10.1016/j.jpainsymman.2017.09.008 -
Palliative & Supportive Care Oct 2017The objective of this study was to examine the religious/spiritual beliefs of followers of the five major world religions about frequently encountered medical situations... (Review)
Review
OBJECTIVE
The objective of this study was to examine the religious/spiritual beliefs of followers of the five major world religions about frequently encountered medical situations at the end of life (EoL).
METHOD
This was a systematic review of observational studies on the religious aspects of commonly encountered EoL situations. The databases used for retrieving studies were: Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Observational studies, including surveys from healthcare providers or the general population, and case studies were included for review. Articles written from a purely theoretical or philosophical perspective were excluded.
RESULTS
Our search strategy generated 968 references, 40 of which were included for review, while 5 studies were added from reference lists. Whenever possible, we organized the results into five categories that would be clinically meaningful for palliative care practices at the EoL: advanced directives, euthanasia and physician-assisted suicide, physical requirements (artificial nutrition, hydration, and pain management), autopsy practices, and other EoL religious considerations. A wide degree of heterogeneity was observed within religions, depending on the country of origin, level of education, and degree of intrinsic religiosity.
SIGNIFICANCE OF RESULTS
Our review describes the religious practices pertaining to major EoL issues and explains the variations in EoL decision making by clinicians and patients based on their religious teachings and beliefs. Prospective studies with validated tools for religiosity should be performed in the future to assess the impact of religion on EoL care.
Topics: Attitude to Health; Buddhism; Christianity; Health Personnel; Hinduism; Humans; Islam; Judaism; Religion; Suicide, Assisted; Terminal Care
PubMed: 28901283
DOI: 10.1017/S1478951516001061 -
BMC Geriatrics Jul 2017It is challenging to use shared decision-making with patients who have a chronic health condition or, especially, multimorbidity. A patient-goal-oriented approach can... (Comparative Study)
Comparative Study Review
BACKGROUND
It is challenging to use shared decision-making with patients who have a chronic health condition or, especially, multimorbidity. A patient-goal-oriented approach can thus be beneficial. This study aims to identify and evaluate studies on the effects of interventions that support collaborative goal setting or health priority setting compared to usual care for elderly people with a chronic health condition or multimorbidity.
METHODS
This systematic review was based on EPOC, PRISMA and MOOSE guidelines. Pubmed, PsychInfo, CINAHL, Web of Science, Embase and the Cochrane Central Register of Controlled Trials were searched systematically. The following eligibility criteria were applied: 1. Randomised (cluster) controlled trials, non-randomised controlled trials, controlled before-after studies, interrupted time series or repeated measures study design; 2. Single intervention directed specifically at collaborative goal setting or health priority setting or a multifactorial intervention including these elements; 3. Study population of patients with multimorbidity or at least one chronic disease (mean age ± standard deviation (SD) incl. age 65). 4. Studies reporting on outcome measures reducible to outcomes for collaborative goal setting or health priority setting.
RESULTS
A narrative analysis was performed. Eight articles describing five unique interventions, including four cluster randomised controlled trials and one randomised controlled trial, were identified. Four intervention studies, representing 904, 183, 387 and 1921 patients respectively, were multifactorial and showed statistically significant effects on the application of goal setting (Patient Assessment of Chronic Illness Care (PACIC) goal setting subscale), the number of advance directives or the inclusion of goals in care plans. Explicit attention for goal setting or priority setting by a professional was a common element in these multifactorial interventions. One study, which implemented a single-factor intervention on 322 patients, did not have significant effects on doctor-patient agreement. All the studies had methodological concerns in varying degrees.
CONCLUSIONS
Collaborative goal setting and/or priority setting can probably best be integrated in complex care interventions. Further research should determine the mix of essential elements in a multifactorial intervention to provide recommendations for daily practice. In addition, the necessity of methodological innovation and the application of mixed evaluation models must be highlighted to deal with the complexity of goal setting and/or priority setting intervention studies.
Topics: Aged; Chronic Disease; Decision Making; Goals; Health Priorities; Humans; Intersectoral Collaboration; Multimorbidity; Patient-Centered Care
PubMed: 28760149
DOI: 10.1186/s12877-017-0534-0