Transgenerational Dynamics and Hospice Care

This course provides an educational forum for patients and their families and friends who are dealing with cancer and other potentially life-threatening illnesses. Using the basic concepts of transpersonal psychology, as formulated by Carl G. Jung, the course explores the changes experienced by patients upon diagnosis and opens the way for learning strategies to enhance life, give it new meaning and use illness as a challenge for personal growth. It differs from a support group because it has structure, objectives and content. Like a support group, however, participants engage in self- discovery without lectures. The forum is theirs, and facilitators simply function as guides.     

Advance care planning in Belgium and The Netherlands: a nationwide retrospective study via sentinel networks of general practitioners

Context

Advance care planning (ACP) is an important part of patient-centered palliative care. There have been few nationwide studies of ACP, especially in Europe.

Objectives

To investigate the prevalence and characteristics of ACP in two European countries and identify the associated factors.

Methods

A mortality follow-back study was undertaken in 2007 via representative nationwide Sentinel Networks of general practitioners (GPs) in Belgium and The Netherlands using similar standardized procedures. All GPs reported on each non-suddenly deceased patient in their practice. Our main outcome measure was whether or not ACP, that is, an agreement for medical treatment and/or medical decisions in the last phase of life in the case of the patient losing competence, was present.

Results

Among 1072 non-sudden deaths, ACP was done with 34% of patients and most often related to the forgoing of potential life-prolonging treatments in general (24%). In 8% of cases, ACP was made in consultation with the patient and in writing. In 23% of cases, care was planned with the patient’s family only. Multivariate analysis revealed that ACP was more often made with patients if they were capable of decision making during the last three days of life (odds ratio [OR] 3.86; 95% confidence interval [CI] 2.4-6.1), received treatment aimed at palliation in the last week (OR 2.57; 95% CI 1.6-4.2), had contact with a GP in the last week (OR 2.71; 95% CI 1.7-4.1), died of cancer (OR 1.46; 95% CI 1.1-2.0), or died at home (OR 2.16; 95% CI 1.5-3.0).

Conclusion

In these countries, ACP is done with approximately one-third of the studied terminally ill patient population. Most agreements are made only verbally, and care also is often planned with family only. ACP relates strongly both to patient factors and to health care measures performed at the very end of life.     

Experiences with advance care planning: older people and family members' perspective

jeong s.y.‐s., higgins i. & mcmillan m. (2011) Experiences with advance care planning: older people and family members’ perspective. International Journal of Older People Nursing 6 , 176–186 doi: 10.1111/j.1748‐3743.2009.00201.x Aims and objectives. The aim of this study is to report the findings of a case study that explored the phenomenon of advance care planning and advanced care directives in residential care settings in Australia. In particular, this study focuses on the experiences of residents’ and family members’. Background. Understanding the phenomenon of advance care planning and advanced care directives is vital to end of life decision making. There are few studies that report the experiences of older people and family members in relation to advance care planning and advanced care directives. Methods. A case‐study research was conducted and data was collected over 7 months involving participant observation, field notes, semi‐structured interviews and document analysis. Findings. The participants’ early experiences with advance care planning were expressed in unpleasant, hostile and negative ways. However, those emotions and concerns were transformed to more stable, amenable and positive attitudes and feelings as issues were resolved. The factors that enhanced or inhibited the transition were described. Conclusion. Older people and families view the end of life with broader psychosocial and spiritual meanings shaped by a lifetime of experiences. Advance care planning led to a different level of appreciation of personal entity and transcendence. However, advance care planning demands concerted action and support by everyone involved.     

An Interventional Study for the Early Identification of Patients With Palliative Care Needs and the Promotion of Advance Care Planning and Advance Directives

ContextPrograms identifying patients needing palliative care and promoting advance care planning (ACP) are rare in Asia.ObjectivesThis interventional cohort study aimed to identify hospitalized patients with palliative care needs using a validated palliative care screening tool (PCST), examine the ability of the PCST to predict mortality, and explore effects of a pragmatic ACP program targeted by PCST on the utilization of life-sustaining treatment during the last three months of life.MethodsIn this prospective study, we used PCST to evaluate patients' palliative care needs between 2015 and 2016 and followed patients for three months. ACP with advance directives (ADs) was systematically offered to all patients with PCST score ≥4.ResultsOf 47,153 hospitalized patients, 10.4% had PCST score ≥4. During follow-up, 2121 individuals died within three months of palliative care screening: 1225 (25.0%) with PCST score ≥4 and 896 (2.1%) with PCST score <4. After controlling for covariates, PCST score ≥4 was significantly associated with a higher mortality within three months of screening (adjusted odds ratio [AOR] 6.86; 95% CI 6.16–7.63). Moreover, ACP consultation (AOR 0.78; 95% CI 0.66–0.92) and AD completion (AOR 0.49; 95% CI 0.36–0.65) were associated with a lower likelihood of receiving life-sustaining treatments during the last three months of life.ConclusionWe demonstrated the feasibility of implementing a comprehensive palliative care program to identify patients with palliative care needs and promote ACP and AD in Eastern Asia. ACP consultation and AD completion were associated with reduced utilization of life-sustaining treatments during the last three months of life.     

Advance Care Planning in Community-Dwelling Patients With Dementia

Context

Little is known about advance care planning (ACP) among community-dwelling patients with dementia.

Using the stages of change model to improve communication about advance care planning

TOPIC: Advance care planning (ACP) is a term intended to describe the dynamic process of discussing wishes for future medical care. PURPOSE: To demonstrate how a behavior change model can be used to enhance ACP. SOURCES: Authors' personal experience, workshops, literature review. CONCLUSIONS: Incorporating behavioral change theory helps develop workable interventions and provides strategies for nurses to approach patients appropriately about planning for future medical care.     

Advance directives in the primary care setting

Advance directives have been available for more than 20 years, yet only 2% of patients report having had a discussion about them with their physician. Physicians and patients appear to be reluctant to bring up the subject despite evidence that patients not only want help with advance directives, but report more satisfaction with their health care when the topic is addressed. The primary care setting is particularly well-suited to the establishment of advance directives. A clearer understanding of the benefits of advance directives to physicians and their patients can hopefully increase the use of this important health care resource.     

Advance Care Planning in Early Stage Dementia

Dementia is a chronic illness that involves progressive loss of cognitive and functional abilities. In the early stages, persons with dementia actively face their cognitive decline, adjust to cognitive loss, and are able to take an active role in discussing values and preferences for future care. Preparing patients and families for what to expect in the course of dementia is vital in ascertaining an individual’s wishes regarding supportive and life-sustaining interventions. Nurse practitioners in primary care have a responsibility to initiate advance care planning conversations with persons in the early stages of dementia.     

Experiences with advance care planning: nurses' perspective

jeong s.y.‐s., higgins i. & mcmillan m. (2011 ) Experiences with advance care planning: nurses’ perspective. International Journal of Older People Nursing  6 , 165–175 doi: 10.1111/j.1748‐3743.2009.00200.x Aims and objectives. The aim of this paper is to report the findings of a case study that explored the phenomenon of advanced care planning and advance care directives in residential care settings in Australia. In particular, this paper focuses on the experiences of Registered Nurses with advanced care planning and advance care directives. Background. Nurses need to know how to engage with residents and families when they invest time and effort on advanced care planning and documentation of advance care directives. Methods. A case‐study design involving participant observation, field note recording, semi structured interviews and document analysis was used. Data were collected over 7 months. Data analysis involved thematic content analysis. Findings. The factors that enhanced and inhibited the experiences of the Registered Nurses with advanced care planning were identified. The enhancing factors include; ‘it is their essence of who they are’, and ‘back‐up from family members and other nursing staff’. The inhibiting factors are ‘lack of time’, ‘a culture of do everything and don’t go there’, and ‘lack of family involvement’. Conclusion. The findings of the current study provided nurses with evidence of the positive nature of experiences of older people, family members, and nurses themselves with advanced care planning in an attempt to better implement and practise advanced care planning.     

Advance Directives in Hospitalized Patients: A Retrospective Cohort Study

The purpose of this study was to examine processes for advance directives (ADs) in hospitalized patients to inform improvements in practice and policy. This was a retrospective study examining electronic records of 5,330 inpatients admitted over a 3-month period. During admission, 63.5% of patients were queried, with 37.2% of patients having ADs and only 14.4% available in the record. Older age and Medicare insurance were associated with having ADs. Opportunities exist for nurse practitioners to change structure and processes related to ADs improving completion and availability.     

Improving Advance Care Planning in Outpatients With Decompensated Cirrhosis: A Pilot Study

BackgroundDespite significant morbidity and mortality among patients with decompensated cirrhosis, reported rates of advance directive (AD) completion and goals of care discussions (GCDs) between patients and providers are very low. We aimed to improve these rates by implementing a hepatologist-led advance care planning (ACP) intervention.MeasuresRates of AD and GCD completion, as well as self-reported barriers to ACP.InterventionProvider-led ACP in patients with decompensated cirrhosis without a prior documented AD.OutcomesSixty-two patients were seen over 115 clinic visits. After the intervention, AD completion rates increased from 8% to 31% and GCD completion rates rose from 0% to 51%. Women (P = 0.048) and nonmarried adults (P = 0.01) had greater changes in AD completion compared to men and married adults, respectively. Needing more time during visits was seen as the major barrier to ACP among providers.Conclusions/Lessons LearnedAddressing provider and system-specific barriers dramatically improved documentation rates of ACP.     

Attitudes of the General Public,Cancer Patients,Family Caregivers,and Physicians Toward Advance Care Planning: A Nationwide Survey Before the Enforcement of the Life-Sustaining Treatment Decision-Making Act

Context

To respect a patient's wish for end-of-life care, “the Act on Decisions on Life-Sustaining Treatment for Patients at the End-of-Life” was enacted in South Korea in 2016. Current understanding of people who would be involved in advance care planning (ACP) is crucial to disseminate it systematically.