Keeping morality out and the GP in. Consultations in Danish general practice as a context for smoking cessation advice

OBJECTIVE: To describe consultations in Danish general practice as a context for a mass strategy of smoking cessation advice. METHODS: The focus of the study was on consultations for health problems that were not related to smoking. Interviews with eleven patients and their six GPs were grounded in observation of their own consultations. RESULTS: Patients and GPs agreed that the GP should adopt an attitude of moral acceptance towards patients. Ideals of moral acceptance of patients in general practice consultations were challenged by the prevailing negative moral values associated with smoking. A general aim of mutuality in the conversation in consultations could not always be achieved in smoking cessation advice. Achieving mutuality was especially a problem when smoking cessation advice was repeated at short intervals. CONCLUSION: Two elements of Danish general practice consultations were challenged by smoking cessation advice to patients without smoking-related illness: the ideal of moral acceptance of patients in general practice consultations held by GPs and patients and the wish for mutuality in the conversation during consultations. PRACTICE IMPLICATIONS: A conversation about smoking based on motivational interviewing would fit in the context of Danish general practice. Relieving the conversation of blocks due to moral implications, however, is still a challenge.     

Examining patients’ trust in physicians and the VA healthcare system in a prospective cohort followed for six-months after an exacerbation of heart failure

Objective

To examine the associations of several characteristics with patients’ trust in physician and the healthcare system.

Methods

A prospective cohort of patients were followed after an exacerbation of heart failure at one of two veterans affairs (VA) hospitals. Patients rated pre-visit and post-visit trust in physician and in the VA healthcare system at follow-up outpatient visits. The associations of trust in physician and VA with covariates were analyzed using multivariate mixed-effects regression.

Results

After adjusting for covariates, post-visit trust in physician was significantly higher than pre-visit trust (P < 0.001), but was not significantly different by race. Trust in VA did not change significantly over time (P > 0.20), but was significantly lower for Black patients (P < 0.001). High self-efficacy to communicate was independently associated with both trust in physician and VA (P < 0.001).

Conclusions

Trust in physician improved over the course of each visit. Trust in VA was not associated with time, but was lower among Black patients. Trust was higher when ratings of communication were higher.

Practice implications

Trust in physician improved at each visit and was independently associated with communication. Interventions designed to improve communication should be tested for their ability to improve trust in physician and trust in the healthcare system.     

Shame,honor and responsibility in clinical dialog about lifestyle issues: A qualitative study about patients’ presentations of self

Objective

To explore how patients enact presentations of self in consultations dealing with lifestyle in general practice.

Methods

We conducted a qualitative observational study with thematic, cross-case analysis of video-recorded consultations inspired by discourse analysis.

Results

Patients presented themselves with an orientation toward responsibility in dialog about lifestyle. They described how they were taking care of themselves and doing their best. In this respect, they demonstrated their achievements as matters of honor. If one lifestyle issue was considered problematic, in some cases patients shifted attention to another, of which they were more proud. In areas where they were not doing well, some patients revealed shame for not acting responsibly. In such cases, patients spoke of themselves in terms of self-deprecation or admitted not living up to expected standards.

Conclusion

Negotiations of shame and honor, revolving around personal responsibility, are embedded in clinical discourse about lifestyle. Patients take a proactive role in presenting and defending the self against shame.

Practice implications

GPs should pay more attention to the tacit role of shame in consultations. Failure to do so could lead to distance and hostility while a strategy to acknowledge the impact of shame could help develop and strengthen the doctor–patient relationship.     

Predictors and moderators of outcome in different brief interventions for smoking cessation in general medical practice

Objective

To explore demographic-, health-, and smoking-related predictors and moderators of outcome in smokers who participated in two different brief smoking cessation interventions.

Methods

Data were acquired using a quasi-randomized controlled trial that tested the efficacy of computer-generated tailored letters and physician-delivered brief advice against assessment only. Daily smokers (n = 1499) were recruited from 34 general medical practices. We used Generalized Estimating Equation analyses to investigate the relationship between 6-month prolonged smoking abstinence assessed at 12-, 18-, and 24-month follow-ups and potential predictors and moderators.

Results

Female gender (OR = 1.49, 95% CI = 1.01–2.19), higher level of education (OR = 1.82, 95% CI = 1.18–2.82), intention to quit smoking (OR = 1.66, 95% CI = 1.16–2.38), and smoking cessation self-efficacy (OR = 1.30, 95% CI = 1.03–1.64) were positively, nicotine dependence (OR = 0.84, 95% CI = 0.76–0.94) and the presence of a smoking partner (OR = 0.60, 95% CI = 0.42–0.85) were negatively associated with smoking abstinence. Compared to assessment only, physician advice was less effective for people without an intention to quit smoking and for unemployed.

Conclusion

Smoking cessation interventions might be improved by tailoring them to demographic- and smoking-related variables which were identified as predictors in this study.

Practice implications

The results suggest that tailored letters are a more universally applicable brief intervention in general medical practice than physician advice.     

Physician smoking status, attitudes toward smoking, and cessation advice to patients: an international survey

Objective

The smoking status of physicians can impact interactions with patients about smoking. The ‘Smoking: The Opinions of Physicians’ (STOP) survey examined whether an association existed between physician smoking status and beliefs about smoking and cessation and a physician's clinical interactions with patients relevant to smoking cessation, and perceptions of barriers to assisting with quitting.

Methods

General and family practitioners across 16 countries were surveyed via telephone or face-to-face interviews using a convenience-sample methodology. Physician smoking status was self-reported.

Results

Of 4473 physicians invited, 2836 (63%) participated in the survey, 1200 (42%) of whom were smokers. Significantly fewer smoking than non-smoking physicians volunteered that smoking was a harmful activity (64% vs 77%; P < 0.001). More non-smokers agreed that smoking cessation was the single biggest step to improving health (88% vs 82%; P < 0.001) and discussed smoking at every visit (45% vs 34%; P < 0.001). Although more non-smoking physicians identified willpower (37% vs 32%; P < 0.001) and lack of interest (28% vs 22%; P < 0.001) as barriers to quitting, more smoking physicians saw stress as a barrier (16% vs 10%; P < 0.001).

Conclusion

Smoking physicians are less likely to initiate cessation interventions.

Practice implications

There is a need for specific strategies to encourage smoking physicians to quit, and to motivate all practitioners to adopt systematic approaches to assisting with smoking cessation.     

Sequence-analysis of video-recorded practitioner–patient communication about smoking in general practice: Do smokers express negative statements about quitting?

Objective

To examine the extent to which smokers express negative statements about quitting and the extent to which these statements influence general practitioners’ (GPs’) and practice nurses’ (PNs’) (dis)continuation of guideline-recommended smoking cessation care.

Methods

Fifty-two video-consultations were observed (GP-consultations: 2007–2008; PN-consultations: 2010–2011). Dialogues were transcribed verbatim and professionals’ and patients’ speech units were coded and analysed using sequential analyses (n = 1424 speech units).

Results

GPs focused on asking about smoking (GPs: 42.4% versus PNs: 26.2%, p = 0.011) and advising them to quit (GPs: 15.3% versus PNs: 3.5%, p < 0.001), whereas PNs focused on assisting them with quitting (GPs: 25.4% versus PNs: 55.2%, p < 0.001). Overall, patients expressed more negative statements about quitting than positive statements (negative: 25.3% versus positive: 11.9%, p < 0.001), especially when PNs assessed their willingness to quit (OR 3.61, 95% CI 1.44–9.01) or assisted them with quitting (OR 2.23, 95% CI 1.43–3.48).

Practice implications

An alternative approach to smoking cessation care is proposed in which GPs’ tasks are limited to asking, advising, and arranging follow-up. This approach seems the least likely to evoke negative statements of patients about quitting during dialogues with GPs and is compatible with the tasks and skills of PNs who could, subsequently, assist smokers with quitting.     

"I did it my way"--an explorative study of the smoking cessation process among Danish youth

Objective

To explore the smoking cessation process of adolescents and their attitudes and beliefs towards smoking cessation and cessation interventions.

Method

Focus group discussions and individual interviews during April–May 2004 with 26 persons aged 15–21 years who all initiated a quit attempt on 1 January 2004.

Results

The approach towards all stages of the youth smoking cessation process varied greatly among both successful and unsuccessful quitters. Apart from ‘commitment’ or the amount of energy put into a cessation attempt, there were no differences in the way successful and unsuccessful quitters approached the quit attempt. ‘Smoking friends’ and ‘social support’ were important for maintaining cessation. Further, participants had negative attitudes towards formalized smoking cessation interventions.

Conclusion

There are many approaches to the smoking cessation process. Whether an attempt is successful depends more on individual conditions and the amount of commitment invested in the attempt than on the specific cessation strategy used.

Practice Implications

Future adolescent smoking cessation interventions should be flexible regarding both structure and content and should focus on the individual learning process, rather than adhering to rigid cessation strategies.     

Experiences of using email for general practice consultations: a qualitative study

Background

Reports suggest approximately 21–23% of GPs in the UK have consulted with patients using email, but little is known about the nature of this use and what it means for clinicians and patients in general practice.

Aim

To understand the use of email consultation in general practice by investigating the experiences of existing users and views of experts.

Design and setting

A qualitative study conducted in 2010 using purposive sampling and semi-structured interviews in general practice and community settings in some London boroughs.

Method

A maximum variation sample of GPs and patients who had used email for consultation in general practice were recruited, as were policy and/or implementation experts. Interviews continued until saturation was achieved.

Results

In total 10 GPs, 14 patients, and six experts were interviewed. Consultation by email was often triggered by logistic or practical issues; motivators for ongoing use were the benefits, such as convenience, for GPs and patients. Both GPs and patients reported concerns about safety and lack of guidance about the ‘rules of engagement’ in email consultations, with GPs also concerned about workload. In response, both groups attempted to introduce their own rules, although this only went some way to addressing uncertainty. Long term, participants felt there was a need for regulation and guidance.

Conclusion

Consultations by email in general practice occur in an unregulated and unstructured way. Current UK policy is to promote consultations by email, making it crucial to consider the responsibility and workload faced by clinicians, and the changes required to ensure safe use; not doing so may risk safety breaches and result in suboptimal care for patients.     

General practice counseling for patients with chronic obstructive pulmonary disease to quit smoking: Impact after 1 year of two complex interventions

Objective

To evaluate two counseling programs in general practice to help smokers with chronic obstructive pulmonary disease (COPD) to quit smoking.

Methods

Cluster randomized controlled trial including 68 general practices (667 patients) using a randomly assigned intervention program with counseling and advice about nicotine replacement therapy (and additional bupropion-SR in one of the programs) or usual care. Usual care consisted of periodic regular check-ups and COPD information. The main outcome measure was biochemically verified point prevalence at 12 months.

Results

The two intervention groups were treated as one in the analysis because they were equally effective. The intervention resulted in a significantly self-reported higher success rate (14.5%) compared to usual care (7.4%); odds ratio = 2.1, 95% confidence interval = 1.1-4.1. Biochemically verified quit rates were 7.5% (intervention) and 3.4% (usual care); odds ratio = 2.3, 95% confidence interval = 0.9-6.0.

Conclusion

The program doubled the cessation rates (statistically nonsignificant). Too few participants used the additional bupropion-SR to prove its effectiveness.

Practice implications

The protocols can be used for COPD patients in general practice, but expectations should be modest. If quitting is unsuccessful, a stepped care approach should be considered.     

Adenosine receptors in COPD and asymptomatic smokers: effects of smoking cessation

Our group has shown that 1-year smoking cessation persisted or increased airway inflammation in chronic obstructive pulmonary disease (COPD). We compared adenosine and adenosine receptor (AR) expression in COPD and asymptomatic smokers (AS) before and after 1-year smoking cessation. Sputum cytospins and bronchial biopsies of (ex)smoking COPD patients and AS were studied for A₁R, A_2AR, A_2BR, and A₃R expression. Adenosine and inflammatory mediators were measured in sputum supernatants. At baseline, COPD patients had lower levels of adenosine and higher levels of vascular endothelial growth factor in sputum than AS. Smoking cessation induced significantly different effects in COPD than in AS, i.e. an increase in percentages of A₃R expressing neutrophils and A₁R expressing macrophages in COPD as increase in adenosine and monocyte chemoattractant protein-1 levels in sputum. Adenosine-related effector mechanisms may contribute to the persistence and progression of airway inflammation in COPD following 1-year smoking cessation.     

Communication matters: The impact of communication and participation in decision making on breast cancer patients’ depression and quality of life

Objective

This study explored the impact of breast cancer patients’ experiences of physician–patient communication and participation in decision making on patient depression and quality of life three and six months after primary treatment.

Methods

Participants were 135 German breast cancer patients, recruited within a week after the beginning of treatment. Women were asked to complete a self-administered questionnaire at baseline and three and six months later.

Results

Patients who rated their level of information at baseline as high were less depressed after three (p = .010) and six months (p < .001) and experienced higher quality of life after three (p < .001) and six months (p = .049). Patients who participated as much as they had wanted were more satisfied with the decision making process (p < .001) and had lower depression scores three months later (p = .005). The level of participation itself (passive, collaborative, active) and the treatment type had no impact.

Conclusion

The findings reveal the significance of physician–patient communication and stress the meaning of baseline depression for later adjustment.

Practice implications

A high level of information and tailoring the involvement in decision making to patients’ desired level can help patients to better cope with their illness. Physicians should assess and treat depression early in cancer treatment.     

Development of an interactive, Web-delivered system to increase provider-patient engagement in smoking cessation

Background

Patient self-management interventions for smoking cessation are effective but underused. Health care providers do not routinely refer smokers to these interventions.

Objective

The objective of our study was to uncover barriers and facilitators to the use of an e-referral system that will be evaluated in a community-based randomized trial. The e-referral system will allow providers to refer smokers to an online smoking intervention during routine clinical care.

Methods

We devised a four-step development and pilot testing process: (1) system conceptualization using Delphi to identify key functionalities that would overcome barriers in provider referrals for smoking cessation, (2) Web system programming using agile software development and best programming practices with usability refinement using think-aloud testing, (3) implementation planning using the nominal group technique for the effective integration of the system into the workflow of practices, and (4) pilot testing to identify practice recruitment and system-use barriers in real-world settings.

Results

Our Delphi process (step 1) conceptualized three key e-referral functions: (1) Refer Your Smokers, allowing providers to e-refer patients at the point of care by entering their emails directly into the system, (2) practice reports, providing feedback regarding referrals and impact of smoking-cessation counseling, and (3) secure messaging, facilitating provider–patient communication. Usability testing (step 2) suggested the system was easy to use, but implementation planning (step 3) suggested several important approaches to encourage use (eg, proactive email cues to encourage practices to participate). Pilot testing (step 4) in 5 practices had limited success, with only 2 patients referred; we uncovered important recruitment and system-use barriers (eg, lack of study champion, training, and motivation, registration difficulties, and forgetting to refer).

Conclusions

Implementing a system to be used in a clinical setting is complex, as several issues can affect system use. In our ongoing large randomized trial, preliminary analysis with the first 50 practices using the system for 3 months demonstrated that our rigorous preimplementation evaluation helped us successfully identify and overcome these barriers before the main trial.

Trial

Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00797628","term_id":"NCT00797628"}}NCT00797628; http://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00797628","term_id":"NCT00797628"}}NCT00797628 (Archived by WebCite at http://www.webcitation.org/61feCfjCy)     

An economic evaluation of a computer-tailored e-learning program to promote smoking cessation counseling guideline adherence among practice nurses

ObjectiveTo conduct an economic evaluation of a tailored e-learning program, which successfully improved practice nurses’ smoking cessation guideline adherence.MethodsThe economic evaluation was embedded in a randomized controlled trial, in which 269 practice nurses recruited 388 smoking patients. Cost-effectiveness was assessed using guideline adherence as effect measure on practice nurse level, and continued smoking abstinence on patient level. Cost-utility was assessed on patient level, using patients’ Quality Adjusted Life Years (QALYs) as effect measure.ResultsThe e-learning program was likely to be cost-effective on practice nurse level, as adherence to an additional guideline step cost €1,586. On patient level, cost-effectiveness was slightly likely after six months (cost per additional quitter: €7,126), but not after twelve months. The cost-utility analysis revealed slight cost-effectiveness (cost per QALY gained: €18,431) on patient level.ConclusionProviding practice nurses with a tailored e-learning program is cost-effective to improve their smoking cessation counseling. Though, cost-effectiveness on patient level was not found after twelve months, potentially resulting from smoking relapse.Practice implicationsWidespread implementation of the e-learning program can improve the quality of smoking cessation care in general practice. Strategies to prevent patients’ smoking relapse should be further explored to improve patients’ long-term abstinence.     

Breast cancer patients’ trust in physicians: The impact of patients’ perception of physicians’ communication behaviors and hospital organizational climate

Objective

To examine whether patients’ perception of a hospital's organizational climate has an impact on their trust in physicians after accounting for physicians’ communication behaviors as perceived by the patients and patient characteristics.

Methods

Patients undergoing treatment in breast centers in the German state of North Rhein-Westphalia in 2006 were asked to complete a standardized postal questionnaire. Disease characteristics were then added by the medical personnel. Multiple linear regressions were performed.

Results

80.5% of the patients responded to the survey. 37% of the variance in patients’ trust in physicians can be explained by the variables included in our final model (N = 2226; R² adj. = 0.372; p < 0.001). Breast cancer patients’ trust in their physicians is strongly associated with their perception of a hospital's organizational climate. The impact of their perception of physicians’ communication behaviors persists after introducing hospital organizational characteristics. Perceived physician accessibility shows the strongest association with trust.

Conclusions

A trusting physician–patient relationship among breast cancer patients is associated with both the perceived quality of the hospital organizational climate and perceived physicians’ communication behaviors.

Practice implications

With regard to clinical organization, efforts should be put into improving the organizational climate and making physicians more accessible to patients.     

Women's and residents’ experiences of communication in the diagnostic mammography suite

Objective

To gain understanding of radiology residents’ and women's experiences, concerns, information needs, coping strategies and perspectives about optimal communication during diagnostic mammography.

Methods

Qualitative analysis of focus groups of radiology residents and women who had undergone diagnostic mammograms.

Results

Five categories of themes emerged from our analysis: information needs, perspectives and ideals, emotional experiences and observations, working together, individual experiences, and others’ roles. Women preferred continuous orientation, clear explanations and emotional support by physicians and radiology technologists throughout diagnostic processes. Communication about diagnostic mammogram results evoked the threat of breast cancer and was experienced as “bad news” by women, but not necessarily by all radiology residents. Lack of collaboration among radiologists, technologists and other healthcare professionals engendered confusion and anxiety in patients. Radiology residents felt inadequately prepared to meet the communication challenges of providing information and emotional support tailored to women's needs in this context.

Conclusion

Women's experiences are influenced by the extent to which they receive clear information and support, and perceive collaboration among professionals involved in the diagnostic mammography process.

Practice implications

Radiology education must address communication with patients and among healthcare professionals involved in the care of patients undergoing diagnostic procedures and interventions.     

Addressing tobacco use disorder in smokers in early remission from alcohol dependence: The case for integrating smoking cessation services in substance use disorder treatment programs

Despite the declining overall rate of cigarette smoking in the general population in the United States, the prevalence of smoking is estimated to be as high as 80% among treatment-seeking alcoholics. The serious adverse health effects of tobacco and heavy alcohol use are synergistic and recent evidence suggests that smoking slows the process of cognitive recovery following alcohol abstinence. In addition, substantial evidence shows that treatment for tobacco dependence does not jeopardize alcohol abstinence. In this paper, we focus on the impact and treatment implications of tobacco dependence among treatment-seeking alcoholics through a review of five areas of research. We begin with brief reviews of two areas of research: studies investigating the genetic and neurobiological vulnerability of comorbid tobacco and alcohol dependence and studies investigating the consequences of comorbid dependence on neurobiological and cognitive functioning. We then review literature on the effects of smoking cessation on drinking urges and alcohol use and the effectiveness of smoking cessation interventions with alcoholic smokers. Finally, we offer recommendations for research with an emphasis on clinical research for enhancing smoking cessation outcomes in this population.     

Oncology healthcare providers’ implementation of the 5A's model of brief intervention for smoking cessation: Patients’ perceptions

Objective

Health care providers (HCPs) can play an important role in promoting smoking cessation and preventing relapse. Public Health Service guidelines recommend the “5A's” model of brief intervention. The goal of the current study was to examine cancer patients’ perceptions of 5A's model implementation by their oncology HCPs.

Methods

This study included 81 thoracic and 87 head and neck cancer patients at a large NCI-designated comprehensive cancer center. Patients completed questionnaires assessing perceptions of their oncology HCPs’ implementation of the 5A's model of brief intervention.

Results

Results indicate partial implementation of the 5A's model. The majority of patients reported that their providers had asked about smoking and advised them to quit, however; only half reported that their interest in quitting had been assessed, and few reported assistance in quitting or follow-up. Delivery of the 5A's was greater among patients who requested cessation advice from their HCPs.

Conclusion

The current findings suggest a need to increase adherence to the 5A's in the oncology setting.

Practical implications

Efforts to increase smoking cessation treatment provision by HCPs may improve the rate of cessation among cancer patients, and ultimately translate into better long-term cancer treatment outcomes.     

Residents’ and standardized patients’ perspectives on empathy: Issues of agreement

Objective

We investigated correlations between residents’ scores on the Jefferson Scale of Empathy (JSE), residents’ perceptions of their empathy during standardized-patient encounters, and the perceptions of standardized patients.

Methods

Participants were 214 first-year residents in internal medicine or family medicine from 13 residency programs taking standardized patient-based clinical skills assessment in 2011. We analyzed correlations between residents’ JSE scores; standardized patients’ perspectives on residents’ empathy during OSCE encounters, using the Jefferson Scale of Patient Perceptions of Physician Empathy; and residents’ perspectives on their own empathy, using a modified version of this scale.

Results

Residents’ JSE scores correlated with their perceptions of their own empathy during encounters but correlated poorly with patients’ assessments of resident empathy.

Conclusion

The poor correlation between residents’ and standardized patients’ assessments of residents’ empathy raises questions about residents’ abilities to gauge the effectiveness of their empathic communications. The study also points to a lack of congruence between the assessment of empathy by standardized patients and residents as receivers and conveyors of empathy, respectively.

Practice implications

This study adds to the literature on empathy as a teachable skill set and raises questions about use of OSCEs to assess trainee empathy.     

The content of general practice consultations: cross-sectional study based on video recordings

Background

Demographic and policy changes appear to be increasing the complexity of consultations in general practice.

Aim

To describe the number and types of problems discussed in general practice consultations, differences between problems raised by patients or doctors, and between problems discussed and recorded in medical records.

Design and setting

Cross-sectional study based on video recordings of consultations in 22 general practices in Bristol and North Somerset.

Method

Consultations were examined between 30 representative GPs and adults making a pre-booked day-time appointment. The main outcome measures were number and types of problems and issues discussed; who raised each problem/issue; consultation duration; whether problems were recorded and coded.

Results

Of 318 eligible patients, 229 (72.0%) participated. On average, 2.5 (95% CI = 2.3 to 2.6) problems were discussed in each consultation, with 41% of consultations involving at least three problems. Seventy-two per cent (165/229) of consultations included problems in multiple disease areas. Mean consultation duration was 11.9 minutes (95% CI = 11.2 to 12.6). Most problems discussed were raised by patients, but 43% (99/229) of consultations included problems raised by doctors. Consultation duration increased by 2 minutes per additional problem. Of 562 problems discussed, 81% (n = 455) were recorded in notes, but only 37% (n = 206) were Read Coded.

Conclusion

Consultations in general practice are complex encounters, dealing with multiple problems across a wide range of disease areas in a short time. Additional problems are dealt with very briefly. GPs, like patients, bring an agenda to consultations. There is systematic bias in the types of problems coded in electronic medical records databases.     

End-of-life expectations and experiences among nursing home patients and their relatives—A synthesis of qualitative studies

Objective

Synthesize research about patients’ and relatives’ expectations and experiences on how doctors can improve end-of-life care in nursing homes.

Methods

We systematically searched qualitative studies in English in seven databases (Medline, Embase, PsycINFO, CINAHL, Ageline, Cochrane Systematic Reviews and Cochrane Trials). We included 14 publications in the analysis with meta-ethnography.

Results

Patients and families emphasized the importance of health personnel anticipating illness trajectories and recognizing the information and palliation needed. Family members who became proxy decision-makers reported uncertainty and distress when guidance from health personnel was lacking. They worried about staff shortage and emphasized doctor availability. Relatives and health personnel seldom recognized patients’ ability to consent, and patients’ preferences were not always recognized.

Conclusion

Nursing home patients and their relatives wanted doctors more involved in end-of-life care. They expected doctors to acknowledge their preferences and provide guidance and symptom relief.

Practice implications

High-quality end-of-life care in nursing homes relies on organization, funding and skilled staff, including available doctors who are able to recognize illness trajectories and perform individualized Advance Care Planning.