Associations of Advance Directive Knowledge,Attitudes, and Barriers/Benefits With Preferences for Advance Treatment Directives Among Patients With Heart Failure and Their Caregivers

BackgroundPatients with heart failure (HF) have not been considered as major beneficiaries of advance directives (ADs). We analyzed factors affecting the preferences for the adoption of ADs by patients with HF and their caregivers.Methods and ResultsSeventy-one patient (mean age: 68 years)–caregiver (mean age: 55 years) dyads were enrolled during clinic visits for routine care at a single institution and completed questionnaires during in-person visits. Cohen's kappa coefficients and generalized estimating equation models were used to analyze the data. The agreement on dyadic perspectives for aggressive treatments was poor or fair, whereas agreement relative to hospice care was moderate (k = 0.42, 95% confidence interval = 0.087–0.754). Both patients and caregivers demonstrated poor knowledge of ADs and similar levels of perceived benefits and barriers to advance care planning. However, the caregivers had more positive attitudes toward ADs than patients. Patients and caregivers who were older and/or males had greater odds of preferring aggressive treatments and/or hospice care. Further, those with depressive symptoms had lower odds of preferring hospice care.ConclusionThe dyadic agreement was moderately high only for hospice care preferences. Both patients and caregivers demonstrated knowledge of shortfalls regarding ADs. Timely AD discussions could increase dyadic agreement and enhance informed and shared decision-making regarding medical care.     

Interdisciplinary End-of-Life Care in Nursing Homes

ABSTRACT

About 25% of deaths in the United States now occur in nursing homes, and this proportion is increasing. Current end-of-life (EOL) care in these facilities faces substantial challenges, including under-management of pain, dyspnea, and other symptoms, a clash of cultures between palliative care/hospice teams and the nursing facility, and reimbursement policy that discourages the use of hospice. For ethnic minorities, these challenges are more striking. Improvement in EOL care in nursing homes requires integration between the traditional rehabilitative/restorative mission of long-term care and the palliative model of hospice. Education, better utilization of hospice, cooperation in quality improvement, and changes in reimbursement policy will lead to better care for these increasingly frail and elderly patients.     

Factors influencing attitudes toward advance directives in Korean older adults

AimWe aimed to determine the factors influencing attitudes toward advance directives in Korean older adults with consideration of an Asian cultural background.MethodsWe recruited community-dwelling older adults aged 60 years or older at a regional senior welfare center in Korea. Demographic factors and mental and physical health status were examined using questionnaires and a physical examination. The questionnaire also assessed perceived necessity of advance directives and related experiences.ResultsMost participants (79.32%) agreed that advance directives were necessary. Older adults with high education levels (odds ratio [OR] 2.31, 95% confidence interval [CI] 0.84–6.34), low economic status (OR 2.09, 95% C.I. 0.60–7.27), and poor cognitive function (adjusted odds ratio [aOR] 2.10, 95% CI 0.89–4.97) had a greater odds of agreeing that advance directives are necessary. All participants with self-care problems (9/9) and most participants with at risk status of physical functioning (13/14) reported agreement. Death-related experiences were also associated. Notably, individuals who had discussions on end-of-life care with family members showed a greater odds of agreeing that advance directives are necessary (aOR 2.12, 95% CI 0.88–5.11).ConclusionsThe factors associated with increased agreement that advance directives are necessary were high education level, low economic status, poor cognitive function, problems in self-care, poor physical functioning, death-related experiences. Especially, discussions of end-of-life care with family members increased the agreement. Thus, discussion on end-of-life care should be encouraged and the factors influencing older adults’ attitudes toward advance directives should be considered in developing policies for such discussion.     

What Explains Racial Differences in the Use of Advance Directives and Attitudes Toward Hospice Care?

Cultural beliefs and values are thought to account for differences between African Americans and whites in the use of advance directives and beliefs about hospice care, but few data clarify which beliefs and values explain these differences. Two hundred five adults aged 65 and older who received primary care in the Duke University Health System were surveyed. The survey included five scales: Hospice Beliefs and Attitudes, Preferences for Care, Spirituality, Healthcare System Distrust, and Beliefs About Dying and Advance Care Planning. African Americans were less likely than white subjects to have completed an advance directive (35.5% vs 67.4%, P<.001) and had less favorable beliefs about hospice care (Hospice Beliefs and Attitudes Scale score, P<.001). African Americans were more likely to express discomfort discussing death, want aggressive care at the end of life, have spiritual beliefs that conflict with the goals of palliative care, and distrust the healthcare system. In multivariate analyses, none of these factors alone completely explained racial differences in possession of an advance directive or beliefs about hospice care, but when all of these factors were combined, race was no longer a significant predictor of either of the two outcomes. These findings suggest that ethnicity is a marker of common cultural beliefs and values that, in combination, influence decision-making at the end of life. This study has implications for the design of healthcare delivery models and programs that provide culturally sensitive end-of-life care to a growing population of ethnically diverse older adults.     

The Utilization of Palliative Care Services in Patients with Cirrhosis who have been Denied Liver Transplantation: A Single Center Retrospective Review

Introduction and AimUtilization of palliative care services in patients dying of end-stage liver disease (ESLD) is understudied. We performed a retrospective review of palliative care services among patients with ESLD unsuitable for liver transplantation (LT) at a tertiary care center.Material and MethodsDeceased ESLD patients considered unsuitable for LT from 2007-2012 were identified. Patients were excluded if they received a transplant, had an incomplete workup, were lost to follow up or whose condition improved so LT was not needed. Of the 1,175 patients reviewed, 116 met inclusion criteria.ResultsForty patients (34.4%) received an inpatient palliative care (PC) consultation and forty-one patients (35.3%) were referred directly to hospice. Thirty-three patients (28.4%) transitioned to comfort measures without PC consultation (median survival < 1 day). The median interval between LT denial and PC consultation or hospice was 28 days. Median survival after PC consult or hospice referral was 15 days. In conclusion, in a single center retrospective review of ESLD patients, palliative care services, when utilized, were for care at the very end of life. Without consultation, aggressive interventions continued until hours before death. We propose that ESLD patients could benefit from PC consultation at time of LT evaluation or based on MELD scores.     

Opiniones: End‐of‐Life Care Preferences and Planning of Older Latinos

OBJECTIVES: To measure end‐of‐life (EOL) care preferences and advance care planning (ACP) in older Latinos and to examine the relationship between culture‐based attitudes and extent of ACP. DESIGN: Cross‐sectional interview. SETTING: Twenty‐two senior centers in greater Los Angeles. PARTICIPANTS: One hundred forty‐seven Latinos aged 60 and older. MEASUREMENTS: EOL care preferences, extent of ACP, attitudes regarding patient autonomy, family‐centered decision‐making, trust in healthcare providers, and health and sociodemographic characteristics. RESULTS: If seriously ill, 84% of participants would prefer medical care focused on comfort rather than care focused on extending life, yet 47% had never discussed such preferences with their family or doctor, and 77% had no advance directive. Most participants favored family‐centered decision making (64%) and limited patient autonomy (63%). Greater acculturation, education, and desire for autonomy were associated with having an advance directive (P‐values <.03). Controlling for sociodemographic characteristics, greater acculturation (adjusted odds ratio (AOR)=1.6, 95% confidence interval (CI)=1.1–2.4) and preferring greater autonomy (AOR=1.6, 95% CI=1.1–2.3) were independently associated with having an advance directive. CONCLUSIONS: The majority of older Latinos studied preferred less‐aggressive, comfort‐focused EOL care, yet few had documented or communicated this preference. This discrepancy places older Latinos at risk of receiving high‐intensity care inconsistent with their preferences.     

Awareness and Completion of Advance Directives in Older Korean‐American Adults

There has been growing concern about racial and ethnic disparities in completion rates of advance directives (ADs) in community‐dwelling older populations. Although differences in AD completion rates between non‐Hispanic whites and African Americans have been reported, not much is known about the awareness and completion of ADs in other groups of ethnic minorities. Using a sample of community‐dwelling Korean‐American older adults (n = 675) as a target, factors associated with their awareness and completion of ADs were explored. Guided by Andersen's behavioral health model, predisposing (age, sex, marital status, education), need (chronic conditions, functional disability), and enabling (health insurance, acculturation) variables were included in the separate logistic regression models of AD awareness and AD completion. In both models, acculturation was found to be a significant predictor; those who were more acculturated were more likely to be aware of ADs and to have completed ADs. This study contributes to the knowledge about the role of acculturation in explaining AD awareness and completion in Korean‐American older adults and provides recommendations for possible AD educational interventions for this older adult minority population.     

Hospice Care: Nurses’ Experience and Perception of Older Adult Patients’ Experience

Objectives: The current study sought to understand the differences hospice nurses perceived in caring for older adult patients who utilize hospice for longer and shorter periods, older adult patients’ experience of hospice services, and if length of hospice stays influenced the patients’ end-of-life experience.

Methods: Interpretative Phenomenological Analysis was used to extract themes and subthemes from 10 interviews conducted with hospice nursing staff.

Results: Four major themes were identified pertaining to nurses perspective on older adults’ views of hospice and how length of hospice use impacts end-of-life care.

Conclusion: These themes suggest hospice nursing staff believe longer hospice stays are more positive and that older adults identify more positive aspects of hospice when using it for longer periods of time. Results suggest that nurses believe length of use directly impacts patient care and the experience of hospice services.

Clinical Implications: Participating nurses reported that older adults have a lack of information on hospice services. It was suggested that more information is needed and that providing such education may lead to longer hospice stays.     

Missed opportunities! End of life decision making and discussions in implantable cardioverter defibrillator recipients

BackgroundRecent guidelines highlight the need for clinician-patient discussions regarding end-of-life (EOL) choices prior to implantable cardioverter defibrillator (ICD) implantation. Health literacy could affect the quality and quantity of such discussions.ObjectiveOur objective was to determine the association of health literacy with experiences, attitudes, and knowledge of the ICD at EOL.MethodsIn this cross-sectional study, we used validated instruments to measure health literacy and patient experiences, attitudes, and knowledge of the ICD at EOL.ResultsOf the 240 ICD recipients, 76% of participants reported never having discussed the implications of a future withdrawal of defibrillation therapy with their healthcare provider. Increased odds of choosing to maintain defibrillation therapy were associated with female gender and lower ICD knowledge.ConclusionsFrom patients’ perspectives, EOL discussions with providers were minimal. Most patients hold misperceptions about ICD function that could interfere with optimal EOL care, particularly for those with inadequate health literacy.     

Quality of end-of-life care of home-based care with or without palliative services for patients with advanced illnesses

Palliative care has improved quality of end-of-life (EOL) care for patients with cancer, and these benefits may be extended to patients with other serious illnesses. EOL care quality for patients with home-based care is a critical problem for health care providers. We compare EOL quality care between patients with advanced illnesses receiving home-based care with and without palliative services.The medical records of deceased patients who received home-based care at a community teaching hospital in south Taiwan from January to December 2019 were collected retrospectively. We analyzed EOL care quality indicators during the last month of life.A total of 164 patients were included for analysis. Fifty-two (31.7%) received palliative services (HP group), and 112 (68.3%) did not receive palliative services (non-HP group). Regarding the quality indicators of EOL care, we discovered that a lower percentage of the HP group died in a hospital than did that of the non-HP group (34.6% vs 62.5%, P = .001) through univariate analysis. We found that the HP group had lower scores on the aggressiveness of EOL care than did the non-HP group (0.5 ± 0.9 vs 1.0 ± 1.0, P<.001). Furthermore, palliative services were a significant and negative factor of dying in a hospital after adjustment (OR = 0.13, 95%CI = 0.05–0.36, P < .001).For patients with advanced illnesses receiving home-based care, palliative services are associated with lower scores on the aggressiveness of EOL care and a reduced probability of dying in a hospital.     

Advance directives among people living with HIV: room for improvement

While HIV has become a largely chronic disease, age-associated comorbidities are prevalent in people living with HIV (PLWH). Therefore, PLWH are appropriate for advance care planning (ACP) and advance directives (ADs) completion. We sought to characterize AD completion among outpatient PLWH. We conducted a retrospective chart review of PLWH who receive their routine care at the University of Wisconsin HIV clinic. Data were extracted from the electronic health record. Variables were entered into a stepwise multivariate logistic regression model to assess which factors were independently associated with AD completion. Five hundred and eighty eight charts were reviewed. Eighty-one percent of subjects were male and 72% were white; mean age was 46.8 years. ADs were completed by 134 subjects and 6.7% of those were completed at the HIV clinic. In the final multivariate model, those who had completed an AD were more likely to be older than age 45; ever been diagnosed with AIDS; have cardiovascular disease, neurologic disorder, chronic kidney disease, or malignancy. In this study, a small percentage of patients had documented ADs, with only a small proportion completed in the HIV clinic. The HIV clinic is an underutilized resource to offer ACP. Interventions are needed to provide the necessary ACP resources for PLWH.     

The effect of rapid response teams on end-of-life care: A retrospective chart review

BACKGROUND:

A subset of critically ill patients have end-of-life (EOL) goals that are unclear. Rapid response teams (RRTs) may aid in the identification of these patients and the delivery of their EOL care.

OBJECTIVES:

To characterize the impact of RRT discussion on EOL care, and to examine how a preprinted order (PPO) set for EOL care influenced EOL discussions and outcomes.

METHODS:

A single-centre retrospective chart review of all RRT calls (January 2009 to December 2010) was performed. The effect of RRT EOL discussions and the effect of a hospital-wide PPO set on EOL care was examined. Charts were from the Ontario Ministry of Health and Long-Term Care Critical Care Information Systemic database, and were interrogated by two reviewers.

RESULTS:

In patients whose EOL status changed following RRT EOL discussion, there were fewer intensive care unit (ICU) transfers (8.4% versus 17%; P<0.001), decreased ICU length of stay (5.8 days versus 20 days; P=0.08), increased palliative care consultations (34% versus 5.3%; P<0.001) and an increased proportion who died within 24 h of consultation (25% versus 8.3%; P<0.001). More patients experienced a change in EOL status following the introduction of an EOL PPO, from 20% (before) to 31% (after) (P<0.05).

CONCLUSIONS:

A change in EOL status following RRT-led EOL discussion was associated with reduced ICU transfers and enhanced access to palliative care services. Further study is required to identify and deconstruct barriers impairing timely and appropriate EOL discussions.     

Hospice as Experienced by LTC Nurses and Their Perception of Resident Experiences

Objectives: This study utilized qualitative methods to better understand long-term care (LTC) nursing staff’s experience with hospice services and their perceptions of resident choice to utilize hospice services, as well as understand differences LTC nurses have experienced in regards to resident deaths. Methods: Interpretative Phenomenological Analysis (IPA) was utilized to extract themes and subthemes from 10 interviews that occurred with LTC nursing staff. Content analysis was also utilized to extract one noteworthy concept, which was a comparison of two resident deaths, with and without the utilization of hospice services.Results: Three main themes were extracted from the data: LTC nursing participant’s positive view of hospice, their perception that residents view hospice very negatively, and why residents choose to utilize hospice services. Participants also identified aspects of a “bad” or “good” death, with clear relationships noted when using hospice services. Conclusions: Findings identified a difference between the LTC nursing staff’s positive view of hospice and their belief that their residents view hospice services very negatively. According to these nurses’ experiences, to most residents, hospice meant something rather negative and feared. Clinical Implications: An intervention providing information about hospice services for LTC resident population may increase the percentage of older adults who utilize hospice services.     

Higher Pain Intensity,Depression, and Being 75 Years or Older are Associated with Lower Levels of Self-Reported Physical Activity in Older Adults with Pain Attending Primary Care

ABSTRACT

Objective: This study investigated whether pain characteristics (intensity, frequency, duration and number of pain sites), depression, age, sex and comorbidities are associated with lower levels of selfreported physical activity in older adults with pain at the primary healthcare setting.Methods: A total of 504 participants aged 60 years of age and over were assessed for: socio-demographics, comorbidities, pain, depression, and physical activity. Associations between these variables were investigated using ordinal logistic regression.Results: Reporting severe pain or worst imaginable pain, being older (≥ 75 years), and feeling depressed were significantly associated with lower physical activity in the univariate (OR = 2.33, 2.93, 2.31, and 2.23, respectively) and multivariate models (Adj OR = 2.21, 2.47, 2.49, and 1.97, respectively).Conclusions: Interventions aiming to increase physical activity for older adults in primary care should consider the needs of those reporting higher pain intensity, feeling depressed and who are 75 years or older.     

Attitudes and preferences of Korean-American older adults and caregivers on end-of-life care

A growing body of literature suggests that diverse attitudes toward the end of life exist across and within ethnic minority groups. This focus-group pilot study examined social and cultural factors influencing views of Korean-American older adults and caregivers on advance care planning and hospice care. A total of 20 older adults and 16 caregivers in west central Florida participated in one of four focus groups. This study found diverse attitudes among Korean Americans toward end-of-life care and cultural and structural barriers to advance care planning and hospice use. Older adults and caregivers both expressed a lack of knowledge about advance care planning and hospice and agreed that the family would make the final decision about the end-of-life care, while acknowledging the challenge of initiating communications about treatment preferences. They interpreted the Korean value of filial piety to support both curative and palliative treatment. The traditional norm of home death and importance of physician communication influenced preferences for hospice and advance care planning, respectively. Future outreach and education efforts should include development of culturally sensitive educational and communication tools and collaboration with ethnic community organizations and healthcare providers in the dissemination and education of these instruments.     

Factors associated with emergency department revisits among older adults in two Swedish regions: A prospective cohort study

ObjectivesTo assess the association between baseline characteristics at an index ED visit and ED revisit within 30 days among adults aged ≥ 65 years in two Swedish regions.MethodsThis was a register-based prospective cohort study. The sample included (N=16 688; N=101 017) older adults who have had an index ED visit in 2014 at hospital based EDs in the regions of Dalarna and Stockholm, Sweden. Several registers were linked to obtain information on sociodemographic factors, living conditions, social care, polypharmacy and health care use. Multivariate logistic regression was used to analyse the data.ResultsSeventeen percent of the study sample in Dalarna and 20.1% in Stockholm revisited ED within 30 days after an index ED visit. In both regions, male gender, being in the last year of life, excessive polypharmacy (≥ 10 drugs), ≥11 primary care visits and ED care utilization were positively associated with ED revisits. In Stockholm, but not in Dalarna, low level of education, polypharmacy, and institutional care was also associated with ED revisits. In contrast, home help was associated with ED revisits in Dalarna but not in Stockholm.ConclusionThese findings call for further in-depth examinations of variations within single countries. ED revisits among older adults are driven by need of care but also by the social and care situation.     

Intervention to Improve Care at Life’s End in Inpatient Settings: The BEACON Trial

Background

Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings.

Objective

To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings.

Design

Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design.

Participants

Six Veterans Affairs Medical Centers (VAMCs).

Intervention

Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools.

Main Measures

Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends.

Key Results

Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints.

Conclusions

This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-013-2724-6) contains supplementary material, which is available to authorized users.KEY WORDS: palliative care, end-of-life care, palliative medicine, hospice, inpatient     

Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities

Background

Verbal and physical aggressive behaviours are among the most disturbing and distressing behaviours displayed by older patients in long-term care facilities. Aggressive behaviour (AB) is often the reason for using physical or chemical restraints with nursing home residents and is a major concern for caregivers. AB is associated with increased health care costs due to staff turnover and absenteeism.

Methods

The goals of this secondary analysis of a cross-sectional study are to determine the prevalence of verbal and physical aggressive behaviours and to identify associated factors among older adults in long-term care facilities in the Quebec City area (n = 2 332).

Results

The same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia.

Conclusion

Cognitive impairment severity is the most significant predisposing factor for aggressive behaviour among older adults in long-term care facilities in the Quebec City area. Physical and chemical restraints were also significantly associated with AB. Based on these results, we suggest that caregivers should provide care to older adults with AB using approaches such as the progressively lowered stress threshold model and reactance theory which stress the importance of paying attention to the severity of cognitive impairment and avoiding the use of chemical or physical restraints.